Safety

MR. MARK EBONY C. SUMALINOG, RN MSN

 INTRODUCTION

• Age-related changes can reduce the capacity of older

adults to protect themselves from injury and increase their
vulnerability to safety hazards

• Gerontological nurses need to identify safety risks when

assessing older adults and provide interventions to
address existing and potential threats to safety, life and
well-being
 AGING AND RISK TO SAFETY
NURSING DIAGNOSIS
Decrease in intracellular fluid Deficient Fluid Volume Deficit r/t
easier development of dehydration
Loss of subcutaneous tissue; less Risk of injury and Risk of Acute
natural insulation ; lower basal confusion r/t to hypothermia
metabolic rate
Decreased efficiency of heart Activity Intolerance r/t alterations
(decrease) in Cardiac Output
Reduced strength and elasticity of Risk of infection r/t reduced ability to
respiratory muscles; decreased lung expel accumulated or foreign matter
expansion; inefficient cough from lungs
response; less ciliary activity
 AGING AND RISK TO SAFETY
NURSING DIAGNOSIS
Reduced Oxygen use under stress Risk of ineffective peripheral tissue
perfusion and Risk of Ineffective
cerebral tissue perfusion r/t changes
in cardiovascular response to stress

Poor condition of teeth Risk of infection r/t dental disease or

aspirated tooth particles

Weak Gag reflex Risk of infection r/t aspiration

Altered taste sensation Imbalanced nutrition: More than body

requirements of salt or sweets r/t
taste deficit
 AGING AND RISK TO SAFETY
NURSING DIAGNOSIS
Reduction in filtration of wastes by Risk of Injury r/t ineffective
kidneys elimination of wastes from
bloodstream

Higher prevalence of urinary Risk of infection r/t stasis of urine

retention

More alkaline vaginal secretion Risk of infection r/t inadequate acid

envt. to inhibit bacterial growth
Decreased Muscle strength Risk of injury r/t dec. muscle strength
 AGING AND RISK TO SAFETY
NURSING DIAGNOSIS
Demineralization of the bone Risk of Injury and impaired physical
mobility r/t increased tendency of the
bones to fracture

Delayed response and reaction time
Poor vision and hearing
Reduced lacrimal secretions
Risk of injury r/t respond in a timely
manner
Risk of injury and impaired home
maintenance r/t misperception of
environment
Risk of injury and risk of infection r/t
dec. ability to protect cornea
 AGING AND RISK TO SAFETY
NURSING DIAGNOSIS
Distorted depth perception Risk of injury r/t dec. ability to judge
changes in level of walking surfaces

Increased threshold for pain and Risk of injury, risk of infection, and
touch impaired skin integrity r/t less ability
to sense problems such as pain and
pressure
Less elasticity and more dryness and Impaired skin integrity and risk of
fragility of skin infection r/t easier skin breakdown
Poor short term memory Risk of injury and non compliance r/t
inability to recall medication
administration, treatments
 AGING AND RISK TO SAFETY
NURSING DIAGNOSIS
High prevalence of polypharmacy Ineffective health maintenance and
risk of injury r/t combining drugs
inappropriately, drug interactions and
side effects
 Importance of the Environment to Health and Wellness

• The environment can be divided into two:

MICROENVIRONMENT and MACROENVIRONMENT

• Micro-environment: immediate surroundings with which

we closely interact (furnishings, wall coverings, lighting,
room temperature and room sounds)

• Macro-environment: elements in the larger world

(weather, pollution, traffic, and natural resources)
 Microenvironment as focus
• Environment provides more than shelter

• It should promote continued development, stimulation,

and satisfaction to enhance our psychological well-being

• This is important in older adults since they spend most of

their time in their homes, bedroom, or in a facility
 Microenvironment as focus
• To achieve fullest satisfaction from their
microenvironment, older adults must have various levels
of needs met within their surroundings

• This can be exemplified by comparing environmental

needs with the basic human needs as postulated by
Maslow
 Environmental Needs Based of Maslow's Heirarchy
Basic Human Environmental
Needs Needs
Security A haven from external threats, ability to safeguard
personal possessions, adequate lighting, locks,
smoke detectors, alarms

