Approximately one-third of people with hypertension are unaware that they have it.Acute and Chronic Physical Illnesses |
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As the older adult population continues to grow and life spans continue to increase, the number of chronic illnesses among older adults will also increase. These chronic conditions require effective disease management. It is estimated that, by the year 2030, approximately 150 million individuals will have a chronic condition, compared to 99 million in 1995 (Robert Wood Johnson Foundation, 1996). The Alliance for Aging Research (2002) reports that the average older adult has the following chronic medical conditions.
Hypertension results from many nonmodifiable and modifiable risk factors and lifestyle behaviors. It is a serious risk factor for the development of many types of cardiovascular and renal diseases. (See Table 4.1 for a list of the JNC-VII criteria for blood pressure.) Hypertension is considered a silent killer because it has no signs and symptoms.
Approximately one-third of people with hypertension are unaware that they have it.
The American Heart Association (2005) estimates that, of those with hypertension, at least half are not on medication and about 25% more are on inadequate hypertensive therapy.
The combination of diabetes and smoking together is more dangerous than either risk factor alone, and increases the risk of adverse events resulting from hypertension.
Nursing interventions for the treatment of hypertension include
Diet and lifestyle modification
Exercise
Stress management
Medication management
First-line therapy consists of thiazide diuretics such as hydrochlorothiazide (HCTZ®) or Diuril® and beta blockers such as atenolol (Tenormin®), labetolol (Normodyne®), or propranolol (Inderal®). Angiotensin-converting enzymes (ACE inhibitors) such as benazepril (Lotensin®) or captopril (Capoten®) calcium channel blockers such as amlodipine (Norvasc®) and diltiazem (Cardizen®) are used for first-line therapy only when diuretics and beta blockers are contraindicated.
Side effects of antihypertensive medications may include dry, persistent cough and erectile dysfunction.
Congestive heart failure (CHF) is a chronic medical condition that results in acute medical crises; it occurs more commonly as people age.
In the United States, approximately 4.8 million people have CHF, and each year, 400,000 new cases are diagnosed.
Approximately one-half of older adults with CHF will die within 5 years of being diagnosed with the disease.
The presentation and outcome of CHF are often influenced by the presence of comorbidity.
About 80% of all clients with CHF are age 65 and older.
CHF affects approximately 1 million older adults annually.
CHF is a multifaceted disease exacerbated by normal changes in the heart that accompany aging.
CHF commonly occurs when the pumping ability of the heart is impaired and it can no longer deliver adequate blood circulation to supply the body’s metabolic requirements.
CHF may be used to refer to either left ventricular failure or right ventricular failure. The pathology in most older adults is left ventricular dysfunction.
CHF is often caused by a myocardial infarction and coronary artery disease.
Other causes of CHF include
Valvular dysfunction
Arrhythmias
Infections
Rheumatic heart disease
Hyperthyroidism
Anemia
Excess salt and fluid intake
Steroid administration
The discontinuation of cardiac medications
The typical presentation of CHF in older adults includes the sudden development of
Shortness of breath
Dyspnea with exertion
Fatigue
Weakness
Alteration in function
Change in cognition
Pedal edema
Fluid in lungs
Other symptoms may include
Diaphoresis
Tachycardia
Palpitations
Anorexia
Insomnia
Normal and pathological aging changes may make the early assessment and treatment of CHF difficult.
Pedal edema or weight gain due to CHF may be confused with normal pedal edema that occurs with aging or the side effects of steroid treatment for chronic obstructive pulmonary disease.
Altered cough reflex may prevent early detection of pulmonary changes.
Chest pain or tightness, fatigue, general weakness, a nonproductive cough, and insomnia may be commonly attributable to other conditions of aging and orthopnea.
Nurses play an important role in identifying early symptoms of CHF through awareness of common signs and symptoms in older adults. Effective management of CHF in older adults includes
Education about
Self-care—alternating periods of activity with rest
Low-salt or sodium-restricted diets
Medication administration involving a combination of angiotensin-converting enzyme (ACE) inhibitors, digoxin, and diuretics and ACE inhibitors such as benazepril (Lotensin®) or captopril (Capoten®)
Early identification of symptoms
Administration of diuretics to decrease cardiac workload. Without further symptoms, and adequate urinary output, older adults may be evaluated for several hours in the emergency department, home, or outpatient facility and then discharged.
The persistence of symptoms or failure to reduce cardiac output requires further treatment and hospitalization.
Angina occurs in approximately 13.7% of women and 21% of men aged 65 to 69.
The Merck Manual of Geriatrics (Beers & Berkow, 2000) reports that myocardial infarction (MI) occurs in approximately 35% of older adults, and 60% of hospitalizations due to acute MI occur in persons 65 years and older. Moreover, 38% of women and 25% of men will die within 1 year of their MI (American Heart Association, 2008).
