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HEALTH ASS 305 ASSESSING THE OLDER ADULT,100% CORRECT

HEALTH ASS 305 ASSESSING THE OLDER ADULT As you well know, the population of the US is aging. The percentage of older patients (always high) is even... [Show More] higher now. Older adults present with unique needs as well as a more complex health picture. The old-old (>85) is the fastest growing segment of the population. 82% have at least one chronic condition. Age-associated changes are most pronounced in advanced age of 85 years or older, may alter the older person’s response to illness, show great variability among individuals, are often impacted by genetic and long-term lifestyle factors, and commonly involve a decline in functional reserve with reduced response to stressors. Age Related Changes: Cardiovascular • 1. Arterial wall thickening and stiffening, decreased compliance. • 2. Left ventricular and atrial hypertrophy. Sclerosis of atrial and mitral valves. • 3. Strong arterial pulses, diminished peripheral pulses, cool extremities. • Hartford Institute for Geriatric Nursing Gerontological changes: Are important in nursing assessment and care because they can adversely affect health and function. Must be differentiated from pathological processes to allow development of appropriate interventions; Predispose to disease, thus emphasizing the need for risk evaluation of the older adult; Can interact reciprocally with illness, resulting in altered disease presentation, response to treatment, and outcomes. Implications of the above changes: Decreased cardiac reserve. a. At rest: No change in heart rate, cardiac output. b. Under physiological stress and exercise: Decreased maximal heart rate and cardiac output, resulting in fatigue, shortness of breath, slow recovery from tachycardia. c. Risk of isolated systolic hypertension; inflamed varicosities. d. Risk of arrhythmias, postural and diuretic-induced hypotension. May cause syncope. Implications for assessment 1. ECG; heart rate, rhythm, murmurs, heart sounds (S4 common - The fourth heart sound can be detected occasionally by inspection, commonly by palpation and auscultation, Commonly, its presence indicates increased resistance to filling of the left or right ventricle because of a reduction in ventricular wall compliance; S3 in disease [can be normal in younger adults]) -). Third heart sound is a very important clue to heart failure or volume overload, it does not appear until the problem is relatively far advanced. The left lateral position is of critical importance because the S3 and S4 are often heard only with the patient turned to the side. 2. Palpate carotid artery & peripheral pulses for symmetry.1 2. Assess BP (lying, sitting, standing) and pulse pressure. 2 Age Related Changes: Pulmonary • 1. Decreased respiratory muscle strength; stiffer chest wall with reduced compliance. • 2. Diminished ciliary & macrophage activity, drier mucus membranes. Decreased cough reflex. • 3. Decreased response to hypoxia and hypercapnia. B. Implications 1. Reduced pulmonary functional reserve. a. At rest: No change. b. With exertion: Dyspnea, decreased exercise tolerance. 2. Decreased respiratory excursion and chest/lung expansion with less effective exhalation. Respiratory rate 12-24 breaths per minute. 3. Decreased cough and mucus/foreign matter clearance. 4. Increased risk of infection and bronchospasm with airway obstruction. C. Parameters of Pulmonary Assessment 1. Assess respiration rate, rhythm, regularity, volume, depth,1 and exercise capacity. 3 Auscultate breath sounds throughout lung fields.4 2. Inspect thorax appearance, symmetry of chest expansion. Obtain smoking history. 3. Monitor secretions, breathing rate during sedation, positioning,1,5 arterial blood gases, pulse oximetry.6 4. Assess cough, need for suctioning.7 Age Related Changes: Genitourinary • Decreases in kidney mass, blood flow, GFR (10% decrement/decade after age 30). Decreased drug clearance. • 2. Reduced bladder elasticity, muscle tone, capacity. • 3. Increased postvoid residual, nocturnal urine production. • 4. In males, prostate enlargement with risk of BPH. Implications 1. Reduced renal functional reserve; risk of renal complications in illness. 2. Risk of nephrotoxic injury and adverse reactions from drugs. 3. Risk of volume overload (in heart failure), dehydration, hyponatremia (with thiazide diuretics), hypernatremia (associated with fever), hyperkalemia (with potassium-sparing diuretics). Reduced excretion of acid load. 4. Increased risk of urinary urgency, incontinence (not a normal finding), urinary tract infection, nocturnal polyuria. Potential for falls. Parameters of Renal and Genitourinary Assessment Assess renal function (GFR through creatinine clearance). Assess choice/need/dose of nephrotoxic agents and renally cleared drugs.14(Assess for fluid/electrolyte and acid/base imbalances. 