Physiological A shelter in which to live, adequate ventilation,

room temperature, functioning utilities and
appliances, pest control
 Environmental Needs Based of Maslow's Heirarchy
Basic Human Environmental
Needs Needs
Self- A space that promotes the realization of all potential,
actualization inspiring objects, beautiful grounds and relaxation aids

Self-esteem A home one can feel pride in having, elegant decor,

status symbol
Trust A niche in which one can feel confident, control over
lifestyle, consistent layout/ furnishings, temperature
and lighting
Love A place one derives pleasure from being, familiar, and
comfortable furniture, favorite objects, attractive
It can be hypothesized that higher level satisfaction can not
be achieved unless the lower needs are fulfilled:
Examples:
• They do not think installing a free smoke detector is important when there are
rodents in their apartment
• They refuse to have their house remodelled because it will make them look
affluent in a high-crime neighbourhood and be a target of burglary
• They remain socially isolated rather than invite guests to a house perceived as
shabby/ poor
• They are unwilling to engage in creative arts and crafts if they are adjusting to a
new unfamiliar residence
 IMPACT OF AGING ON ENVIRONMENTAL
SAFETY AND FUNCTION
LIMITATIONS POTENTIAL ENVIRONMENTAL IMPACT

Presbyopia Decreased ability to focus and visualize near

objects
Cornea less translucent, More external light needed to produce adequate
transmits less light image on retina
Decreased opacity of Colors more washed out, more contrast required
sclera, allows more light
to enter eye
Yellowing of lens Distorted color vision, particularly for browns,
beiges, blues, greens and violets
Senile cataracts cloud Glare more bothersome
lens
 IMPACT OF AGING ON ENVIRONMENTAL
SAFETY AND FUNCTION
LIMITATIONS POTENTIAL ENVIRONMENTAL IMPACT

Macular Degeneration Vision more difficult, more magnification needed

Senile miosis, pupil size Slower light to dark accomodation

decreased, lesser light
reaches retina
Decreased visual field Poor peripheral vision

Presbycusis Distortion of normal sounds

Dependency on hearing amplification of all environmental sounds

aid
 IMPACT OF AGING ON ENVIRONMENTAL
SAFETY AND FUNCTION
LIMITATIONS POTENTIAL ENVIRONMENTAL IMPACT

Reduced olfaction odors, smoke, gas leaks difficult to detect

less discriminating touch less stimulation from textures

sensation
less body insulation, more sensitivity to lower environmental
lower body temperature temperatures
slower nerve conduction slower response to stimuli, lesser ability to
regain balance
decreased muscle tone increased difficulty rising from a seated position,
and strength fatigue, less elevation of toes during ambulation,
shuffling gait
 IMPACT OF AGING ON ENVIRONMENTAL
SAFETY AND FUNCTION
LIMITATIONS POTENTIAL ENVIRONMENTAL IMPACT

Stiff joints difficulty climbing stairs, manipulating knobs and

handles
urinary frequency, frequent need for accessible bathroom
nocturia
shortness of breath, stairs, long hallways difficult to negotiate
easily fatigued
poor short-term memory forget to lock doors, turn off appliances

high use of medications increased risk of falls

causing hypotension,
dizziness
 IMPACT OF AGING ON ENVIRONMENTAL
SAFETY AND FUNCTION
• Based on common limitations found among older adults,
most of them needs an environment that is safe,
functional, comfortable, personal and normalizing
and that compensates for their limitations

• Creating such an environment requires considering

lighting, temperature, colors, scents, floor coverings,
furniture, sensory stimulations, noise control,
bathroom hazards and psychosocial factors

• Smoke detector
• Telephone
• Fire extinguisher
• Vented heating system
• minimal clutter
• functioning refrigerator
• proper food storage
• adequately lighted hallways
and stairways
Sample Checklist
• Handrails on stairs
• floor surface even, easy to
clean, requiring no wax, free
of loose scatter rugs and deep
pile carpets
• doorways unobstructed,
painted a contrasting color
from wall
• baththub or shower with
nonslip surface, safety rails,
no electric outlets nearby

