Nutrition/GI/Anemia (6-8 questions) Nutrition 40-60% of hospitalized older adults= malnourished or at risk for malnutrition Risk factors= physiological,

, social, economic, chronic health probs Physiological Changes with Aging that affect Nutrition Olfactory Alterations: 50% of those >65 report impairment in olfaction (greater in men) Age-related decline; often unrecognized Impairment in odor identification, odor discrimination, nasal pungency Impairment can also be caused by nasal sinus disease, head trauma, URI, neurodegenerative disease (AD,Parkinsons), environmental toxins, drugs Taste Alterations: Hypogeusia: taste Ageusia: absent taste Dysgeusia: altered taste (most common) # of papillae & taste buds per papillae Some taste loss is due to changes at level of cell membrane rather than loss of buds Reduce taste buds/papillae: Meds, radiation, disease Degenerative changes in central taste pathways alter taste perception Changes in salt, bitter detection mostly (sweet is preserved: older people love sweets because they still taste right) Meds: account for most loss of taste! (sulfydryl groups, HIV drugs, antibiotics) Can cause distorted taste, unpleasant (metallic, bitter, salty, medicinal, acidic) taste, loss of taste Taste & Smell comorbidities: Neurologic: Alz Disease, Downs Synd, Guillain-Barre, head trauma, Korsakoffs Synd, MS, Parkinsons Dis Nutritional: Cancer, Chronic Renal Failure, Liver Dis, Niacin (B3) Def, Burns, Zinc Def, B12 Def Changes in taste alters appetite, food choices, nutrient intake, health status, motivation to eat, may ability to detect spoiled food Progressive in food intake + energy expenditure during middle age = adiposity in 50s, 60s, slows down after 70 Unintentional weight loss occurs due to inadequate nutritional intake Under-nutrition Sarcopenia Impaired immunity, wound healing Physical frailty Quality of life Nutritional Considerations Older adults feel satiated/fuller sooner Dysphagia: make sure they get a full evaluation Special Dysphagia diets are aimed at swallowing problems vs. motility problems Dont help if a constipation/diarrhea problem exists too GERD: avoid the following High-fat food, ETOH, chocolate, nicotine, peppermint, acidic foods (orange, tomato, apple juice) Type B Gastritis Consider providing B12 supplements Consider B6, vitamin D supplementation Constipation 6-8 glasses of H2O/day, fiber Liver disease high calorie, high protein diet Oral Care Xerostomia: dry mouth due to saliva (+ poor oral health) Impaired ability to lubricate, chew, swallow food Caused by antidepressants, antihypertensives, bronchodilators Meds can cause Anorexia (dig, fluoxetine, quinidine, hydralazine, vit A, psychoactives, morphine, methotrexate) Malabsorption (sorbitol, cholestyramine) Increased energy metabolism (thyroxine, theophylline) Nausea (antibiotics, theophylline, ASA) Disability/Chronic Illness/Impaired Cognitive Status Can hinder ability to prepare, ingest, excrete food Environmental Affects on Nutrition Those w/limited income may restrict # of meals/day or dietary quality of meals Isolation may cause a person to lose desire to cook; appetite of widows Lack of access to transportation affects ability to buy food

Depression Associated with dietary intake, appetite, weight loss Higher depressive symptoms associated w/poor nutrition

Inflammation and Aging Chronic, low-grade inflammation in aging Could be related to underlying disease (CVD, DM, Alz Dis, Parkinsons Dis, rheumatoid arthritis) Thought to be crucial for counteracting stressors Aging: levels of proinflammatory cytokines (IL-6, TNF-): cytokines cause food intake, body weight, temp Types of Malnutrition Macronutrient: energy (carbs, protein, fat) Micronutrient: vitamins & minerals Lots of undernourished ppl live in developing countries= malnutrition is a major public health problem Poverty= main cause of malnutrition (-same slide then says disease= main cx of malnutrition?) No running water: bacterial, parasitic disease Malnutrition in the Elderly Undernourishment characterized by insufficient dietary intake, poor appetite, muscle wasting & weight loss Starvation-related malnutrition Chronic starvation w/o inflammation (ex: anorexia nervosa) Chronic disease-related malnutrition Chronic mild to moderate inflammation (common in elderly) Acute disease or injury related malnutrition Acute, severe inflammation (ex: gunshot wound) Protein-energy malnutrition: imbalance between nutrient supplies & requirements Primary protein calorie malnutrition: poor eating habits: nutritional needs not met Secondary protein calorie malnutrition: alteration/defect in ingestion, digestion, absorption, metab.; disease-related malnutrition Marasmus: depletion of muscle mass & fat stores Malnourished, cachectic appearance Normal visceral protein and organ function History of weight loss Adapted to decreased nutrient intake Function fairly well unless exposed to additional metabolic stress (common in COPD pts) rd Kwashiorkor: hypoalbuminemic malnutrition; (low-albumin = 3 spacing = edema) Dont appear malnourished Loss of visceral protein (low albumin, transferrin, prealbumin) Inadequate protein intake relative to the bodys needs during hypermetabolic states - injury, infection and draining wounds Mixed-Marasmus Kwashiorkor: combo of marasmus/kwashiorkor Unintentional Weight Loss Important indicator of malnutrition; could be due to anorexia, starvation, sarcopenia Loss of 10 lbs over 6 mos., intentional or unintentional= critical indicator = morbidity & mortality Long-Term Unintentional: 5+ kg or 5% over 5-10 years Acute Unintentional: 7.5% loss over 6 mos. Significant Unintentional: 5% loss over 1 month or 10% loss over 6 mos. Causes of Weight Loss Cachexia: inflammatory disease; severe wasting of fat & fat-free mass Starvation: pure protein deficiency, conserves lean body mass & depletes fat mass Sarcopenia: age related loss of muscle or lean mass, muscle strength & function; weight may not change 2 BMI: kg/m Normal= 18.5- 24.9 Overweight= 25- 29.9 Obese= >30 Sarcopenic Obesity: frequently occurs w/advancing age Loss of muscle protein mass Decline in functional status *not all sarcopenic ppl have low BMI = Increased fat mass may mask body weight loss = Inflammatory state Malnutrition= major factor in poor health consequences of older adult Increased length of hospital stay Increased hospital costs Diminished muscle strength Poor wound healing

Development of pressure ulcers Infections Postoperative complications Functional impairment Death

Screening and Assessment Obtain accurate wt & ht by DIRECTLY MEASURING! (Dont ask, may not be accurate- women estimate ) If pt cant stand: a) Knee-height- takes age into account b) Demi-span- 1 arm out to side, measure mid-sternal notch to the base of ring finger doesnt: account for age but does account for gender **Both are estimates of standing height Ask about usual weight, history of weight loss, any intentional/unintentional wt. loss = concerned with 10 lb. wt. loss over 6 mos. = red flag!! Ideal body weight: 80-90%= mild malnutrition 70-79%= moderate malnutrition 0-69%= severe malnutrition Visceral Proteins: (longest half-life shortest half-life) Albumin: 3.5 g/dL indicates malnutrition; 3.5-5 = normal Not always good indicator of nutritional status; long half-life, so it tells nutritional status 20 days ago. Highly affected by hydration status: high with dehydration, low when hydrated Take Albumin level along with CRP level (elevated due to inflammation: 0-1 mg/dL normal) that will tell you if Albumin level is due to inflammation or poor nutrition. Transferrin: 200 mg/dL indicates malnutrition; inverse relationship w/iron Prealbumin: 15 mg/dL indicates malnutrition Retinol-binding protein: normal = 2.7- 7.6 mg/dL Nutrition Screening identifies ppl that may have risk factors; risk factors present & assess to see if have disease ASPEN screen: ids someone malnourished or at r/f malnutrition to determine need for detailed assessment ESPEN screen: rapid, simple process conducted by admitting staff or community healthcare teams Joint commission says monitor every pt w/in 24 hours of admission Mini-nutritional assessment: most valid & reliable tool; higher score= better (14= best; 11= do assessment) Measuring mid arm circumference= use non-dominant arm, elbow at 90 angle Allows for observation of changes in status Find midpoint between shoulder blade and elbow; mark it Measure circumference where mark is (22+ cm= 1 pt for muscles) Treatment Improve PO intake- mealtime rounds to ensure they are eating encourage family visits, small frequent meals, sit up in chair, mouth care Manage NPO order- elderly pts scheduled in morning for procedures Start specialized nutritional support- if pt cant/shouldnt/wont eat adequately if benefits > risks **Determine advanced directives first** Oral Supplements- should NOT replace meals; give btw. meals (but not preceding meals) + at bed Assess for Refeeding Syndrome- consequence of depletion followed by repletion Watch for hypophosphatemia, hypokalemia, hypomagnesemia, hyper/hypoglycemia *Phosphorus level= most important Ensure caloric goals reached slowly over 3-4 days Enteral nutrition: nutrition via GI tract Medicare doesnt always cover nutritional supplements When pt. leaves hospital they may not buy them Teach how to get nutrients other ways Special Nutritional Needs Liver failure: Dec Protein, Inc Carbs Renal Failure: Inc Protein with Dialysis, If not on dialysis then monitor protein intake with H/H levels Diabetes: Dec Carbs, Inc Fat, Inc Fiber COPD: frequent high calorie feedings; dont want to wear pt out with big meals that require lots of O2 Inc Fat, Dec Carbs because carbs require most O2 consumption and produce more CO2 Post-Pyloric Feeding= better because there is r/f aspiration compared to pre-pyloric Formula Selection Continuous vs. Intermittent vs. Bolus

 Bolus not recommended b/c can cx dumping syn. (cramping, diarrhea) Dont dilute formula with water Can cause diarrhea from bacterial communication Can flush tube with tap water unless hospital policy prevents it (may prefer NS.. snobs) Safe Enteral Feeding= be ALERT Aseptic technique Label enteral equipment Elevate HOB 30 Right pt/ Right formula/ Right tube Trace all lines, tubing back to pt (avoid misconnections) Safe Enteral Meds= be AWARE Ask pharmacist if its ok to put med in tube Water only to dilute, flush Add med 1 at a time Remember the rights Establish EBP protocol Xray to confirm placement of tube not in lungs

Nursing Tips Encourage old ppl to eat in dining room to increase intake Dont administer tx or other activities during meals Use standard dinnerware instead of bibs, disposable tableware Allow food choices Minimize environmental noise Cue whenever possible with words, gestures (open mouth, chew) Encourage self-feed w/multiple methods vs. assisted feeding to minimize time Dysphagia pt= provide 30 min rest before meal; upright @ 90 angle Chin-down position helpful in reducing aspiration Vary placement of food in pts mouth (prevent aspiration of food from being left in mouth) RDA: recommended dietary allowance DRI: dietary reference intake EAR: estimated avg. requirement AI: adequate intake UL: tolerable upper limit Reference levels change at @ 50 y.o. Energy: uses actual weight; most accurate estimate of resting metabolic rate for overweight & obese people Sedentary adult= 25 kcal/kg/day Active adult= 40 kcal/kg/day Carbs= 4 kcal/gram (45- 65% of total kcal) Protein= 4 kcal/gram (10- 35% of total kcal) Fat= 9 kcal/gram (20- 35% of total kcal; <10% sat fat) Anemia Common disorder of aging, but falsely attributed to normal aging--- NOT NORMAL! Classified by size of RBC= mean corpuscular volume (MCV) Causes decrease in O2 carrying capacity of the blood. Body adjusts by Inc CO, Inc RR, Inc release of O2 from hgb and redistributing blood to the vital organs Older adults may take longer to make those adjustments to Anemia will present earlier May not have any s/s until severe progression of disorder s/s= chronic fatigue, SOB/dyspnea, peripheral edema, dizziness, pallor of oral mucosa/conjunctiva (different for older adults, ppl of color) s/s of when disorder advances= mental status (confusion, depression, agitation, apathy), tachycardia, palpitations, systolic murmurs, angina Diagnosis Hemoglobin (Hgb) level *males with Hgb <13 g/dL or women <12 g/dL; AAs lower by up to 1 g/dL (both sexes) *false high with dehydrated pt, smokers, those living at high altitudes Hematocrit (Hct) level *RBC count + indices; reticulocyte count; WBC count + diff; platelet count Types of Anemia 1) Microcytic Anemia: Iron deficiency Dec Hgb, Dec MCV Pale, small RBC

