High-Acuity Nursing, 6th Edition

The Older Adult High-Acuity Patient Objectives: 1. Describe the characteristics of the aging population. 2. Apply knowledge of age-related changes in neurologic and neurosensory function. 3. Apply knowledge of the age-related changes in cardiovascular and pulmonary function. 4. Apply knowledge of the age-related changes in integumentary and musculoskeletal function. 5. Apply knowledge of the age-related changes in gastrointestinal and genitourinary function. 6. Apply knowledge of the age-related changes in endocrine and immune function. 7. Differentiate between dementia, delirium, and depression, and describe their impact on older high-acuity patients and their families. 8. Discuss falls, pain, and pharmacology as factors that impact hospitalization in the older patient. 9. Demonstrate the use of common geriatric assessment tools. 10. Demonstrate the nursing management of older patients with high-risk injuries and trauma. 11. Explain special situations including the culture of caring for older adults and end-of-life care. I. The Older Adult Patient A. The older adult patient 1. Nurses working in high-acuity areas should understand the age-related changes that make older patients vulnerable to complications and that might impact the outcome of their hospitalization. 2. Older adults may present with common problems in uncommon ways: symptoms are less predictable; older patients may have multiple other comorbidities or chronic conditions, multiple medications, and adverse drug reactions; and they are at greater risk for disability and becoming permanently critically ill. 3. The application of early and appropriate interventions and protocols can improve care, promote optimal function, prevent complications, and provide for the best possible outcomes for hospitalized elderly patients. B. Characteristics of the older adult population 1. Demographics a) Demographic characteristics in the U.S. (people are living longer) (1) Population aged 65+ expected to double within next 20 years. (2) By 2030, ~1 in 5 (over 72 million) will be 65+. (3) More than 70,000 centenarians exist. (4) Fastest-growing group is people 85+. (5) The “age wave” will peak in 2030, when most baby boomers are 65+. 2. General health  a) High rates of chronic disease are related to high levels of disability. (1) 82% have at least one chronic condition (many have multiple). (2) Over half have some difficulty with daily activities or self-care. (3) Most common conditions: (a) Hypertension (b) Arthritis or joint problems (c) Heart disease (d) Cancer (e) Diabetes (f) Stroke (g) Asthma (h) Chronic bronchitis 3. Health care  a) Increased use of health care services by the older population (1) Older adults will be a majority in general hospital setting. (a) 3 times more hospitalization rates (b) 55% in the intensive care unit 4. Ethnic diversity a) Increasing racial and ethnic diversity in aging population (1) Growing immigrant and minority populations. (2) Older adults; changing percentages. (a) 2008: 6.8% non-Hispanic whites (b) 2050: 20% non-Hispanic whites (3) Nurses will need to strive to provide culturally competent care. PowerPoint Slides 1. Nurse has to assess each older adult individually. Multiple medications. Adverse drug reactions. Greater risk for disability and becoming permanently critically ill. Older patients may have multiple other comorbidities or chronic conditions. 2. Aging Demographics Characteristics in the U.S. Population aged 65+ to double within next 20 years. By 2030, ~1 in 5 will be 65+. More than 70,000 centenarians exist. Fastest growing group is people 85+. “Age wave” will peak in 2030. 3a. High rates of chronic disease —> high levels of disability: 82% have at least one chronic condition. Over half have difficulty with ADL. 3b. Most common chronic disease conditions: Hypertension Arthritis or joint problem Heart disease Cancer Diabetes Stroke Asthma Chronic bronchitis 4. Increased use of health care services by the older population: Older adults will be a majority in general hospital setting. 5. Increasing racial and ethnic diversity in aging population: Growing immigrant and minority populations. Older adults; changing percentages. Nurses will need to strive to provide culturally competent care. II. Neurologic and Neurosensory Systems Changes A. Neurologic system 1. Nursing implications of central nervous system changes  a) Aging affects many aspects of a person’s life experience: (1) Physical (2) Psychological (3) Social (4) Spiritual (5) Economic b) Aging process: gradual loss of function in all organ systems: (1) Changes associated with the normal aging process (2) Changes occurring due to a pathological process c) The application of early and appropriate interventions: (1) Improves care. (2) Promotes optimal function. (3) Prevents complications. (4) Provides the best possible outcomes. d) Age-related alterations in the central nervous system (CNS) (1) Loss of nerve cells begins at age 30. (2) Neurotransmitters are not synthesized at the same rate. (3) Declines in nervous system conduction. (4) Memory processes are slower. (5) Learning takes longer. (6) Blood brain barrier is more permeable (medications cross over). (7) Increased cranial dead space. e) Age-related central nervous changes impact the neurologic exam: (1) Mental status (2) Level of consciousness (LOC) (3) Ability to communicate and follow commands (4) Short- and long-term memory (5) Fine and gross motor function f) CNS changes impact ability to perform self-care. (1) Ability to follow instructions (2) Ability to interpret instructions B. Neurosensory systems 1. Changes include: a) As individuals age, there is a decline in all of the sensory receptors: (1) Protein deficiency. (2) Negatively impacts older adults’ ability to interact in their environment. b) Visual: Visual acuity and depth perception decrease. (1) Pupils are smaller; pupillary response to light is decreased. (2) Cornea becomes thicker, flatter, and more irregular in shape. (3) Lens becomes more opaque (cataracts and glaucoma are common). c) Smell: The sensitivity to smells is diminished: (1) More difficulty discriminating between varying intensities of a flavor (2) Taste sensation affected d) Auditory: Auditory function declines and there is decreased sensitivity to sound: (1) Increase in cerumen impactions blocks sound and affects hearing. (2) Difficulty hearing high-pitched sounds and rushed speech. (3) Require more time to process and respond to auditory stimuli. e) Touch: Sensitivity in the fingertips, palms, and lower extremities deteriorates with aging. 2. Nursing implications of neurosensory changes  a) Physiologic changes combine to alter ability to adapt to changes in the environment. (1) Decline in proprioception (2) Decline in balance (3) Decline in postural control PowerPoint Slides 1. Aging affects many aspects of a person’s life experience Physical Psychological Social Spiritual Economic 2. Aging process: gradual loss of function in all organ systems Changes associated with the normal aging process Changes occurring due to a pathological process 3. The application of early and appropriate nursing interventions Improves care. Promotes optimal function. Prevents complications. Provides the best possible outcomes. 4. Age-related alterations in the central nervous system (CNS): Loss of nerve cells begins at age 30. Neurotransmitters are not synthesized at the same rate. Declines in nervous system conduction. Memory processes are slower. Learning takes longer. Blood brain barrier is more permeable (medications cross over). Increased cranial dead space. 