Health Promotion, Health Maintenance, and Home Health Considerations CHAPTER 4 83 Nursing Care Plan 4-1 HEALTH MAINTENANCE Mrs. Fisher is an alert, well-groomed 82-year-old who lives alone in an apartment. She has a history of type 2 diabetes mellitus. Her blood glucose levels, which you test weekly, are consistently 200 mg/dL or higher. Her primary care provider has prescribed a 1200-calorie diabetic diet and an oral hypoglycemic medication. When you arrive at Mrs. Fisher’s apartment early for a home visit, you find an open box of ginger snaps next to the chair where she was sitting. She says, “I like to sit around most of the day and read, or watch TV.” You ask about the cookies and she replies, “They’re not very sweet; I need to have some food that I enjoy. I won’t live forever, you know.” You check the bottle of oral hypoglycemic medication and find that she has taken only two tablets in the past week. She states, “I forget to take them. They don’t help anyway, and they cost too much.” NURSING DIAGNOSIS Noncompliance DEFINING CHARACTERISTICS • Consistently elevated blood glucose levels • Failure to take prescribed medications • Failure to follow prescribed diet • Complaints of lifestyle changes in conflict with personal values PATIENT GOALS/OUTCOMES IDENTIFICATION Mrs. Fisher will do the following: • Follow her prescribed diet • Increase her activity level • Take her prescribed medications • Achieve blood glucose levels of less than 120 mg/dL NURSING INTERVENTIONS/IMPLEMENTATION 1. Assess Mrs. Fisher for any signs of tissue breakdown or other problems related to hyperglycemia. 2. Allow her to verbalize feelings and problems experienced with activity, diet, and medications. 3. Review her daily food intake. 4. Explain the importance of following her prescribed diet. 5. Set up a reminder system for daily medications. 6. Explore ways of increasing her physical activity. 7. Encourage her to comply with the plan of care. 8. Praise positive health care behaviors. 9. Continue to monitor her blood glucose level and notify the primary care provider if it remains elevated. 10. Arrange a consultation with the dietitian at her next primary care provider’s office visit. EVALUATION At the next home visit a week later, you find that Mrs. Fisher’s blood glucose level is 174 mg/dL. She states proudly that with the new medication system, she has remembered to take six of her oral hypoglycemic tablets and forgot one day only. She further states that she has taken four short walks with her neighbor. After providing positive feedback on these signs of improved health maintenance, you discuss diet with her. Mrs. Fisher states that she has tried to be more careful, but, because she still likes an occasional cookie, she will limit herself to one or two at most a day. Improvement is demonstrated, but Mrs. Fisher’s goals are met only partially. You will continue with the plan of care and reassess her again in one week. CRITICAL THINKING QUESTIONS 1. What additional approaches could be implemented to improve compliance with the medication regimen? 2. How could you help Mrs. Fisher decrease her snack intake? Can you suggest ways to motivate her to increase her activity? NURSING GOALS/OUTCOMES IDENTIFICATION 1. Assess the older adult’s ability to resume normal health-maintenance practices. After hospitaliza- tion or rehabilitation in an extended-care facility, older adults must be assessed carefully to deter- The nursing goals for an older adult demonstrating mine whether they are capable of returning home ineffective health maintenance are to verbalize appro- and resuming normal health-maintenance prac- priate health maintenance practices, demonstrate tices. Ideally, discharge from the facility should be adequate health maintenance practices, and identify delayed until the nurse can be reasonably sure that community resources that can assist in health the patient is ready to take responsibility for his or maintenance. her own health care needs. If possible, an assess- ment of the home environment should also be NURSING INTERVENTIONS/IMPLEMENTATION made before discharge, and should be modified to The following nursing interventions for ineffective health maintenance should take place in hospitals or extended-care facilities:
84 UNIT II Basic Skills for Gerontologic Nursing Box 4-6 Recommended Health Practices to Maintain Wellness Box 4-5 Characteristics of Older Adults Who Are Likely to Experience Ineffectiveness in • Eat a well-balanced, plant-based diet. Health Maintenance • Establish a regular exercise program. • Quit smoking. • Lack of adequate knowledge about recommended • Consume alcohol in moderation. health practices • Get routine immunizations as recommended. • Stay involved in activities and with others. • Physical limitations • Keep a healthy attitude. • Lack of adaptive behaviors to environmental changes • See the dentist and primary care provider regularly. • Limited financial resources • Altered cognitive or perceptual function 3. Assist in identifying family or community • Difficulty accessing health-related goods or services resources that promote health maintenance. • Loss of motivation because of grief, hopelessness, or Individuals living in their homes may be unaware of services that are available to provide help. Often, powerlessness a little assistance is all that is needed to enable an older person to live a healthy, independent lifestyle. promote health maintenance and safety if necessary. If assistance is delayed, health maintenance may A referral for a follow-up visit after discharge helps deteriorate to a point at which hospitalization or ensure that the older adult is safe and able to meet institutional placement is required. These services his or her health-maintenance needs. should be identified before they are required to 2. Teach the skills required to monitor health status avoid delays or waiting lists for the services. when the patient returns home. Before discharge from a health care institution, older adults should 4. Use any appropriate interventions that are used in have a thorough explanation and printed handouts the institutional setting. to reinforce the following topics: what they need to do to maintain health, including when to call or see NURSING PROCESS FOR NONCOMPLIANCE the primary care provider; what medications are required and when they should be taken; how to perform home screening procedures (e.g., blood glucose monitoring and daily weights); and how to Several institutions are moving away from the termi- keep records and monitor their health condition. nology of noncompliance and toward using the term 3. Consult with the social worker or with agencies nonadherence, as there is less of a negative connotation that can assist with health-maintenance practices. attached to that term. Truthfully, it is very difficult to The community social worker or social agencies adhere 100% to every aspect of a treatment regimen: may be able to help older adults meet their health- exercise, diet, medications, annual screening proce- maintenance needs by providing transportation, dures, and it is not uncommon to label a patient as delivering food or groceries, assisting with home “noncompliant” who has made great strides on many maintenance, or offering other services. aspects of their health care but has slipped up on one The following interventions should take place in the particular piece. However, the current NANDA termi- home: nology includes the nursing diagnosis “noncompli- 1. Assess the existing health-maintenance practices. ance,” so that will be the primary word used in this The nurse should assess the older person’s knowl- text to describe the lack of following the prescribed edge of the factors that promote health. Any problem treatment plan. areas should be examined in greater detail. The nurse should also determine what motivates the A person should only be considered to be noncom- person to maintain his or her health, because these pliant when he or she fails to follow through with motivators may be valuable if modifications in recommended health practices in spite of adequate health care practices become necessary. teaching and resources. Failing to take prescribed 2. Explain and reinforce positive health-maintenance medications, failing to attend scheduled medical behaviors. The nurse should review health prac- appointments, and failing to follow prescribed diets tices regarding diet, safety, stress management, are examples of noncompliant behaviors. Many factors exercise, elimination, and sleep. It is important to may be related to noncompliance: cognitive impair- review when and how to contact a physician, par- ment, inadequate knowledge, inadequate resources, ticularly in cases of a serious illness or emergency. lack of transportation, fear, anger, decreased self- If older adults are receiving treatment for any health esteem, substance abuse, and conflict of beliefs or problems, they should know what health care values. Noncompliance should be suspected when a behaviors are recommended to maintain the highest person does not show the expected amount of progress level of wellness (Box 4-6). They should know what toward wellness, when a person gets worse instead of medications to take and when to take them, as well better, or when a person develops repeated or unex- as how to perform any special care or treatments. pected complications.
Health Promotion, Health Maintenance, and Home Health Considerations CHAPTER 4 85 Box 4-7 Characteristics of Older Adults Who Are system of reminders; people with poor self-esteem Likely to Be at Risk for Noncompliance need to feel valued before care is accepted. Individuals who exhibit self-neglect may require • Cognitive, perceptual, or developmental problems treatments for depression, dementia, or any physi- • Deficient knowledge of the treatment plan cal problems that are hampering their ability for • Lack of adequate financial resources self-care. The individual may need to be monitored • Poor self-esteem or altered body image to observe and intervene in the event of any exces- • Lack of a support system of friends and family sive deterioration in their health or levels of self- • Lack of motivation care. Treatment should include home health care • Substance abuse problems that is provided in a way that does not reduce • Negative past experiences with the health care system autonomy any more than necessary. Self-neglect • Differing cultural, religious, or health beliefs may be an indicator that a person would benefit from assisted living or some other form of residen- ASSESSMENT/DATA COLLECTION tial care. These individuals might improve if they have more opportunities for social interaction. If people are legally determined to be incompetent of making decisions about their own care, they may • Does the person verbalize unwillingness or inability have a legal guardian appointed and be compelled to follow through with the necessary health main- to accept help. If they are in possession of their tenance or medical care recommendations? mental faculties, they have a right to refuse treatment. • Does the person verbalize a conflict between per- 2. Provide care in a nonjudgmental manner. The sonal beliefs or values and the treatment plan? values and beliefs of older adults are often different from those of their caregivers. If the nurse indicates • Are there unexpected relapses, or do the health verbally or nonverbally that the older person’s problems appear to be getting worse instead of beliefs and practices are in some way inferior, the better? nurse is not likely to be able to convince the person to comply with the desired health practices. • Does the person often miss medical appointments? 3. Actively include the patient in planning care, and What reasons does he or she give? adapt or modify the care plan so that it is more acceptable to the patient. Develop all plans with, • Is there more medication left in the bottle than not for, the older person. Each individual can then would be expected if it were taken properly? incorporate his or her unique culture, beliefs, and values into the plan being developed. This enables • Are there signs of the presence of prohibited foods older adults to retain control and responsibility for (e.g., candy for persons with diabetes and salt their own health care. When they “own” the plan shaker for persons with sodium restriction)? and determine the goals, they are more likely to be compliant. Box 4-7 lists the characteristics of older persons who 4. Emphasize the benefits of compliant behavior. are at risk for noncompliance. Many aging people do not comply with recom- mended health care practices because they do not NURSING DIAGNOSIS really believe that compliance will help. If the person has the opportunity to benefit when he or she is compliant, active involvement in care is more likely. For example, if a person with diabetes con- Noncompliance tinually sneaks extra food and therefore frequently has high blood glucose levels, the nurse can dem- PATIENT GOALS/OUTCOMES onstrate how much lower the blood glucose level is when the person follows the prescribed diet. If less insulin or fewer injections would be required when the blood glucose level is controlled, these benefits The patient goals for an older person demonstrating should be stressed. Unfortunately, it is not always noncompliance are to identify factors that contribute possible to see any obvious immediate benefits to noncompliant behavior and demonstrate the accep- from compliant behavior. tance of treatment. 5. Acknowledge the aging person’s right not to comply with the plan of care. If an alert older NURSING INTERVENTIONS person chooses not to comply with the plan of care despite explanations, teaching, and reminders, the The following nursing interventions for noncompli- ance should take place in hospitals or extended-care facilities: 1. Identify the reasons for noncompliant behavior. A person might not comply with recommended health-maintenance practices for many reasons. Unless the nurse can determine the specific reasons why the person is not following the recommended practices, interventions are likely to be inappropri- ate and unsuccessful. If the person does not take medication because of forgetfulness, more teaching will not help. If the person refuses medication because he or she feels unworthy of living, no amount of reminders will help. Interventions must address the root problem. Forgetful people need a
86 UNIT II Basic Skills for Gerontologic Nursing responsible assistant or nurse. A simple glance in nurse must recognize that this is, in fact, a right of the box lets the person know whether he or she has the individual. taken the right medication at the right time. Bold markings on a calendar, preferably one with large The following interventions should take place in the print, can be used to mark special events. Signs in home: bold letters can be posted in appropriate places. For 1. Assess the support system. In the home setting, it example, “take a drink” can be posted over the sink of a person whose fluid intake is inadequate. is particularly important to identify the strengths of 3. Enlist the help of family, friends, and neighbors older adults and the amount of support they receive to provide reminders. Reminder phone calls from from friends and family. The likelihood of achieving friends or family are useful for less frequent occa- compliance is far greater when patients are willing sions such as doctor visits. It is wise for the friend to learn and to modify their behavior and when or family member to call the person the day before they have others who are willing to help. Individuals the appointment and then again on the day of the who resist intervention and receive little support appointment to ensure that he or she has not forgot- are likely to continue to have problems with ten. It is even better for a responsible friend or compliance. family member to transport the person to the 2. Help structure the environment to promote com- medical appointment. Responsible friends and pliance. Many individuals are noncompliant simply family members can also provide help in setting up because they are confused or forgetful. Memory the weekly pillbox and preparing other reminders devices can catch their attention and verify that around the home. critical actions take place. For example, if the person 4. Involve social service agencies in promoting com- forgets to eat meals, a checklist for the days of the pliance. If the person is noncompliant because of week and the three basic meals can be posted on the financial or transportation problems, a social worker refrigerator door. Each time the person fixes a meal, or social service agency may be able to provide the box is checked. Medications that need to be assistance that enables the person to comply with taken twice a day can be “tagged” to an activity that the care plan. occurs twice a day, such as teeth brushing. The 5. Use any appropriate interventions that are used medication container can be placed next to the in the institutional setting (see Nursing Care toothpaste tube to serve as a reminder. Special Plan 4-1). divided containers are also available for people who have trouble remembering to take their medication. Medication for an entire week can be prepared by a Get Ready for the NCLEX® Examination! Additional Learning Resources Key Points Go to your Evolve website at http://evolve.elsevier .com/Williams/geriatric for the additional online resources. • A large percentage of today’s aging population continues to live independently, despite a variety of Online Resources: chronic health problems. • Fruits and Veggies: More Matters: • Health maintenance is an ongoing challenge for older www.fruitsandveggiesmorematters.org/ adults, their families, and health care providers. • My Plate: www.choosemyplate.gov/ • Careful assessment of the aging person’s perception of • US Department of Education, National Institute on health, health practices, and knowledge of safety factors is an important part of nursing care in all Disability and Rehabilitation Research: settings. www.abledata.com • Early detection of problems and early intervention can Review Questions for the NCLEX® Examination prevent more serious complications and enable older adults to maintain the highest possible level of wellness 1. What is the activity that best promotes health and function. maintenance for the typical older adult? 1. One hour of low-impact tai chi per week • Home health assistance, both unpaid and paid, can 2. One 30-minute walk, 3 to 5 times a week help older adults remain independent for a longer 3. Step aerobics for 20 minutes, 2 times a week period of time. 4. Riding for 5 to 10 minutes on a stationary bike, daily • Nurses play an important role in case management and in providing services to older adults in their homes. • Caution should be used when selecting home care providers for older adults.
