HESI Gerontology Study Guide
HESI Gerontology Study Guide
Gerontologic Nursing HESI Study Guide
• Healthy aging is now an achievable goal for
... [Show More] many.
• Aging and disease are separate entities.
• Aging is an individual process that affects each person differently.
• The chronologic age of 65 is the standard in the United States for being considered an older adult (elderly).
• By 2050, one in five Americans will be over the age of 65.
• The concept of aging is further defined as young-old (65 to 74), middle-old (75 to 84), old-old (over 85), elite-old (over 90), centenarian (over 100), and super-centenarian (110 and over).
• Eighty percent of people over the age of 70 have at least one chronic condition, and 50% have multiple health problems.
Theories of Aging
1. Psychosocial Theories:
a. Disengagement Theory: Progressive social disengagement occurs naturally with aging and is accepted by the older adult. Variation in disengagement across older populations is related to cultural style and behaviors in different geographic regions.
b. Activity Theory: Successful again requires a high level of activity and involvement to maintain life satisfaction and positive self – esteem.
2. Biologic Theories:
a. Pacemaker Theory: A programmed decline or cessation of many concepts occurs in the nervous and endocrine systems.
b. Immunity Theory: A programmed accumulation of damage and decline of the immune systems’ function (immunosenescence) takes place due to oxidative stress.
c. Wear-and-Tear Theory: After repeated use, damaged cells in the body structures wear out from the harmful effects of internal and external stressors, now known as free radicals.
HESI Hint
The concept of aging is shifting from viewing older adults as frail and dependent to being able to engage in healthy living. The majority of those aged 65 and older regard their health as good or excellent. The ability to perform activities of daily living (ADLs) is a more accurate measure of an older person’s age than chronologic age.
3. Developmental Theories:
a. Erik Erikson’s Theory: Theory identifies 8 stages of developmental tasks throughout the life span; 8th stage is integrity versus despair
b. Maslow’s Theory: Maslow’s hierarchy of needs ranks an individual’s needs from the most basic to the most complex. Maslow uses the terms physiologic, safety and security, belonging, self-esteem, and self-actualization needs to describe the process that generally motivates individuals to move through life.
Physiologic Changes
• Aging effects every cell in every organ of the body, but not at the same rate
• Three physiologic changes are clinically significant in making older adults vulnerable to injury & disease:
o Loss in compensatory reserve (making up for a loss in physiological compensation; vital signs)
o Progressive loss in efficiency of the body to repair damaged tissue
o Decreased functioning of the immune system processes
• Diseases in older adults do not always present with classic signs and symptoms
• Physiologic changes increase more rapidly with increasing age
• Aging changes are influenced by genetic makeup & environment
HESI Hint
NCLEX-RN questions may ask about teaching and designing rehabilitation programs for older adults. The answers should contain information about exercise and nutrition.
Integumentary System: Skin, hair, and nail changes occur with aging and can cause problems concerning discomfort and self-esteem.
• Thin Skin provides a less effective barrier to trauma due to a loss of subcutaneous tissue.
o Increased risk for dehydration due to decline in lean mass & loss of body water
o Decreased ability of the skin to detect and regulate temperature
o Dry skin resulting from a decrease in endocrine secretion
o Loss of elastin & increased vascular fragility
• Keratinocytes become smaller and regeneration slows; wound healing is slower.
• Hair loss occurs; women have increased facial hair
• Vascular hyperplasia causes more varicosities (brown or blue discolorations)
• Increased appearance of “age spots” and/or “liver spots” and raised lesions (seborrheic keratosis)
• Nails becomes brittle & thick.
Nursing Assessment
1. Skin dryness & tears
2. Nails for changes in shape, color, and brittleness
3. Lesions to differentiate normal from abnormal;
4. Bony prominences for signs of pressure ulcers
Nursing Plans & Interventions
A. Encourage the use of oils or lubricants on the skin at least twice a day.
B. Discourage the use of powder, which can be drying.
C. Teach to avoid overexposure to sunlight.
D. Encourage balanced nutrition and increased fluid intake.
E. Teach to maintain adequate humidity in the environment.
F. Teach to avoid temperature extremes.
G. Teach good foot care.
H. Observe bony prominences for signs of pressure.
I. Teach that poor peripheral circulation may slow the healing of foot and hand lesions.
HESI Hint
The NCLEX will test your ability to differentiate normal and pathologic causes of skin and hair conditions; for example, the differences between seborrheic keratosis and melanoma.
