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Oldage Care

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I.

AGING AND GERONTOLOGY

II. PHYSIOLOGICAL CHANGES


A. Integumentary system
1. Loss of pigment in hair and skin
2. Wrinkling of the skin
Care of the Older Client

A. Aging is the biopsychosocial process of change that


occurs in a person between birth and death.
B. Gerontology is the study of the aging process.
u
D. Cardiovascular system
35

The older client is at risk for falls because of the


changes that occur in the neurological and musculo-
skeletal systems.

1. Diminished energy and endurance, with low-


ered tolerance to exercise
2. Decreased compliance of the heart muscle, with
heart valves becoming thicker and more rigid
3. Decreased cardiac output and decreased effi-
3. Thinning of the epidermis and easy bruising and ciency of blood return to the heart
tearing of the skin (Fig. 35-1) 4. Decreased compensatory response, so less able
4. Decreased skin turgor, elasticity, and subcutane- to respond to increased demands on the cardio-
ous fat vascular system
5. Increased nail thickness and decreased nail 5. Decreased resting heart rate
growth 6. Weak peripheral pulses
6. Decreased perspiration 7. Increased blood pressure but susceptibility to
7. Dry, itchy, scaly skin postural hypotension
8. Seborrheic dermatitis and keratosis formation E. Respiratory system
(overgrowth and thickening of the skin) 1. Decreased stretch and compliance of the chest wall
B. Neurological system 2. Decreased strength and function of respiratory
1. Slowed reflexes muscles
2. Slight tremors and difficulty with fine motor 3. Decreased size and number of alveoli
movement 4. The respiratory rate usually remains unchanged
3. Loss of balance 5. Decreased depth of respirations and oxygen intake
4. Increased incidence of awakening after sleep onset 6. Decreased ability to cough and expectorate sputum
5. Increased susceptibility to hypothermia and F. Hematological system
hyperthermia 1. Hemoglobin and hematocrit average levels
6. Short-term memory decline possible toward the low end of normal
7. Long-term memory usually maintained 2. Prone to increased blood clotting
C. Musculoskeletal system 3. Decreased protein available for protein-bound
1. Decreased muscle mass and strength and atro- medications
phy of muscles G. Immune system
2. Decreased mobility, range of motion, flexibility, 1. Tendency for lymphocyte counts to be low with
coordination, and stability altered immunoglobulin production
3. Change of gait, with shortened step and wider 2. Decreased resistance to infection and disease
base H. Gastrointestinal system
4. Posture and stature changes causing a decrease 1. Decreased need for calories because of lowered
in height (Fig. 35-2) basal metabolic rate
5. Increased brittleness of the bones 2. Decreased appetite, thirst, and oral intake
6. Deterioration of joint capsule components 3. Decreased lean body weight
7. Kyphosis of the dorsal spine (increased convex- 4. Decreased stomach emptying time
ity in the curvature of the spine) 5. Increased tendency toward constipation
411
s
412 UNIT VI Growth and Development Across the Life Span

J. Renal system
1. Decreased kidney size, function, and ability to
concentrate urine
2. Decreased glomerular filtration rate
3. Decreased capacity of the bladder
4. Increased residual urine and increased incidence
of infection and possibly incontinence
5. Impaired medication excretion
K. Reproductive system
1. Decreased testosterone production and
decreased size of the testes
2. Changes in the prostate gland, leading to uri-
nary problems
3. Decreased secretion of hormones with the cessa-
s FIGURE 35-1 Paper-thin, transparent skin. (From Ignatavicius, D.,
& Workman, M. [2010]. Medical-surgical nursing: Patient-centered
tion of menses
collaborative care. [6th ed., p. 465]. St. Louis: Saunders.) 4. Vaginal changes, including decreased muscle
tone and lubrication
5. Impotence or sexual dysfunction for both gen-
Height
ders; sexual function varies and depends on gen-
5'6"
eral physical condition, mental health status,
5'3" and medications
L. Special senses
5' 1. Decreased visual acuity
4'9"
2. Decreased accommodation in eyes, requiring
increased adjustment time to changes in light
4'6" 3. Decreased peripheral vision and increased sensi-
tivity to glare
4'3"
4. Presbyopia and cataract formation
5. Possible loss of hearing ability; low-pitched
tones are heard more easily
6. Inability to discern taste of food
7. Decreased sense of smell
8. Changes in touch sensation
9. Decreased pain awareness