Health Promotion, Health Maintenance, and Home Health Considerations CHAPTER 4 87 2. The nurse recognizes that regular dental visits are: 5. When attempting to help an older adult improve his or 1. Necessary for only those older adults who still have her health-maintenance practices, the nurse will need their natural teeth to assess which factors? (Select all that apply.) 2. Recommended on a yearly basis for all older adults, 1. Physical strength and endurance even those with dentures 2. Availability of transportation 3. Not necessary if the person brushes and flosses 3. Cultural beliefs properly three times a day 4. Cognitive and sensory changes 4. Desirable, but not necessary unless pain or another 5. Socioeconomic status problem occurs 6. Religious beliefs 7. Social support system 3. An older adult does not follow through with health 8. Educational level recommendations from the primary health care provider. The older adult does not take prescribed 6. Your patient, Mr. Palakiko, tells you he understands that medications or keep medical appointments. For which he is at greater risk of certain diseases because of his diagnosis should the nurse formulate a care plan? Pacific Island heritage. Based on what you have 1. Noncompliance learned, which disorder(s) is he likely to be at risk for? 2. Knowledge deficit (Select all that apply.) 3. Disturbed thought processes 1. Obesity 4. Impaired health seeking behavior 2. Stomach cancer 3. Diabetes mellitus 4. Which immunizations should older adults receive on a 4. Hypertension yearly basis? (Select all that apply.) 1. Pneumonia vaccine 2. Influenza vaccine 3. Tetanus vaccine 4. Polio vaccine 5. Hepatitis-B vaccine
chapter 5 Communicating with Older Adults http://evolve.elsevier.com/Williams/geriatric 4. Discuss the verbal communication techniques used when sending and receiving messages. Objectives 1. Identify communication techniques that are effective with 5. Differentiate between social and therapeutic communication. older adults. 2. Define empathetic listening. 6. Discuss ways communication is affected by culture. 3. Identify the significance of nonverbal communication with rapport (ră-PŎR, p. 88) older adults. symbols (SĬM-băls, p. 90) Key Terms confrontation (KŎN-frăn-tā-shŭn, p. 97) empathy (ĔM-pă-thē, p. 93) proxemics (prŏk-SĒ-mĭks, p. 91) Communication is the process of exchanging informa- Effective communication is not easy, even among tion: sending messages back and forth between indi- people of the same age group and background. viduals or groups of people. Problems between Communication among people from different age individuals, families, or groups, as well as difficulties groups and backgrounds is even more challenging. on the job or in society, are often the result of poor This is particularly true when one of the parties is communication. Each of us who participates in com- older; however, effective communication can occur munication is a unique individual with our own even when people hold significantly different values, personal values, beliefs, perceptions, culture, and beliefs, and perspectives. Effective communication understanding of how the world operates. This is par- does not mean that we will like or agree with every- ticularly important to remember when working with thing that another person says, but rather that we older adults. The older adults of today formed their respect the person’s right to think and say it. This opinions, values, and beliefs in a very different society atmosphere of mutual respect and understanding from ours today. Today’s oldest adults grew up during helps build trust and rapport. Conscious, ongoing the Great Depression, when men sold apples on street effort is required to become an effective communicator. corners and searched for pieces of coal in railroad yards to survive. They lived through a major world Effective communication requires the following: war and witnessed the beginning of the Nuclear Age 1. The need or desire to share information when the first atomic bomb was dropped. They grew 2. Acceptance that there is value and merit in what the up in a world without many of today’s conveniences, including televisions and private telephone lines. The other person has to say, demonstrated by a willing- upcoming generation of older adults is very different. ness to treat the other person with genuine dignity The Baby Boomers, who came of age during the and respect Vietnam War, grew up in a world challenged by drugs, 3. Understanding of factors that may interfere with or protests, and “free love.” They grew up with stereos, become barriers to communication television, and astronauts walking on the moon. Most 4. Development of the skills and techniques that facili- Baby Boomers have adapted to the use of cell phones tate effective interchange of information and computers. Technology was, and will continue to be, a part of their lives. INFORMATION SHARING (FRAMING THE MESSAGE) Whatever their background, older adults have had Verbal communication involves sending and receiving time to encounter many situations, both good and bad. messages using words. Some verbal communication is It is often difficult for a younger person to understand formal, structured, and precise; some is informal, the experiences that have made older adults whom unstructured, and flexible. Formal or therapeutic they are today. The most effective way to bridge the communications have a specific intent and purpose. gulf between the generations is good communication Informal or social conversations are less specific and (Table 5-1). are used for socialization. Both have a place in nursing. Nurses must be effective in both formal and informal 88
Communicating with Older Adults CHAPTER 5 89 Table 5-1 Communication Dos and Don’ts When on past employment, family, or other interests. Working with Older Adults Increased knowledge of the individual enhances the ability to respond empathetically. Effective verbal DO DON’T communication requires the ability to use a variety of Identify yourself. techniques when sending and receiving messages. Assume that the person knows who you are. When communicating verbally, whether in a formal or an informal situation, nurses should know as much Address the person using Use “baby talk” or as possible about the other person involved. A per- their preferred name (e.g., patronizing names such son’s age, marital status, cultural or ethnic orientation, Mrs. Smith and Bill). as “sweetie” or “honey.” educational background, interests, and the ability to hear and see influence the communication techniques Speak clearly and slowly in Shout. used and the words chosen. We need to be careful to a low tone of voice. choose words that the patient can understand; not so simple that we are “talking down” to the patient, but Get to know the person. Make generalizations also not so technical or “medical” that the meaning is about older people. unclear. Avoid acronyms, such as TURP or CBC, unless you are sure that the person understands them. Careful Listen empathetically. Pay too much attention to listening to the patient’s speech can give clues about tasks and forget the the appropriate level of language. person. Pay attention to body Consider nonverbal language, yours and messages as theirs. insignificant. Use touch appropriately and Be afraid to use touch as Cultural Considerations frequently. a method of communication. communication and must know how and when to use Communication Styles each type. • Americans tend to be bold and ask direct questions, Nonverbal communication takes place without particularly in a crisis. We expect the answers to be words. We are communicating all the time, whether similarly clear and direct. we are aware of it or not. Research has shown that, when discussing feelings and attitudes, only 7% of • Members of other cultures may prefer to proceed less communication comes from the actual words we use; directly and need to establish a relationship through the other 93% is nonverbal. Although this 93/7 rule “small talk” before addressing more serious concerns. cannot be applied to all communication situations, it Although this may seem less productive, your awareness raises a point about the importance of nonverbal com- that the patient and his or her family may be more munication. Approximately 38% of communication is comfortable with this type of communication can transmitted by paralinguistic cues (i.e., tone, pitch, contribute to greater success in the long-term rate, speed, and volume of voice), and 55% is transmit- relationship. ted by body cues. The importance of understanding nonverbal communication can be summed up in the Communication statement, “What you are saying (nonverbally) is so loud I can’t hear you.” FORMAL OR THERAPEUTIC COMMUNICATION Misunderstanding of Medical Jargon Therapeutic communication is a conscious and delib- Some home health nurses had a good laugh at the office erate process used to gather information related to a when one nurse recounted the following experience during a patient’s overall health status (physical, psychosocial, home visit: spiritual, etc.) and to respond with verbal and nonver- bal approaches that promote the patient’s well-being Her older adult patient reported that he was recently hos- or improve the patient’s understanding of ongoing pitalized. When she explored the reason for this hospitalization, care. This type of communication looks easy and he told her, “I was castrated.” She asked whether he knew natural when performed by an experienced health pro- why this was necessary. He replied, “Because of my prosti- fessional, but it is a skill that requires time, effort, and tute.” At this point, she pulled things together in her mind (and practice to develop. Careful use of words and lan- restrained the unprofessional urge to break out in laughter), guage is an art. Knowledge of the individual’s educa- realizing that what her patient meant to say was that he was tional background and interests provides a starting catheterized because of problems with his prostate gland. This point for conversation. Social discussions often center is an example of medical terminology gone awry. Also remember that different words can have different meanings to persons of different generations or cul- tures. Gay may mean happy and lighthearted or an alternative lifestyle. Cool may be a temperature or something really good. Likewise, hot may be a tem- perature or an extremely attractive person. Consider the culture, ethnicity, experiences, and perspective of the older patient when choosing your words.
90 UNIT II Basic Skills for Gerontologic Nursing Communication INFORMAL OR SOCIAL COMMUNICATION Simple chitchat does have a place in nurse-patient If two people entered a room, one wearing a white laboratory communications. If nurses talked only about things coat with a stethoscope around her neck and the other wearing related to health treatment, they would know little a clerical collar and a cross, what message would you receive? about their patients. Small talk; pleasantries; and con- Would these people have to say anything for communication versations about the weather, a favorite television to take place? What is being communicated? The items we show, or the latest news can demonstrate that you wear or carry (e.g., clothing, jewelry, stethoscopes, masks, think of the patient as a real person, not just a patient. gowns, and gloves) send messages; we use these symbols to Likewise, older patients often like to know something communicate something about who we are. Distinctive uni- about the nurses who care for them; they may ask forms are worn to make people identifiable. Police officers, about your family, hobbies, and interests. This is par- flight attendants, clergy, and nurses wear uniforms so that they ticularly true in extended-care facilities, because the can be recognized even in a crowd. nursing staff often becomes a new family for the aging person. Do not be afraid to be “human” when com- SYMBOLS municating with older adults, but be careful not to overdisclose information that might make the patient In the health care setting, uniform styles and colors view you in an unprofessional light. help patients distinguish the various caregivers. Many patients, particularly older adults, were unhappy Be honest with your older patients. When you do when nurses stopped wearing caps. The white uniform not have time to visit, explain why so that patients do and cap were symbols that helped older adults distin- not personalize and think they have done something guish nurses from other caregivers, and to distinguish wrong. Do not be afraid to use humor appropriately, the level of education attained by that nurse. For this but choose the right time and place, and make sure it reason, nurses in some long term care facilities con- is culturally sensitive. It has been said that “laughter tinue to wear white uniforms and caps. In other set- is the best medicine.” Remember that it is okay to tings, nurses may not wear any uniform, or they may laugh at yourself, but never at the other person. wear scrubs. Street clothes, such as a navy blue outfit Aging does not cause people to lose their sense of with an identifying name tag, are preferred in some humor. A humorous story or cartoon may help brighten agencies, particularly in home care or public health their day. center. This can be confusing to older adults because such clothing is not distinctive enough to identify the NONVERBAL COMMUNICATION individual as a nurse and because many older adults cannot read the small print on name tags. Older adults Because so much of communication is nonverbal, it is have been heard to say to caregivers, “Who are you? essential that we examine each aspect of nonverbal What are you going to do to me?” Although nurses communication to consider its effect on our interac- may not place much importance on wearing a uniform, tions with the older adult (Figure 5-1). it plays an important role in communication. FIGURE 5-1 Nonverbal communication signals that the nurse is Cultural Considerations interested in the patient and in what he or she is saying. (From Sorrentino SA, Remmert LN: Mosby’s essentials for nursing assistants, ed 5, St. Louis, 2014, Mosby.) Nonverbal Communication • Culture and nonverbal communication play important roles in patient perceptions. For example, Russian immigrants new to the United States may perceive that they are being treated incompetently and without adequate respect, based on cultural misunderstandings. • In Russia, illness is viewed as a serious matter, and patients expect to be treated by stern, authoritarian care providers who give directions without seeking input from the patients. Care providers wear appropriate uniforms, indicating their role and status. • By contrast, in the United States, the patient is likely to be attended to by smiling, friendly, nonauthoritarian care providers who seek to involve the patient in decision making. • American caregivers are normally dressed in scrubs or casual clothing that does little to identify their role or status. This contrast can lead to the mistaken interpretation that the caregivers are inexperienced and do not take the patient’s concerns seriously.