Musculoskeletal System: Age-related changes in the musculoskeletal system are gradual but have a significant impact on levels of mobility, which puts older adults at risk for falls and fractures.
• The Musculoskeletal system is composed on bones, joints, tendons, ligaments, and muscles.
• Age – related changes are not life threatening, but can affect function & quality of life.
• Bone loss begins around age 40 and is more common in women than in men; thus; osteoporosis occurs more often in women.
• Shortening of the trunk (torso) due to thinning of the vertebral disks.
• Loss of bone calcium, atrophic (decrease in size) cartilage and muscle occurs.
• Bone mineral density (BMD) decreases, resulting in osteopenia and osteoporosis.
• Range of motion (ROM) of joint decreases.
• Progressive loss of cartilage occurs, resulting in osteoarthritis.
• Muscle cells are lost and not replaced.
• Lean body mass decreases with increased body fat.
Nursing Assessment
1. Dietary intake of calcium and vitamin D
2. Weight; underweight or overweight
3. Lifestyle habits; inappropriate nutrition, smoking, and inadequate exercise
4. History of fractures
5. ROM
6. Pain and chronic pain management strategies
Nursing Plans & Interventions
A. Teach that adequate calcium intake may help lessen osteoporotic changes.
B. Establish muscle-strengthening program (small weights, aquatic therapy).
C. Prevent accidents by ensuring a clutter-free, safe environment.
D. Provide adequate lighting day and night to prevent falls.
E. Teach clients not to back up but to turn around to move in the direction they wish to go.
F. Teach clients to walk looking straight ahead instead of looking down at their feet to optimize balance.
G. Encourage regular exercise inclusive of balance, weight-bearing, and low-resistance training.
H. Teach to avoid excessive joint strain.
I. Teach that medications (diuretics and sedatives) may contribute to falls.
a. The following are ways to help prevent or decrease the occurrence of falls:
i. Install adequate lighting.
ii. Install grab bars in bathtubs.
iii. Wear proper footwear that supports the foot and contributes to balance; shoes should be made of nonslippery materials.
iv. Place a bell on any resident cats; cats move quickly and can get underfoot.
v. Paint the edges of stairs a bright color.
J. Discourage excessive alcohol intake and encourage smoking cessation.
K. Encourage older people to change positions slowly to prevent orthostatic hypotension.
Nursing Plans & Interventions for Osteoporosis
A. Create a hazard-free environment.
B. Keep bed in low position.
C. Encourage client to wear shoes or nonskid slippers when out of bed.
D. Encourage environmental safety.
1. Provide adequate lighting.
2. Keep floor clear.
3. Discourage use of throw rugs.
4. Clean spills promptly.
5. Keep side rails up at all times.
E. Provide assistance with ambulation.
1. Client may need walker or cane.
2. Client may need standby assistance when initially getting out of bed or chair.
F. Teach regular exercise program.
1. ROM exercise several times a day
2. Ambulation several times a day
3. Use of proper body mechanics
4. Regular weight-bearing exercises promote bone formation
G. Provide diet that is high in protein, calcium, and vitamin D; discourage use of alcohol and caffeine.
H. Encourage preventive measures for females.
1. Hormone replacement therapy (HRT) has been used as a primary prevention strategy for reducing bone loss in the postmenopausal woman. However, recent studies demonstrated that HRT may increase a woman’s risk of breast cancer, cardiovascular disease, and stroke. If using HRT, the benefits should outweigh the risks.
2. Take prescribed medications to prevent further loss of BMD.
a. Bisphosphonates: inhibit osteoclast-mediated bone resorption, thereby increasing BMD. Common side effects are anorexia, weight loss, and gastritis. Instruct the client to take with full glass of water, take 30 minutes before food or other medications, and remain upright for at least 30 minutes after taking.
1. Alendronate (Fosamax)
2. Etidronate (Didronel)
3. Ibandronate (Boniva)
4. Pamidronate (Aredia)
5. Risedronate (Actonel)
6. Tiludronate (Skelid)
b. Selective estrogen receptor modulator: to mimic the effect of estrogen on bone by reducing bone resorption without stimulating the tissues of the breast or uterus. The most common side effects are leg cramps and hot flashes.