III. PSYCHOSOCIAL CONCERNS


A. Adjustment to deterioration in physical and mental
health and well-being
B. Threat to independent functioning and fear of
Age 40 60 70 becoming a burden to loved ones
s FIGURE 35-2 A normal spine at age 40 years of age and
C. Adjustment to retirement and loss of income
osteoporotic changes at 60 and 70 years of age. These changes can D. Loss of skills and competencies developed early in life
cause a loss of as much as 6 inches in height and can result in the so- E. Coping with changes in role function and social life
called dowager’s hump (far right) in the upper thoracic vertebrae. F. Diminished quantity and quality of relationships
(From Ignatavicius, D., & Workman, M. [2010]. Medical-surgical and coping with loss
nursing: Patient-centered collaborative care. [6th ed., p. 1156]. St.
Louis: Saunders.)
G. Dependence on governmental and social systems
H. Access to social support systems
6. Increased susceptibility for dehydration I. Costs of health care and medications
7. Tooth loss
8. Difficulty in chewing and swallowing food
IV. MENTAL HEALTH CONCERNS (Box 35-1)
I. Endocrine system
1. Decreased secretion of hormones, with specific A. Depression: The increased dependency that older
changes related to each hormone’s function adults may experience can lead to hopelessness, help-
2. Decreased metabolic rate lessness, lowered sense of self-control, and decreased
3. Decreased glucose tolerance, with resistance to self-esteem and self-worth; these changes can inter-
insulin in peripheral tissues fere with daily functioning and lead to depression.
CHAPTER 35 Care of the Older Client
s
413

t
Box 35-1 Mental Health Concerns t
Box 35-2 Nonspecific Symptoms That
Possibly Indicate Illness or Infection
Depression
Grief Apathy Fatigue
Isolation Anorexia Incontinence
Suicide Changes in functional status Self-neglect
Confusion Shortness of breath
Dyspnea Tachypnea
B. Grief: Client reacts to the perception of loss, including Falling Vital sign changes
physical, psychological, social, and spiritual aspects.
C. Isolation: Client is alone and desires contact with
others but is unable to make that contact.
D. Suicide: Depression can lead to thoughts of self-harm.

Any suicide threat from an older client should be


B. Determine the use of over-the-counter medications.
taken seriously.
C. Polypharmacy
1. Routinely monitor the number of prescription
V. PAIN
and nonprescription medications used and
A. Description determine whether any can be eliminated or
1. Pain can occur from numerous causes and most combined.
often occurs from degenerative changes in the 2. Keep the use of medications to a minimum.
musculoskeletal system. 3. Overprescribing medications leads to increased
2. The failure to alleviate pain in the older client problems with more side effects, increased inter-
can lead to functional limitations affecting his action between medications, replication of med-
or her ability to function independently. ication treatment, diminished quality of life,
B. Assessment and increased costs.
1. Restlessness D. Medication dosages normally are prescribed at one
2. Verbal reporting of pain third to one half of normal adult dosages.
3. Agitation E. Closely monitor the client for adverse effects and
4. Moaning response to therapy because of the increased risk
5. Crying for medication toxicity.
C. Interventions F. Assess for medication interactions in the client tak-
1. Monitor the client for signs of pain. ing multiple medications.
2. Identify the pattern of pain. G. Advise the client to use one pharmacy and notify
3. Identify the precipitating factor(s) for the pain. the consulting physician(s) of the medications
4. Monitor the impact of the pain on activities of taken.
daily living.
5. Provide pain relief through measures such as dis- A common sign of an adverse reaction to a med-
traction, relaxation, massage, and biofeedback. ication in the older client is an acute change in men-
6. Administer pain medication as prescribed, and tal status.
instruct the client in its use.
7. Evaluate the effects of pain-reducing measures. H. Administration of medications
1. The client should be in a sitting position when
VI. INFECTION (Box 35-2) taking medication.
2. The mouth is checked for dryness because
A. Confusion is a common sign of infection in the
medication may stick and dissolve in the
older adult, especially infection of the urinary tract.
mouth.
B. Carefully monitor the older adult with infection
3. Liquid preparations can be used if the client
because of the diminished and altered immune
has difficulty swallowing tablets.
response.
4. Tablets can be crushed if necessary and given
C. Nonspecific symptoms may indicate illness or
with textured food (nectar, applesauce) if not
infection (see Box 35-2).
contraindicated.
5. Enteric-coated tablets are not crushed and cap-
VII. MEDICATIONS
sules are not opened.
A. Major problems with prescriptive medications 6. If administering a suppository, avoid inserting
include adverse effects, medication interactions, the suppository immediately after removing it
medication errors, noncompliance, and cost. from the refrigerator; a suppository may take
s
414 UNIT VI Growth and Development Across the Life Span

