Geriatrics 2

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Gerontology: -Specialization of care of the elderly
-Emphasis placed on:
*promoting and maintaining functional status
*promoting independence
*maintaining dignity
Social Security: -"Old age insurance"
-Allow choices about what happens after retirement
-To improve quality of life
Medicare: -Added to the SS act of 1935
-Provides health care to those over 65
*part A: inpatient care, skilled nursing and long term care
*part B: (optional to those who pay for it) MD services, outpatient services, and durable medical equipment
Medicaid: -AKA Medi-Cal
-Provides medical care for all ages on welfare or medically indigent (MIA)
-State and federally funded
Omnibus Budget Reconciliation Act: -States that each resident in long term care be at his/her highest practice level of well-being
-Accredits and reviews long term care facilities
SPICES: -Used for geri assessment
-S: skin inpairment
-P: poor nutrition
-C: cognitive impairment
-E: evidence of falls
-S: sleep disorders
Erikson: -Ego integrity vs despair
-Ego differentation versus role preoccupation
-Body transcendence versus body preoccupation
Disengagement Theory: -Society and the individual gradually withdraw, or disengage, from each other
-The individual becomes centered on themselves and freed form societal roles
Activity Theory: -Individual continues a middle-aged lifestyle, denying the existence of old age as long as possible
-Maintaining activity in the presence of losses i.e when retirement occurs, establishing new friendships to replace the role of work
Continuity Theory: -Basic personality does not change. Patterns developed over lifetime will determine whether individual remains active
-Recognition of the unique features of the individual all for adaptation to aging
Physiological Changes: -Circulation:
*thickening of walls of blood vessels
*Narrowing of the lumen of vessels
*Loss of vessel elasticity
*Lowering cardiac output
-Oxygenation:
*rigidity of chest wall
*fewer aveoli
-Mobility and Activity:
*Decreased muscle mass with more fat cells
*Decalcification of bones
*Degenerative bone changes
-Nutrition:
*Periodontal disease (loss of teath)
*Decrease in digestive secretions
*Food intolerances
-Skin Integrity:
*loss of subcutaneous fat layers
*decreased number of sweat glands
*intolerance to heat and cold
nails become thickened
-Urinart Elimination:
*decreased renal blood flow
*less bladder capacity, sphincter control
-Regulation (endocrine):
*decreased insulin
*women lose the ability to bear children
*men's sperm count diminishes
-Sensation and Perception:
*learning occurs slowly
*degree of recent memory loss
*decreased proprioception
-Vision:
*pupils decrease in size, admit less light
*decreased accommodation, lens darken
-Hearing:
*thickening of the tympanic membrane
*sclerosis of inner ear
-Smell: degerneration of olfactory bulb decreases ability to smell
-Touch: decrease in skin receptors
-Taste: fewer taste buds on tongue and mouth
Cognitive Changes: Depression: -S/S: insomnia, fatigue, anorexia, weight loss
-SIG:
*S: sleep disturbances
*I: interest decreased
*G: guilty feelings
-Decreased Energy: CAPS
*C: concentration
*A: appetite decreased or increased
*P: psychomotor function decreased
*S: uicidal ideations
Treatment for Depression: -Antidepressants: takes 6wks to work
-Herbs: St John's Wart should not be taken with other antidepressants
-Offer hope
-Encourage the expression of feelings
-Ensure physical needs are met
Cognitive Changes: Delirium: -Various symptoms that impair cerebral circulation
-Onset is rapid
-S/S:
*disorientation x2
*altered attetion span
*labile mood
*poor judgement
*altered LOC
*disturbance of sleep patterns
-Detecting confusion early is imperative
-Reversible usually caused by dehydration, electrolyte imbalance, or hyperglycemia
Cognitive Changes: Dementia: -Progressive deterioration of intellect not part of the normal aging process includes: memory, language, cognition, and mood disturbances and can effect ability to perform ADLs
-Gradual onset
-Irreversible
Cognitive Changes: Alzheimers Disease: -Most common cause of dementia
-Likelihood of developing doubles every 5 years after age of 60
-Brain atrophies neurofibrillary tangles seen in the cortex
-Develops progressively at different rates
-Early:
*trouble identifying people
*indecisive
*forgets nouns
*declining interest in life
*increased suicide rate
-Late:
*unable to retain simple directions
*deterioration of motor ability
*major communication problems
*mood swings
Cognitive Changes: Oter Dementias: -Multi-infarct dementia
*caused by small cerebral infarctions
*damage to brain tissue diffuse
-Creutzfeldt-Jacob
*Mad cow disease
*rapid neurological impairment
*transmitted through slow virus
-Pick's Disease
*atrophy of lobes of the brain
Treatment: -Provide Care: FOCUS
*F: face to face
*O: orient frequently
*C: continue to care
*U: unsticking
*S: structure/safety
*E: exchange feelings
*D: direct approach
-Treat symptoms: sedaives (resperidol)
-Slow Progression: aricept, hydrochloride, tacrine, anti-parkinsons, ginkobilboba
-Family support
5 As: -Amnesia: memory loss (short term)
-Anomia: inability to remember things, names
-Apraxia: use things in the wrong way
-Agnosia: inability to recognize common objects, sensations
-Aphasia: can't express self through speech
Functional Status: ADLs: -BATTED:
*B: bathing
*A: ambulation
*T: toileting
*T: Transferring
*E: eating
*D: dressing
Functional Status: Instrumental ADLs: -SCUM:
*S: shopping
*C: cooking/cleaning
*U: use telephone & transportation
*M: managing money & meds
