Objective 5 2023 PDF

Required Readings: Ch 8, 9, 10, Ch 11 (p. 158-166) Objective 5: Health Promotion, Maintenance, & Health Challenges Health Maintenance & Aging This objective focuses on maintaining health & managing challenges in older adults with respect to: • • • • • • Nutrition Hydration Elimination Sleep Exer...

Required Readings: Ch 8, 9, 10, Ch 11 (p. 158-166) Objective 5: Health Promotion, Maintenance, & Health Challenges Health Maintenance & Aging This objective focuses on maintaining health & managing challenges in older adults with respect to: • • • • • • Nutrition Hydration Elimination Sleep Exercise Managing skin conditions associated with immobility Nutritional Needs for the Older Adult • Leading indicator of health status • Critical to maintaining health in older adults • Is related to happiness, quality of life, independence, maintaining physical health, & social / mental functioning. Factors Impacting Nutritional Status • • • • • Changes in taste & smell affects appetite. Digestive changes / Oral Health. Regulation of appetite Periodontitis, worn & brittle teeth affect eating Xerostomia (dry mouth) – common with aging • *can be side effect of medications. Can affect eating, chewing (mastication) swallowing food. • Approximately 22.3% of men & 21.1% of women >60 – without natural teeth (edentulous) • Cost of dental care – issue for older adults Promoting Nutritional Intake Practice good oral hygiene. Ensure properly fitting dentures. Seek prompt treatment of dental caries & periodontal disease. Eat meals in relaxed atmosphere. Maintain adequate intake of fluids. Assess for dysphagia (difficulty swallowing) *60% LTC residents. Box 6-6, Chp. 6, Promoting Healthy Digestion Preventing Aspiration in Persons with Dysphagia Provide a 30 min rest period before eating. Make sure the person is seated - 90 degree position (High Fowler’s). Avoid food with mixed consistency (e.g. fruit cup). Feed as tolerated, don’t rush. Cut food in a bite size that the person can tolerate. Follow specific instructions from speech-language pathologist. Place food in the unimpaired side of mouth (in a patient who had a stroke). Caution: drugs like sedatives & hypnotics affect cough reflex. Suction as necessary. Supervise all meals. Check for retained food particles in mouth. Nutritional Needs: Older Adult Total caloric intake should be measured according to changes in metabolic rate & decrease in physical activity. The older adult should eat a well-balanced diet & maintain healthy weight. Encourage nutrient dense food. Consume 30-45 mL unsaturated fats per day (fish, nuts, oil-based salad dressings, veg oils, nonhydrogenated margarine). Consume no more than one drink of alcohol per day. Consume fibre rich foods (20 – 30 grams of fibre per day). Consume 4700 mg/day of potassium with food. See Box 8.1 Nutritional Needs: Older Adult Increase fluids especially water (1500 – 2000 mL per day) *remember: thirst mechanism decreased & at risk for dehydration. Increase amounts of Calcium, Vit. D. Monitor salt intake. A person with high blood pressure should not consume more than 1500 mg of sodium per day. Nutritional Challenges: Older Adults Mobility (shop/prepare). Socioeconomic status. Chronic illness / conditions (diabetes, dysphagia, arthritis, stroke). Social isolation (over or under indulgence). Drugs / alcohol / Medications. Poor eating habits, e.g. Fad diets. Malnutrition / Obesity. Improving Nutritional Intake in LTC Serve meals in a chair. Provide analgesics & antiemetics (for nausea) on a schedule so that the person is more comfortable at meal-time. Determine food preferences. Have food available 24/7, snacks etc. Encourage family to be present. Make sure glasses are worn (Box 8.1 p. 103) Hydration • Adequate fluid intake = Health Maintenance • It is important to maintain fluid balance in older adults because: • • • • Dehydration can lead to & contribute to poor health outcomes. It is necessary for renal (kidney) and bowel function & metabolic processes. Recall: water distribution decreases with aging. Decrease in thirst sensation. • Water is an essential part of nutrition • Older adults should take in 1500 – 2000 ml of fluid per day. • A balance of fluid intake & output is important for all ages. Hydration Management Factors that increases risk for changes in fluid Balance: • Age-related changes (ie.water loss in older adults). • Medications. • Functional impairments. • Illness. Dehydration Results form insufficient intake & can seriously impact on the health of older adults. Risk factor for delirium, thrombus formation (blood clot), infections, kidney stones. Contributes to constipation, falls, medication toxicity, renal failure, seizure, electrolyte imbalance, hyperthermia, & delayed wound healing. Increased fluid loss combined with decreased fluid intake due to decreased thirst is the most common reason for dehydration on older adults. Screening for Dehydration • • • • • • • • • • • • Drugs End of life High fever Yellow urine turns dark Dizziness (orthostasis) Reduced oral intake Axillae dry Tachycardia Incontinence (fear of) Oral problems Neurological impairment (confusion) Sunken eyes Elimination Challenges: Incontinence Urinary Incontinence: unintentional loss of urine 38% in community dwellers. LTC – 60%, 90% of those with