• Hot water temperature less
than 43 ℃
• Windows screened, easy to
reach and open
• ample number of safe
electrical outlets, preferably 3
ft higher than level of floor for
easy reach, not overloaded
• safe stove with burner control
on front
Sample Checklist
• faucet handles easy to
operate, clearly marked hot
and cold
• proper storage of medications,
absence of outdated
prescription
• shelves within easy reach,
sturdy
 Sample Checklist
For wheelchair use:
• doorways and hallways clear and wide enough for passage
• ramps and elevators
• bathroom layout to provide maneuvering
• sinks, furnitures low enough to reach
 LIGHTING

Light has more profound effect than simply illuminating an

area. Light also affects the ff.:
• Function- individual more mobile and participate in more
activities
• Orientation- may lose perception of time in rooms
constantly lit or darkened for long periods of time
• Mood and Behavior- In restaurants, customers are
quieter and eat more slowly with soft illumination levels
than harsh, high ones
 LIGHTING

• Several diffuse lighting sources than a few bright ones are

best in areas used by older adults
• fluorescent light can be bothersome because of eye strain
and glare
• sunlight can be filtered by sheer curtains
• Nurse should assess for glare (light bouncing from floors
and furniture); evaluate light in seating position
 LIGHTING
• Nightlights help facilitate orientation during the night and
provide visibility to locate light switches or lamps for night
time mobility
• a soft red light can be useful at night in the bedroom to
improve night vision
• exposure to natural light during the normal 24 hr dark-light
cycle helps maintain body rhythms, which in turn influences
body temperature ,sleep cycles, hormone production and
other functions.
 TEMPERATURES
• Older adults are sensitive to lower temperatures
• RECOMMENDED TEMPERATURE for older adults is
not lower than 75 F (24℃)
• Room temperature LESS THAN 70 F (21℃) can lead
to hypothermia in older adults
• Brain damage may result if temperature EXCEEDS 106
F (41℃)
 COLORS
• CONTRASTING COLORS are helpful in defining doors,
stairs, and level changes within the area
• certain colors may be used to define different areas-
eg. bedrooms may be blue and green; eating and activity
areas may be orange and red; and lounge areas may be
gray and beige
• AVOID WAVY AND DIAGONAL PATTERNS for floor and
wall coverings- may create confusion/ dizziness
 SCENTS
• The use of essential oils for aromatherapy

• An organ called the amygdala is housed in the limbic

system and stores memories associated with different
scents (memories can be dormant for many years)

• Essential oils can also be used topically through

massage or baths
 FLOOR COVERINGS

Carpeting can reduce number of fractures associated with

falls; HOWEVER, CARPETING DOES CREATE
PROBLEMS LIKE:
• static electricity and cling- older adults have a shuffling
gait and may experience discomfort from static electricity;
clinging of slippers may cause falls
• difficult wheelchair mobility- the more plush the carpet
is, the more difficult it becomes to roll wheels on its
surface
 FLOOR COVERINGS
• Cleaning- spills are difficult to clean
• Odors- cigarette smokes and other odors can cling to
carpeting, creating an unpleasant odor that lasts. Urine,
vomitus, and other substances demand special
deodorizing efforts
• Pests- cockroaches, moths, fleas and other pests can
reside
 FLOOR COVERINGS
• Carpeting can be applied to wall surfaces rather than the
floor- this can provide a noise buffer, textural variation,
and a decor with a fewer housekeeping and maintenance
problems
• scattered and area rugs causes falls
• tiled floor covering should be laid on a wood
foundation rather than directly to the cement surface for
better insulation and cushion
 FLOOR COVERINGS
• single and solid color is preferable for floors
• a non-glare floor is beneficial
• non-slip treatments in bathrooms, kitchen, and areas
leading from outside doors (avoid floor wax)
 SENSORY STIMULATION

Much can be done to create an environment that is

pleasing and stimulating to the senses.

