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Physiologic Changes of Aging
Gerontological & Community Based Nursing:
Age related changes affecting nutrition & hydration in older adults
Reduced need for caloric intake r/t↓body mass & ↑adipose tissue
Basil metabolism rate ↓ 2 % q decade of life
General ↓ in activity level
∆’s in taste (sweet intact & ↓Sour, salt, bitter)
∆’s in sense of smell believed to be related to other factors (∆’s in CNS function, medications, smoking)
Other factors affecting nutrition
Socialization- eating alone Income- strong relationship between
poor nutrition & low income Transportation –access to shopping Housing- substandard housing (SRO) Dentition (see box 8-3 text) – poor
oral health – risk factor for dehydration & malnutrition; ↑risk oral cancers
Nutrition concerns
Two major concerns: Obesity – exacerbates age related
health issues> type II diabetes, CAD, osteoarthritis,
↓ mobility, Malnutrition – often unrecognized Precursor to frailty
Malnutrition in older adults
Protein – Calorie Malnutrition PCM most common type of malnutritionc/b muscle wasting, low BMI;↓albumin /serum proteins
50% nursing home; 50% hospitalized 44% home health elders - malnourished
Malnutrition - Risk factors
Psychosocial
Mechanical
“I’m Dying of Thirst!”
In young, water makes up about 2/3 of our body weight
The brain is composed of about 95% water
The blood is about 82% water The lungs are about 90% water
In the elderly total body water drops to about 50% of the body’s weight
Hydration
Small changes in water content make a big difference in the elderly because: Kidneys lose their ability to concentrate
urine as effectively There is a decreasing sense of thirst in
the elderly Recommended daily fluid intake for the
elderly is 1500-2000ml of non-caffeinated fluids
Dehydration
Dehydration is one of the most common fluid and electrolyte problems experienced by the elderly
Most often r/t disease process NOT access to water (Thomas et.al. 2008)
Result of - fluid loss + ↓ fluid intake r/t
↓ thirst & ↓kidney function (↓creatinine clearance)
Dehydration
How it happens ↓body fluids ->↑’s concentration of solutes in the
blood (increased osmolality) Na levels ↑ To regain balance between intracellular &
extracellular-H2O molecules shift out of cells into more concentrated blood
With ↓H2O in extracellular space –fluid continues to shift into extracellular space-dry cells become dysfunctional ->dehydration
Dehydration
Dehydration in elderly can cause: Delirium UTI URI Urinary incontinence Constipation Pressure ulcers Cardiovascular symptoms Death
Factors that contribute to Dehydration
MedicationsDiureticsSedativesAntipsychoti
cs
ETOH abuseDementiaSelf feeding
defecits ImmobilityFeverDiarrhea
Physiologic Signs of Dehydration Poor skin turgor
On the forehead or sternum, not the hand or arm
Sunken eyes Dry mucus
membranes Irritability Confusion Dizziness Muscle weakness ↓UOP ↑ HR
Acute weight loss (> 2 pounds in a few days) 2.2 pounds (1
Kg) = 1 liter of water
Orthostatic hypotension
BUN/creatinine ratio >25:1
Tachycardia
Diagnosing Dehydration
All must be present to diagnose clinical dehydration: Suspicion of decreased intake or
increased output Two physiologic signs of dehydration
Dehydration
Prevention preferable to treatment! Adequate water intake
Remember: dehydration and malnutrition often go hand in hand
Oral hydration Water Sports drinks
Treatment for dehydration
Goal – replace missing fluid Avoid hypertonic solutions Encourage salt-free oral fluids (serum Na level elevated) IV fluids (hypotonic low-sodium
fluids eg. D5W)
Hypovolemia – isotonic fluid loss (loss of fluids + solutes) from extracellular space.
r/t excessive fluid loss (bleeding) + reduced fluid intake
Third space fluid shift (eg. Ascites- fluid shifts to abdominal cavity)
Check orthostatic B/P
Bladder Function in the Elderly
Diminished bladder control Warning period between desire to
void and micturation is shortened or lost
Nocturnal frequency is common in men and women
Urinary Incontinence
One of the most common conditions in the care of older adults
Related to Cognitive impairments Difficulty in walking Difficulty manipulating clothing Medications
Diuretics Sedatives Hypnotics(Risk factors – Box 9-4 text)
Incontinence Generates feelings of shame, fear, guilt,
dependence Psychological consequences include
anxiety, embarrassment =>depressive symptoms
Social restriction/isolation Avoidance of sexual activity
Physical consequences include Skin problems Pressure ulcers UTIs Falls
Types of Urinary Incontinence
Categorized based on symptoms Stress Urge Overflow Iatrogenic Mixed Functional
Stress Incontinence (Anatomic Incontinence) Involuntary leaking
of urine while exercising, coughing, sneezing, laughing or lifting
Most common type in women Often develops
after child birth In men usually
related to benign prostatic hyperplasia (BPH)
Pressure on bladder causes leaking
Urge Incontinence (Overactive Bladder)
Frequent, sudden urge to urinate with little control of the bladder Especially when
sleeping, drinking, or listening to running water
May also be a sign of UTI or kidney infection Problems caused by oversensitive
bladder
Overflow Incontinence
Incomplete emptying of bladder
Frequent urination and/or constant dribbling of urine
Generally caused by weakened bladder muscle d/t nerve damage including diabetes Bladder doesn't empty completely, leading
to frequent urination or dribbling.