Communicating with Older Adults CHAPTER 5 91 TONE OF VOICE body language. Explore the situation using techniques, Think of the sound of a whisper, shout, or whine. Try such as reflective or open-ended statements. (These saying, “I don’t want to do that,” first in a whisper, techniques are clarified later in the chapter.) shout, and whine, and then in a normal speaking voice. Was your understanding of the message the SPACE, DISTANCE, AND POSITION same in each situation? Probably not. To survive, we Physical space, distance, and position are other ways learn early in life to understand that tone of voice is a we communicate. The study of the use of personal fairly reliable way of judging a person’s emotions. space in communication is referred to as proxemics. Because the nonverbal message is so strong, we typi- Personal space refers to how close we allow someone to cally respond to the emotion we perceive from the tone get to us before we feel uncomfortable. The amount of of voice and may not even hear the words. When a space that separates two individuals when they com- person shouts at us, we normally shout back. Shouting municate is significant. In the traditional American is often associated with anger or displeasure, yet many culture, most people are comfortable when strangers people shout in an attempt to communicate with are 12 feet or more away. This is considered public someone who is hard of hearing. Shouting is not an space; at this distance, there is no real positive or nega- appropriate way to deal with hearing problems, tive connection with the other person. Between 4 and because our tone of voice may lead the hearing- 12 feet is considered social space. This is a comfortable impaired person to think we are angry. Speaking in a distance for a casual relationship, in which communi- low tone of voice close to the person’s good ear is cation is at an impersonal level. If you stay this far much more effective. Use of other nonverbal methods away from your patients, you are communicating of communication, such as communication boards or indifference. A distance of 18 inches to 4 feet is con gestures, can also help. sidered personal space. This is the optimal distance for close interpersonal communication with another BODY LANGUAGE person. A nurse who communicates from within this You walk past a room and observe a nurse standing in space is usually viewed as concerned and interested. the doorway, with his or her head sticking into the The space within 18 inches of the body is considered room and body still in the hallway. The verbal com- intimate space. Most people allow only trusted indi- munication is, “Can I help you?” but the nonverbal viduals to get this close. Entering the intimate space communication is, “I’m in a hurry. You really don’t without permission is usually perceived as a threat. want anything, do you?” We communicate many things by how we move, stand, sit, and position our A nurse or other caregiver may approach an older bodies. In dealing with all patients, it is important that adult to provide care or treatment and, without think- we be aware of what we communicate through our ing, enter this intimate space too quickly. An older body language. adult who has poor vision or hearing, who has been sleeping, or who is not totally alert may be startled by In situations in which the words and body language this approach. The person may not be able to recognize are conveying two different messages, most people the nurse as a trusted person at first and may strike respond to the body language. Standing at the door, out verbally or physically from fear of physical attack. hurrying down the hallway, sitting behind the nurses’ It is essential to recognize the importance of personal station, and working in the medication or treatment space and to obtain the older adult’s attention and room all communicate that you are busy and do not permission before attempting to perform any phy want to be interrupted. Many older adults and their sical care. families are intimidated by this body language and may hesitate to interrupt, even to report serious con- GESTURES cerns. Nurses must be careful not to create barriers Gestures are a specific type of nonverbal communica- between themselves and their patients. Going into the tion intended to convey ideas. Gestures are highly cul- rooms to talk with patients, sitting down at eye level tural and generational; those that are acceptable in one with residents, and spending time in the lounge with culture may be offensive in another. Some gestures visitors are all ways of nonverbally communicating that are accepted today as commonplace were once that you are truly interested and concerned. considered crude or insulting. Gestures that have a certain meaning in one culture may have a different Another part of nonverbal communication involves meaning in another. For example, nodding the head watching for the messages that patients are communi- up and down means yes in most cultures, but to cating to us through their body language. For example, some Eskimo tribes it means no. Before using gestures, patients who slump down or slouch in their chairs it is wise to determine that both parties have the may be communicating many things, such as fatigue same understanding of just what a particular gesture or physical weakness, lack of interest, sadness, or defi- means. ance. Turning away from the nurse could indicate anger, fear, or lack of interest. When body language Gestures are helpful for people who cannot use says something different from the words, believe the words. After a stroke, many individuals suffer from a
92 UNIT II Basic Skills for Gerontologic Nursing and some groups from Southeast Asia), averting the eyes communicates respect. When dealing with older condition called aphasia. Because of brain damage, adults, it is important to be sensitive to the meaning of these individuals may not be able to recognize words eye contact for them. Face-to-face, eye-to-eye contact or to “find” the words they want to use. This inability can be helpful when communicating with older adults, to communicate wants, needs, and feelings is often providing this does not frighten or intimidate them. frustrating, and the use of gestures and other nonver- Eye contact is often interpreted to be a sign of atten- bal forms of communication can be effective. tiveness and acceptance. Face-to-face contact also max- imizes the chance that an older adult with hearing Cultural Considerations problems can read lips if necessary. Sitting at the bedside may facilitate eye contact. PACE OR SPEED OF COMMUNICATION Preventing Cultural Bias in Caregiving Nurses are often younger than the aging people they serve. The resulting difference in rate of speech and Culture, language, and communication are closely connected. movement can be overwhelming and frustrating to Failure to recognize the impact of culture on communication older adults. Many choose not to respond or interact can be a barrier to effective health care. with younger nurses because they feel they are being hurried. Do not become impatient or uneasy with Health care providers, like others, often base their evalua- silence; give the older person enough time to think and tion of a patient’s words or behavior on their own culture and organize a response. Provide encouragement and reas- ethnic assumptions. To minimize cultural misunderstanding, surance that they will have all of the time they need. health care providers should: Nurses have too often been observed completing sen- • Recognize their own cultural biases and assumptions. tences for older adults when they should have the • Increase their knowledge and understanding of the patience to wait for the individuals to organize their thoughts and speak. Many times, nurses complete the attitudes, beliefs, and communication styles of other communication according to their own way of think- cultures. ing rather than waiting to hear what the older adult • Recruit, retain, and promote health care providers from all wants to say. This is disrespectful and demoralizing. ethnic and cultural backgrounds. Patience and active listening are greatly needed skills • Provide skilled interpreters, visual aids, and educational when working with older adults. “Slower is better” materials for predominant language groups. should be the motto impressed in the mind of anyone • Address complaints or grievances that arise from who chooses to work with older adults. cross-cultural misunderstandings to provide more culturally sensitive care. TIME AND TIMING Timing is related to the pace of communication, but it FACIAL EXPRESSIONS has other distinct implications as well. The amount of Facial expressions are yet another form of communica- time a person must wait after seeking attention is tion. The human face is most expressive, and facial important. Delays in response to a call light or direct expressions have been shown to communicate across request from a person may be interpreted as a lack of cultural and age barriers. Smiles, frowns, and grimaces concern, even if this is not intended. The person’s appear to have the same meaning whether you are in response may manifest in anger, displeasure, anxiety, the outback of Australia or in a boardroom on Wall fear, and other feelings. Studies have shown that Street. Humans respond to facial expressions from the nurses take longer to respond to terminally ill patients. time they are born. We tend to mirror the expressions Nurses also tend to give delayed responses to demand- of the person with whom we are communicating: ing individuals. This sets up a vicious cycle, because smiles tend to elicit smiles, and frowns elicit frowns. the longer a person waits for a response, the greater Fear, anger, joy, and a variety of other emotions can be his or her anger, fear, and anxiety becomes. This only conveyed by a simple change in facial expression. We increases the demanding behaviors, which often occur must be aware of this fact and ensure that our expres- in an attempt to reduce fear. If the older adult’s needs sions communicate what is intended. Too often, nurses are dealt with promptly, the number of demands tends are preoccupied while interacting with an older adult. to decrease, not increase. Making older adults wait A frown, inadvertently made by a nurse performing a unnecessarily constitutes a subtle form of abuse. difficult intravenous (IV) insertion, may lead the indi- vidual to think that he or she has done something Many older individuals have an altered sense of wrong. A wrinkled nose, particularly when cleaning time. A message that is communicated too early may up an episode of incontinence, could be viewed as a lead to either forgetfulness or to repeated questions of lack of acceptance. A smile when listening to serious “Is it time yet?” A message that is communicated too concerns may make the person wonder whether the late may lead to distress and frustration. Older adults nurse really cares about what is being said. EYE CONTACT “Look me in the eye” is a phrase many white Americans have heard. Looking someone in the eye is perceived in our culture and other cultures as a measure of honesty. Yet in some cultures (e.g., African Americans
Communicating with Older Adults CHAPTER 5 93 often need more preparation time than younger indi- viduals need to get ready for an activity, such as going person is experiencing pain so as not to cause further to the bathroom or getting necessary items together. discomfort. Communicating an exciting message late in the even ing (either good or bad news) may disturb older Whereas appropriate use of touch is of great bene adults to the point that they are unable to sleep. Be fit to older adults, inappropriate touching can be aware of these issues and choose the proper time to destructive. Touch is inappropriate when it is used to communicate. communicate anger or frustration. Rough handling, TOUCH slapping, pushing, or otherwise communicating dis- Touch is a form of communication. No words are pleasure constitutes patient abuse and is completely required, and there is no need for high-level sensory unacceptable. Cultural beliefs may dictate when, who, or cognitive functioning. When all else fails, touch is and how people may touch. If there is any question left. Caring touch is a basic need for all humans, and regarding the appropriateness of touch, clarification many older adults suffer from touch deprivation. should be obtained beforehand. Many older people have no one to meet this need. Research shows that psychotic patients and older SILENCE adults are touched the least by caregivers. Those who Saying nothing is also saying something. Being with most need physical contact and the comfort provided another person and remaining silent is difficult for by touch receive the least. many people, including nurses. At times, words can be intrusive; they can interfere with true communication. Use of touch as a method of communication is often Many times, older adults require more time to compose difficult and uncomfortable, particularly for young or their thoughts. Silence permits them to focus on the inexperienced nurses. Touching is a very personal point of discussion, while continuous talking is dis- form of communication. Affection, understanding, tracting. At times, no words are necessary; silence is trust, hope, and concern can be communicated by a therapeutic. During intense grief, pain, or anxiety, hand placed on a shoulder, a stroke of the forehead, or simply being there without saying or doing anything a frail hand held by another stronger one. Touch is a may be the most appropriate form of communication common method of expressing concern and caring. you can give. The simple presence of another human People who are emotionally close hold hands and expresses true concern and can be worth more than all touch and hug one another. High on the list of things of the words in the world. lonely older people say they miss are hugs and touch- ing. Empathetic use of touch is a much-needed skill ACCEPTANCE, DIGNITY, AND RESPECT when working with older adults. When words do not IN COMMUNICATION work, touch often does (Figure 5-2). If there is any doubt whether the patient wants to be touched, the Empathy is defined as the willingness to attempt to nurse can ask or watch how the person responds to the understand the unique world of another person. It is touch. Touching should be done with caution when a the ability to put oneself in another person’s place and to understand what he or she is feeling and thinking FIGURE 5-2 Comfort and well-being can be promoted with eye in that situation. Empathetic listening involves actively contact and gentle touch. (From deWit SC: Fundamental concepts trying to truly understand the other person. and skills for nursing, ed 4, St. Louis, 2014, Saunders.) Effective communication starts with proper intro- ductions. Determine how each older adult wishes to be addressed. It is presumptuous to become too famil- iar with older adults by addressing them by their first names. It is better to start by using the older adult’s proper title and name (e.g., Mrs. Quinn and Dr. Jones) and then clarifying which form of address the person prefers. If someone wishes to be called by a first name or a nickname, the person will usually say so. In special situations, such as when a patient has dementia or other alterations in cognition, first names may be most appropriate, because that may be the only name the person can remember. People who are unskilled at working with older adults may use a sing-song voice, use inflection to make statements sound like questions, or refer to older adults by “baby talk” names such as “sweetie” or “honey,” thinking that this conveys affection and caring. This type of speech may be appropriate with young children, but it is patronizing and demeaning