A variety of factors can precipitate angina and MI among older adults, the most common of which is coronary artery disease.
Other causes of MI include
Alular dysfunction
Arrhythmias
Infections
Rheumatic heart disease
Hyperthyroidism
Anemia
Excess salt and fluid intake
Steroid administration
Discontinuation of cardiac medications
Angina results from a lack of oxygen supply to the heart muscle due to reduced blood flow around the heart’s blood vessels.
Angina is the most common symptom of myocardial ischemia and is experienced commonly among older adults with coronary artery disease.
Myocardial infarction is a serious, sudden heart condition usually characterized by varying degrees of chest pain or discomfort, weakness, sweating, nausea, and vomiting, sometimes causing loss of consciousness.
MI occurs when a part of the heart muscle dies because of sudden total interruption of blood flow to that area.
The classic clinical presentation of MI regardless of gender results in pain.
The pain and dysrhythmias of MI are often more serious in older adults than in younger clients as a result of both normal and pathological aging changes.
Older adults may not exhibit normal signs of MI, such as
Crushing, radiating chest pain
Gray or cyanotic skin
Diaphoresis
Severe anxiety
Nausea and vomiting
Hiccoughs
In older adults, symptoms of MI may be insidious or vague (silent heart attack), because older adults may:
Be reluctant to complain
Lack communication ability to complain
Have post-stroke aphasia
Have dementia
Some older adults may attribute the symptoms of angina and MI to
Normal aging changes
Symptoms of other disease processes
Older adults may not have chest pain but may complain about any combination of
Pain in the back, shoulder, jaw, or abdomen
Diminished level of consciousness or acute confusion
Nausea and vomiting
Hypotension
Dizziness or syncope
Transient ischemic attack
Cerebral vascular accident
Weakness
Fatigue
Falls
Restlessness
Incontinence
Nurses play an important role in identifying early symptoms of angina and MI. Because both of these diseases may present as pain among older adults, attention to pain complaints must be considered seriously and proper assessment implemented.
Nurses’ beliefs that pain is a natural and expected part of aging is among one of the most prevalent myths that prevent appropriate treatment of angina and MI among older adults.
Many older adults tend to hesitate to report pain because they think nothing can be done to manage the pain and/or they are afraid to bother the nurse.
Objective pain is aided by the presence of many standardized tools for assessing pain in older adults. A frequently used measure of pain evaluation is a numeric rating scale in which clients are asked to indicate the pain they are experiencing on a scale of 1 to 10, with 1 being very little pain and 10 being the worst pain imaginable.
After pain complaints are validated, further symptoms of angina and MI should be evaluated with the interdisciplinary team using
Electrocardiograms
Cardiac enzyme evaluation
MIs are medical emergencies and must be managed accordingly.
Drug therapy for chronic angina usually involves
Daily application of nitroglycerin patches (Nitrodisc®, Nitro-Dur®) to enhance perfusion to the cardiac vessels
Maintenance of sublingual nitroglycerin pills (Nitrostat®, Nitrolingual®) in the case of angina. Proper teaching regarding the application of patches and the administration of sublingual nitroglycerin is needed
Lipid-lowering medications known popularly as statins, which are often effective in reducing further occlusion of the cardiac vessels
Assessing cholesterol levels in clients within the normal range in order to reduce morbidity and mortality among this population
Selective beta-blocker medications such as acebutolol (Sectral®) and atenonol (Tenormin®), which also may be prescribed to prevent MI in patients with angina
Nurses may also implement programs of
Weight loss for obese clients
Physical activity
Low-cholesterol and low-sodium diets
Peripheral vascular disease (PVD) is a broad term that refers to altered circulation in the extremities—usually the legs—resulting from poor vascularization over many years.
Risk factors for PVD include
Diabetes
Smoking
High-fat diets
Sedentary lifestyle
Intermittent claudication refers to vascular-related pain that develops in the muscles of the legs while walking.
Symptoms may be misattributed to arthritis or neuropathy.
PVD is assessed by the amount of distance ambulated before the onset of pain.
Surgical procedures may be available to improve circulation in the case of disabling PVD.
Exercise has been found to be effective when tolerated to promote collateral circulation.
Deep vein thrombosis occurs when a blood clot, or thrombus, develops in the large veins of the legs and is a major risk of immobility after surgery.
DVT is characterized by acute onset of pain and edema in the affected extremity.
Because a clot may become free and clog a major artery, such as a pulmonary artery, DVTs are medical emergencies and should be treated accordingly with surgery and/or clot-dissolving medications.
Patients at high risk may continue to remain on Coumadin and should be counseled to wear antiembolitic stockings.