Nursing Interventions Related To Falls: -Eliminate environmental and personal risks that contribute to risk
-Participate in fall prevention programs
-Educate on the correct use of assistive devices
-Review select medication use & educate as needed
-Assess for changes in vision, balance, & coordination, mobility, and mentation
-Conduct osteoporosis prevention education
-Encourage regular physical exercise
-Counsel on proper nutrition and weight control
Parkinson's Disease: -Progressive neurological disorder affecting brain centers thta control movement
-S/S: bradykinesia
*resting tremors
*muscle weakness
*mask-like facial expression
*shuffling gait
-Treatment:
*Levodopa (a dopaminergic) therapy given in combo with carbida to prevent levodopa breakdown
*antihistamine to allay tremors
*dopamine agonists
*anticholinergic to control rigidity
*MOA inhibitors
Osteoarthritis: -Degenerative joint disease
-Most common disabling joint disorder
-S/S:
*pain and stiffnes
*functional impairment
*bony nodules may be present
-Treatment:
*NSAIDs
*tylenol
*intraarticular injections of steroids
*heat
*weight reduction
*orthotic devices
Nutrition: -Basic nutrition needs same as other adults
-Caloric needs decrease d/t:
*older body less mass increase in adipose tissue
*do not burn as many calories
*decreased activity level
*reduced carbs and fats
*1 gram protein per Kg needed
Medications: -OA is most at risk for toxicity d/t polypharmacy (interactions of several durgs)
-Increased risks d/t pharmokinetics and pharmodynamics
Pharmokinetics: -Decreased intracellular fluid: effects distribution
-Increased % body fat: fat soluble drugs include morphine, digoxin, tagament, and lithium
-Increased gastric pH: decreased enzyme
-Decreased cardiac output: effects distribution
-Decreased kidney function: effects secretion
-Increased half life of med
-Less albumin to bind with med: effects distribution (dilantin, calcium-channel blockers, coumadin, lasix)
Pharmodynamics: -Increased adverse reactions (including toxicity)
-S/S: may be different for different drugs
-Adverse reaction may not occur until after the med is discontinued (due to half-life increased)
Digoxin: -Most common drug complication
-S/S of toxicity:
*GI: n/v, weakness, anorexia
*CNS: headache, blurred or yellow vision, confusion
*Cardiac: arrhythmias
-Therapeutic blood levels available
-Excreted by the kidneys
-Water soluble
Pharmodynamics Side Effects: -Diuretic Therapy: dehydration, weakness
-Corticosteroids: fluid retention, psych symptoms, increased blood surgar
-Sleep Meds: excessive sedation
-Over The Counter: avoid OTC use
Admin of Medications to Older Adult: -Why is drug being ordered
-Is the smallest dose being prescribed
-Any allergies
-Any drug interactions
-Special instructions
-Most effective route
-Use Micromedix to print out drug info for pt
-Destroy unused drugs
-Use one pharmacy if possible
-Use multi-day despensers
Elder Abuse: -Inflicting pain or injury
-Stealing
-Mismanaging funds
-Misusing funds
-Withholding food
-Misusing meds
-Sexual abuse
-Confinement
-State law requires notification of authorities
Pt Self Determination Act: -By law pt must be asked if they have an advanced directive
End Of Life Care: -Provision of palliative care
-Control of symptoms
-Principle of Double Effect
-Withholding/withdrawing treatment
-Hospice Care
Palliative Care: -To relieve the symptoms of without fixing or repairing the underlying condition
-Increasing quality of life for terminally ill pt
Principle of Double Effect: -Dealing with one problem but causing another
-Example: giving morphine for pain but causing respiratory depression
Power of Attorney: -Authorizes a person to act on behalf of the pt
Durable Power of Attorney: -Authorizes a person to act on behalf of the pt if the pt becomes incompacitated
Advanced Directives: -Legal protection for patients rights and wishes
Living Wills: -Describe preferences if unable to make decisions
Hospice Care: -All requires advance care planning
-Eligibility:
*Serious progressive illness
*Limited life expectancy
*Informed choice of palliative care
Community Resources: -Home Care: episodic or ongoing
-Assisted Living: combination of housing and personalized health care, max independence
-Adult Day Care
-Meals on Wheels
-Long Term Care:
*only 5% of population are in long term facilities
*most residents have one or more chronic illness
Retinal Detachment: -Refers to seperation of the retinal pigment epithelium (RPE) from the sensory layer
-A tear occurs in the sensory retina and allows liquid vitreous to seep through the sensory retina and cuase detachement
-Shade or curtain coming across vision, cobwebs, bright flashing lights, or floaters
-Treatment: includes surgically attempting to reattach the retina to the RPE
Conjunctivitis: -AKA pink eye
-perulent drainage from eye
-higly contagious
-Caused by bacteria, or allergic reaction
-Prevention: good handwashing
-Tx: antibiotics, antihistamine
Fluid in the Eye: -Aqueous Humor: anterior humor (nurtures eye)
-Vitreous Humor: inside the eye (behind the lens, gel-like)
Tears: -Consist of three layers
*Lipoid
*Aqueous
*Mucoid
Optical Nerve: -Cranial Nerve II
-Transmits impulses from the retina to the occipital lobe
Myopia: -Near-sightedness: image is focused in front of the retina
-Laser surgery best for this type of refractive error
Hyperopia: -Far sightedness: image is focused in back of retina
Astigmatism: -A condition that occurs when the front surface of the eye (the cornea) is slightly irregular in shape. This irregular shape prevents light from focusing properly on the back of the eye (the retina). As a result, vision may be blurred at all distances.