5. Age-related central nervous changes impact the neurologic exam: Mental status Level of consciousness (LOC) Ability to communicate and follow commands Short- and long-term memory Fine and gross motor function 6. Age affects self-care: CNS changes impact ability to perform self-care: Ability to follow instructions Ability to interpret instructions 7. As individuals age, there is a decline in all of the sensory receptors. Decline begins in second decade of life; rapid decline after 45–65. Negatively impacts older adults’ ability to interact in their environment. 8. Visual: Visual acuity and depth perception decrease. Pupils are smaller; pupillary response to light is decreased. Cornea becomes thicker, flatter, and more irregular in shape. Lens becomes more opaque (cataracts and glaucoma are common). 9. Olfactory: The sensitivity to smells is diminished: More difficulty discriminating between varying intensities of a flavor Taste sensation affected 10. Auditory: Auditory function declines, and there is decreased sensitivity to sound: Increase in cerumen impactions blocks sound and affects hearing. Difficulty hearing high-pitched sounds and rushed speech. Require more time to process and respond to auditory stimuli. 11. Touch: Sensitivity in the fingertips, palms, and lower extremities deteriorates with aging. 12. Physiologic changes combine to alter ability to adapt to changes in the environment: Decline in proprioception Decline in balance Decline in postural control III. Cardiovascular and Pulmonary Systems Changes A. Cardiovascular system 1. Coronary heart disease (CHD) statistics: a) CHD is the leading cause of death in America. b) 82% who die of CHD are age 65 or older. 2. Cardiovascular changes alter the function of myocardium and peripheral vasculature. a) Changes: (1) Decreased elasticity (2) Increased stiffness of the arterial walls (3) Heart muscle is replaced with fat (4) Loss of elastic tissue (5) Increase in collagen b) Results: (1) Ventricular hypertrophy (2) Arteriosclerosis (3) Increased systolic blood pressure (4) Decline in ventricular compliance 3. Age-associated physiologic changes combine to impact cardiovascular function: a) Increased prevalence of peripheral vascular disease b) Increased prevalence of coronary heart disease 4. Nursing implications of cardiovascular changes a) Elderly patients with cardiac ischemia and acute myocardial infarction (AMI): (1) Can present atypically. (a) Shortness of breath; abdominal, throat, or back pain (b) Syncope, acute confusion, flu-like syndromes, stroke, and/or falls (2) Can delay or confuse their diagnosis and treatment. 5. Diagnostic tests can be less reliable in the older patient. a) 50% of elderly patients do not have ST-T wave changes in ischemia. b) Creatine kinase levels might be in the normal range. 6. Therapeutic intervention a) Therapeutic treatments are applicable, but modifications may be considered. b) Physiologic age of an individual as well as chronological age should be assessed. c) Vigilant clinical assessment and monitoring to prevent complications. B. Pulmonary system 1. Physiological changes in respiratory system result from changes in compliance of chest wall lung tissue. a) Costal cartilage connecting rib cage calcifies; kyphosis develops. b) Vertebral collapse from osteoporosis. c) Increased anteroposterior (AP) diameter. d) Loss of lung elasticity. e) Decreased rib mobility and decreased strength of respiratory muscles. (1) Decline in maximum inspiratory and expiratory force by as much as 50% 2. Loss of epithelial cells a) Results in decrease in protective mucus, increasing risk for infections. b) Surface area of the lungs is decreased, resulting in less capacity. 3. Nursing implications of pulmonary system changes a) Respiratory disorders are commonly encountered in those: (1) Recovering from surgery. (2) Suffering from rib fractures or chest injuries. (3) Receiving narcotics. (4) With artificial airways. (5) Deconditioned. (6) With altered nutritional or hydration status. b) Nurses need to accurately assess respiratory status to determine: (1) Adequacy of gas exchange. (2) Ventilation and perfusion. (3) Worsening respiratory function. c) Increased complexity of care of the elderly patient on a mechanical ventilator: (1) Increased risk of ventilator-associated pneumonia (VAP) directly related to ventilation. (2) Implement VAP prevention guidelines. (3) Older patient might experience greater difficulty weaning from a ventilator. (4) Monitor with increased vigilance when weaning from a ventilator. PowerPoint Slides 1. Coronary heart disease (CHD) statistics: CHD is the leading cause of death in America. 82% who die of CHD are age 65 or older. 2. Cardiovascular (CV) changes alter the function of myocardium and peripheral vasculature: Changes Results 3. Age-associated physiologic changes combine to impact CV function: Increased prevalence of peripheral vascular disease Increased prevalence coronary heart disease 4. Disease presentation in elderly patients with cardiac ischemia and acute myocardial infarction (AMI) Can present atypically. Can delay or confuse their diagnosis and treatment. 5. Diagnostic tests can be less reliable in the older patient: 50% do not have ST-T wave changes in ischemia. Creatine kinase levels might be in the normal range. 6. Therapeutic interventions in the elderly: Therapeutic treatments are applicable (consider modifications). Assess physiologic age as well as chronological age. Vigilant clinical assessment and monitoring. 7. Respiratory physiological changes result from changes in compliance of chest wall or lung tissue: Costal cartilage connecting rib cage calcifies; kyphosis develops. Vertebral collapse from osteoporosis. Increased anteroposterior (AP) diameter. Loss of lung elasticity. Decreased rib mobility; decreased respiratory muscle strength. 8. Epithelial cell changes: Decrease in protective mucus (increases risk for infections) Surface area of the lungs is decreased (less capacity) 9. Respiratory disorders are commonly encountered in those: Recovering from surgery. Suffering from rib fractures or chest injuries. Receiving narcotics. With artificial airways. Deconditioned. With altered nutritional or hydration status. 10. Nurses need to accurately assess respiratory status. Determine: Adequacy of gas exchange. Ventilation and perfusion. Worsening respiratory function. 11. Increased complexity of care on a mechanical ventilator: Increased risk of VAP directly related to ventilation Greater difficulty weaning from a ventilator IV. Integumentary and Musculoskeletal Systems Changes A. Integumentary system 1. Continuous aging process is manifested through changes in the skin: a) Wrinkling and sagging. b) Loss of skin turgor. c) Ecchymosis. d) Skin becomes more transparent (underlying veins more visible). e) Loss of dermal and epidermal thickness. f) Skin becomes thin (more prone to skin breakdown and injury). 2. Number and efficiency of sweat glands decreases with aging, predisposing the patient to: a) Hypothermia. b) Hyperthermia. c) Fluid and electrolyte imbalances. 