Suggestions include:
• textured wall surfaces
• soft blankets and spreads
• differently shaped and textured objects to hold (pillow)
• murals, pictures, sculptures, and wall hangings
• plants and freshly cut flowers
 SENSORY STIMULATION
• coffee brewing, food cooking, perfumes (as desired) and
oils
• birds to listen and animals to pet
• soft music
 NOISE CONTROL

• Ideally, noise control begins with the design of the

building
• Careful landscaping and walls can buffer outdoor sounds
• Acoustic ceilings, drapes, and carpeting- also useful
on walls- are helpful, as attention to appliance and
equipment maintenance
• Radios and television should not be playing when no one
is listening. Use earphones to prevent them from being
exposed to high volumes
 PSYCHOSOCIAL CONSIDERATIONS

• The human element makes the picture complete (objects

are only part of the picture)
• TERRITORIALITY is common
many of us would become uncomfortable with a visitor to our
office sifting though the papers in our desk, or a house guest
looking through our closets
• The more dependent an older adult is, the more personal
space and privacy is invaded (eg. institutionalized setting)
 PSYCHOSOCIAL CONSIDERATIONS

SEVERAL BASIC MEASURES:

• Define specific areas and possessions that are the
individual's (chair, closet, room in the house, this side of
the room)
• Provide privacy areas for periods of solitude. If not
available, arrange furniture to achieve maximum privacy
(eg. beds on different sides of the room, and plants as room
dividers)
 PSYCHOSOCIAL CONSIDERATIONS

• Request permission to enter personal space. (imagine a

5-10 feet of invisible circle around the person)
• Allow maximum control over one's space
 PSYCHOSOCIAL CONSIDERATIONS
• Clocks, calendars and newspapers to promote
orientation
• Easily accessible books and magazines to challenge
the mind
• Games and hobbies can offer stimulation (alternative to
watching television)
• Placement of chairs to promote interaction with
other people
 PSYCHOSOCIAL CONSIDERATIONS

An institutionalized older adult may have a variety of

reactions, such as:
• DEPRESSION over the loss of health, personal
possessions and independence
• REGRESSION because of the inability to manage the
stress at hand
• HUMILIATION by having to request basic necessities
and minor desires, such as toileting, a cup of tea or cigar
• ANGER at the loss of control and freedom
 PSYCHOSOCIAL CONSIDERATIONS

Nursing homes can not offer the same satisfaction as the

person's own home, but the institutional environment
can be enhanced through:
• an attractive decor
• inclusion of the individual's personal possession
• respect for privacy and personal territory
• recognition of the individuality of the resident
• allowance of maximum control over activities and
decision making
• environmental modifications to compensate for deficits
 THE PROBLEM OF FALLS
Age-related factors
• History of falls, female aged 75 years and older, impaired
vision, gait disturbance, Postural hypotension

Health Conditions
• physical disability, incontinence, delirium, dementia, mood
disturbance, dizziness, weakness, fatigue, ataxia,
paralysis, edema, use of cane, walker, wheelchair, use of
restraints, presence of IV and indwelling catheter
 THE PROBLEM OF FALLS

Health conditions
• unstable cardiac conditions, neurologic diseases,
Parkinsonism, TIA, CVA, DM, PVD, orthopaedic disease,
foot problems, multiple diagnosis

Medications
• Antidepressants, Anti-hypertensives, Anti-psychotics,
diuretics, sedatives, tranquilizers, multiple medications
 THE PROBLEM OF FALLS

Environmental Factors
• Newly admitted to hospital/ home, unfamiliar environment,
highly polished floors, inadequate lighting, absence of railings,
grab bars, poor environmental design, clutter, equipment
• caregiver related factors: unsafe practices, poor supervision of
problem behaviors, improper use of restraints
• unsafe clothing: poor fitting shoes and socks, long robes or
pants
 INTERVENTION AGAINST FALLS
• Assess risk of injury to patients (Hendrich II Fall Risk Model)
• orient patient to new environment
• encourage patient to wear prescribed eyeglasses, hearing aids, and
prosthetic devices
• ensure patient uses canes, walker, and wheelchair properly and only when
prescribed
• avoid the use of physical or chemical restraints unless assessed to be
absolutely necessary, use proper procedures to ensure safety when they are
used
• advise patients to change position slowly, holding on to a stable object
• keep floors free from clutter
 INTERVENTION AGAINST FALLS
• provide good lighting in all areas
• store cleaning solutions and other poisonous substances in a safe area
• encourage patients to use handrails and grab bars
• assist patients as needed with transfers
• review medications used for continued need, effectiveness, appropriateness
of dosage, instruct patient in safe medication use
• be sure patients wear well-fitted, low heeled shoes and robes and pants
of an appropriate length
• promptly detect and obtain treatment for changes in physical or mental
health status
 INTERVENTION AGAINST FALLS

