Exam 2 Flashcards
(250 cards)
1
Q
Health Assessment of the Older Adults Includes:
A
Physical Functional Developmental Cultural Psychosocial
2
Q
Health Assessment of the Older Adults Requires:
A
- Patience
- Good listening skills
- Observation skills for detail
- Non-judgmental approach
- Ability to ask difficult questions
- Understanding of normal changes in the older adult
- Wait to allow them to answer
- Use a matter-of-fact tone of voice for difficult questions (they will often mirror/pick up your cues)
3
Q
Health Assessment of the Older Adults: History
A
- They will have a longer medical and social history
- Knowing parent hx is important because of hereditary issues
4
Q
Health Assessment of the Older Adults: Review of Systems (ROS)
A
- Symptoms
- Start with open-ended to see what they’ll give you, then move to specifics
5
Q
Health Assessment of the Older Adults: Physical Exam
A
- Always consider patient comfort
- Good to discuss symptoms while conducting PE (Box 7.3, 7.4, 7.6)
ht&wt temp BP skin ears hearing eyes vision mouth neck chest/pulmonary heart extremities abdomen/GI msclsklt neuro GU: male/female
6
Q
Health Assessment of the Older Adults: Physical Assessment Tools
A
- Used to ID changes over time, nonspecific symptoms
- Assessment is a learned skill
7
Q
FANCAPES
A
Fluids - hydration
Aeration - pulmonary, CV (O2, SOB, cyanosis, RR, etc.)
Nutrition - malnutrition (increased frailty)
Communication - ability to communicate (speak, hear, visual, gestures, etc.)
Activity - participate in physical activity
Pain - physical, emotional, spiritual
Elimination - constipation, incontinence (not normal, but common)
Social Skills - interactions with others
8
Q
SPICES
A
- Useful for determining areas where further assessment is needed (yes/no)
- NOT a stand-alone tool (directs/leads to use of other evaluation tools)
Sleep disorders Problems with eating Incontinence Confusion Evidence of falls Skin breakdown
9
Q
tool used to lead to another assessment
A
SPICES
10
Q
Functional Assessment Tools
A
KATZ - ADLs (6- independent, 0- dependent)
Lawton - IADL scale
FAST - functional stages of Alzheimer’s Dementia (1-7)
11
Q
test for constructional apraxia
A
clock drawing test (Mini-Cog)
12
Q
Cognition Tools
A
MMSE - screens for cognitive impairment
Mini-Cog - screens for cognitive impairment
- clock drawing test (constructional apraxia = indicator of Alzheimer’s)
13
Q
Mood Assessment Tool
assess satisfaction with life beyond physical health that may lead to increase functional decline and health problems
A
Geriatric Depression Scale (GDS)
scored based on bold yes/no
14
Q
Vulnerability
A
Physical Crime Fraud Environmental Temperature Safety Aging in Place
15
Q
Physical Vulnerability
A
increasing vulnerability to environmental risks and mistreatment by others as older adults become less physically or cognitively able to cope or recognize real or potential hazards
16
Q
Crime Vulnerability
A
Violent (family, strangers)
17
Q
Fraud Vulnerability
A
Fraudulent schemes against elders
18
Q
Environmental Vulnerability
A
Neurosensory changes
Physiological changes
Medications
19
Q
Temperature Vulnerability
A
- Caretakers
- Economics
- Fever (a one degree change from baseline may be significant in older adults
- Hypo/Hyperthermia
20
Q
Hypothermia
A
Core temp <95*F
Box 20-7 p266
21
Q
Risk Factors for Hypothermia (box 20.6)
A
Thermoregulatory impairment (vasoconstriction, sensation, behavior to react to cold, shivering, metabolic response)
Conditions that decrease heat production
(hypothyroidism/pituitarism/glycemia, anemia, malnutrition, immobility, thinning hair, DKA)
Conditions that increase heat loss
(open wounds, inflammatory skin conditions, burns)
Conditions that impair central/peripheral control of thermoregulation
(stroke, brain tumor, wernicke’s encephalopathy, uremia, acute illness)
Drugs (tranquilizers, sedative-hypnotics, antidepressants, vasoactive drugs, alcohol)
22
Q
Hyperthermia
A
Ambient temp >90*F
box 20-5 p 265
23
Q
Heat Syndromes (table 20-1 p264)
A
Heat Fatigue Heat Syncope Heat Cramps Heat Exhaustion Heat Stroke
24
Q
Safety Vulnerability
A
Home (Fire and Burns - box 20-4 p263)
Transportation (critical for the older adults to remain independent and functional)
Driving (a life changing event)
Assistive technology:
- Gerotechnology (term used to describe assistive technologies for older people)
- smart homes
- telemedicine
- environmental control systems
25
Aging in Place
the ability to live in one's own home and community safely, independently, and comfortably
26
Aging in Community Models
- Naturally occurring retirement communities (NORCs)
- Village model
- Cohousing
- Shared housing
27
Geriatric Syndromes
```
Falls and Gait Abnormalities
Frailty
Delirium
Urinary Incontinence
Sleep Disorders
Pressure Ulcers
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28
Skin in Older Adults
* Often overlooked because focus is on acute problems or disease
* Can affect health and compromise quality of life
* Many age-related changes are visible due to aging, genetics, environment
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Functions of Skin:
* Protect underlying structures
* Regulate body temperature
* Sensory input
* Stores fat
* Metabolism of salt and water
* Gas exchange
* Production of vitamin D
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Age Related Changes to Epidermis:
- Decreased protection against UV rays
| - Slower wound healing
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Age Related Changes to Dermis:
- 20% Loss of thickness = skin tears and bruises more easily
| - Dermal blood vessels decrease = cooler skin temp, and increase susceptibility to skin cancer
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Extremely dry, cracked, and itchy skin
- Most common skin problem associated with aging
- Caused by decrease in epidermal filaggrin, which is a protein required for binding of keratin into macrofibrils
- Seen primarily on the extremities, mostly legs, but may affect trunk and face
Xerosis
| - Best practices (Box 13-2). (Hydration)
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Most common skin problem associated with aging
Xerosis
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Itchy skin (not a disease, but a symptom)
Pruritis
- Can cause skin injury secondary to scratching
- Aggravated by perfumed detergents, fabric softeners, heat, sweating, restrictive clothing, fatigue, exercise, and medications
- May result from systemic disease such as chronic renal failure, biliary, or hepatic disease
- Failure to control itching increases risk for eczema, excoriations, cracks, infection
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Causes intense itching
- Caused by tiny mite, Sarcoptes scabiei
- Contagious, easily transmitted through close physical contact; intimate or casual
Scabies
- Scabies with thick crust contain large number of mites and eggs
- May be transmitted on clothing, linen, furniture
- Diagnosed visually or via skin scraping
- Treated with prescribed lotions and creams; clothes and linens need to be washed in hot, soapy water and dried with high heat; rooms cleaned and vacuumed
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Fragility of dermal capillaries secondary to dermal thinning causing blood vessels to rupture
- Extravasation of blood into surrounding tissue
Purpura