3. Nursing Implications of Integumentary Changes a) Nurses should complete a thorough skin assessment to monitor for changes in skin integrity. (1) Identify potentially life-threatening rashes, as well as cellulitis. (a) Rashes can be a side effect of a medication. (b) Cellulitis can be due to a contamination of the deep layer of skin. (2) Detect skin break (allows bacteria to enter). (3) Provide information regarding blood supply and venous drainage. (4) Detect skin breakdown. (5) Tissue ischemia. b) Risk of Skin Breakdown (1) Maintaining skin integrity. (a) A few hours on a backboard can alter skin integrity. (b) A few hours on an operating room table can alter skin integrity. (c) High-risk patients might require specialty beds. (2) Pressure ulcers can delay recovery, prolong hospitalization, and impact quality of life. (a) Use support surfaces. (b) Reposition the patient frequently. (c) Optimize nutritional status. (d) Moisturize sacral skin. c) Thermoregulation Problems. (1) Age-related skin changes can cause difficulty with thermoregulation. (a) Prevent heat loss by monitoring room temperature. (b) Keep the patient covered while bathing. (c) Use warmed blankets when necessary (2) Nursing care to promote skin integrity at IV sites includes: (a) Close monitoring for infiltrations. (b) Use of nonrestrictive dressings and paper tape. B. Musculoskeletal system 1. Common musculoskeletal issues in the older adult: a) Decreased muscle mass b) Bone demineralization c) Increased joint stiffness d) Decreased joint mobility e) Decreased muscle strength f) Fractures more common (pelvis, femur) 2. Age-related changes in other subsystems contribute to muscle mass and strength loss: a) Reductions in neuron-muscular innervation b) Insulin activity c) Estrogen d) Testosterone and growth hormone levels e) Weight loss f) Protein deficiency g) Physical inactivity 3. Osteoporosis a) Primary osteoporosis (1) A common result of aging, independent of disease and medication use b) Secondary osteoporosis (1) Caused by a disease process or medication 4. Osteoarthritis is the most common arthritic condition among older adults: a) Affects 12% of U.S. adults. b) Pathophysiology is not directly related to the aging process. c) Cartilage between joints becomes irregular and eventually is diminished. d) Pain and loss of function are complications. 5. Compression of the spinal column or the spinal nerves is caused by: a) Degenerative stenosis (narrowing of the spinal canal). b) Thinning of the cartilage between the vertebrae. c) Development of bone spurs around the vertebrae. 6. Nursing implications of musculoskeletal changes a) Posture, gait, balance, symmetry, and alignment can be altered. b) Weakness, joint-related pain, and fractures threaten mobility. (1) Might require adaptations in patient care c) Limitations on comfort, recovery, and physical therapy. PowerPoint Slides 1. Continuous aging process is manifested through skin changes: Wrinkling and sagging. Loss of skin turgor. Ecchymosis. Skin becomes more transparent. Loss of dermal and epidermal thickness. 2. Number and efficiency of sweat glands decreases with aging: Hypothermia Hyperthermia Fluid and electrolyte imbalances 3. Nursing Assessment: Monitor for changes in skin integrity: Identify potentially life-threatening conditions. Detect skin break. Provide information (blood supply, venous drainage). Detect skin breakdown. Tissue ischemia. 4. Maintaining skin integrity: A few hours on a backboard can alter skin integrity. A few hours on an operating room table can alter skin integrity. High-risk patients may require specialty beds. 5. Pressure ulcers can delay recovery, prolong hospitalization, and impact QOL. Use support surfaces. Reposition the patient frequently. Optimize nutritional status. Moisturize sacral skin. 6. Age-related skin changes cause thermoregulation difficulty. Prevent heat loss by monitoring room temperature. Keep the patient covered while bathing. Use warmed blankets when necessary. 7. Nursing care to promote skin integrity at IV sites includes: Close monitoring for infiltrations. Use of nonrestrictive dressings and paper tape. 8. Common musculoskeletal issues in the older adult: Decreased muscle mass Bone demineralization Increased joint stiffness Decreased joint mobility Decreased muscle strength Fractures more common 9. Other age-related changes contribute to muscle mass and strength loss: Reductions in neuron-muscular innervation Insulin activity Estrogen Testosterone and growth hormone levels Weight loss Protein deficiency Physical inactivity 10. Osteoporosis Primary osteoporosis Secondary osteoporosis 11. Osteoarthritis is the most common arthritic condition: Affects 12% of U.S. adults Pathophysiology is not directly related to aging process Cartilage between joints becomes irregular, diminished Pain and loss of function 12. Compression of spinal column or spinal nerves is caused by: Degenerative stenosis. Thinning of the cartilage between vertebrae. Development of bone spurs around vertebrae. 13. Important implications for patient care: Posture, gait, balance, symmetry, and alignment. Weakness, joint-related pain, and fractures threaten mobility. Limitations on comfort, recovery, and physical therapy. V. Gastrointestinal and Genitourinary Systems Changes A. Gastrointestinal (GI) System 1. Oral cavity changes a) Changes affecting the teeth include: (1) Wearing of tooth surfaces. (2) Thinning of enamel. (3) Cracking of teeth. (4) Tooth loss. (5) Periodontal disease. b) Oral tissues become more fragile. c) Salivary production can be altered. d) Osteoporosis or atrophy of the jawbone 2. Esophageal changes a) Changes in motility are not normal age-related changes. (1) Refer patient for further evaluation if: (a) Patient is having difficulty swallowing. (b) Patient is experiencing significant problems with reflux. b) Neurological diseases can contribute to altered motility. 3. Stomach changes a) Secretion of digestive juices is diminished b) Gastric acidity decreases (possibly from chronic infection with Helicobacter pylori) (1) Increases the risk for growth of bacteria in the stomach (2) Increases the risk of aspiration pneumonia 4. Small intestine changes: a) Absorptive capacity of cells is altered. b) Impacts the absorption of vitamins and minerals. 5. Large intestine changes—histological changes contribute to: a) Muscle atrophy. b) Slower transit rate. c) Diminished sphincter tone. d) Diminished compliance of the rectum. 6. Pancreas change. a) Exocrine function is decreased. 7. Liver changes a) Blood flow to the liver is reduced. b) Hepatocyte count is decreased. c) Hepatic regeneration is reduced. d) Decreased capacity to metabolize drugs 8. Nursing implications of gastrointestinal system changes  a) Symptoms of concern that relate to the health of the GI system: (1) Pain (2) Dysphagia (3) Dyspepsia (4) Nausea (5) Vomiting (6) Anorexia (7) Weight loss (8) Changes in stool characteristics (9) Gastrointestinal bleeding b) Many factors contribute to constipation: (1) Sedentary lifestyle (2) Poor diet (3) Dehydration (4) Systemic illness (5) Medications B. Genitourinary (GU) System 1. Kidney changes a) Renal blood flow decreases by 50% due to: (1) Atrophy of the efferent and afferent arterioles. (2) Sclerotic glomeruli. (3) Decrease in number and size of nephrons. b) Decline in glomerular filtration rate. c) Decrease in creatinine clearance. d) Renal tubular function declines. e) Decreased ability to absorb glucose. 2. Ureter changes a) Vulnerable to reflux of the vesicoureteral junction b) Leads to reflux of urine 3. Bladder changes a) Muscles weaken—can lead to incomplete emptying. b) Collagen content increases, limiting distensibility. c) Bladder capacity decreases; frequency of urination increases. 