Nursing Electives 2 CARE OF THE CHRONICALLY ILL AND THE OLDER PERSON

By: Elizabeth F. Hacias Course Credit Course Description Course Objective : : 2 units Lecture (36 hours) This course deals with the concepts, principles and techniques of nursing care management of clients with chronic illness and the older persons. : At the end of the course, and given scenarios/situations, the student should be able to: 1. Utilize the nursing process in the care of individuals with chronic illness and care of the older person. 2. Discuss special concerns, issues and trends in caring for the chronically ill and the older person.

Grading System
Class Standing : Quizzes Recitation Assignment Attitude X X X X 40% 25 % 25 % 10 % 100 %

PRELIM GRADE (PG) = 2 (Class Standing) + Prelim Exam 3 MIDTERM GRADE (MG) : Class Average (CA) = 2 (CS) + Midterm Exam 3 Midterm Grade = 2 (CA) + PG 3 FINAL GRADE (FG) : Class Average (CA) = 2 (CS) + Final Exam 3 Final Grade = 2 (CA) + Midterm Grade 3

I. TERMINOLOGIES
1. Geriatrics - the branch of medicine concerned with the diagnosis, treatment and prevention of disease in older people and the problems specific to aging. 2. Geriatric Nursing - nursing subfield which involves caring for older adults 3. Gerontology - from the Greek word geron, "old man" and logy, "study of" - the study of the social, psychological, and biological aspects of aging. 4. Aging - the organic process of growing older and showing the effects of increasing age 5. Old Age - the last period of human life, now often considered to be the years after 65. 6. Senescence - from the Latin word senex, meaning old man, old age, or advanced in age. - the process of becoming old 7. Senility - the physical and mental decline associated with old age

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8. Chronic Illness - An illness that persists for 3 months or more II. The Adult A. Early Adult 17yrs to 40 / 45 yrs. B. Middle Adult 40 / 45 yrs. to 60 / 65 yrs. C. Late Adult 60 / 65 yrs. and above Koziers Divisions of Old Age: Young-old - 65 to 74 Mid-old - 75 to 84 Old-old - 80 to 85 and older WHOs Division of Old Age: Elderly - 65 to 75 Old - 76 to 90 Very Old - 90 and above

Daniel Levinsons Four Eras of Life (each lasting approximately twenty-five years) I. Childhood and adolescence: birth to 20 II. Early adulthood: 17- 45 - establishes a distinction between the me and not-me; - beginning of a more independent, responsible adult life that includes sexual maturity A. Early adult transition: 17- 22 - seeks independence by separating from family B. Entering the adult world: 22 - 28 - experiments with different careers & lifestyles C. Age thirty transition: 28 - 33 - makes lifestyle adjustments D. Settling down: 33 - 40 - experiences greater stability III. Middle adulthood: 40 - 65 A. Midlife transition: 40 - 45 - neglected parts of self seek expression; aware of death B. Entering middle adulthood: 45 - 50 - choices are made; commit to new tasks C. Age fifty transition: 50 - 55 - evaluate the entire life structure D. Culmination of middle adulthood: 55 - 60 - opportunity to prepare self in order to carry out main objectives for the coming era. IV. Late adulthood: 60+ - spends time reflecting on past achievements & regrets; - makes peace with self and others Late adult transition: 60 65 - need to reduce the level of responsibility ; - less authority and power which needs getting used to. Stephen Jay Goulds Seven Stages of Adult Development (Believes that transformation is a central theme during adulthood) want to separate from their family feel they could be pulled back into their family autonomous but still feel the need to prove themselves to their parents marriage & careers are well established; no longer feel necessary to prove self period of self reflection; see time as finite, with little time left to shape lives of children interested in social activities with friends & spouse & desire both sympathy & affection from spouse period of transformation, with a realization of mortality & a concern for health;

16 to 18 18 to 22 22 to 28 28 to 35 35 to 43 43 to 50 50 to 60

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increase in warmth & decrease in negativism Robert Pecks Theory on Adult Development (Believes that although physical capabilities & functions decrease with old age, mental & social capacities tend to increase in the latter part of life) Stage 1: Ego Differentiation vs Work-role preoccupation Ego Differentiation A person finds new meaning and value in his or her life. Work Role Preoccupation defining oneself through work or an occupation One role should replace the work role as a source of self esteem on retirement Stage 2: Body transcendence vs Body preoccupation Body Transcendence A person accepts the limitations that accompanies the aging process Body Pre-occupation dwells on diminishing abilities Individual should adjust to decreasing physical capacities & at the same time maintain feelings of well being Stage 3: Ego transcendence vs Ego preoccupation Ego Transcendence person believes his or her life has worth and life contributions will live on after death Ego Preoccupation. person feels that he or she has lived a useless life Acceptance without fear of ones death as inevitable and not to hold on to life because he lived a useless life ; Self-examination occurs.

III. Theories of Aging

I. Biologic Theories A. Genetic theories 1. Random error theory 2. Gene regulation theory 3. Somatic mutation 4. DNA damage theory B. Non Genetic Cellular theories 1. Free Radical theory 2. Cross- Linking theory 3. Accumulation theory 4. Deprivation theory 5. Wear-and- Tear theory (Hans Selye ) II. Physiologic Theories A. Biologic Clock theory B. Immune theory III. Neuroendocrine Theory A. Glycation theory IV. Psychosocial Theories A. Continuity theory B. Activity theory C. Symbolic Interaction theory D. Disengagement theory

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V. Developmental Theories A. Sigmund Freud - Psychosexual Development B. Erik Erikson Psychosocial Development C. Jean Piaget Cognitive Development D. Lawrence Kohlberg Moral Development E. James Fowlers Religious Development F. Robert Havighurst Developmental Tasks I. Biologic Theories A. Genetic Theories 1. Random Error Theory or Error Catastrophe Theory - Errors occur during protein synthesis of DNA where an enzyme that is not an exact copy of the original is created. These errors are perpetuated which leads to systems not functioning at optimum level. As the process goes on, the original cell function ability would be altered making the next transcription contain errors causing the aging and death of an organism Example: HutchinsonGilford progeria syndrome (progeria), premature aging. It is characterized by age- associated symptoms at an extremely young age. 2. Gene Regulation Theory a. A growth substance fails to be produced, results in cessation of cell growth and reproduction b. That one or more harmful genes in the organism become active in later life, causing failure of the organism to survive That there are two types of genes: a. Juvenescent genes - those that mediate youthful vigor and mature adult well being; - function in early life b. Senescent genes - those that promote functional decline and structural deterioration; - activated in middle age 3. Somatic Mutation Theory - Mutations occurring in cells other than the reproductive cells - Throughout your life time, your body is constantly creating new cells. Every time one of your cells divide to create two new cells, there is a possibility that the DNA from the first cell will be copied incorrectly. This results in a mutation. The body can correct or destroy most of the mutations, but not all of them. Eventually the mutated cells accumulate, copy themselves and accumulate with increasing age, causing cells to deteriorate and malfunction. As people live beyond 90 and 100 years, more of them die from multiple organ failure due to aging. The lungs, heart, liver, kidneys, muscles, and every other organ suffers from the effects of long term somatic mutation. 4. DNA Damage Theory - Aging is a result of unrepaired DNA damage accumulation. - irreparable DNA damage is caused by environmental pollutants, low dose ionizing radiation and food additives, particularly nitrites and nitrates. DNA damage can have two main results: a. Mutation - Mutagens cause mutation - Changes in a genomic sequence because Enzymes does not recognize the cell as damaged b. Cell death / apoptosis - Mechanism responsible for the physiologic deletion of cells to avoid replication of damaged cells

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- Enzymes detect the damaged cell and tend to destroy the cell B. Non-Genetic Theories 1. Free Radical Theory or Oxidative Stress theory - Free radicals are molecules with unpaired electrons and as they interact with our tissues they steal electrons from other molecules and cause what is called oxidation. This prevents proteins and other essential molecules to function as they should Antioxidants - chemicals that prevent the formation of free radicals thus, it is called the Free Radical Sponge - neutralize free radicals, which damage cells, clog arteries and contribute to chronic illness and aging. Sources of Anti Oxidant 1. Whole, organic foods 2. Leafy vegetables, fruits, wine, and chocolate. 3. Exercise 4. A clean environment 5. Stress free lifestyle 2. Cross Linkage Theory or Glycosylation Theory - that normally separated molecular structures are bound together through chemical reactions. - The process of cross- linking occurs because exposure to certain types of sugar lead to the process known as glycation which in turn lead to the formation of Advance Glycation-End products ( AGE). The AGEs induce cross linking of collagen which in turn increases Example: Stiffness of skeletal muscle and cartilage (Primary cause of arteriosclerosis) Cross-Linkage Agents can be found in the following: 1. Unsaturated fats 2. Polyvalent metal ions (eg. Aluminum, Zinc and magnesium) 3. Excessive radiation exposure 3. Accumulation Theory - When cells produce more waste than they can properly eliminate, this can interfere with normal cell function, ultimately killing the cell. - a waste product called lipofuscin is a small granular yellow-brown pigment which is a product of the oxidation of unsaturated fatty acids, (can appear in nerve cells, heart, muscle, kidney, liver, ganglion cells and adrenals) accumulates in the cells as small granules and increases in size as a person ages. Because lipofuscin builds up over time, it has been described as "the ashes of our dwindling metabolic fires" The key to fight against lipofuscin accumulation: a. avoid oxidative damage b. avoid direct exposure to sunlight, wear sunglasses, to prevent buildup of lipofuscin (druzen) that can cause macular degeneration c. avoid contact with x-rays and microwaves d. remain cautious while dealing with toxic substances e. proper diet; menu may consist of sardines, broccoli, blueberries, Green Tea and olive oil. 4. Deprivation Theory - Aging is caused by vascular changes that deprive cells of essential nutrients & O2 - Nutrient & Oxygen deprivation leads to senescence of deprived cells. - Physical abuse, starvation, and poverty are seen as forms of deprivation.