Causes: inadequate iron intake or malabsorption of iron Diagnosis: serum ferritin <10 mcg/L, reticulocyte count, check for occult stool Treatment: Ferrous sulfate 325 mg daily Take on empty stomach (may cause GI discomfort; take with small meals if nausea occurs; give with vit. C= orange juice) Recommend red meat, leafy green vegs Thalassemia- occurs in people of Mediterranean descent Decrease in the amount of hgb produced 2) Macrocytic: A.) B12 Deficiency Failed GI absorption= Pernicious Anemia Normal hgb, Inc MCV Causes: lack of intrinsic factor, malignancy, CRF Diagnosis: serum B12 <200 pg/mL, check methylmalonic acid, homocysteine; do Schilling test *May have NEUROLOGIC CHANGES Treatment: IV vit. B12 daily for a week, then once/week for 4 weeks, then one dose/month B.) Folic Acid Deficiency Normal hgb, Inc MCV, Normal B12 Serum folate <4 ng/mL Causes: Inadequate intake, malabsorption syndromes, poor nutrition, ETOH abuse, underlying malignancies Treatment: folic acid replacement 1mg/day 3) Hemolytic Anemia: Premature RBC destruction = not enough RBCs in the blood Causes: autoimmune antibodies, inherited enzyme deficits, infections, leukemia, Hodgkins/Non-Hodgkins Lymphoma,trauma, mechanical factors (prosthetic heart valves), burns, exposure (toxic chemicals, venoms), drugs (ibuprofen, penicillin, ASA) Treatment: folic acid & dietary replacement= leafy greens, fruits, cereals, meats 4) Normocytic anemia Anemia of chronic disease (chronic disease, infection or inflammation) 4-8 weeks of illness Causes: Dec erythropoietin production, Dec RBC survival, impaired transport of iron to bone marrow Reticulocyte count low Serum iron normal/slightly low, Serum ferritin normal/slightly elevated Renal Insufficiency erythropoiesis, RBC survival, Serum iron stores normal Chronic Liver disease RBC production/survival Lots of alcohol = toxic to bone, liver = Fe levels, total iron binding capacity Malnutrition Missing essential nutrients, folic acid, Vit. C Production of RBC decreases (normocytic anemia) Malignancies= CA, chemo can cause marrow function, appetite, cause N+V Nutritional deficiencies: caloric, protein, vitamin intake 5) Aplastic Anemia Not very common in old age; associated with radiation, chemical substances Transfusions Can quickly reverse severe anemia Hct <30% (norms= males 41-53%, females 36-46%) **use with caution: give slowly w/diuretic (20 mg furosemide); monitor VS & UO; check blood type *Make sure to make sure there is no underlying diagnosis before treating anemia *Ask baseline level of fxn, activity level, and recent activity status *Lifestyle factors= smoking, ETOH, depression, obesity, poor nutrition, sedentary life, family hx blood disorders *Physical exam= may cause vague symptoms of fatigue, depression, weakness Resp. = activity intolerance (observe them walking); assess for HR, RR, weakness, pulse ox Skin = pallor, bruising, poor turgor; presence of rashes, urticaria, itching May have lymph node size; size of liver, spleen GI Changes in Aging Some are due to normal aging Polypharmacy, stress, poor nutrition, comorbidities, poor hygene can lead to GI dysfunction Many systemic changes are DT CV or neuro manifestations, rather than GI system itself One of the biggest problems= lack of teeth; many dont have dental insurance b/c they are retired

Common Problems Dec motility through out the GI tract Oral Cavity + Pharynx: tooth loss, bacteria growth, dec tastebuds Esophagus: dec motility, GERD Stomach: dec gastric acid, dec motility, malabsorption of Iron/Ca/folic-acid/B12, PUD, Cancer Small Intestines: atrophy of muscles + mucosal surfaces = dec of absorption of fats/B12 = undernourished, weak, dilation Large Intestines: dec tone anal sphincter + dec muscle tone (urge to defecate = incontinence, constipation, incomplete empty) Gallbladder: inc incidence of gallstones Pancreas: fibrosis/fatty acid deposits/atrophy, dec pancreatic enzymes, dec digestion of fat, cancer Liver: dec size of liver, dec hepatic blood flow, dec drug metabolism, immunologic/metabolic dysfunction, risk for toxicity! *Older adults may complain of symptoms r/t GI tract but not r/t specific diagnosis Nausea/Vomiting Controlled in the Medulla Nausea without Vomiting comes from the brain not the GI Interventions Clear liquids > eat bland foods > eat solid foods Small, frequent feedings Fluid replacement/metabolic balance is priority if vomiting occurs Can cause confusion in older adults Anorexia Lack of appetite Interventions Monitor I&Os, weight Small, frequent feeds Determine if drugs alter their taste sensation Abdominal Pain Difficult to fully assess Interventions Provide comfort measures, pain relief, treat cause (IV fluids, NGT, etc) Could be r/t chemo/radiation Ask when last BM was? gas? difficulty passing stool? Gas Belching, bloating, fullness, flatus Interventions Routine exercise; eliminate gas-forming foods 7-20 gas passages/day = normal (more than that could = due to the foods they eat) Belching= due to unconscious air breathing (make sure belching is not from PUD, gastritis)

Diarrhea Inc frequency of stools or change in consistency Can be due to increased mobility, absorption of H20, absorption of nutrients Important to ask what it looks like, amount, color, smell + what normal bowel patterns are Chronic diarrhea Avoid gas-forming foods, vegs, spices, milk products Acute diarrhea Consume bland foods (BRAT diet), clear liquids *BRAT= bananas, rice, applesauce, toast/tea Assess for dehydration Watch F&E, teach about s/s dehydration (confusion, thirst, dizzy, weak) Often diarrhea self-induced b/c old ppl believe they need to poop everyday (take meds to induce) Constipation Defined according to pts perception of abnormal bowel function Causes Diet, dec fiber intake, mechanical obstruction, med SEs, comorbidities, mobility issues Treatment fluids, fiber, light exercise, develop regular toileting routine, respond to urge Ask about use of OTC laxative meds; worry about abuse As long as consistency is normal and they have BM @ reg. intervals = all cool Fecal Incontinence Involuntary passing of stool; acute or chronic

Treatment: focus on preventing Develop bowel control program, position with feet up to discourage BM, teach ways to odor, use adult diapers, skin care Help to prevent embarrassment: loss of control can impact pts quality of life; can devastate pt Can be due to: neuro probs, lax abuse, lactose intolerance, diabetic neuropathy, immobility

Gingivitis Can occur with long-term use of Dilantin Get good dental care history- regular visits q6mos? daily dental care? nutritional status? One of greatest causes of VAP = poor oral care Dentures- clean? fit well? in mouth while eating? Dysphagia Weakened esophageal smooth muscle or incompetent sphincter function = difficulty swallowing Causes Stroke, neuro disease, local trauma, tissue damage, tumors May compromise nutritional status & r/f aspiration pneumonia Treatment Maintain fluid/nutrition status Prevent aspiration Emotional support ___________________________________________________________________________________________________________ _____________ Falls/Musculoskeletal (7-9 questions) Falls Important to differentiate between intrinsic and extrinsic causes of falling in older adults Goals to prevention: promote safety; respect autonomy of pt for decision making Falls affect 1/3 of older adults (home or in an institution) *30% are preventable; therefore, not all falls are considered preventable Older adults >75 y.o. are frail, have limited physiologic reserve Highest rate of falls= white men Fall prevention: identify high risk adults Modify medication if meds are causing a problem Behavioral modification One of National Pt. Safety Goals= hospitals must have a risk assessment & fall reduction program Many falls occur when pt is in a hurry, tries to get up quickly, or has a lapse in memory Falls may have a negative connotation; may reduce a pts ability to function on own Age Related Changes that Increase falls Vision Presbyopia (inflexibility of lens); accomodation; depth; cataracts Teach pt to watch door edges, curbs; wear sunglasses, glasses, wide-brimmed hats Hearing Presbycussis (loss of high tones); atrophy of ossicle in inner ear in vestibular system = balance (susceptible to falls; feedback to brain altered) Provide visual cueing to help pt Cardiovascular BP w/position = Orthostatic Hypotension Teach pt to get up slow & dangle legs at bedside before standing Bradycardia/tachycardia common Musculoskeletal supportive cartilage Osteoarthritis- weight-bearing joints erode Treatement- anti-inflammatory meds; exercise; braces; joint replacements If left untreated, leads to immobility & sedentary lifestyle = muscle weakness Encourage/supervise ambulation; use ambulatory aides; ROM activities; ice/heat; PT Neurological reaction time; longer to respond verbally & physically Functional impairments & disease can cause muscle weakness AE of meds can cause loss of postural stability = falls Treatment = assess, monitor mobility, promote autonomy Related Nursing Responsibilities: 1. Location of pt room in relation to nursing station 2. Remember lots of falls happen @ shift 3. Call bell close, bed low, bed alarms/chair alarms, toilet incontinent 4. Promote independent activity

*physiatrist/PT eval; use walking aid; shoes w/sturdy heels + leather/rubber soles Classification of Falls Multifactorial Extrinsic: steps, floor surfaces, edges/curbs, inadequate lighting, restrain use(lead to death, further injury; 4 side rails climbing over end of bed) Intrinsic: concurrent disease, gait/balance/stability, incontinence, mental status/cognition, fractures Intentional: psych, for attention Isolated: just one fall Cluster: several falls, related to one thing that can be corrected = no more falls Premonitory Prodromal: preceding something Risk Assessment: thorough eval, risk factors Serious Injuries r/t Falls: 1. Hip fractures (high mortality rate) 2. Head trauma 3. Internal bleeding Falls also cause psychological trauma (depression, anxiety, stress-related syndromes, fear of falling) Pt History: important to remember falls arent normal Note fall frequency Any prodromal s/s, events Evaluate memory of event (intact & recall) Hx of disease that can = falls Physical Exam Assess CV status- take apical rate, BP Assess motor response-gait analysis Assess sensory input- vision, hearing Might want to consider having pt/family keep fall diary (dear diary) Institutional management= bed/chair alarms + hourly rounding Prevent falls by maximizing health/functional status unnecessary meds their risk-taking behavior environmental hazards Provide nightlights; tips on walkers/canes; rugs tacked down; grab bars installed Teach pt to not over reach; avoid ETOH , avoid rushing Total Hip Replacement Concern for dislocation: maintain hip abduction/neutral positioning Total Knee Replacement Muscle strength and ROM exercises

Musculoskeletal Function Age-Related in Structure, Function muscle mass, strength elasticity of ligaments, tendons, cartilage bone mass (weaker bones) Intervertebral disks lose water narrowing of vertebral space; height (1.5-3 inches) Flattening of the lordotic curve posture, gait s pain, impaired mobility, self-care deficits, r/f falls Common Problems of MS system: Falls, fractures Hip fracture Colles fracture- distal fracture of radius Clavicular fracture osteoarthritis Rheumatoid arthritis Gouty arthritis Osteoporosis Pagets disease Osteomyelitis Amputation Polymyalgia rheumatica Foot Problems- corns, calluses, bunions, hammertoe, nails

Osteoarthritis (degenerative joint disease-DJD) Non-inflammatory disease of joints = progressive cartilage deterioration + formation of new bone in the joint space #1 chronic complaint among elderly; affects 66 million Mainly affects knees, ankles (also DIP, PIP, hips, spine; MCP affected more by RA) Signs and Symptoms Pain with activity, relieved with rest Stiffness with rest, relieved with activity Crepitis with ROM Heberdens nodes & Bouchards nodes Risk factors= obesity, trauma, lifestyle, genetic factors, aging Overuse of joints (repetitive mvmnt) Aging, obesity primary osteoarthritis Treatment: goal to prevent/preserve mvmnt, strength Rest, joint protection, heat/cold, nutrition Exercise, complimentary/alternative therapy Plan activities to be spread out, alternate rest/activity Meds Acetaminophen, NSAIDS Glucosamine (inflammation) Condroitin (strengthens cartilage) Capsaisin cream (topical antiinflam.) Will burn at first Intraarticular corticosteroid injections Surgery= arthroplasty (scope to remold joint) Spinal Stenosis Bony overgrowth of the facet joints in the vertebrae = narrowing of the spinal column = nerve compression (can be caused by osteoarthritis) Progressive back pain & weakness of the lower extremeties Most common in lumbar region (L3-L4) Claudication: painful aching, cramping, uncomfortable, or tired feeling in legs Occurs while walking; relieved by rest Burning, numbness of lower extremeties Occurs more when theyre upright Difference between osteoarthritis (OA) vs. rheumatoid arthritis (RA)= OA is localized, RA is systemic rheumatoid arthritis osteoarthritis rd th th th age at onset 3 or 4 decades 5 or 6 decades Onset gradual gradual disease course exacerbations, remissions variable, progressive duration of stiffness 1- 24 hours 30 minutes joint pain worse in morning worse after activity joints involved PIP, MCP, MTP, knees, hips, wrists DIP, knees, hips, lumbar/cervical spine symmetric pattern almost always occasionally constitutional manifestations present absent synovial fluid few cells, normal viscosity cells, viscosity x-ray findings abnormalities present abnormalities present ESR almost always occasionally positive rheumatoid factor almost always never Constitutional manifestations= symptoms that can affect many different systems (ex: fever, fatigue, malaise) Rheumatoid Arthritis (RA): Autoimmune; Genetic Factors More common in women than men Signs and Symptoms Chronic Systemic: fatigue, weakness, fever, anemia, anorexia, wt. loss Joints: painful, stiff, swollen, deformed, dec ROM mushy, boggy, red joints Stiffness mostly in the AM = relieved with mvmt Pannus formation= synovial fluid inc and thickens Causes deformities *can frozen/immobile joints (alkalosis) Diagnosis: CBC, ESR, rheumatoid factor, antinuclear antibody, CRP