dementia. Related to many health issues, medications, levels of function. Acute (transient) and chronic (established). Types: Urge, stress, overflow, functional, iatrogenic. Types of Urinary Incontinence Urge • Overactive bladder, the ‘need to go,’ *most common type. Stress • Loss of urine caused by increase in intra-abdominal pressure due to coughing, sneezing, exercising, lifting, laughing. Overflow • Loss of urine due to an overextended bladder. Functional Incontinence • Urinary tract is intact, person not able to reach the toilet due to environmental barriers. Negative Health Consequences: Urinary Incontinence Psychosocial implications: depression, social isolation, anxiety, avoidance sexual activity. Associated with increase risk for falls, skin irritations, pressure ulcers, UTIs. Older adults often reduce their fluid intake to try & control urine leaking - can lead to dehydration. Measures to Reduce Urinary Incontinence Assessment is important. Scheduled or timed voiding, keep bladder diary. Prompted voiding (scheduled with verbal prompts). Bladder training (increase increments between voiding). Pelvic floor muscles (Kegal). Addressing environmental barriers. Lifestyle modifications (increase fluids, reduce caffeine, weight reduction, regular bowel habits & physical activity. Measures to Address Urinary Incontinence (Community Dwellers) Encourage the older person to empty the bladder before, after meals, bedtime & whenever the need arises. Encourage the older person to void every 2 hours during the day & every 4 hours at night. Encourage the older person to drink 1.5 L – 2 L before 8:00 p.m., (promotes kidney function). Elimination Challenges: Constipation Constipation is a common / symptom with older adults, not an expected age-related change. • Symptom of other problems e.g. poor habits, low fluid intake, poor diet, medication side effects, colonic dysmotility & masses, other illnesses. Constipation if not addressed can lead to fecal impaction. • This can be a serious condition that requires treatment to resolve. Interventions to Address Constipation Assess cause with a thorough history and physical examination. Increase fluids to 1500 – 2000 mL per day. Increase fiber. Regular physical activity. Encourage regular toileting. Laxatives are ordered only when other measures not effective. Elimination Challenges: Fecal Incontinence Uncontrolled loss of fecal waste. Often accompanies urinary incontinence. Prevalence: Approx. 2 – 17% community dwellers. • Approx. 50 – 65% in long-term care residents. Risks Factors: Diabetes, irritable bowel syndrome, spinal cord injuries, MS, damage to pelvic floor muscles / tissues. Sleep & Rest Needs: Older Adults • Sleep is vital to conserve energy, prevent fatigue & maintain optimal organ function. • It is common for older adults to have sleep challenges. • Challenges should not be regarded as a normal aging change. • It should be investigated to promote better sleep & to ensure there is not an underlying health issue. Sleep & Rest Needs • Sleep Structure: 5 stages • Stages 1 – 4 are non-Rapid Eye Movement Sleep (REM). • • • • Stage 1 – Lightest level Stage 2 – Onset of sleep Stage 3 & 4 – Sleep is deepest & most restorative REM – 25% of sleep, provides energy to the brain, supports daytime performance. Age-Related Changes: Sleep Structure Starting between ages 20 – 30 adults spend more time in stage 1 of sleep. Less time in stages 3 & 4 (less deep sleep). These are the stages that leaves you feeling rested. Less REM. More light sleeping transitions between stage 1 & 2. Lighter sleep. Interrupted / disjointed. Frequented awakening. Reduced total sleep time, longer time to fall asleep. More daytime naps. Sleep Disorders: Insomnia A subjective perception of not getting enough sleep Factors Affecting Sleep • Gastroesophageal Reflux Disease (GERD): more gastric acid produced during REM • Meds affecting sleep: e.g. bronchodilators, antidepressants, diuretics, nicotine, alcohol (Box 10-4, pg 143) Sleep Disorders: Sleep Apnea Stop breathing (> 10 seconds) Contributing factors • Increase in systemic & pulmonary arterial pressure & changes in cerebral blood flow (increased risk for stroke). • Age (changes to musculature of neck), obesity, sleeping supine, alcohol other drugs. Treatment • CPAP (Continuous Positive Airway Pressure) apparatus to use when sleeping. Sleep Hygiene Recommendations Use bedroom only for sleeping & sexual activity Have regular bedtime hours Limit naps to 30 min Get regular exercise, not too close to bedtime Limit caffeine, nicotine, diuretics later in day Avoid alcohol – 2 hours before bedtime. Don’t eat too close to bedtime (don’t be too full or too hungry). Keep environment conducive to sleeping. Avoid working on computer too close to bedtime. (Box 10-7 pg 146 Sleep Hygiene Rules) Promoting Sleep in LTC Limit intake of caffeine before bedtime Light snack & warm beverage before bedtime Quiet environment, soft lights, comfortable temp Limit interruptions Encourage going to washroom before bed Manage pain Try to keep routines Box 10-9 pg 147 Suggestions for Promoting Sleep Exercise / Activity Needs: Older Adult • Physical Activity – is a very important component to healthy aging (well supported in research). • Regular exercise contributes to both mental, physical health & functional status as a person ages. • Exercise decreases risk of chronic illness & functional limitations. • Benefits of exercise are seen even in frail older adults. • Only 13% of older adults are doing 150 min. of moderate to vigorous exercise / week. • Many feel they are too old to exercise. • Exercise can dramatically improve health in older adults. Exercise Types: Older Adult • Endurance exercises • Strength resistance exercises (twice a week) • Balance exercises (e.g. Tai Chi) • Flexibility exercises (3 days per week) • *Older adults should obtain appropriate screening before beginning an exercise program. Exercise Recommendations: Older Adults Make it fun, use music. Begin slow (lower – moderate intensity, smooth rhythmic movements). Assess perceived barriers to exercise. Include warm-up & cool down. Provide education regarding benefits. Lifestyle activities build endurance (with activities such as raking, gardening). (Box 10-11 pg 149 Suggestions for Exercice) Physical Activity Considerations: Older Adult Obtain assessment important before starting. Stop exercising if: SOB, chest pain, dizziness, severe joint pain. Educate clients on benefits / reduce fears. Goal setting & individualize plan. Include choices of types of exercise. Group exercise may increase compliance & enhance socialization. Skin Problems: Associated with Limited Mobility Fungal Infections (Candida albicans or ‘yeast’ Risk Factors • obesity, diabetes, malnourishment, medications (steroids, antibiotics) • Common areas: moist warm dark places like skin folds, axilla, groin, pendulous breasts, corner of the mouth, vagina, mouth (thrush) Management • Prevention is key. • Dry target areas well after bathing, (esp. after incontinence of urine or feces.) • Loose fitting clothes. • Hair dryer on low (with supervision) *check agency policy, safety risks. • Use powder in skin folds. • Mobilize as tolerated. • Encourage appropriate nutrition & hydration as tolerated. • Administer antifungals meds as ordered. Skin Problems: Associated with Limited Mobility • Pressure Ulcers (Injuries) • Any lesion caused by unrelieved pressure that results in tissue damage. • At-risk groups: those with hip fractures; critical care patients; quadriplegic clients, those with sensory deficits e.g. dementias. • Risk Factors • • • • • • • Shearing forces & friction Moisture Decreased movement & sensation Circulatory Problems Poor Nutrition Age Dehydration Pressure Ulcers Staged describing the severity / depth of the ulceration. Staging I – V provides direction for most appropriate intervention • I: Reddened (Erythema) area. • II: Reddened + blister or break in skin. • III: Shallow crater that extends to subcutaneous tissue ( may have drainage). • IV: Tissue deeply ulcerated, exposing muscle and bone; local infection can lead to sepsis. • V: Can be described as ‘Unstageable’. Assess: Size, location, odour, sinus tracts, exudate, condition of surrounding skin. • *See Box 11-7 ‘Key aspects of assessment of a pressure ulcer’ Pressure Ulcer Prevention Daily assessment of skin. Assessment of risk. (Braden Scale Fig. 11-2 p 163) Check pressure, friction, shearing forces. Proper positioning, transferring & turning techniques, encourage nutrition / ensure hydration. *Individualized Plan for Prevention Avoid massaging bony prominences Promote skin integrity by reducing the force & shearing during cleansing, use protective barrier creams which reduces friction (Box 11-6, pg 164 Risk Assessment & Prevention of Pressure Injuries) Skin Problems: Vascular Insufficiency Two types of vascular insufficiency (poor circulation): • Arterial • Venous When there is compromised circulation to the legs and feet, arterial and venous ulcers can develop. • Diabetes & high Blood Pressure (Hypertension) are often present in older adults with vascular insufficiency Arterial Insufficiency • Happens with peripheral vascular disease (PVD). Circulation to lower legs & muscles is impaired • Symptoms • Muscle fatigue when exercising, pain occurs if the leg is elevated, can advance to intermittent claudication pain. • Underlying cause is poor circulation and is triggered by trauma (bumping leg against bed or wheelchair). • Has a ‘punched out’ appearance. • Difficult to heal, may require surgery (to reduce circulation). Venous Insufficiency • Venous ulcer may result due to damage from a deep vein blood clot (thrombosis). • Also, due to impaired functioning of the valves in the veins. • Symptoms • Swelling in lower legs (edema), pain is usually not as severe as arterial, pain is deeper in limb. Can have weeping clear fluid from tissue. Skin is often discolored, brownish. Vascular Insufficiency: Nursing Implications If Arterial – dangle leg, if venous – elevate leg Assess the quality of pain, when is the person feeling most pain? Arterial may require surgery to restore circulation (otherwise if advanced could lead to amputation because of tissue death [gangrene]). Teach patient to protect lower leg and foot to prevent injury – ulcer and infection. Distinguishing between type of ulcer is important – to make sure appropriate treatment is provided Pressure stockings used for venous insufficiency Prevent infection and care for as ordered, for example dressings may be applied. Topical medication or antibiotics may be indicated