Pneumonia is the leading cause of death from infectious disease in the United States and the overall sixth leading cause of death in the United States (Institute for Clinical Systems Improvement, 2003). The death rate from pneumonia is especially high among older adults who have had surgery or mechanical ventilation.
Normal changes of aging such as lowered immune status impact pneumonia as do changes in respiratory function, including
Altered cough reflex
Diminished airway clearance
Further risk factors for pneumonia are the presence of chronic diseases and conditions such as
Chronic obstructive pulmonary disease
Congestive heart failure
Gastroesophageal reflux disease
Impaired swallowing
Tube feeding
Impaired mobility
Alterations in levels of nutrition
The traditional symptoms of pneumonia are often absent or difficult to assess among older adults. These symptoms include
Cough
Fever
Dyspnea
Purulent sputum
Pleuritic chest pain
Most older adults with pneumonia have a presentation of disease that consists of
Anorexia
Confusion, delirium, or change in behavior
Altered functional abilities
Decompensation of underlying illnesses
Nursing interventions for the treatment of pneumonia include
The administration of medications aimed at destroying the causative organism or virus
Proper diet
Hydration
Treatment of fever and discomfort with acetaminophen or NSAIDs
Respiratory therapy such as postural drainage
Evaluation of complications that require follow-up or further therapy, including
Dyspnea
Worsening cough
Onset or worsening of chills
Fever occurring more than 48 hours after drug therapy is started
Intolerance of the medications
Influenza, commonly known as the flu, is a contagious viral disease that frequently infects the population in the winter months.
The Centers for Disease Control (2007a) reports that between 10% and 20% of the U.S. population is infected with the flu each year.
The flu is often only a mild disease in healthy children and adults, manifesting symptoms such as fever, sore throat, dry cough, headache, and aching muscles.
Older adults are more likely to develop life-threatening complications from the flu, such as
Changes in mental status
Dehydration
Pneumonia
Extreme tiredness
Each year, approximately 36,000 U.S. residents die from influenza, and 114,000 are hospitalized from the disease (Centers for Disease Control, 2007a).
Older adults may present with flu symptoms differently from their younger counterparts.
In older adults, the classic symptoms of cough, congestion, nausea, and vomiting may be absent or attributed to other disease processes.
Older adults with the flu may present with acute confusion or delirium.
Nutrition
Hydration
Rest
Symptomatic treatment of the disease includes the use of fever reducers such as acetaminophen or ibuprofen and cough suppressants.
Vaccination remains the most commonly used method of preventing and reducing the impact of the flu.
Vaccination is required each year because the flu viruses change constantly and unpredictably.
Medicare currently reimburses providers for annual influenza vaccinations.
Some characteristics of tuberculosis:
Infectious disease caused by mycobacterium tuberulosis
Spread through droplets
Infection may be prevented by respiratory clearance mechanisms (50% from high carriers)
Lodges in lung and results in tubercle
Long latency period
The epidemiology of tuberculosis:
One-third of the world’s population is infected with latent disease (4% to 6% of U.S. residents).
8 to 10 million worldwide will develop active infections annually.
It is primarily a disease of young adults, but the risk of tuberculosis among older adults is significantly increased in the institutionalized population.
Symptoms of tuberculosis:
Fatigue
Anorexia
Weight loss
Cough
Night sweats
Fever
Chest pain
May be peripheral involvement
Diagnosis of tuberculosis:
PPD or Mantoux > 5mm or greater
QuantiFERRON-TB (better at detecting latent infection and immunization with bacillus Calmette-Guérin)
Lab—acid fast bacilli (may take 3 to 8 weeks)
Active and passive disease treatment
Strong clinical suspicion
Multiple drug treatment regimen with isoniazid, rifampin, pyrazinamide, and ethambutol
Obstructive airway diseases collectively rank as the fourth leading cause of death in the United States. Chronic bronchitis, asthma, and emphysema are the three major obstructive airway diseases that collectively represent chronic obstructive pulmonary disease (COPD) found prevalently among older adults.
Chronic bronchitis is caused by the inflammation of respiratory passages and results in edema and the development of sputum that tends to make breathing very difficult and in some cases impossible.
Asthma is manifested by the onset of bronchospasm, mucosal edema, and large amounts of sputum production.
Asthma is on the rise in the United States; the incidence and death rates of the disease are increasing among all age groups, including older adults.
Some older adults grow old with the disease and some experience new onset asthma in their later years.
Emphysema results from damage to the alveoli (the functional units in the lungs), which results in a reduction in the lung tissue available for aeration (alveolar-capillary diffusion interface).
Chronic obstructive pulmonary disease can be the result of many factors, including
Air pollution
Smoking
Nursing interventions for chronic obstructive pulmonary disease vary, but the goals of all disease therapies are to
Maintain patent airways with the use of suction and medication.
Teach patients about the use of inhalers.
Teach patients about energy conservation.