Functional Incontinence
Unable to control bladder before reaching the BR R/t limitations of moving, thinking or
communicating Iatrogenic
Associated with medication side effects
Mixed Incontinence More than one type of incontinence Typically stress incontinence and
urge incontinence
Nursing Interventions Understanding type of incontinence Goal setting
Curing incontinence versus Minimizing effects
Attitude Nurses should not demonstrate:
Acceptance of inevitability of incontinence
Disgust—decreases self-worth of elder and increases dependence
Nurses should: Treat incontinence as curable Adopt a teaching role
Nursing Interventions
Environmental Dietary changes Bowel training Sphincter training exercises Biofeedback training Medication Surgery(see Box9-6 text)
Nursing Care
All health care providers should strive to understand the causes of incontinence, risk factors and evidence-based interventions
Failure to address continence promotion has enormous consequences in terms of economics and burden of care
Fecal Incontinence
Inability to control passage of stool Devastating social implications for
individuals and families Multifactorial
•Intestinal transit time
•Pelvic floor and sphincter tone
•Pelvic musculature
•Rectal sensitivity
•Accessibility of toilet
•Presence of urge
•Medications •Use of laxatives
•Bulk in diet
•Fluid intake •Exercise •Presence of hemorrhoids
Nursing Intervention
Fecal incontinence is symptom, nurses should seek out cause
Attitude Goal setting
Planned Realistic Consistent
Maslow’s Hierarchy Elimination is
key to maintenance of physiologic and biologic integrity
What other implications does it have?
Healthy Skin and Aging
Skin is the largest organ in the body Many purposes
Protects underlying structures Heat-regulating mechanism Sense organ Metabolism of salt and water Stores fat Gas exchange Conversion of vitamin D
Skin
Subject to damage Photo aging
Development of skin cancer Sunscreen
Skin cancers Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma
Other Skin Problems
Seborrheic Keratosis Benign growths
mainly on trunk, face, scalp
Candida albicans Fungal infection Usually found in
folds of skin R/t antibiotics,
steroid use
Carcinomas of the skin
Basal cell –most common malignant skin cancer
Squamous cell 2nd most common skin cancer
Vascular Insufficiency
Leads to complications of skin: mild dermatitis ulcerations gangrene
Arterial insufficiency r/t atherosclerotic plaques ischemia Symptoms:
Pain with exercise Pain at rest
Susceptible to infections 2o to even mild trauma
Affects 10% of those > 65 y.o.
Lower Extremity Arterial Disease
Claudication discomfort, cramps
or pain in the hips, thighs or calves with walking
LEAD Risk Factors
Same as those associated with coronary artery disease Smoking High blood pressure (hypertension) High levels of blood cholesterol or triglycerides
(hypercholesterolemia, hyperlipidemia) Obesity Sedentary lifestyle Diabetes Family history of heart disease or arterial
disease
LEAD Signs & Symptoms
Decreased hair growth on the legs and feet Discoloration of the affected leg or foot when
dangling (from pale to bluish-red) Diminished or absent pulses in the affected leg or
foot Temperature difference in affected leg or foot
(cooler than other extremity) Change in sensation (numbness, tingling, cramping,
pain) Presence of non-healing wound on affected lower
extremity Shrinking of calf muscles Presence of thickened toenails Development of gangrene
Venous Insufficiency—Signs & Symptoms
Symptoms of CVI may include: Varicose veins; Ulceration or skin breakdown; Reddened or discolored skin on the leg; Edema or swelling.
CVI—Risk Factors
CVI can also be caused by: A thrombus, or blood clot, that blocks blood
flow in a vein, called deep vein thrombosis; or Phlebitis, an inflammation of a superficial vein
that causes a blood clot to form. Risk factors may include:
Heredity; Obesity; Pregnancy; Sedentary lifestyle; Smoking; Jobs requiring long periods of standing or
sitting in one place; and Age and sex (women in their 50s are more
prone to developing CVI).
Pressure Ulcers
Pressure ulcers develop as a result of compression between a bony prominence and another hard surface
Serious and costly problems Lead to severe complications and
death
Stage I through IV Pressure ulcer
Stage I Erythemia within 30 minutes of pressure
Stage II Partial thickness loss of epidermis & dermis
Stage III Full thickness loss through to subcutaneous tissue
Stage IV Deep
tissue destruction
Determining Risk for Pressure Ulcers
Important factors Severity of illness Involuntary weight loss
Hypoproteinemia Dehydration Vitamin deficiencies
Braden Scale—risk assessment tool1. Sensory perception2. Skin moisture3. Activity4. Mobility5. Friction and shearing6. Nutritional status (very important)
Nursing Implication
Prevention!! An ounce of prevention is worth a pound
of cure Turning schedule Supportive surfaces Activity level Meticulous cleaning and skin care Nutrition Avoid sedative medications
Feet Number and severity of foot
problems increase with age Nursing assessment can identify
potential problems and actual problems needing attention
Useful guide for assessment in box 11-6
Guide for comprehensive assessment of the lower extremities (LEs) in figure
Nursing interventions
Proper toenail care Reducing dependent edema Promoting foot massage to
stimulate circulation