- Commonly seen on dorsal forearm and hands
- Increases with age
- Persons on blood thinners are more susceptible
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Occurs because skin is thin and fragile
| - Painful, acute, accidental in nature
Skin Tears
- Categorized according to the Payne-Martin classification system
- Management: proper assessment, control of bleeding, cleanse with nontoxic solution, appropriate dressing, management of exudate, and prevention of infection/wounds
- Consider the patient on anticoagulants. (Box 13.5)
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Benign growth
- Mainly see on trunk, face, scalp, and neck
- Waxy, raised, stuck-on appearance
- Flesh colored or pigmented, various sizes
- Raised brown, scaly patch of skin
Seborrheic Keratosis (picture in doc)
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Precancerous
- Related to exposure to UV light
- Risk: increased age, fair complexion
- Rough scaly sandpaper patches
- Pink to reddish brown with erythematous base
- Raised, crusty red patches, some with scabs
Actinic Keratosis (picture in doc)
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Viral infection caused by reactivation of the varicella-zoster (chicken pox) virus
- Preceded by itching, tingling, rash along the dermatome prior to outbreak of vesicular lesions
- Lesions rupture, crust over, and heal
Herpes Zoster (Shingles)
- Infectious until it crusts over
- Treatment: analgesics, calamine lotion, antiviral agents, Zoster vaccine if greater than 60 years
- Complications: postherpetic neuralgia, eye involvement
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Caused by fungus Candida albicans found on the skin
- Found in warm, moist areas of skin, like skinfolds, axilla, groin
- Commonly called “thrush” when inside the mouth
Candidiasis
- Risk factors for infection: obesity, malnourishment, antibiotic, or steroid use, immunocompromised, chemotherapy, and diabetes
- Tips for best practice (Box 13-6)
- Keep it clean and dry
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Skin Cancer
* Cancer of the skin is the most common cancer
* Major public health problem on the rise
* One in five Americans will develop skin cancer in their lifetime
* Caucasian populations are at a higher risk
* All skin types should minimize sun exposure
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Most common malignant skin cancer
• Mainly in older persons
• Slow growing and metastasis rare
• Triggered by extensive sun exposure, burns, chronic irritation, or ulceration
• Early detection and treatment minimizes damage
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Basal Cell
(Image of raised mole with irregular borders and visible vasculature on man’s nose)
```
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Second most common form of skin cancer
• Aggressive and high incidence of metastasis
• Major risk factors are sun exposure, fair skin, immunosuppression
• Slightly different clinical presentations and may be overlooked
• Treatment depends on size, histology, and patient preference
Squamous Cell
| Raised mole with irregular borders and dry, crusty ulceration
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Neoplasm of the melanocytes
• Accounts for less than 2% of all skin cancers (but high incidence in death)
• Highest incidence in Caucasians
• Multicolored, raised, asymmetrical, irregular borders
• More common in men than women
Melanoma
| • Risk factors: more than 50 moles, sun sensitivity, history excessive sun exposure, severe sunburns, tanning beds.
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ABCDE Danger Signs (skin cancer)
| Box 13.8
```
Asymmetry of a mole
Border is irregular
Color variation
Diameter greater than the size of a pencil eraser
Elevation & Enlargement
```
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Indoor tanning
* Melanoma is most common cancer in people less than 30 years
* Indoor tanning increases risk of melanoma by 75% when started before age 35
* 2.5 times more likely to develop than squamous cell
* 1.5 times more likely to develop than basal cell
* Goal of Healthy People 2030 is to reduce the use of indoor tanning devices
48
Pressure Ulcers
* 70% of pressure ulcers (PU) occur in older adults
* A PU is a “localized injury” to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear
* Affects health and quality of life
* Considered a geriatric syndrome*
* Major cause of morbidity and mortality worldwide
* National Pressure Ulcer Advisory Panel has developed a PU registry to track the problem
49
Pressure Ulcers Characteristics
* Most frequently occur on the posterior aspects of the body, especially sacrum, heels, and greater trochanter
* May also be seen on lateral knees and ankles, pinna of the ears, occiput, elbows, and scapulae
* 25%-35% of PU are on the heels
* Persons with peripheral vascular disease at greatest risk for development of heel ulcers
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Red, purple discoloration of intact skin
Stage I PU
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Red discolored skin with open areas
Stage II PU
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excoriated, red, sanguineous tissue
Stage III PU
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ulcer showing muscle
Stage IV PU
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ulcer with black, necrotic center
Unstageable PU
55
Classification of Pressure Ulcers
* EPUAP and NPUAP (Box 13-10)
* Medical Device-Related Pressure Injury
* Mucosal Membrane Pressure Injury
* Pressure injuries are always classified by the highest stage “achieved”
* Reverse staging is never used
56
Pressure Ulcer Risk Factors
* Changes in skin
* Comorbid illnesses
* Nutrition status
* Frailty
* Surgical procedure (orthopedic/cardiac)
* Cognitive deficits
* Incontinence
* Reduced mobility
* Risks (Box 13-11)
* Consider intensity and duration of pressure and tissue tolerance
* Redness or blanching may NOT be the first sign of PU in darker pigmented persons, but may look purplish in color or look like a bruise
57
Prevention of PU
* Prevention is key
* A comprehensive PU program with multiple interventions appears to improve outcomes
* Significant interventions include addressing limited mobility, compromised skin integrity, and nutritional support
* A team approach is best when addressing this complex problem
* Position the patient every two hours
* Prevent friction and shearing when re-positioning and moving the patient
* Assess the skin often – when moving the patient, bathing, changing brief, etc.
* Use the Braden Scale
58
Head to toe skin assessment in the older adult
* Key nursing sensitive quality indicator
* Can significantly impair recovery and rehabilitation and impact quality of life
* Increased risk of mortality
* High prevalence of health care litigation
* Centers for Medicare and Medicaid consider PU a preventable adverse event and do not reimburse treatment for PU acquired during admission
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Assessment of PU
```
• Thorough assessment of skin
- Braden Scale
• Nutritional evaluation
• Laboratory studies
• Positioning
• Incontinence care
```
Wound care specialist nursing when indicated
60
Which is the most common malignant skin cancer?
Basal cell carcinoma
61
What is the #1 treatment of PU?
