Transcript PPT_12

Chapter 12:
The Critically Ill Older Patient
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Normal Aging
Intrinsic
Aging
Extrinsic
Aging
Specific
Individual
Factors
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Organic Changes With Aging
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Conflict with
Developmental Tasks
Reaching
Developmental Tasks
• Giving up the home to
live in an extendedcare facility or with
adult children
• Maintaining a social
network
• Loss of spouse and
friends; feeling
isolated
• Decrease in income
and increase in
medication costs
• Determining meaning
of one’s life
• Contributing to society
after retirement
• Maintaining healthy
habits
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Age-Related Sensory System Changes
Vision
• Decreased visual
acuity and night vision
• Changes in depth
perception
• Change in perception
to blues, greens, and
purples
• Increased eye dryness
Hearing
• Increased cerumen
• Problems
differentiating
background noise from
sound nearby
• Problems
understanding speech
(-f-,-s-, -th-, -ch-, and
–sh-)
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Age-Related Changes in Smell, Taste, and
Touch
• Smell: decreased ability to distinguish noxious odors
(change in appetite; risk for eating bad food; decreased
ability to smell smoke)
• Taste: decreased ability to taste sweet and salty foods
– Able to taste bitter and sour foods
• Touch: decrease in temperature perception and touch
sensation
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Question
Which of the following statements about age-related
hearing and equilibrium in the older patient is correct?
A. There is an increase in thinner cerumen.
B. There is an increase in threshold sensitivity.
C. There is a reduction in the ability to understand highfrequency sounds.
D. There are changes in the pinna resulting in decreased
balance.
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Answer
C. There is a reduction in the ability to understand highfrequency sounds.
Rationale: Changes that occur in hearing and equilibrium
include a reduction in the ability to hear high-frequency
sounds (f, s, th, ch, and sh). There is an increase in
thicker cerumen that can block the canal, decreasing
the ability to hear. There is a decrease in hearing that
affects the threshold sensitivity and ability to
comprehend speech. The change in the cochlea can lead
to changes in balance.
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Skin Changes in the Older Patient
Age-Related Changes
• Skin thins, becomes
dry, and loses
elasticity
• Decrease in
subcutaneous fat
• Decrease in sweat
glands, risk for
hyperthermia
Nursing Interventions
• Assess risk for
developing skin
breakdown using the
Morse Scale.
• Avoid soap, and use
lotion.
• Support joints when
moving patient to
prevent tears or
shearing actions.
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Cardiac Changes in the Older Patient
•
S4
•
Muscle fibers in the endocardium atrophy
•
Atherosclerosis of blood vessels
•
Left ventricle decreases in compliance
•
Number of pacemaker cells declines
•
Baroreceptors are less sensitive; changes in posture can
lead to orthostatic hypotension
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Common Age-Related Changes in the ECG
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Respiratory Changes in the Older Patient
•
Decrease in elasticity of lungs and decline in muscle
strength
•
Calcification of bony structures to thorax
•
Fewer cilia
•
Decreased PaO2
•
Few bibasilar crackles due to atelectasis. Ask client to
take a deep breath and cough. If the crackles
disappear, they are due to aging. If they remain, they
are due to pathology.
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Renal System Changes in the Older
Patient
• Decrease in number of nephrons: a person loses
1mL/min/year of glomerular filtration rate (GFR) after
age 30
– Because of the decline in muscle mass, serum
creatinine isn’t the best indicator of renal function.
– The GFR is the best indicator.
• Decrease in renal blood flow (altered excretion of drugs)
• Decrease in ability to regulate fluids/electrolytes
• Increase in asymptomatic bacteriuria
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Important Nursing Considerations for
Older Adults With Urinary Incontinence
• Always look for underlying causes that can be changed.
• Provide a toileting schedule when changes cannot be
found.
• Refer the client to a urologist to search for interventions
to correct the incontinence.
• Maintain the client’s dignity; avoid calling protective
undergarments “diapers,” etc.
• Avoid placing a Foley catheter if possible. If
catheterization is needed, remove it as soon as possible.