Treatment DMARDS (disease modifying antirheumatic drug) Initiated early in disease; may be a few months until best level hit Drugs progression and function Hydroxychloroquinine (Plaquenil): can cause retinal damage Methotrexate: immunosuppressant, r/f infection Azanthioprine (Imuran): immunosuppressant, r/f infection Gold therapy NSAID & COX-2 inhibitors: can casue GI bleed Tumor Necrosing Factor: r/f infection Corticosteroids Ice packs, moist heat, PT/OT for ADLs

Gouty Arthritis Acute attacks of arthritis due to serum uric acid (high uricemia) Acute or chronic condition- at r/f kidney stones w/ uric acid (>8.5) Signs and Symptoms Extreme pain usually in great toe, wrist; red tender joint & possibly fever, malaise Risk factors Obesity, alcoholism, diabetes, HTN, renal disease, diuretic use Joint inflammation due to urate crystals (trophi) in the jt Treatment Pain relief, NSAIDS, colchicine (acute), allopurinol (chronic), moist heat, elevate, paraffin wraps, splints to take weight off joints, stretch gloves or stockings NSG diagnoses Disturbed sleep; psychosocial adjustment; self-care issues and want to their endurance to fatigue Osteoporosis Common yet preventable Metabolic Bone Disorder: reduction in bone mass and loss of bone strength 3 Types: 1. Estrogen related 2. Age related (Over 70) 3. Secondary to disease or med use (long-term steroid use, methortrexate, heparin, dilantin, Hyperthyroidism; Hyperparathyroidism, Alcohol use, immobility) Affects women more than men Risk factors White/asian; age; small/thin stature Early menopause or oophorectomy (estrogen loss = bone stability) Sedentary lifestyle (lack wt. bearing activity) Insufficient calcium or vit. D intake Renal or hepatic failure Genetic/family hx Smoking, ETOH, caffeine (r/f osteoporosis) Signs and Symptoms Often a silent disease Fracture, back pain, height, kyphosis (hunchback), stooped posture Diagnosis= via DEXAscan (bone density scan) Treatment Nutrition Calcium supplement (calcium carbonate= best; take w/meals/full glass of water) Exercise Prevent falls Meds= Calcitonin (Calcimar), Bisphosphonates (Fosamax, Boniva) = bone resorption (C/I w/GI probs) *take 1 hr. before meal & w/8oz. of H2O; remain upright after taking Elective Estrogen Receptor Modulators (Evista)- estrogen replacement (C/I w/breast CA) Remember to Vit. D too, helps to absorb Ca Weird dietary sources of Ca that HESI will pull: oysters, salmon, greens, beans, molasses, tofu Pagets Disease Inflammatory disease of bone where osteoclasts & osteoblasts proliferate Abnormal bone remodeling = deformity & bone enlargement Common in pelvis, femur, skull, tibia, spine (can cause cord compression, paralysis) More common in men >40 y.o. Signs and Symptoms Bone pain, HA, hearing loss (Due to bone deformities), fractures Osteomyelitis

Acute or chronic infection of bone Chronic doesnt respond to abx but acute is usually fixed w/abx in 4 wks. Causes inflammation or death of bone Signs and Symptoms Pain at site, may have purulent drainage Treatment Must immobilize joint; goal= IV then PO antibiotics

Amputation Common surgical procedure in older adults Ensure you explore coping, expectation before surgery Conditions that lead to amputation= PVD (foot ulcers), DM, atherosclerosis, inadequate circulation, infections, neoplasms, trauma Goals Educate pt; ensure they have attitude for physical/emotional adjustment, help pt achieve self-care at home & in community Treatment Prepare the stump to wear a prosthesis Ensure adequate healing time before fitting of prosthetic Stump wrapping Prevent contractures, complications, infection, bleeding When aging with an amputation. Adapt home/environment for WC use Prevent wear & tear of other joints Treat chronic pain Polymyalgia Rheumatica Chronic inflammatory condition characterized by sudden onset of muscle stiffness, aching Usually affects neck/shoulders/hip girdle Onset between 50-65 y.o.; women more than then me Similar presentation to OA, Ra Signs and Symptoms Muscle stiffness in morning lasting >1hr., fever, malaise, anorexia, wt. loss Symptoms last > 4 weeks Absence of muscle weakness, joint swelling, ROM Treatment: NSAIDS, steroids Foot Problems 1. corns= small & round, hard, thick skin on areas of pressure, rubbing; on tops of toes, btw. toes 2. calluses= larger, flatter, hard thick skin; usually on bottoms of feet st nd 3. bunion (hallux valgus)= metatarsalphalangeal jt. enlarged @ base of big toe= 1 points 2 toe nd rd th th 4. hammertoe= deformity of PIP jt. of 2 , 3 , 4 , or 5 toe= permanently contracted/bent Gero Rehab: Goals Assist older adult in achieving personal optimum level of health, well-being via holistic care in therapeutic environment Consider special needs, roles, social relationships, potential comorbidities that occur in aging Care environment a. acute care med-surg units b. intermediate rehab & skilled-care facilities c. intensive rehab units d. outpatient rehab services Enhance fitness & activity: Goal= maintain or improve function: maintaining mobility can prevent or effects of deconditioning PT= develop exercise plan Good activities= swimming, walking, cycling, rowing, dancing Include: 1. endurance training 2. strength training 3. balance exercises 4. flexibility exercises Benefits muscle strength & endurance diastolic BP, body fat, r/f CAD

 bone mineral density, joint flexibility, mental health *Use functional assessments to measure baseline & progress; set goals with the patient Musculoskeletal Trauma Types of fractures include Complete Incomplete Open or compound Closed or simple Pathologic (spontaneous) Fatigue or stress Compression Fat Embolism Fat embolism syndromeserious complication resulting from a fracture; fat globules are released from yellow bone marrow into bloodstream Long bone fractures Altered mental status, increased respirations, dyspnea, chest pain, SaO2 Treatment bedrest, oxygen, fluids, possible steroid therapy Musculoskeletal Assessment Change in bone alignment Alteration in length of extremity Change in shape of bone Pain upon movement Decreased ROM Crepitus Ecchymotic skin Subcutaneous emphysema with bubbles under the skin Swelling at the fracture site Special Assessment Considerations For fractures of the shoulder and upper arm, assess patient in sitting or standing position. Support the affected arm to promote comfort. For distal areas of the arm, assess patient in a supine position. For fracture of lower extremities and pelvis, patient is in supine position. Risk for Peripheral Neurovascular Dysfunction Interventions include: Emergency careassess for respiratory distress, bleeding, and head injury Nonsurgical managementclosed reduction and immobilization with a bandage, splint, cast, or traction Casts Rigid device that immobilizes the affected body part while allowing other body parts to move Cast materialsplaster, fiberglass, polyester-cotton Types of casts for various parts of the bodyarm, leg, brace, body Handle with care immediately after application Cast care and patient education Cast complicationsinfection, circulation impairment, peripheral nerve damage, complications of immobility Traction Application of a pulling force to the body to provide reduction, alignment, and rest at that site Types of tractionskin, skeletal, plaster, brace, circumferential Traction care: Maintain correct balance between traction pull and countertraction force Care of weights Skin inspection Pin care Assessment of neurovascular status Operative Procedures Open reduction with internal fixation External fixation Postoperative caresimilar to that for any surgery; certain complications specific to fractures and musculoskeletal surgery include fat embolism and venous thromboembolism Fractures of the Pelvis Associated internal damage the chief concern in fracture management of pelvic fractures Nonweight-bearing fracture of the pelvis Weight-bearing fracture of the pelvis Compression Fractures of the Spine Most are associated with osteoporosis rather than acute spinal injury. Multiple hairline fractures result when bone mass diminishes. Nonsurgical management includes bedrest, analgesics, and physical therapy.

 Minimally invasive surgeries are vertebroplasty and kyphoplasty, in which bone cement is injected. Hip Fractures Most disabling for older adults 24% will die within one year Signs and Symptoms: externally rotated, shortened limb, tenderness, severe pain Traction is applied until patient is stabilized Intracapsular or extracapsular Treatment of choicesurgical repair, when possible, to allow the older patient to get out of bed Open reduction with internal fixation Intramedullary rod, pins, a prosthesis, or a fixed sliding plate Nursing Diagnosis Pain related to discomfort Impaired physical mobility Risk for skin integrity Risk for infection Complications Hip Surgery Dislocation Infection: Monitor temperature, assess drainage, inflammation Venous thromboembolism: Sequential compression device, anticoagulant, leg exercises Hypotension, bleeding Neurovascular Compromise: Color, Temperature, Distal Pulse, Capillary refill, Movement, Sensation Post Op Hip Abduction pillow between legs Incentive spirometry Out of bed as soon as possible Anticipate pain, administer medications Check skin, keep heels off bed Observe for Hip Dislocation: Hip pain, Shortening of affected leg, Leg rotation = Notify surgeon immediately Older Patient Higher risk for complications due to compromised circulation. Encourage heel pumps Quadriceps setting exercises Patient Education - Hip Do not sit or stand for prolong periods Do not cross legs Do not bend hip more than 90 degrees Use assistive device for dressing (shoes and socks) Raised toilet seat Straight back chair Pain management Incisional care What to report ___________________________________________________________________________________________________________ _____________ Cardiovascular and Respiratory (4-6 questions) Cardiovascular Age Related Changes Heart rate decreases, LV wall thickens, increase in O2 demand, increased collagen and decreased elastin in heart and vessel walls Decrease myocardial muscle contraction; decrease CO and cardiac reserve Decrease diastolic pressure, Increased systolic arterial pressure = Increased risk for heart disease Calicification of blood vessels, decreased elasticity: blood vessels and cardiac walls stiffen cant adapt to fluctuations in HR and BP Less sensitivity to baroreceptors BP decreases and HR doesnt increase = orthostatic hypotension Common CV problems: Ischemic heart disease, HTN, HF, Arrythmia, Valvular Conditions, PVD Coronary Artery Disease #1 Cause of CAD: Artherosclerosis Final outcomes of CAD: MI (No blood flow to area), Angina (Inadequate blood flow to area), Death Exceeding 240 mg/dl of serum cholesterol significantly increases the risk for CAD (>150: plaque and atherosclerosis accelerates) Vascular Resistance is the major determinant of diastolic blood pressure Risk Factors Non-Modifiable Male Gender Increased Age (women >55; men>45)

Heredity Race (African American) Family hx (cardiac death in mother >65, father>55) Modifiable DM (2-4X the risk) Smoker HTN Sedentary Lifestyle Obesity Metabolic Syndrome Signs and Symptoms SOB, fatigue, syncope, confussion, abd/back pain Treatment Goal: restore balance between Myocardial 02 demand and supply *Older adults: alterations in body mass, H2O consumption, liver size, renal function, plasma protein concentration = Inc concentration and Dec excretion of drugs = smaller doses prescribed! Nitrates: Dec Preload, Dec Afterload = Vasodialation Dec myocardial O2 demand May trigger tachycardia and orthostatic hypotension = fall risk Can take prophylacticly (before sex, exercise, etc) Beta Blockers: Dec HR, Dec SV, Dec contractility = Dec myocardial demand = Dec sympathetic nervous system SE: Bradycardia, hypotension, dyspnea, syncope, gait issues, bronchoconstriction, depression, Heart Block Patients with lung issues = Metoprolol, Atenolol Sudden withdrawal can cause MI Older people: start low, go slow (more sensitive to dec HR = exercise issues + syncope) Ca Channel Blockers: Dec BP, Dec contractility = Inc coronary perfusion = Dec demand + Inc perfusion SE: Bradycardia, hypotension, syncope, HA, dyspnea, palpatations, peripheral edema Verapamil + Diltiazem = BAD for older people: dec HR and Inc Heart Block Amlodipine = GOOD for older people: 1x daily dosing, Dec BP, safe with CHF Fibrinolytics, Anticoagulants, Antiplatelets: Dec clotting Must be given within 6 hours of onset Observe for arrythmias, allergic reactions, bleeding Heparin = follow-up treatment, prevents secondary clotting Heparin: PTT Coumadin: INR (Antidote: Vit K) Aspirin Antihyperlipidemics: Dec lipid levels = Dec cholesterol levels + Inc excretion SE: Gi disturbances = constipation LDL level of less than 70 can reverse plaque formation Non-Pharma Treatment Percutaneous Transluminal Coronary Angioplasty Compress obstruction = Inc blood flow Stents Hold the artery open = Inc blood flow Coronary Artery Bypass Graft Replace Artery = Inc blood flow