4. Problems in the urination process might be due to: a) Altered sphincter muscles. b) Neural controls. c) Outlet size. d) Muscle strength. e) Obstruction. f) Sensation of the need to void. 5. Contributors to altered genitourinary function in the older adult: a) Increased prevalence of atherosclerosis b) Hypertension c) Heart failure d) Diabetes e) Infection f) Exposure to nephrotoxins 6. Nursing implications for GU changes are numerous: a) Fluid balance b) Renal failure c) UTIs d) Incontinence e) Sexual dysfunction 7. Increased vulnerability to fluid and electrolyte imbalances: a) Decreased urinary concentrating ability b) Limitations in excretion of water, sodium, potassium, and acid c) GU system’s declining ability to compensate 8. Nursing implications of genitourinary changes: a) Urinary tract infections (UTIs) b) Responsible for most community-acquired bacteremia c) Attributed to the presence of indwelling catheters in the hospital d) Often symptoms are not apparent e) Older adult patient might present with atypical manifestations: (1) Mental changes (2) Confusion (3) Nausea and vomiting (4) Abdominal pain f) Atypical manifestations can result in delay in diagnosis 9. Nurses should routinely assess: a) Hemoglobin b) Hematocrit c) BUN d) Serum creatinine e) Urine albumin f) Glucose g) PH h) Microscopic examination of urinary sediment i) Screening for bacteria 10. Nurses should consider urinary symptoms: a) Nocturia b) Dysuria c) Frequency d) Urgency e) Incontinence PowerPoint Slides 1. Oral cavity changes Changes affecting the teeth include: Oral tissues become more fragile. Salivary production can be altered. Osteoporosis or atrophy of the jawbone. 2. Esophageal changes Changes in motility are not normal age-related changes. Neurological diseases can contribute to altered motility. 3. Stomach changes Secretion of digestive juices is diminished. Gastric acidity decreases. 4. Small intestine changes Absorptive capacity of cells is altered. Impacts the absorption of vitamins and minerals. 5. Large intestine changes—histological changes contribute to: Muscle atrophy. Slower transit rate. Diminished sphincter tone. Diminished compliance of the rectum. 6. Pancreas changes Exocrine function is decreased. 7. Liver changes Blood flow to the liver is reduced. Hepatocyte number is decreased. Hepatic regeneration is reduced. Decreased capacity to metabolize drugs. 8. GI symptoms of concern: Pain Dysphagia Dyspepsia Nausea/vomiting Anorexia Weight loss Changes in stool characteristics Gastrointestinal bleeding 9. Many factors contribute to constipation: Sedentary lifestyle Poor diet Dehydration Systemic illness Medications 10. Kidney changes Renal blood flow decreases. Decline in glomerular filtration rate. Decrease in creatinine clearance. Renal tubular function declines. Decreased ability to absorb glucose. 11. Ureter changes: Vulnerable to reflux of the vesicoureteral junction. Leads to reflux of urine. 12. Bladder changes: Muscles weaken. Collagen content increases. Bladder capacity decreases. 13. Problems in the urination process can be due to: Altered sphincter muscles. Neural controls. Outlet size. Muscle strength. Obstruction. Sensation of the need to void. 14. Other contributors to altered genitourinary function in the older adult: Increased prevalence of atherosclerosis Hypertension Heart failure Diabetes Infection Exposure to nephrotoxins 15. Nursing implications for GU changes are numerous: Fluid balance Renal failure UTIs Incontinence Sexual dysfunction 16. Increased vulnerability to fluid and electrolyte imbalances Decreased urinary concentrating ability Limitations in excretion of water, sodium, potassium, acid GU system’s declining ability to compensate 17. Urinary tract infections (UTIs) Responsible for most community-acquired bacteremia Attributed to the presence of indwelling catheters Often symptoms are not apparent Older adult patient might present atypically Atypical manifestations can cause delayed diagnosis 18. Nursing assessment should routinely include: Hemoglobin. Hematocrit. BUN. Serum creatinine. Urine albumin. Glucose. PH. Microscopic examination of urinary sediment. Screening for bacteriuria. 19. Nurses should consider urinary symptoms: Nocturia Dysuria Frequency Urgency Incontinence VI. Endocrine and Immune Systems Changes A. Endocrine system 1. Hormone changes a) Decreased production of estrogen b) Decreased production of progesterone c) Decreased production of testosterone 2. Pancreas changes a) Pancreas secretes less insulin. b) Increase in insulin resistance. c) Decreased ability to metabolize glucose. d) Increase in the prevalence of diabetes mellitus (DM). (1) ~25.8% of the population with diabetes is aged 65+. 3. Nursing Implications of Endocrine System Changes  a) Thyroid changes (1) Aging body uses less thyroid hormone. (2) Thyroid gland atrophies. (3) Increased risk for hypothyroidism. (4) TSH values can be elevated. (5) Basal metabolic rates decrease. b) Glucose metabolism changes (1) Influences on glucose metabolism: illness, medications, and nutritional alterations. (2) Assess macro vascular, micro vascular, and retinal complications. (3) Assess foot complications and foot ulcers. c) Thyroid conditions are often undiagnosed. (1) Hypothyroidism is associated with: (a) Slowing of mental and physical function. (b) Intolerance to cold. (c) Weight gain. (d) Constipation. (e) Alterations in blood pressure. (f) Anemia. d) Hyperthyroidism (1) Irregular heart rhythms (tachycardia and atrial fibrillation) (2) Congestive heart failure (3) Weight loss (4) Fatigue (5) Muscular weakness e) Thyroid storm is a dangerous complication of hyperthyroidism (1) Fever (2) Tachycardia (3) Nausea (4) Vomiting (5) Mental status changes (6) Heart complications B. Immune system 1. The immune system of an older person is more vulnerable. a) Cell-mediated immunity declines with aging. b) T-cell function decreases. c) Humoral-mediated immunity and antibody responses are impaired. 2. Infection can present atypically in an older person. a) Fever might be absent (elderly patients have lower basal temperature). b) Diagnosis might be delayed. c) Nonspecific expressions of infection can include: (1) Changes in mental status. (2) Altered mental status (delirium, somnolence, and coma). (3) Functional decline. (4) Hypothermia. (5) Unexplained hypo- or hyperglycemia. (6) Acidosis. (7) Tachycardia. (8) Falls. (9) Tachypnea. (10) Anorexia. (11) Malaise. (12) Generalized weakness. (13) Urinary incontinence. 3. Pneumonia and influenza are among the top ten causes of death for older adults. a) It is vital to identify pneumonia early. (1) Breath sound assessment and monitoring of oxygen status. b) Influenza and pneumococcal vaccines decrease the risk for pneumonia. (1) A vaccination history is important to obtain. 4. Nursing implications of immunologic changes  a) Nurses must anticipate patients at high risk for infection and assess them appropriately. (1) Consider preexisting illnesses. (2) Consider recent history of diagnostic tests involving invasive or indwelling lines. (3) Carefully monitor clinical signs. 5. Bacteremia —> systemic inflammatory response (SIRS) a) SIRS can further deteriorate to severe sepsis and septic shock. b) Incidence of SIRS in older adults is significant. (1) ~60% of those who develop sepsis in the U.S. are 65+ c) Risk factors: institutionalization, hospitalization, indwelling catheters. PowerPoint Slides 1. Hormone changes Decreased production of estrogen Decreased production of progesterone Decreased production of testosterone 2. Pancreas changes Pancreas secretes less insulin. Increase in insulin resistance. Decreased ability to metabolize glucose. Increase in the prevalence of diabetes mellitus. 3. Changes in the thyroid Aging body uses less thyroid hormone. Thyroid gland atrophies. Increased risk for hypothyroidism. TSH values can be elevated. Basal metabolic rates decrease. 