94 UNIT II Basic Skills for Gerontologic Nursing and really talk with older patients more often. Empathetic listening requires the ability to focus on the to older adults and inappropriate. This type of com- aging person, not simply on the tasks at hand. If we munication, sometimes called Elderspeak, is a form of do not really listen, our older patients are likely to stop ageism. Elderspeak also includes incorrect use of the talking and we will all be poorer for the loss. pronoun we—as in “Are we ready to get dressed now?” when the correct pronoun would be you. Elderspeak BARRIERS TO COMMUNICATION should always be avoided, because it has a subtle way of diminishing an older person’s self-esteem. Use a For effective communication, we must learn to identify normal conversational tone of voice whenever possi- the barriers that can interfere with an exchange and ble. Avoid language that stereotypes or dehumanizes the methods that help overcome these barriers. the older adult. Such language may be overheard by Effective communication is not easy. More than just the the older patient or family members, who may inter- ability to talk to someone, communication involves all pret it as disrespectful. It is best to first speak in terms of the ways that we send messages to someone else, of the person; for example, refer to “Ms. Todd, who has including nonverbal ways. Different physical prob- diabetes”—not the “diabetic in bed 14B.” Also, be lems require different communication approaches. mindful of the possible negative connotation that Communication makes use of all of the senses. Hearing words can have to older adults or their family members; and vision are the senses used most often in commu- substitute more positive terms when possible. For nication, but touch, smell, and even taste also play a example: part in the relay of messages. It is important to remem- • Instead of diapers, say briefs, pads, or use a trade ber this when communicating with older adults, because their perceptions may be altered by normal name, such as Depends. physiologic changes that occur with aging. Pain or • Instead of blind or deaf, say visually or hearing- extreme fatigue may make communication difficult. It is best to limit conversation to essential topics during impaired. these times. A variety of disease processes, such as • Instead of senile or dementia, say cognitively strokes and dementia, significantly affect communi cation processes and require specific approaches. challenged. Diverse social and cultural backgrounds of older • Instead of nursing home, say care facility. adults also make the area of communication a chal- lenge for nurses. Communication Coordinated Care Listen… There is a reason we have two ears and only one mouth. We Communication Skills are supposed to listen twice as much as we talk! SUPERVISION When it is necessary to correct a subordinate for unsatisfactory To communicate effectively, we must first learn to performance, try to avoid “you” messages, such as “You never listen actively and empathetically. Listening is more complete your assignments.” Instead, use assertive “I” mes- than simply hearing. Hearing involves the ability of sages, for example, “I am upset and disappointed when the ears to detect sound, whereas listening involves patients’ needs are not thoroughly met.” This is less likely to interpretation (i.e., figuring out what the sounds result in an argument and will more likely lead to problem mean). We have not really listened until we under- solving. Also, be sure to praise people in public but correct stand for certain what was intended by the speaker. them in private. We cannot simply listen to the words; we must listen for the meaning of the words. HEARING IMPAIRMENT If the person wears a hearing aid, make sure that it is Active listening skills are needed in all areas of clean, that the batteries are working, and that the nursing, but particularly in dealing with older adults. device is in the correct ear. Try to minimize background Empathetic listening requires sensitivity to the noise because this can distort sounds and make hearing strengths and limitations of the aging individual (e.g., more difficult. Many people who are hearing impaired hearing changes, vision changes, fatigue, and pain). spontaneously begin to read lips. In addition to the Empathetic listening involves patience when an older basic strategies, the following actions are likely to be adult needs extra time to voice a response, or repeats beneficial: the same thing many times. It includes a willingness 1. Stand in front of the person, at eye level. to spend time getting to know the older adult better as 2. Do not eat or drink while you are having a a human being, not just as another body in need of skilled physical care. Listening to an older person rem- conversation. inisce about his or her life can help the nurse gain better understanding of the person’s values, percep- tions, strengths, needs, and concerns (Chapter 11). Too often, nurses provide excellent physical care to people they have not taken the time to know. Nurses need to stop talking “over” patients while they do procedures, put away their clipboards, and sit down
Communicating with Older Adults CHAPTER 5 95 FIGURE 5-3 Communication with the elder with a vision or hearing APHASIA deficit. Sit in front of the patient where your lips can be seen to Individuals who have had a stroke or other head inju- communicate. (From deWit SC: Fundamental concepts and skills for ries may experience aphasia, which is a partial or total nursing, ed 4, St. Louis, 2014, Saunders.) loss of the ability to use or understand words. It affects the ability to understand and express oneself through Box 5-1 Basic Strategies for Communicating with words, gestures, and writing but does not necessarily Impaired Older Adults affect intellectual function. Consultation with a speech therapist can help the nurse devise approaches that • Try not to startle the person when starting a will optimize function. In addition to the basic strate- communication. gies, some commonly recommended approaches include the following: • Identify yourself; remind the person who you are. 1. Keep messages simple but adult. • Communicate when the person is most alert. 2. Use nonverbal modes of communication, such as • Eliminate or reduce noise and distractions. • Make sure you have the person’s attention before picture boards, gestures, yes/no responses, and facial expressions. speaking. 3. Use visual aids to support. • Focus on abilities, not disabilities. 4. Try increasingly specific guesses or questions to • Select topics of interest to the person. determine concerns (e.g., Is something wrong with • Use a variety of words or descriptions until meanings your meal? The coffee? It’s too hot? You want milk?). 5. Praise attempts to speak, and avoid correcting or are clear. criticizing errors. • Ask clear, specific questions; one question at a time. 6. Reassure the person that it is okay to be frustrated, • Pay attention to the emotional context of but avoid empty platitudes such as “You’ll be fine.” One intervention worth trying when working with conversation. an aphasic patient: singing. A different part of the • Use pictures and gestures in addition to words. brain is used for singing than is used for speaking. • Have the person sit up for conversation whenever You may find that while speech is hesitant and difficult for an aphasic patient to produce, singing an old possible. Keep messages simple and repeat as familiar song with the patient may lead to a surpris- needed. ingly fluid verbal output. Researchers are studying • Do not interrupt. Maintain a slower pace of the use of singing therapy, and some stroke patients communication. have shown great progress in their speech recovery • Make sure the person doesn’t have any other needs (Knox, 2011). before you leave. DEMENTIA 3. Keep your hands away from your face when Dementia causes both cognitive and language deficits. speaking. The older person suffering from dementia has no control over these changes, so the responsibility for 4. Try different ways (words) of saying the same thing. effective communication rests with the nurse. Depend 5. Speak more slowly and slightly louder while modu- ing on the severity of the dementia, the individual may demonstrate different levels of function. The abilities lating the voice to a lower pitch. and limitations of each individual suffering from 6. Avoid exaggerated mouth motions during speech. dementia must be evaluated, so that the most effective 7. Use visual cues or written materials that support interactions can be planned. Some characteristics of dementia include a limited attention span, inability to the spoken words (Figure 5-3). focus on more than one thought at a time, confusion Box 5-1 provides additional strategies for communicat- of fact and fantasy, and the inability to follow complex ing with impaired older adults. instruction. According to the Alzheimer’s Association, “For persons with dementia, behavior is frequently a form of communication.” Problems with communi- cation can result in agitation, restlessness, abusive language, or combativeness. Repetitive vocalizations, urgency, and change in tone or pace of speech can indicate an unmet need, even when the sounds are meaningless. Try to determine the meaning of the behavior, not ignore it as meaningless. In addition to the basic strategies, some recommended approaches include:
96 UNIT II Basic Skills for Gerontologic Nursing Immigrants from many European, Central American, African, and Asian countries bring varied levels of 1. Talk about one thing or ask only one question at English proficiency, which presents us with communi- a time. cation challenges. To communicate effectively, we need to know what language a person speaks. We also need 2. Limit choices; too many options are confusing. to know what level the person is most comfortable 3. Keep the conversation in the here and now. using because, during times of stress, a person may 4. Ask simple yes/no questions. revert to his or her first language. Facilities that accept 5. Try “filling in” or “repairing” thoughts. Rather federal funds (such as Medicaid) are legally required to provide language access to all patients (O’Neill, than letting a person get upset trying to find the 2014). To be an effective interpreter, a person needs to right words, you may offer some likely choices. be proficient in both languages, have an understand- However, be careful not to get in the habit of fin- ing of the clinical concepts they are expected to explain, ishing the thoughts and sentences of patients who and trained regarding the ethics of the job. A study are not cognitively impaired. done in a pediatric setting revealed that even official 6. Avoid asking questions that require information or interpreters made many serious errors that were poten- recall, such as “How was your day?” tially dangerous, although most studies do note that 7. Use gestures or demonstrate an action so that the even more mistakes are made with “unofficial” or ad person can mimic your behavior. hoc interpreters, such as family members. Family and 8. Avoid the use of an intercom, which may confuse friends of the patient do not have formal training the person. and may bring personal and emotional connections 9. Avoid arguing if the person does not accept your that could influence the communication or make the reality. patient reluctant to share information. Although family 10. Redirect the person who is acting out to a more members are not the most appropriate persons to appropriate activity. interpret sensitive or technical medical information, 11. Share activities such as looking at a magazine, they may be helpful in translating simple nonmedical viewing family photos, or listening to music. questions or requests. 12. Avoid trying too hard to communicate. If words do not work, try gentle touch. Some basic rules to keep in mind when working 13. Watch your tone of voice because patients with with an interpreter include the following: dementia are often very sensitive to nonverbal • Ask short questions and provide brief units of infor- cues and may sense your frustration and become more agitated or upset. mation so that the interpreter does not lose the main idea in translation. CULTURAL DIFFERENCES • Avoid excessively technical language. A Chinese guide in Beijing asked his tour group (in • Avoid slang, idioms, or colloquial expressions. very clear English), “What do you call a person who • Encourage the interpreter to give you the response speaks more than one language?” The group replied, using the patient’s own words, without input or “Multilingual.” He then asked, “What do you call a paraphrasing, whenever possible. person who speaks only one language?” The group • Focus on the patient, not the interpreter. was not sure how to reply, so he provided the answer: • Listen for emotional tone and nonverbal clues when “Americans.” Although this is rather a strong general- the patient responds, even if you do not understand ization, the majority of Americans still speak only one the words. language: English. We tend to expect everyone else, no • Allow enough time. matter where we are in the world, to understand us. • Make sure that there is mutuality by encouraging If others do not speak English, Americans’ typical the patient to ask questions of the staff through the response is to talk more loudly, as if volume will make interpreter. a difference. Fortunately (or, some would say, unfortu- In addition to making adaptations for language, nately), most other countries have a significant number pay close attention to nonverbal communications. of people with some knowledge of English in addition Ignorance of cultural beliefs and practices can lead to to their native language. mistakes that damage rapport. When in doubt, ask the older adult or family if there are any special actions or Cultural Considerations behaviors that should be avoided. Critical Thinking Language Courses for Health Care Workers Many community colleges and multicultural centers offer special courses in languages for health care providers. Often, Culture, Ethnicity, and Communication these courses are specifically designed to meet the needs of the local community. This benefits the minority communities as • Which cultural or ethnic group(s) do you consider yourself well as the nurses, who have the opportunity to become par- to be part of? ticularly desirable employees. • List all of the cultural or ethnic groups with whom you occasionally or regularly have contact.