Hypertension Final outcomes of HTN: Stroke (vascular), End Stage Renal Failure (renal), Heart Failure (cardiac) African American males have the greatest incidence Treatment begins with BP of >140/90 in 2 consecutive BP checks (Antihypertensives: usually 2 needed = Thiazide and another) Goal: BP of 120/80 consistently Signs and Symptoms Dizziness, Fatigue, Vertigo, HA, Palpitations Pseudo-hypertension Result of calcification/thickening of arteries = doesnt allow bracial artery to compress with BP testing Common in older adults Diagnosis Determine cause: primary HTN or secondary HTN H/H: r/o Anemia UA: r/o Proteinuria (renal failure) Echo: Left Vent failure/hypertrophy Pharm Management: Take meds as ordered, Do NOT skip doses Start low, Go slow to avoid orthostatic hypotension = Fall Risk st Diuretic + Beta Blocker = 1 line treatment

Thiazide Diuretics (S/E: hypotension, dehydration, hypoCa+, ototoxicity, electrolyte imbalances) Beta Blockers Dec CO, Cardioprotective (S/E: decreased HR, BP) Metoporolol and Atenolol = good for elderly with lung issues, PVD ACE-I Good for people with dec L vent function and preserves renal function (S/E: COUGH, rash, hyperK+, neutropenia) Dont use with acute renal failure, renal artery stenosis CCB Vasodialation! (S/E: Inc orthostatic hypotension, constipation, HA, weakness) Use when diuretics dont work Lifestyle Management: Limit alcohol intake to 1 drink/day Limit Na+ intake Stop smoking Maintain a low fat diet that also consists of adequate vit/minerals, leafy veggies Exercise and lose wt. (even 10lbs may make a significant difference) Have BP checked regularly and report any significant rise to physician Assess all meds (prescript and OTC) for Inc BP (cold meds can Inc BP)

Congestive Heart Failure Inability to pump enough blood to perfuse organs Risk for CHF in elderly doubles if pt also has HTN > 160/90 Common causes-CAD, HTN, DM 22% of men and 46% of women will develop HF within 6 yrs of having an MI Risk Factors: Liver disease, anemia, hyperthryroidism, PE, infection, bowel problems, rheumatic heart disease, MI, increasing age, HTN, DM Signs and Symptoms SOB, Edema, Coughing/Wheezing, Fatigue, lack of appetite/nausea, confusion, Increased HR Old People: Dec renal and systemic blood flow, Inc arterial stiffness, Inc peripheral resistance, Dec vent compliance, Dec max aerobic capacity Diagnostics: ECG, ECHO (rule out MI), CBC, UA, BUN, CR, BNP (>400), THRYROID (r/o hyperthyroidism) Treatment Check O2 saturation: <90% requires intervention, 2L O2 Systolic CHF Cant Pump Enough st Ace I + Diuretics = 1 line treatment Dig: mod-severe CHF (improves s/s but doesnt prolong life) Anticoag: with Afib Dobutamine: with refractory CHF (increases force of contractions and decreases demand of the heart) Diastolic CHF Cant Fill Enough Goal: Dec vent filling pressure and control symptoms st Diuretics + Nitro = 1 line treatment Ca Channel Blockers, Beta Blockers, ACE-I = GOOD Digoxin = NOT GOOD (Inc myocardial O2 demand) Pharma for CHF ACE-I Dec progression of CHF Dec afterload/preload = Vasodialation Diuretics Dec preload = Dec pulmonary/systemic congestion Loop Diuretics preferred Monitor for HypoKalemia esp with Dig therapy Elderly with notmal renal function and Dec ankle edema = thiazide diuretics Digoxin Use with systolic dysfunction and Afib Used with ACE-I Toxicity!!! Beta Blockers Dec stress on the heart = Dec HR Sympathomimetics

 Respiratory

Inc myocardial contraction Tachycardia can occur Dopamine and Dobutamine = Inc CO (more work for less effort) Teach lifestyle modification as discussed in HTN management Weigh every day and report >3 lbs/1 wk or >1-2lbs/1 day Reduce Na+ intake to 2-3 g/day Exercise to tolerance level (will differ person to person) Alternate rest and activity Prognosis: Men 1.7 yrs; Women 3.2 years

Age Related Changes: Ribs become less mobile and chest wall compliance decreases (decreased expansion ability) Kyphosis or scoliosis: decreased expansion ability; increased AP Diameter Loss of elastic recoil (lungs dont spring back as well) Decreased muscle strength and diaphragm flattens RR increases and resp. are more shallow PaO2 drops by 1 mmHg/yr after age 60 Decreased cilia Ventilatory response to hypoxia and hypercapnia = decreased by 50% Factors affecting lung function: Exercise and immobility Smoking Obesity Sleep Apnea Anesthesia and surgery (can worsen breathing) Common condition in the older adult Asthma, COPD, chronic bronchitis, emphysema, TB, influenza, pneumonia, pulm. Edema, PE, obstructive sleep apnea, adult resp. distress syndrome COPD: includes BRONCHITIS AND EMPHYSEMA Progressive air-flow limitation Hyperproduction of mucus Airway becomes inflamed and fibrotic NOT fully reversible and eventually leads to lung damage Primary Risk Factors: Age, male gender, reduced lung function, air pollution, SMOKING, familial allergies, poor nutrition and alcohol Emphysema: Progressive destruction of Alveoli Chronic Bronchitis: (Inc mucus with cough) Barrel chest and accessory muscle use Smoking #1 cause Inc hgb levels Dec O2 but normal CO2 levels Pink Puffer Blue Bloater Thin, wt. loss Unexplained wt. gain and pedal edema Dyspnea Frequent resp. infections Flattening of diaphragm Dyspnea on exertion Hypoxia Polycythemia: chronic hypoxia and hypercapnia Crackles and wheezes Crackles on auscultation Clubbing Tachycardia Air Trapping: air in, no air out Productive cough: purulent sputum

Complications of COPD: Cor Pulmonale and Pulmonary HTN Infection: Strep, pneumonia, influenza Acute Resp. Failure (often delay getting help) PUD and GERD (microaspirations) Right sided Heart Failure Treatment: Smoking cessation Meds Bronchodilators (1st line) Inhaled Beta2-Agonists bronchodilation Inc mucus clearance

Inc diaphragmatic function Anticholinergics Relaxes muscles Dec mucus production Corticosteroids Dec frequency of attacks Inc overall health No PO steroids, IH only Antibiotics No proven use but used anyway O2 Therapy, Breathing Training/Chest PT (pursued-lip and abdominal breathing) Goals: PaO2 80%, SaO2 90% Nutrition: frequent, small meals, Dec CHO, Inc PRO, Dec FAT Infection prevention (exercise, PT) and possible surgery (lung removal)

Pneumonia Inflammation on the lung parenchyma Leading cause of death among the elderly; >65 have 5-10x death rate than younger adults Causes: bacterial, viral, aspiration Increased Risk Factors of Older Adults Normal age related factors Underlying chronic illnesses Weakened cough reflex Decreased mobility Group living 3x more likely to get pneumonia = nursing home concern Signs and Symptoms Older Adults may not present with the typical: chills, chest pain, sweating and productive cough Older Adults Specific Presentation: Altered mental status, dehydration, and failure to thrive! HA, weakness, fever, nonproductive hacking cough, muscle pain, weakness, SOB, anxiety, crackles in lungs Treatment Depends on the type (Bacterial: 10-14 dys antibiotics) (Clarithromycin (Macrolids) recommended for community-acquired) Hydration Rest Nutrition Tylenol/ASA unless contraindicated Monitor for worsening Hospitalization often required in frail adults Vaccine recommended: Pneumococcal TB Number one fatal communicable disease in US Contracted through inhalation of droplets Active infection: inflammation of airway leading to lesions or necrosis Can remain dormant in the system for years Risks Older population, residents living in LTC facilities, urban, poor, minority groups, pts with AIDS Signs and Symptoms Low-grade fever Night sweats Anorexia Wt. loss Nonproductive cough Rusty sputum Diagnostics: PPD, CXR Older People have an increased chance of false PPD test results Mantoux Test: recommended 2xs with CXR If positive with symptoms then follow up CBC, ESR, Chem Panel, Bone Marrow Biopsy, Sputum Test If positive without symptoms then Isoniazid therapy for 4 months Treatment: 4 drugs x 6 mths (18-24 mths if resistant) Izonazid (INH), Rifampin, Ethambutal, Streptomycin, Pyrazinamide Monitor LFTs: may cause liver damage, Older People are at risk for Hepatitis = Peripheral Neuropathy Nursing Interventions Health promo/screening Isolation Med administration Pt. education Follow-up

 Monitor for s/s of hepatotoxicity ___________________________________________________________________________________________________________ _____________ Sleep (1-3 questions) Sleep Disorders Sleep changes associated with Aging: Takes longer to fall asleep and less sleep efficiency More noctural awakening and daytime sleepiness Decreased Stage 4 (deep sleep) and REM (active sleep) 21% of adults >65 rate sleep as fair or poor Prolonged periods of sleep deprivation can lead to disorganization, hallucinations and delusions Other factors affecting sleep Environment (noise, lighting, temp., pain) Lifestyle changes (loss of spouse, retirement, relocation, new roommate) Dietary influences (caffeine, fluids, alcohol), Meds, Depression and Dementia Insomnia The most prevalent sleep disorder Frequent awakenings, daytime sleepiness, early awakenings Contributors HTN, arthritis, DM, cancer, CVA, depression, osteoporosis, resp. disease Results of Insomina Dec quality of life, Inc daytime sleepiness, attention/memory problems, depressed mood, night time falls, overuse of hypnotic/OTC meds Sleep Apnea (Central) Periods of cessation of respiration = central = diaphragmatic + intercostal Leads to sudden premature death, cardiac arrythmias, angina, MI, HTN, stroke, renal dysfunction, impotence, depression and cog impairment Lasts 10sec-2min Usually seen with insomnia, mild snoring, depression Sleep Apnea (Obstructive) More common in the elderly Airflow dec due to obstruction Usually seen with obesity, short neck, small neck circumference, jaw deformities, large tongue, narrow airway, deviated septum Awakening with HA or Confussion Treatment for Sleep Apnea Meds Sleep with multiple pillows Avoid alcohol and sedatives Humidified air Dental device Wt. loss CPAP, BIPAP Surgery (remove excess tissue of soft palate) Periodic limb movement/Restless leg syndrome Related to decrease in iron, renal failure, DM, tobacco, alcohol, caffeine Repetative kicking leg mvmts = distruption of sleep to self and partner Treatment Medication: Levadopa, Permax, Gabapentin, etc Assess for sleep disorders with Epsworth Sleep Scale and Pittsburgh Sleep Quality Index Interventions for sleep disorders Sleep Hygiene Exercise Environmental: dark, quiet, etc Relaxation Herbal Therapy ___________________________________________________________________________________________________________ _____________ Endocrine (1-3 questions)