Teaching safe and effective oxygen administration.
Administer steroid medications as needed to decrease airway inflammation.
Administer opioids that have been supported as safe and effective in reducing terminal dyspnea and respiratory distress at the end of life.
Gastroesophageal reflux disease (GERD) occurs frequently in older adults as a result of improper closure of the lower esophageal sphincter.
This leads to regurgitation of stomach acid into the esophagus, leading to erosion or metaplasia.
GERD places older adults at higher risk for esophageal cancers.
Risk factors of GERD include (Miller, 2007)
Diets high in fat, caffeine, chocolate, peppermint, and garlic
Alcoholism
Consumption of large meals
History of hiatal hernia
Smoking
Use of the following medications:
Calcium channel blockers
Nitrates
Nonsteroidal anti-inflammatories (NSAIDs)
Anticholinergics
Signs and symptoms of GERD include
Foul taste in mouth
Heartburn
Nausea
Belching
Dry cough
Treatment usually involves
Administration of proton pump inhibitors Nexium™, Pepcid™, or Protonix™
Diet modifications to avoid causative foods
Elevating the head of the bed
Smoking cessation
Anemia is a pathological illness among older adults generally resulting from abnormal hemoglobin and hematocrit levels. Older adults with anemia must be assessed to determine the responsible pathology.
Medications may cause anemia among older adults.
Proton pump inhibitors taken for more than 5 years decrease the amount of intrinsic factor available for B12 absorption, resulting in macrocytic anemia.
Other risk factors for anemia include
Crohn’s disease
Ulcers
Gastritis
Surgical procedures such as ileostomies or colectomies or small bowel resection
Renal disease
HIV
Other diseases that decrease bone marrow production
Assessment for anemia includes frequent evaluation of hemoglobin, hematocrit, and associated blood values specific to type of anemia.
Treatment includes
Diets high in protein and iron
Vitamin supplementation
Urinary tract infections are the most common type of infection among older adults and are caused by an accumulation of pathological bacteria in the urine. The rate of urinary tract infections increases significantly among the institutionalized elderly.
The symptoms of urinary tract infections are
Incontinence
Increased confusion
Falls
Urinary frequency
Dysuria
Suprapubic discomfort
Fever
Costovertebral tenderness
Diagnosis generally involves the collection of a urine specimen for culture and sensitivity.
Antibiotic treatment should occur only in the presence of symptoms.
A short course of antibiotics is usually recommended. Prolonged treatment may result in vaginitis in older women.
Treatment for longer periods of time may be needed among the older population due to their decreased natural immune responses.
In-dwelling catheters should be avoided when possible due to the increased risk of developing infections.
While health care providers are becoming increasingly knowledgeable regarding the unique needs of older adults, the sexuality of this population remains largely unrecognized. Nurses often ignore the sexuality of older adults during assessments, assuming that this aspect of human functioning is no longer applicable. The possibility of an older adult contracting a sexually transmitted disease (STD) is real; these diseases include
Neisseria gonorrhorae (gonorrhea)
May be asymptomatic in women but painful in men
Screen with smear
Treatment:
Ceftriaxone
Ciprofloxacin
Levofloxacin
Treponema palladium (syphilis)
May be asymptomatic in both men and women but they both may be carriers
Can result in late cardiovascular and neurological effects
Screening is complicated
Should test exposed individuals
Treatment includes antibiotics
Penicillin
Chlamydia trachomates (chlamydia)
Over 15 strands of this virus
The most common sexually transmitted disease
Major risk factor for pelvic inflammatory disorder
May be asymptomatic in women but painful in men
Assessment includes a screen with smear (clean cervical os)
Treatment:
Azithromycin or doxcycline or ceftriaxone
Herpes types 1 and 2
Genital herpes
One in five individuals has herpes
Spread through direct contact with lesions during sexual encounters
Screen for morphology of lesions
Treatment:
Acyclovir
Famciclovir
Valacyclovir (first episode, recurrence, and suppression regimens)
Human papilloma virus
Group of more than 70 viruses that affect genital mucous membranes
May be asymptomatic
May be associated with some cancers
Nurses must conduct sexual assessments on older adults with the same frequency as other system assessments.
PLISSIT Model of Sex Therapy |
p |
Obtain Permission from the client to initiate sexual discussion. |
LI |
Provide the Limited Information needed to function sexually. |
SS |
Give Specific Suggestions for the individual to proceed with sexual relations. |
IT |
Provide Intensive Therapy surrounding the issues of sexuality for that client. |
Note. From Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for the behavioral treatment for sexual problems. Journal of Sex Education Therapy, 2(2), pp. 1–15. |
|
Lack of experience and general discomfort with sexuality among health care providers are often barriers to assessing and managing the sexuality needs of older adults.