1. Raloxifene (Evista)
2. Teriparatide (Forteo)
3. High calcium and vitamin D intake beginning in early adulthood
4. Calcium supplementation after menopause (Tums are an excellent source of calcium).
5. Weight-bearing exercise
I. Dual-energy x-ray absorptiometry (DEXA), which measures bone density in the spine, hips, and forearm, as a 119 baseline after menopause, with frequency as recommended by health care provider
J. Osteopenia is defined as bone loss that is more than normal and has a T-score less than or equal to a range of −1 to −2.5 but is not yet at the level for a diagnosis of osteoporosis. BMD is commonly reported as a “T-score,” which is the difference between the client’s BMD and the BMD of “young normal adults” of the same gender. The difference between the client’s score and the young adult norm is expressed as standard deviation below or above the average.
HESI Hint
Postmenopausal, thin, white women are at highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium, and supplemental calcium. Tums are an excellent source of calcium, but they are also high in sodium, so hypertensive or edematous individuals should seek another source of supplemental calcium. The main cause of fractures in older adults, especially in women, is osteoporosis. The main fracture sites seem to be hip, vertebral bodies, and Colles fracture of the forearm.
HESI Hint
Impaired mobility, impaired skin integrity, decreased peripheral circulation, and a lack of
physical activity place older adults at risk for the development of pressure ulcers.
Cardiovascular System
• Age – related changes in the cardiovascular system predispose the older person to the development of dysrhythmias and other cardiac problem
• Cardiac Output decreases as a result of a decrease in HR and stroke volume.
• Cardiac output decreases because vessels lose elasticity. The heart’s contractability decreases in response to increased demands.
• Diastolic murmurs are present in more than ½ of older adults because the mitral and aortic valves become thick and rigid.
• Dysrhythmias (bradycardia, tachycardia, atrial fibrillation, and heart block) become more come as one ages, in part of higher systolic blood pressure and the increased size of the atria.
o Dysrhythmias in older adults are particularly serious because older people cannot tolerate decreased cardiac output, which can result in syncope, falls, and transient ischemic attacks (TIAs). The pulse may be rapid, slow, or irregular in this population.
• Significant increases in systolic BP occur as a result of altered distribution of blood flow and increased peripheral resistance.
• Arteriosclerosis increases with age and can cause cardiovascular problems.
o Peripheral Vascular Disease
o Edema
o Coronary artery disease: acute coronary insufficiency, myocardial infarction, dysrhythmias, heart failure (HF)
• Much heart disease is preventable.
Nursing Assessment
1. BP and vital signs
2. History of dizziness or blackouts with sudden position change (orthostatic hypotension)
3. Diuresis after lying down
4. Feelings of heart palpitations
5. Angina
a. Angina symptoms may be absent in older adults. They can also be confused with gastrointestinal (GI) symptoms.
6. Swelling in hands and feet (rings and shoes have become tight)
7. Weight gain without changes in eating pattern
8. Difficulty breathing at night (without elevation of the head of the bed). Confusion and personality changes can result from oxygen deficit.
Nursing Plans & Interventions
A. Monitor BP in lying, sitting, and standing positions.
B. Encourage frequent rest periods to avoid fatigue.
C. Encourage regular, low-impact exercise.
D. Teach to change positions slowly to avoid falls and injuries.
E. Take apical and radial pulse; note deficits or rhythm abnormalities.
F. Teach to avoid extreme hot and cold because of decreased peripheral sensation.
G. Teach to avoid sitting with feet in a dependent position.
H. Assess edema: Weigh daily if indicated.
I. Encourage strict adherence to medication regimen.
J. Teach not to stop medications without prior approval from health care provider.
K. Determine support system for follow-up.
Respiratory System
• Older adults have increased demands for oxygen. The life span of an older adult increases the chance for exposure to toxic or infectious agents. Due to the aging process, multiple exposures over time can be damaging to the lungs and even life threatening.
• Major age – related changes to the respiratory system:
o Breathing mechanics: lungs lose elasticity; muscles become rigid and lose muscle mass and strength.
