BACHELOR OF SCIENCE IN NURSING

PHARMACOLOGY
COURSE MODULE COURSE UNIT WEEK
1 5 5
Nursing Care of the Older Adult in Chronic Illness

Read course and unit objectives

✔ Use study guide prior to class attendance
✔ Upload required learning resources; refer to unit
terminologies for jargons
✔ Proactively participate in online discussions
✔ Participate in weekly discussion board (Canvas)
✔ Answer and submit course unit tasks

At the end of the course unit (CU), learners will be able to:

Cognitive:

1. Explain the importance of sensory function and the impact of sensory deficits on older
adults.
2. Identify signs of and nursing interventions for older adults with cataracts, glaucoma,
macular degeneration, diabetes retinopathy, and hearing impairment.
3. Interpret the Physiologic, Psychologic, and Environmental causes of ACS.
4. Differentiate Dementia and ACS.
 .
.

Affective:
1. Develop awareness on the potential causes of dementia.
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and
graciously.

Psychomotor:
1. Apply effective communication to clients with impaired verbal problem.
2. Participate actively during class discussions and group activities

Mauk, Kristen. (2010). Gerontological nursing: competencies for care.MA: Jones & Bartlett
Publishers.610.7365 G31 2010
Eliopoulos (2018). Gerontological Nursing 9th Edition.Wolters Kluwer
LECTURIO Aging Process (Nursing): Sensory /Perception Alteration

Good sensory function is an extremely valuable asset that is often taken for granted.
For instance, people are better able to protect themselves from harm when they can see, hear,
smell, touch, and communicate. The reduced ability to protect oneself from hazards because
of sensory deficits can result in serious falls from unseen obstacle, missed alarms and
warnings, ingestion of hazards because of sensory deficits can result to serious falls from
unseen obstacle, missed alarms and warnings, ingestion of hazardous substances form not
recognizing bad tastes, an inability to detect the odor of smoke or gas, and burns and skin
breakdown because of decrease cutaneous sensation of excessive temperature and pressure.

SENSORY IMPAIRMENT

1. Visual Impairment

 Personal cost for older person with visual impairment

◦ Loss of independence

◦ Social isolation

◦ Depression
 ◦ Decreased quality of life

 Signs of difficulty with vision

◦ Squinting or tilting head to see

◦ Changes in ability to drive, read, watch television, or write

◦ Holding objects closer to the face

◦ Difficulty with color discrimination and walking up or down stairs

◦ Hesitation in reaching for objects

◦ Not being able to find something (American Society on Aging, 2003)

Cataract
 Opacity of the crystalline lens or its capsule (partial or complete)

 Causes

- injury -- traumatic
- exposure to heat, UV light
- heredity / congenital
- aging (>55) – senile
- DM – secondary
- smoking & alcoholism
 Lens clouding → decreased light to retina → limited vision

 Development is slow and painless

 Leading cause of blindness in the world

 > 50% of adults > 65 years have cataracts → visual problems

 Cataract

❑ Risk factors

◦ Increased age

◦ Smoking and alcohol

◦ Diabetes, hyperlipidemia

◦ Trauma to the eye

◦ Exposure to the sun and UVB rays

 ◦ Corticosteroid medications

❑ Symptoms

◦ Blurred vision

◦ Glare

◦ Halos around objects

◦ Double vision

◦ Lack of color contrast or faded colors

◦ Poor night vision

Surgery
❑ Phacoemulsification

- “small incision cataract surgery”

- small incision done outside the cornea
- a tiny probe is inserted which emits ultrasound waves that soften & break up the lens
so that it can be removed by suction
❑ Extracapsular / Intracapsular cataract surgery

- incision is longer on the side of cornea & removes the cloudy core on the lens in
one piece
- the rest of the lens is removed by suction

Glaucoma
❑ Increase in intraocular pressure (IOP) → optic nerve damage → vision loss

❑ Open angle

◦ Slowed flow of aqueous humor through trabecular meshwork → build up→

increased IOP → damage to renal nerve fiber → loss of vision

◦ Painless vision loss

 Midperipheral visual field loss

Glaucoma
❑ Angle-closure

◦ Angle of the iris obstructs drainage of aqueous humor through trabecular

meshwork → increased IOP → visual changes

◦ Symptoms
  Unilateral headache

 Visual blurring

 Nausea and vomiting

 Photophobia

Risk Factors for Glaucoma

❑ Increased intraocular pressure

❑ Older than 60 years of age

❑ Family history of glaucoma

❑ Personal history of myopia, diabetes, hypertension, or migraines

❑ African American ancestry

Nursing Care
❑ Explain the importance of continued use of eye medications as ordered to prevent
further visual loss