Blindness: -Legally blind: 20/200
-Absolute Blindness: 20/400 to no light
-BCVA: Best Corrected Vision Acuity
Ptosis: -Drooping of eye lid
Hystagmus: -Oscillating movement of the eye
Assessment Tools: -Ocular History
-Visual Acuity: Snellen Chart
-External Eye Exam
-Are pupils: equal, reactive, round, accomidating
-Direct Ophthalmoscopy: to look into the eye (deep look into), allows views of different layers of eye
-Fluorescein Angiography: vasculation of the eye, important for diabetics, detects bleeding of the retina, helps identifiy macular degeneration, may impart a gold tint to the skin and color urine orange for 24 hours
-Tonometry: intra-ocular pressure test (used for glaucoma), normal 10-21mmHg
Glaucoma: -A group of ocular conditions characterized by optic nerve damage
-Optic nerve damage related to IOP caused by congestion of aqueous humor in the eye
-One of the leading causes of irreversible blindness
-Preventable, painless, permanent
-Normal angle between iris and cornea is 45 degrees
Glaucoma Stages: -Initiating events: illness, emotional stress, congenital narrow angles, long term use of corticosteroids
-Structural alteration in the aqueous outflow system
-Functional alterations: increased IOP or impaired blood flow
-Optic Nerve Damage: atrophy of the optic nerve
-Visual loss
Glaucoma S/S: -blurred vision
-halos around lights
-difficulty focusing or adjusting eyes in low lighting
-loss of peripheral vision
-headache
-by the time pt is experiencing these symptoms damage is permanent
Glaucoma Assessment: -Tonometry: to measure the eye IOP
-Opthalmoscopy: to inspect the optic nerve
-Gonioscopy: to examine the filtration angle of the anterior chamber
-Perimetry: to assess the visual fields
-Cupping of optic nerve are tale-tale signs
-Glaucoma pts see as if looking into a tunnel
Open Angle Glaucoma: -Caused by aging, usually seen in both eyes
-OPEN:
*O: occasionally see halos or tunnels around light
*P: peripheral vision goes first/painless
*E: early stages are asymptomatic/ enlarged optic cup
*N: not an emergency
Glaucoma Medications: -olol= beta blocker
-BAHM:
*beta blockers: reduces production of aqueous humor
*A: anhydrase inhibitor: decreases rate of formation of fluid (acetagolamide)
*H: hyperosmotics: reduces rate of formation of fluid (mannitol)
*M: miotics (cholinergics): facilitates outflow (pilocarpine)
Closed Angle Glaucoma: -Onset is immediate, comes on right away and is very painful
-Angle becomes closed for some reason
-Most likely seen in only one eye
-Emergency situation
-Laser type procedure to open angle up
Cataracts: -A lens opacity or cloudiness
-Leading cause of blindness in the world
-Can happen at any age
-S/S: sensitivity to glare and decrease in visual acuity, irregularity in the pupil, sometimes double vision
-Treatment: removal through surgery, intraocular lens implant
-Increased Risk: myopia, diabetes rect, aging
-Complications: infection, mobility, pt should not stoop over, they should sleep on unaffected eye, wear sunglasses, and/or eye patch for first 24 hours then qhs for 3days to 2 wks
-6-12 weeks for vision to return
Macular Degeneration: -+ amsler test (will see wavey lines)
-Loss of central vision, most pts retain peripheral vision
-Causes are unknown, growth of blood vessels leak blood and fluid
-Tx: laser surgery to try to close up vessels
*Photodynamic therapy: dye in IV (verteporfin), pt needs to wear dark sunglasses and cover body d/t UV sensitivity for several wks
Eye medications: -Miotics: constricts eye (cholinergics)
-Mydriatics: dilate eye (atropine)
-Cycloplegics: paralysing (epi)
Ocular Trauma: -Chemical Burn: flush eye
-Trauma: assessing vision, pupil reaction, patch both eyes because they move together
Eye Diseases and S/S Overview: -Glaucoma: tunnel or halo
-Cataracts: blurred vision
-Retinal Detachment: curtain or cobwebs
-Macular Degeneration: black spot in central vision

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