Prevention
62
Nutrition in the older adult
* The quality and quantity of diet are important factors in preventing, delaying onset, and managing chronic illnesses associated with aging
* Diet can affect longevity, and when combined with lifestyle changes, reduces disease risk
* About half of all American adults have one or more preventable diet-related chronic diseases, including cardiovascular disease, type 2 diabetes, and overweight and obesity
* Age-related changes affect the gastrointestinal (GI) system (Box 14-1), but are not the primary cause of inadequate nutrition in older persons
* Factors impacting nutritional needs are most likely related to:
- Chronic disease
- Lifelong eating habits
- Ethnicity
- Socialization
- Income
- Transportation
- Housing
- Mood
- Food knowledge
- Functional impairments
- Health
- Dentition
63
Age-related Nutritional Requirements
* Based on 2015-2020 Dietary Guidelines for Americans
* Choose My Plate is a guide that provides a visual depiction of daily food intake (myplate.gov)
* Older adults generally need less calories because activity decreases, and metabolic rates slow down
- Still require the same or higher amounts of nutrients
- Increase Protein for “vulnerable adults”
64
Dietary Recommendations
Fats: less than 10% of total calories, limit saturated fat and trans fatty acids
Protein: increase for older adult who tends to experience protein deficiency when ill; minimizes frailty
Fiber: 25 g fiber recommended daily (Box 14-4)
Vitamins and minerals: consumption of five servings of fruits/vegetables provides adequate A, C, E, and potassium; changes of aging contribute to decreased absorption of B12
65
Obesity (Overnutrition)
* Obesity is a global epidemic and major public health concern
* It is associated with increased costs, functional impairments, disability, chronic disease, and admission to nursing home
* More than a third of persons over 60 years are obese
66
Obesity Paradox
Some research found that persons who survived to 70 years had lower mortality rate if they were overweight
67
Malnutrition (Undernutrition)
* Rising incidence in acute care, long-term care (LTC), and in the community
* Institutionalized older adults at high risk for malnutrition due to chronic disease and functional impairments
* Increased risk of infection, pressure ulcers (PUs), anemia, hip fractures, hypotension, impaired cognition, and increased morbidity and mortality
* Can be related to inadequate consumption of micro and macro nutrients, or consequence of inflammation
* Comprehensive screening and assessment are critical to identify older adults at risk
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Factors Affecting Fulfillment of Nutritional Needs
```
• Lifelong eating habits
• Socialization
• Socioeconomic deprivation
• Transportation
• Chronic diseases and conditions
- Polypharmacy
- Inactivity
- High-fat, high-volume meals
- Inactivity
- Comorbid conditions
```
69
Chronic Conditions That Affect Nutrition
* GERD
* Diverticular disease
* Dysphagia
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A syndrome where there is damage to the mucosa from gastric contents moving backward from the stomach to the esophagus
GERD
71
GERD Risk Factors
- Hiatal hernia
- Obesity
- Cigarette smoking and second-hand smoke
72
GERD: Older adult’s atypical symptoms
o Persistent cough (GERD cough)
o Exacerbations of asthma
o Intermittent chest pain
73
Dysphagia
Difficulty Swallowing
- Prevalent in the elderly
- Aspiration, Distress, Dehydration, Malnutrition
• Can occur secondary to deficits in any of the phases of swallowing.
- Stroke
- Parkinson’s Disease
- Neurological damage (Otopharyngeal Dysphagia)
- Muscular damage
• Refer to speech language pathologist
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Nutrition screening and assessment (Box 14-14)
- Several screening tools available
- Minimum Data Set—includes risk factors and triggers for further evaluation
- Interview and physical examination
- Anthropometrical measurements
- Weight/height considerations
- Biochemical analysis/measures of visceral protein
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Nutrition Interventions
* Formulated around specific problems
* Nurses hold a pivotal role in ensuring adequate nutrition to promote healthy aging
* Collaboration with interprofessional team
* Considerations: modification of environment, supervision, feeding techniques that enhance intake and preserve dignity and independence
* Evaluate the outcome
76
Nutritional Problems in Institutional Setting: Feeding assistance
* Estimated that 50% of all residents unable to eat independently (What will you assess for…?)
* Inadequate staffing is associated with poor nutrition and hydration
* The Centers for Medicare and Medicaid Services implemented a rule that allows feeding assistance, with 8 hours of approved training
* See Box 14-15
77
Approaches to Enhancing Intake in LTC: Interventions
* Restorative dining rooms
* Consideration of ethnic food choices
* Easy access to refreshment stations with juices, water, healthy snacks, and finger foods
* Family involvement when possible
* See other best practices (Box 14-16)
* Other considerations: restrictive diets and caloric supplements, pharmacological therapy, and patient education
78
What is the estimated number of institutionalized older adults who are unable to eat independently?
50%
79
Which condition affects nutrition in the older adult?
Dysphagia
80
Hydration Management
* Water is important for thermoregulation and dilution of water-soluble medications, facilitates bowel and renal function, and maintains metabolic processes
* A significant number of older adults drink less than 1 mL of fluid/day, less than the recommended amount of 1500 mL/day
* Adequate fluid consumption and maintenance of fluid balance is essential to health
81
Age-related changes affecting hydration*
- Thirst sensation diminishes
- Creatinine clearance declines
- Total body water decreases
- Loss of muscle mass and increase in fat cells
- See Box 15-1 for more changes
(Other contributing factors include medications, functional impairment, and other comorbid conditions like diabetes)
82
Complex problem that results in reduction of total body water
*Considered a geriatric syndrome (often related to changes of aging in older adults)
Dehydration
* Majority of older people develop dehydration from increase fluid losses combined with decreased fluid intake, related to decreased thirst
* Risk factors for dehydration include emotional illness, surgery, trauma, higher physiological demands (see Box 15-4) *pg. 193
83
Significant issues associated with dehydration
```
Thromboembolic complications
Kidney stones
Constipation
Falls
Medication toxicity
Renal failure
Seizure
Electrolyte imbalance
Hyperthermia
Delayed wound healing
```
84
S/S Dehydration
* Often atypical in the older adult
* Skin turgor is not a reliable indicator in older adults
* Look for:
- dry mucous membranes in mouth and nose
- furrows on the tongue
- orthostasis
- speech incoherence
- rapid pulse
- decreased urine output
- extremity weakness
- dry axilla
- sunken eyes
85
Laboratory tests and urine (dehydration)
Labs: serum sodium, serum, and urine osmolarity, and specific gravity
Most cases of dehydration have an elevated blood urea nitrogen (BUN); however, there are many other causes for elevation of BUN/creatinine ratio
Observe urine patterns for changes
86
Dehydration Interventions
* Based on comprehensive assessment, risk identification, and hydration management
* Monitor closely and implementation of intake and output is essential
* Oral hydration is the first treatment approach
* Water is the best fluid to offer
* See Box 15-5
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Rehydration
depends on severity and type of dehydration
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IV Rehydration
Replace 50% of loss within first 12 hours or sufficient amount to relieve tachycardia and hypotension
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Hypodermoclysis rehydration
Infusion of isotonic fluids into the subcutaneous space
- Not for severe dehydration (requiring more than 3L)
90
Oral Health
* Dental health increasingly neglected with advanced age, debilitation, and limited mobility
* Poor oral health associated with dehydration, malnutrition, and other systemic diseases
* Tips for best practice: Promoting Oral Health (Box 15-6)
* Healthy People 2030
91
Mouth dryness and hyposalivation
Xerostomia
* 30% of older adults affected
* Affects eating, swallowing, speaking
* More than 400 medications cause hyposalivation
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Xerostomia Treatment
- Review medications
- Good oral hygiene
- Adequate water
- Avoid alcohol and caffeine
- OTC oral saliva substitutes
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Oral Cancers
* Occur more frequently later in life
* Occur more frequently in men than women
* Early detection essential as 60% of cases aren’t diagnosed until Stage 4
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Oral Cancer Risk Factors (Box 15-7)
- Tobacco use (esp. chewing tobacco)
- Alcohol use
- HPV (human papillomavirus) infection
- Genetic susceptibility
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Assessment of Oral Health
* Physical examination of oral cavity and oral health
* Federal regulations mandate annual examination for LTC residents
* Oral health instrument: The Kayser-Jones Brief Oral Health Status Examination (BOHSE)
96
Interventions for Oral Health
* Promote oral health through teaching persons and caregivers recommended interventions, screening for oral disease, making dental referrals
* Provide supervision and evaluation of oral care in hospitals and LTC facilities
* Box 15-10
97
Dentures
* Patient and/or caregiver education of proper cleaning techniques
* Tips for best practices: Denture Care (Box 15-12)
* Damaged and ill-fitting dentures are a common problem
* Only 13% of persons with dentures get an annual dental examination
* Box 15-11
98
Oral hygiene in hospitals and LTC
* Lack of attention to oral hygiene contributes to poor nutrition and negative outcomes
* Cleaning teeth with a toothbrush after meals lowers risk of aspiration pneumonia
* Crucial in prevention ventilator-associated pneumonia
* LTC residents vulnerable secondary to cognitive impairment and dependency on staff to provide good oral care
99
Tube feedings and oral hygiene
* Tube feedings are associated with significant pathological colonization in the mouth
* Provide oral care twice a day for persons with gastrostomy tubes and brush teeth after each feeding
* Only toothbrushes assist in the removal of plaque; use foam swabs to clean mouth of edentulous
100
Which is NOT an age-related change that affects hydration?