❑ Explain the need for continued medical supervision for observation of IOP to ensure
control of the disorder

❑ Teach client to avoid exertion, stooping, straining for a bowel movement, coughing,
heavy lifting, or wearing constricting clothing, since these increase IOP

❑ Instruct the client to report severe eye or brow pain & nausea to the physician

Eye Examination
Visual Acuity
- always start with the right eye to ensure accurate recording
- cover the eye not being tested with an occluder
- 20/20 at 6 y/o
- Numerator (20 ft, the distance the person stands from the chart)
- Denominator (distance from which the normal eye can read the chart)
- CF, HP, LP, NLP
Age-Related Macular Degeneration (ARMD)
❑ Two types

▪ Dry (atrophic form)-involutional mac deg

 Breakdown or thinning of macular tissue related to the aging process

 Atrophy
  Retinal pigment degeneration

 Drusen accumulations

 Other symptoms

 Slow progression of visual loss

Age-Related Macular Degeneration (ARMD)

❑ Wet (Neovascular exudates)-exudative macular degeneration

▪ Blood or serum lead from newly formed blood vessels beneath retina→ scar
formation + visual problems

▪ Other symptoms

 More light required for reading

 Blurred vision

 Central scotomas

 Metamorphopsia

Other symptoms of Macular D

❑ Difficulty performing tasks – close central vision – reading and sewing

❑ Decreased color vision

❑ Dark or empty area in the center of vision

❑ Straight lines appearing wavy and crooked

❑ Words on a page looks blurred

Risk Factors for ARMD

❑ Age (above the age of 50)

❑ Cigarette smoking

❑ Family history of ARMD

❑ Increased exposure to ultraviolet light

❑ Caucasian race and light colored eyes

❑ Hypertension or cardiovascular disease

❑ Lack of dietary intake of antioxidants and zinc

Nursing Diagnoses for Vision- Impaired Older Patients
❑ Evaluate functional ability

▪ Perform activities of daily living, including the ability to read medication labels

▪ Drive or take public transportation

▪ Ambulate safely in familiar and strange environments

▪ Shop and pay for food and personal items

▪ Prepare food while maintaining a safe and hygienic environment

▪ Engage in recreational and leisure activities

Nursing Diagnoses for Vision- Impaired Older Patients

❑ Sensory/perceptual alterations: visual

▪ Encompasses a variety of nursing goals and interventions communication

 Safety

 Mobility

 Self-care activities

 Mood assessment

2. Hearing loss
❑ > 30% aged 65 to 76 years

❑ 50% >75 years

❑ Older men > older women

❑ Caucasian men and women > African American men and women

❑ Temporary threshold shift (TTS)

❑ Sounds < 75 dB(A) → temporary hearing loss

❑ Sounds > 85 dB(A) for 8hrs/day + many years → permanent loss

Risk Factors
▪ Long-term exposure to excessive noise

▪ Impacted cerumen (ear wax)

▪ Ototoxic medications
 ▪ Tumors

▪ Diseases that affect sensorineural hearing

▪ Smoking

▪ History of middle ear infection

▪ Chemical exposure (e.g., long duration of exposure to trichloroethylene)

A. Conductive Hearing Loss

Sound unable to be transmitted → poor reception + amplification
◦ Site of problem

 External or middle ear

❑ Cause

▪ Otitis externa

▪ Impacted cerumen

❑ Most common and reversible

▪ Otitis media

▪ Benign tumors

▪ Tympanic membrane perforation

▪ Foreign bodies

▪ Otosclerosis

 Conductive Hearing Loss

❑ Transmission hearing loss

❑ Damage external or middle ear

❑ Failure of sound waves to be transmitted through the external and/or middle ear

❑ Causes

- impacted earwax
- perforated eardrum
- otosclerosis (decreased mobility of the ossicles)
❑ Treatment
 - hearing aids that amplify the sound, since the inner ear and organs of sound
perception are not damaged

B.Sensorineural Hearing Loss

❑ Problems with cochlea + auditory nerve → sound distortion

❑ Causes

▪ Presbycusis

▪ (bilateral progressive hearing loss especially at high frequencies in

elderly people)
▪ High-frequency hearing loss from excessive noise (industrial noise, gunfire,
“rock & roll” deafness)
 Impaired ability to hear high pitches