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5. Wear and Tear Theory - The wear and tear theory of aging suggests that years of damage to cells, tissues and organs eventually wears them out. Once they wear out, they can no longer function correctly, killing them and then the body. Stress - Is a non-specific response of the body to any demands made upon it. Stages of the General Adaptation Syndrome (GAS) 1. Alarm Stage a. Shock Phase - Stressor may be perceived consciously or unconsciously by the person. b. Countershock Phase - The changes produced in the body in the shock phase is reversed. 2. Resistance Stage - Occurs with continued exposure. - Adaptation begins when the body starts to benefit from the increased access to the energy reserves provided by the alarm reaction. 3. Exhaustion Stage - The adaptation that the body made during the second stage cannot be maintained because the ways used to cope with the stressor have been exhausted. II. Physiologic Theories 1. Biologic Clock theory - The "biologic clock" theory states that cells are pre-determined to continue through a finite number of divisions before dying off. - According to this theory, cell mortality is encoded into cell DNA. It would take place even without "accumulated damage." - Aging is programmed ; This is based on the idea that from conception to death, human development is governed by a biological "clock." This clock sets the appropriate time for various changes to take place. - Changes in vision, loss of calcium in the bones, decreasing hearing acuity and lowered vital capacity of the lungs are all examples of programmed aging. This theory was divided into three subcategories: a. Endocrine Theory - This theory states: biological clocks act through hormones, secreted by the endocrine glands, to control the pace of ageing. - Production of some hormones declines with age. a.1 Human growth hormone (GH) levels decrease with age. a.2 Sex hormones (estrogen and testosterone) levels also fall off (thinning of bones). a.3 Hormones like melatonin (sleep) and thyroxin (metabolism) also decline with age. b. Programmed senescence theory - Senescence is the age when an organisms viability is reduced dramatically due to impaired physiology c. Immunulogical Theory - Programmed decline in the functioning of the immune system leads to increased vulnerability to infectious diseases thus causing ageing and death.

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2. Immune Theory - The immune system theory of aging is that the rate of aging is largely controlled by the immune system. - Before age 20, the thymus (which produced certain immune cells) begins to shrink. Thus, as we age, the numbers of critical cells in the immune system decrease and become less functional. Thymic involution - major change that occurs as the body ages - thymus, is the organ where T cells mature. Immunosenescence - age related decrease in the function of the immune system Immune System - network of specialized cells, tissues and organs that provide the body with protection against invading organisms. - Protect us against viruses and bacteria - Helps to identify and remove cancer cells and toxins. Immune system acts in 2 ways: a. by generating antibodies that react with the proteins of foreign organisms B lymphocytes humoral immunity; - produces antibody molecules in response to an antigen b. by forming cells that engulf and digest foreign cells T lymphocytes cell mediated immunity; - defend the body from infectious disease, cancer, and foreign substances III. Neuroendocrine Theory 1. Glycation Theory (Maillard reaction, or non-enzymatic glycosylation) - The glycation hypothesis of aging suggests that modification of proteins by glucose and associated browning or Maillard reactions leads to: a. gradual cross-linking b. polymerization c. development of brown-color products d. linked to protein clumps in Alzheimers patients - A reaction by which reducing sugars become attached to proteins without the assistance of an enzyme. Glycation causes: a. connective tissue to lose elasticity b. reduced kidney function c. slowed wound healing d. reduced vital capacity of the lung e. contributes to cataracts Prevention of Glycation: 1. Lifestyle - food cooked at high temperatures and other diets that cause high blood glucose levels be avoided 2. Diet composed of fruits, fish, lean protein, whole-grain pasta, vegetables, olive oil and even a little toast of red wine 3. Avoid direct exposure to sun

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Firewall against Glycation: 1. Benfotiamine - cause vascular, nerve, kidney and retinal damage to a halt when connected with high blood sugar levels. 2. Magnesium - assists in controlling the blood sugar level thereby avoiding glycation 3. Vitamin C - Permits Hydroxylation, a mechanism that encourages collagen molecules to better protect and resist against potential cell damage. 4. L-Carnosine - avoids glycation, generate an enzyme that counterattack AGEs already formed. IV. Psychosocial Theories 1. Continuity theory - states that older adults will usually maintain the same activities, behaviours, personalities, and relationships as they did in their earlier years of life. - Old age is not seen as a separate period of life, but as a continuation of some patterns set earlier, especially coping strategies of acting, thinking, and feeling. Elements of Continuity Theory: a. Internal structure - personality, ideas, and beliefs - provides the individual a way to make future decisions based on their internal foundation of the past. b. External structure - relationships & social roles - provides a support for maintaining a stable self-concept and lifestyle 2. Activity Theory / Implicit Theory of Aging / Normal Theory of Aging / Lay Theory of Aging - States that continuing activities from middle age promotes well-being and satisfaction in aging. Thus older adults who are actively involved in a variety of situations and who establish new roles and relationships are more likely to age with a sense of satisfaction. - To maintain a positive sense of self the person must substitute new roles for those that are lost because of age. Assumptions in the Activity Theory: a. There is an abrupt beginning of old age. b. The process of aging leaves people alone & cut-off. c. People should be encouraged to remain active & develop own-age friends. d. Standards & expectations of middle age should be projected to older age. e. Aging persons should be encouraged to expand & be involved. What are the problems with activity theory? a. Differences in personality b. Differences in physical function c. Control over social situation d. Socioeconomic effects e. Cultural effects

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3. Symbolic Interaction Theory Symbolic Interaction - the way we learn to interpret and give meaning to the world through our interactions with others. Symbolic Interaction Theory - describes the family as a unit of interacting personalities - It focuses attention on the way that people interact through symbols (words, gestures, rules, and roles) Three core principles to this theory: 1. Meaning (something we assign) 2. Language (constructed through our social interactions) 3. Thought or Minding (influences our interpretations) Major Premises of Symbolic Interaction Theory: 1. Human beings act toward things on the basis of the meaning they have 2. The meaning attributed to those things arises out of social interaction with others 3. These meanings are modified through an interpretative process 4. Disengagement Theory - States that "aging is an inevitable, mutual withdrawal or disengagement, resulting in decreased interaction between the aging person and others in the social system he belongs to" - Withdrawal may be initiated by the aging person or by society, and may be partial or total. Postulate 1 - Everyone expects death, and one's abilities will likely deteriorate over time. As a result, every person will lose ties to others in his or her society Postulate 2 - Because individual interactions between people strengthen norms, an individual who has fewer varieties of interactions has greater freedom from the norms imposed by interaction. Postulate 3 - Because men have a centrally instrumental role, and women a socio-emotional one, disengagement differs between men & women. Postulate 4 - The individual's life is punctuated by ego changes. This is affected by the individual, prompted by either ego changes or the organization (which is bound to organizational imperatives) or both. Postulate 5 - When both the individual and society are ready for disengagement, complete disengagement results. - When neither is ready, continuing engagement results. - When the individual is ready and society is not, a disjunction between the expectations of the individual and of the members of this social systems results, but engagement usually continues - When society is ready and the individual is not, the result of the disjunction is usually disengagement. Postulate 6 - Man's central role is work, and woman's is marriage and family. - If individuals abandon their central roles, they drastically lose social life space, and so suffer crisis and demoralization unless they assume the different roles required by the disengaged state.

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Postulate 7 - This postulate contains two main concepts a. Readiness for disengagement occurs if: a.1 An individual is aware of the shortness of life and scarcity of time. a.2 Individuals perceive their life space decreasing. a.3 A person loses ego energy. b. Each level of society grants individuals permission to disengage because of the following: b.1 Requirements of the rational-legal occupational system in the society. b.2 The nature of the nuclear family. b.3 The differential death rate Postulate 8 - Fewer interactions and disengagement from central roles lead to the relationships in the remaining roles changing. In turn, relational rewards become more diverse, and vertical solidarities are transformed to horizontal ones. Postulate 9 - Disengagement theory is independent of culture, but the form it takes is bound by culture. V. Developmental Theories 1. Sigmund Freuds Psychosexual Theory - Freud believed that few people successfully completed all 5 of the stages. Instead, he felt that most people tied up their libido (sex drive) at one of the stages, which prevented them from using that energy at a later stage. The Genital Stage - The individual develops a strong sexual interest in the opposite sex. - Involves the development of the genitals, and libido begins to be used in its sexual role. 2. Erik Ericksons Psychosocial Development - In each stage, the person must complete a life task that is essential to his or her well-being and mental health. These tasks allow the person to achieve lifes virtues: Hope, Purpose, Fidelity, Love, Caring, and Wisdom. 18 - 40 yrs - Intimacy vs Isolation 30 - 65 yrs - Generativity vs Stagnation 50+ - Integrity vs Despair A. Intimacy vs. Isolation (18 to 40 years) - To form an intense lasting relationship or a commitment to another person, a cause, an institution, or a creative effort. - A strong sense of personal identity was important to developing intimate relationships. - Those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression. Virtue: Love Unresolved: Persistent aloneness/isolation, emotional distance in all relationships, prejudices against others, lack of established vocation OR Possessiveness and jealousy, dependency of parents and or partner, abusiveness toward loved ones, and inability to try new things socially or vocationally

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B. Generativity vs. Self absorption or Stagnation (40 to 65 years) - Being creative and productive to achieve the life goals established for oneself while considering the welfare of future generations. - Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. - Those who fail to attain this skill will feel unproductive and uninvolved in the world. Virtue: Care Unresolved: Self-centeredness/self-indulgence, exaggerated concern for appearance and possessions, lack of interest in the welfare of others OR too many professional or community activities to the detriment of the family and self C. Ego Integrity vs. Despair (65 years to death) - To review ones life & derive meaning from both positive & negative events, while achieving a positive sense of self. - Those who feel proud of their accomplishments will feel a sense of integrity. - Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. Virtue: Wisdom Unresolved: Sense of helplessness, hopelessness, worthlessness, uselessness and meaninglessness OR Inability to reduce activities, overtaxing strength and abilities, feeling indispensable and denial of death as inevitable. 3. Jean Piaget s Cognitive Development Theory - A comprehensive theory about the nature and development of human intelligence. - According to Piagets cognitive-developmental theory, children are driven by heredity and environment. They construct knowledge actively as they manipulate and explore their worlds. Formal Operation Thought (11yrs. - Adulthood) - Marks the beginning of abstract reasoning and Deductive reasoning - Ideas can be compared and classified ; capable of using a future time perspective rather than being tied to the here-and-now thinking of childhood; think about possibilities and think through hypotheses; able to search systematically for answers to problems Adolescent egocentrism can be dissected into two types of social thinking: a. Imaginary audience - involves attention getting behavior b. Personal fable - involves an adolescent's sense of personal uniqueness and invincibility 4. Lawrence Kohlberg s Moral Development - He claimed that logic and morality develop through constructive stages. - He theorized that the process of moral development was principally concerned with justice and that its development continued throughout the lifespan. - Moral reasoning, the basis for ethical behavior, has six identifiable developmental stages. A moral person is Someone who strives to be kind, fair, and responsible. Someone who does not rely on excuses and lies. Someone who has good intentions, and that ones goal is primarily the well- being of others.