Communicating with Older Adults CHAPTER 5 97 • Consider the cultural or ethnic group with which you become defensive. Many students and new nurses identify. approach patient assessment with a list of 50 questions • Identify any gestures you consider acceptable. that must be answered. After the first 10 questions, • Is direct eye contact typical? Are there times when patients begin to feel as though they are on trial and direct eye contact is not considered appropriate? communicate only the bare minimum of information. • How close do people stand when talking to each other? Direct questions tend to yield brief answers and often • Do people touch frequently? Whom do they touch? a yes or no only. Where or how do they touch? What type of touch is not allowed? Are there gender differences related to USING OPEN-ENDED TECHNIQUES touching? Open-ended communication techniques include open- ended questions, reflective statements, clarifying state- • Do you live primarily in the “here and now,” or do you ments, and paraphrasing. These techniques allow the think it is essential to plan for the future? patient more leeway to respond, thus establishing a more empathetic climate. The patient is more likely to • How important is it in your culture to be on time and keep feel that you are interested in him or her personally appointments? Does this differ between social situations and not just trying to fill out a stack of forms. Examples and business situations? of open-ended techniques include the following: “And after you moved to the nursing home, what hap- • Do you feel comfortable or ill at ease when communicating pened?”; “And then?”; “That must have been frighten- with individuals from other cultures? Does your comfort ing!”; “What I heard you say is …”; “It sounds like you level change when the interaction is one-on-one or when think (feel)…” Open-ended techniques allow patients you are in a group? Does it change if you are the only to express more about their feelings and perceptions. member of a specific culture or ethnicity in a group They also allow verification that the information being dominated by another culture or ethnicity? relayed is accurate. • Identify two or three situations in which you felt that a CONFRONTING person from another age, cultural, or ethnic group did not Confronting is used when there are inconsistencies in understand you or misinterpreted your nonverbal information or when verbal and nonverbal messages communication. appear contradictory. Confrontation is one of the most difficult communication techniques to use and should • Identify two or three situations in which you felt that you be used only after good rapport has been established. did not accurately understand the communication sent by It is never advisable to confront a highly agitated or a person from another age, cultural, or ethnic group. confused person, because conflict and a breakdown in communication will result. Confrontation should be • Can you think of any specific beliefs or practices from your used only when there is adequate time to explore the culture that you would want a nurse caring for you to problem and come to some form of resolution. understand? COMMUNICATING WITH VISITORS SKILLS AND TECHNIQUES AND FAMILIES Be prepared to interact with the friends, family INFORMING members, and visitors of your patient. These people make up the older adult’s social network and support Informing uses direct statements regarding facts. A system. Families and friends are interested and con- good information statement is clear, concise, and cerned about what is happening to their loved ones. expressed in words the patient can understand. When Not only do they turn to nurses for information and the nurse is informing, the nurse is active and the reassurance, but they can also be a good source of patient is passive. Informing is the least effective form information. of communication because the patient is not actively involved. When giving information, ask the patients to These significant others, as they are often called, restate what they understand using their own words. can help in many ways if nurses are responsive to A message may need to be repeated and rephrased to them. Many of the older adult’s significant others are ensure understanding. This should be done tactfully themselves senior citizens. Communication with these and with care not to show signs of annoyance or individuals may also require special attention and the frustration. use of special techniques. It is important to take the time to develop good rapport with your patients’ sig- DIRECT QUESTIONING nificant others. Good communication with these important people can do a great deal to facilitate care. It is best to keep communication conversational and Because they have known the patient longer and better not too aggressive. Too many direct questions can than the nursing staff, they are often able to detect overwhelm an older person and may block rather than expand communication. Direct questioning is helpful when nurses need to obtain specific information or in emergency situations when time is precious. Direct questions tend to include the words who, what, when, where, do you, and don’t you. Direct questioning is appropriate when information must be obtained quickly; however, if it is overused, patients may
98 UNIT II Basic Skills for Gerontologic Nursing • Respond to the person’s emotional reaction, for example, “I’ll try to help you. Is there anything I can subtle changes before trained nurses can. Many times, do?” or “Do you want to talk about how you’re nurses need to rely on the significant others to inter- feeling?” pret the behaviors and communications of older adults. Listen to what they have to say. • Develop a follow-up plan. Help the older person and significant others with appointments, referrals, Critical Thinking transportation, and so forth. • Communicate significant information to other care- givers as part of a plan of care. Communication Skills • Look at the people on each side of you in class. What is HAVING DIFFICULT CONVERSATIONS Emotionally loaded topics are likely to generate strong their body language communicating? emotions and often lead to conflict. Conflict is a normal • Think of a person you consider to be a good and routine part of human interaction; it can occur between older adults and adult children, nurses and communicator. Next, think of a person you consider to be older adults, nurses and patients’ families, nurses and a poor communicator. Fold a piece of paper in half. Write other nurses, or nurses and physicians. Difficult con- the name of the effective communicator on one side and versations may occur in clinical areas or in home set- the ineffective communicator on the other side. Below tings involving friends and family members. each name, list the characteristics that make that communicator effective or ineffective. Compare and Some people prefer to avoid conflict entirely and contrast your findings. pretend it does not exist, but avoidance just delays • Compare your own communication skills to those of the solving problems that need to be addressed. The fol- people whose names you wrote down. Which one are you lowing guidelines are suggestions based on conflict more like? How? What can you do to become more resolution research: effective in your communication ability? • Pick a place that is private and a time when you will DELIVERING BAD NEWS be free from distractions. No one likes to get bad news, and no one likes to be • Try to focus on a single topic; do not bring up old the one who has to tell someone else bad news. Most people try to avoid this daunting task. Ideally, this task grievances that get in the way. should be performed by the most experienced and • If a conversation is not going well, take a look at knowledgeable person, such as the physician, but, occasionally, the nurse must be the one to break bad your own feelings and motivations. Are you react- news to an older adult. This could be information ing to this issue or to another issue that was prob- regarding the patient’s health or about someone close lematic in the past? to the patient, for instance, the death of a spouse or • Express your feelings using “I” statements, such as other loved one. The EPEC Project, funded by the “I get upset when … doesn’t get done” rather than Robert Wood Johnson Foundation, has developed “you” statements, such as “You always ignore what guidelines for physicians that have relevance for I ask you to do.” nursing practice. Important concepts include the • Respect the right of the other person to agree or following: disagree. • Prepare yourself. Make sure you have all of the • Keep a balance between talking and listening. Try not to dominate the conversation. information and that it is accurate. • View each communication as a new opportunity to • Think through what you want to say so that the learn something about the other person and about his or her unique feelings, beliefs, and perspectives. message is compassionate and culturally sensitive. Listen to the other person and seek clarification as • Establish an environment respectful of patient’s to his or her reasons and feelings. • Do not prejudge or assume that you already privacy. know what the person is going to say. You may • Determine whether anyone else (chaplain, family be wrong. • Be aware of your own feelings regarding the issue members, etc.) should be present when the news is under discussion. Keep feelings separate from facts. delivered. The fact that someone does not do what you want • Make sure there is adequate time, free from inter- does not mean that the person does not like you or ruptions, to deal with the expected emotional that he or she is doing it to upset you. response. • Avoid blaming the other person. Look for ways to • Determine what the person already knows and, if solve disagreements. possible, how much they want to know. • Accept that difficult conversations are part of life • Recognize that ethical and cultural variations may and that things do not always go right. influence the way information is delivered. • Use simple, direct, but sensitive language to begin the message, such as, “I’m afraid I have bad news for you.”
Communicating with Older Adults CHAPTER 5 99 • Learn from both negative and positive interactions, Box 5-2 Additional Tips for Improving and try to improve future communication. Nurse-Physician Communication • Try to achieve a win-win solution. • Work at developing professional relationships. • Know what you want to find out or report when IMPROVING COMMUNICATION BETWEEN OLDER ADULT AND PHYSICIAN calling. Clear communication between the older adult • Assume that you are both on the same team. and their physician is essential. Most physicians are • Report good news, not just problems and bad news. aware of effective communication protocols, but, • At some point, try to meet face to face with because of time constraints or other factors, they may not always use these techniques. Ineffective commu physicians you speak with on the phone. nication can result in frustration for both parties and • Do not seek out conflict, but be prepared that it may can contribute to a lack of adherence by the patient. Also, it is not uncommon for an older adult to become happen occasionally. passive, evasive, or tentative when talking with the physician. Adapted from Burke M, Boal J, Mitchell R: Communicating for better care: Improving nurse-physician communication. American Journal of Nursing, The nurse can often help minimize these problems 104:40, 2004. by (1) suggesting that the patient keep a written list of concerns and questions so nothing is forgotten; (2) Box 5-3 Example of ISBAR-R Communication asking the physician to repeat and summarize direc- tions to the patient; (3) identifying printed materials INTRODUCTION: Hello, I’m May, the evening shift that support the physician recommendation; (4) sug- nurse, are you ready for shift report on Mrs. Reynolds gesting that a trusted friend or family member be in room 168A? present to take notes and help the older adult express concerns; or (5) acting as a patient advocate by asking SITUATION: You are communicating the 11:00 P.M. the physician to clarify questions or concerns the change-of-shift report for a long-term patient who had patient has verbalized to you. suffered a stroke and requires total care. COMMUNICATING WITH PHYSICIANS BACKGROUND: Mrs. Reynolds, a former lawyer, is a The quality of communication between nurses and 57-year-old patient who was admitted in this facility physicians can have a significant impact on the quality two years ago after her stroke. Three days ago, Mrs. of care older patients receive. Communication prob- Reynolds spoke her first 2 words since her stroke. lems between nurses and physicians can lead to job Her physician has ordered speech therapy to work frustration, blame, and distrust, all of which diminish with her twice a week. She is on a soft diet with the level of care provided and increase the risk for thickened liquids. During speech therapy, she can problems or errors. Conversely, good communications become upset and teary if she gets overwhelmed. tend to improve job satisfaction, decrease errors, and Her family resides 2,000 miles away and visit every 6 promote quality care of the older adult patients. months. She keeps a stuffed Care Bear by her side at Physicians and nurses are busy. No one has time to all times. waste on unnecessary or nonproductive interactions. Mutual respect and a willingness to collaborate for the ASSESSMENT: Mrs. Reynolds is alert and responds good of the older adult can form a strong basis for to her name with eye contact. T 97.8°, P 80, R 24, good interactions. The nurse can use many strategies BP 127/81, O2 saturation 97% on room air. G-tube to decrease frustrations and optimize the efficiency placement confirmed, patent, and flushed with 10 mL and effectiveness of communication (Box 5-2). residual. During dinner, Mrs. Reynolds grasped the spoon in her left hand but required assistance bringing Many of the difficulties in nurse-physician commu- it to her mouth. nication have to do with our differences in training. Nurses are taught to communicate in narrative form, RECOMMENDATION: Monitor VS twice a shift. Check including all possible details. Physicians are taught patency of G-tube before medications and beginning more of a “bullet point” style of communication, overnight feeding. Allow her to grasp items as hand conveying brief descriptions of key elements. Many exercise. Perform light ROM exercises and administer facilities now promote the ISBAR-R communication antianxiety medication before bedtime. Provide a skin for improved communication that is concise, yet check during your shift. complete. ISBAR-R is an acronym that stands for Introduction, Situation, Background, Assessment, READBACK: Ask receiving nurse if there are any Recommendation, and Readback (Box 5-3). As one questions and to read back notes for clarification. nursing student noted, “nurses write novels, doctors From de Wit S, O’Neill PA: Fundamentals of Nursing, ed 4, St. Louis, 2014, Saunders. BP, Blood pressure; G-tube, gastrostomy tube; P, pulse; PRN, as needed; R, respirations; ROM, range of motion; T, temperature; VS, vital signs. write ‘Cliffs Notes;” ISBAR-R is where they meet in the middle” (Yee, 2013). When you call a physician, start by identifying who you are (name and title), the patient or patients you are calling about, and the specific reason for the contact.