Declining muscle strength may impair cough efficiency. This fact makes older people more susceptible to chronic bronchitis, emphysema, and pneumonia.
o Oxygenation: Increased ventilation and perfusion are imbalanced; increased dead space in the lungs and a decrease of alveolar surface area.
o Ventilation control: decreased reaction of peripheral and central chemoreceptors to hypoxia and hypercapnia (excessive CO2 in blood stream).
o Immune response: decrease of cilia; decreased ability to clear mucus secretions, decreased ability to cough and deep breathe, and decreased immune response.
o Exercise capability: decrease of strength and muscle in body.
o Breathing ability: decreased reaction to hypoxemia and hypercapnia.
Nursing Assessment
1. Confusion (may be the first sign of respiratory infection)
2. Vital signs for elevated temperature, BP
3. Lungs for congestion or atelectasis
4. Vital capacity
5. Dyspnea and fatigue
6. Cough reflex and sputum production
HESI Hint
Chronic obstructive pulmonary disease is the major cause of respiratory disability in older adults. Aspiration pneumonia is a major cause of death in older adults.
Nursing Plans & Interventions
A. Encourage clients to receive an influenza vaccine yearly.
B. Encourage clients to receive the pneumonia vaccine after age 65 (a second dose may be given one additional time after about 5 years).
C. Remember that hypoxia can manifest as confusion.
D. If the client is a smoker, encourage him or her to stop. (Regardless of age, cardiovascular and respiratory status improves with smoking cessation and exercise.)
E. For older postoperative clients, turning, deep breathing, and use of incentive spirometer are imperative to prevent complications.
F. Encourage deep breathing. Teach breathing techniques such as pursed-lip breathing to facilitate respirations.
Gastrointestinal (GI) System
• Age – related changes are bothersome and can affect comfort, function, and quality of life, but are rarely a direct cause of death
• Decreased saliva and dry mouth (xerostomia) are common.
• Dental caries (tooth decay) and loss of teeth increase, resulting in decreased ability to chew food.
• Hunger sensations decrease due to diminishing taste buds.
• Relaxation of the lower esophageal sphincter or a sliding hiatal hernia increase the risk of gastroesophageal reflux disease and aspiration.
• The production of pepsin and hydrochloric acid decreases.
• Delayed gastric emptying makes digestion of large amounts of food difficult
• Decreased peristalsis and decreased absorption in the small intestine of protein, fats, minerals (calcium), vitamins b1 &b2, and carbohydrates contribute to constipation problems. Decreased muscle tone of the colon also causes constipation.
• Decreased enzyme production in the liver affects drug metabolism and detoxification processes.
• Decreased enzyme production in the liver affects drug metabolism and detoxification processes.
• Weight changes, especially weight loss, can be early indicators of health problems.
Nursing Assessment
1. Brittle teeth due to thinning enamel
2. Receding gums resulting from periodontal disease (the major cause of tooth loss after the age of 30)
3. Decrease in taste sensation and appetite
4. Dry mouth due to a decrease in saliva production
5. Elimination pattern for evidence of constipation or diarrhea
6. Poor tolerance of high-fat meals and poor absorption of fat-soluble vitamins
7. Decreased glucose tolerance
8. Fluid intake
9. Weight changes
Nursing Plans & Interventions
A. Encourage good oral hygiene (the use of a soft toothbrush, dental floss, and regular dental visits).
B. Assess dentures for proper fit.
C. Educate older clients about hidden sodium (canned soups, antacids, over-the-counter medications).
D. Promote adequate bowel functioning.
a) Determine what is normal GI functioning for each individual.
b) Encourage client to increase fiber and bulk in the diet.
c) Provide adequate hydration.
d) Encourage regular exercise.
e) Encourage eating small, frequent meals.
f) Discourage the use of laxatives and enemas.
g) Document bowel movements: frequency and consistency.
HESI Hint
Older people may appear to eat small quantities of food at mealtimes. This is because the digestive system of older people features a decrease in the contraction time of the muscles, resulting in more time needed for the cardiac sphincter to open. It takes more time for the food to be transmitted to the stomach; thus, the sensation of fullness may occur before the entire meal is consumed.
Genitourinary System: There are functional and structural changes, as well as psychosocial changes, in the older adult pertaining to the urinary system.
Kidney
• Size and weight of the kidney decrease due to reduced renal tissue growth.