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GI Changes in the Older Patient
• Decrease in size and number of taste buds
• Decrease in production of saliva
• Decrease in size of liver
• Decrease in GI tract motility
• Decrease in secretion of hydrochloric acid in the stomach
and decrease in mucosal lining of the stomach and GI
tract
• Decrease in absorption of calcium and iron
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Age-Related Changes in the
Musculoskeletal System
• Decrease in muscle mass and strength
• Decrease in bone density
• Decrease in overall height
• Changes in joints
• Changes in gait and posture
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Age-Related Changes in the Endocrine
System
• Decrease in hormone production
• Change in ability to regulate body temperature
• Decrease in basal metabolic rate
• Insulin resistance and decreased glucose tolerance
• Renal tubules become less sensitive to antidiuretic
hormone (ADH)
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Management of Diabetes in Older
Patients
• A1C < 7%: every 3
months
• Lipid profile: every
year
• Urine test for
microalbuminuria:
yearly
• Dilated eye exam:
yearly
• TSH
• ECG
• Dental exam
• Monitor BP each visit
• Foot exam: each visit
• Assess for barriers to
treatment (financial,
physical, educational)
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Reproductive System Changes
Older Women
• Decreased hormones
• Atrophy of sexual
organs
• Vaginal dryness
• Breast tissues lose
connective tissue and
gain adipose tissue
Older Men
• Decrease in seminal
fluid and force of
ejaculation
• Prostate hypertrophies
– Decreased force of
urinary stream
– Potential for
urinary retention
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Age-Related Changes in the Neurological
System
• Atrophy of brain
• Increase in space inside the cranium
• Decline in number of neurons
• Decline in short-term memory
• Longer reaction time
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Question
Which statement made by the older adult patient warrants
more patient education on sleep hygiene?
A. I will nap in the early morning for no longer than 30
minutes.
B. I will exercise for 30 minutes before going to bed.
C. I will eat most of my daily food intake before dinner.
D. I will establish a bedtime ritual.
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Answer
B. I will exercise for 30 minutes before going to bed.
Rationale: A person should avoid exercising close to
bedtime because the activity would increase the
wakefulness cycle. This client needs more patient
education regarding spacing activity and sleep.
Proper sleep hygiene includes avoiding daytime naps that
are longer than 30 minutes. Establishing and maintaining
a bedtime ritual and consistent schedule will promote
sleep. A person should avoid eating a large meal or
drinking caffeine or alcohol before bedtime.
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Symptoms of Depression
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Drugs That May Cause Depression in the
Older Person
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Geriatric Depression Scale
See Box 12-10.
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Question
An older adult patient with a history of depression is
admitted to the ICU to rule out myocardial infarction.
The nurse should report which of the following to the
cardiologist?
A. The patient is taking a beta-blocker.
B. The patient is taking a tricyclic antidepressant.
C. The patient is taking baby aspirin.
D. The patient is taking morphine sulfate.
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Answer
B. The client is taking a tricyclic antidepressant.
Rationale: The nurse needs to report that the client is
taking a tricyclic antidepressant, which can cause false
ECG changes that may appear as myocardial damage.
The cardiac enzymes will be used to determine whether
the patient has myocardial damage. A tricyclic
antidepressant can also place the cardiac patient at risk
for ventricular dysrhythmias, which means the drug
dosage may need to be reduced or a different drug used.
The other meds are part of an acceptable treatment
regimen for a client with a MI.
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Reversible Causes of Dementia and
Delirium
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Assessment Areas for Potential Abuse or
Neglect of the Older Patient
• Physical abuse
• Emotional abuse
• Sexual abuse
• Neglect and self-neglect
• Abandonment
• Financial or material exploitation
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Safe Medication Administration
Considerations for the Older Patient
• Have the patient bring all medications to the visit. Look
for medications to avoid according to the Beers criteria,
prescription duplication, noncompliance, or potential drug
interactions.
• Assess use of over-the-counter and herbal supplements.
• Assess alcohol intake.
• Assess renal and liver function.
• Assess the patient’s knowledge of medications.
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