a. ) Thirst sensation diminishes
b. ) Creatinine clearance declines
c. ) Total body water decreases
d. ) Loss of fat cells and increase in muscle mass
d. Loss of fat cells and increase in muscle mass
101
Signs and symptoms of dehydration in an older adult include all the following except:
a. ) dry mucous membranes in mouth and nose.
b. ) decreased skin turgor.
c. ) dry axilla.
d. ) speech incoherence.
b. decreased skin turgor.
102
Elimination Problems
* Can be severe enough to interfere with ability to continue independent living and threaten body’s capacity to function and survive
* Can threaten a person’s independence and well-being
* Nurses are in a key position to implement evidence-based assessment and interventions to enhance continence and improve function, independence, and quality of life
103
Age-Related Changes in the Renal and Urological System
* Age-related loss of nephrons, kidney mass, and ability to concentrate urine generally lead to little change in the body’s ability to maintain adequate fluid homeostasis
* Renal disease or urinary tract obstruction can amplify age-related decline in function
* Urinary incontinence (UI) and frequency should never be considered a normal part of aging – However, it is often found r/t other issues.
104
Urinary Incontinence
* UI is a stigmatized, underreported, underdiagnosed, and undertreated condition that is not a normal part of aging
* Individuals may not seek treatment because they may be embarrassed or think it is normal
* UI is an important but neglected geriatric syndrome
* Viewed as an inconvenience instead of a treatable condition
* Nurses must take the lead in implementing approaches to continence promotion and public health education
105
UI facts and figures
* Public health problem affecting millions of adults worldwide
* Over 25 million Americans live with bladder leakage
* More common in women and peaks at menopause, and steady increase in aging men
* More prevalent than diabetes and Alzheimer’s disease
* More expensive than diabetes
106
UI Risk factors
* Many risk factors are associated with changes in aging
* See Box 16-4: Risk factors for UI
* Dementia is a high-risk factor for UI because a person may not be able to find the bathroom or recognize the urge to void
* Drugs that increase urine output, sedatives, tranquilizers, hypnotics that produce drowsiness, confusion, or limited mobility promote incontinence by dulling the transmission or desire to urinate
107
Consequences of UI
* Affects quality of life and has physical, psychosocial, and economic consequences
* Associated with increased risk for falls, fractures, and hospitalization
* Affects self-esteem and increases risk for depression, anxiety, dignity, autonomy, social isolation, skin breakdown, and sexual activity
* Increases the risk for admission to the nursing home in those over 65 years of age
* Psychosocial impact affects the person and his or her family caregivers
108
Types of UI
• Classified as either transient (acute) or established (chronic)
See Table 16-1
109
has a sudden onset, present 6 months or less, and is usually caused by treatable factors, like urinary tract infection (UTI), delirium, constipation, stool impaction, or increased urine production
Transient UI
110
UI may have sudden or gradual onset and is categorized as: (1) stress, (2) urge, (3) overflow, (4) functional, (5) mixed
Established UI
111
UI Assessment
* UI should routinely be addressed on the initial assessment
* 80% of incontinence can be cured or treated to minimize detrimental affects
* Nurses play a key role in identification of UI
* Assessment is multidimensional and includes continence patterns, alterations, and contributing factors
* See Boxes 16-6 and 16-7 for continence assessment
112
UI Interventions
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• Treatment choices (Box 16-8)
• Lifestyle
• Environmental
• Behavioral
- Scheduled voiding
- Pelvic floor muscle exercises
- Habit/bladder retraining
- Prompted voiding
```
113
Continence Programs in LTC Settings
* Are required by Centers for Medicare and Medicaid regulations
* Monitoring and documentation of continence status related to implemented continence care is a quality indicator in nursing homes
* Barriers to implementation and continuation of toileting programs include inadequate staffing, lack of knowledge about UI and existing evidence-based protocols, and insufficient professional staff
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Usually used for weak detrusor muscle, blockage of urethra, reflux incontinence
Intermittent catheterization
115
- Long-term use increases risk of recurrent UTIs
| - Those with more care needs, cognitive impairment, and pressure injuries are at higher risk of catheter placement
Indwelling catheter
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"condom catheters" used for male patients
external catheter
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Urinary Incontinence Management: Absorbent products
Protective undergarments or briefs
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Urinary Incontinence Management: Pharmacological interventions
- NOT considered first-line treatment
- anticholinergics
- antimuscarinics
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Urinary Incontinence Management: Surgical interventions
- *Indicated for stress incontinence
| - Most common procedure colposuspension and "slings"
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Urinary Incontinence Management: Nonsurgical devices
intravaginal or intraurethral devices to relieve stress
121
Most common cause of bacterial sepsis in older adults (10x more common in women)
Urinary Tract Infections
* Assessment and appropriate treatment of UTIs in older people, particularly in the nursing home, is complex
* Persons may be cognitively impaired or do not present with classic symptoms
* The diagnosis of symptomatic UTI is based on clinical features and laboratory evidence
* Tips for Best Practice (Figure 16-11)
122
Bowel Elimination
* Bowel function is only slightly altered by physiological changes of aging, but can be a source of concern and potentially serious
* Normal elimination should be easy passage of feces, without undue straining or a feeling of incomplete evacuation or defecation
123
Constipation
* Defined as the reduction in the frequency of stool or difficulty in formation or passage of stool
* The Rome Criteria outlines operational definitions of constipation and guide to diagnosis
* Associated with impaired quality of life, significant health care costs, large economic burden, and can lead to serious consequences
* It is a symptom, not a disease
124
Fecal Impaction
* More commonly seen in institutionalized older adults who require narcotic medications for chronic pain
* Unrecognized, unattended, or neglected constipation eventually leads to fecal impaction
* Removal of fecal impaction is at times worse than the misery of the condition
* Management requires digital removal of the hard, compacted stool from the rectum with lubrication containing lidocaine jelly
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Constipation Assessment
* It is important to obtain a bowel history including usual patterns, frequency, size, consistency, any changes, and occurrence of straining and hard stools
* The precipitants and causes of constipation must be included in the evaluation
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Constipation Interventions
* Table 16.2
* Nonpharmacological interventions
* Physical activity
* Positioning
* Toileting regimen
* Pharmacological interventions
* Enemas
* Alternative treatments
127
Involuntary loss of liquid or solid stool that is a social and hygienic problem
Fecal Incontinence
* Higher prevalence rates are found in persons with diabetes, irritable bowel syndrome, stroke, multiple sclerosis, spinal cord injury
* Also associated with UI
* Devastating social ramifications for persons and families
* Skin breakdown
128
Fecal Incontinence Assessment
* The term accidental bowel leakage is preferred over fecal incontinence
* Assessment should include complete client history as in UI and investigation into stool consistency and frequency, use of laxatives or enemas, surgical and obstetric history, medications, effects of incontinence on quality of life, focused physical examination with attention to the gastrointestinal system, and a bowel record
129
Fecal Incontinence Interventions
* Environmental manipulations (accessible toilet)
* Dietary alterations
* Habit-training schedule
* Pelvic floor muscle exercises
* Improving transfer and ambulation ability
* Sphincter training exercises
* Biofeedback
* Medications
* Surgical intervention
130
Which is a risk factor for UI?