A model to guide sexual assessment and intervention of older adults is available (Exhibit 8.1) and has been widely used among younger populations.
The assessment of older adults’ sexuality should take place in a quiet area that affords clients necessary privacy.
The establishment of a trusting relationship between the health care provider and client is essential.
Nurses must be cautious to be respectful of older adults’ sexual beliefs and practices and must prevent judgmental thoughts and comments.
Appropriate history questions regarding sexuality include
Number and history of partners
Sexual practices
Physical signs and symptoms of sexual problems
Presence of problems
Level of satisfaction with current sexuality
Use of protection and precautions. In the older adult population, STDs such as syphilis, genital herpes, and hepatitis may remain from earlier years and be passed unknowingly to partners.
Although the presence of cancer is seen in all populations, the incidence and prevalence of cancer is disproportionate in the elderly population.
Approximately 75% of all malignancies in the United States occur among older adults, who, at present, constitute about 13% of the population.
Individuals aged 65 and older accounted for 56% of all cases of breast cancer and 80% of all prostate cancer in 2002.
Advanced age is a risk factor for the development of cancer.
Older adults are more likely to be diagnosed with cancer at an advanced stage when the cancer is less amenable to treatment and increased morbidity and mortality are more likely.
Cancer diagnosis and mortality are strongly associated with race and socioeconomic status.
For both older men and women, lung cancer is the leading cause of mortality.
Lung cancer mortality rates are followed by prostate cancer and colorectal cancer for older men and breast cancer and colorectal cancer for older women.
Ageism and myths of aging prevented older adults from being involved in clinical trials for new cancer treatments; health care providers often perceived this population to be at high risk for adverse effects from the negative effects of cancer therapy.
More recently, older adults have begun to receive aggressive treatments for cancer and are tolerating these treatments well. While special consideration for the normal and pathological changes of aging must be made, older adults should be offered the same treatments available to younger populations.
Nurses play an instrumental role in the primary and secondary prevention of cancer (see chapter 5, Health Promotion).
Providing support and information during the diagnosis is essential in treatment decision making and promoting effective cancer outcomes and quality of life.
Of all men diagnosed with cancer each year, more than 30% will be diagnosed with prostate cancer.
This rate is higher for African Americans (American Cancer Society, 2007).
Prostate cancer is nearly 100 percent survivable if detected early (US Too! International, 2004).
The availability of prostate-specific antigen testing for prostate cancer has greatly increased the detection and treatment of early-stage prostate tumors in older men.
Treatment for prostate cancer includes the options of
Internal radiation (brachytherapy)
External beam radiation therapy
Radical prostatectomy
Active surveillance or watchful waiting
Hormonal therapy for late-stage disease
Nurses will be involved in administering treatments aimed at reducing the symptomatology surrounding this disease as well as aiding treatment.
Among older women, over 214,000 new cases of breast cancer were diagnosed in the United States in 2006, resulting in over 40,000 estimated deaths.
Like prostate cancer in men, the risk of developing breast cancer increases with age among women.
Breast self-examination and mammography are helpful in screening for breast cancer.
The progression in lumpectomy and mastectomy procedures as well as new developments in radiation and chemotherapy treatments have sharply increased the survival rate for breast cancer for older women.
The nursing role in screening and administering treatments for breast cancer is essential in promoting good outcomes for these older women clients.
Osteoarthritis (OA) is one of the most common chronic disorders among older adults.
OA is the number one cause of pain among older adults.
OA affects approximately 46.4 million Americans, 8.8% of whom report an arthritis-related disability (Centers for Disease Control, 2007b).
OA can be a primary disorder or a secondary disorder resulting from a previous anatomic abnormality, injury, or procedure or from occupational factors.
Nursing assessment for OA includes
The evaluation of pain, because this is the presenting symptom for most patients
Radiographic examination of the joints, which helps to aid in the diagnosis and staging of OA
The nursing role for the treatment for OA is aimed at
Relieving pain and preserving or restoring function
Pharmacological treatments frequently include
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Acetaminophen
Narcotic pain relievers, when necessary
Various complementary and alternative therapies aimed at reducing pain and improving function are used frequently among older adults with OA.
Vitamins C, D, and E have shown some evidence of reducing symptoms.
Ginger and glucosamine also have been used extensively by older adults to reduce arthritis-related pain.
Nurses must exercise caution in the administration of nutraceuticals and provide teaching regarding the possible danger of these herbals because little is known about the interaction of these medications with prescription medications that are used to treat other diseases.
Acupuncture is becoming a more popular nonpharmacological OA management strategy.
Joint replacement among older adults with osteoarthritis is gaining in popularity.
Hip replacement surgery is common and greatly decreases pain and improves mobility among older adults.
Prosthesis may become dislodged if early adduction of hip is sustained.