a while to dissolve because of decreased body


core temperature.
MORE QUESTIONS ON THE CD!
7. When administering parenteral solution or
medication, monitor the site, because it may Practice Questions
ooze or bleed because of decreased tissue elas- 356. The nurse is providing medication instructions to
ticity; an immobile limb is not used for admin- an older client who is taking digoxin (Lanoxin)
istering parenteral medication. daily. The nurse notes that which age-related
8. Monitor client compliance with taking pre- body changes could place the client at risk for
scribed medications. digoxin toxicity?
9. Monitor the client for safety in correctly taking 1. Decreased muscle strength and loss of bone
medications, including an assessment of their density
ability to read the instructions and discriminate 2. Decreased cough efficiency and decreased
among the pills and their color and shape. vital capacity
10. Use a medication cassette to facilitate proper 3. Decreased salivation and decreased gastroin-
administration of medication. testinal motility
4. Decreased lean body mass and decreased glo-
merular filtration rate
VIII. ABUSE OF THE OLDER ADULT
A. Abuse involves physical, emotional, or sexual 357. The nurse employed in a long-term care facility is
abuse and also can involve neglect or economic caring for an older male client. Which nursing
exploitation. action contributes to encouraging autonomy in
B. Categories of mistreatment to the older client. the client?
1. Domestic mistreatment takes place in the home 1. Planning his meals
of the older adult and is usually carried out by a 2. Decorating his room
family member or significant other; this can 3. Scheduling his barber appointments
include physical maltreatment, neglect, or 4. Allowing him to choose social activities
abandonment.
2. Institutional mistreatment takes place when an 358. The home care nurse is visiting an older female
older adult experiences abuse when hospitalized client whose husband died 6 months ago. Which
or living somewhere other than home (e.g., behavior by the client indicates ineffective coping?
long-term care facility). 1. Neglecting her personal grooming
3. Self-neglect is the choice by a mentally compe- 2. Looking at old snapshots of her family
tent individual to avoid medical care or other 3. Participating in a senior citizens0 program
services that could improve optimal function, 4. Visiting her husband’s grave once a month
lack caring for oneself, and engage in actions
that negatively affect his or her personal safety; 359. The nurse is providing instructions to a nursing
unless declared legally incompetent, an individ- assistant regarding care of an older client with
ual has the right to refuse care. hearing loss. The nurse tells the assistant that cli-
ents with a hearing loss:
Individuals at most risk for abuse include those 1. Are often distracted
who are dependent because of their immobility or 2. Have middle ear changes
altered mental status. 3. Respond to low-pitched tones
4. Develop moist cerumen production
C. Factors that contribute to abuse and neglect
include long-standing family violence, caregiver 360. The nurse is providing an educational session to
stress, and the individual’s increasing dependence new employees, and the topic is abuse of the
on others. older client. The nurse helps the employees iden-
D. Abusers tend to be male, engage in substance tify that which client is most typical of a victim of
abuse, and have a mental illness or dementia; in abuse?
addition, they tend to depend on the older client 1. A 75-year-old man who has moderate hyper-
for financial assistance or other resources. tension
E. Victims may attempt to dismiss injuries as acciden- 2. A 68-year-old man who has newly diagnosed
tal, and abusers may prevent victims from receiving cataracts
proper medical care to avoid discovery. 3. A 90-year-old woman who has advanced Par-
F. Victims often are isolated socially by their abusers. kinson’s disease
G. For additional information on abuse of the older 4. A 70-year-old woman who has early diagnosed
client, see Chapter 76. Lyme disease
361. The nurse is performing an assessment on an 1.
CHAPTER 35 Care of the Older Client