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III. Post conventional level 5. Social contract & Individual Rights - Right action pertains to general individual rights . - There are differing opinions on what is right and wrong and that laws are really just a social contract based on majority decision and inevitable compromise. - People at this stage disobey rules if they find them to be inconsistent with their personal values & will also argue for certain laws to be changed if they are no longer "working". 6. Universal Principles (Principled conscience) - If there is a conflict between a social law or custom and universal principles, the universal principles take precedence. - Application of the golden rule: treating people with equality. 7. Transcendental Morality or Morality of Cosmic Orientation - Linked religion with moral reasoning. - Kohlberg's theory centers on the notion that justice and values are the essential characteristic of moral reasoning. - Justice itself relies heavily upon the notion of sound reasoning based on principles. 5. James Fowler's Stages of Faith Development - It focuses on the meaning and purpose of one's life, as shown by this definition: "... faith need not be approached as necessarily as a religious matter. Rather, faith becomes the designation for a way of leaning into life. It points to a way of making sense of one's existence Stage 4 - Individuative-Reflective (Early Adult) Strengths of this stage is: capacity for critical reflection Weakness of this stage is: Individual may put excess confidence in the rational, conscious mind, thus ignoring unconscious forces which is more prominent in the next stage. Stage 5 - Conjunctive Faith (Mid life Crisis) - There is a complex understanding of a multidimensional, interdependent "truth" that cannot be explained by any particular statement. - People in this stage are willing to engage in dialog with those of other faiths in the belief that they might learn something that will allow them to correct their own truths. Stage 6 - Universalizing Faith / Enlightenment - The individual would treat any person with compassion and with universal principles of love and justice. - They are able to sacrifice their own well-being to that of their cause; risk their own safety in order to help the helpless in unexpected ways. - Reached only by the very, very few. Examples are: Gandhi, Martin Luther King, Jr. and Mother Teresa. 6. Robert Havighurst - He recognized that each human has three sources for developmental tasks. They are: 1. Tasks that arise from physical maturation: (Learning to walk, talk, control of bowel & urine, behaving in an acceptable manner to opposite sex, adjusting to menopause). 2. Tasks that arise from personal values: (Choosing an occupation, figuring out ones philosophical outlook). 3. Tasks that arise due to pressures of society:

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(Learning to read, learning to be responsible citizen). - The Havighurst theory is age dependent & all served logical functions depending on their age. A. Middle Adulthood (30 to 60 yrs.) 1. Helping teenage children to become happy and responsible adults 2. Achieving adult social and civic responsibility 3. Satisfactory career achievement 4. Developing adult leisure time activities 5. Relating to one's spouse as a person 6. Accepting the physiological changes of middle age 7. Adjusting to aging parent B. Later Maturity (61and above) 1. Adjusting to decreasing strength and health 2. Adjusting to retirement and reduced income 3. Adjusting to death of spouse 4. Establishing relations with one's own age group 5. Meeting social and civic obligations 6. Establishing satisfactory living quarters

Comprehensive Geriatric Assessment:

The geriatric assessment is a multidimensional, multidisciplinary diagnostic instrument designed to collect data on the medical, psychosocial and functional capabilities and limitations of elderly patients. The geriatric assessment differs from a standard medical evaluation in three general ways: (1) it focuses on elderly individuals with complex problems, (2) it emphasizes functional status and quality of life, and (3) it frequently takes advantage of an interdisciplinary team of providers. Five I's of Geriatrics 1. Intellectual impairment, 2. Immobility, 3. Instability, 4. Incontinence and 5. Iatrogenic disorders. To assess older people effectively, take into account the following: 1. Common age-related changes 2. Role transitions 3. Psychological adjustments HISTORY TAKING Demographic Data - Full name - Age, sex and birth date - Marital status - Source of history and reliability of historian Chief Complaint - Primary reason for visit, ideally in patient's own words

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- Duration of presenting symptoms Present Illness - Chronological narrative of reasons for patient visit. - Persistence, change, severity, character, resolution and disabling effects of initial symptoms. - Presence of new symptoms and/or associated symptoms - History of similar symptoms in the past - Aggravating and mitigating factors Past History - Previous medical history. - General state of health - Childhood diseases - Immunizations (Tetanus-diphtheria, pertussis, measles, mumps, rubella, hepatitis A&B, influenza, varicella, flu., polio) - Chronological list of adult medical diseases, injuries and operations (not already mentioned in "Present Illness") - Hospitalizations (not already mentioned) - Allergies, including clinical description of exposure - Medications, including dosage, duration and indication - Diet Social History - Birthplace and residences (if not native born, year of entry into the present country) - Level of education - Ethnicity and race - Marital status - Quality of significant relationships and health of partner - Vocation, including type of industry, past and present industrial exposures, duration of employment and retirement - Avocations, including hobbies and other interests - Habits, including quality of sleep, exercise, recreation, consumption of alcohol and other drugs (including route of administration), tobacco use (in pack per years), alcohol use, and travels (local or abroad) - Significant life experiences Family History - Presence of disease with recognized familial importance in first degree relatives type II diabetes, tuberculosis, cancer, hypertension, allergy, heart disease, neurological or psychiatric disease, arthritis, osteoporosis, bleeding tendency - Similar presenting symptoms in family members. THE PHYSICAL ASSESSMENT Vital Signs Temperature = 36C to 38C Reduction in number of sweat glands, thus, body cant sweat freely leading to heat exhaustion Loss of sebaceous fat or insulin make it difficult to maintain body heat Pulse Rate = 60 to 100 Resting heart rate slows down as person age Respiratory Rate = 16 to 25 Blood Pressure = 140 mm/90 Hg Arterial stiffness increases, causing false high BP result

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Blood vessels tend to respond more slowly to changes in body position as a person ages (orthostatic hypotension) Height = decreases 2 to 3 inches (5 to 7.5 cm) There may be changes in curvature of spine due to senile kyphosis (widows hump) Weight = loss of more than 10% Indicates depression, physiologic disorder, or a mechanical problem with eating SKIN Thinning & sagging skin, Creases & furrows, increased likelihood of pressure ulcers - Reduced amount of subcutaneous fats thus, distance between the outer layer of the skin surface & the underlying bones becomes reduced (protective effects of fat pads & subcutaneous tissue diminish) - (check skin turgor by pinching subcutaneous tissue at forehead or over the xiphoid process) Mucous membranes drier & rougher - Decreased activity of the sebaceous glands and unable to retain fluid - Gradual decrease in total body water and sebum production Ecchymosis & petechiae - Vitamin C deficiency Lentigo senilis - irregular area of dark pigmentation which look like large freckles especially in dorsum of hands, arms, face. Knees or elbows are darker - Decreased collagen & melanin Dilated capillaries & small arteries on exposed portions of skin Nursing interventions/ health teachings: 1. Avoid brisk rubbing of skin 2. Avoid hot water 3. Avoid excessive use of soap during baths 4. Pat skin dry 5. Use lotions for dryness & itching HAIR - Hair pigment decreases - Hair thins NAILS - Brittle and flake - Pale nail beds & slow capillary refill may be a sign of anemia HEAD - Nose elongates - Mouth changes shape as a result of tooth loss or the necessity of wearing dentures - Dry parched lips indicate dehydration. - Cheek becomes pendulous, wrinkled and baggy - Ears may have hairy tragus EYES - Eyes deeper in sockets (age induced fatty tissue loss) - Eyelids baggy and wrinkled ; Iris fades ; Pupils smaller ; Lens enlarges - Eyes dull and lusterless & often have a watery look (plugged or kinked canaliculi & nasolacrimal duct) - Quantity of tears decrease (blockage of tear ducts & can cause keratitis sicca, burning, dry, or irritated eyes) - Conjunctiva thinner and sclera yellowish (presence of fat deposits) - Lipid deposits on the periphery of the cornea (arcus senilis) - Cornea flattens with age causing astigmatism.

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1. 2. 3. 4.

Poorly fitting dentures may produce fissures or cracks at the corners of the mouth (cheilosis) Vit. B complex deficiencies produce cheilosis Poor oral hygiene can cause white exudates coating the mucosa or tongue. Sublingual varicosities may be a result of iron deficiency anemia Shoulders stoop and thus seem smaller Womans breast becomes flabby and sag Abdomen bulges and droops Hips seem flabbier and broader Waistline broadens giving a sac like appearance Upper arm becomes flabby & heavy, while lower arms seem to shrink in diameter Hands become scrawny, veins at the back of the hands are prominent Nails of the hands and feet become thick, tough and brittle Legs become flabby and veins prominent especially around the ankles Feet become larger as a result of sagging muscles, and bunions and calluses often appear

TRUNK LIMBS -

SENSORY VISION
Lens become less transparent & can actually become clouded which results in cataract Less night and depth vision Floaters can appear Accommodation decreases due to presbyopia Impaired color vision, especially greens and blues due to degeneration of cones Predisposed to glaucoma due to increased pressure in the eye Blindness due to decreased absorption of intraocular fluid Degeneration of the macula, (a patch of retina where lens focuses light), which ultimately result in blindness HEARING Presbycusis - Irreversible, sensorineural loss with age where men are more affected than women - Loss occurs in higher range of sound - By 60 years, most adults have trouble hearing above 4000Hz SMELL - Becomes less acute with age due to atrophy of the cells in the nose & increased hairiness of the nostrils TOUCH - Skin becomes dry and harder thus sensation becomes less and less acute - Greater decline of sensitivity on the forehead and arms than the legs TASTE - Decreased perception of taste, particularly sweet and salty due to atrophy of the taste buds in the tongue and the inner surface of the cheeks -