 Rare, severe hearing loss or deafness

▪ Damage as a result of excessive noise exposure

▪ Meniere’s disease

▪ Tumors

▪ Infection

❑ Perceptive / “Nerve” hearing loss

❑ Pathologic changes in the inner ear, VIII cranial nerve, and/or auditory centers of the
brain

❑ Causes

- Presbycusis (bilateral progressive hearing loss especially at high frequencies in

elderly people)
- High-frequency hearing loss from excessive noise (industrial noise, gunfire,
“rock & roll” deafness)

Hearing Loss Assessment

◦ History

◦ Physical examination

 Inspection

 Examination of ear canal

  Childhood ear infections → ruptured eardrum → jagged white scars
on tympanic membrane in elderly

◦ Hearing Handicap Inventory for the Elderly (HHIE-S)

o Talk with family members

Common Hearing Problems in Older Persons

❑ Tinnitus

▪ Objective—pulsatile sounds with turbulent blood flow through the ear

 Hypertension

 Anemia

 Hyperthyroidism

▪ Subjective—perception of sound without sound stimulus

 Medications

 Infections

 Neurological conditions

 Disorders related to hearing loss

Nursing Diagnoses Associated with Hearing Impairment

❑ Assessment

▪ Ability to perform activities of daily living

 Communication

 Driving or taking public transportation

 Safety awareness including the ability to hear alarms, doorbells

 Engaging in leisure and recreational activities

Nursing Diagnoses Associated with Hearing Impairment

❑ Diagnosis

▪ Sensory/perceptual alterations: hearing with a variety of nursing goals and

interventions

 Communication
  Safety

 Self-care activities

 Mood

 Recreation and leisure activities

Protocol in cerumen removal

❑ Clip and remove ear hairs

❑ Instill softening agent, mineral oil, carbamide peroxide or glycerin solution

❑ Irrigate the ear using bulb syringe

❑ Use a solution of 3oz 3% hydrogen peroxide in 1 qt water warmed to 98 to 100 F., or

plain normal saline solution

❑ Place a towel around the client’s neck and tip head to the side being drained-have an
emesis basin

❑ Tip the head to side that is being irrigated

❑ Place the tip of the irrigating device just inside the external meatus –tip visible

❑ Straighten auditory meatus draw pinna up and down

❑ Flow of irrigating fluid should be steady, lavage continues until the cerumen is removed

❑ Drain excess fluid by tilting the head toward the affected side

❑ Impacted cerumen must be manuallt extracted by a physician or apn with an otoscope

and a curette

3. Taste
❑ Contributing factors to taste alterations

▪ Oral condition

▪ Olfactory function

▪ Medications

▪ Diseases

▪ Surgical interventions

▪ Environmental exposure
 ▪ Medical conditions

Taste
❑ Oral status can affect gustatory function

▪ Poor dentition → improper chewing → less flavor release

▪ Improperly fitting dentures → obstruction of palate → decreased taste perception

▪ Oral infections → release of acidic substances → altered taste + impaired

salivary stimulations → decreased ability for food to dissolve → diminished flavor

❑ Focused assessment for taste disturbances

▪ Head and neck

▪ Mucous membranes

▪ Interview with focus on past dietary habits

❑ Education

▪ Implications of inability to distinguished between salt and sugar

▪ Decreased taste → lack of motivation to prepare + eat → malnutrition

Xerostomia
❑ Cause

◦ Systemic diseases

◦ Radiation

◦ Medications

◦ Sjogren’s syndrome

❑ Implications

◦ Altered taste

◦ Difficulty swallowing → Risk for aspiration pneumonia

◦ Periodontal disease

◦ Speech difficulties → embarrassment → social isolation

◦ Dry lips + dry mucosa → increased infection + dental caries

 ◦ Halitosis

◦ Sleeping problems

Nursing Diagnoses Associated with Taste Impairment

❑ Sensory/perceptual alterations: gustatory

❑ Intake less than necessary for caloric requirements

4. Olfactory Dysfunction
❑ Statistics

◦ Males > females

❑ Causes

◦ Nasal and sinus disease

◦ Upper respiratory infection

◦ Head trauma

◦ Secondary

 Chemotherapy or other medications

 Radiation

 Current or past use of cocaine or tobacco

 Poor dentition

Olfactory Dysfunction
❑ Special concerns

◦ Safety related to smoke and fire

◦ Malnourishment

❑ Sense of smell fails to be detected because it is not adequately tested

◦ Use three familiar smells

◦ Repeat with both nostrils, in different orders

❑ Nursing diagnoses associated with hyposmia

 ◦ Sensory/perceptual alterations: olfactory

Nursing Diagnoses
❑ Nursing diagnosis associated with hyposmia

◦ Sensory/perceptual alterations: olfactory

❑ Nursing diagnosis for changes in physical sensations

◦ Sensory/perceptual alterations: tactile

Nursing Assessment
❑ Assess safety and preventive measures

❑ Additional assessment

▪ Nutrition

▪ Patient safety

 Date and label all foods

 Place natural gas detectors in the home (for gas heat)

