Week 5

Nursing Care of the Older

Adult in Chronic Illness
CARE OF THE OLDER CLIENT
Learning Objectives:
 SENSORY
IMPAIRMENT
1. Visual Impairment

▪ Personal cost for older person with

visual impairment

❖ Loss of independence
❖ Social isolation
❖ Depression
❖ Decreased quality of life
Signs of difficulty with vision

❖ Squinting or tilting head to see

❖ Changes in ability to drive, read
❖ Holding objects closer to the face
❖ Difficulty with color discrimination
❖ Hesitation in reaching for objects
❖ Not being able to find something (American
Society on Aging, 2003)
 Cataract
Opacity of the crystalline lens or its capsule (partial
or complete)

Causes:
- injury -- traumatic
- exposure to heat, UV light
- heredity / congenital
- aging (>55) – senile
- DM – secondary
- smoking & alcoholismAnlysis of teaching
Risk factors:
◦Increased age
◦Smoking and alcohol
◦Diabetes, hyperlipidemia
◦Trauma to the eye
◦Exposure to the sun and UVB rays
◦Corticosteroid medications
Symptoms:
◦Blurred vision
◦Glare
◦Halos around objects
◦Double vision
◦Lack of color contrast or faded colors
◦Poor night vision
Surgery

▪ Phacoemulsification
a tiny probe is inserted which emits ultrasound waves that
soften & break up the lens so that it can be removed by
suction.

▪ Extracapsular / Intracapsular cataract

surgery
incision is longer on the side of cornea & removes the
cloudy core on the lens in one piece
 Glaucoma
Increase in intraocular pressure (IOP) optic nerve
damage vision loss.

❖ Open angle

◦Slowed flow of aqueous humor through trabecular

meshwork build up increased IOP damage to renal
nerve fiber loss of vision
 Glaucoma
❖ Angle-closure
Angle of the iris obstructs drainage of aqueous
humor through trabecular meshwork increased IOP
visual changes.

◦Symptoms:
Unilateral headache
Visual blurring
Nausea and vomiting
Photophobia
 Risk Factors for Glaucoma
❖ Increased intraocular pressure
❖ Older than 60 years of age
❖ Family history of glaucoma
❖ Personal history of myopia, diabetes
hypertension, or migraines
❖ African American ancestry
 Nursing Care
❖ Continued use of eye medications as ordered.
❖ Observation of IOP
❖ Avoid exertion, stooping, straining for a bowel
movement, coughing, heavy lifting, or wearing
constricting clothing,
❖ Instruct the client to report severe eye or brow
pain & nausea to the physician
❖ Eye Examination
 CAge-Related Macular
Degeneration (ARMD)
Two types
❖ Dry (atrophic form)-involutional mac deg
▪ Breakdown or thinning of macular tissue
▪ Atrophy
▪ Retinal pigment degeneration
▪ Drusen accumulations
▪ Slow progression of visual loss
 Age-Related Macular
Degeneration (ARMD)
❖ Wet (Neovascular exudates)-exudative macular
degeneration.

▪ Retina scar formation + visual problems

▪ Blurred vision
▪ Central scotomas
▪ Metamorphopsia
 Risk Factors for ARMD
Age (above the age of 50)
Cigarette smoking
Family history of ARMD
Increased exposure to ultraviolet light
Caucasian race and light colored eyes
Hypertension or cardiovascular disease
Lack of dietary intake of antioxidants and zinc
Nursing Diagnoses for Vision-
Impaired Older Patients

❖ Evaluate functional ability

❖Sensory/perceptual alterations:
visual
 2. Hearing loss

❖ > 30% aged 65 to 76 years

50% >75 years
❖ Older men > older women
❖ Caucasian men and women > African
American men and women
❖ Temporary threshold shift (TTS)
 A. Conductive Hearing Loss
Sound unable to be transmitted poor
reception + amplification
◦Site of problem

Causes:
Otitis externa
Impacted cerumen
 Treatment
hearing aids that amplify the sound, since the inner
ear and organs of sound perception are not
damaged.

B. Sensorineural Hearing Loss

Problems with cochlea + auditory nerve sound
distortion
 Causes:

• Presbycusis (bilateral progressive hearing loss

especially at high frequencies in elderly people)
• High-frequency hearing loss from excessive
noise (industrial noise, gunfire,
• “rock & roll” deafness)
 Hearing Loss Assessment
◦History
◦Physical examination
Inspection
Examination of ear canal
Childhood ear infections ruptured eardrum jagged
white scars on tympanic membrane in elderly
◦Hearing Handicap Inventory for the Elderly (HHIE-S)
oTalk with family members
Common Hearing Problems in
Older Persons
❖ Tinnitus

Nursing Diagnoses Associated with Hearing

Impairment
❖ Assessment
❖ Diagnosis

Protocol in cerumen removal

 3. Taste

➢ Oral status can affect gustatory function

❖ Poor dentition improper chewing
❖ Improperly fitting dentures Oral infections

➢ Focused assessment for taste

disturbances
➢ Education
 Xerostomia
Causes:
◦Systemic diseases
◦Radiation
◦Medications
◦Sjogren’s syndrome