Endocrine Disorders Andropause: decrease in testosterone Menopause: decrease in estrogen Adrenopause: decrease in adrenal function Somatopause: decrease in growth hormone (changes nutrition, metabolism and body temp, salt/water balance) *Can be revered with hormones, but is that good or bad? Metabolic Syndrome Common multifactorial syndrome of aging Increases the risk for CAD and heart disease Highly associated with Increased waist circumference (apple or pear shape) Older people can tolerate inc sugar levels and have a sensitivity to glucose dec drugs Signs and Symptoms BP >129/84 or on antiHTN meds Plasma triglycerides >149 or on meds HDL <40 or <50 for women or on meds FBS >99 Risk factors: abdominal obesity, insulin resistance Hypoglycemic unawareness: not as aware of symptoms of hypoglycemia; less likely to treat symptoms appropriately because of decrease in psychomotor decline Diabetes Mellitus 7th leading cause of death among the elderly Risk increases with ageaffects 40% of the aging population Causes dysfunction of the heart, kidneys, nerves, eyes, blood vessels Relative insulin insufficiency Risk Factors: Race (African Americans) Gestational diabetes (higher risk for type 2 DM) Family hx Obesity HTN Low HDL Diagnosis in the elderly: glucose intolerance screening q 3 yrs with fasting blood sugar * May not present with classic symptoms: frequent infections, fatigue Nursing interventions: Foot care (skin alterations) Insulin (avoid hypoglycemia; use simplest method) Diet and exercise (know s/s hypo) (PRO 12-20%; FAT<30%; CHO 45-60%; increase fiber and decrease salt) Emergency meds (glucagon, glusose tabs, med alert bracelet) Sick day management Vision problems Assess cognitive abilities (usually give NPH/Reg because its easy to manage, though it does provide less precise control) Meds: stepwise approach: Metformin: watch BUN/CR, GI problems Sulfonyreas: more likely to have lowering of blood sugar and GI symptoms, pancytopenia, long half-life Avandia (thiazolidonides): can cause MI, worsen CHF, hepatotoxic, edema Diuretics: increase glucose BB: mask s/s of hypoglycemia Anticonvulsants/AntiHTN/Steroids: increase glucose Signs and Symptoms Hypoglycemia Hyperglycemia: Diaphoresis Dehydration Tachycardia 3 Ps HA Decrease LOC Fatigue Blurred Vision Older People specific presentation: Fatigue, blurred vision, weight change (up or down), infections, impotence, foot/leg wounds, UTIs, numbness Treatment: 15 g CHO or 4 oz juice; glucagon IM for emergency

Hyperthryroidism (TSH Dec) In older adults caused by nodular or uninodular toxic goiter Iodine induced hyperthyroidism (amniodarone use!) Classis gero presentation: tachycardia (not if on BB), fatigue, tremors, nervousness, exophthalmos, restless, irritable, heat intolerance Diagnostics: low TSH level and high T3/T4 Treatment: radioactive sodium iodine (check Q6months) and BB for tachycardia AFib is a common complication Hypothryroidism: (more common) Diagnostics: high TSH and low T3/T4 (sometimes can be normal levels; subclinical), screen Q5yrs Classic gero presentation: fatigue, cold intolerance, wt gain, muscle cramps, parasthesia, confussion Hashimotos disease or autoimmune thyroiditis is most common cause Drug induced: lithium, amiodarone, iodine Treatment: thyroid replacementL-Thyroxine for life; follow up 3, 6 and 12 mths Watch for cardiac issues as a result of treatment ___________________________________________________________________________________________________________ _____________ Genitourinary (11-13 questions) GU Disorders Aging related to Urinary function Older adults are at a higher risk for developing incontinence Bladder capacity decreases and involuntary bladder contraction increase leading to frequency and urgency Increased urine formation at night Thinning and increased friability of the urethral mucosa Decreased muscle tone of urethra and pelvic floor muscles Prostate enlargement common Age-Related Changes in Renal function: Kidneys are smaller; decreased GFR Renal blood flow decreases CV disease and DM on renal function Straight Cath for urinary retention Urinary Analysis Urine clarity: pus in the urine Urine Specific gravity: looks at hydration Urine Acetone: DM Urine PRO: Renal Failure Common GU Problems: incontinence, infection, Renal failure, Bladder CA, BPH, prostate cancer, ED, intimacy Urinary Incontinence 30-50% of women and 9-28% of men Acute: Underlying cause either illness or medication Diappers and toileted: delirium, infection, atrophic changes (epithelial cells), psychological problems, DM, restricted mobility, stool impaction, enlarged prostate Chronic (4 types) Stress incontinence: due to sudden increase in intraabdominal pressurecough, sneeze Related to pregnancy, obesity, surgery, exercise, meds Triggered by laughing, sneezing, coughing Small amounts of urine lost Treatment: kegels Urge: caused by abnormal detruser muscle contraction Related to birth defects, spine/nerve damage, prostate problems or cancer Sudden, unexpected need to viod Moderate to large amounts of urine lost Treatment: kegels Overflow: chronically full bladder increased bladder pressure > than urethral resistance Birth defects, spine/nerve damage, MS, loss of bladder tone, surgery, meds No warning prior to incontinent episode Treatment: treat cause, intermittent cath, bladder scans for post-viod residuals Functional: inability or unwillingness to use the toilet appropriately Inability to get to bathroom facilities due to functional reasons Obesity, clutter, immobility, restraints May be associated with urge incontinence Treatment: modify environment and lifestyle

Hx: ask about frequency, pain, empying, color of urine, odor?? Comorbidities? PMH, PSH? OB hx? Meds? Bowel habts (constipation increases risk) any previous treatments? Assessments: What kind of incontinence do they have? Functional : ADLs, Mobility, Mental status and cog. Status Environmental: Proximity of BR, size of BR, toilet heights, Barriers? Caregiver? Psychosocial: effect of incontinence on the pts life, motivation Treatment and Nursing: Encourage pts to not decrease fluids=constipation, restrict caffeine, decrease fluids after 6 pm for nocturia, elevate legs in the evening to decrease edema and nocturia Bladder retraining and pelvic floor exercises (3-5 min/day in 3-4 sessions) Scheduled toileting, habit training and prompted voiding Meds: Alpha Agonists: increase urethral tone (can cause insomnia, restlessness and increased BP) Anticholinergics/Antispasmodics Alpha Antagonists/5 alpha-reductase inhibitors to treat the prostrate in men Intermittent straight cath and condom catheters in men Most incontinence caused by overative bladder Meds: Detrol LA and Ditropan XL (Antimuscarinic and Anticholinergic) Renal Failure Acute: sudden loss of renal function Retention of waste products, fluid/electrolyte imbalance and acid/base disturbance Prerenal: blood flow to kidneys decreased Intrarenal: damage to the tissue inside the kidney Postrenal: obstruction to outflow of urine; urethral tumor Uremic S/S: Decreased urine output Anorexia, nausea, fatigue, swelling and crackles, Elevated BUN/CR and decreased Creatinine clearance Chronic Kidney Failure Decreased renal reserve 40-75%; renal insufficiency <20-40% nephrons; ESRD <15% nephrons Kidney failure defined GFR <15% ml/min (usually need renal transplant and dialysis) Comorbidities: Diabetic nephropathy, HTN, Scleroderma, Lupus, Amyloidosis, Glomerulonephritis, Cystic Kidney Disease Signs and Symptoms Urine frequency, color, amount and appearance N/v/anorexia (accumulation of metabolic wastes) Wt. loss (monitor pts. wt.) Confusion Fatigue Pruritis Rales and pericardial rub Management Maintain fluid and electrolyte balance (BUN, CR, CBCanemia) Monitor nephritic syndrome Dietlow PRO, low Na+, low K+ Manage fatigue and low energy Labs: metabolic acidosis, hyperinsulinemia, increase in triglyceride levels Urinary Tract Infection Second most common bacterial infection; (Escherichia coli is the most common), women >80 higher risk; long term care facilities Risk Factors Decline of immune function ObstructionBPH, Tumor, Constipation Urinary Catheters DM, CVA, Cognitive Impairment Antibiotic overuse Signs and Symptoms Can also have bacteria in the urine without s/s Classic symptoms are often not present in the older adult: fatigue, anorexia, decreased body temp, new urinary incontinence Upper tract infection: flank pain, fever, chills, change in mental status

Diagnostics: Urine dip stick/UA/Urinalysis/Urine C &S Treatment: Antibiotics, drink fluids

Bladder Cancer 4th most common cancer in men and 8th most common in women More common with increasing age Risk Factors: Chronic bladder irrigation Smoking Occupation Related: dyes, rubber, chemical, sewer workers and lab techs Signs and Symptoms *Painless hematuria dysuria, urgency, burning with urination, frequency and nocturia Diagnosis: Treatment: Intravenous pyelogram Surgery (90%) UA and cystoscopy Radiation, Chemo, Immunotherapy BPH Noncancerous enlargement of the prostate Prostate gland constricts the urethra and obstructs the outflow of urine (increases risk for UTI) 80% of men over age 80 may be diagnosed Structural, functional and hormonal changes Family hx increases risk (especially with primary relative) Environmental influences Diets high in zinc, margarine/butter; decreased risk with fresh fruit intake Complication: UTI, urinary retention Signs and Symptoms Obstructive Irritative Decrease in caliber/force of urinary stream frequency Hesitancy urgency Intermittency dysuria Dribbling bladder pain Sesnation of not completely emptying nocturia and incontinence Questions to ask: How often have you had the sensation of not fully emptying your bladder after urinating? How often do you urinate again , <2 hrs after your last urination? Stop/Start during urination? Hesitancy? Strain to get stream started? Weak stream? Diagnostics: PSA Conservative treatment: Dietary Avoid decongestants and anticholinergics 5-Alpha-Reductase Inhibitors: Proscar, Avodart, SE: decreased libido, decreased ejaculate and ED Alpha Adrenergic blocker: Flomax SE: orthostatic HTN, dizziness, decreased ejaculate; take first dose at night to decrease s/s hypotension, do not combine with viagra Herbals: saw palmetto: increase risk of bleedingdo not use in pts with GI problems, D/C before surgery, may increase BP **Take meds until pt. sees relief; decrease caffeine, avoid artificial sweeteners, drinking large amounts of water can worsen s/s TURP: transurethral resection of the prostate GOLD STANDARD; done by urology; able to resect the prostate; no incision needed; restores urinary drainage Nursing: treat any UTI before surgery, educate pre/postop; can have permanent sexual/urinary dysfunction Postop care: complications include hemorrhage, bladder spasms (pt. will complain of acute suprapubic pain), UI and infection Bladder irrigation: 3-way catheter: draining fluid and instilling continuous fluid to decrease clots (sterile saline) Document drainage: D/C when drainage stops bright red: arterial bleed, possibly hemorrhage darker red: venous bleed volume of blood? Hemorrhage?: document output q 2 hrs and vitals q 4 hrs Sterile water to flush Asceptic technique Tape catheter to leg Maintain closed drainage system Dont allow irrigate to go dry: continuously infused and drained from bladder If outflow less than inflow=check catheter patency for kinks and clots If outflow blocked and cannot be reestablished by manual irrigation=call MD

Bleeding: blood clots expected 24-36 hrs postop Avoid increased abdominal pressure: sitting/walking long periods of time; straining (use stool softeners) Bladder spasm: check for clots, avoid urinating around foley; antispasmodics (belladonna/opium suppositories) Sphincter tone: decreased after catheter removal; UT or dribbling; kegel exercises Patient Education : Care of catheter; watch for s/s of infection Fluids 2-3 L/day; void within 6 hrs of procedure Refrain from driving or intercourse until follow up with MD Retrograde ejaculation: semen goes backward instead of out. Yuck. 2 mths for bladder capacity to return to normal Urinate q 2-3 hrs Avoid caffeine, spicy food and artificial sweeteners Cancer of the Prostate Second most common cancer Incidence increases with age African Americans have an increased risk Risk Factors: Age Ethnicity Family hx: first degree relatives and genetic predisposition High Fat diet and vit E/D deficiency Viruses Screening is best; may be asymptomatic; the earlier detected the better the prognosis Men with life expectancy of <10 yrs are unlikely to benefit from screening/ >75 yrs old Digital Rectal exam PSA levels Normal 60-69 yo: 0-4 ng/ml Normal 70-79 yo: 7 ng/nl >10 ng/ml = cancer Hard nodules on prostate; slow growing and can metastasize Signs and Symptoms Asymptomatic in early states; similar to BPH: dysuria, hesitancy, driblling, frequency, urgency, nocturia Look for *hematuria Pain in the lumbosacral area that radiates to hips/legs with urinary retention indicates metastasis (bone pain; can spread to lungs, adrenal glands and liver) Nursing Interventions PROSTATE SCREENING; care after prostatectomy similar to care for BPH If discharged with catheter teach: clean meatus once daily with soap and water ; increase fluids, keep collection bad lower than bladder, secure to thigh Postop complications Bleeding, hemorrhage, urine color, urine retention and blood clots (DVT, PE) S/S bladder infection: spasm, fever, hematuria, incontinence Impotence Defined as inability to attain and maintain erection long enough for intercourse Increases with age and in treatable (Viagra) Organic cause Gradual deterioration of function related to disease, surgery or vascular (prostate, DM, HTN) Functional cause Psychological problems (depression, stress) (If pt. has nocturnal erections/morning erections=functional) Risk Factors: Diabetes Renal Failure HTN Meds: Dig, AntiHTN, Sedatives, hypnotics, antidep, sleeping meds, tranquilizers MS Psych factors Thryroid Disorders Alcoholism Check innervation and libido and testosterone levels Treatment ViagraSE: blindness, priapism, hypotension; no nitrates and no alpha blockers; pt needs to have strong enough heart for sex Vacuum pumps Penile implants Drugs injected into the penis (can cause excess scar tissue)