15 Evaluate nocturnal polyuria, urinary incontinence, BPH. 13 Assess UTI symptoms Assess fall risk if nocturnal or urgent voiding Age Related Changes: GI • 1 Decreases in strength of muscles of mastication, taste, and thirst perception. • 2. Decreased gastric motility with delayed emptying. • 3. Atrophy of protective mucosa. • 4. Malabsorption of carbohydrates, vitamins B12 and D, folic acid, calcium. • 5. Impaired sensation to defecate. • 6. Reduced hepatic reserve. Decreased metabolism of drugs. Implications 1. Risk of chewing impairment, fluid/electrolyte imbalances, poor nutrition. 2. Gastric changes: altered drug absorption, increased risk of GERD, maldigestion, NSAID-induced ulcers. 3. Constipation not a normal finding. Risk of fecal incontinence with disease (not in healthy aging). 4. Stable liver function tests. Risk of adverse drug reactions. Parameters of Oropharyngeal and Gastrointestinal Assessment 1. Assess abdomen, bowel sounds. 2. Assess oral cavity); chewing and swallowing capacity, dysphagia (coughing, choking with food/fluid intake). 17If aspiration, assess lungs rales) for infection and typical/atypical symptoms. 3. Monitor weight, calculate BMI, compare to standards. Determine dietary intake, compare to nutritional guidelines. 4. Assess for GERD; constipation and fecal incontinence; fecal impaction by digital examination of rectum or palpation of abdomen. Age Related Changes: Musculoskeletal • Sarcopenia with increased weakness and poor exercise tolerance. • 2. Lean body mass replaced by fat with redistribution of fat. • 3. Bone loss in women and men after peak mass at 30 to 35 years. • 4. Decreased ligament and tendon strength. Intervertebral disc degeneration. Articular cartilage erosion. Changes in stature with kyphosis, height reduction. Sarcopenia is the age-related decrease in muscle mass and strength 1. Sarcopenia: increased risk of disability, falls, unstable gait. 2. Risk of osteopenia and osteoporosis. 3. Limited ROM, joint instability, risk of osteoarthritis. Age Related Changes: Neurological • 1. Decrease in neurons and neurotransmitters. • 2. Modifications in cerebral dendrites, glial support cells, synapses. • 3. Compromised thermoregulation. 1. Impairments in general muscle strength; deep-tendon reflexes; nerve conduction velocity. Slowed motor skills and potential deficits in balance and coordination. 2. Decreased temperature sensitivity. Blunted or absent fever response. 3. Slowed speed of cognitive processing. Some cognitive decline is common but not universal. Most memory functions adequate for normal life. 4. Increased risk of sleep disorders, delirium, neurodegenerative diseases. C. Parameters of Nervous System and Cognition Assessments 1. Assess, with periodic reassessment, baseline functional status. During acute illness, monitor functional status and delirium. 2. Evaluate and periodically assess cognitive function. 3. Assess impact of age-related changes on level of safety and attentiveness in daily tasks. 4. Assess temperature during illness or surgery. Age Related Changes: Immune System • Immune response dysfunction with increased susceptibility to infection, reduced efficacy of vaccination, chronic inflammatory state. Follow CDC immunization recommendations for pneumococcal infections, seasonal, influenza, zoster, tetanus, hepatitis for the older adult Atypical Presentation of Disease • 1. Diseases especially infections may manifest with atypical symptoms in older adults. • 2. Symptoms/signs often subtle include nonspecific declines in function or mental status, decreased appetite, incontinence, falls, fatigue, exacerbation of chronic illness. 5 • 3. Fever blunted or absent in very old, frail or malnourished adults. Baseline oral temperature in older adults 40 is 97.4 °F (36.3 °C) versus 98.6 °F (37 °C) in younger adults . 1. Note any change from baseline in function, mental status, behavior, appetite, chronic illness18. 2. Assess fever; Determine baseline and monitor for changes; 2–2.4 °F (1.1–1.3 °C) above baseline16. Oral temperatures above 99 °F (37.2 °C) or greater also indicate fever18. 3. Note typical and atypical symptoms of pneumococcal pneumonia16,19,41, tuberculosis33,influenza16,UTI16, peritonitis39, and GERD42. Atypical Presentation of Illness: Infection • Absence of fever • Sepsis without usual leukocytosis and fever • Falls, decreased appetite or fluid intake, confusion, change in functional status Considering the frequency of infections in older adults, more often affecting the urinary tract, the respiratory tract, the skin or the GI tract, an infection should be suspected with any change in condition, including falls, a decrease in food or fluid intake, confusion, and/or a change in functional status For example, a patient with Pneumonia would typically present with fever, cough with sputum production and SOB. Elderly may not have any of these symptoms but present with confusion, malaise, anorexia. UTI typical presentation: burning on urination, frequency, hematuria. Atypical presentation would not have any of these but could present as confusion, incontinence, and