• review home environment for safety risk and assist patient in obtaining
assistance in eliminating risks (senior housing)
• if safety risk are associated with insufficient finances, refer patient to a social
service agency to explore possibility of obtaining assistance
 ALTERNATIVES TO RESTRAINTS

• placing patient in a room near the nursing station in which close

observation and frequent contact are facilitated
• one-to-one supervision and companionship
• use of electronic devices that alert staff when the patient attempts to get
out of bed or leaves the designated area
• repositioning, soothing communication, touch and other comfort measures
• frequent reality orientation and reassurance
• diversional activities
 Interventions to Reduce Intrinsic Risks to Safety

• It takes a longer time for older adults to recover from a fall

• The longer the time, THE RISK OF HAVING MORE
COMPLICATIONS OCCUR!
• INTRINSIC FACTORS present in older adults need additional
preventive measures to promote safety
 Reducing Hydration and Nutrition
Adequate fluid intake can be difficult in older adults-
• physically incapable, depressed or demented
• thirst perception declines with age
• self-imposed fluid restriction to address urinary frequency
• mental capacity may not respond well to thirst

- May provide soft drinks, coffee, juices, jello, ice chips, fresh citrus
fruits (other than plain water)
 Reducing Hydration and Nutrition

• Poor oral health, GI symptoms, altered cognition, depression and

dependency on others for food can lead to poor food intake
• limited funds, problems in shopping food, and lack of motivation
to prepare healthy meals
• fatigue, weakness, dizziness and other symptoms associated with
poor nutrition can predispose an elderly to accidents and illness

- appropriate QUANTITY AND QUALITY OF FOOD intake can

increase body's resistance to such problems
 Risks Associated with Sensory Deficits

• Annual eye examinations are helpful to ensure appropriate

corrective lenses and detect many eye disorders that increase in
prevalence with age
• Poor peripheral vision- approach from the front rather than from
the back or side; furniture should be arrange in full view
• Good lighting, eliminating clutter on stairways, using contrasting
colors on stairs, and providing signals when a change in level
is being approached for poor proprioception
 Risks Associated with Sensory Deficits

• bright red, orange, yellow and contrasting colors on doors

and windows can be appealing
• cleaning solutions, medications and other materials should be
labelled in large letters to prevent accidents or errors
• hearing deficits- audiometric evaluation; do not purchase a
hearing aid without it
• explanations and directions for diagnostics, medication
administration, and other therapeutic measures SHOULD BE IN
WRITTEN AND VERBAL FORM
 Risks Associated with Sensory Deficits

• Hearing impaired individuals SHOULD live next to someone with

adequate hearing to alert them in situations like fire
• Specially trained dogs
• Lip reading (can be difficult in dimly lit rooms)- direct flashlight
on lips
• Use stethoscope to amplify conversation- place earpieces to
the older adult's ears and talk to the bell portion
• Electric stoves are better than gas stoves for older adults who
can not detect gas leaks
 Mobility Limitations

• Slower response and reaction time may be safety

hazards- crossing the street, older drivers may not react quickly in
the streets resulting to accidents
• Slower movement and poor coordination subject older adults to
falls and accidents- loose rug, slippery floors, clutter and poorly
fitting slippers and shoes; therefore, eliminate them
• Older persons should not be advised to take the risk such as
climbing ladders or sitting on ledges to wash windows
 Monitoring Body Temperature

• Temperature fluctuations can be hazardous to older adults

• Know the baseline norm (36 C is normal in older adults)
• An elevation may indicate infection, and if undiscovered or
untreated can lead to more serious complications (eg. elevates
from 36 C to 37 C)
• For every 1 C elevation, the heart rate increases
approximately 10 beats per minute- older adults can't tolerate
it well
 PREVENTING INFECTION