a. High caffeine intake
b. Smoking
c. Estrogen deficiency
d. All of the above
d. All of the above
131
Which persons have the highest risk for fecal incontinence?
a. Persons living in the community
b. Persons residing in nursing homes
c. Persons in the hospital
d. Persons that are younger in age
b. Persons residing in nursing homes
132
Sleep
• Occupies a third of our lives
- is a vital function that affects cognition and performance
• Sleep is a barometer of health
- sleep assessment and interventions for sleep concerns should receive as much attention as other vital signs
• Insufficient sleep is a public health epidemic
- the Centers for Disease Control and Prevention has called for continued public health surveillance of sleep quality, duration, behaviors, and disorders to monitor for sleep difficulties and their health impact
• Increased attention in recent years.
133
the most important biorhythm
circadian sleep-wake rhythm
134
natural circadian rhythm and aging
* As people age, the natural circadian rhythm may become less responsive to external stimuli, such as changes in light during the course of the day
* Endogenous changes in the production of melatonin are diminished, resulting in less sleep efficacy
135
the body progresses through ____ normal sleep patterns consisting of ___ and non-rapid eye movement sleep
5
rapid eye movement (REM)
box 17.1
136
age-related sleep changes
box 17-2
137
sleep complaints
linked to other health problems and sleep disorders
138
most common sleep disorder worldwide
insomnia
139
insomnia
* Most common sleep disorder worldwide
* Interferes with sleep quality and quantity and is associated with subjective complaints of sleep characterized by:
- Sleep initiation
- Sleep duration
- Sleep consolidation
- Sleep quality
• Risk factors for sleep disturbance (Box 17-3)
140
Insomnia and Alzheimer’s disease (AD)
* About three-quarters of individuals with dementia experience sleep dysregulation
* Caregivers also experience poor sleep quality, leading to stress and health problems
* Sleep disruption is associated with increased neuropsychiatric symptoms, functional decline, morbidity, and mortality
141
Restless legs syndrome/Willis Ekbom disease
Neurological movement disorder of the legs
- Diagnosis is based on a sleep study
142
REM sleep behavior disorder
Loss of normal voluntary muscle atonia during REM sleep, associated with complex behavior while dreaming
143
Circadian rhythm sleep disorder
Relatively normal sleep occurs at abnormal times
144
Promoting Healthy Aging: Implications for Gerontological Nursing
Assessment (Sleep)
* Nurses are in an excellent position to assess sleep and suggest interventions to improve the quality of the older person’s sleep
* Assessment for sleep disorders and contributing factors to poor sleep (pain, chronic illness, medications, alcohol use, depression, anxiety) are important
* Complete assessment data (Box 17-5)
* Sleep diary (Box 17-6)
145
Sleep Interventions: Nonpharmacological Treatment
- Directed at identifiable cause
- Considered first-line treatment for insomnia
- Nonpharmacologic interventions (Box 17-8)
- Sleep habits
- Relaxation techniques
- CCBT
- Tai chi/quigong
146
Sleep in hospitals and nursing homes
- 22%-61% of hospitalized patients experience impaired sleep
| - Suggestions to promote sleep in the hospital or nursing home (Box 17-9)
147
Sleep Interventions: Pharmacological Treatment
- Use of over-the-counter sleep aids and prescription sedatives and hypnotic medications is increasing in the United States
- Benzodiazepines are one of the most abused drugs, along with opiates, in the older population
- Benzodiazepines or other sedative hypnotics should not be used in older adults as a first choice of treatment for insomnia
- Pharmacological interventions and behavioral interventions should be used together
148
Sleep Disordered Breathing and Sleep Apnea
- Affects approximately 25% of older adults with obstructive sleep apnea (OSA) being the most common form.
- Untreated OSA is related to heart failure, cardiac dysrhythmias, stroke, type 2 diabetes, osteoporosis, and even death
- Age-related decline in the activity of the upper airway muscles, resulting in compromised pharyngeal patency, predisposes older adults to OSA
- Risk factors for OSA (Box 17-12)
149
Sleep Assessment
- The individual may present with complaints of insomnia or daytime sleepiness, and assessment should include assessment of insomnia complaints
- If OSA is suspected, a referral for a sleep study should be made
- Recognition of OSA in older adults may be more difficult because they may not have a sleeping partner
150
Sleep Interventions
- Therapy depends on the severity and type of sleep apnea, as well as the presence of comorbid illness
- Continuous positive airway pressure is recommended as initial therapy
- Teaching should include the effects of untreated OSA and emphasize the need for treatment
151
What is the most common sleep disorder?
a. OSA insomnia
b. Restless leg syndrome
c. Insomnia
d. Circadian rhythm sleep disorders
c. Insomnia
152
Untreated OSA can lead to all of the following, EXCEPT:
a. heart disease.
b. cardiac dysrhythmias.
c. stroke.
d. type 2 diabetes.
