3/27/2003 Mary Roache, RN, MSN, CS 1

The Well Older Adult

Mary Roche, RN, MSN, CSMary Roche, RN, MSN, CS

Community College of Rhode IslandCommunity College of Rhode Island

4/19/234/19/23

3/27/2003 Mary Roache, RN, MSN, CS 2

Credits

• Materials for this presentation are based on:

– Fundamentals of Nursing - Caring and Clinical Judgement by Helen Harkreader, PhD, RN. - Copyright 2000 by W.B. Saunders Company

• This presentation was built for and is the copyrighted property of Mary Roche, RN.

• This presentation is publicly available for viewing under the Web Developments section at http://www.stacyhouse.com

3/27/2003 Mary Roache, RN, MSN, CS 3

Course Objectives 1. After studying this chapter you should be able to:

• Describe the older adult by stages of life and demographics.

• Discuss factors affecting health in older adults.

• Describe modifications of the health history and physical examination for the older adult.

• Discuss nursing diagnoses relevant to health maintenance for the older adult.

• Plan for goal-directed interventions for health maintenance of the older adult.

• Evaluate outcomes that describe progress toward the goals of health maintenance.

3/27/2003 Mary Roache, RN, MSN, CS 4

Concepts Of Older Adult

Many people use the term 'elderly' when describing an older person, especially when that person is frail, chronically ill, and in need of assistance from others.

Here we prefer the term 'older adult' and will use it to describe any adult over 65.

Many people now live healthy, productive lives well into their 80s.

When aging is viewed in the context of normal human development and not in the framework of abnormal decline, older adults can be seen as experts in the field of living.

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Concepts Of Older Adult

Successful aging can then be appreciated as a process of creating a positive relationship with the self as we physiologically and psychosocially experience growth, change, and loss.

Biological effects of age do cause people to redefine health goals with each decade.

Most people do not fear old age itself, but do fear the infirmity that can accompany old age.

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Concepts Of Older Adult

Though approximately 85% of older adults have some chronic health problem, most do not define themselves as ill.

Nursing care for the older adult is aimed at

helping clients maintain or improve this perceived level of wellness, and

at forestalling the effects of chronic illness for as long as possible.

Factors Affecting Older Adults

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Nutrition and Fluids

Nutritional status has a large impact on the older adult’s overall health. Almost 5 million older Americans suffer food insecurity, in which the household does not always have adequate food.

Do not assume that if a family is above poverty level that they have adequate food.

Several factors can contribute to poor nutritional status in the older adult. Included can be:

poor oral health;

use of multiple medicines that can alter absorption of food

reduced mobility that can make food preparation a challenge.

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Activity and Exercise

Regular exercise promotes appetite, mental health and balance.

Regular exercise helps to decrease stress.

Proper assessment is needed to match the older adult to appropriate exercise.

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Alcohol Abuse

Studies suggest that about 3 million older adults are affected by alcoholism.

It is frequently difficult to detect alcohol abuse.

This is especially true of older adults who require less alcohol to achieve higher blood alcohol concentrations than when then were younger.

Teach the client to avoid drinking alcohol when taking any medications.

Alcohol can interact with medications and alter the way then are metabolized.

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Sleep and Rest

Older adults need 5 to 7 hours of sleep daily. As age increases, so can the need for rest periods throughout the day.

Age related changes that can affect a person’s ability to sleep at night include nocturia, muscle cramps, and anxiety.

The length of Stage 4, the deep and restful sleep, may decrease with age.

Environmental Factors

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Cultural And Religious Factors

Culture and ethnic origins are more likely to be important influences in older adults, especially when the older adult is a first generation American.

Aging people have lived as the people they are for a long time.

In the context of the assessment you can determine the strength of the client’s affiliation to an ethnic group.

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Socioeconomic Factors

The present generation is the most financially secure group of older adults in our nation’s history.

Due to economic boom following WWII.

Enhanced by Medicare (starting in 1965).

More than three-fifths of people ages 65 and older depend on Social Security to provide half or more of their income.

About 12% of non-institutionalized population over 55 lives below the poverty level.

Rising cost of medical care and medications is unpredictable.

Physiological Factors

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Chronic Illness

Chronic illnesses such as arthritis, hypertension, heart disease and diabetes can be major concerns for older adults.

Most older adults have at least one chronic disease.

Even so, 51% of all older adults are not limited in their self-care by the disease process.

The goals for older adults who have chronic illness are to:

maintain self-care,

prevent complications,

delay decline, and

achieve the highest possible quality of life.

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Sensory Deficits

Visual changes with aging include a decrease in visual acuity and accommodation, the ability to focus at various distances.

Pupils may become less responsive to light, reducing ability to see well in dimly lit areas or at night.