• Contact with persons who have known or suspected infections

SHOULD BE AVOIDED, as should crowds during flu season
• Vaccines should be kept up-to-date: flu vaccine annually;
pneumococcal vaccines once in a lifetime; tetanus
vaccines every 10 years
• prevent immobility, malnutrition, and poor hygiene
• Garlic and Ginseng to fight and prevent infection
 SUGGESTING SENSIBLE CLOTHING

• Shoes that are too large offer poor support

• Heels, long robes and loose hosiery can lead to falls
• Garters and tight fitting shoes can obstruct circulation
• Hats and scarves decrease the visual field
• Clothing that is practical, properly fitting and conducive to
activity is advisable
 USING MEDICATIONS CAUTIOUSLY

• Drugs should be prescribed only when necessary and only after

non-pharmacologic measures of treatment have
proved ineffective
• Older adults and caregivers should be taught the proper use, side
effects and interactions of all drugs they are taking
• Discrete use of over the counter drugs
 AVOIDING CRIME

• Older adults are ready targets for criminals; older adults become
reluctant to leave their homes
• Reasonable discretion should be used in traveling alone at night
and in opening doors to strangers
• Should use caution in negotiating contracts; seek
family members or professionals as needed
 PROMOTING SAFE DRIVING

• Older adults are 15 times more likely to die than the

younger ones in car accidents
• Evaluate their continued ability to drive safely (poor vision,
use of medications that reduce alertness and slower reflexes)-
driving is a complex skill that needs rapid cognitive and
psychomotor responses
• Restrict driving to daytime, avoid congested areas, and
drive only when weather is good
 Promoting Early Detection of Problems

• Regular professional assessment is IMPORTANT

• Self-evaluation by older adults can be beneficial because they will
recognize changes or abnormalities in themselves that signals
problems
• Teach them to take their own temperature and pulse
(do not assume that they know)
• Teach them to listen to their own lungs with a
stethoscope
 Promoting Early Detection of Problems

• Teach them to observe changes in their own sputum,

urine, and feces
• Teach them to identify the effectiveness, side effects and
adverse reactions of their medications
• Teach them to recognize symptoms that should warrant
professional evaluation
 Promoting Early Detection of Problems

Other situations to note includes-

• smoking in bed
• incontinence
• inappropriate use of walker or other mobility aid
• dizziness resulting from a new medication
• driving a car with poor vision
• cashing Social Security checks in high-crime area
• having an active pet that is constantly underfoot
 Risks Associated with Functional Impairment

• Referring the individual to an occupational therapists,

audiologists, ophthalmologist, psychiatrist, and other specialist for
evaluation of the existing condition and prescription of appropriate
treatment
• Providing assistive devices and mobility aids and
instruction in their use
• Helping the person to prepare an label drugs for unit dose
administration; develop a triggering and recording system for
drug administration
 Risks Associated with Functional Impairment

• arranging for telephone reassurance, home health aid, home

delivered meals, housekeeper, emergency alarm system, or other
community resources to assist the impaired persons
• instructing and SUPPORTING FAMILY CAREGIVERS as
they supervise and care for the impaired individual
• modifying the individual's environment to reduce hazards and
promote function
 SAFE MEDICATION USE

• Older adults are also more likely, than other populations, to take
more than one medication regularly, increasing the risk of
interactions and adverse reactions (POLYPHARMACY)
• drugs act differently in older adults than in younger ones;
therefore requiring careful dosage adjustment and monitoring
• close supervision is needed and adherence to sound
principles of safe drug use to minimize the risks associated
with drug therapy
 SAFE MEDICATION USE

• Most commonly used drugs by the older population:

Cardiovascular agents, Anti-hypertensives, Analgesics, Anti-
arthritic agents, Sedatives, Tranquilizers, Laxatives, and Antacids

• This drugs can cause adverse effects like confusion, dizziness,

falls, F&E imbalance that threatens older people's quality of life

• Furthermore, when taken together, can cause serious adverse

effects
 SAFE MEDICATION USE

• Ex. Acetaminophen- accumulation to toxic level if more than 500 mg

Vitamin C supplements are ingested daily

• Ex. Allopurinol- impairs iron absorption, leading to IDA

• Ex. Aluminum antacids- depletes phosphate and calcium;

decreases absorption of vitamin A, C and D and magnesium,
thiamine and iron

• Ex. Antihistamines- when taken with alkaline food (milk, cream,

almonds, and alcohol) can PROLONG ACTION
 Altered Pharmacokinetics: Absorption
• Route of administration-
Drugs given IM, SQ, PO and rectally are not absorbed
efficiently as drugs that are inhaled, applied topically or IV