a. heart disease
153
Physical Activity and Aging
* Regular physical activity throughout life is essential for healthy aging
* Enhances health and functional status while decreasing the number of chronic illnesses and functional limitations
* A protective factor for depression
* Health benefits of physical activity (Box 18-1)
* Only 16% of older adults exercise regularly
* Physical inactivity is identified as a leading risk factor for global mortality (hypertension, smoking, high blood glucose level, physical inactivity, obesity)
* Even a small amount of physical activity, at least 30 minutes of moderate activity several days a week, can improve health
154
Activity Assessment
* Assessment of function and mobility are components of a health assessment for older adults
* Exercise counseling should be provided as part of the assessment
* Frail individuals will need more comprehensive assessment to adapt exercise recommendations to their abilities to ensure benefit without compromising safety
155
Activity Screenings/Interventions
* CDC “Growing Stronger” program
* Older adults are less likely to receive exercise counseling from their primary care providers than younger individuals
* Nurses can design and lead exercise and physical activity programs for groups of older adults in the community or in long-term care
156
Physical Activity Guidelines
* Guidelines for physical activity for adults 65 years of age or older who are generally fit and have no limiting health conditions are presented in Box 18-5
* Guidelines for teaching about exercise (Table 18-1)
157
Incorporating Physical Activity into Lifestyle
* Doesn’t require expensive equipment
* Benefits of group exercise in terms of social and emotional health have been reported
* Muscle strengthening exercises without weight bearing provide joint stability
* Swimming is a low-risk activity that provides aerobic benefit, and water-based exercises are particularly beneficial for individuals with arthritis or other mobility limitations
* Tips for adoption of physical activity (Box 18-5)
158
Special Considerations for Activity
* The benefits of physical activity extend to the more physically frail older adult, those who are nonambulatory, experience cognitive impairment, and those residing in assisted living facilities or skilled nursing facilities
* Research suggests that older adults with cognitive impairment who participate in exercise programs may improve strength and endurance, cognitive function, and ability to perform activities of daily living
159
Maintaining Function in Acute Care Settings
* There is a growing awareness of the need to focus on hospitalized older adults
* Hospitalization is associated with significantly greater loss of total, lean, and fat mass strength in older persons
* A baseline assessment of functional ability is important and can assist in setting appropriate goals for hospitalized individuals
* The plan of care should include interventions to maintain or improve function for all acutely ill older adults
160
Function-Focused Care (FFC)
* Comprehensive, systems-level approach that prioritizes the preservation and restoration of functional capacity
* A philosophy of care in which nurses acknowledge older adults’ physical activities and cognitive capabilities with regard to function and integrate functional and physical activities into all care interactions
* Tips for FFC in acute care (Box 18-8)
161
How much time should be devoted to moderate activity in order to improve health? (Box 18-7)
a. 30 minutes three times a week
b. 60 minutes daily
c. 45 minutes two times a week
d. 30 minutes daily 5 times a week
d. 30 minutes daily 5x/week
162
In order to effectively incorporate physical activity into lifestyle, a person:
a. doesn’t need expensive gym equipment.
b. incorporates muscle strengthening exercises without weight bearing.
c. considers group exercise for its social and emotional health benefits.
d. all of the above.
d. all of the above
163
Mobility and Aging
* Mobility is intimately linked to health status and quality of life
* Mobility and comparative degrees of agility are based on muscle strength, flexibility, postural stability, vibratory sensation, cognition, and perceptions of stability
* Gait and mobility impairments are not an inevitable consequence of aging, but often a result of chronic disease or trauma
* Impairment of mobility is an early predictor of physical disability and associated with poor outcomes such as falling, loss of independence, depression, decreased quality of life, institutionalization, and death
* Maintenance of mobility and function is an essential component of best practice gerontological nursing and is effective in preventing falls, unnecessary decline, and loss of independence
164
One of the most important geriatric syndromes and the leading cause of morbidity and mortality for older people
Falls
* Leading cause of both fatal and nonfatal injuries
* Most falls may be preventable
* Falls are a significant public health problem
* A key nursing quality indicator
* Education on falls and fall risk reduction is an important consideration in the Quality and Safety Education for Nurses safety competency
165
Consequences of Falls
Hip fractures
- 95% of hip fractures are caused by falls
- Hip fractures are associated with considerable morbidity and mortality
Traumatic brain injury (TBI)
- Persons over the age of 75 years have the highest rates of TBI-related hospitalization and death
- Falls are the leading cause of TBI for older adults
- Signs and symptoms of TBI (Box 19-2)
Fallophobia
- Fear of falling is an important predictor of general functional decline and risk factor for future falls
166
Fall Risk Factors
* Falls are a symptom of a problem and are rarely benign in older people
* Seven types of fall classifications (Box 19-3)
* A history of falls is an important risk factor and individuals who have fallen have three times the risk of falling again
* Individual risk factors can be intrinsic or extrinsic (Box 19-4)
* Gait disturbances
- Affect 10%-60% of people older than 65 years
- Are not a normal consequence of aging alone, but most likely indicative of underlying pathological condition
• Foot deformities
- Falls were reduced in those with disabling foot pain who received enhanced podiatry care
- Most adults over age 65 have some form of altered foot integrity
167
Promoting Healthy Aging: Foot assessment
* Nursing care should be directed toward optimal comfort and function, removing possible mechanical irritants, and decreasing likelihood of infection
* The nurse has the important function of assessing the feet for clues of functional ability and their owner’s well-being
* Foot assessment (Box 19-5)
168
Orthostatic and postprandial hypotension
* The detection of orthostatic hypotension (OH) (decrease: 20mm/10mm +) is of clinical importance to falls prevention since OH is treatable
* OH, coupled with syncope has been found to be predictive of falls
* Measuring orthostatic BP (Box 19-7)
* Care of resident with OH (Box 19-8)
* Postprandial hypotension occurs after the ingestion of a carbohydrate meal and may be related to release of vasodilatory peptide
• Cognitive impairment
- Older adults with cognitive impairment, such as dementia or delirium, are at increased risk for falls
• Vision and hearing
- Poor visual acuity, reduced contrast sensitivity, decreased visual field, cataracts, and use of nonmitotic glaucoma medications have all been associated with falls
• Medications
- Medications implicated in fall risk include those that cause drowsiness, mental confusion, problems with balance or loss of urinary control, and sudden drops in blood pressure when standing
169
Fall Screening and Assessment
* Fall risk assessment should be an integral part of primary health care for the older adult
* The intensity of the assessment will vary with the target population
- Low-risk community-dwelling individuals
- Those who report a single fall
- High-risk populations
170
Screening and assessment hospital/long-term care (LTC)
* Individuals admitted to acute care or LTC should have an initial assessment on admission, after any change in condition, and at regular intervals during their stay
* Assessment is an ongoing process that includes multiple and continual types of assessment, reassessment, and evaluation following a fall or intervention to reduce risk
171
Fall Risk Assessment Instruments
* Fall risk assessment instruments are commonly included in fall prevention interventions
* The National Center for Patient Safety recommends the Morse Fall Scale, except for LTC
* The Hartford Foundation for Geriatric Nursing recommends the Hendrich II Fall Risk Model, which has been validated with skilled nursing and rehabilitation populations
172
Post-Fall Assessment
* Determination of why a fall occurred is vital and provides information on underlying fall etiologies so that appropriate plans of care can be instituted
* The purpose of the postfall assessment is to identify the clinical status of the person, verify and treat injuries, identify underlying causes, and assist with risk reduction interventions
* Components of a postfall assessment include fall-focused history, fall circumstances, medical problems, medication review, mobility assessment, vision and hearing assessment, neurological examination, and cardiovascular examination
173
Fall Interventions
* Fall risk reduction programs (Box 19-11)
* ACE
* NICHE
* GRN
* HELP
* Vision screening
* Medication reduction
* CV assessment
* Hip protectors/assistive devices
* Education
174
Environmental Modifications (Falls)
* CDC fall prevention checklist
* Assistive devices
* Safe patient handling
* Wheelchairs
* Osteoporosis treatment/Vitamin D supplementation
* Hip protectors
* Alarms/motion sensors/staff observation
175
Consequences of restraints
* Physical restraints may exacerbate many of the problems they are used for and can cause serious injury and death, as well as emotional and physical problems
* The most common mechanism of restraint-related death is asphyxiation
* Use of restraints is a great source of physical and psychological distress to older adults and may intensify agitation and contribute to depression
176
Side Rails (restraints)
* Side rails are now defined as restraints or restrictive devices when used to impede a person’s ability to voluntarily get out of bed and the person cannot lower them by him or herself
* No evidence that side rails decrease the risk or rate of fall occurrence
177
Restraint-Free Care
* Is now a standard of practice and an indicator of quality care in all health care settings, although the transition to the standard of care is still in progress
* Tips for dealing with tubes, lines, and other medical devices (Box 19-17)
* Alternative strategies to restraints (Box 19-19)
178
Risk factors for falls include:
a. OH (orthostatic hypotension)
b. cognitive impairment.