4. Changes in glucose metabolism Influences: illness, medications, nutritional alterations Assess macrovascular, microvascular, retinal complications Assess foot complications and foot ulcers 5a. Hypothyroidism is associated with Slowing of mental and physical function. Intolerance to cold. Weight gain. Constipation. Alterations in blood pressure. Anemia. 5b. Hyperthyroidism is associated with Irregular heart rhythms. Congestive heart failure. Weight loss. Fatigue. Muscular weakness. 5c. Thyroid storm is associated with Fever. Tachycardia. Nausea. Vomiting. Mental status changes. Heart complications. 6. The immune system of an older person is more vulnerable. Cell-mediated immunity declines with aging. T-cell function decreases. Humoral-mediated immunity and antibody responses are impaired. 7a. Infection can present atypically in an older person. Fever might be absent. Diagnosis might be delayed. Nonspecific expressions of infection can exist. 7b. Nonspecific expressions of infection Changes in mental status Altered mental status Functional decline Hypothermia Unexplained hypo- or hyperglycemia Acidosis Tachycardia Falls Tachypnea Anorexia Malaise Generalized weakness Urinary incontinence 8. Pneumonia and influenza are among the top ten causes of death. It is vital to identify pneumonia early. Influenza and pneumococcal vaccines decrease risk for pneumonia. 9. Nurses must anticipate patients at high risk for infection. Consider preexisting illnesses. Consider recent history of diagnostic tests. Carefully monitor clinical signs. 10. Systemic inflammatory response Bacteremia —> systemic inflammatory response (SIRS). SIRS can further deteriorate to severe sepsis, and septic shock. Incidence of SIRS in older adults is significant. Risk factors: institutionalization, hospitalization, indwelling catheters. VII. Cognitive Conditions Impacting Hospitalization A. The “three Ds”-dementia, depression, and delirium 1. Common and often missed by health professionals 2. Mistaken for one another 3. The normal older adult retains memory and thinking abilities throughout life. a) Loss of memory, confusion, and low mood are not a normal part of aging. b) When an older patient exhibits these symptoms, evaluate. B. Dementia 1. Dementia: cognitive impairment (loss of memory and thinking ability). Causes are: a) Nonreversible dementia (1) Alzheimer’s disease (responsible for the largest percentage) (2) Lewy body disease (3) Vascular dementia (4) Small strokes b) Reversible dementia (1) Hypothyroidism (2) B12 deficiency (3) Depression (4) Delirium 2. Alzheimer's disease: description a) 5.2 million affected (could double by 2050) b) Progressive and irreversible brain damage c) Characterized by amyloid plaques and neurofibrillary tangles in the brain d) Course: lose ability to make decisions, care for self, and communicate 3. Alzheimer’s disease: Early diagnosis and treatment is valuable. a) No cure is available. b) Current treatments can improve symptoms. c) Current treatments can slow progression of the disease. C. Depression 1. Depression—causes a) Lifelong problem b) Result of losses (retirement, widowhood, social isolation) c) Chronic stress d) Related to illness 2. Depression—statistics a) Found in10–12% of community-dwelling older adults. b) Rates are higher among those in institutional settings. c) The highest rate of suicide of any age group is among older men. d) Very common in older people with conditions causing pain or disabling conditions. 3. Depression—signs and symptoms a) Difficulty sleeping b) Poor appetite c) Feelings of hopelessness d) Apathy e) Difficulty concentrating f) Low self-esteem g) Low mood (changes in mood) h) Aches and pains 4. Depression—treatment a) Diagnosis based on presence of persistent symptoms not related to loss. b) Depression is very treatable in the older adult. c) Newer medications produce few side effects. d) Long-term treatment should include socialization. e) Counseling is very effective in this age group. D. Delirium 1. Delirium (acute confusion) is the rapid onset of problems with cognition. a) Characterized by fluctuating symptoms of inattention and confusion b) Caused by an insult to the brain as a result of acute illness c) Often indicates a change in status (can be the first sign of a complication) 2. Delirium statistics a) Develops in up to 62% of older people in the hospital overall b) Develops in up to half of postoperative older patients c) Can be prevented in about one-third of patients d) Many times, delirium is reversible 3. Delirium can have many symptoms: lethargy/inattentiveness to agitation/restlessness. a) Hyperactive delirium is noticeable. b) Hypoactive (“quiet”) delirium might not be noticed. PowerPoint Slides 1. Overlapping geriatric syndromes Three Ds—dementia, depression, delirium Common, often missed and mistaken for one another 2. Three Ds are not normal aging. Normal adults retain memory and thinking abilities throughout life. Loss of memory, confusion, and low mood are not normal. When an older patient exhibits these symptoms, evaluate. 3. Two types of dementia Dementia: cognitive impairment Nonreversible dementia Reversible dementia 4. Alzheimer's disease: description 5.2 million affected Progressive and irreversible brain damage Characterized by amyloid plaques and neurofibrillary tangles Course: lose ability to decide, care for self, communicate 5. Alzheimer's disease: Early diagnosis and treatment is valuable. No cure is available. Current treatments can improve symptoms. Current treatments slow progression of disease. 6. Causes of depression Lifelong problem Result of losses Chronic stress Related to illness 7. Statistics about depression Found in 10–12% of community-dwelling older adults. Rates are higher in institutional settings. Highest rate of suicide is among older men. Very common with pain or disabling conditions. 8. Signs and symptoms of depression Difficulty sleeping Poor appetite Feelings of hopelessness Apathy Difficulty concentrating Low self-esteem Low mood (changes in mood) Aches and pains 9. Treatment of depression Dx based on presence of persistent symptoms. Depression is treatable in the older adult. Newer medications produce few side effects. Long-term treatment should include socialization. Counseling is effective in this age group. 10. Delirium is the rapid onset of cognition problems. Characterized by fluctuating symptoms of inattention and confusion Caused by an insult to the brain as a result of acute illness Often indicates a change in status 11. Delirium statistics Develops in up to 62% of older people in the hospital overall. Develops in up to half of postoperative older patients. Can be prevented in about one-third of patients. Many times, delirium is reversible. 12. Two types of delirium Delirium can have many symptoms. Hyperactive delirium is noticeable. Hypoactive (“quiet”) delirium might not be noticed. 13. Management of delirium: Identify causes and remove them. Infection Pain Fever Sleep disturbance Immobility Sensory disturbance Hypoxia Dehydration Medications VIII. Factors Impacting Hospitalization A. Falls 1. Falls are a common accident in acute care, resulting in injury and increasing length of stay in older patients. 