These surgical procedures are used primarily to replace hip and knee joints that are dysfunctional because of the long-term effects of osteoarthritis.
Older individuals in their 80s and 90s typically have these procedures.
Although the rehabilitation may be long and intense, joint replacements bring new mobility and have the potential to greatly improve quality of life.
Osteoporosis is among the most common chronic diseases of older adulthood.
Physiologically, osteoporosis results from a demineralization of the bone and is evidenced by a decrease in the mass and density of the skeleton.
The most common areas of bone loss are the vertebrae, distal radius, and proximal femur.
Osteoporosis affects approximately 44 million women and men aged 50 and older in the United States. It is estimated that this number will grow to over 52 million by the year 2010 (National Osteoporosis Foundation, 2003).
In older adults with osteoporosis, the overall decline in bone mass weakens the bone, making it vulnerable to even slight trauma.
Normal changes of aging in the sensory system and in neuromuscular coordination combine with medications and environmental factors to place older adults with osteoporosis at high risk for fall-related fractures.
Fractures of the humerus and femoral neck are common, as are hip fractures in women over age 65.
Hip fractures result in greater morbidity and mortality among older adults than any other type of fracture.
Fractures in older adults often place these individuals in a spiral of iatrogenesis, with an increased risk of impaired mobility, decubitus ulcers, pneumonia, and incontinence.
Older individuals who are at highest risk for osteoporosis include
Small, thin women who have fair skin and light hair and eyes
Older adults with a family history of osteoporosis
Postmenopausal women
Women over age 65
Men over age 80
Older individuals are at greater risk if they
Have diets low in calcium
Smoke
Consume excess alcohol
Drink caffeine
Lead sedentary lifestyles
Older adults with osteoporosis may develop kyphosis late in the disease.
Kyphosis is a convex curvature of the spine that causes loss of height and chronic back pain as well as abdominal protuberance, gastrointestinal discomfort, and pulmonary insufficiency.
Bone density screenings can detect bone loss for those at risk for developing osteoporosis. However, because there are often no symptoms of this disease, osteoporosis is seldom diagnosed until a traumatic fracture is sustained.
Nursing interventions for the prevention of osteoarthritis include
Encouraging diets high in calcium (1,500 mg per day).
Advising a program of regular weight-bearing exercise.
Medications that have been shown to prevent further bone loss in those diagnosed with osteoporosis. Alendronate sodium (Fosamax®) taken once a week or risedronate (Actonel®) or raloxifene (Evista®) has been shown to prevent further bone loss and develop new bone mass.
Nursing interventions also might include fall-prevention strategies (see chapter 5).
Diabetes mellitus (DM) is a chronic medical disease manifested by an increase in blood glucose levels.
The Centers for Disease Control (2005) report that 17 million Americans have DM, and over 200,000 people die annually from diabetes-related complications.
DM is often a silent killer; it is estimated that 5.9 million Americans are unaware that they have the disease. Due to better screening and educational efforts at the state and national levels, diagnosis rates for diabetes increased 49% from 1990 to 2000, and they are expected to continue to rise (Mokdad et al., 2001).
DM is a chronic metabolic disease characterized by a deficiency in the production and utilization of the pancreatic hormone insulin. In older adults, elevated blood glucose levels symptomatic of DM result from altered insulin availability.
There are two different types of diabetes mellitus: type 1 and type 2.
Type 1 is also known as juvenile-onset DM or insulin-dependent DM.
Type 2 DM generally appears during adulthood and is known as adult-onset DM or, more commonly, non–insulin dependent diabetes mellitus (NIDDM).
Diabetes mellitus is considered a risk factor for heart disease.
More than 80% of persons with DM die of heart or blood vessel disease.
Smoking drastically increases the risk of cardiovascular disease in diabetics by constricting already compromised blood vessels.
Nursing interventions for diabetes must begin with a thorough assessment of blood glucose values and HgA1C levels, which provide short- and long-term insulin function indicators.
The type of therapy should be tailored to the individual client’s needs and issues.
Self-management of NIDDM in the elderly includes
Diet
Medication
Oral hypoglycemics
Insulin therapy
Blood glucose monitoring
Foot examinations
Exercise
10% to 20% of HIV infections occur in people aged 50 and older.
This number is most likely low because of misdiagnosis and will continue to rise as the population of older adults grows.
Older adults progress from HIV to AIDS more quickly than younger adults because of normal and pathological aging changes.
Due to the normal and pathological changes of aging, symptoms of HIV and AIDS may go undetected.
The awareness of the possibility of sexually transmitted diseases among older adults heightens the awareness of these potential disorders.
When sexual history questions lead the nurse to believe that the older adult is sexually active, especially with more than one partner, diagnostic testing should be conducted.