Vaginitis Vaginal canal more fragile due to atrophy Less lubrication More alkaline pH due to lower estrogen levels Signs and Symptoms Similar to UTI or yeast infection (itchy, smelly) Treatment Topical estrogen creams and estrogen replacement therapy; lubrication; avoid douches, perfumes; wear cotton underwear Intimacy Relationships continue but not a lot of intimacysexuality if often ignored because of anxiety, fear, embarrassment Other problems with old sex: ED, decrease in libido, decrease in lubrication, may not have orgasm each time, resp. problems, arthritis, HF, cancer, HIV Promote sexual function in community dwelling elders: privacy, education, understanding, communicaion Aerobic exercise, proper diet, quit smoking, Viagra, try new positions Avoid ageism, provide privacy Dont allow sexually inappropriate behavior ________________________________________________________________________________________________________________ ____________ Polypharmacy /Substance Abuse/Labs (5-7 questions) Substance Abuse Hazardous Use: harmful or potentially harmful amount of use. Older Adults: 3+ drinks at 1 sitting or 7+ drinks per week Substance Abuse: maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances Substance Dependence: a cluster of cognitive, behavioral and psychological symptoms indicating that the individual continues to use despite the significant substance related problems. Tolerance, withdrawal, compulsive drug-taking, drug-seeking behaviors Signs and Symptoms Erratic changes in mood, affect or behavior Malnutrition Bladder/Bowel incontinence Gait disturbances Recurring falls Burns Head trauma Commonly Abused by Older Adults Alcohol Prescription Drugs: Benzos Nicotine Caffeine Decreased use of elicit drugs Reasons for use: grief, retirement, loneliness, and physical/emotional illness Age Related Changes Physiologic: depression, depending on duration of use = liver damage, cardiac exhaustion, etc Psychological: decreased memory, feelings of loss, etc Social: decreased money, decreased social supports, etc Substance Abuse = increased suicide risk Screening Tools CAGE questions 1. Cut down 2. Annoyed by you 3. Guilty feelings 4. Eye opener Michigan Alcoholism Screening Test (opiods/narcotics) 25 questions about habits 0-3 Normal drinker, 4-9 Possible problem drinker, 10+ Heavy drinker Alcohol Legal and Socialized 10-15% of all Older People Assessment Anxiety, nervousness, memory impairment, depression, blackouts, confusion (poor hygene, malnutrition), wt loss, falls Evidenced in body = liver damage, facial edema, jaundice, ascites, trembling, etc Alcohol withdrawal

Interventions Withdrawal happens frequently upon hospital admission (24-48 hrs after) Give sedatives, monitor vitals, provide nutritional support Acamprosate: treatment of Alcohol Abuse (monitor renal function) AA meetings, therapy, etc

Prescription Drugs Abuse 2-3x higher in the elderly Polypharmacy = to many drugs prescribed that actually needed Commonly used drugs (lots of cross tolerance = cross addiction, alcohol and benzos) CV meds, diuretics, anticoagulants Benzos *most common to cause dependence Cathartics, antacids Thyroid meds Assessment Watch for: tendency to repeatedly loose/throw away meds, scripts from multi-prescribers, frequency of ED visits, strong preferences for specific meds, above average knowledge about meds, severity of complaint doesnt match clinical presentation. Interventions Plan for detox Manage withdrawal Non-prescription Drugs Most commonly used: analgesics (NSAIDS, ASA, etc), laxatives, antacids, cough meds, vitamins, herbals Ask the pt amt and frequency Biggest concern = drug to drug reactions Nicotine Withdrawal: depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, dec HR, inc appetite Interventions Ask about previous attempts to quit (takes 2-3 times usually) Gum, spray, Colonadine, Wellbutrin = Zyban Caffeine Enhanced in Older Adults Stimulates sympathetic nervous system = inc motor activity, muscle capacity, alertness, dec fatigue, rapid pulse, dec metabolism Mimics many psych/medical illnesses Withdrawal: HA, fatigue, depression, anxiety, N/V, muscle pain, stiffness Treating Substance Abuse The As The Rs 1. Ask about substance abuse 1. Relevance of quitting 2. Advise to quit 2. Risks to health 3. Assess willingness 3. Rewards to quitting 4. Assist in attempt 4. Roadblocks to success 5. Arrange for follow-up 5. Reinforce! Labs Clotting PT = 11-12.5 sec Inc: liver disease, Vit K deficiency, bile duct obstruction, Tylenol OD Dec: Coumadin use INR = 2-3 sec Inc: recurrent thromboembolism or mechanical heart valves PTT = 60-70 sec Used to measure adequate anticoagulation with Heparin therapy Heparin: faster effect on the body than Coumadin but it doesnt last as long Platelets = 150,000-400,000/mm3 Low levels = Bleeding risk Dec: bone marrow suppression S/S of Bleeding: Change in LOC, blood in stool, ecchymosis, bleeding gums, coughing up blood Inflammation Erythrocyte Sedimentation Rate (ESR) Time it takes for RBCs to settle in NSS over 1hr Inc: inflammation, used with WBC count to determine if its infection related Good for monitoring Arthritis progression Older Adults: have a normal elevation, making it harder to interpret results

C-Reactive Protein Marker present in acute phase of an inflammatory response Happens faster than ESR Useful in evaluating CV disease, MI, Organ Transplant, Post-surgical Recovery, Failure to Respond to Antibiotic Treatment

Electrolytes Older Adults have serious problems with electrolyte balance caused by Dehydration, Dec Thirst, Dec Functional Ability, Dec Kidney Function, Diuretic Use Dec Ca Dec Ph Dec Mg by 15% between 30-80 yrs old Inc Glucose over 50 yrs old = Ketoacidosis prone Kidney Function BUN Slightly raised in elderly, more in men CR Inc along with Inc BUN = Kidney Failure Creatine Clearance Measures GFR Physiologic decline would be thought to produce a dec GFR but doesnt because there is a parallel decline in muscle mass and dec CR production So, CR clearance levels are used to determine GFR Metabolism Uric Acid Inc: Gout, Thiazide Diuretic, Caffeine, Low-dose ASA, Antiparkinson Drugs Amylase Tested to R/O Pancreatitis (would be elevated) Protein

Nutritional status and Healing Total Protein: Albumin and Globulin Prealbumin: Short-term nutrition (1/2 life = 72 hours) Albumin: Long-term nutrition (1/2 life = 21 days)

Cholesterol Triglycerides: HDL and LDL Total Cholesterol: binds to HDL and LDL HDL: Good, Dec in men LDL: Bad, Inc in women after menopause = Dec estrogen levels (Estrogen is protective) Thyroid Hyperthyroidism: low TSH level and high T3/T4 Hypothyroidism: high TSH and low T3/T4 (very common in elderly) Heart

BNP CHF detection, produced based on ventricle stretch and pressure overload Inc: CHF but doesnt determine systolic or diastolic Creatinine Kinase (CPK) Inc: MI Troponin Released with MI Can be detected immediately-2 weeks Lactate Dehydrogenase Used along with CPK to determine heart damage

Liver Enzymes Determine drug metabolism Alkaline Phosphatase Liver and Bone disorders Normally slightly increased in old age Aspartate Aminotransferase Hepatitis, liver necrosis, skeletal muscle damage Inc 3-5x with TB

Prostate Acid Phospatase Used to diagnose prostate cancer and monitor treatment PSA Not diagnostic but present with all Prostate issues Pharmacodynamics Absorption Oral Dec secretion of gastric acid, Dec gastric emptying, Dec motility, Dec absorptive capacity, Dec blood flow Slowed absorption but the same amount is absorbed Inc gastric PH = drugs that need an acidic environment, problem! Topical Dec water content, Dec tissue perfusion Water soluble drugs, problem! Distribution Dec body water = Inc concentration of water soluble drugs = Aminoglycosides, Digoxin, Lithium Dec lean body mass = Inc concentration of fat soluble drugs = Benzos Dec albumin levels = Inc concentration of protein binding drugs = Naproxen Metabolism Normal part of aging 35% dec of hepatic blood flow st Dec 1 pass = Inc amount of active drug enters the systemic blood flow = toxicity risk Drug metabolism is slowed = prolonged life = Inc drug effects Excretion Dec kidney function (normal with aging, determined by GFR) = Inc life = toxicity risk Drug doses often need to be decreased due to decreased renal function, inability to excrete the regular dose Nursing Know what the toxicity will look like (ie serum levels, S/S, etc) If a pt reports falls, tremors, change of LOC, etc always ask them if they are taking new drugs or a dose change. Changes often occur in Older People due to Dec # of receptors Dec receptor binding Altered cellular response to the drug-receptor interaction ***Increase the amount of free drug circulating in the body Must take the following into consideration with Older People General Health # of meds being taken Liver and Kidney function Co-morbidities Beers Criteria Outlines drugs that are no good for the elderly Long-term use of short-term drugs (Benzos, H2 Blockers, Antibiotics, etc) Inc doses of drugs prescribed above dosage limits (iron supplements, H2 Blockers, Antipsychotics, etc) DO NOT USE IN THE ELDERLY: Digoxin, Darvocet, Benadryl, Prozac Prevention of Polypharmacy Use one pharmacy Tell all providers of all other drugs being taken Proscribed OTC Vitamins Supplements Herbals OBRA 87 Legislated the appropriate use of meds to be used with institutionalized Older Pts Chemical restraint use Unnecessary drug use Psychotropic Drugs: should not be used unless necessary to treat a specific condition that is diagnosed and documented in the pts record Pts who are given antipsychotic, antidepressant, sedative-hypnotic or anxiolytic drugs must be treated with: Gradual dosing decreases

 Drug holidays to determine continued need Behavioral programming PRN doses are not to be used more than 2x in 7days Without further assessment Unless for the purpose of titrating dose for optimal response Unless for management of unexpected behaviors that are otherwise unmanageable Absolutely not to be used for wandering depression anxiety poor self care insomnia nervousness restlessness unsociability agitate behavior when not a danger to self or others dec memory indifference to surroundings Antipsychotics in Elderly Cause sedation and EPS Atypical (new) cause less EPS, but cause weight gain/DM/Hyperlipidemia/Myocarditis/Cardiac issues Benzos Should be limited to less than 4 months consecutive use Should be limited to unless attempt at gradual dose decrease is unsuccessful Dose decrease should be considered after 4 months Anticholinergic Effects in Elderly Dry as a Bone = No secretions Red as a Beet = flushing r/t absence of sweating Hot as a Hare = temp elevation from absence of sweating Blind as a Bat = Cytoplegia + Mydriasis Mad as a Hatter = Mental confusion, delirium Nursing Interventions Medication Review Check each drugs for anticholinergic profile Review each drug for Interactions with other drugs and herbals Allergies Duplicate efforts Have pt bring all drugs in packages and assess for Exp dates Unused/Unfilled scripts Overlaps-Duplications st One drug shouldnt be used to handle the SE of another drug, change the 1 drug to a drug with a different SE profile Education th 5 grade reading level or lower Include info to dec SE: examples Adequate fluid/fiber Diuretics in the AM to prevent sleep issues Liquids/Lozenges for dry mouth Instruct pt on which SE must be reported Difficulty with ADLs Cognitive changes Falls Anorexia, N/V/D Weight changes Change of mood, anxiety, and depression can result from Antihypertensives (Beta Blockers) Antiparkinsonism Drugs Steroids NSAIDs Narcotics Antineoplastics CNS depressants Psychotropics Accommodations Normal limitations: sensory, motor, cognitive Impact ability to understand instructions, open package Use weekly pill box Home healthcare nurses Medication alternatives Constipation

Avoid cheese Inc fiber and fluid Inc exercise Insomnia Adapt environment to promote sleep Review meds and schedule Encourage exercise Dec daytime sleep/napping Sour Stomach Identify trouble foods Educate to sit upright 30 min after eating Anxiety Suggest counseling Teach/stress relaxation techniques Pain Suggest distraction pr guided imagery Encourage position changes and elevation Exercise if tolerated