Crusting
s 415

older client who is having difficulty sleeping at 2. Wrinkling


night. Which statement, if made by the client, 3. Deepening of expression lines
indicates that teaching about improving sleep is 4. Thinning and loss of elasticity in the skin
necessary?
1. “I swim three times a week.” 364. The home health nurse is visiting a client for the
2. “I have stopped smoking cigars.” first time. While assessing the client’s medica-
3. “I drink hot chocolate before bedtime.” tion, it is noted that there are at least 19 prescrip-
4. “I read for 40 minutes before bedtime.” tion and several over-the-counter medications
that the client has been taking. Which interven-
362. The visiting nurse observes that the older male tion should the nurse take first?
client is confined by his daughter-in-law to his 1. Check for drug-drug interactions.
room. When the nurse suggests that he walk to 2. Determine whether there are any adverse side
the den and join the family, he says, “I’m in effects.
everyone’s way; my daughter-in-law needs me 3. Determine whether there are medication
to stay here.” The most important action for the duplications.
nurse to take is to: 4. Call the prescribing physician and report any
1. Say nothing, because it is best for the nurse polypharmacy.
to remain neutral and wait to be asked
for help.
2. Suggest to the client and daughter-in-law that Alternate Item Format:
they consider a nursing home for the client. Multiple Response
3. Say to the daughter-in-law, “Confining your 365. Which of the following are normal age-related
father-in-law to his room is inhuman.” physiological changes? Select all that apply.
4. Suggest appropriate resources to the client 1. Increased heart rate
and daughter-in-law, such as respite care and 2. Decline in visual acuity
a senior citizens’ center. 3. Decreased respiratory rate
4. Decline in long-term memory
363. The nurse is performing an assessment on an 5. Increased susceptibility to urinary tract
older adult client. Which assessment data would infections
indicate a potential complication associated with 6. Increased incidence of awakening after sleep
the skin of this client? onset

ANSWERS Ignatavicius, D., & Workman, M. (2010). Medical-surgical


nursing: Patient-centered collaborative care (6th ed., p. 19).
356. 4
St. Louis: Saunders.
Rationale: The older client is at risk for medication toxicity
Perry, A., & Potter, P. (2010). Clinical nursing skills &
because of decreased lean body mass and an age-associated
techniques (7th ed., pp. 510–511). St. Louis: Mosby.
decreased glomerular filtration rate. Although options 1, 2,
and 3 identify age-related changes that occur in the older cli- 357. 4
ent, they are not associated specifically with this risk. Rationale: Autonomy is the personal freedom to direct one’s
Test-Taking Strategy: Use the process of elimination and own life as long as it does not impinge on the rights of others.
focus on the subject age-related body changes that could An autonomous person is capable of rational thought. This
place the client at risk for medication toxicity. Note that individual can identify problems, search for alternatives, and
option 4 is the only option that addresses renal excretion. If select solutions that allow continued personal freedom as
you had difficulty with this question, review the physiological long as others and their rights and property are not harmed.
changes associated with aging and those that place the older Loss of autonomy, and therefore independence, is a real fear
client at risk for medication toxicity. of older clients. Option 4 is the only option that allows the
Level of Cognitive Ability: Understanding client to be a decision maker.
Client Needs: Physiological Integrity Test-Taking Strategy: Use the process of elimination,
Integrated Process: Teaching and Learning focusing on the subject encouraging autonomy. Recalling the
Content Area: Fundamental Skills—Developmental Stages definition of autonomy will direct you to the correct option.
References: Ebersole, P., Hess, P., Touhy, T., Jett, K., & Luggen, Remember that giving the client choices is essential to promote
A. (2008). Toward healthy aging (7th ed., p. 309). St. Louis: independence. Review the concept of autonomy as it relates to
Mosby. the older client if you had difficulty with this question.
s
416 UNIT VI Growth and Development Across the Life Span