• Concentration and Solubility of Drug-

Drugs that are highly soluble (aqueous solution) and in higher
concentrations are absorbed with greater speed than less soluble
and concentrated drugs
 Altered Pharmacokinetics: Absorption
• Diseases and Symptoms-
DM and hypokalemia can increase the absorption of drugs;
whereas pain and mucosal edema slows absorption

Dec. intracellular fluid, inc. gastric pH, dec. gastric blood flow,
reduced cardiac output and circulation can slow drug absorption
 Altered Pharmacokinetics: Absorption

• Exercise stimulates circulation and aids in absorption

• Properly used heat and massage can increase blood flow at
the absorption site
• Preventing fluid volume deficit, hypothermia, and
hypotension is beneficial in facilitating absorption
• Preparations that neutralizes gastric pH should be avoided if a low
gastric pH is required for drug absorption
 Altered Pharmacokinetics: Distribution

• changes in circulation, membrane permeability, body temperature,

and tissue structure can modify these process
• older adults have more adipose tissue compared to
lean body mass; therefore, lipid-soluble drugs (drugs stored in
adipose tissue) will have increased tissue concentration,
decreased plasma concentrations and a longer duration in the
body
• decreased cardiac output can increase plasma levels of
drugs while reducing deposition in their reservoirs (water-soluble
drugs)
 Altered Pharmacokinetics:
Metabolism, Detoxification and Excretion

• conditions such as dehydration, hyperthermia, immobility, and

liver disease can decrease the metabolism of drugs
• drugs can accumulate to toxic levels and cause serious
adverse reactions
• careful monitoring is essential; creatinine clearance must be
calculated based on the age, weight and serum creatinine level of
the individual (serum creatinine alone does not reflect creatinine
clearance)
 Altered Pharmacokinetics:
Metabolism, Detoxification and Excretion
• in advanced age, there may be a reduced secretion of
some enzymes, which interferes with the metabolism of the
drug that requires enzymatic activity

• detoxification and conjugation of drugs is reduced

therefore the drug stays longer in the blood stream

• reduced efficiency of body organs with advanced age affects

the kidneys as well, complicating drug excretion in older
adults
 Altered Pharmacokinetics:
Metabolism, Detoxification and Excretion

• liver decreases in size and function with age and hepatic blood
flow decline by 45%. This affects the metabolism of drugs such as
antibiotics, cimetidine, chlordiazepoxide, digoxin, lithium,
meperidine, nortriptyline and quinidine
 Increased Risk of Adverse Effects

The following are some general factors to remember in regard to

adverse reactions:
• adverse reactions may differ in older adults
• a prolonged time may be required for an adverse reaction to occur
• it may be demonstrated even after the drug has been
discontinued
• it may also develop suddenly, even with a drug that has been
used over a long period of time without problems
 Increased Risk of Adverse Effects

• mental dysfunction often are early symptoms of adverse reactions

to commonly prescribed medications
 Promoting the Safe Use of Drugs

• Beers Criteria: avoiding potentially inappropriate drugs in older

adults (refer to page 232, box 18-1), and drugs that are
inappropriate to use in a specific condition (refer to page 233,
table 18-4)
 Reviewing Necessity and Effectiveness of
Prescribed Drugs

• Why is the drug ordered?