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NORMAL & PATHOLOGICAL CHANGES & THEIR IMPACT IN COMMUNICATION MODALITY VISION Normal Changes Changes in lens pupil & iris. Results in poor visual acuity, presbyopia, increase sensitivity to light and glare Pathological Changes Impact On Communication Macular degeneration Isolation, Insecurity, Diabetic retinopathy Depression, Embarrassment Glaucoma Decrease in exchange of Senile cataracts communication Retinal detachments Conductive problems Hearing loss due to exposure Inattention, repetitive Sensori neural problems to noise, ototoxic substances, questions, isolation, insecurity, (Presbycusis) results in loss in medications, poisons, acute decrease in social functioning, sensitivity to pitch with high trauma & certain medical depression , loneliness, frequency consonants, poor conditions difficulties in following word recognition instructions Decrease respiration Dysarthia (CVA) Difficulties in producing Overproduction of mucus/ Verbal apraxia language, coherent meaningful reduced saliva, Loss of teeth (paraysis of speech muscles) & verbal communication Decrease elasticity of muscle Aphasia Difficulty in understanding tone, Results in shaky & COPD verbal communication breathy voice, tremulous & Mechanical ventilation frequent attempts of throat Laryngectomy clearing Reduction in the no. of Dementia, Parkinsons or Use of mouth to explore the receptors Diabetes can impact somato quality of the objects safety Reduction of blood flow sensory functioning might be compromised Results in a reduction in tactile & vibration sensations, decreased sensitivity to warm & cold stimuli Due to decline in many Parkinsons disease Disability Reduced ability to sensory organs, cognitive communicate nonverbal functioning & bodily strength information, insecurity & loss results in reduced velocity and of independence accuracy & greater variability across individuals Decline in information Delirium Depending on cognitive processing speed, divided Dementia impairment, Disorientation & attention, sustained attention Alzheimers Disease inappropriate response, ability to perform visuospatial difficulties in finding words, task and short term memory depression, loss of insight, isolation, inability to earn new information In general, older adults reports Depression Slowed response, lack of levels of satisfaction that are motivation decrease in social similar to younger adults activity

HEARING

SPEECH & LANGUAGE

TOUCH

MOVEMENT

COGNITIVE

PSYCHOLO GICAL

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I. RESPIRATORY SYSTEM - Lung expansion may be reduced due to decreased elasticity of the rib cage and more rigid lungs - Hyper resonance due to loss of elastic recoil capability which stretches the alveoli and bronchioles and decreased number and size of alveoli - Diminished sounds at the lung bases due to closed airways; Inspiration will be significantly more audible than expiration. - Crackles due to reduced mobility and reduced respiratory fluid - Pulmonary function decreases - Vital capacity declines II. CARDIOVASCULAR SYSTEM - By age 70 cardiac output is reduced 70% because heart is smaller and becomes less elastic with age and heart valves become sclerotic - More arrhythmias due to more rigid arteries and more irritable heart muscle - PMI in an older person may be displaced downward to the left. - Normal is around the 5th or 6th left intercostals space at the midclavicular line. - There is an extra diastolic heart sounds, S3 in response to an increased diastolic flow and S4 heard after S2 and before S1. S4 is most audible over the hearts apex. III. GASTROINTESTINAL SYSTEM - Abdominal wall is thinner due to muscle wasting and loss of fibro connective tissue, and muscle tone is more relaxed - Reduced GI secretions; Reduced GI motility - Liver metabolizes less efficiently; Decreased weight of liver; Reduced regenerative capacity of liver - The normal liver size at midclavicular line is 2 to 4 inches (5.5 to 12 cm) in diameter IV. MUSCULOSKELETAL SYSTEM - Adipose tissue increases with age; Lean body mass decreases - Bone mineral content diminished - Decrease in height from narrow vertebral spaces - Less resilient connective tissue - Synovial fluid more viscous - May have exaggerated curvature of spine and joint stiffness V. NEUROLOGICAL SYSTEM - Weakness, spasticity, tremors, rigidity and decreased coordination in ROM, gait and balance. - Older adult tends to take smaller steps, reduce the height of his steps, reduce his arm swing & flex his elbows and knees - All of the above is due to degeneration of neurons of central and peripheral nervous system and slowed nerve transmission - Temperature changes because hypothalamus is less effective in regulating body temperature - Reduced REM sleep, decreased deep sleep - After 50, we lose 1% of neurons each year Immediate recall: - Name certain number of objects or have him repeat a group of numbers immediately Recent memory: - Ask about events that occurred in the past 24 to 48 hrs. Remote memory: - Recall significant events that occurred many years ago

19
Cranial Nerves: I. Olfactory progressive loss of smell II. Optic decreased visual acuity, presbyopia & limited peripheral vision III. Oculomotor drooping eyelid and slowed eyeball movement IV. Oculomotor turns eye downward & laterally V. Trigeminal slowed chewing, face & mouth touch & pain (slowed reaction) VI. Abducens turns eye laterally VII. Facial Nerve - decreased perception of taste, particularly sweet and salty; drooping or relaxation of muscles in the forehead and around the eyes and mouth VIII. Auditory nerve presbycusis or loss of high tone hearing, later generalized to all frequencies. IX. Glossopharyngeal nerve sluggish or absent gag reflex X. Vagus taste XI. Vagus weak trapezius & sternocleidomastoid muscle XII. Hypoglossal nerve unilateral tongue weakness (may also be caused by malnutrition or structural malformation of the face) VI. IMMUNE SYSTEM - Decline in immune function - Trouble differentiating between self and non-self auto-immune problems - Decreased antibody response - Fatty marrow replaced red marrow - Vitamin B12 absorption might decrease - Decreased hemoglobin and hematocrit VII. ENDOCRINE SYSTEM - Decreased ability to tolerate stress - best seen in glucose metabolism - Hormonal decrease : Estrogen levels Testosterone Aldosterone Cortisol Progesterone VIII. URINARY SYSTEM - After 40, renal function decreases; At 90, loss of 50% of function - Filtration and reabsorption reduced; Size and number of nephrons decrease - Less able to clear drugs from the system; Smaller kidneys and bladder IX. REPRODUCTIVE SYSTEM A. MALE - Reduced testosterone level - Testes atrophy and soften ; Pubic hair are sparse & grey with age - Decrease in sperm production ; Seminal fluid decrease & more viscous - Erections take more time ; It takes longer to achieve a second orgasm - Refractory period after ejaculation may lengthen to days. - Ejaculation may take longer to achieve, may be less expulsive, and may be shorter in duration - Rectal sphincter contractions may be experienced but does not interfere with orgasm - Men older than 50 have some degree of prostatic enlargement. The gland becomes large enough to compress the urethra and sometimes the bladder, to obstruct urine flow. - Prostate gland is about to 1 inches (2 to 4 cm) in diameter

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B. FEMALE - Ovulation ceases due to declining estrogen and progesterone levels - Vagina atrophies, introitus constricts and loses elasticity and uterus shrinks, ovaries regress - Vaginal irritation and clitoral pain are common due to diminished vaginal secretions - Orgasmic contractions are fewer and may be accompanied by painful uterine contractions - Infrequent rectal sphincter contractions that do not interfere with orgasm and the post coital need to void - Obstruction may be due to uterine prolapse or pelvic cancer. - Bladder muscles weaken resulting to cystocele leading to frequent urination, urgency, incontinence, urine retention & infection. - Vulnerable to infection from urinary stasis or poor personal hygiene due to immobilization PSYCHOSEXUAL CHANGES A. Factors affecting sexual behavior in old age: a. Earlier sexual pattern e. Marital status b. Compatibility of spouse f. Over familiarity c. Social attitudes g. Impotence d. Preoccupation with outside problems B. Substitute sources of sexual satisfaction in old age: a. Masturbation c. Thinking about sex b. Erotic dreams and daydreams d. Sexual recrudescence STRATEGIES TO ENHANCE SEXUAL FUNCTION IN OLDER ADULTS 1. Dietary strategies a. Avoid alcohol or tobacco b. Well balanced meal 2. Medication strategies a. Pain medications before sexual activity b. Discuss if medications that impair sexual function can be discontinued 3. Environmental adaptations a. Plan for sexual activity when most rested b. Allow conjugal visits or home visits c. Live pets provide sensory stimulation d. Offer objects to touch, fondle, and hold (dolls, stuffed animals) 4. Psychologic strategies a. Communicate desires to partner b. Discuss fears and concerns with care provider c. Encourage routine visits to hair dresser to promote self esteem & well being d. Join a support group e. Use relaxation techniques 5. Physical strategies a. Improve exercise tolerance by participating in exercise program b. Use touch, kissing, and hugging c. Use pillows under painful joints d. Take a warm shower before activity e. Get regular check ups

21 Principles In The Care of the Elderly

Health promotion activities aimed at improving or enhancing health. Primary prevention activities designed to completely prevent a disease from occurring. Secondary prevention efforts directed toward early detection and management of disease. Tertiary prevention efforts used to manage clinical diseases in order to prevent them from progressing or to avoid complications of the disease. Health screening population-wide efforts to detect early disease.

Important Factors for maintaining Health in Elderly :

1. Avoidance of disease (reducing risk factors for disease) 2. Maintaining and improving physical and mental health 3. Active engagement with life

SLEEP PATTERN
Increased sleep latency a delay in the onset of sleep Increased nocturnal awakenings trips to the bathroom, dyspnea, chest pain, arthritis pain, coughing, snoring, leg cramps, and noise Increased early morning awakenings due to changes in the circadian rhythm or to any of the reasons for nocturnal awakenings Increased daytime sleepiness due to sleep disturbances Reduced sleep efficiency relative percentage of time in bed spent asleep (75%) Factors influencing sleep quality: 1. Environment (home environment, noise, lighting, temperature) 2. Pain and discomfort 3. Lifestyle changes (loss of spouse, retirement, having a room mate, relocation) 4. Dietary influences (caffeine, alcohol, fluid intake, hunger and thirst) 5. Medication use (causing sleep by intent, causing drowsiness, insomnia or other sleep disturbance by side effect) 6. Medical conditions 7. Depression 8. Dementia

MENTAL FUNCTION
1. Learning - Need more time to integrate responses, less accurate, less capable of dealing with new material. 2. Reasoning and problem solving ability - Reduced speed to reach a conclusion because they are cautious. 3. Creativity - Lack the capacity for or interest in creative thinking 4. Recall - Some use cues (visual, auditory) to aid their ability to recall 5. Reminiscing - Increasing more marked with advancing age 6. Sense of humor - Comprehension of the comic tends to decrease but appreciate for the comic that they comprehend increases 7. Vocabulary - Very slight deterioration. Learning new words is more difficult than frequent 8. Mental rigidity - More pronounced because they learn slowly & with more difficulty ; - They believe that old values and ways of doing things is better than new ones. 9. Reaction time - Slowed due to the diminished conduction speed of nerve fibers and can delay further muscle tone as a result of diminished physical activity 10. Memory - Has poor recent memories but better remote memories because they are not strongly motivated to remember things - may be lack of attentiveness due to not hearing clearly distinctly what others say.