c. vision and hearing problems.
d. foot deformities.
e. all of the above.
e. all of the above
179
The use of restraints can lead to:
a. death.
b. depression.
c. exacerbation of agitation.
d. asphyxiation.
e. all of the above.
e. all of the above
180
Acute Illness
Occurs suddenly and often without warning
| Stroke, myocardial infarction, hip fracture, infection
181
Chronic Illness
- Persists regardless of treatment, is of long duration, and usually progresses slowly
- Managed rather than cured
- Always present but not always visible
- Chronic diseases are not always obvious and may not interfere with the person’s day-to-day life until late in the disease, but are nonetheless present and require ongoing treatment
- The most common chronic diseases are heart disease, cancer, diabetes, obesity, and osteoarthritis
- In older adults, a chronic disease may not be diagnosed until some amount of “end organ damage” has already occurred.
- Many chronic diseases could be eliminated through preventative strategies, especially when started at a young age
```
- Major global lifestyle risk factors for the development of chronic disease
(Box 21-1)
Tobacco use
Unhealthy diet
Physical inactivity
Alcohol abuse
```
182
Chronic Diseases
```
Hypertension
High Cholesterol
Arthritis
Heart Disease
Heart Failure
Diabetes
Chronic Kidney Disease
Depression
Alzheimer’s Disease/Dementia
Chronic Obstructive Pulmonary Disease
```
183
Preventative Phase (pre-trajectory)
at risk for developing the disease (primary prevention)
184
Definitive Phase (trajectory onset)
onset of symptoms and/or disability
185
Stable Phase
being managed adequately (e.g., medication keeping it under control)
186
Unstable Phase
exacerbation of disease
187
Acute Phase
sudden onset of symptoms and complications (possible hospitalization)
188
Comeback Phase
may or may not happen; recovery after acute phase
189
Crisis Phase
critical or life-threatening (e.g., heart attack - need treatment)
190
Downward Phase
condition/symptoms worsening, damage is building, disability increases (management not working)
191
Dying Phase
can be rapid or gradual onset, ending in death
192
Frailty
* multidimensional symptom
- Associations between age and chronic disease and the development of frailty remains in question
```
- The formal diagnosis is made in the presence of at least three of the following: (select all four on the exam)
Unintentional weight loss
Self-reported exhaustion
Weak grip strength
Slow walking speed and low activity
```
- Tips for assessing frailty (Box 21-3)
- Frailty is “a multidimensional syndrome characterized by decreased reserves and diminished resistance to stressors”
- The frailer, the faster one proceeds along the Chronic Illness Trajectory, the less likely one can move backward toward stability, and the greater the risk for death at any time the person becomes unstable.
- Tips for managing frailty (Box 21-4)
193
Frailty is diagnosed in the presence of at least three of the following (select all four on exam)
- Unintentional weight loss
- Self-reported exhaustion
- Weak grip strength
- Slow walking speed and low activity
194
the most common CV chronic condition in people over 65
Hypertension
- Treatment goal in the >60 age group is a SBP <150 and DBP <90
- therapeutic lifestyle changes (table 22-3)
195
the most common cause for hospitalizations, re-hospitalization, and disability in people over 65
Heart Failure (damage from HTN)
- Insufficient oxygen delivery
- Left side - pump failure to body
- Right side - pump failure to lungs
- CHF - pulmonary edema (crackles) = must remove fluid
- Ascites - generally > 25 mL in the peritoneal cavity
196
HF Interventions
* Activity/Exercise
* Medications
* Sodium Restriction
* Supplemental Oxygen
* Daily Weights
* May restrict fluid
197
Arterial Insufficiency
PAD
* Inflow
* Pain worse with use
* Pain improves with rest
* Numbness/tingling
* Cool and pale when elevated
* Blood cannot get to feet
198
Venous Insufficiency
CVI
* Outflow
* Pain worse with immobility
* Pain improves with elevation
* Warm, dark, red, purple skin
* Dull gray in darker pigmented persons
* Blood pools in feet
199
Cardiovascular Interventions
Assessment of All risk factors and existing diseases
Lifestyle changes
Medication and Education tailored to specific disease process
- Referral for financial assistance w/medications if needed
Focus:
- Symptom Management
- Prevention of exacerbation
200
Parkinson's disease
- Dopamine is lost or inhibited
- Onset at approximately 60 y/o
- Progressive over 10 to 20 years
- There is no definitive diagnosis, so they look for 2/3 of the following symptoms: muscle rigidity, stiffness, slowness of movement (?)
- Considered a terminal diagnosis (because they will live with it until they die)
201
primary Parkinsonism
known cause or r/t secondary effect of another disorder
202
idiopathic Parkinsonism
cause unknown or unidentified
203
Classic triad of Parkinson's
1. Cogwheel Rigidity
- arms, legs, neck affected
- small jerking movements when affected muscles stretched
- muscle rigidity
2. Bradykinesia/Dyskinesia
- all skeletal muscles affected
- difficulty starting, continuing, and/or coordinating movement
- shuffling
- may become frozen (Akinesia) - absence or poverty of movement
3. Resting/Non-intention tremors
- hands, feet, neck, face, lips, tongue, jaw most affected
- fine, rhythmic, purposeless tremors (disappear with sleep and purposeful movements)
- pill rolling, small handwriting, low monotone voice
- Complications: falls, fractures, impaired communication, and social isolation
204
Parkinson's Interventions
- There is no cure
- Treatment focus is on replacing, mimicking, or slowing down the breakdown of dopamine
- Levodopa (L-dopa) is the first-line treatment
- Client Education
Weeks to months to take effect
Watch protein intake
High protein decreases function of meds
205
Parkinson's Nursing Interventions
* Preservation of functional ability and quality of life
* Increased independence and ADLs
* Prevent complications and excess disability
* Coping mechanisms
* Increased socialization
* Increase strength and ROM
* Teach Exercises
- Lift toes when walking
- Widen legs while walking
- Small steps while looking forward
- Swing arms with walking to improve balance and ROM
- Carry bag to counterbalance is necessary
- Facial exercises
- Read aloud
206
Thyroid Physiology
Controls metabolic rate, oxygen consumption, and energy production.