• Is the smallest possible dosage ordered?
• Is the patient allergic to the drug?
• Can this drug interact with other drugs, herbs, or nutritional
supplements that are being used?
• Are there any special instructions accompanying the drug's
administration?
• Is the most effective route of administration being used?
 Promoting Safe and Effective Administration

• Proper oral hygiene, ample fluids for assistance with swallowing

and mobility, proper positioning and examining the oral cavity after
administration will ensure the patient receives the full benefit of
the medicine during its travel through the GI system.
• Combining the medication with food and drinks can
make the medication palatable and prevent gastric irritation
• oral hygiene after the administration to remove after taste
• enteric-coated and sustained release capsule should not be
crushed
 Promoting Safe and Effective Administration

• Suppositories takes time melt and may require extra effort

to ensure it is not expelled.
– circulation in the lower bowel and vagina is decreased and the body
temperature is lower compared to younger individuals
• Upper outer quadrant of the buttocks is the best site for
IM injection. Apply pressure if ooze of blood occurs.
• alternating the injection site will help to reduce discomfort.
do not inject in an immobile limb because it reduces the rate of
absorption
 Promoting Safe and Effective Administration
• IV- declining cardiac and renal function makes the older adult
susceptible not just to dehydration but also over-hydration.

The nurse must closely monitor for signs of circulatory overload:

elevated BP, RR, coughing, shortness of breath and symptoms
associated with pulmonary edema.

Monitor also for weight, I and O, and urine's specific gravity.

 Providing Patient Teaching
Older adults are responsible for self medication; therefore, the nurse
must assess for risks for medication errors:
• Use of multiple medications Presence of expired or
• cognitive impairment borrowed medications at home
• hearing deficits
• arthritis or weak hands
• Hx of non-compliance with medical care
• lack of knowledge regarding medications
• limited finances
• illiteracy
• Lack of support system
• Hx of inappropriate medications
 Factors that could interfere with safe drug administration

• Functional limitation: ex. stroke

• Cognitive limitation: ex: forgetfulness
• Educational limitation: ex: low educational attainment
• Sensory limitation: ex: visual deficits
• Financial limitation: ex: limited funds
• Choice: ex: denial of one’s condition
 Promoting Safe and Effective Administration
• A detailed description, both verbal and written, should be
given to older people and their caregivers, outlining the drug's
name, dosage schedule, route of administration, action, special
precautions, incompatible foods or drugs and adverse reactions.

• a color coded dosage schedule can assist the person who

have visual deficits or who are illiterate

• medications with large prints and caps can be easily

removed by weak and arthritic hand
 Promoting Safe and Effective Administration
• nurse reviews the patient's medication schedule and new
symptoms every patient visit

• CLASSIC MEDICATION ERRORS:

incorrect dosage, noncompliance arising from misunderstanding,
discontinuation or unnecessary continuation of drugs without
medical advice, and the use of medications prescribed for
a previous illness.
 Tips for Safe Drug Use: Teaching Tool

• Keep a current list of all of the following that you

use:
– prescription drugs
– OTC drugs
– vitamins, minerals and other supplements
– herbal and homeopathic remedies
– show this to your HCP
 Tips for Safe Drug Use: Teaching Tool
• For each drug, herb, homeopathic remedy or nutritional
supplement that you use, know (and if possible, have this
information written down) the:
– dosage
– administration schedule
– administration instructions (take on full or empty stomach, take only if
symptoms is present, discontinue after how many days)
– purpose
– usual side effects
– adverse effects that you should bring to the attention of your HCP
– precautions (when not to take it, interactions with food and other drugs)
– storage instruction
– where purchased or obtained
 Tips for Safe Drug Use: Teaching Tool
• Learn as much as you can about the drugs you are taking by
reading the literature that comes with the drug and consumer drug
reference books that are available at the bookstore

• recognize that your drug dosage may be different from

someone else's dosage who is taking the same drug

• be aware that you can develop adverse effects to drugs that

you have taken for years without problems. Review symptoms
with HCP
 Tips for Safe Drug Use: Teaching Tool
• Try to reduce the drugs your are using. Discuss with your HCP
improvements in your symptoms or other changes that could
cause a drug to no longer be needed

• periodically review your drug dosages with your HCP to see if any
changes in your body's function could lead to reduced dosages

• try to manage new symptoms naturally rather than with drugs

• do not take new drugs without consulting your HCP

 REVIEW OF SELECTED DRUGS
• Analgesics • Cholesterol-lowering drugs
• Antacids • Cognitive enhancing drugs
• Antibiotics • Digoxin
• Anticoagulants • Diuretics
• Anticonvulsants • Laxatives
• Anti-diabetics • Psychoactive drugs:
• Anti-hypertensives anxiolytics, antipsychotics,
• NSAIDS sedatives/hypnotics