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a. Short memory affected by aging; Person perceives the information adequately and need not recognize it mentally b. secondary memory declining with age; Aging diminishes the ability to retrieve information from storage in the brain due to slowed CNS functioning Promotion of Mental Health: a. Continued physical and mental activity (exercise & mental stimulation) b. Optimum nutrition, including supplements c. Strong support system (Family, Church, Friends) d. Regularly scheduled activities based on personal preferences and interests Prevention of Mental Illness or Disorders: a. Avoid social isolation b. Seek help when symptoms occur c. Use of essential prescribed medications

PSYCHOSOCIAL
A. Personality / Body Image - Slimness - Distinguished- looking gray hair - Lined face that displays character - Wrinkled hands that conveys a lifetime of hard work - Some may see his/her body is less dependable therefore less desirable B. Conditions affecting change of interests in Old Age - Health - Gender - Marital status - Social Status - Values - Economic status - Place of residence

COMMUNICATION
- Lines of communication must be clear to develop an appropriate NCP - Nurses need to communicate effectively with older patients with a variety of physical and cognitive impairments in order to develop a therapeutic relationship with each patient Ability to communicate depends on: 1. Physiological Process (Listening, Speaking, Gestures, Reading, Writing, Touching, Moving) 2. Psychological Process 3. Cognitive process (attention, memory, self-awareness, organization & reasoning) GUIDELINES FOR VERBAL COMMUNICATION 1. Do not yell or speak too loudly to patients. 2. Try to be at eye level with the patient. 3. Try to minimize background noise as it can make it difficult for the patient to hear. 4. Monitor the patients reaction. 5. Touch the patient if appropriate and acceptable. 6. Supplement verbal instructions with written instructions as needed. 7. Do not give long-winded speeches or complicated instructions to persons with cognitive impairment, anxiety or pain 8. Ask how the patient would like to be addressed 9. Attentive listening is an important part of communication 10. The caring response and careful listening of the nurse is comforting to the patient 11. Encourage reminiscing gives comfort and reassurance to patients that they can talk about a time in their life when circumstances are better

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SENSORY MODALITIES IN COMMUNICATION A. Vision - Where 70% of all sensory information come from - There is consistent decline in the ability to see at low levels of illumination and a decline in color sensitivity. B. Speech - Primary form of communication - Requires both visual & auditory - Involves pronunciation & articulation to form a language ROLE OF THE BRAIN IN COMMUNICATION 1. ORGANIZE INFORMATION 2. RESPOND TO CHANGE 3. RECOGNIZE COMPLETE OR AMBIGUOUS INFORMATION Wernicke's area - individual words of the sentence are recognized then structure of the utterance is decoded (Parsing) Brocas area - symbolic information is retrieved and processed then put into words (Naming) Motor cortex - structures in a sentence in order to articulate the utterance (Phrasing) THE FOCUS OF HEALTH PROMOTION - to minimize the loss of independence associated with illness and functional decline 1. Physical Activity - Functional decline in the elderly is attributable, at least in part to physical inactivity. Effects of moderate physical activity: a. Decrease overall mortality b. Decreasing CHD, colon cancer c. Decrease in the incidence and improving the management of DM and HPN d. Decrease obesity e. Improving depression, quality of life, functional status f. Decrease falls and injury 2. Nutrition - Four of the 10 leading causes of death (cancer, DM, CHD, CVA) are associated with unhealthy dietary pattern Reasons why elderly are prone to poor nutrition: a. They have multiple chronic disease e. Maybe taking multiple medications b. Tooth or mouth problem f. May need assistance with self-care c. Social isolation g. BMI of 22-27 is considered normal d. May have economic hardship 3. Tobacco use - Estimated 4.5 million of elderly ages 65 years older smoke cigarettes Guidelines to screen tobacco use and assess the clients willingness to quit: 5 As ASK about smoking status at each health care visit ADVISE the client to quit smoking ASSESS clients willingness to quit smoking at this time ASSIST client to quit using counselling and pharmacotherapy ARRANGE for follow-up within 1 week of scheduled quit date.

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5 Rs RELEVANCE (Ask the client to think about why quitting maybe personally relevant for him/her) RISKS (of smoking are identified by client) REWARDS (of quitting are identified by client) ROADBLOCKS (or barriers to quitting are identified) REPETITION (of this process at every visit) 4. Safety Fall risk assessment: I - inflammation of joints or joint deformity HATEhypotension (orthostatic BP change) auditory and visual abnormalities tremor equilibrium problems

F - foot problems A - arrythmias, heart block, valvular disease L - leg length discrepancy L - lack of conditioning (generalized weakness) I - illness N nutrition (poor, weight loss) G - gait disturbances CLASSIFICATIONS OF FALL 1. Extrinsic (Environmental) 2. Intrinsic (Illness or disease related) 3. Multifactorial (a combination of both intrinsic and extrinsic factors) 4. Intentional (fall on purpose maybe to do harm) 5. Isolated (a one - time event that was purely accidental) 6. Cluster (in individuals with specific disease who decompensate) 7. Premonitory (produced by specific medical illnesses) 8. Prodromal (onset of frequent falling heralding an acute medical problem) EVALUATION OF CLIENTS WHO FALL: S Symptoms at the time of Fall P Previous Fall L Location of the Fall A Activity at the time of the Fall T Time of the Fall T Trauma post fall 5. Immunization - Annual Influenza vaccination for all adults 65 years old or older - Pneumococcal vaccine given once for client who are 65 years old or older - Tetanus and Diptheria vaccine given every 10 years

25 CULTURAL DIVERSITY AND MEDICATION SAFETY

Cultural diversity and ethnic background can affect the older persons beliefs about health, illness, medications, and physiological response to medications. Some cultures will engage in extensive folk remedies and herbal preparations before they initiate treatment. Ethnic beliefs can also affect adherence to instructions to take meds as prescribed Physiologic response to meds may also depend on the race or ethnic background of the older person. MEDICATION SAFETY - Alterations in physiological function resulting from normal processes of aging must be carefully considered in prescribing, administering and monitoring meds 1. Basic knowledge about the indications for the medications: - Correct dosages - Correct administration - Anticipated side effects - Potential adverse drug reaction - Contraindications for each medications 2. PHARMACOKINETICS - the time course by which the body absorbs, distributes, metabolize and excretes drugs - how drugs move through the body and how quickly this occurs - Alterations in physiological function resulting from normal processes of aging must be carefully considered in prescribing, administering and monitoring meds A. ABSORPTION - the movement of a drug from the site of administration into the plasma a. Decreased stomach acid and intestinal blood flow b. The stomach-emptying time also slows as a person ages. - These changes decrease the rate, but not the amount, of drug absorption; - These may delay the onset of action and peak effect of medications. B. DISTRIBUTION - the movement of a drug from the plasma into the cells. a. Higher percentage of fat to lean body mass b. Decrease in total body water c. Decreased plasma albumin - It may be necessary to decrease the dose of some highly fat soluble, water soluble, and highly protein bound medications to compensate for the physiologic changes of the aging body. - This may result in a drug effect which is less intense than expected, but the effect may last longer as a result of slow release of drug from fatty tissue. - Since the serum albumin levels decline with aging, this may lead to higher levels of free (not bound to albumin) drugs, therefore a need to lower the normal dose. C. METABOLISM (Biotransformation) - the irreversible transformation of parent compounds into daughter metabolites. - Decrease in liver blood flow, liver size, and enzyme activity. - These changes can affect the ability of the liver to break down drugs so that they are easily eliminated. - Due to a decrease in liver function, it may be necessary to reduce the dose of some medications that are metabolized by the liver

26
D. EXCRETION - the removal of the substances from the body. - In rare cases, some drugs irreversibly accumulate in body tissue. - Decreased kidney function and blood flow to the kidneys. - Due to this decrease, it is common to decrease the dose of drugs that are eliminated by the kidneys. - The specific site of action of a drug (drug receptor site) may also change, both in numbers and in sensitivity; this may make the elderly more (or less) sensitive to a drug effect; this may produce a more toxic or diminished effect 3. PHARMACODYNAMICS - Biochemical and physiological effects of drugs on the body - What drugs do once they are in the body. Changes in pharmacodynamics in the older person may be due to: a. Decrease in the number of receptors b. Decrease in receptor binding c. Altered cellular response to the drug-receptor interaction. RULE OF THUMB: START LOW, GO SLOW - The drug should be administered at about one half the recommended adult dose, and the healthcare should wait twice as long as recommended in the literature before increasing the dose. - This rule will help prevent toxic effects and adverse drug reactions. ADVERSE DRUG EVENTS - Preventable adverse drug events in older adults are often the result of misuse, overuse, or under use of medications. Causes of ADEs and ADRs 1. Inappropriate drug or dosing 2. Drug-drug interactions 3. Drug-disease interaction 4. Polypharmacy 5. Non-compliance PREVENTION OF ADEs AND ADRs 1. AVOID POLYPHARMACY 2. Drug Therapy should be used only if there is a specific diagnosis or clearly documented symptom or condition to be treated. 3. The use of a drug to treat side effects of another drug should be avoided. 4. Change the offending drug or decrease the dose to decrease the side effects and avoid the need for another medication. 5. Explore non pharmacologic treatment options 6. Review patient's medications regularly every six to twelve months, and with any medication change.