Nursing Diagnoses Associated with

Taste Impairment
❖ Sensory/perceptual alterations: gustatory
❖ Intake less than necessary for caloric requirements
 4. Olfactory Dysfunction

Statistics
◦Males > females
Causes:
◦Nasal and sinus disease
◦Upper respiratory infection
◦Head trauma
 Nursing Diagnoses
▪ Nursing diagnosis associated with hyposmia
◦Sensory/perceptual alterations: olfactory

▪ Nursing diagnosis for changes in physical

sensations
◦Sensory/perceptual alterations: tactile
 Eye Examinations
❖ Healthy older adults
❖ Diabetics

Assessment of Vision
Observe appearance
• Clothing cleanliness
• Self-care
• Indications of bumps and bruises
 Interview
❖ Adequacy of vision
❖ Recent changes in vision
❖ Visual problems

Vision
• Snellen chart or reading from print
• Visual field testing
• Extraocular movements
Visual Aids
• Helpful aids for visually impaired
 Visual Difficulties May Limit
Independence
Identification of Safety Problems at
Home

ARMD Preventive Measures

Nurses should encourage
 B. Extracranial Disease
1. Cardiovascular abnormalities

a. Decrease cardiac output state-myocardial infarction,

arrhythmias, congestive heart failure, cardiogenic
shock

b. Alterations in peripheral vascular resistance-

increased and decrease states

c. Vascular occlusion-disseminated intravascular

coagulopathy, emboli
 PHYSIOLOGIC, PSYCHOLOGIC, AND
ENVIRONMENTAL CAUSES OF ACUTE
CONFUSIONAL STATES IN HOSPITALIZED
OLDER ADULTS

I. PHYSIOLOGIC
A. Primary Cerebral Disease
1. Nonstructural factors
2. Structural Factors
 2. Pulmonary abnormalities

a. Inadequate gas exchange states-pulmonary

disease, alveolar hypoventilation
b. Infection-pneumonia

3. Systemic infective processes-

acute and chronic
a. Viral
b. Bacterial- endocarditis, pyelonephritis, cystitis,
mycosis
 4. Metabolic disturbances
a. Electrolytes abnormalities-hypercalcemia,
hyponatremia and hypernatrimia, hypokalemia and
hyperkalemia, hypochloremia and hyperchloremia,
hyperphosphatemia

5. Drug intoxifications- therapeutic

and substance abuse
6. Endocrine disturbance

7. Nutritional deficiencies

8. Physiologic stress-pain, surgery

9. Alterations in temperature regulation-

hypothermia and hyperthermia
10. Unknown physiologic abnormality-
sometimes defined as pseudodelirium

II. PSYCHOLOGIC

III. ENVIRONMENTAL
 Differentiating Dementia and ACS
CLINICAL FEATURE ACUTE CONFUSIONAL STATE DEMENTIA
Onset Acute/subacute; depends on cause; often Chronic, generally insidious;depend on cause
occurs at twilight
Course Short; diural fluctuations in symptoms; worse Long; no diural effects; symptoms progressive,
at night, dark, and on awakening yet relatively stable over time
Duration Hours to less than 1 month Months to years
Awareness Fluctuates, generally reduced Generally clear
Alertness Fluctuates-reduced or increased Generally normal
Attention Impaired, often fluctuates Generally normal
Orientation Fluctuates in severity, generally impaired May be impaired
Memory Recent and immediate memory impaired; Recent and remote memory impaired; loss of
unable to register new information or recall recent memory is first sign; some loss of
recent events common knowledge
Thinking Disorganized, distorted, fragmented, slow, or Difficulty with abstraction and word finding
accelerated
Perception Distorted, illusions, delusions, or Misperceptions often absent
hallucinations
Sleep-wake cycle Disturbed, cycle reversed Fragmented
How do you communicate effectively with the elderly with
impaired verbal communication?
Thank you for listening
Time ：××× Teacher：×××
 References:

Mauk, Kristen. (2010). Gerontological nursing: competencies for care.MA: Jones & Bartlett
Publishers.610.7365 G31 2010
Eliopoulos (2018). Gerontological Nursing 9th Edition.Wolters Kluwer
Meiner (2019). Gerontologic Nursing 6th Edition. ELS
Miller (2019).Nursing for Wellness in Older Adults 8th Edition . Wolters Kluwer
Touhy ( 2018). Ebersole and Hess Gerontological Nursing and Health Aging
Filit (2017). Brocklehurts Testbook of Geriatric Medicine and Gerontology
Patińo, Mary Jane. (2016). Caregiving volume 1. Manila: Rex Book Store. F 649.1 P27 2016,v.1, c1
Doenges, Marylinn E. (2002). Nursing care plans: guidelines for individualizing patient care, 6th ed.
Philadelphia: F. A. Davis Company. R 610.73 D67 2002, c5
Meiner, S. E. (2007). Gerontological Nursing 3rd Edition. Quezon City. pp. 310-311, 371.
Wold, Gloria Hoffman. (2012). Basic geriatric nursing, 5th ed. MO: Elsevier.618.970231 W83 2012, c1
Websites:
http://thepoint.lww.com/Eliopoulos8e
http:www.sleepfoundation.org