Level of Cognitive Ability: Applying process. This will direct you to option 3. If you had difficulty
Client Needs: Safe and Effective Care Environment with this question review the characteristics associated with
Integrated Process: Caring elder abuse.
Content Area: Fundamental Skills—Developmental Stages Level of Cognitive Ability: Applying
Reference: Potter, P., & Perry, A. (2009). Fundamentals of Client Needs: Psychosocial Integrity
nursing (7th ed., pp. 9–10, 314, 348). St. Louis: Mosby. Integrated Process: Teaching and Learning
Content Area: Mental Health
358. 1 Reference: Ebersole, P., Hess, P., Touhy, T., Jett, K., & Luggen,
Rationale: Coping mechanisms are behaviors used to decrease A. (2008). Toward healthy aging (7th ed., p. 453). St. Louis:
stress and anxiety. In response to a death, ineffective coping is Mosby.
manifested by an extreme behavior that in some cases may be
harmful to the individual physically or psychologically. Option 361. 3
1 is indicative of a behavior that identifies an ineffective coping Rationale: Many nonpharmacological sleep aids can be used
behavior in the grieving process. to influence sleep. However, the client should avoid caffein-
Test-Taking Strategy: Note the subject, an ineffective coping ated beverages and stimulants such as tea, cola, and choco-
behavior. Eliminate options 2, 3, and 4 because they are com- late. The client should exercise regularly, because exercise
parable or alike and are positive activities in which the indi- promotes sleep by burning off tension that accumulates dur-
vidual is engaging to get on with her life. Review coping ing the day. A 20- to 30-minute walk, swim, or bicycle ride
mechanisms in response to grief and loss if you had difficulty three times a week is helpful. The client should sleep on a
with this question. bed with a firm mattress. Smoking and alcohol should be
Level of Cognitive Ability: Analyzing avoided. The client should avoid large meals; peanuts, beans,
Client Needs: Psychosocial Integrity fruit, raw vegetables, and other foods that produce gas; and
Integrated Process: Nursing Process—Assessment snacks that are high in fat because they are difficult to digest.
Content Area: Mental Health Test-Taking Strategy: Note the strategic words that teaching
References: Ebersole, P., Hess, P., Touhy, T., Jett, K., & Luggen, A. about improving sleep is necessary. These words indicate a nega-
(2008). Toward healthy aging (7th ed., p. 643). St. Louis: Mosby. tive event query and ask you to select an option that is
Touhy, T., & Jett, K. (2010). Ebersole and Hess’ gerontological an incorrect statement. Options 1, 2, and 4 are positive state-
nursing & healthy aging (3rd ed., pp. 382–383). St. Louis: Mosby. ments indicating that the client understands the methods of
improving sleep. Review the factors that can interfere with
359. 3 sleep in the older client if you had difficulty with this question.
Rationale: Presbycusis refers to the age-related irreversible Level of Cognitive Ability: Analyzing
degenerative changes of the inner ear that lead to decreased Client Needs: Physiological Integrity
hearing ability. As a result of these changes, the older Integrated Process: Teaching and Learning
client has a decreased response to high-frequency sounds. Content Area: Fundamental Skills—Developmental Stages
Low-pitched voice tones are heard more easily and can be Reference: Touhy, T., & Jett, K. (2010). Ebersole and Hess’
interpreted by the older client. Options 1, 2, and 4 are not gerontological nursing & healthy aging (3rd ed., p. 155). St. Louis:
accurate characteristics related to aging. Mosby.
Test-Taking Strategy: Think about the age-related changes
that occur in the older client. Recalling that the client with a 362. 4
hearing loss responds to low-pitched tones will direct you to Rationale: Assisting clients and families to become aware of
option 3. If you had difficulty with this question, review the available community support systems is a role and responsi-
characteristics associated with presbycusis and hearing loss. bility of the nurse. Observing that the client has begun to be
Level of Cognitive Ability: Applying confined to his room makes it necessary for the nurse to inter-
Client Needs: Physiological Integrity vene legally and ethically, so option 1 is not appropriate and
Integrated Process: Teaching and Learning is passive in terms of advocacy. Option 2 suggests committing
Content Area: Fundamental Skills—Developmental Stages the client to a nursing home and is a premature action on the
Reference: Ebersole, P., Hess, P., Touhy, T., Jett, K., & Luggen, nurse’s part. Although the data provided tell the nurse that
A. (2008). Toward healthy aging (7th ed., pp. 351–352). this client requires nursing care, the nurse does not know
St. Louis: Mosby. the extent of the nursing care required. Option 3 is incorrect
and judgmental.
360. 3 Test-Taking Strategy: Note the strategic words most important
Rationale: Elder abuse includes physical, sexual, or psycho- action. Using principles related to the ethical and legal respon-
logical abuse, misuse of property, and violation of rights. sibility of the nurse and knowledge of the nurse’s role will
The typical abuse victim is a woman of advanced age with direct you to option 4. Option 1 avoids the situation, option
few social contacts and at least one physical or mental 2 is a premature action, and option 3 is a nontherapeutic
impairment that limits her ability to perform activities of statement. Review the roles and responsibilities of the nurse
daily living. In addition, the client usually lives alone or with in caring for the older client if you had difficulty with this
the abuser and depends on the abuser for care. question.
Test-Taking Strategy: Read each option carefully and identify Level of Cognitive Ability: Applying
the client who is most defenseless as the result of the disease Client Needs: Safe and Effective Care Environment

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