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POLYPHARMACY - The prescription, administration or use of more medications than are clinically indicated in a given patient. - Includes the use of a medication that has no apparent indication - Continuing a medication after a condition has been resolved - Use of a medication to treat the side effects of another medication - Use of an inappropriate dose - Patient self-medicates with OTC meds and herbal remedies to treat the same condition or to manage symptoms of an adverse drug effect. ALTERNATIVE AND COMPLEMENTARY MEDICINE - People of all ages are using alternative or complementary medicine in addition to their routine medications. - 30% of those over age 65 use at least one alternative medicine modality CHIROPRACTIC 11% HERBAL MEDICINES 8% HIGH-DOSE OR MEGAVITAMINS 5% SPIRITUAL/RELIGIOUS HEALING 4% ADHERENCE AND COMPLIANCE INTELLIGENT NONCOMPLIANCE - reducing medications or discontinuing a drug when the person experienced side effects that were bothersome. NONCOMPLIANCE - objectionable to some patients and clinicians since it implies a patient must surrender to the orders of the clinician ADHERENCE - various levels of cognitive and physical skills are needed by the older person to safely take medications as prescribed. STRATEGIES FOR ENHANCING COMPLIANCE ENABLING STRATEGIES: - To prepare patient to be compliant. Examples: Counselling, Patient education, Simplifying regimens Increasing access to medical care and to prescriptions Prescription of less costly therapies CONSEQUENCE STRATEGIES - To reinforce compliant behavior Example: Patients to maintain records of medication taking and rewards for compliance STIMULANT STRATEGIES - To prompt pill taking Example: Tailoring doses to daily rituals Use of reminder cards in prominent places in home Home visits to reinforce compliance Medication reminder system (e.g. phone calls, text)

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CHRONIC ILLNESS
- An illness that persists for a long period of time (3 months or more), long-lasting or recurrent - "chronic" comes from the Greek chronos. - In ancient Greece, the "father of medicine" Hippocrates distinguished diseases that were acute (abrupt, sharp and brief) from those that were chronic.

I. DEMENTIA
- A general term that refers to progressive, degenerative brain dysfunction, including deterioration in memory, concentration, language skills, visuospatial skills, and reasoning that interferes with persons daily functioning RISK FACTORS IN DEMENTIA 1. Age 2. Family history 3. Genetic Factors 4. History of head trauma 5. Vascular disease 6. Certain type of infections

PREDISPOSING FACTORS OF DEMENTIA 1. Degenerative neurological disorders (Alzheimers) 2. Vascular disorders (Multiple-infarct dementia; Infections as HIV dementia complex) 3. Chronic drug use 4. Depression 5. Types of hydrocephalus TYPES OF DEMENTIA 1. Alzheimers disease - presence of amyloid plaques (found in the tissue between the nerve cells) and neurofibrillary tangles (bundles of twisted filaments found within neurons) 2. Vascular dementia - caused by brain damage from cerebrovascular or cardiovascular problems - may also result from genetic diseases, endocarditis 3. Frontotemporal dementia - presence of an abnormal form of tau protein in the brain, which accumulates into neurofibrillary tangles which disrupts normal cell activities and may cause the cells to die. 4. Dementia Pugilistica - called chronic traumatic encephalopathy or Boxer's syndrome, is caused by head trauma 5. Corticobasal degeneration (CBD) - is a progressive disorder characterized by nerve cell loss and atrophy of multiple areas of the brain 6. Dementia with Lewy bodies - many of the remaining nerve cells in the substantia nigra contain abnormal structures called Lewy bodies which is the hallmark of the disease. - Lewy bodies (contain a protein called alpha- synuclein that has been linked to Parkinsons disease) may also appear in the brain's cortex, or outer layer. 7. Creutzfeldt-Jakob disease (CJD) - results from an abnormal form of a protein called a prion - caused by a mutation in the gene for the prion protein

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WARNING SIGNS OF DEMENTIA 1. Frequent forgetfulness, (recent events) 2. Forgetting common words 3. Becoming lost in familiar areas 4. Difficulty with common tasks

5. 6. 7. 8.

Misplacing objects in unusual places Poor judgement especially with finances Changes in mood, behavior or personality Lack of interest in life activities

DIAGNOSIS OF DEMENTIA History and physical examination Review of medications Laboratory tests: CBC, thyroid stimulating hormone, vitamin B12 level, syphilis serology Neuropsychological testing : Mini Mental State Exam (MMSE), Clinical Dementia Rating (CDR), Global Deterioration Scale (GDS)/Functional Assessment Staging (FAST) Imaging studies : CT scan and/or MRI, PET scan PREVENTION OF DEMENTIA 1. Habits that maintain a healthy lifestyle: a. Eat low-fat diet b. Avoid smoking c. Moderate use of alcohol d. Control high blood pressure and diabetes e. Exercise regularly 2. Take safeguards to prevent infections 3. Use protective equipment for vehicles to prevent head injuries * Overall goal of nursing care is to promote a meaningful life for individuals with dementia and their caregivers. 1. Stop or change medications that lead to confusion 2. Do mental exercises 3. Treat other conditions that lead to confusion, and taking specific dementia medications. NURSING DIAGNOSIS FOR DEMENTIA - Impaired Verbal Communication - Bathing or Hygiene Self-Care Deficit - Risk for Injury - Impaired Social Interaction - Risk for Violence: Self-directed or Others-directed II. ALZHEIMERS DISEASE - the most common cause of dementia in older adult, representing 60-80% of dementia. - named after Dr. Alois Alzheimer, who first described the condition 100 years ago RISK FACTORS: 1. Age 2. Family History 3. Presence of apolipoprotein E (ApoE) 4 allele (Amyloid plaques) CLINICAL DIAGNOSIS OF AD: 1. Neuroimaging by CT or MRI 2. Screening tools such as MMSE

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3. Neuropsychiatric testing MAJOR SYMPTOMS OF AD: 1. Impaired memory (especially recent memory) 2. Disorientation 3. Impaired abstract thinking 4. Impaired judgement and impulse control changes in personality STAGES OF ALZHEIMERS DISEASE Stage 1 (Early stage or very mild alzheimers) - Can persists up to 2 years - Memory loss that may be seen as a symptom of old age Stage 2 (Middle stage or mild alzheimers) a. moderate memory loss b. difficulty handling complex financial transaction c. poor problem solving, withdrawing from usual social activities Stage 3 (Late stage or moderate alzheimers) a. includes all symptoms of stage 2 b. memory loss is severe c. maybe confused about identity & relationship of relatives d. increasingly dependent on others e. incomplete sentences and poor comprehension of written and spoken language f. disruptive emotional changes may occur Stage 4 (Terminal phase or severe alzheimers) a. emotional recognition of family but names and identification are lost b. language is limited to short phrases and repeated words c. complete dependence on others for all care and needs d. death is frequently attributed to complications associated with chronic debilitation. TREATMENT FOR ALZHEIMERS DISEASE 1. Medications to treat cognitive & functional symptoms a. Cholinesterase inhibitors (ChEIs) ex: Tacrine, Donepezil, Rivastigmine, Galantamine - Act by stopping or slowing the action of acetylcholinesterase to breakdown acetylcholine, increasing acetylcholine b. Memantine(Namendra) - For moderate to severe AD c. Estrogen and anti-inflammatory agents, antioxidants (Vit E & C and gingko biloba) and statins (cholesterol-lowering agents) NURSING DIAGNOSIS FOR ALZHEIMERS DISEASE - Imbalanced Nutrition Less than Body Requirements - Disturbed Thought Processes - Disturbed Sensory Perception - Impaired Verbal Communication - Self-care Deficit; Hygiene, Grooming, Toileting - Impaired Physical Mobility - Risk for Injury

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MUSCULOSKELETAL DISORDERS
- Number and size of muscle fibers progressively decrease which results in a decrease in skeletal muscle mass and thus lean body mass. - Reduced levels of exercise and physical activity leads to reduced skeletal muscle protein synthesis. - Deficiency of hormones, such as Growth hormone (GH), Estrogen, Testosterone leads to: a. Fracture b. Arthritis c. Osteoporosis

I. ARTHRITIS
- Inflammation of the joints usually accompanied by pain, swelling, and stiffness, and resulting from infection, trauma, degenerative changes, metabolic disturbances, or other causes. a. Osteoarthritis b. Rheumatoid arthritis c. Gouty arthritis FORMS OF ARTHRITIS 1. Osteoarthritis - results from daily wear and tear of the joint causing deterioration or loss of the cartilage that acts as a protective cushion between bones, particularly in weightbearing joints such as the knees & hips 2. Rheumatoid arthritis - acquired from daily wear and tear of the joint causing erosion of two opposing bones which often affects joints in the fingers, wrists, knees and elbows 3. Gouty arthritis - caused by deposition of uric acid crystals in the joint, causing inflammation which often affects the big toe. TREATMENT FOR OSTEOARTHRITIS Arthritis cannot be cured but it can be treated Goal of Treatment: 1. Reduce pain and stiffness 2. Allow for greater movement 3. Slow the progression of the disease Treatment: 1. Lifestyle change Weight loss Stretching, Strengthening and Fitness exercises 2. Heat application 3. Medications NSAIDs Ibuprofen and Naproxen 4. Surgery arthrodesis (immobilizing a joint) Osteotomy (cutting a bone) TREATMENT FOR RHEUMATOID ARTHRITIS Goal of Treatment: 1. Reduce joint inflammation and pain 2. Maximize joint function 3. Prevent joint destruction and deformity

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Treatment: 1. Medications Acetylsalicylate (aspirin), Naproxen (Naprosyn), Ibuprofen (Advil, Medipren, Motrin), and Etodolac (Lodine) Celecoxib (Celebrex), offers anti-inflammatory effects 2. Surgery Arthroscopy Synovectomy Osteotomy Hip Arthroplasty PREVENTION OF RHEUMATOID ARTHRITIS - Rest - Physical and occupational therapy - Exercise - Mechanical support devices - Weight reduction TREATMENT FOR GOUTY ARTHRITIS Goal of Treatment: 1. Rapid pain relief 2. Prevent future attacks 3. Prevent long-term complications Treatment: 1. NSAIDs Steroids or Colchicine Allopurinol (reduces the production of uric acid) Probenecid (increases uric acid excretion in the urine) 2. Low Purine diet Limit alcohol (reduces the release of uric acid by the kidneys into the urine) Limit meat & sea foods 3. Weight management Exercise Low calorie diet Prevention of Gouty Arthritis - Lifestyle changes - Low cholesterol diet - Low purine diet - Stay hydrated - Avoid alcohol - Weight management - Regular Exercise

II. OSTEOPOROSIS
- a condition characterized by a decrease in the density of bone, decreasing its strength and resulting in fragile bones. - Osteoporosis leads to abnormally porous bone that is compressible, like a sponge. - This disorder weakens the bone and results in frequent fractures (breaks) in the bones - Osteopenia is a condition of bone that is slightly less dense than normal bone but not to the degree of bone in osteoporosis RISK FACTORS: 1. Female gender 2. Caucasian or Asian race 3. Thin and small body frame 4. Family history of osteoporosis