Complimentary/Alternative Medicine Accu-pressure Accu-puncture Mind-Body therapy Journaling Meditation Animal assisted therapy Imagery Music therapy Manipulative and Body Based Therapy Massage Tai-Chi Biological Based Therapy Herbs Aroma Food Vitamins/Minerals Energy Therapy Reiki ________________________________________________________________________________________________________________ ___________ Geriatric Syndromes, etc (2-4 questions) Geriatric Syndrome Clinical conditions that do not fit into a specific disease category Inc occurrence in older adults, especially frail people Impact quality of life and function Not usually able to identify a cause Theraputic management is critical, even in the absence of a cause *No direct cause and effect = multiple factors/etiology Examples: delirium, falls, frailty, syncopy, urinary incontinence, pressure ulcers, functional decline Frailty Continuum (slow process) Pre-frail>frail>failure to thrive>death Usually reversible if treated in pre-frail Very common process in older adults Initiated by disease, lack of activity, inadequate nutrition, stress and physiologic changes Sarcopenia (loss of skeletal muscle), shrinking/wt loss, weakness, poor endurance, exhaustion, slowness, decreased activity Poor energy regulation Abnormal function in inflammatory and neuroendocrine systems Decreased ability to maintain homeostasis Treatment for frailty Optimal management of illness that causes frailty Prevent Sarcopenia = muscle strengthening, resistance training Nutrition program Appetite stimulants are minimally effective, lots of side effects

Geriatric Failure to Thrive Wt loss more than 5% of baseline, Decreased appetite, malnutrition, inactivity, dehydration, depressive symptoms, impaired immune function, Decreased cholesterol levels, Exhaustion Nursing Implications Early recognition and supportive treatment before advanced deterioration Risk benefit ratio (esp end-of-life) Holistic care Assess for polypharmacy that mimics GFTT Disability is NOT frailty st Bathing is lost 1 = Minimally dependant Eating and Toileting is lost last = very dependant Disability doesnt cross into other body systems: a person with a spinal cord injury will still have an appetite Transitions Set of standard actions designed to ensure the coordination and continuity of healthcare as pts transfer between different locations or levels of care within one location. Older adults are increasingly vulnerable during transitions Med errors Confusion in new settings Inappropriate teaching Transition information Include: care plan, summery of care provided, pts goals/preferences, Advanced Directives in place, updated list of problems, baseline physical information, cognitive assessment, medication list, allergies, contact info for family/caregiver, primary provider info Full explanation of transfer to patient and family Full medication reconciliation Any outstanding tests and follow-up plan Conversation with pt/family regarding warning signs and who to contact _____________________________________________________________________________________________________ ____________ Sensory Disorders (3-5 questions) Vision Changes with Aging Eyelids loose tone = ptosis, malposition of the eyes Conjunctiva thins and turns yellow Dryness = lack of tears Arcus Senilis = noticeable ring around the cornea, fatty deposit Pupil decreases = allows less light in Lens increases in density = difficulty in differentiating colors Peripheral vision decreases, night vision diminishes, sensitivity to light develops Common Complaints Floaters and Flashers Dry eyes Presbyopia = Decreased vision and clarity, need for reading glasses Ectropion = Eyes turn inwards Extropion = Eyes turn outwards Blepharitis = Redness, irritation, itching, burning, tearing and photophobia, remove bacteria and heal affected area Glaucoma Increased intraocular pressure (extra aqueous humor) Optic nerve damage due to pressure st nd 1 cause of blindness in AA (2 overall) Can lead to Permanent Vision Loss Cool compress, Darkened room Acute Glaucoma Sudden onset, 911 Closed angle or Narrow angle Glaucoma Pupillary blockage limits the flow of aqueous humor Contributing Factors Sudden eye trauma Small cornea Small anterior chamber

Signs/Symptoms Severe Unilateral eye pain (can cause N/V, bradycardia) Blurred vision Seeing halos around lights Red eyes *Worse in the AM Medications Miotics = restrict pupils Hyperosmotic Diuretics = remove extra fluids Chronic Glaucoma Open angle, primary open-angle glaucoma Common in AAs st Peripheral Vision is lost 1 = can lead to blindness Signs/Symptoms Tired eyes Headaches Misty vision Seeing halos around lights Treatment No cure, Decrease IOP Beta Blockers Alpha Agonists (can cause brownish pigment in eyes) Osmotic Diuretics (can cause hearing loss, tinnitus) nd Glaucoma 2 to Disease

Cateracts Clouding of the lenses = light isnt transmitted through Contributing factors Trauma Congenital Exposure to Radiation/UV Maternal exposure to Rubella during pregnancy Prolonged use of steroids Chronic infection/inflammation HTN, DM Smoking, alcohol, malnutrition Signs/Symptoms Gradual loss of vision Fuzzy vision Sensitivity to light (night vision issues) Halo affect Surgery Outpatient Removal of lens and insertion of lens implant Complications = retinal detachment, macular degeneration Eye Pain = hemorrhage, infection Age Related Macular Degeneration Damage or breakdown of Macula (Capillaries) Central Vision Loss (poor reading, close vision) White, women, family hx Smoker, sun exposure, Decreased dietary intake of Zinc and Antioxidents Dry Nonextudative 90% Cells get thinner Slow progression Better prognosis Wet Extudative 10% Abnormal hemorrhages of on the retina Sudden onset More severe vision loss

Treatment No Cure Frequent eye exams magnifying glass reading lamps modify environment Antioxidant therapy Retinal cell transplant or regeneration Medications

Diabetic Retinopathy 911: No early outward signs Most common diabetic complication 4 Stages Mild: micro aneurisms on retina Moderate: blockage of some retina supplying vessels Severe: blockage of many = retina deprived of needed circulation Proliferative: Advanced stage, new vessels form to compensate, they break and cause degenration Prevention is best! Retinal Detachment 911 May look like spots moving across the eye, blurred vision, light flashes, curtains Keep person calm, quiet May require surgery Hearing Age Related Changes Poor balance Increased Cerumin = Impaction Puritis = Itching

Hearing Loss Presbycusis Sensorineural Loss Bilateral st High pitch lost 1 Background noise makes conversation difficult Men more than women Cause unknown Conductive Loss Cerumin, infection, tumors, otosclerosis Dizziness/Disequilibrium Not a normal part of aging! 5 Age-related conditions of disequilibrium Benign Paroxysmal Positional Vertigo: severe vertigo precipitated by change in head position Ampullary Disequilibrium: vertigo associated with rotational head movements Macular Disequilibrium: severe dizziness when moving against gravity (standing up) Vestibular ataxia of aging: constant feeling of imbalance with ambulation Menieres Disease: severe vertigo accompanied by tinnitus and progressive low frequency sensorineural hearing loss Caused by pressure within the labrynth = swelling of the cochlea Loss of balance, N/V, spasmodic eye movements _____________________________________________________________________________________________________ ____________ Skin Disorders (4-6 questions) Age Related Changes Loss of thickness, elasticity, vascularity and strength that can delay healing and increase risk of skin tears and brusing Increase in brown-pigmented spots Loss of SubQ tissue causing wrinkling and sagging of the skin, which can affect self-esteem, temp control, and drug efficacy Loss of hair, thinning and graying of hair Thicker nails with longitudinal lines

Decreased sebaceous and sweat gland activity, which affects thermoregulation and decreases sweating, dry skin Higher incidence of benign and malignant skin growths

Common Skin Problems Benign Skin Growths Cherry Angiomas = red, purple dome shaped papules Seborrheic Keratoses = scaly growths that appear crumbly, brown/black Skin Tags Inflammatory Dermatitis Common with parkinsons, stroke Red, swollen base covered by white scales Starts at scalp and works its way down the body Psoriasis Auto-immune Pink plaques with white scales on top Puritis Dry, itchy skin Can be caused by liver, renal, hematological, thyroid conditions Candidiasis Yeast infection Herpes Zoster Shingles Reaction to latent chickenpox virus Common occurrence in immunocompromised pts Not infectious to people who have had the chickenpox, contagious to others Outbreak occurs along a dermatome (nerve) Possibility of postherpetic neuralgia Skin Cancers Basal Cell Carcinoma Most common skin cancer Light skin, extensive sun exposure Mets to bone, lungs, brain Treatment: remove lesion Squamous Cell Carinoma Most common on scalp, outer ears, lower lip, hands Mets to lymph nodes Often look like bleeding warts Found on black people too, not just sun exposed areas Treatment: removal of lesion Melanoma st th 1 deadly skin cancer (6 deadly cancer overall) Treated early = 100% recovery rate Light skinned people, non-sun exposed areas mostly Mets to all organs of the body Lesion: Asymmetry, Boarders (uneven), Color (varied), Diameter (Over 6mm), Elevation/enlargement Lower Extremity Ulcers Arterial Ulcers Less common Caused by PAD Arteriosclerosis = Ischemia = Eventual tissue death = Ulcer st Pain with exercise, at night, while resting = 1 symptom Pain at rest indicates majorly restricted vessels Leg becomes blue, cool; skin thins, shiny, dry; decreased hair, thickened nails Located on feet and toes Treatment: revascularization, amputation Venous Ulcers Increased in Women Caused by Venous HTN st Discoloration and thickening of skin = 1 symptom Located on medial aspect of the legs Flat, shallow craters with irregular boarders. Lots of extudate and edema Treatment: elevate and compression treatment Diabetic Neuropathic Ulcers Older adults who live alone or with mental confusion are at increased risk = less means to recognize the ulcer st Pain and Temperature = 1 symptom with neuropathy

Bilateral, symmetric, and located on the bottom of the foot Pain relieved by walking Proper shoes and foot care! Treatment: diabetic healing, amputation Pressure Ulcers Pressure = hypoxia = necrosis of the tissue Can lead to Osteomylitis (bone infection), bacturemia (blood infection) Risk factors Pressure: Immobility/paralysis, Dec activity, Dec sensory perception Tissue Tolerance: Inc moisture/friction/shearing, Poor nutrition (dec albumin (<3.5), dec protein), Dec arterial pressure/BP Other: emotional stress, smoking, skin temp, Incontinence Braden Score: Pressure Ulcer Risk Higher score = Lower risk Care Use Saline to clean Clean with each dressing change If necrotic tissue is present consider high pressure irrigation Debride necrotic tissue Do not debride eschar tissue on heals Moist wound environment, control extudate, eliminate dead space Staging Stage 1 Area of red/pink or mottled skin thats unblanchable Warmth, redness, edema Stage 2 Abrasion, blister, shallow crater = partial thickness loss Warmth in the area surrounding Stage 3 Deep crater, may extend to foscia = full thickness loss SubQ tissue is damaged or necrotic Bacterial infection = common, causes drainage Stage 4 Extensive tissue necrosis or damage to muscle, bone, supporting structures = full tissue loss May appear dry, black, with a build-up of necrotic tissue (eschar) May be wet/oozing Unstageable Cant assess the damage below the top layer of eschar

Nail Disorders Onchomycosis Fungal infection of the nails Degeneration of the nail bed Yellow, brown, white & Ridges and pitting Treatment: Topical Antifungal _____________________________________________________________________________________________________ ____________ Neurological Disorders (4-6 questions) Mental Health Depression Inc risk Older people Women over 85 Unmarried/Widowed Urban area LTC facility Physical illness/terminal illness Disability/immobility Dec social support Dec self-esteem Significant loss Assessment (5 or more) Sadness Anhedonia

 Wt loss/gain Sleep to much/little Psychomotor agitation/retardation Fatigue/loss of interest Worthlessness/guilt Impaired concentration Recurrent thoughts of suicide or death Strategies for Care SSRIs Psychosocial interactions NSG interventions Community resources Suicide Older people: decreased attempts but increased success Delirium Acute confusion (often correctable by fixing the cause) 4 Basic Features Acute Onset (lasts hours-days) Inattention Disorganized Thinking Altered LOC Mini-mental exam, Mini-cognitive exam Dementia Progressive brain deterioration = Irreversible Progressive forgetfulness, memory loss, loss of other cognitive function Caused by increase in plaques and tangles in the brain Liver/Renal/Electrolyte Imbalances/Vit B12 Deficiency all mimic Dementia so they must be R/O first Neurologic Age Related Changes Shrinking and reduced number of neurons Change in receptor sites Dec neurotransmitters Muscle atrophy Dec electrical conduction Dec taste, smell, touch, balance Altered reflexes Changes in sleep-wake cycle Orthostatic changes Dec ability to learn new information Slowing autonomic system 1 sign of Cognitive decline = Change in functional status Older adults experience no more memory loss than younger people, they just need more time. Dec cognitive function is an effect of disease, not a normal aging process!
st

Alzheimers Disease (Dementia) Gradual Onset Continuing cognitive decline not caused by medical/physical/psychological/neurological condition Progressive Brain Deterioration Progressive forgetfulness, memory loss, loss of cognitive function Plaques/tangles interfere with nerve cell function and lead to neurological death Genetic and Environmental factors A genetic connection exists in people who are diagnosed early in life A viral connection exists in people who have had Herpes Zoster Head trauma, toxin exposure, Vit B12 Deficiency AAs 4x more risk then whites Age is the #1 risk factor (risk doubles Q5yrs over 65) Diagnosis No testing = autopsy only Stages of AD Mild Stage Good time to discuss Advanced Directives