100 UNIT II Basic Skills for Gerontologic Nursing Adult learners are oriented toward problem solving, and they view learning as most desirable when it is Plan ahead and have a focus for the communication. relevant to their own lives. Teaching will be most effec- Gather any assessment data you might need before tive when the patient recognizes and accepts the calling the physician. Know what you want to report importance of learning new information or techniques. or find out. Be organized, clear, precise, and complete. Older adults will be more willing to learn when the Provide background information. Remember, the phy- topic is important to them. For this reason, the nurse sician is not looking at the chart and may see the older should try to determine ahead of time those things the adult once a month, or even less frequently in the case older patient thinks are most important. Prioritize of an independent older adult. Provide all necessary teaching by starting with the area that the patient per- and relevant information that might be needed. ceives to be most important, then linking that informa- Identify the patient by name, major diagnoses, and any tion to the other things the nurse thinks are necessary medications related to currently presenting symptoms or important. Work in small, discrete blocks of infor- or concerns. Be prepared to clarify any data or infor- mation, proceeding from simple, more familiar con- mation that the physician may request. cepts to more complex or difficult ones. Success breeds success: when older adults realize that they have mas- Keep a list of issues to be reported or discussed with tered one skill or piece of information, they are more each physician so that all issues can be covered in one likely to have a positive attitude toward additional interaction. This will prevent repetitive interruptions learning. for both the physician and the nurse. Identifying parameters (or guidelines) when the physician wishes Choose the right place and time for teaching. The to be contacted (e.g., patient’s blood sugar over 200 right place depends on the material the session will and blood pressure under 120 systolic) can minimize cover. Information that is viewed as personal or private problems related to under or over notification. is best taught in a quiet space away from others. More general information (such as nutrition teaching or Emergency situations need to be handled immedi- stress reduction) may be best taught in a group, where ately, but these make up a small portion of nurse- older adults are free to share personal experiences and physician interaction. Most communications involve solutions with others. Wherever teaching takes place, either routine or somewhat urgent information that the space should be adjusted for the older adult. The can be handled in a more methodical, planned manner. temperature should be set appropriately, chairs should It is helpful to determine whether there is a best time be supportive and comfortable, lighting should be and method to use when contacting the physician adequate and free of glare, and bathrooms should be regarding nonemergency situations, such as tele- readily accessible. Snacks and beverages are appreci- phone, cell phone, Fax, e-mail, texting, or others. ated by most older adults and can make a group learn- Planning ahead to identify the best time and methods ing session a positive social interaction. approved by your facility will optimize communica- tion and enhance care of the patient while minimizing When selecting a teaching time, avoid times when frustration. the patient is stressed, fatigued, or in pain; all of these PATIENT TEACHING situations interfere with the patient’s ability to process Education plays an important role in promoting and information accurately. Also, avoid times when older maintaining the health of older adults. Teaching may adults may be distracted by things of higher priority be a one-on-one session or a group experience. The to them, such as a favorite television show or antici- ability to teach, explain, and motivate is increasingly pated visit from friends or family. When selecting a part of the role of today’s nurse. To perform this role time for teaching, make sure there is adequate time to successfully, you need to know basic principles and discuss the important information. Remember that techniques of adult education and adaptations specific older individuals will need more time to process infor- to older adults. mation. Avoid trying to teach too much at one time. Break teaching into manageable blocks of concepts to It has been said that “you can’t teach an old dog allow time for reflection and learning. Whenever pos- new tricks.” Research has shown that this is not true. sible, provide printed materials to supplement and Older adults can learn new things. It has been estab- reinforce the content (Box 5-4). Practical examples or lished that mental abilities, such as numeric tasks, illustrations may be more effective than a quick recita- word fluency, inductive reasoning, and spatial orienta- tion of facts. If the teaching involves a psychomotor tion develop through the first four decades of life and skill, such as drawing up insulin or changing a dress- then hold fairly stable until the seventies in most indi- ing, the older adult should receive one or more dem- viduals, even longer in others. Although younger indi- onstrations of the skill and then be given ample viduals tend to do better at learning information that opportunities to practice and perform the skill with requires memorization, older individuals compensate supervision. Be patient and supportive, regardless of by using the verbal skills, experience, and judgment the amount of time needed. Remember, the goal is they have acquired over time. Learning is maximized learning, not speed. when it can draw on the previous experiences of older adults.
Communicating with Older Adults CHAPTER 5 101 Box 5-4 Modification in Preparing or Selecting information, and use visual cues or materials to Printed Materials for Older Adults reinforce a verbal message. Reinforce verbal informa- tion with printed material and audiovisual aids, such • Limit the amount of material on a single page. as videos. Encourage hands-on practice. Use as many • Allow enough white space so that material is clear senses as possible, but not necessarily all at once, as this may be confusing. and distinct. • Use at least a 12-point font for printed materials. Clinical Situation • Use thicker letters rather than fine print. • Avoid elaborate fonts; stick with simple, basic lettering. Communicating with Older Adults • Stick to one style of font per document. A physician and a clergyman happened to arrive in an older • Use a normal mixture of capital and small letters. adult’s room at the same time. The patient became very • Select paper and ink of strongly contrasting colors. anxious and started to cry. The physician and the clergyman were taken aback because the patient was doing well and was Modifications may be needed to compensate for ready for discharge. After much time was spent calming the common sensory changes experienced with aging. patient and listening carefully, they realized that the patient Face older individuals when speaking. Speak clearly. responded as she did because she thought the doctor was Try to avoid microphones or amplifiers that might going to tell her that she was dying and that the clergyman distort sounds or interfere with hearing aids. Repeat was there to console her. Get Ready for the NCLEX® Examination! Review Questions for the NCLEX® Examination Key Points 1. Which interventions would be appropriate when teaching a client with presbycusis? (Select all • Keys to effective communication include knowing the that apply.) other person and having respect for his or her 1. Stand on the affected side. uniqueness. 2. Speak much more loudly. 3. Use “Elderspeak.” • To develop rapport and communicate effectively with 4. Provide audiovisual tapes. older adults, nurses must identify sensory changes that 5. Repeat information. can interfere with the transmission of messages and 6. Face the client when talking. cultural or age-related values that can result in 7. Ensure adequate lighting. misunderstandings. 2. Which actions are most likely to enhance • Nurses must accurately recognize and interpret both communication with an older adult? (Select all verbal and nonverbal messages being sent by older that apply.) adults, their families, and their friends. Nurses also 1. Identify yourself; remind the person who you are. must be aware of the messages they themselves are 2. Ask many questions to find out about the person. sending. 3. Play music or turn on the TV to help the person relax. 4. Use friendly terms like Dearie. • The desire to interact effectively with others, patience, 5. Stay in the living area where other people are around. acceptance, respect, empathy, and the use of 6. Use pictures and gestures in addition to words. appropriate communication techniques are essential 7. Be patient and avoid interrupting. parts of effective nursing practice. 3. The nurse tries to use communication techniques that • Specific approaches and adaptations are needed to are most effective at establishing an empathetic promote effective communications with older climate. Which is the most effective method to use? individuals experiencing sensory and cognitive 1. Open-ended responses changes. 2. Direct questioning 3. Informing • Effective communications with physicians are important 4. Confrontational responses for quality patient care. 4. When are older adults most responsive to teaching? • Communication through teaching is part of the nurse’s 1. When the information is interesting role in health promotion and management. 2. When the information is new 3. When the information is relevant to their lives Additional Learning Resources 4. When the information is presented well Go to your Evolve website at http://evolve.elsevier .com/Williams/geriatric for the additional online resources.
chapter 6 Maintaining Fluid Balance and Meeting Nutritional Needs http://evolve.elsevier.com/Williams/geriatric 6. Identify the older adults who are most at risk for problems related to nutrition and hydration. Objectives 7. Select appropriate nursing diagnoses related to nutritional 1. Identify the various types of nutrients. or metabolic problems. 2. Discuss the components of a healthy diet for older adults. 3. Describe age-related changes in nutrition and fluid 8. Identify interventions that will help older persons meet their nutrition and hydration needs. requirements. 4. Examine age-related changes that affect nutrition, frailty syndrome (p. 110) hematocrit (hē-MĂT-ŏ-krĭt, p. 115) digestion, and hydration. hemoglobin (HĒ-mō-glō-bĭn, p. 115) 5. Describe methods of assessing the nutritional status and interstitial (ĭn-tĕr-STĬSH-ăl, p. 120) intracellular (ĭn-tră-SĔL-ū-lăr, p. 120) practices of older adults. intravascular (ĭn-tră-VĂS-cū-lăr, p. 120) malnutrition (măl-nū-TRĬSH-ŭn, p. 110) Key Terms minerals (MĬN-ĕr-ălz, p. 107) nasogastric (nā-zō-GĂS-trĭk, p. 119) anemia (ă-NĒ-mē-ă, p. 106) proteins (PRŌ-tēnz, p. 104) basal metabolic rate (BĀ-săl mĕt-ă-BŎL-ĭk rāt, p. 103) supplement (SŬP-lĕ-mĕnt, p. 119) blood urea nitrogen (blŭd ū-RĒ-ă NĬ-trō-jĕn, p. 115) trace element (p. 109) body mass index (p. 103) vitamins (VĪ-tă-mĭnz, p. 106) calories (KĂL-ŏ-rēs, p. 102) carbohydrates (kăr-bō-HĪ-drāts, p. 104) complementary proteins (p. 105) complete proteins (p. 105) creatinine (krē-ĂT-ĭ-nēn, p. 115) dietary reference intakes (DRIs) (p. 104) dysphagia (p. 124) edema (ĕ-DĒ-mă, p. 120) electrolyte (ē-LĔK-trō-līt, p. 115) Nutrition plays an important role in health mainte- knowledgeable about basic nutrition and diet therapy. nance, rehabilitation, and prevention and control of Good nutrition practices play a vital role in health disease. When dealing with nutritional issues, nurses maintenance and health promotion. Good eating habits who work with older adults must consider the follow- throughout life promote physical wellness and mental ing: (1) the basic components of a well-balanced diet well-being. Inadequate nutrition and fluid intake can for older adults; (2) how the normal physiologic result in serious problems such as malnutrition and changes of aging change nutritional needs; (3) how the dehydration. Poor nutrition practices can contribute to normal physiologic changes of aging may interfere the development of osteoporosis and skin ulcers, and with the purchase, preparation, and consumption of can complicate existing conditions, such as cardiovas- nutrients; and (4) how cognitive, psychosocial, and cular disease and diabetes mellitus. pathologic changes commonly seen in aging impact one’s nutritional status. CALORIC INTAKE Calories are units of heat that are used to measure the NUTRITION AND AGING available energy in consumed food. Because people’s energy requirements differ widely, the number of calo- Nutritional needs do not remain static throughout ries they require also differs significantly. Many factors life. Like other needs, older adults’ nutritional needs influence how many calories will be used by a person: are not exactly the same as those of younger individu- activity patterns, gender, body size, age, body tem- als. An understanding of older adults’ nutritional perature, emotional status, and the temperature of the needs is essential to providing good nursing care. climate in which the person lives. Both acute and To assess nutritional adequacy and select interven- chronic illnesses also have an impact on caloric needs. tions that promote good nutrition, nurses must be In general, when a person’s caloric intake is in balance 102