2. Older patients are at higher risk of falls due to: a) Musculoskeletal and sensory changes, combined with chronic conditions. b) Cognitive problems and medications such as antidepressants, benzodiazepines, antipsychotics, and psychotropic drugs. c) A higher RN staffing skill mix was associated with reduced falls. d) Fall prevention for older adults in acute care comprises several levels. (1) First Level (a) A safe environment (b) Use of appropriate beds and side rails (c) No clutter or tripping hazards (d) Safe equipment such as bedside commodes. (2) Second level (a) Adequate surveillance to meet patient needs (b) Frequent nursing rounds to address toileting needs (c) Increased observation of delirious or confused patients (d) Routine ambulation or getting older patients up in the chair as able. (3) Third level (a) Assessment of any additional fall risks and planning interventions to address these risks. Delirium to reduce confusion. B. Pain 1. Achieving adequate pain control for the older adult in the high-acuity setting can be challenging. a) Variety of types of pain b) Causes of pain c) Physical manifestations of pain 2. Pain affects older adults’ ability to function and their QOL. Pain can be due to: a) An acute condition (fracture). b) Postoperative pain. c) Chronic disease (osteoarthritis, back pain, bone and joint disorders). 3. Pain assessment a) Age-related changes impact the ability to perceive and report pain. b) Ability to discriminate between painful stimuli declines with age. c) Impacts the ability to accurately assess pain: (1) A thorough nursing assessment is required. (2) Pain scales and pain assessment tools exist. (3) Assess nonverbal behavior (facial expressions, body language). 4. Pain medications a) Undertreatment of pain is commonly described among older adults. b) Leads to depression, social isolation, gait problems, sleep disturbances. c) Pain medication should be given routinely to avoid severe pain. (1) Necessitates higher levels of medication. (2) Interferes with recovery from acute conditions. d) Assess pain frequently. e) Create a healing environment to decrease the perception of pain. 5. Pain medications present a challenge in the older patient. a) Nonsteroidal anti-inflammatory drugs have increased risks. b) Meperidine should be avoided (commonly causes neurotoxicity in older patients). c) Evaluating a patient for any untoward reactions to treatments C. Pharmacotherapy 1. Administration of medications to the older adult is complicated because of: a) Drug toxicity. b) Medication errors. c) Adverse drug reactions (ADR). d) Potentially inappropriate medications (PIM). e) Age-related physiologic changes affecting PK and PD. f) Polypharmacy. g) Self-medication. h) Patient–family noncompliance 2. Physiologic Changes a) Consider conditions that potentially could affect ADME. b) Absorption (1) Decreased surface area of the small intestine (2) Decreased splanchnic blood flow (3) Altered gastric pH (4) Decreased gastric motility c) Distribution (1) Decrease in lean body mass (2) Increase in fat content (3) Decrease in total body water content d) Metabolism, Excretion (1) Altered liver and kidney function (2) Decrease in renal filtration 3. Drug dosage and frequency of administration might need to be altered or adjusted frequently. a) Drugs remain present and active for longer period of times. b) Increased opportunity to produce side effects. c) Tolerance for medications might be altered due to a decrease in renal filtration. d) Medications might be active in an older person’s system longer and might be more potent. e) Typical signs of drug toxicity: CNS changes, orthostatic hypotension, and falls. 4. Polypharmacy a) Older adult might have medications that interact/counteract with each other. Evaluate: (1) Prescription medications. (2) Over-the-counter medications. (3) Vitamins and minerals. (4) Alcohol. (5) Caffeine. (6) Tobacco use. (7) Home remedies. 5. Adverse drug reactions a) Inappropriate medications for the elderly—problems, solutions, considerations. b) Identify medications increasing the risk for adverse drug reactions. (1) Beers’ Criteria for Potentially Inappropriate Medication Use in the Elderly b) When an older adult receives a new medication, “start low and go slow.” c) The therapeutic window might be narrow. d) Monitor patient reactions to any new medication. 6. Problems with patient management of medication a) Short-term memory impairment: (1) Incorrect dosages (2) Multiple doses (3) Skipped doses b) Impaired vision can affect dosage. c) Impaired agility opening containers can lead to missed doses. d) Financial factors and transportation issues can prevent filling prescriptions. PowerPoint Slides 1. Falls Falls are a common accident in acute care. Older patients are at higher risk. Fall prevention for older adults in acute care comprises several levels. 2. Achieving adequate pain control is challenging. Variety of types of pain Causes of pain Physical manifestations of pain 3. Pain affects ability to function and QOL. Pain can be due to: Acute condition. Postoperative pain. Chronic disease. 4. Age-related changes impact ability to perceive and report pain. Ability to discriminate between painful stimuli declines. Impacts the ability to accurately assess pain. 5. Undertreatment of pain is commonly described. Leads to depression, social isolation, gait problems, sleep disturbances. Give pain medication routinely to avoid severe pain. Assess pain frequently. Create healing environment to decrease perception of pain. 6. Pain medications present a challenge. NSAIDs have increased risks. Meperidine should be avoided (neurotoxicity). Evaluate patient for any bad reactions. 7. Administration of medications is complicated because of Drug toxicity. Medication errors. Adverse drug reactions. Potentially inappropriate medications. Age-related physiologic changes affecting PK and PD. Polypharmacy. Self-medication. Patient–family noncompliance. 8a. Conditions affecting ADME—Absorption: Decreased surface area of the small intestine Decreased splanchnic blood flow Altered gastric pH Decreased gastric motility 8b. Conditions affecting ADME—Distribution: Decrease in lean body mass Increase in fat content Decrease in total body water content 8c. Conditions affecting ADME—Metabolism and Excretion: Altered liver and kidney function Decrease in renal filtration 9. Special elderly complications—Drug dosage/frequency might need to altered/adjusted. Drugs remain present/active longer. Increased opportunity to produce side effects. Tolerance for medications might be altered. Medications might be active longer and be more potent. Typical signs of drug toxicity: CNS changes, orthostatic hypotension, falls. 10. Medications can interact/counteract with each other. Evaluate Prescription medications. Over-the-counter medications. Vitamins and minerals. Alcohol. Caffeine. Tobacco use. Home remedies. 11. Inappropriate medications—problems, solutions, considerations: Identify medications increasing risk for adverse reactions. When an older adult receives new medication, “start low and go slow.” The therapeutic window might be narrow. Monitor patient reactions to any new medication. 