Memory loss Getting lost in familiar places Difficulty with normal activities, finances Bad decision making Moody and anxious Moderate Stage Safety #1 Concern Increased memory loss Difficulty with language Inability to learn new things or adapt to new situations Hallucinations, delusions, paranoia, etc Sundowners Syndrome Inc confusion and agitation at sundown/night time Increases in unfamiliar settings Keep familiar objects around Use lights to keep rhythm Redirect pts Provide companionship and attention Avoid daytime napping Provide physical activity Identify triggers and eliminate them Severe Stage Safety #1 Concern Weight loss, dysphagia, speech unintelligible Bowel/Bladder incontinence Ulcers Inability to recognize family Seizures, neuromuscular symptoms Increased sleeping Behavior is extremely disruptive/upsetting to families Assist the families to understand and deal with the changes The pt cant be blamed for their behavior, their brain has changed, not the same person anymore Advise them to keep calm, dont confront the pt Try to find the triggers of the behavior and modify them Provide constant routine, decrease stimulation, provide safety Nursing Wandering = no escape environment, no restraints, medic alert bracelet, make neighbors aware Paranoia = dont whisper around them Hallucinations = dont confront, reassure them Outbursts = calm them Non-Pharma Treatment Reality orientation (calendars, photos, clocks, etc) Validation: feelings and memories Reminiscence: long-term memory use Environmental: anticipate pts needs Physical comfort Respite Videos: good for pt and caregiver Pharma Treatment Cholinesterase Inhibitors (not a cure, slows progression) Monitor LFTs Cognex, Anicept, Exelon, Remilyn, Memantidine Ginko-Biloba: stabilizes cognitive function Pharma for Altered Thought Process Neroleptics Haloperidol, Olazapine, Risperidol Anticonvulsants Carbamazepine, Valproic Acid Anxiolytic Lorazapam, Busiperon Antidepressants Trazodone

Parkinsons Disease Chronic, Slow Progression Increases with Age Genetically Linked = Chromosome 4 Progressive, degenerative disorder of the Basal Ganglia (control smooth muscle mvmt)

Loss of neurons in the brainstem (Substantia Nigra) Balance to form normal motor function Dopamine: Inhibitory Acytalcholine: Excitatory *In PD dopamine in lacking so Acytalcholine is free to cause increased mvmt (tremors and rigidity) Signs/Symptoms Bradykinesia: Slow mvmt Increased muscle tone: rigidity (cog wheeling) Resting tremors Impaired postural reflexes: freezing, propulsion, retropulsion Pill rolling Incoordination Shuffling gait Sweating Sleep issues Speech problems Lack of facial mvmt, emotion Drooling, dysphagia Visual problems Bowel/Bladder/Sexual dysfunction Depression/Anxiety/Panic disorders Dementia/memory loss/confusion Treatment MAOIs: not great for older people = hypertensive crisis Dopaminergics Have a 5 year time limit of action Worsen Postural HTN Increase the release of Dopamine Used to stop rigidity, bradykinesia, tremors Levadopa (synthetic dopamine) Sinemet (Levadopa and Carbadopa): Dec SE of nausea associated with Levadopa Amantadine (Symmetrel) Dopamine Receptor Agonists Monitor mental status, Insomnia Peramax and Parlodel = Mimic dopamine Anticholinergics Blocks acytalcholine Artane and Cogentin COMT Used in combo with Dopaminergics Monitor LFTs Enhance effects of Dopamine Tolapone and Entacapone CVA/TIA (TIA: stroke S/S last less than 24 hrs, leave no residual effects) Increased with high BP and high Cholesterol Risk Factors: HTN, DM, Sedentary lifestyle, substance abuse, high fat diet, Afib, Carotid Stenosis, Heart Disease, obesity, stress, Increased age, Men, AAs, Family hx 3 Types of Stroke Thrombolytic: clot forms in the vessel in the brain (L-sided facial droop) Embolic: Clot forms somewhere else and travels to the brain (L-sided facial droop) Hemorrhagic: Blood vessel bursts (Worst headache of my life) Common in Older People Treatment Hemorrhagic: Control bleeding, Evacuate clot Ischemic: Give t-pa (activase) within 3 hours of onse Avoid D5W = Increase cerebral edema _____________________________________________________________________________________________________ ____________

Solid Organ Cancers/Pain Management/End of Life Care (8-10 questions) Solid Organ Cancers Women Men

Breast Prostate Lung (most deadly) Lung (most deadly) Colorectal Colorectal Uterine Urethral Non-Hodgkins Lymphoma Melanoma Smoking: the leading cause of all cancer deaths! AAs overall highest rate of cancer Age is the most important determinant of cancer risk Three Phases of Cancer Growth Initiation: risk factors Promotion: environmental factor that potentiates the growth Progression: Growth Cancer Prevention Fresh fruits and veggies (antipromoters) Decrease exposure to known carcinogens (smoking, sun, lead, pesticides, etc) Cancer screening (mammography, colonoscopy, pap, etc) Not worth it if life expectancy is less than 5 yrs Early Warning Signs Change in Bowel or Bladder A sore that doesnt heal Unusual bleeding or discharge Thickening or lump Indigestion or dysphagia Obvious change in wart or mole Nagging cough or hoarsness Older Adults Experience with Cancer On avg in addition to Cancer the older adult will have 3 additional comorbidities and be on 5 other meds Quality Vs Quantity Depression Grief and Loss Financial planning Social isolation Staging of a Cancer Tumor T = Tumor location, size and invasion (into tissue or bone) N = Lymph node involvement M = Metastasized Treatment Decisions Treatment should be based on cancer type and stage, functional status, organ function, pulmonary function, cardiopulmonary test results and co-morbidities. Not on Age Treatment may be aimed at symptom mgmt rather than curative Lung Cancer Leading cause of cancer death Risk Factors: SMOKING Occupational hazards Signs/Symptoms Early Persistent cough Blood streaked sputum Chest pain Dyspnea Late Anorexia Weight loss Reoccurring Bronchitis Older People: Dyspnea and Wt loss more than Pain Detection Tumors can grow for years before symptoms begin to show Chest X-rays and Sputum testing can detect small tumors Early detection will increase the time between detection and death but doesnt lengthen life Types of Lung Cancer Small Cell (Oat Cell) Cancer Fast growing Mets quickly Highly associated with Smoking Poor Prognosis

Sensitive to Chemo (not curative, length of life extended but not necessarily quality) and Radiation (palliative, can dec dyspnea = inc comfort) Non-small Cell (squamous, adenocarcinomas, large cell) Squamous = Smoking Slower growing types Surgery and if mets then chemo/radiation too

Liver Cancer CT Scan = Diagnosis Alpha Fetal Proteins + with Liver Cancer Treatment is usually palliative Metastatic cancer is the most common type of liver cancer: usually mets from lung, breats, kidney and gi Primary tumors are usually associated cirrhosis from Hep B/C Often Asymptomatic at diagnosis Clinical Presentation Hepatosplenomegally Peripheral edema Ascites Dull abd pain Jaundice Anorexia Weakness Treatment: determined by tumor stage and livers functional status 6-8 weeks prognosis if untreated Surgical resection/transplant: 5 year survival rate = less than 50% Pancreatic Cancer Incidence increases with age More than 98% of all people with Pancreatic Cancer will die Women, AAs Clinical features depend on location of tumor Jaundice Vague abd or back pain N/V/Wt loss Generalized weakness Similar symptoms to pancreatitis, 3-6 months before diagnosis Treatment: determined by tumor characteristics (curative is rare) Stomach Cancer Men, Poor, Urban Adenocarcinoma of the stomach wall Contributing Factors Mucosal Injury: aging, autoimmunity or repeated exposure to irritants Atrophic astritis Pernicious Anemia Adenomatous polyps hyperplastic polyps achlorohydria Diagnosis: well advanced because symptoms mimic other gi issues Endoscopy Treatment: Surgical removal of tumor (Ideal = inc survival), Chemo/Radiation Pain Most of liver, lung, pancreatic and stomach cancers are ultimately fatal *Realistic expectations that treatment will prolong life or improve quality of life must be discussed with the pt Pt should be informed of all adverse effects of treatment Quality of life must be determined by the pt not by us! Pain Mgmt Pain is NOT a normal part of aging Pain tolerance decreases as we age = older adults are more susceptible to pain Classification of Pain Acute Persistent Neuropathic: Nerves have a decreased response to analgesics Psychologically Based: somatic disorders Nociceptive: result of stimulation of pain receptors

 Mixed or undetermined Consequences of unrelieved pain Depression, anxiety Decreased socialization Sleep issues Decreased ambulation, mobility, posture, constipation, incontinence Prolonged recovery, increased healthcare cost Premature death Goals for treatment Relief from pain Control of chronic disease Maintenance of mobility and functional status Promotion of self care and max independence Improved quality of life Barriers to Pain Assessment Intensity, frequency and pain perception in the older adult Older adults under report pain Validity of pain assessment tools in older adults Fear of addiction Tolerance to opiates Lack of ed for nurses Principles of Pain Mgmt Always ask about pain Accept the pts word Never underestimate the impact of pain Be compulsive about pain assessment Dont wait for a diagnosis to treat pain Use drugs and non-drugs Mobilize pt physically Go low and slow with drugs Anticipate anxiety and depression Evaluate treatment plan End of Life Communicating bad news Just get started Find out what the pt already knows Find out how much the pt wants to know Share info Respond to feelings Plan/follow up Defined Loss: losing or being deprived of something Bereavement: State or situation of having experienced a death related loss Grief: Ones psychological, physical, behavioral, social, and spiritual reactions to loss Anticipated: Grieving before the actual loss Disenfranchised: Grief that cant or is not openly acknowledged (gay partners, not married, suicide, OD, etc) Complicated Chronic: prolonged, never reaches a conclusion Delayed: grievers response is delayed Exaggerated: normal response grows to an unmanageable level Masked: experiencing loss but cant show it Mourning: ritualistic behaviors in which people engage during bereavement Tasks of mourning Accept reality of loss Experience and work through pain Adjust to new environment without the person Emotionally relocate the deceased and move on Phases of Loss Early: shock, denial Middle: pain, separation Late: reintegration and relief, balance Grief Counseling Increase reality of loss Help person deal with expressed and latent effects

 Assist the person to deal with the impediments to readjust Encourage the person to move through the phases and to reinvest in new relationships Major concerns of Older People Fear of their own death is rare More afraid of long debilitating illness Fear of being a burden Fear of pain, suffering, and decreased quality of life Fear of dying suddenly and not being discovered Advanced Directives Durable power of attorney Living Will Appointment of health Care Rep DNR Life-prolonging declaration Five Wishes Allow Natural Death Options for end of life care Curative/Acute Care Hospice Care Not prolong or shorten life Pain relief and symptom management Psychological and Spiritual pain relief Pt has ultimate autonomy over care Unit of care is pt and family Common Physical Problems that are Managed Pain Dyspnea Constipation Delirium Altered Urinary Elimination Altered Skin Integrity Loss of Appetite Dry Mouth N/V Restlessness Dysphagia Nutritional Problems Changes during the last few hours Weakness/fatigue LOC Urine Output Dec Discoloration of extremities Laborous breathing Death rattle Benefits/Burdens of Artificial Hydration/Nutrition Prolongs life if time is needed (waiting for a family member to get there) May improve delirium Maintains appearance of care/family fear of starvation Unproven Benefits: reduces aspiration pneumonia, pt suffering, infections, skin breakdown Burdens: Maintaining parenteral access, Increases secretions/ascites/effusions/edema, site care, IV bag changes Alternatives to Artificial Feedings Allow pt to eat/drink when they want No oral/Non-oral nutrition/fluids = expect death within 14 days Family Remind them dehydration is not painful, may actually be protective (dec lung secretions, etc) Care with Dec fluid Frequent mouth care: mouth swabs Eye care: saline drops Skin care: lotion Palliative Care: Sedation Sedation doesnt quicken death Use for refractory symptoms in pts who are dying Comfort Measures Only DNR on file

 Address hunger and thirst Symptom Mgmt Standardized Nsg care The Final Hours Discontinue testing Discontinue vital signs Avoid unnecessary needle sticks Allow pt and family uninterrupted time together Ensure that family understands what to expect Ensure that care givers understand and will honor advanced directives

Signs of Death Cessation of heart beat and respiration pupils fixed and dilated no response to stimuli eyelids open without blinking decreasing body temp jaw relaxed and open body color is a waxen pallor Pronouncement of Death Recognize the extreme emotional response to verbal pronouncement of death Establish eye contact with family Introduce yourself to family you dont know, allow them to ask questions about what happen at time of death Examine for breath and heart sounds Note time of death Discuss legal next of kin about autopsy/organ donation/funeral home