33
5. Personal history of fracture as an adult CAUSES OF OSTEOPOROSIS 1. Excessive alcohol consumption 2. Lack of exercise 3. Diet low in calcium 4. Poor nutrition and poor general health 5. Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) 6. Low estrogen levels in women (such as occur in menopause or with early surgical removal of both ovaries) 7. Low testosterone levels in men (hypogonadism) 8. Chemotherapy that can cause early menopause due to its toxic effects on the ovaries Treatment for Osteoporosis 1. Lifestyle changes - quit cigarette smoking, curtailing excessive alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D 2. Medications that stop bone loss and increase bone strength - Alendronate (Fosamax), Risedronate (Actonel), Raloxifene (Evista), Ibandronate (Boniva). Calcitonin (Calcimar) 3. Medications that increase bone formation - Teriparatide (Forteo)

CARDIOVASCULAR SYSTEM
Slight increase in the size of the heart (left ventricle, heart wall thickens) Deposits of the "aging pigment," lipofuscin, causing valve stiffness Decreased blood volume due to reduction in total body water thus, less fluid in the bloodstream Reduced Red blood cells (hemoglobin & hematocrit) contributes to fatigue Decreased lymphocytes (immunity) which reduces ability to resist infection. Less sensitive baroreceptors which monitor the BP and make changes to help maintain constant BP when a person changes positions or activities thus causing orthostatic hypotension - The capillary walls thicken slightly causing a slightly slower rate of exchange of nutrients and wastes. - The main artery from the heart (aorta) becomes thicker, stiffer, and less flexible which makes the BP higher and makes the heart work harder leading to thickening of the heart muscle (hypertrophy) 1. Hypertension 5. Coronary Artery Disease 2. Congestive Heart Failure a. Angina 3. Stroke b. Myocardial Infarction 4. Peripheral Vascular Disease

I. HYPERTENSION
- Hypertension (HTN) or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. - Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure CLASSIFICATIONS OF HYPERTENSION 1. Primary High blood pressure with no obvious medical cause 90-95% 2. Secondary Caused by other conditions that affect the kidneys, arteries, heart or endocrine system 5-10%

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3. Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic pressure common in the elderly. RISK FACTORS FOR HYPERTENSION - Age - Smoking - Race - Stress - Familial history - Sedentary lifestyle - Use of birth control pills - Use of certain medications - Obesity DIAGNOSTIC TESTS FOR HYPERTENSION 1. Laboratory CBC Renal profiles Lipid panels Electrolyte profiles Thyroid profiles 2. Radiography Chest x-ray IntraVenous Pyelography Renal angiogram 3. Electrocardiography

Creatinine clearance Aldosterone level Glucose levels Urinalysis

MANAGEMENT FOR HYPERTENSION 1. Medication Thiazide diuretics or beta blockers (drug of choice if no other coexisting medical condition) Thiazide diuretic with either: Potassium-sparing diuretic Beta blocker Calcium channel blocker Angiotensin-converting enzyme inhibitor (ACEIs) Angiotensin receptor blockers (ARBs) 2. Lifestyle modification Low fat low sodium diet Adopt a regular exercise habit Keeping body weight under control Limit alcohol intake and stop smoking 3. Regular monitoring of blood pressure 4. Compliance to medications Do not skip doses NURSING DIAGNOSIS FOR HYPERTENSION - Excess Fluid Volume - Decreased Cardiac Output - Risk for Deficient Fluid Volume - Risk for Injury - Non Compliance with Medical Regimen - Deficient Knowledge

II. CORONARY ARTERY DISEASE

- Coronary Heart Disease / Ischemic Heart Disease - Caused by hardening and narrowing of the blood vessels of the heart (atherosclerosis) resulting in an

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impaired blood supply to the myocardium - Most common cause of death in persons over 65 years RISK FACTORS - Smoking - Increase in pulse pressure - Hypertension - Concurrent diagnosis of DM - Obesity - Advancing age - Inactivity - Increase in total LDL (Low-Density Lipoproteins) the 'bad' cholesterol that transports cholesterol in the blood - Decreases in HDL (High Density Lipoproteins) the good' cholesterol that removes harmful bad cholesterol from where it doesn't belong CLASSIFICATIONS OF ANGINA PECTORIS - From Latin term squeezing of the chest 1. Stable angina Effort angina which refers to the more common myocardial ischemia can be managed with medication and lifestyle modification. 2. Unstable angina Crescendo angina" refers to angina that changes or worsens needs immediate treatment DIFFERENCE BETWEEN ANGINA AND MYOCARDIAL INFARCTION
Angina Pain description Pain radiation Prompted by Accompanying symptoms Diagnostics Squeezing pain or pressure of short duration (<5 min) on sternal area May or may not radiate to right arm, neck, jaw or throat Exercise or stress Relieved by rest or nitroglycerin Breathlessness, dizziness, confusion, extreme fatigue 1. ECG 2. Nuclear Imaging 3. MRI or Positron Emission Tomography (PET) 4. Exercise Stress Test 5. Cardiac Catheterization 6. Laboratory: lipid profiles cardiac enzymes troponin complex 1. Nitroglycerin SL, nasal or epidermal topical ointment or transdermal patches 2. Beta blockers 3. ACE inhibitors 4. Lifestyle changes avoid smoking MI Chest pain appearing as tightness, fullness or pressure Radiating to arms, unexplained numbness in arms, neck & back With or without activity Not relieved by rest or Ntroglycerine Sweating, nausea, pallor, dizziness, indigestion or epigastric discomfort not relieved by antacid 1. ECG 2. Angiogram or cardiac catheterization Nursing Responsibilities after the procedure: keep leg straight with pressure on the femoral artery entry site monitor entry site for bleeding avoid lifting or driving Steps in Acute Care Treatment Of M.I. M morphine O oxygen N nitroglycerine A aspirin if not contraindicated 1. Beta blockers, ACE inhibitors, antihypertensive 2. Angioplasty

Treatment

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avoid heavy meals, caffeine avoid emotional and physical strain 3. Coronary Artery Bypass Graft (CABG) or open heart surgery 4. Implantable Cardiac Defibrillator (ICD)

NURSING DIAGNOSIS FOR ANGINA PECTORIS - Decreased Cardiac Output - Ineffective Tissue Perfusion: Cardiopulmonary, Cerebral, Renal, Gastrointestinal, Peripheral - Acute Pain - Anxiety - Activity Intolerance - Ineffective Sexuality Patterns - Deficient Knowledge

III. CONGESTIVE HEART FAILURE

- Congestive Cardiac Failure (CCF) - Inability of the heart to provide sufficient pump action to distribute blood flow to meet the needs of the body - In the elderly, the most common cause of heart failure is coronary artery disease - Other causes are: Hypertension, Valvular heart disease, Cardiomyopathy, Ventricular aneurysm SIGNS & SYMPTOMS OF CONGESTIVE HEART FAILURE 1. Left sided Tachypnea , Rales or crackles in the lung base, cyanosis, gallop rhythm (additional heart sounds), heart murmurs 2. Right sided Pitting peripheral edema, ascites, and hepatomegaly Distention of jugular veins, wheezing, cough, dyspnea, orthopnea, fatigue, increased heart rate, confusion, weight gain, paroxysmal nocturnal dyspnea often leading to insomia TREATMENT FOR CONGESTIVE HEART FAILURE The goals of Treatment are: to correct underlying causes to relieve symptoms to prevent worsening of the condition Symptoms are relieved by: removing excess fluid from the body improving blood flow improving heart muscle function increasing delivery of oxygen to the body tissues TREATMENT FOR CONGESTIVE HEART FAILURE 1. Lifestyle changes 2. Medications Diuretics - Furosemide (Lasix), Spironolactone (Aldactone) Inotrope - Digoxin (Lanoxin) ; reduce heart failure symptoms Ace Inhibitors - Captopril (Capoten) Nitrate - Nitroglycerine (to treat acute chest pain)

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Beta-blockers - Atenolol (Tenormin), Propanolol (Inderal) - slow down the heart rate, lower blood pressure, and have a direct effect on the heart muscle to lessen the workload of the heart. NURSING DIAGNOSIS FOR CONGESTIVE HEART FAILURE - Decreased Cardiac Output - Impaired Gas Exchange - Excess Fluid Volume - Constipation - Disturbed Sleep Pattern - Fatigue - Ineffective Coping - Deficient Knowledge

IV. CEREBRO VASCULAR DISEASE

1. Transient Ischemic Attack (TIA) - also called mini stroke - leaves little to no permanent damage within the brain - characterized by transient focal neurological signs and symptoms that occur suddenly and last a short time, usually less than hour and never longer than 24 hours. - In elderly, it is caused by micro embolism to the brain from atherosclerotic plaques in the aortocranial arteries. SIGNS & SYMPTOMS OF TIA Numbness or weakness of face, arm, hand, or leg, especially on one side of the body Confusion Trouble speaking or understanding speech Trouble seeing in one or both eyes (double vision, blurred vision, or blindness) Loss of balance or coordination Severe headache with no known cause Vomiting Loss of consciousness Spinning sensation (vertigo) Sudden collapse Seizures (in a small number of cases). TREATMENT OF TIA a. Lifestyle changes Quit smoking Low fat low sodium diet Increase physical activity (Exercise) Lose weight Cut on alcohol consumption b. Medications to help keep blood from clotting c. Surgery Carotid Endarterectomy (CEA) Catheter-based Percutaneous Transluminal Angioplasty (PTA) Carotid Artery Angioplasty and Stenting (CAS) 2. Stroke - Also known as cerebrovascular accident (CVA) or brain attack.