12. Problems with patient management of medication: Short-term memory impairment. Impaired vision can affect dosage. Impaired agility opening containers. Financial factors and transportation issues. IX. Geriatric Assessment Tools for the High-Acuity Nurse 1. Geriatric assessment tools are commonly used to screen for problems in older patients. A. Assessment of mental status 1. Mental status assessment—Detects dementia. a) Test patient’s memory, ability to concentrate, and ability to follow directions. b) Simple scoring methods determine if the person has normal cognition. c) Example: Mini-Cog (takes just three minutes): (1) Repeat and recall three items (2) Draw the face of a clock with numbers and hands (3) Then try to repeat the original three items 2. Delirium assessment—Delirium is diagnosed by identifying delirium symptoms. a) Screening instrument walks the nurse through the patient assessment. b) Example: confusion assessment method (CAM): (1) Have an acute onset of symptoms. (2) Have fluctuating course and inattention. (3) Show altered level of consciousness or disorganized thinking. c) Example: ICU CAM (1) Patient completes specific tasks to determine cognitive status (a) Squeezes nurse’s hand when certain letters are recited 3. Geriatric depression scale (GDS) screens for depressive symptoms: a) Nurse asks patient a series of questions about mood over the past two weeks. b) Patient responds yes or no. c) Score is based on the number of answers that indicate depression. B. Skin assessment 1. Skin assessment—Standardized skin assessment will identify those at high risk. a) Assessment of risk for skin breakdown begins at admission. b) Daily assessment and reevaluation of skin integrity. c) Example: Braden scale for predicting pressure sores: (1) Subscales are scored based on descriptive criteria. (a) Sensory, perception, moisture, mobility, nutrition, friction, shear (2) Lower score indicates a higher risk for pressure sore development. (3) Ulcers are prevented by reducing the risk factors. C. Falls and mobility assessment 1. Falls and mobility assessment—Identify patients at risk for falling. a) Use on admission, after any change (even daily). b) Use to identify what interventions to use, such as: (1) Assisting with transfers. (2) Therapy to increase muscle strength. (3) Frequent toileting. (4) Heavy surveillance (for delirious patients). c) Example: Hendrich II fall risk model: (1) Key risk factors: confusion or disorientation, depression, altered elimination, dizziness, male, antiepileptic drugs or benzodiazepines, difficulty getting up and walking around d) Example: Morse fall scale: (1) Key risk factors: history of falling, multiple conditions, mental status changes, need for a walking aid, walking problems, presence of IV therapy D. Pain assessment 1. Pain Assessment—Lack of objective measures has produced pain intensity scales. a) Most important consideration in pain assessment is patient’s account of the pain. b) Assess pain: impact on the older adult’s ability to function. c) Assess pain: impact on ability to recover from the present health condition. d) Consistent use of any scale brings objectivity to pain assessment. e) The most important consideration in the assessment of the presence and severity of pain is the patient’s account of the pain. f) Nurses work with patients to set goals for pain management. E. Laboratory data assessment 1. Assessment laboratory data a) It is important to be aware of the age-related alterations in laboratory trends PowerPoint Slides 1. Geriatric assessment tools are commonly used to screen for problems in older patients. 2. Mental status assessment detects dementia. Tests memory, concentration, direction following. Simple scoring methods determine normal cognition. Example: Mini-Cog (takes just three minutes). 3. Delirium diagnosed by identifying symptoms: Screening instrument walks through patient assessment. Example: confusion assessment method (CAM). Example: ICU CAM. 4. Geriatric depression scale (GDS)—Screens for depressive symptoms. Series of questions about mood over the past two weeks. Patient responds yes or no. Score the number of depressed answers. 5. Standardized skin assessment identifies risk. Assess skin breakdown at admission Assessment/evaluation of skin integrity daily. Example: Braden scale for predicting pressure sores 6. Falls and mobility assessment—Identify patients at risk. Use on admission, after any change Use to identify interventions to use Example: Hendrich II fall risk model Example: Morse fall scale 7. Lack of objective measures has produced pain intensity scales. Most important —> patient’s account of pain. Assess pain: impact on ability to function. Assess pain: impact on ability to recover. Patient’s account of the pain. Nurses work with patients to set goals for pain management. 8. Assessment laboratory data Age-related alterations in laboratory trends Table 3-16 data X. High-Risk Injuries and Complications of Trauma A. Traumatic injury: An overview 1. Traumatic injuries are a leading cause of death in the elderly. Contributing factors: a) Altered sensory function b) Changes in motor strength, postural stability, balance, and coordination c) Exacerbations of medical conditions d) Medication therapies (1) Antihypertensive (2) Oral hypoglycemic agents that might induce syncope (3) Diuretics without potassium supplements (4) ?-blocking agents 2. Typical traumatic injuries a) Falls—the most common cause of injury. b) Motor vehicle crashes account for the most fatalities. c) Burns have a high mortality rate in the elderly. 3. Nursing considerations a) Nursing care is aimed at stabilizing the injuries and preventing complications. (1) More difficulty compensating for injury or trauma (2) Greater risk for complications b) Priorities for care in the high-acuity area include: (1) Monitor oxygenation status. (2) Early hemodynamic monitoring is important; older adults don't tolerate hypo perfusion. (a) Monitor noninvasively: urine output, LOC, pedal pulses (b) Monitor invasively: cardiac output measurements (3) Assessment of hypovolemic shock is challenging. (a) Tachycardia can be obscured, as the heart rate might not respond to blood loss. (b) Volume overload is a concern (particularly with cardiac and renal disease). (c) Thermoregulatory mechanisms might be impaired. 4. Determining the cause a) Perform an in-depth history for information. b) Assess syncopal episodes (cardiovascular disease, hypertension treatment). c) Cardiac dysrhythmias can be a contributing factor. (1) Anemia, hormonal, or electrolyte imbalances d) Other risk factors: diminished senses, diminished reflexes, agility, and coordination. B. Specific types of traumatic injury 1. Head and spine injuries a) Subdural hematomas occur more frequently following a head injury. b) Considerable intracranial bleeding before appearance of symptoms. c) Classic signs of headache and vomiting might be absent. 2. Chest injuries a) Ribs fracture due to osteoporosis. b) Preexisting pulmonary disease and diminished pulmonary reserve: (1) Increase the risk of pulmonary failure. (2) Necessitate intubation and mechanical ventilation. 3. Abdominal injuries a) Fragile ribs and a weakened abdominal wall: (1) Increase the likelihood of abdominal injury with very little force. b) Abdominal trauma has a high mortality rate: (1) Postoperative, pulmonary, infectious complications. c) Typical signs of peritoneal irritation might be absent: (1) Diminished sensation and abdominal wall muscle tone. 4. Pelvic injuries a) Pelvic fractures are associated with great blood loss. b) Early control of hemorrhage is essential. (1) Fewer compensatory responses to combat hypovolemic shock. c) Perform embolization of major pelvic arteries. d) Perform early stabilization with external fixation. 5. Orthopedic trauma a) Loss of bone mass and osteoporosis increase the susceptibility of the older adult to traumatic injuries, which often result in significant fractures such as hip, femur, humerus, wrist, head, or spine injuries. b) Bone fractures result in acute pain and immobility. c) Early stabilization of fractures is important to prevent complications of prolonged immobility. 6. Burn injury a) Mortality of a burn in an older adult is very high. b) Elderly tend to have greater depth and size of burn: (1) Thin skin, slow reactions, reduced mobility, diminished sensations. c) Prolonged healing (particularly in the presence of malnutrition). d) Elderly do not scar as much as younger patients do (pressure garments not essential). e) Common sources of burns: (1) Flame injuries associated with cooking. f) Scald injuries associated with bathing. PowerPoint Slides 1. Traumatic injuries are a result of Altered sensory function. Changes in strength, stability, balance, coordination. Exacerbations of medical conditions. Medication therapies. 