anorexia. Atypical Presentation of Illness: MI • Absence of chest pain • Vague symptoms of fatigue, nausea and a decrease in functional status. • Classic presentation: shortness of breath more common complaint than chest pain Most myocardial infarctions in older adults do NOT present with clinical symptoms such as chest pain. Clinicians need to be astute to patients at risk who present with vague symptoms of fatigue, nausea, and a decline in functional status. When patients do present with a more classic picture of an acute event, a more common complaint than chest pain is shortness of breath. Symptoms that may Indicate Impending Major Illness in Older Patients CONFUSION APATHY SELF-NEGLECT ANOREXIA FALLING DYSPNEA INCONTINENCE FATIGUE It is essential to take reports seriously from patients, family and non-professional care providers as to subtle symptoms such as mild confusion, changes in ability to perform activities of daily living (ADL), and decreased appetite. Timely identification of acute illnesses with vague presentation enables early treatment of illness resulting in reduced morbidity and mortality and an enhanced quality of life in older adults. CHALLENGES OF ASSESSING THE OLDER ADULT • Atypical disease presentation • Extensive medical histories • Communication/Sensory deficits Older adults may have more chronic health problems. cluster of health problems may complicate your assessment. Keep in mind that the most frequently occurring conditions reported in older adults are hypertension, arthritis, heart disease, cancer, diabetes, and sinusitis. • Older adults may mistake a health problem for a normal part of aging. Consequently, patients may not report symptoms that they believe to be normal. For example, an older man may assume that frequent nighttime voiding is a normal part of aging when it could indicate benign prostatic hyperplasia (BPH) or another medical condition. Frequent nighttime voiding can also be linked to use of certain medications, such as diuretics. • Older patients are more likely to develop cognitive problems when experiencing acute and chronic illnesses. For example, confusion and cognitive impairment frequently occur with infection and polypharmacy. Never interpret confusion as a normal sign of aging. Any sudden change in cognition (occurring over hours or a few days) may signal an acute, reversible condition. Special Assessment Considerations ▪ Extra time is usually needed ▪ Help patient into the exam room ▪ Dressing and undressing ▪ Address by last name ▪ Ask one question at a time ▪ Allow adequate response time ▪ Repeat questions and confirm answers Special Assessment Considerations ▪ Patient is the primary source of information ▪ Use medical records, family and friends for clarification ▪ Establish a caring relationship ▪ Start with questions that focus on orientation and past information ▪ Use common lay language Subjective data collection • Special needs • Impaired hearing • Visually impaired • Aphasia • Alzheimer’s or related  MMSE FOCUS AREAS • Mobility • Medications • Nutrition • Acute and persistent pain • Sexuality • Urinary incontinence & skin breakdown • Smoking and alcohol • Risk for falls MOBILITY • Activities of daily living • Basic self-care activities • Bathing • Dressing • Toileting • Feeding • Transferring • Instrumental activities of daily living o Higher level functions ▪ Shopping ▪ Preparing food ▪ Housekeeping ▪ Laundry ▪ Taking medicine ▪ Managing money ▪ Driving MEDICATIONS • Experience more side effects from medications due to the smaller size and decreased functioning of the liver and kidneys • Poly-pharmacy • Visual impairment may cause mistakes • Ask if they know why they are taking a medication • OTC-vitamins, herbs, minerals, cold preparations • Should bring meds to clinic or hospital for staff to see RISK FOR FALLS • History • Medications • Gait or muscular weakness • Dizziness, vertigo, or loss of consciousness a time of fall • Visual changes • Environmental problems • Major illnesses Environmental Structure and Hazards • Stairs • Accessibility of the bathroom and kitchen • Help with kitchen and household activities • Assistive devices • Referrals NUTRITION • Assessing for risk • Finances, transportation • Functional & sensory deficiencies  Taste changes  Poor fitting dentures  Weight loss  Depression • 1/3 with deficiencies Acute and persistent pain • 80% of clinic visits • MS, joint, back pain • Less likely to report pain • Fear of extra cost • Extra treatment • Fear of progression of disease • Lead to depression, social isolation, physical disability • Use visual analog pain scale Urinary incontinence • Do not report due to embarrassment • May believe is normal part of getting old • Many risk factors • Age, limited mobility, caffeine intake, impaired cognition, prostate enlargement, diuretics, DM, stroke SEXUALITY • “Tell me about your sex life” • Loss of lifetime partner • Sex education • Use of condoms • STD SMOKING AND ALCOHOL • Harmful, risk for heart & pulmonary disease • 10% have alcohol related problems • Increase # of the elderly with drinking problems • Detecting alcohol use • Memory loss • Depression, anxiety, change in hygiene/appearance • Impaired gait • Malnutrition CURRENT HEALTH STATUS • Reason for seeking treatment “chief complaints” • May be over lapping • Set priorities • Use open ended questions PAST HEALTH HISTORY • Obtain a comprehensive medical history • Known problems • Specific diseases • Hospitalizations • Childhood illnesses (missed school or in bed for extended periods) ex. Rheumatic fever COMMON OLDER AGE SURGERIES • Cataract surgery • Joint replacements • Removal of skin lesions • GB, appendix, uterus, or prostate • Obvious scars FAMILY HISTORY • Mortality • Alzheimer’s • Familial conditions • HTN • Heart disease • Diabetes • Cancer • Drug/alcohol addiction • Mental illness Family history will give indications of diseases patient is at risk for. ROS • Perform usual review and focus on problems that are prevalent in the older adult COMMON SYMPTOMS • Incontinence • Sleep • Pain • Cognitive changes • Depression • Injuries caused by elder abuse SUPPORT SYSTEMS • Personal and community support • Types of interactions (phone calls and visits) ADVANCE DIRECTIVES AND PREFERENCES FOR CARE • 1990 Patient –Determination Act • Gives patients choice regarding health care interventions. • Nurses are at the forefront of these discussion. SCREENING AND PREVENTION • Pneumonia • Mammogram • Prostate Exam (Rectal and PSA) • Fecal occult Blood • Cholesterol • Depression “Do you feel sad or depressed” Physical Assessment • Friendly environment • Warm room • Minimum background noise • Higher than standard seating, with arm rests • Broad based- step stools • Minimize position changes • Only uncover the part being examined. • Make safety a priority • Explain what you are doing GENERAL SURVEY • Appearance, hygiene, emotional status • Posture and gait– senile kyphosis • Skin lesions • SOB • Vital signs, ht and weight In oldest patients, subQ tissue is lost, giving a more angular appearance. Posture generally more flexed. Gait may change with wider stance and smaller steps. Pulse rate remains unchanged at rest. Adjustments to activity may be slow. Maximum heart rate is decreased. Returns to normal more slowly. Respirations often slightly higher than for younger adults. Temperature slightly lower than in young adults. Integumentary • Graying of hair • Thinning of hair and balding • Hirsutism • Coarse, dry hair, • Flaky scalp • Nails yellow, dry, ridges, fungal infections • Decreased turgor ,bruising, dermatitis An aging-related decline in melanin production makes the hair less vibrant in color, leading to graying. Also, the hair thins; many older adults lose their hair altogether. Dermal vascular beds diminish with age as well, altering hair distribution patterns. Some men are genetically predisposed to baldness and may experience hair loss at younger ages. Assessing the nails Regardless of the patient’s age, nail surfaces normally are flat or slightly curved. Note their color, length, and cleanliness. Check for abnormalities. Clubbing may indicate a cardiac or pulmonary disorder; pitting and transverse groves may signify peripheral vascular disease, arterial insufficiency, or diabetes. Brittleness may stem from decreased vascular supply, whereas yellow or brown nails may signal a fungal infection. Wrinkled skin results from loss of elasticity and turgor. With age, the skin gradually thins and loses density, making it more susceptible to bruising and tears. Inspect the skin for lesions and moles. Check for pressure ulcers. Pressure ulcers are most common on the sacrum, heels, and trochanters. Preventable and stem primarily from decreased mobility and activity, insufficient caloric intake, and incontinence. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses for care related to hospital-acquired pressure ulcers, so clinicians must be able to quickly identify at-risk patients and implement preventive strategies. COMMON SKIN LESSIONS • Solar Lentigines (liver spots) • Actinic keratosis (rough precancerous) • Seborrheic keratosis (benign pigmented waxy lesions on face and trunk) When examining moles, look for irregular shapes; ask the patient if any moles have gotten bigger or changed color. Positive findings indicate the need for further evaluation by a primary care provider or dermatologist. Keep in mind that excessive sun exposure exacerbates aging-related changes and may lead to skin cancers such as melanoma. LENTIGINES (LIVER SPOTS) ACTINIC KERATOSIS SEBORRHEIC KERATOSIS HEENT • Decreased peripheral vision • Presbyopia • Dry eyes • Arcus senilis • Xanthelasma • Senile ectropion and entropion • Smaller pupils, retina and optic disc paler Note whether the patient’s eyes, eyebrows, nose, and mouth are centered and symmetrical. Asymmetrical features suggest a stroke. Look for appropriateness of affect and behavior. [Show Less]

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