• Glomerular filtration rate decreases due to a decrease in renal blood flow resulting from lower cardiac output. Decreased renal clearance of drugs is the result.
• Tubular function diminishes.
• Increased risk for reflux of urine into the ureters.
• Chronic diseases such as atherosclerosis and hypertension also decrease renal functioning in older adults.
Nursing Assessment
A. Signs of dehydration or electrolyte imbalance
a. Decreased skin turgor (tenting)
b. Intake/output
c. Confusion
d. Concentrated urine
e. Medications such as diuretics
B. Laboratory values
a. Proteinuria
b. Increased blood urea nitrogen and creatinine
c. Presence of blood in urine
Nursing Plans & Interventions
A. Encourage an intake of at least 2 to 3 liters of fluid daily, if not contraindicated.
B. Instruct client about signs and symptoms of dehydration and to contact health care provider immediately.
C. Instruct client about the importance of completing antibiotics until the entire prescription is gone, even if symptoms go away.
D. Write out antibiotic schedule, including any special instructions. Print in large letters.
Bladder
• The capacity of the bladder decreases by one-half, resulting in urinary frequency and nocturia.
• Emptying the bladder may become difficult because of a weakening of the bladder and perineal muscles and because of a decrease in sensation of urge to void. (This sets up a propensity for urinary tract infections [UTIs] due to residual urine in the bladder.)
• Increased frequency and dribbling may occur in men because of a weakened bladder and an enlarged prostate.
• Prostatic enlargement may cause urinary retention and bladder infection in men.
• Women may experience stress incontinence.
• The nurse should monitor intake and output to assess renal function.
• A decrease in the filtration efficiency of the kidneys has grave implications for people who are taking medication, particularly penicillin, tetracycline, and digoxin, which are cleared from the bloodstream primarily by the kidneys.
o These drugs remain active longer in an older person’s system.
o As people age, the total number of functioning glomeruli decreases until renal function has been reduced by nearly 50%.
o Drug levels may be more potent, indicating a need to adjust/reduce the dose and frequency of administration.
Nursing Plans & Interventions
1. Initiate a bladder-training program if indicated.
2. Encourage older women to void at first urge when possible.
3. Initiate a skin-care program if incontinence is present.
4. 295
5. Provide methods of dealing with incontinence. Kegel exercises can help.
a. Kegel exercises consist of tightening and relaxing the vaginal and urinary meatus muscles.
6. Teach to avoid sleeping pills and sedation, which may cause nocturnal incontinence.
7. Teach to avoid caffeine because it promotes diuresis.
a. Caffeine inhibits the production of antidiuretic hormone (ADH).
HESI Hint
Older adults may be embarrassed because they are incontinent. They may seek isolation, thereby predisposing themselves to loneliness.
Reproductive System
• Age-related changes are related to hormonal and nervous system control.
• Unless there is a medical condition, women do not have difficulty maintaining sexual function as they age.
o Women’s ovarian function decreases; breast tissue involutes.
o Ovaries and the uterus slowly atrophy, and neither may be palpable.
o Perineal muscle weakness and atrophy of the vulva occur with age.
o Vaginal mucous membrane becomes dry, elasticity of tissue decreases, surface becomes smooth, and secretions become reduced and more alkaline. May lead to dyspareunia (painful intercourse).
o Libido may or may not decline.
Many older adults are sexually active or maintain an interest in sexual activities; therefore, nurses should obtain a sexual assessment among older women and men in the acute care, community, and long-term care settings.
• Age-related changes
o Testes atrophy, lose weight, and soften.
o Erection changes are seen.
o Prostate enlargement due to changes in testosterone levels
o Libido may or may not decline.
• Older men may still experience orgasmic pleasure. For older men, the most common physiologic changes are
o An erection that is less firm
o Shorter duration of erection
o Diminished force of ejaculation
• The term for male menopause is andropause. Diminished testosterone is believed to be the cause of androgen decline in the aging male (ADAM).