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 103 with the energy needs of the body, his or her weight BMI (kg/m2) Weight (pounds) ϫ 703 remains constant. When caloric intake exceeds energy ϭ Height (inches)2 needs, the excess is converted into adipose (fat) tissue for storage, and the individual gains weight. When Weight in Pounds caloric intake is less than the energy needs, the person 120 130 140 150 160 170 180 190 200 210 220 230 240 250 loses weight. Height in Feet and Inches 4’6 29 31 34 36 39 41 43 46 48 51 53 56 58 60 Various nutrients provide different amounts of calo- 4’8 27 29 31 34 36 38 40 43 45 47 49 52 54 56 ries. Fats, which can come from either plant sources 4’10 25 27 29 31 34 36 38 40 42 44 46 48 50 52 (e.g., oleomargarine) or animal sources (e.g., butter), 5’0 23 25 27 29 31 33 35 37 39 41 43 45 47 49 yield 9 calories/g. Proteins and carbohydrates yield 5’2 22 24 26 27 29 31 33 35 37 38 40 42 44 46 4 calories/g. Vitamins, minerals, and water yield no 5’4 21 22 24 26 28 29 31 33 34 36 38 40 41 43 calories. Alcohol yields 7 calories/g and has no nutri- 5’6 19 21 23 24 26 27 29 31 32 34 36 37 39 40 tional value. 5’8 18 20 21 23 24 26 27 29 30 32 34 35 37 38 5’10 17 19 20 22 23 24 26 27 29 30 32 33 35 36 Studies have shown that caloric needs in healthy 6’0 16 18 19 20 22 23 24 26 27 28 30 31 33 34 individuals decrease gradually with age, as there is a 6’2 15 17 18 19 21 22 23 24 26 27 28 30 31 32 decrease in muscle and lean tissue mass and an increase 6’4 15 16 17 18 20 21 22 23 24 26 27 28 29 30 in adipose tissue. With these muscle and fat changes, 6’6 14 15 16 17 19 20 21 22 23 24 25 27 28 29 the basal metabolic rate (the rate at which the body 6’8 13 14 15 17 18 19 20 21 22 23 24 25 26 28 uses calories) decreases. The normal decrease in physi- cal activity commonly seen with aging further slows Underweight Normal Overweight the rate at which the body burns calories. Healthy weight individuals who maintain an active lifestyle that includes exercise may see little need to change their Obese Severely caloric intake. Inactive individuals may need to restrict obese caloric intake significantly. The lowest recommended daily intake to adequately meet nutritional needs is FIGURE 6-1 Body mass index (BMI) chart. (From Lewis SL, Dirksen 1,200 calories. SR, Heitkemper MM, et al: Medical-surgical nursing: Assessment and management of clinical problems, ed 9, St. Louis, 2015, When determining the adequacy of caloric intake, Mosby.) disease processes must be considered. Diseases that result in restricted mobility and physical activity (e.g., determined by comparing his or her intake to accepted arthritis and stroke) are likely to decrease caloric needs. standards. Based on the current Dietary Guidelines for Other disease processes (e.g., cancer and critical illness) Americans, MyPlate is a visual representation of healthy can greatly increase the body’s calorie requirements, eating habits designed by the U.S. government (Figure because illnesses increase metabolism. Individuals suf- 6-2). The plate is divided into color-coded food groups, fering from diabetes mellitus require special prescribed which include vegetables, fruits, grains, and protein, diets to control and treat the disease. This diet nor- with dairy on the side. Regardless of the total amount mally includes consistent carbohydrate intake and bal- of food consumed, the proportion of food from each anced amounts of fats and proteins. group should remain in balance. Body mass index (BMI) is a number calculated using The plan is intended to be simple so that people of a person’s weight and height that is a reliable way all ages and educational background are able to use it. to measure body fatness for most people. Using the More than just a diet, MyPlate offers a health plan that BMI chart, you can determine if someone is under- encourages users to adopt healthier eating habits and weight, within normal weight parameters, or obese increase physical activity. General recommendations (Figure 6-1). from the U.S. Department of Agriculture (USDA) (2011) for the general population include: NUTRIENTS • Enjoy food but eat less of it Although caloric needs often decrease with age, the • Avoid oversized portions need to include all of the various nutrients does not. • Increase intake of fruits, vegetables, and whole Therefore, foods high in nutritional value (nutrient dense) and relatively low in calories must be selected grains to maximize the amount of nutrients the body receives • Choose low-fat or fat-free dairy products while reducing the number of calories. • Reduce intake of sodium • Drink water instead of sugary beverages Vital nutrients needed by all people include carbo- • Make physical activity an everyday occurrence hydrates, protein, fats, vitamins, minerals, and fluids. Additional tips and resources, including recipes Because many foods contain a combination of these and interactive tools, are available at www. nutrients, various methods of determining nutritional ChooseMyPlate.gov. balance have been developed. One way to measure the adequacy of a person’s diet and nutritional intake is
104 UNIT II Basic Skills for Gerontologic Nursing Box 6-1 Ways to Increase Protein Intake FIGURE 6-2 MyPlate. (From U.S. Department of Agriculture, www. • Add eggs Add extra whites to pancakes, omelets, choosemyplate.gov.) and scrambled eggs; add hardboiled eggs to casseroles and salads. A modified food guide for older adults is available in Appendix C. • Add cheese Sprinkle on salads, melt on sandwiches, serve on crackers, add to casseroles, use to top More precise standards for measuring the nutri- vegetables, blend in mashed potatoes, use in tional adequacy of a diet are found in the dietary cheesecake. reference intakes (DRIs) (see Additional Learning Resources at chapter end). These references contain • Add milk, cream, and yogurt Add when baking or specific recommendations for calories, macronutrients making pancakes. Use in hot cocoa, sauces, milk (protein, carbohydrate, fat), water, fiber, minerals (iron, shakes, smoothies, on fruit, with cereal, as a desert magnesium, manganese, zinc, etc.), vitamins, and topping. electrolytes. • Add legumes and beans Cook these in soups and Use of the DRIs requires careful weighing and mea- stews. Use bean curd on salads. Serve ethnic dishes surement of portions and use of nutritional references made with chickpeas, such as hummus or falafel. or complete nutrition labels that list every ingredient in detail. Older adults may consult these recommenda- • Add peanut butter Use in cookies, as a dip for fruit or tions when selecting vitamins or other nutrients. vegetables, in sauces, and on sandwiches. Nutritional labels are commonly used by physicians, nurses, or dietitians when developing a specific thera- making them more nutritious than foods containing peutic diet plan. A more general checklist that older simple carbohydrates only. The Institute of Medicine adults can use to determine their nutritional health is recommends that 45% to 65% of calories should come shown in Figure 6-3. from carbohydrates, with an emphasis on complex Carbohydrates carbohydrates (USDA, 2010). This recommendation is Carbohydrates include sugars and starches that com- also appropriate for the older adult. prise approximately half of the standard American diet. Carbohydrates provide a ready source of energy In addition to providing essential nutrients, complex for the body and are divided into two categories: carbohydrates usually contain significant amounts of simple and complex. Simple carbohydrates are used soluble fiber, a substance humans cannot digest, which most readily by the body because their bonds are easily forms bulk and aids in bowel elimination. Fiber is broken. Table sugar, honey, syrup, and candy are recommended as helpful in preventing constipation, examples of simple carbohydrates. Complex carbohy- diverticulosis, and diverticulitis. A diet high in complex drates must be broken down into simple sugars before carbohydrates is recommended as part of the control they can be used by the body. This breakdown requires of many disease processes. The soluble fiber in complex time and energy. Foods such as vegetables, whole carbohydrates has been shown to reduce blood choles- grains, and fruits contain complex carbohydrates. terol levels, which is helpful for individuals who are Foods that contain complex carbohydrates usually also at risk for coronary artery disease. Complex carbohy- contain other nutrients (e.g., minerals and vitamins), drates also play an important role in the control of diabetes, because they effectively meet energy needs without causing rapid increases in blood glucose levels the way simple sugars do. Proteins Proteins are composed of amino acids, which are essential for tissue repair and healing. Protein needs remain constant or may increase slightly with aging to compensate for the loss of lean body tissue (Box 6-1). According to Dietary Guidelines for Americans (2010), the DRI of protein for adult women is 46 g/day; for adult men, the RDA is 56 g/day. Data from the National Health and Nutrition Examination Survey reveal that 10% to 25% of women older than age 55 consume less than half of the recommended daily amount of protein. Increasing protein consumption has been linked with a lower incidence of frailty among older women (Health in Aging, 2014). Protein consumption can be affected by many factors, including the ability to procure and prepare food, the cost of foods containing protein, and even the ability to chew common high- protein foods.
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 105 FIGURE 6-3 Determine your nutritional health. Checklist of warning signs of poor nutrition. (From the Nutritional Screening Initiative, Washington, DC.) Tissue replacement and repair continue throughout cereals (whole grains and rice), contain smaller life. Any condition in which tissue integrity is altered amounts of incomplete proteins, which do not indi- (e.g., surgery and pressure ulcers) increases the amount vidually contain all of the necessary amino acids. of protein needed to aid in tissue repair. Red meats, Complementary proteins consist of two or more incom- poultry, fish, eggs, and dairy products are good sources plete proteins that together provide adequate amounts of complete proteins, which contain all of the amino of essential amino acids. In the past, it was thought acids necessary for making and repairing tissues. Plant that incomplete proteins needed to be carefully com- foods, such as legumes (peas and beans), nuts, and bined during meal planning. The current thinking,
106 UNIT II Basic Skills for Gerontologic Nursing The benefits of vitamins for older adults are being closely examined. Researchers who subscribe to the however, is that the body can combine complementary free radical theory of aging are studying the effects proteins eaten the same day (Centers for Disease of antioxidant vitamins. It is theorized that anti Control and Prevention, 2012). oxidant vitamins can block or neutralize free radicals and prevent cell damage, thereby slowing Some foods that are high in protein, such as steak, the effects of aging and preventing diseases such ham, organ meats, egg yolks, hard cheese, and whole as cancer, heart disease, and Alzheimer disease. milk, also contain large amounts of fats. Excessive con- Although research into this area is promising, many sumption of proteins with a high fat content can con- experts are not yet convinced of the effectiveness tribute to elevated blood levels of cholesterol and of antioxidant vitamins or satisfied that we have an triglycerides, which, in turn, contribute to plaque for- adequate understanding of their method of action, mation and atherosclerotic changes in the blood therapeutic dosage, and long-term effects. Vitamins A, vessels. Atherosclerosis often results in hypertension C, and E, along with beta carotene, are considered and heart disease. For this reason, many physicians antioxidants. and dietitians recommend that high-fat protein foods be restricted. A person who is on a fat-restricted diet Vitamin deficiencies have been connected to a should consume low-fat proteins, such as fish and lean variety of problems experienced by older adults, poultry, as well as protein from plant sources, such as including the following: peas and beans. • Vitamin A deficiency: Poor wound healing, dry Fats skin, and night blindness. It is recommended that fats be limited to approxi- • Vitamin B6 deficiency: Neurologic and immuno- mately 20% to 35% of the total daily caloric intake. This recommendation does not change with aging. A certain logic problems, elevated homocysteine levels (risk amount of fat is necessary and desirable in the diet to factor for cardiovascular disease). Clinical manifes- aid in the absorption of fat-soluble vitamins and to tations of B6 deficiency may include nausea, vomit- provide adequate amounts of essential fatty acids. Fat ing, loss of appetite, dermatitis, motor weakness, is desirable because it adds flavor to food and provides dizziness, depression, and sore tongue. Supplements a sense of fullness with a meal. Foods with no fat of vitamin B6 help reverse these problems. would be unappealing, poor tasting, and not very • Vitamin B12 deficiency: Neurologic changes that satisfying. affect sensation, balance, and memory; elevated homocysteine levels. B12 deficiency can be related to When considering fat intake in the diet, it is impor- inadequate protein consumption or physiologic tant to watch the type of fats ingested. The body incor- changes in digestion. Normal aging changes result porates fats into substances called lipoproteins, in the decreased production of gastric acid and which contain cholesterol and proteins. There are three pepsin, which are necessary for protein digestion. important types of lipoproteins: high-density lipopro- When less protein is digested, less B12 is available tein (HDL), low-density lipoprotein (LDL), and very- for absorption. Clinical manifestations of B12 defi- low-density lipoprotein (VLDL). LDL is primarily ciency can include vomiting, fatigue, constipation, composed of cholesterol and is believed to contribute anemia, decreased memory, and depression. If to blood vessel disease. VLDL is primarily composed detected early and treated with supplements, symp- of triglycerides and may contribute to vessel disease toms may be reversible. but to a lesser extent. HDL, the so-called healthy fat, • Vitamin C deficiency: Weakness, dry mouth, skin is primarily composed of protein that appears to changes, delayed tissue healing, atherosclerosis, protect against blood vessel disease. and decreased cognitive function. • Vitamin D deficiency: Bone demineralization or Some individuals who have been eating high- osteoporosis, because it is essential for calcium cholesterol foods for their entire lives may be reluctant absorption; depression; immune system dysfunc- to change their eating habits as they age. They may tion. Vitamin D deficiency is more common in find it difficult or unpleasant to shop for and prepare older adults because of less exposure to the sun, foods in new ways. Others can successfully alter reduced capacity of the skin to synthesize the their dietary intake to avoid foods high in these vitamin, and decreased dietary intake. Clinical substances. symptoms include weakness, gait disturbance, and pain. Adequate intake of vitamin D and calcium Vitamins supplements can help prevent or even reverse the Vitamins are organic compounds found naturally in severity of this problem. Research in Great Britain foods. They can also be produced synthetically. showed a 19% to 26% decrease in falls by older Vitamins are needed for a variety of metabolic and individuals taking vitamin D in doses between physiologic processes. Vitamins are classified as fat- 700 IU and 1000 IU daily. soluble or water-soluble. The fat-soluble vitamins • Vitamin K deficiency: Increased risk of fractures. include vitamins A, D, E, and K. Vitamin C and the B-complex vitamins are water-soluble (Table 6-1).