Cataracts, or clouding of the lens, are a common age-related change.

Glaucoma, also common in the older adult, is a degenerative disease of increasing intraocular pressure that arises when aqueous humor is unable to drain properly from the anterior chamber of the eye. Glaucoma can lead to optic nerve damage if left untreated.

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Sensory Deficits

Yearly checks of intraocular pressure should be encouraged for all people age 40 and older, but especially for African-Americans, who have a high risk for this condition.

Hearing loss is not a normal part of aging. However, it is not uncommon to gradually lose the ability to hear high-frequency sounds.

When an older adult fails to answer your questions appropriately, suspect hearing loss.

When talking with the person, face her and use short, direct phrases while you assess her hearing acuity.

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Cognitive Development

Cognitive performance is difficult to predict because of the many factors that must be considered.

Tests show that typically intelligence does not decrease with age.

Two validated tools to assess cognitive function are Mini-Mental State Evaluation developed by Folstein, Folstein, and McHugh (1975), and the Short Portable Mental Status Questionnaire developed by Pfeiffer (1975).

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Cognitive Development

What has been documented is that healthy older adults do not demonstrate a decline in such intellectual abilities as wisdom, judgment, and common sense.

They may have a slight, gradual decline in short-term memory, calculation ability, word fluency, and abstraction beginning at about age 60.

Older adults can learn new skills, but it may be at a slower rate.

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Mobility Concerns

Normal aging does not necessarily limit mobility.

Remaining active throughout one’s life is a way to maintain healthy movement in old age.

As a person ages, gait changes can result from changes in muscles and joints. Muscle strength, flexibility, stability, and cognition are some of the factors that contribute to mobility.

When illness affects any of these factors, mobility may decline and the risk of falls may arise.

Falls cause about one-third of serious illnesses in people over age 75. They are the primary cause of femoral neck fractures.

Among clients who fracture a hip as a result of a fall, only about half of those walking independently before the fracture can do so after surgical repair.

Psychosocial Factors

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Self-concept and Self-image

Ageism is a stereotype, prejudice, or discrimination against people, especially older adults, based on their age. It is a very narrow definition.

Constant ageist statements about oneself or one’s age cohort is a sign of low self-esteem.

Encourage self-expression about individual strengths and weaknesses.

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Roles and Relationships

Work is a large part of how people define themselves and construct their self-esteem. Now it is not unusual to spend 20 years as a retiree.

Other roles take on significance; being a grandparent for example.

For the older adult the role of spouse changes and long marriages can bring satisfaction as well as challenge.

The death of a spouse is a common consequence of a long life and one of the most stressful passages for the older adult.

Assess a bereaved widow or widower who feels unable to live without the deceased spouse for dysfunctional grieving.

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Depression

Depression, although not a normal part of aging, is the most common problem in older adults.

Estimates claim that 10-65% of people over age 60 have depressive symptoms at some time during their old age.

The incidence is higher among nursing home residents than among older adults who live in the community.

Because depression commonly occurs simultaneously with other diseases, it can be overlooked.

Depressive disorders may cause or contribute to medical illness.

A possible source of depression is drug therapy. When assessing for depression and its causes, make sure you take a thorough drug history.

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Coping Strategies

Older adults have strategies in place to cope.

You must assess the coping skills of the client and provide support as the client utilizes strategies to cope with stress.

Only if a client cannot successfully handle a situation alone will you step in to help her strengthen her weaknesses so she can overcome her restrictions.

Allow the client as much participation as possible.

Assessment of the Older Adult

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General Assessment

Before undertaking an assessment of an older adult, it is important to establish a trusting relationship.

Prepare the environment to promote the client’s comfort.

The purpose of the assessment is to identify strengths and limitations so you can plan nursing interventions to optimize function and independence.

Focus on function.

Structure questions to elicit functional data.

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Health History

Review behaviors the client uses to adapt to changes.

Take a history of the person’s lifetime health seeking behaviors.

Assess for the physical and social resources needed to maintain health.

Assess for past health history that is important to understanding the current health status.

Functional assessment identifies the older adult’s strengths and weakness in the activities of daily living.

These include the activities involved with eating, grooming, dressing, toileting, mobility, social interaction, and problem solving.

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Physical Examination

Head and neck

Cognitive function

Cardiovascular function

Respiratory function

Musculoskeletal function

GI function

Bowel function

Urinary function

Sexual function

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Head and Neck

As you perform the exam you may see age related changes such as retraction of the gingivae, atrophy of taste buds.

These changes can lead to loss of teeth and loss of taste.

Determine the client’s ability to swallow without choking.

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Cognitive Function

Measuring should be done carefully.

Testing of older adults should be done to accommodate age.