Symptoms of HIV among older adults mimic other disease symptoms and may include
Diarrhea
Enlarged lymph nodes
Fever
Flulike symptoms
Headache
Rash
Fatigue
Anorexia
Weight loss
Because HIV is often transmitted simultaneously with other STDs, the ELISA test may be used to diagnose the presence of the HIV virus.
If this test is positive, the Western blot test may be conducted to confirm HIV infection.
Viral cultures may be used to confirm HIV infection.
CD4 and viral load testing to measure the number of T helper cells helps to stage the disease.
Nursing interventions for older adults with HIV include
Maintenance of health and function
Medication administration and teaching
Antiretroviral agents and highly active antiretroviral agents (the use of three or more antiretroviral agents together)
Nucleoside/nucleotide reverse transcriptase inhibitors
Nonnucleoside reverse transcriptase inhibitors
Protease inhibitors
Fusion inhibitors
Teaching safe sex practices
Parkinson’s disease (PD) is one of the most common neurodegenerative disorders affecting the elderly population. It occurs in 1 of every 100 persons over the age of 60.
It is estimated that 3% of persons over the age of 65 have PD, suggesting that the occurrence of the disease increases with age.
Parkinson’s disease affects men more than women and Whites more than Blacks or Asian Americans.
Age is the primary risk factor for PD and so the disease is of concern among older adults.
PD is a neurodegenerative disorder of slow and insidious onset, where 70% to 80% of the dopamine-producing neurons in the brain are destroyed by the time symptoms are present.
The causes of PD have not been determined.
The roles of environmental toxins, poisons, viruses, and medications have been implicated in the development of PD, and these causes continue to be investigated.
Some medications—including chlorpromazine and haloperiodol as well as reserpine, methyldopa, and metacolpramide—have been linked to the development of PD symptoms.
There are no objective clinical markers for PD.
The diagnosis of PD is typically determined by the presence of three motor signs:
Tremor
Rigidity
Bradykinesia
In addition to these common signs and symptoms, clients with the disease may exhibit cues such as
Postural instability
Autonomic dysfunction
Drug-induced symptoms
Symptom management is the primary focus of nursing care. Psychological, social, and spiritual support are needed as the disease progresses.
Treatment of PD generally combines levodopa with carbidopa (Sinemet®).
Because levodopa competes with protein absorption from the small intestine, effective timing of medication is essential.
As symptoms progress, a client’s ability to perform activities of daily living decreases and the need for pharmacotherapy increases.
To avoid potential side effects, patients may choose nonpharmacological treatment options, delay medical treatment, and postpone potential discomfort from the unwanted side effects.
Physical and occupational therapy may help those with a shuffling gait. Focusing on the client’s balance abilities and providing assistive devices where applicable is recommended.
Nutritional therapy is also essential when caring for patients with Parkinson’s disease.
Immobility is a major contributor to constipation, and, therefore, it is important to assess the dietary needs of PD clients to prevent severe constipation.
Exercise is also extremely therapeutic for clients with PD. It decreases the risk of falls related to the disease and improves
Mobility
Flexibility
Overall function
Cerebral vascular accidents (CVAs), commonly known as strokes, are among the leading cause of chronic disability in the United States.
The risk of CVA increases sharply with age; approximately 75% of new strokes and 88% of stroke deaths occur among those aged 65 and older.
The symptoms of CVA include
Sudden-onset weakness or numbness in the face, leg, or arm on one side of the body
Changes in vision; the loss of vision in one eye
Difficulty speaking or understanding language
Sudden-onset severe headache and dizziness
Unexplained falls
Risk factors for the development of CVA are similar to those of other cardiovascular diseases.
Smoking
Alcohol abuse
Obesity
Diabetes
Hypertension
Advanced age
African American racial background
CVAs are caused by three distinct pathological processes that stem from risk factors for the disease.
Effective auscultation of the carotid arteries for bruits (the sound of turbulent blood flow) during routine health assessments greatly enhances the early detection of occlusions in the vasculature and facilitates stroke prevention.
A hemorrhage results when a blood vessel in the brain ruptures and part of the brain tissue dies.
Emboli, or clots that form in one area of the body, may travel to the brain and cause brain death.
The carotid arteries that carry oxygenated blood to the brain may become clogged and prevent blood flow, resulting in tissue death (ischemia).
Older adults with and without risk factors for the CVA sometimes experience “little strokes” or warning strokes called transient ischemic attacks (TIAs).
TIAs are manifested by lack of consciousness for a period of time lasting from 20 minutes to 24 hours.
Reports of TIAs should be accompanied by a full assessment and the identification of risk factors and symptomatology for CVA.
A plan of care to prevent strokes from occurring in patients with TIAs must be implemented immediately.
Prevention of CVAs generally involves the facilitation of adequate blood flow to the brain.