 Place smoke detectors in strategic locations

 Establish schedules for personal hygiene and house cleaning

 Remove kitchen waste every evening

Learning Objective :Recognize nursing interventions that can be implemented to assist the
aging patient with sensory changes.
Eye Examinations
❑ Healthy older adults

▪ Complete eye examination every 1 to 2 years

 Visual acuity

 Retina

 Intraocular pressure

❑ Diabetics

▪ Complete eye examination annually

Assessment of Vision
❑ Observe appearance
 ▪ Clothing cleanliness

▪ Self-care

▪ Indications of bumps and bruises

Interview
❑ Adequacy of vision

❑ Recent changes in vision

❑ Visual problems

◦ Red eye

◦ Excessive tearing or discharge

◦ Headache or feeling of eyestrain when reading or doing close work

◦ Foreign body sensation in the eye

◦ New onset of double vision or rapid deterioration of visual acuity

◦ New onset of haziness, flashing lights, or moving spots

◦ Loss of central or peripheral vision

◦ Trauma or eye injury

◦ Date of last exam

◦ Inspection

◦ Movement of eyelids

◦ Abnormally colored sclera

◦ Abnormal or absent papillary response

Vision
❑ Snellen chart or reading from print

❑ Visual field testing

❑ Extraocular movements

Visual Aids
❑ Helpful aids for visually impaired
 ◦ Low-vision clinics for suggestions

◦ Telescopic lenses

◦ Books in Braille

◦ Computer scanners and readers

◦ Tinted glasses to reduce glare, large print books and magazines

◦ Seeing eye dogs

◦ Canes

❑ Often rejected because of the stigma attached

❑ Very expensive and not covered by Medicare

❑ Register with Commission for the Blind

◦ Books on tape and tape player

◦ Telephones with large numbers

◦ High-intensity lights

Visual Difficulties May Limit Independence

❑ Interference with ability to drive

❑ Trouble reading and writing

Identification of Safety Problems at Home

❑ Provide adequate lighting in high-traffic areas

❑ Recommend motion sensors to turn on lights when an older person walks into a room

❑ Look for areas where lighting is inconsistent; use proper lampshades to prevent glare

❑ Use contrast when painting so that walls, floors, and other structural elements of the
environment can be discriminated easily

❑ Avoid reflective floors

Identification of Safety Problems at Home

❑ Use “hot” colors, such as red, orange, and yellow for signage

❑ Urge the use of supplementary lamps near work and reading areas
 ❑ Use red colored tape or paint on the edges of stairs and in entryways to provide warning
and signal the need to step up or down

❑ Avoid complicated rug patterns that may overwhelm the eye and obscure steps and
ledges

❑ Teach the importance of walking slowly when entering a room

ARMD Preventive Measures

❑ Nurses should encourage

▪ Wearing ultraviolet protective lenses in sun

▪ Smoking cessation

▪ Exercising routinely

▪ Eating a healthy diet consisting of fruits and vegetables

▪ Taking vitamins in divided doses twice a day to delay progression

 Zinc oxide 80 mgm

PHYSIOLOGIC, PSYCHOLOGIC, AND ENVIRONMENTAL CAUSES OF ACUTE

CONFUSIONAL STATES IN HOSPITALIZED OLDER ADULTS

I. PHYSIOLOGIC

A. Primary Cerebral Disease

1. Nonstructural factors

a. Vascular Insufficiency –transient ischemic attacks, cerebrovascular accidents,

thrombosis

b. Central nervous system infection- acute and chronic meningitis, neurosyphillis,