Nursing Assessment: Women
1. Vital Signs (temperature), discharge, or labial or vulvar redness and pruritus for possible infections (vaginitis).
2. Complaints of hot flashes, mood swings, or night sweats
3. Dyspareunia (painful intercourse)
Nursing Assessment: Men
1. Complaints of urinary problems; prostate enlargement
2. Testosterone hormone levels
Nursing Plans & Interventions: Women
A. Teach client signs of vaginitis; report and treat if present.
B. Promote perineal care as needed.
C. Prescription creams can help with vaginal dryness.
D. Encourage client to obtain mammogram per guidelines.
Nursing Plans & Interventions: Men
A. Encourage annual digital examination for early identification of prostate cancer.
HESI Hint
Sexually active older adults are at risk for sexually transmitted diseases if they seek sexual relations with different partners.
Neurologic System: Neurocognitive disorders (DSM-5) are the major cause of disability in older adults. Dementia, cerebrovascular disorders, and movement disorders.
• The nervous system is the most complex of all systems and functions alone and in conjunction with many systems.
• There is a decrease of neurons and neurotransmitters in the brain, which do not regenerate.
• The neurologic system consists of two main components: the central nervous system (CNS) and the peripheral nervous system (PNS): decrease in both CNS and PNS functioning.
• Intelligence remains constant in the healthy older adult.
• Central processing decreases; performance of tasks is slower.
• PNS changes in aging people may include the following:
o Significantly lower or nonexistent vibratory senses in the lower extremities
o Decrease of tactile sensitivity
o Loss of connection in nerve endings in the skin
o Loss of proprioception, affecting balance
• Sleep disturbances
o Shorter stages of sleep, particularly shorter cycles in stages 3 and 4 and rapid-eye-movement sleep (stage 4 is deep sleep).
o Easily awakened by environmental stimuli. Older adults often compensate by napping during the day, which leads to further disruptions of night sleep.
A common response is the use of prescription sleeping pills, which can create still further problems of disorientation, etc.
Nursing Assessment
1. Comprehensive functional assessment; weaknesses, tremors, and gait disturbances
2. History of falls
3. Pain, headaches, ROM, and neuropathies in extremities
4. Sudden changes in vision, cognition, and muscle weakness
5. Depression
6. Sleep Patterns
Nursing Plans & Interventions
A. Perform a complete mental status examination.
B. Screen for depression.
C. Screen for cognitive impairment.
D. Monitor for conditions caused by lack of sleep.
a. Fatigue, confusion, disorientation
E. Monitor BP and hydration status.
F. Request physical and occupational service evaluations, if indicated.
G. Provide assistive devices as needed for ambulation.
H. Encourage walking, ROM, and balance exercises.
I. Teach individual relaxation techniques, stress management, and adaptive self-care management.
J. Minimize potential sources of injury in the environment.
K. Educate family and caregivers about support groups and other resources (agencies).
Nursing Plans & Interventions: Communicating with Older Adults
A. Address client with respect: “Good morning, Mrs. Jones.”
B. Orient the client to the purpose and length of the interview.
C. Give the older adult time to respond because verbal response slows with age.
D. Choose words based on the client’s sociocultural background and formal education; do not use slang or jargon (Fig. 8.1).
E. Keep questions short and to the point.
F. Give nonverbal cues and responses such as nodding and direct eye contact; avoid patting or stroking the client.
G. Active listening validates the older person. Reminiscence is an excellent way to obtain data about the client’s current health problems and support systems (Fig. 8.2).
H. To help cognitive losses due to alcohol consumption, smoking, and breathing polluted air, the nurse should teach older clients to shop during less crowded times in stores that are familiar to them, slow down well in advance of traffic signals, stay in the slower lane of the freeway, avoid freeways during rush hours, and leave for appointments well ahead of time.
Figure 8.1
I. Discuss the problems family members have in dealing with clients with Alzheimer disease in relation to the following disease manifestations:
1. Depression
2. Night wandering
3. Aggressiveness or passiveness
4. Inability to recognize family members
Endocrine System: In the older adult, glands atrophy and decrease the rate of secretion. The impact is unclear, except it is more prevalent in women than in men due to the decline of estrogen, which causes menopause.
• Consists of the thyroid, parathyroid, pituitary, adrenal, and pineal glands; the thymus; and the endocrine pancreas
• Thyroid activity decreases (see “Hypothyroidism (Hashimoto Disease, Myxedema)” in Chapter 4: Medical-Surgical Nursing). Symptoms are commonly undiagnosed in the older adult because they are attributed to being “normal for age.”
• Metabolic rate slows.