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- The rapid loss of brain function(s) due to disturbance in the blood supply to the brain - This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage - The fourth leading cause of death affecting 50,000 people each year. CLASSIFICATIONS OF STROKE 1. Thrombotic - blood clot usually forms around atherosclerotic plaques 2. Embolic - blockage of an artery by an arterial embolus 3. Hemorrhagic - result in tissue injury due to compression of tissue from an expanding hematoma or hematomas EARLY SIGNS OF STROKE 1. Facial droop (face weakness) 2. Arm drift (when asked to raise both arms, person involuntarily lets one arm drift downward) 3. Abnormal speech (language difficulties) SIGNS AND SYMPTOMS OF STROKE 1. Motor deficit (hemiplegia,dysarthria,dysphagia) 2. Sensory deficit (perceptual deficit) 3. Language deficit (aphasia) 4. Visual deficit (defects in the visual fields, diplopia, decreased acuity) 5. Intellectual or emotional deficit 6. Bowel and bladder dysfunction TREATMENT OF STROKE 1. Thrombolysis ("clot buster") 2. Stroke rehabilitation Speech & language therapy Physical therapy Occupational therapy 3. Neurosurgery Carotid endarterectomy Angioplasty

Laser emulsification Mechanical clot retrieval

PREVENTION OF STROKE 1. Quit smoking 2. Avoid hormone replacement therapy and birth control pills with smoking 3. Eat vegetables to increase intake of folic acid and vitamins B6 and B12, which have been associated with lower blood levels of homocysteine 4. Take aspirin and a blood thinner (if recommended) 5. Keep blood pressure and cholesterol under control Low sodium low fats diet Limit alcohol intake Regular exercise Stay trim NURSING DIAGNOSIS FOR STROKE - Impaired verbal communication - Impaired physical Mobility - Anxiety [specify level] - Deficient knowledge regarding diagnosis, prognosis, and treatment - Risk for disturbed Body Image - Risk for ineffective Sexual Pattern - Self-Care Deficit [specify]

options

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- Disturbed Sensory Perception (specify) - Disturbed Thought Processes - Risk for Injury/Trauma

V. PERIPHERAL VASCULAR DISEASE

- Involves occlusion of the blood supply to arteries, veins and lymphatics in the extremities by atherosclerotic plaques - Risk factors are the same as those for CHD with diabetes and smoking being the greatest risk factor SIGNS AND SYMPTOMS OF PERIPHERAL VASCULAR DISEASE 1. Intermittent claudication involving pain, tightness or weakness in an exercising muscle 2. Complaints of cold feet on warm days 3. Burning pain in the feet when they are warmed 4. Leg pain and cramps when walking and completely relieved by rest 5. Diminished or absent peripheral pulses 6. Presence of bruit over the obstructed artery 7. Trophic changes seen in the leg (thinning of the skin, loss of hair, thick nails and decreased muscle mass) TREATMENT FOR PERIPHERAL VASCULAR DISEASE 1. Lifestyle modification Stop smoking, weight reduction and regular exercise program. 2. Antiplatelet and lipid-lowering therapy 3. Percutaneous transluminal angioplasty 4. Surgical reconstruction with aortobifemoral grafts or femoral-femoral grafts 5. Local treatments to preserve tissue keep feet clean and protected from trauma. Consult a podiatrist for thickened nails & calluses Treat infection with an appropriate antibiotic If ulcers develop regular, gentle cleansing and application of firm bandage NURSING DIAGNOSIS FOR PERIPHERAL VASCULAR DISEASE - Activity Intolerance - Ineffective Tissue Perfusion: Peripheral - Chronic Pain - Risk for Injury - Risk for Impaired Skin Integrity

RESPIRATORY SYSTEM
- Decrease in the lung elasticity reduces the lungs ability to inflate and deflate (elastic recoil) - Rib cage does not move as freely because of arthritic changes thereby decreasing the ease with which the thoracic cavity can expand - Alveoli becomes flatter and shallower decrease in the amount of tissue dividing individual alveoli decrease in the alveolar surface area limits respiratory volume.

I. PNEUMONIA
- An inflammatory condition of the lung - especially affecting the microscopic air sacs (alveoli) that can

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be caused by variety of factors including viruses, bacteria, fungi, and parasites - In addition to infection, pneumonia can also be caused by corrosive chemicals breathed into the lungs or toxic smoke inhalation from fire CLASSIFICATIONS OF PNEUMONIA 1. According to How Acquired: Community Acquired Aspiration Hospital Acquired 2. According to the Area of lung affected Lobar Pneumonia Bronchial Pneumonia Interstitial Pneumonia 3. According to Causative organism Viral Pneumonia Bacterial Pneumonia SIGNS AND SYMPTOMS OF PNEUMONIA - Productive cough - Shortness of breath - Confusion - Low blood pressure - Increased heart rate - Purulent sputum Fever accompanied by shaking chills Sharp or stabbing chest pain during deep breaths Rales or crackles during inspiration Increased respiratory rate Increased vocal resonance Low oxygen saturation 5. Analgesic and antipyretic 6. O2 therapy to treat hypoxemia 7. Chest physiotherapy

TREATMENT OF PNEUMONIA 1. Encourage to get plenty of rest 2. Adequate fluids 3. Antibiotic therapy 4. Prevention of pneumonia thru vaccination

PREVENTION OF PNEUMONIA 1. Vaccination Yearly Influenza vaccine for everyone 6 months and older 2. Environmental measures Reducing indoor air pollution Cessation of smoking 3. Appropriately treating other diseases such as AIDS NURSING DIAGNOSIS FOR PNEUMONIA - Ineffective Breathing Pattern - Ineffective Airway Clearance - Impaired Gas Exchange - Imbalanced Nutrition : less than body requirements - Activity Intolerance

II. TUBERCULOSIS
- an infection, primarily in the lungs, caused by bacteria called Mycobacterium tuberculosis - It is spread usually from person to person by breathing infected air during close contact - TB in older adults often represents reactivation of an earlier infection that may or may not have been diagnosed and treated.

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SIGNS AND SYMPTOMS OF TUBERCULOSIS The classic clinical feature of TB Fever Anorexia Shortness of breath Night sweat Hemoptysis Fatigue Weight loss Severe cough that lasts for more than 2 weeks TREATMENT FOR TUBERCULOSIS 1. Medications 2. Healthy environment Rifampin (Rifadin) 3. Proper nutrition Pyrazinamide 4. Hygiene Isoniazid 5. Regular exercise Ethambutol (Myambutol) 6. Enough rest and sleep NURSING DIAGNOSIS FOR TUBERCULOSIS - Ineffective Airway Clearance - Ineffective Breathing Pattern - Impaired Gas Exchange - Risk for Infection and spread of infection - Imbalanced Nutrition Less Than Body requirements - Knowledge Deficit - Activity Intolerance

III. CHRONIC OBSTRUCTIVE PULMONARY DISEASE

- An irreversible condition in which the airways are narrowed and become obstructed, thus the resistance to airflow is increased during expiration when airways collapse. RISK FACTORS FOR COPD - Smoking, second-hand smoke - Genetic - Predisposition/component SIGNS AND SYMPTOMS OF COPD Cough Breathlessness Leg edema Prolonged expiratory Use of accessory muscles Barrel chest in advanced disease - Hereditary - History of respiratory infection - Excessive alcohol consumption Body weakness Wheezing Ascites Clubbing Decreased breath sounds

DIFFERENCE BETWEEN EMPHYSEMA AND CHRONIC BRONCHITIS Emphysema Definition Abnormal and permanent dilation of the terminal air space of the lungs, combined with destruction of the alveolar wall Also called pink puffers Signs & Symptoms Barrel chest, pursed-lip breathing, use of accessory muscle when breathing Underweight appearance Persistent tachycardia Exertional dyspnea Dimished breath sound Chronic Bronchitis Results from recurrent inflammation and mucus production in the bronchial tubes Common COPD among older adults blue bloaters Tendency for obesity Bluish-red skin Discoloration from cyanosis, polycythemia Frequent cough w/ foul-smelling sputum Dyspnea and activity intolerance Increased anterior-posterior chest diameter

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Wheezes or crackles maybe present Laboratory & Diagnostics ABG analysis Chest x-ray Elevated RBC, Hgb and Hct (in later stage) Chest X-ray Pulmonary function tests

MANAGEMENT FOR COPD Four components: 1. Assess and monitor disease 2. Reduce risk factors Immunization against pneumonia and influenza Remove environmental pollutant Encourage smoking cessation 3. Manage stable COPD Antibiotics for concurrent respiratory infection Bronchodilator therapy Corticosteroid therapy O2 and nebulization therapy 4. Manage exacerbations Mechanical ventilation NURSING DIAGNOSIS FOR COPD - Ineffective airway clearance - Disturbed sleep pattern - Ineffective breathing pattern - Anxiety - Impaired gas exchange - Ineffective individual coping - Activity intolerance - Deficient Knowledge - Imbalanced Nutrition: less than body requirements

ETHICAL ISSUES IN THE CARE OF THE ELDERLY

Pragers Four Principles of Medical Ethics: 1. Beneficence and non-maleficence - Do good and dont do bad Beneficence - The obligation to do good Nonmaleficence - The obligation to avoid harm 2. Autonomy - Patients has the capacity to make health care decisions and should have the right to make decisions about their own bodies, whether or not those decisions are approved of by their physicians or families - Duty to respect persons and their right to independent self - determination regarding the course of their lives and issues concerning the integrity of their bodies and minds 3. Justice - broader societal issue concerning the allocation of limited health care resources. Nondiscrimination - duty to treat individuals fairly; not to discriminate on the basis of irrelevant characteristics Distribution - duty to distribute resources fairly, non-arbitrarily, and non-capriciously Fidelity - duty to keep promises 4. Respect for the sanctity of human life - Men, women and children should be respected, regardless of their mental capacity, physical ability, faith (or absence of faith) or social position. - We can restore human dignity through our witness of caring for each other, even in our times of dependence and need.

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ROLES OF THE GERONTOLOGIC NURSE a. Provider of care b. Teacher c. Manager d. Advocate e. Research consumer References: Sue E. Meiner & Annette G. Lueckenotte. Gerontologic Nursing, 3rd Edition Birchenall Joan M. & Steight. Care of the Older Adults, 3rd Edition. Philadelphia JB Lippincott Co. 1993 Burnside & Mortenson Irene. Psychosocial Nursing Care of the Aged, Mcgraw Hill Book Co. New York St. Louis, 2nd Edition Kozier, Erb, Blais & Wilkinson (2002). Fundamentals of Nursing, concepts, process, and practice, 5th Edition Hurlock Elizabeth, Developmental Psychology, Mcgraw Hill Lippincott JB, Lippincotts Manual of Nursing Practice, Toronto Murray R. & Zenther J., Nursing Assessment and Promotion Through the Lifespan, Pretence Hall