- Influences physical/mental growth, nervous system activity, fluid/electrolyte balance, reproduction, requirements for vitamins, and resistance to infection
- Thyroid stimulating hormone (TSH)
• Released from pituitary
• Monitor treatment effectiveness
207
Thyroid fails to produce adequate TH> low T3 & T4> hypothalamus & pituitary create and release more TSH> possible period of compensation
Hypothyroidism
- slowing in physical and mental activity
208
hypothyroidism s/s
- cold intolerance
- puffiness
- decreased sweating
- coarse hair and skin
- fatigue
- low HR, BP, & CO
- weight gain
- constipation
- infertility
- elevated LDL
- low HDL (arteriosclerosis)
- possible goiter
209
hypothyroidism treatment
Thyroid replacement therapy
- levothyroxine (Synthroid) – watch for heart palpitations/dysrhythmias* (take in the am before breakfast)
210
Increased circulating thyroid hormones (TH)>metabolic rate increases>heightened sympathetic nervous system
Hyperthyroidism
211
hyperthyroidism s/s
- goiter
- exophthalmos (with Grave’s)
- insomnia
- tremors
- oligo to amenorrhea
- HTN
- tachycardia
- A-Fib
- fine and thin hair
- moist and flushed skin
- weight loss
- fluid volume deficit
- bulging eyes
212
hyperthyroidism treatment
Thyroidectomy (surgical removal of part or all of thyroid)
Antithyroid agents
- methimazole (Tapazole)
213
Bones and aging
- When aging, bone renewal cannot keep pace with resorption, reduced bone mineral density (BMD) results, and bones become brittle and fracture more easily
- Reduced BMD is four times more common in older women than men
- Women may lose up to 50% of cortical bone mass by the time of 70 years old
- Factors affecting degree of bone loss
- Excessive loss of BMD leads to osteopenia or OP
214
Joints, Tendons, and Ligaments (Aging)
Age-related deterioration in articular cartilage results from biochemical changes
As joints dry, movement is less fluid, and pain may result if changes progress to the extent where bone rubs on bone
215
Sarcopenia
changes in the skeletal muscle that occurs with aging
- The bulk and strength of skeletal muscle decline each year after the age of 50
- Accelerated loss occurs with disuse and deconditioning
216
most common metabolic bone disease, characterized by bone fragility
results from the gradual loss of cortical and trabecular bone and microarchitectural deterioration
osteoporosis
217
those at highest risk for osteoporosis
postmenopausal caucasian women
218
osteoporosis diagnosis
following a fragility fracture (resulting from forces that would not normally cause a fracture) or through the results of a DEXA scan of the femoral neck and spine
219
primary osteoporosis
likely a normal change of aging, particularly in postmenopausal women who do not take hormone replacement therapy
220
secondary osteoporosis
occurs in up to 30% of women and 50% of men
221
osteoporosis s/s
loss of height more than 3 cm from kyphosis
back pain
222
exercise for osteoporosis
weight-baring, low impact exercise (e.g., walking)
223
osteoarthritis complications
- the most serious consequence is the morbidity and mortality resulting from an OP-related fall
- most common sites for fractures are hips, vertebra, wrist, and pelvis
- hip fractures lead to a high degree of morbidity and premature mortality
224
a biomechanics process affecting the entire joint; cartilaginous lining becomes thin and damaged
osteoarthritis
joint space narrows, bone rubs together, and joint deteriorates
225
joints most commonly affected in osteoarthritis
knees, hips, hands, knees, and spine
226
causes of osteoarthritis
the specific cause is unknown, however, it is believed to be a combination of mechanical forces and molecular events in the affected joint
227
risk factors for osteoarthritis (box 26-3)
Modifiable:
- obesity (esp. in the knee and hips)
- joint injury
- knee pain
- occupation requiring excessive or repeated mechanical stress
- muscle weakness
Nonmodifiable:
- female
- age (beginning ~50 and increases until ~75)
- race (asian American/Pacific Islander with lowest risk)
- familial predisposition
228
osteoarthritis s/s
Classic OA: stiffness with inactivity, pain with activity relieved with rest
stiffness worse in the morning (works out within 20-30 min), pain worse at night (after activity)
on exam: subluxation, joint stability, and swelling may be found, and crepitus is common
as it advances: spinal stenosis develops in the lumbar region and osteophytes develop in the joints of the fingers
229
osteoarthritis complications
- complications are limited to the effect of the degenerative changes on function and quality of life, and side effects of the treatments related to pain
- advanced disease of the knees (most common) and hips, replacements are available and in many cases are very successful
- advanced of the spine: often require the support of pain center
230
ESR & CRP in OA
normal limits
231
ESR & CRP in RA
elevated levels
232
a systemic inflammatory autoimmune disorder affecting primarily the joints
causes bilateral pain, swelling, stiffness, and loss of function
rheumatoid arthritis
inflammation of the synovium causes destruction of the surrounding cartilage and bone
233
RA diagnosis
types and number of joints involved (must include one small joint)
select serological testing
presence of symptoms for >6weeks
- rapid diagnosis is necessary so treatment can begin as early as possible (greatest change joints can be preserved)
234
RA - one episode lasting 3-5 years
monocyclic
235
RA - intensity of symptoms varies over time
polycyclic
236
RA- increase in severity and present all the time
progressive
237
RA s/s
- affects the joints and the system as a whole: pain, fatigue, malaise, weakness, and fever may be present
- characterized by symmetrical polyarticular limitations affecting 5 or more joints
- usually affects the small joints of the wrist, ankle, and hand (although can also affect large joints like the knee)
- tender, warm, swollen joints
238
RA is characterized by
symmetrical polyarticular limitations affecting 5 or more joints
239
RA complications
- are largely a consequence of orthopedic deformities and pain
- joint deformities
- persons with RA are most likely to die CV disease and at a higher rate than the general population
240
most common deformity in RA
boutonniere deformity or hyperextension of the distal interphalangeal (DIP) joint with flexion of the proximal interphalangeal (PIP) joint
(look at pictures + ulnar drift)
241
an inflammatory (rheumatic) arthritis characterized by the deposition of uric acid crystals in the tissues and fluid in the body (uric acid: Na, crystalizes)
Gout
- Either a one-time acute illness or becoming chronic, with intermittent (and unpredictable) acute attacks
242
most typically affected joint in gout
the joint in the great toe
may also occur in the ankle, knee, wrist, or elbow
243
most affected by gout (men/women)
men
244
gout s/s
* Person complains of intense pain in the affected joint or joints, often awakening one from sleep
* Joint is bright red, hot, and too painful to touch
* The pain of gout may be very responsive to oral anti-inflammatories, such as nonsteroidal anti-inflammatory drugs (NSAIDS) and a short course of steroids or colchicine
245
gout complications
* With prolonged elevations of uric acid, it crystallizes, forming insoluble precipitates that gather in subcutaneous tissue
* They are seen as small, white tophi that may be quite painful
* Can collect in the kidneys and form urate renal stones and cause renal failure
246
OP: education and preventative strategies
- Nutrition (Calcium, Vit D)
| - Exercise, lower sodium diet
247
goals in OA and RA
minimize disability by preventing further damage
assuring adequate pain relief (box 26.8)
- nonpharmalogical approaches
- surgery
- pharmacological
248
first goal of treatment in an acute attack of gout
stop it as soon as possible
- may include NSAIDs, colchicine, and sometimes injections of long-acting steroids into the joint
249
goals after acute attack of gout
Prevent another attack, systemic spread of the disease, and the development of chronic gout
250
food to limit in gout
limit foods high in purine (box 26.10)