• Estrogen production ceases with menopause; ovaries, uterus, and vaginal tissue atrophy.
• Gonadal secretion of progesterone and testosterone decreases.
• Insulin production decreases or insulin resistance increases.
• Thyroxine (T4) and triiodothyronine (T3) secreted by the thyroid gland remain unchanged with aging; however, their metabolic clearance rate is decreased. Production of parathyroid hormone decreases, which is made evident by osteoporosis.
• Adrenal changes may affect circadian patterns of adrenocorticotropic hormone (ACTH).
Nursing Assessment
1. Signs & Symptoms of diabetes in older adults; dehydration and confusion
2. History of recurrent infections, fatigue, and nausea; delayed wound healing; paresthesia
3. Weight loss or gain without change in eating pattern
4. Laboratory values; hemoglobin A1c, aldosterone, and cortisol levels
5. Bone density testing
6. Sleeping pattern
7. Depression
Nursing Plans & Interventions
A. Encourage thyroid testing for older clients who seem depressed. Hypothyroidism is often dismissed as depression.
C. Older clients may have difficulty with lifelong medication regimens. Develop memory cues for medications and caution against abrupt withdrawal.
E. Encourage annual physical examination with routine laboratory tests.
F. Encourage annual eye examinations.
G. Teach daily foot care and monthly toenail care.
HESI Hint
The most common endocrine disorders in the older adult are thyroid dysfunction and type 2 diabetes.
Sensory System: The sensory system consists of vision, hearing, taste, touch, and smell. Changes in the sensory system, including balance, occur gradually and are often unnoticed.
• A loss of cells in the olfactory bulb of the brain and a decrease in sensory cells in the nasal lining occur.
• Sensitivity to smells declines.
• Taste perception decreases due to loss of taste buds on the tongue.
• Tear production decreases.
• Abnormal, progressive clouding or opacity of the lens in the eyes occurs (cataracts).
• A partial or complete white ring encircles the periphery of the cornea (arcus senilis).
• Increases intraocular pressure (IOP), usually bilaterally, leads to optic nerve damage (glaucoma).
• Hearing of high pitches diminishes first; the ability to discriminate tones is lost (presbycusis).
Nursing Assessment
1. Assess visual and hearing acuity, as well as glasses and/or hearing aids used
2. Eyes for cloudiness or opacity
3. Ears for wax & hearing loss
4. Evaluate dietary intake for unplanned weight loss and salt and sugar intake.
Nursing Plans & Interventions
A. Provide interventions to supplement loss of sensory input.
B. Encourage social interaction.
C. Make the client’s environment as safe as possible to increase orientation and decrease confusion.
D. Maximize visual and nonvisual aids, such as bright colors, large print for written material, recorded books, lighted mirror, and glasses, if applicable.
E. Encourage the use of hearing aids with frequent battery changes, if applicable.
a. The nurse should use a lower tone of voice when talking to an older person who is hearing impaired.
i. High-pitched tones (e.g., women’s voices) are the first to become difficult to hear.
F. Encourage the use of glasses and frequent cleaning, if applicable.
a. Diminished eyesight results in the following:
i. A loss of independence (driving and the ability to perform ADLs)
ii. A lack of stimulation
iii. The inability to read (recommend audiotapes)
iv. The fear of blindness
G. Encourage the use of artificial tears; teach to avoid rubbing and touching of the eyes (increases risk for infection).
H. Encourage regular eye examinations.
I. Directly face hearing-impaired clients so they may read lips and view facial expressions.
J. Adapt ethnic favorites to dietary and taste limitations.
K. Use frequent touch to compensate for visual and auditory sensory loss and decrease the sense of isolation.
a. The nurse should make the older adult aware that he or she is going to touched and should therefore ask permission before touching the client. The nurse should be cognizant of cultural differences with direct eye contact, touch, and taste.
L. Educate the client’s support system about interventions to maintain a safe and comfortable environment.
Neurocognitive Disorder (NCD): Dementia: Dementia is the permanent, progressive impairment in cognitive functioning manifested by memory loss (both long term and short term) and accompanied by impairment in judgment, abstract thinking, and social behavior.