Carotid endarterectomy procedures are often implemented (cleaning plaque from the carotid artery) to enhance blood flow to the brain and reduce the chance of an embolus breaking off from the plaque and moving to the cerebral vasculature.
CVAs may be best prevented by implementing nursing interventions to reduce risk factors such as obesity and hypertension with
Diet and nutritional management
Exercise and weight reduction
Blood pressure management
Administration of daily aspirin
When symptoms of a stroke are present, diagnostic testing is conducted, including
Computed tomography scan
Carotid or cerebral angiography
Plasminogen activator, a clot-dissolving drug, may be administered immediately (within a few hours of symptom onset)
The plasminogen activator can dissolve clots that may have caused the stroke and quickly restore blood flow to the brain, but it is not effective in
Hemorrhagic stroke
Ischemic stroke
Nursing care for patients with CVA focuses on stabilization of the client and rehabilitation to the highest possible functional level
A decubitus ulcer, commonly known as a pressure sore or bed sore, results from prolonged pressure to an area of the skin against a bed or chair or from rubbing or friction.
One million new pressure ulcers are estimated to develop each year.
Both intrinsic and extrinsic risk factors result in the development of decubitus ulcers, including
Immobility (primary risk factor for development of decubitus/pressure ulcers
Infection
Incontinence
Dementia
Diabetes
Circulatory disorders
Vascular impairment
Edema
Impaired sensation
Transferring
High pressure surfaces
Sheering
Exposure to urine or feces
Circulation
Decubitus ulcers are classified according to the severity of the wound, usually in four stages or types (see Table 8.1)
The most effective nursing intervention for pressure ulcers is prevention
Assessment of risk factors (see Table 8.2) enables nurses to identify and implement preventative measures to avoid the development of these wounds
Preventative measures include
The use of pressure-relieving devices such as
Mattresses
Pads
Footwear
Proper body alignment—Rule of 30 or head of bed elevated 30 degrees
Regular and consistent skin assessment by knowledgeable nursing professionals with a reliable instrument will help to detect decubitus at an early, treatable stage (insert 8–4)
Turning and repositioning schedules
Eliminating risk factors for malnutrition and appropriate meal planning
Dietary supplements may be necessary for providing needed nutrition among chronically ill older adults
Pressure ulcer treatments include
Daily care with recommended products is implemented according to wound stage.
Stage one ulcers (nonblanchable erythema) are protected from further damage with good hygiene and pressure relief; transparent dressings may be used.
Stage two ulcers are characterized by partial thickness skin loss involving epidermis, dermis, or both and generally are treated with occlusive dressings and reevaluated at regular intervals.
Stage three ulcers are characterized by full thickness skin loss and deep craters with or without undermining; utilize normal saline or other product dressings.
Pressure Ulcer Staging System |
Pressure ulcer definition
A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are associated with pressure ulcers; the significance of these factors is yet to be elucidated.
Pressure ulcer stages
Suspected deep-tissue injury
Purple or maroon localized areas of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may begin as tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
Further description
Deep-tissue injury may be difficult to detect in individuals with dark skin. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.
Stage I
Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching, but its color may differ from the surrounding area.
Further description
The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage I may be difficult to detect individuals with dark skin. May indicate at-risk persons (a heralding sign of risk).
Stage II
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Further description
Presents as a shiny or dry shallow ulcer without slough or bruising.a This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.
Stage III
Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Stage IV
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Further description
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
Unstageable
Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Further description
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and, therefore, stage cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body’s natural (biological) cover and should not be removed.
Note. From Updated Pressure Ulcer Staging 2007, by the National Pressure Ulcer Advisory Panel, retrieved from http://www.npuap.org/pr2.htm; Copyright 2007, National Pressure Ulcer Advisory Panel, used with permission.
a Bruising indicates suspected deep-tissue injury.
Cataracts
Result from accumulation of particles in the lens of the eye
Have great impact on vision
Previously have been untreatable
Laser procedures to clear the lens and return vision to normal can be completed in approximately 1 hour and have few side effects
Glaucoma
Results from a pathological accumulation of pressure in the internal chamber of the eye
Requires the consistent use of pressure-relieving eye drops
Lower levels of lighting may be needed to promote patient comfort
Regular ophthalmological appointments for pressure readings are essential
Surgical interventions are available when necessary
High-pitched hearing loss that occurs commonly with aging.
Makes it difficult to hear higher-pitched voices, such as those of women and children.
Treatment is usually associated with amplifying sound with hearing aids.
Older adults sometimes do not like hearing aids because they are embarrassed about needing them and because they amplify all noises in the environment, further aggravating the hearing deficit.
Assess for cerumen impaction as a further complicating factor in the hearing impaired.
Face older adults when speaking to facilitate lip reading.
Do not shout.
Assess for the appropriateness of using alternate forms of communication, such as writing instructions.
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