brain abscess

2. Structural Factors

a. Trauma-subdural hematoma, concussion, contusion, intracranial hemorrhage

b. Tumors- primary and metastatic

c. Normal pressure hydrocephalus

B. Extracranial Disease
1. Cardiovascular abnormalities

a. Decrease cardiac output state-myocardial infarction, arrhythmias, congestive

heart failure, cardiogenic shock

b. Alterations in peripheral vascular resistance-increased and decrease states

c. Vascular occlusion-disseminated intravascular coagulopathy, emboli

2. Pulmonary abnormalities

a. Inadequate gas exchange states-pulmonary disease, alveolar hypoventilation

b. Infection-pneumonia

3. Systemic infective processes-acute and chronic

a. Viral

b. Bacterial- endocarditis, pyelonephritis, cystitis, mycosis

4. Metabolic disturbances

a. Electrolytes abnormalities-hypercalcemia, hyponatremia and hypernatrimia,

hypokalemia and hyperkalemia, hypochloremia and hyperchloremia,

hyperphosphatemia

b. Acidosis and alkalosis

c. Hypoglycemia and hyperglycemia

d. Acute and chronic renal failure

e. Volume depletion-hemorrhage, inadequate fluid intake, diuretics

f. Hepatic failure

g. Porphyria

5. Drug intoxifications- therapeutic and substance abuse

a. Misuse of prescribed medications

b. Side effects of therapeutic medications

c. Drug-drug interaction
 d. Improper use of over-the –counter medications

e. Ingestion of heavy metals and industrial poisons

6. Endocrine disturbance

a. Hypothyroidism and hyperthyroidism

b. Diabetes mellitus

c. Hypopituitarism

d. Hypoparathyroidism and hyperparathyroidism

7. Nutritional deficiencies

a. B Vitamins

b. Vitamin C

c. Protein

8. Physiologic stress-pain, surgery

9. Alterations in temperature regulation-hypothermia and hyperthermia

10. Unknown physiologic abnormality-sometimes defined as pseudodelirium

II. PSYCHOLOGIC

1. Severe emotional stress-postoperative states, relocation, hospitalization

2. Depression

3. Anxiety

4. Pain- acute and chronic

5. Fatigue

6. Grief

7. Sensory/perceptual deficits-noise, alteration in function of senses

8. Mania

9. Paranoia

10. Situational disturbances

III. ENVIRONMENTAL

1. Unfamiliar environment creating a lack of meaning in the environment

2. Sensory deprivation or environmental monotony creating a lack of meaning in the

Environment

3. Sensory overload

4. Immobilization-therapeutic, physical, pharmacologic

5. Sleep deprivation

6. Lack of temporospacial reference points

Differentiating Dementia and ACS

CLINICAL FEATURE ACUTE CONFUSIONAL STATE DEMENTIA

Onset Acute/subacute; depends on cause; Chronic, generally insidious;depend on

often occurs at twilight cause

Course Short; diural fluctuations in symptoms; Long; no diural effects; symptoms

worse at night, dark, and on awakening progressive, yet relatively stable over time

Duration Hours to less than 1 month Months to years

Awareness Fluctuates, generally reduced Generally clear

Alertness Fluctuates-reduced or increased Generally normal

Attention Impaired, often fluctuates Generally normal

Orientation Fluctuates in severity, generally impaired May be impaired

Memory Recent and immediate memory Recent and remote memory impaired;
impaired; unable to register new loss of recent memory is first sign; some
information or recall recent events loss of common knowledge

Thinking Disorganized, distorted, fragmented, Difficulty with abstraction and word finding
slow, or accelerated

Perception Distorted, illusions, delusions, or Misperceptions often absent

hallucinations

Sleep-wake cycle Disturbed, cycle reversed Fragmented

How do you communicate effectively with the elderly with impaired verbal
communication?
➢ Use proper form of address. Establish respect right away by using formal language. ...
➢ Make older patients comfortable. ...
➢ Take a few moments to establish rapport. ...
➢ Try not to rush. ...
➢ Avoid interrupting. ...
➢ Use active listening skills. ...
➢ Demonstrate empathy. ...
➢ Avoid medical jargon.

● Cataract – clouding of crystalline lens of eye

● Glaucoma – eye disease involving increased intraocular pressure
 ● Macular degeneration – loss of central vision due to the development of drusen deposits in the
retinal pigmented epithelium
● Presbyusis – age-related high – frequency sensorineural hearing loss
● Presbyopia – age-related decrease in eye’s ability to change the shape of lens to focus on near
objects
● Xerostomia - refers to a condition in which the salivary glands in your mouth don't make enough saliva
to keep your mouth wet

Watch and Learn:

https://www.youtube.com/watch?v=BwV2EMAdOic

https://www.youtube.com/watch?v=INQFlDsBtq0

Study Questions:
1. What are the effects of aging on sensory function?
2. What can be done to prevent sensory dysfunction vision and hearing losses with aging?
3. Explain language barrier that lead to impaired verbal communication?

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

Websites:
http://thepoint.lww.com/Eliopoulos8e
http:www.sleepfoundation.org
LECTURIO Aging Process (Nursing): Sensory /Perception Alteration