2. Typical traumatic injuries include: Falls are the most common. MVC have the most fatalities. Burns have high mortality rate. 3. Goals of nursing care: Stabilize the injuries, prevent complications: Difficulty compensating for injury or trauma Greater risk for complications 4. Priorities for nursing care in the high-acuity area include: Monitor oxygenation status. Early hemodynamic monitoring is important. Assessment of hypovolemic shock is challenging. Thermoregulatory mechanisms might be impaired. 5. Determining the cause of injury: Perform an in-depth history. Assess syncopal episodes. Cardiac dysrhythmias. Other risk factors. 6. Head and spine injuries Subdural hematomas occur more frequently following a head injury. Considerable intracranial bleeding before appearance of symptoms. Classic signs of headache and vomiting might be absent. Assess for subtle LOC changes and cranial nerve deficits. 7. Chest injuries Ribs fracture due to osteoporosis. Preexisting pulmonary disease, diminished pulmonary reserve. 8. Abdominal injuries Fragile ribs and a weakened abdominal wall. Abdominal trauma has a high mortality rate. Typical signs of peritoneal irritation might be absent. 9. Pelvic injuries Pelvic fractures are associated with great blood loss. Early control of hemorrhage is essential. Perform embolization of major pelvic arteries. Perform early stabilization with external fixation. 10. Orthopedic Trauma Loss of bone mass and osteoporosis increase traumatic injuries. Bone fractures result in acute pain and immobility. Early stabilization of fractures is important to prevent complications of prolonged immobility. 11. Burns Injury Mortality is very high. Elderly have greater depth/size of burn. Prolonged healing. Common sources of burns. XI. Special Considerations: A Culture of Caring and End-of-Life Care 1. Special attention must be given to this patient population to improve outcomes. a) More vulnerable to adverse outcomes b) Greater risk for functional decline or loss of independence when hospitalized A. A culture of caring for older adults 1. Hartford Institute for Geriatric Nursing (HIGN) at New York University’s (NYU) College of Nursing, funded by the John A. Hartford Foundation. a) An exemplary program to help nurses address supportive issues. b) Provides steps the nurse can follow to deliver better care for the older high-acuity patient. c) Physiologic, functional, and psychological needs of older adults. B. End-of-life care 1. End-of-life care—the problem a) In most acute care settings, the focus of patient care is curative. b) Needs of the elderly person at the end of life are often neglected. c) Nurses are challenged with blending high tech and high-touch care. 2. End-of-life care—the solution a) Palliative care should be integrated into acute/critical care settings. b) Hospitals offer specialists who consult on appropriate palliative care: (1) Increase comfort for patients and families (2) Advise staff on appropriate therapies (such as pain medication) 3. Resuscitation a) Before initiating resuscitation, certain ethical and physiologic issues should be taken into consideration. b) Ethical Issues—numerous ethical issues surround resuscitation efforts at the end of life: (1) Benefits (2) Likelihood of failure or adverse effects (3) Futility (4) Decision making c) Much debate about an individual’s right to determine medical treatment decisions (1) In the later stages of dementia, intensive treatments might not be appropriate. (2) Decisions about resuscitation and heroic measures for patients who might not benefit. d) Nursing responsibilities at the end of life (1) Nurses provide education and information about patient status. (2) Nurses provide supportive care to families making difficult decisions. (3) Nurses educate patients and families about CPR, DNR, and advanced directives. e) Physiological Issues (1) Consideration of age should be incorporated into standard resuscitation protocols. (2) Physiological issues (a) Heart rate of an older adult has less ability to increase in response to stressors. (b) Vasopressors or inotropes might be required. (c) Tachycardia might not occur in hypovolemia; nurses must rely on other indicators. (d) Changes in hemodynamic values. (e) Decreased blood pressure. (f) Decreased muscle mass and peripheral vasoconstriction prevents heat conservation. (g) Nurses must monitor for hypothermia (h) Warm environment and warmed IV fluids might be warranted. PowerPoint Slides 1. Special attention must be given to the elderly patient population: More vulnerable to adverse outcomes Greater risk for functional decline when hospitalized 2. Hartford Institute for Geriatric Nursing (HIGN) at New York University’s (NYU) College of Nursing, funded by the John A. Hartford Foundation: An exemplary program to help nurses address supportive issues Provides steps the nurse can follow to deliver better care for the older high-acuity patient. Physiologic, functional, and psychological needs of older adults. 3. End-of-life care—the problem In most acute care settings, focus of patient care is curative. Needs of the elderly person are often neglected. Nurses challenged with blending high tech and high-touch care. 4. End-of-life care—the solution • Palliative care should be integrated. • Hospitals offer specialists who consult on palliative care. 5. Numerous ethical issues surround resuscitation efforts and end-of-life care. Benefits Likelihood of failure or adverse effects Futility Decision making 6. Individual right to decide Debate about an individual’s right to determine treatment decisions. In later dementia, intensive treatments might not be appropriate. Decisions about resuscitation for patients who might not benefit. 7. Nursing responsibilities at the end of life: Provide education and information about patient status Provide supportive care to families making difficult decisions Educate about CPR, DNR, and advanced directives 8. Before initiating resuscitation, certain ethical and physiologic issues should be taken into consideration. 9. Physiological issues of resuscitation: Heart rate of an older adult has less ability to increase. Tachycardia might not occur in hypovolemia; need other indicators. Age-related changes prevent heat conservation. XII. Chapter Summary XIII. Clinical Reasoning Checkpoint XIV. Post-Test XV. References Suggested Classroom Activities Table 3-1 summarizes changes in the central nervous system in the older adult. Discuss this, specifically relating these changes to people that you know or have cared for. Suggestions for Clinical Activities Visit a local senior center or invite older seniors to the classroom. Specifically, meet with a healthy octogenarian, nonagenarian, and centenarian to appreciate the healthy seniors that are not in health care facilities. Ask them to describe their health through the years, their secrets for longevity, and their attitude about aging. Visit a health care facility that treats a large elderly population (or invite an administrator to visit the classroom). Ask about the most common health care problems of the elderly that they see. Discuss how this compares with the list of problems in this section. Wagner et al., Instructor’s Resource Manual for High-Acuity Nursing, 6th Edition ©2014 by Education, Inc.