• Dementia is characterized by the following:
o Personality changes
o Confusion
o Disorientation
o Deterioration of intellectual functioning, loss of memory
o Decline of appropriate judgment and ADLs
o Difficulty performing familiar tasks
o Misplacing things
o Problems with abstract thinking
o Changes in mood or behavior
• The four As of cognitive impairment are agnosia, amnesia, apraxia, and aphasia.
• Types of dementia
o Alzheimer disease: The brains of individuals with Alzheimer disease have an abundance of beta amyloid plaques, 298 neurofibrillary tangles, and atrophic brain cells and tissue. Alzheimer disease is the most common brain disorder and is one of the leading causes of death in the older adult.
o Vascular or multifocal dementia: Ischemic brain lesions develop as a result of a history of hyperlipidemia, hypertension, smoking, or obesity.
o Dementia with Lewy bodies (DLB): Microscopic deposits develop in the brain that damage nerve cells.
o Frontotemporal dementia (Pick disease): The frontal and temporal lobes of the brain degenerate.
Nursing Assessment
1. Memory complaints: short term/long term; recognition of family, friends, or environment
2. Impaired physical functioning: shuffling, difficulty swallowing, and inability to perform ADLs
3. Conditions that mimic dementia
4. Unrecognized medical conditions
a. Acute infection (UTI), dehydration (electrolyte imbalance), medication, pain, and metabolic disorder.
Nursing Plans & Interventions
A. Administer screening tools for depression and cognitive impairment.
B. Keep the client functioning and actively involved in social and family activities for as long as possible.
C. Maintain an orderly, almost ritualistic, schedule to promote a sense of security.
D. Maintain a regularly scheduled reality orientation on a daily basis.
1. Keep the client oriented as to time, place, and person (repeatedly).
2. Keep a calendar and clock within sight at all times.
i. Display a calendar and clock that can be read by the older person (i.e., a clock with large numbers and a calendar that can be read by those with deteriorating vision).
ii. Be sure the date and time are accurate (i.e., keep the calendar current and the clock in working order).
E. Keep familiar objects, such as family pictures, in the older adult’s environment to promote a sense of continuity and security.
F. Administer prescribed drugs to reduce emotional lability, agitation, and irritability or prescribed antidepressant, as indicated.
G. Speak in a slow, calm voice; avoid excitement.
H. Redirect the client who exhibits combative behavior.
I. Educate family and caregivers on safe home environment.
J. Provide support and education to family and long-term caregivers.
K. Encourage end-of-life planning, including a will, do not resuscitate status, power of attorney, and funeral arrangements.
HESI Hint
The major task of old age, according to Erikson, is to redefine self in relation to a changed role. Some people who had been in charge of situations most of their lives may now find themselves in dependent positions, whereas others may continue to function independently.
Psychosocial Changes
Loss
• Loss includes loss of functional ability, decreased self-image, and death of significant others (family members, friends, or pets).
• Loss is a universal, incontestable event of the human experience.
• Regardless of the loss, each event has the potential to cause grief and the process called bereavement or mourning.
• Grief is an individual response and is different depending on social and cultural norms.
• Losses may be compounded (e.g., relocation, loss of support network, economic changes, and/or role changes), causing bereavement overload.
o Losses can make the older adult prone to emotional and mental stress, depression, and substance abuse.
Nursing Assessment
1. Any loss or losses
2. The older adult’s day-to-day functioning (eating and sleeping and work or social patterns).
3. Level of depression and suicide risk
4. The support system in place to assist with loss
5. Ability to express emotions related to the loss or losses
6. Any feelings of uselessness and nonparticipation in social events
7. Any loss of income that affects health care needs and quality of life
8. New or increased alcohol consumption on a daily or weekly basis
9. Past coping styles used with past losses
Nursing Plans & Interventions
A. If needed, refer to grief counseling or a support group.
B. Encourage activities that allow the individual to use past coping strategies that will promote a feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminiscing about significant life experiences.
HESI Hint
Think about how the following situations affect the clients and discuss the nursing care for each:
• A nursing supervisor has a stroke and is sent to a long-term facility for rehabilitation.
• An oil company executive retires after 42 years with the company and travels in his recreational vehicle with his wife and dog.
• Shortly after their 60th wedding anniversary, a man’s wife has a cerebrovascular accident and is paralyzed.
Health Maintenance & Preventative Care
Nursing Plans & Interventions
• Encourage periodic health appraisal and counseling to prevent illness.
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