Older adults need a quiet, well lit, and temperate environment with no distractions.

The environment should be non-threatening to decrease anxiety.

Observe for confusion.

In an older adult, it can signify the presence of an infection even before body temperature changes.

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Cardiovascular function

Because of thickening and stiffening of the system more time is needed for the maximum heart rate to return to its resting rate.

Cardiac output may be reduced during stress.

Blood vessels become more rigid which can increase the systolic blood pressure.

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Cardiovascular Function

Because of thickening and stiffening of the system more time is needed for the maximum heart rate to return to its resting rate.

Cardiac output may be reduced during stress.

Blood vessels become more rigid which can increase the systolic blood pressure.

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Respiratory Function

Age-related changes in the older adult include

increased airway resistance,

a decreased exchange of oxygen and carbon dioxide, and

decreased strength in the accessory muscles.

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Musculoskeletal Function

Age-related changes in bones include a loss of bone mass and density.

As they age, muscles become smaller and have decreased numbers of fibers.

Slower movements are the result of prolonged contraction and relaxation time.

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GI Function

Age-related gastrointestinal changes may include inflammation of the gastric membrane from drug treatments.

This can lead to ulcers or gastritis.

Colon’s muscular strength decreases.

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Bowel Function

Assessment of the abdomen may reveal loss of tone.

Decreased muscle tone in the colon may result in hypoactive bowel sounds.

Assess for an abdominal mass in the left lower quadrant suggesting constipation.

The elderly are also more prone to diverticulitis.

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Urinary Function

Urinary incontinence is not a normal age-related change in the older adult.

When taking history check the client’s daily pattern of urinating (amount, times, frequency, or whether incontinence occurs).

3/27/2003 Mary Roache, RN, MSN, CS 40

Sexual Function

Interest in sexual function does not necessarily decrease as a person ages.

Focused Assessment For Altered Health Maintenance

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Assessment

Assess the older adult for current knowledge of health care.

The onset of chronic disease suggests that the older adult could benefit from changing health practices.

Assess for health seeking behaviors.

To what extent does the older adult believe she can improve?

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Assessment

Assess the client’s ability to adapt to a changing environment.

Is the client involved in learning new things to provide resources for change? (e.g., using a computer or driving).

Assess for the resources to manage health.

Does the client need financial help or does she have interpersonal relationships to buffer stress?

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Diagnosis

There may be justification for more specific nursing diagnoses that will need to be managed to be able to effectively resolve Altered Health Maintenance

Examples include:

Ineffective coping

Spiritual distress

Dysfunctional grieving

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Planning

Planning is an integral part of the care plan.

For the client with Altered Health Maintenance the goal is for her to demonstrate the knowledge she needs to improve her health behavior.

Preventive Regimen for the Older Adult

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Intervention

Three goals of prevention through screening, immunizations, and health education formulated by Noe and Barry (1996) are:

Improving quality of life.

Maintaining function.

Delaying or preventing age-related conditions.

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Promoting Cancer Screening Tests

The diagnosis of prostate cancer, the most common cancer in men is currently being re-evaluated.

You should teach men that it is very important to monitor prostate health. Breast self-exam monthly. Testicular self-exam monthly.

Pap tests for women should be done every 1 to 3 years until 65 and then every year.

Skin and oral cancer screening should take place yearly for those who are at high risk or who identify a suspicious lesion in themselves.

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Encouraging Immunization

Pneumococcal vaccine once.

Tetanus booster every 10 years.

Hepatitis B once.

Two-step TB testing yearly.

Mammogram and Pap smear yearly.

Prostate screening yearly.

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Encouraging Immunization

Plan with older clients for regular visits with a primary health care provider.

Help the client maintain mobility by collaborating with the client to make sure she receives the support she needs to maintain her mobility.

Help the client manage medications.

Instruct the client to carry a complete list of her medications with her (prescriptions and OTC).

Work with the client to monitor and attempt to maintain the least amount of medication possible for the greatest effect.

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Evaluation

Evaluation involves ongoing reassessment of the older adult to establish that expected health outcome criteria are being met.

Keeping the nursing care plan dynamic is essential for assisting older adult clients to their highest level of function.

Ongoing evaluation supports progress and identifies new problems to be solved.

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Presentation Credits

This presentation was developed for Mary Roche under contact with Peter Martin, dba Stacy House Designs.

The presentation is the sole, copyrighted property of Mary Roche.

Copies of this and other presentations can be seen on the Internet at http://www.stacyhouse.com. Please fill out the guestbook selection when visiting that site.

Thank you.

Mary Roche & Peter Martin

The End

Mary Roche, MSN, RN, CS

The End

Mary Roche, MSN, RN, CS

The End

Mary Roche, MSN, RN, CS