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 107 Table 6-1 Summary of Essential Vitamins Fat-Soluble Vitamins Found in milk, butter, cheese, fortified margarine, liver, green and yellow vegetables, and fruits Vitamin A Promotes healthy epithelium, ability to see in dim light, normal mucus formation Many older people may be deficient in vitamin A because of chronic conditions that interfere with fat absorption, such as gallbladder disease and colitis Vitamin D Found in fortified milk and margarine, cod liver oil, fatty fish, and eggs Promotes absorption of calcium May contribute to skeletal changes with aging Vitamin E Found in corn and safflower oils, margarine, seeds, nuts, and leafy green vegetables Promotes integrity of red blood cells Vitamin K Found in leafy green vegetables and liver; synthesized by bacteria in the colon Essential for formation of prothrombin, which is necessary for blood clotting Water-Soluble Vitamins Found in organ meats, pork, legumes, and whole grains Vitamin B1 (thiamine Essential for carbohydrate metabolism hydrochloride) Vitamin B2 (riboflavin) Found in milk, cheese, eggs, organ meats, legumes, and leafy green vegetables Essential for normal tissue maintenance and tear production Niacin Found in lean meats, liver, whole grains, and legumes Essential for energy release from fats, carbohydrates, and proteins Vitamin B6 (hydrochloride) Found in whole grains, vegetables, legumes, meats, and bananas Acts in the processes of protein synthesis and amino acid metabolism May interact with levodopa (taken by patients with Parkinson disease) Folacin (folic acid) Found in whole wheat, legumes, and green vegetables Important in hemoglobin synthesis and in metabolism of amino acids Common deficiency in older adults Vitamin B12 Found in muscle and organ meats, eggs, shellfish, and dairy products (cyanocobalamin) Requires production of intrinsic factor by the stomach for absorption; inadequate absorption can result in pernicious anemia Needed for maturation of red blood cells Deficiency is commonly seen with folacin deficiency Vitamin C (ascorbic acid) Found in citrus fruits, tomatoes, cabbage, melons, strawberries, green peppers, and leafy green vegetables Important in the formation and maintenance of collagen structure of connective tissue Promotes healing and elasticity of capillary walls • Vitamin E deficiency: Immune dysfunction, memory Minerals problems. Vitamin E recently has been connected Minerals are inorganic chemical elements that are to delaying the onset of symptoms in Alzheimer required in many of the body’s functions. Minerals disease. The exact dose required to obtain maximal make up a small proportion of total body weight, yet benefits is under study. a slight mineral imbalance can have serious effects. Older adults who consume well-balanced diets Calcium, the most abundant mineral in the body, is may not require supplemental vitamins. Those with necessary for bone and tooth formation, nerve impulse increased risk factors, such as GI disorders or inade- transmission and conduction, muscle contraction quate nutritional intake, may benefit from selected (including cardiac function), and blood clotting. The vitamin supplements. Supplements should be used main dietary sources of calcium are milk and dairy with caution and under the direction of the primary products. Calcium is normally retained in bone, with care provider or dietitian. Excess amounts of the water- only a small amount (1%) found in the tissues and soluble vitamins are quickly eliminated from the body blood. With aging and with immobility, the bones tend and pose few risks. Excess amounts of the fat-soluble to lose calcium, resulting in osteoporosis. In certain vitamins (A, D, E, and K) are retained in fatty tissue or disease states, abnormal amounts of calcium leave the stored in the liver. Overconsumption of these vitamins bone, enter the bloodstream, and cause hypercalce- can lead to toxic symptoms and even permanent liver mia, which is an elevated level of calcium in the blood. damage. Hypercalcemia is seen with hyperparathyroidism,
108 UNIT II Basic Skills for Gerontologic Nursing Table 6-2 Laboratory Values Used to Assess disuse atrophy, metastatic bone tumors, and vitamin Nutritional Adequacy in Older Adults D excess. DIAGNOSTIC TEST APPROPRIATE RANGE Individuals experiencing hypercalcemia may mani- Hemoglobin fest symptoms, including confusion, abdominal pain, 14–18 g/dL (men) muscle pain, weakness, and anorexia. These symp- 12–16 g/dL (women) toms may be easily missed in older individuals because they are vague and common to many other conditions. Hematocrit 42%–52% (men) Extremely high levels of calcium in the blood can 37%–47% (women) result in shock, kidney failure, and even death. When the kidneys attempt to rid the body of excess calcium, Blood urea 10–20 mg/dL hypercalciuria (increased calcium in the urine) results, nitrogen May be slightly higher in older adult and the risk for renal calculi (kidney stone) formation is increased. Creatinine 0.6–1.2 mg/dL (male) 0.5–1.1 mg/dL (female) Adequate calcium intake is important throughout Slightly decreased in older adults life, but it is particularly important for those at risk for developing osteoporosis, especially postmenopausal Albumin 3.5–5.0 g/dL women. Calcium may arrest the progress of osteopo- rosis. Vitamin D aids in the absorption of calcium. For Calcium 9–10.5 mg/dL this reason, vitamin D is added to milk products, forti- fied margarine, and many calcium supplements. Folic acid 5–25 mg/dL Phosphorus is needed for normal bone and tooth Glucose (fasting) Fasting 70–110 mg/dL formation, activation of some B vitamins, normal neu- Increase in normal range after age 50 romuscular functioning, metabolism of carbohydrates, regulation of acid-base balance, and other physiologic Data from Pagana KD, Pagana TJ: Mosby’s manual of diagnostic and processes. Inadequate nutritional intake of phospho- laboratory tests, ed 4, St. Louis, 2010, Mosby. rus can result in weight loss or anemia. The typical dietary sources of phosphorus compounds are dairy and egg yolks are high in cholesterol, which is often products, meat, egg yolks, peas, beans, nuts, and restricted from the diet. This can make meal planning whole grains. Because of its wide availability, meeting difficult. In addition to increased nutritional intake of the dietary requirements of this mineral normally is iron rich foods, folic acid and iron supplements are not a problem unless the individual is on a highly commonly prescribed. restricted diet. It should be remembered that a concentrated iron Iron is found in the center of the heme portion of formulation (liquid or solid) administered orally can hemoglobin. Hemoglobin in the red blood cells trans- cause GI tract irritation, including diarrhea. To reduce ports oxygen to and removes carbon dioxide from the GI irritation, iron supplements should be taken during cells. Without adequate amounts of iron, the body or after meals. Iron solutions can stain the teeth, so a cannot produce enough hemoglobin. When hemoglo- straw should be used with liquid iron preparations. If bin levels fall below normal, anemia results. Individuals given by injection, it is important to use the Z-track suffering from anemia may manifest many symptoms, method for deep intramuscular administration. Foods depending on the severity of the condition: fatigue, rich in vitamin C should be given in conjunction with exertional dyspnea, tachycardia, palpitations, head- iron to enhance its absorption. Patients should be told ache, insomnia, vertigo, pallor (particularly of the that iron will turn the stool a dark green or black color, mucous membranes), and cool extremities. The normal and nurses should keep this in mind when assessing changes of aging or other disease processes may the stool of individuals receiving iron supplements. resemble these symptoms and prevent recognition of anemia. Laboratory tests for hemoglobin levels are Pernicious anemia is caused by a deficiency in required to determine whether anemia is present intrinsic factor secreted by the stomach. Without this (Table 6-2). Two forms of nutritional anemia are com- factor, vitamin B12, which is required for red blood cell monly seen in older adults: iron-deficiency anemia and maturation in the bone marrow, is not absorbed. In pernicious anemia. addition, there are fewer white blood cells and there may be cellular changes in the existing cells. Individuals Iron-deficiency anemia results from inadequate suffering from pernicious anemia may manifest weak- intake of dietary iron. Rich sources of dietary iron ness; numbness, or tingling in the extremities; anorexia; include red meat, particularly organ meats, such as or weight loss. Treatment typically consists of cyano- liver; shellfish, egg yolks, leafy green vegetables, and cobalamin injections and possibly oral folic acid and dried fruits. Red meat is expensive and, unless prop- iron supplements. erly prepared, can be difficult for older adults to chew. Many people do not like the taste of liver and organ Sodium is a commonly occurring mineral and is meats and will not eat them. Additionally, organ meats one of the important elements in the body. Sodium ions are involved in acid-base balance, fluid balance, nerve impulse transmission, and muscle contraction. Sodium is mostly found in extracellular fluid. Sodium levels are regulated by the kidneys, which retain or eliminate sodium according to the body’s needs.
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 109 Sodium interacts with potassium as part of the fluid FUNCTIONAL FOODS exchange through cell membranes. Sodium is natu- Functional foods are foods that have been found to rally present in many foods. The most common, most have overall health benefits and reduce risk factors familiar concentrated form is sodium chloride, or table for chronic diseases or enhance body processes salt, which is used to flavor and preserve food. The that benefit health (Woo, 2011). Most have cultural typical American diet tends to be higher in sodium origins and include soy, mushrooms, green tea, and than is nutritionally required. Prepared foods, such as black rice. canned soups or vegetables and frozen dinners, are • Soy has been shown to decrease LDL and total cho- common in the diet of many older adults and tend to be high in sodium. Older adults may also use excessive lesterol, increase HDL, increase bone density, stabi- amounts of salt to compensate for the decreased taste lize blood glucose, and reduce breast cancer risk. perception. Excessive blood levels of sodium, or hyper- • Mushrooms can enhance immunity, guard against natremia, can cause fluid retention and hypertension tumors, decrease inflammation, and improve blood and can increase the risk for osteoporosis, as excessive lipid profiles. sodium levels lead to urinary calcium excretion. People • Green tea can reduce risk of cardiovascular disease with hypertension, renal failure, or cardiac conditions and stroke, possibly guard against cancer and are often placed on sodium-restricted diets, and many Parkinson disease, and stabilize blood sugar. Even report that food is unappetizing when prepared with drinking 3 cups of ordinary tea daily has been less sodium. With decreased appetite, these individu- shown to decrease stroke risk. als may eat less. • Black rice is rich in phenolic compounds (antioxi- dants) and minerals. It has been shown to reduce Potassium is the major intracellular ion in the body. body mass index (BMI) and body fat and increase Potassium ions play an important role in acid-base HDL cholesterol. balance, fluid and electrolyte balance, and (with sodium) normal neuromuscular functioning. Potas WATER sium is less abundant in the diets of older adults than Water is essential for life. Humans can survive for are some of the other minerals. Dietary sources of many days without food but not without water. Water potassium include citrus fruits, milk, bananas, and plays a role in many aspects of normal body function- apple juice. Potassium deficiency, or hypokalemia, is a ing. Water is necessary for the formation of many of common problem in older adults. Many diuretic and the body’s secretions, including tears, perspiration, antihypertensive medications deplete the body of and saliva. Water aids in digestion and in transporta- potassium, as can prolonged or frequent diarrhea. tion of electrolytes and nutrients. Water facilitates Symptoms of hypokalemia include muscle weakness, elimination of waste products and plays an important anorexia, palpitations, irritability, drowsiness, depres- role in temperature regulation. sion, and disorientation. Severe muscle weakness is the most common observation related to decreased Approximately 60% of the average adult body is potassium levels. Hypokalemia secondary to digitalis composed of water, with adult men having slightly therapy is often a cause of cardiac arrhythmias. Because more body fluid than do women. Older individuals not all patients who have decreased levels of potas- typically have less body fluid than do younger adults. sium demonstrate observable symptoms, nurses must The total amount of body fluid decreases by approxi- check laboratory studies to verify levels of the electro- mately 8% to 10% in older adults. The amount of water lytes. Supplements are often prescribed to increase low in the bloodstream remains relatively constant with blood potassium levels. aging, but older adults tend to have less fluid in the intracellular and interstitial spaces than do younger Zinc is a trace mineral that plays a role in protein people. This fluid decrease results in loss of skin turgor synthesis. In adults, insufficient zinc may result in and, along with decreased skin elasticity, leads to the delayed wound healing, impaired immune function, wrinkled appearance common with aging. Decreased lethargy, skin changes, diminished sense of smell and fluid increases the risk for dehydration. Inadequate taste, and decreased appetite. Certain conditions, such fluid intake can lead to altered absorption of medica- as cirrhosis of the liver, kidney disease, cancer and tions, interfere with appetite and digestion, and alcoholism, may result in zinc deficiency. Supplemental contribute to problems with constipation. Severe dehy- zinc may be administered. Dietary sources of zinc dration can make existing medical conditions worse include meat, shellfish, and nuts. and can ultimately result in death. Most adults require 2000 to 3000 mL of fluid each day. Most of this is con- Trace elements such as magnesium, copper, iodine, sumed as beverages, such as water, tea, coffee, and fluorine, chromium, selenium, nickel, and sulfur are juice. Solid foods, particularly fruits and vegetables, necessary in very small amounts for normal body contain significant amounts of water. functioning. Selenium is gaining importance as an antioxidant mineral believed to promote heart health; Water is normally lost through urination, perspira- improve tissue elasticity; and decrease the risk of tion, respiration, and defecation. Abnormal fluid loss colorectal, lung, and prostate cancer. occurs with diarrhea, vomiting, diaphoresis, gastric
110 UNIT II Basic Skills for Gerontologic Nursing problem. Nurses working in all health care settings suctioning, and wound drainage; essential minerals must assess, plan, and implement strategies to main- are often lost along with the water. The amount of fluid tain or improve the nutritional status of the older taken into the body should be in balance with the adults in their care. amount eliminated from the body. This is referred to FACTORS AFFECTING NUTRITION as fluid balance. IN OLDER ADULTS The nutritional status of older adults living in the com- MALNUTRITION AND THE OLDER ADULT munity is affected by physiologic, economic, and social factors. Lack of appetite is commonly reported. The In America, where obesity is an increasing problem, reasons for this are multiple and form the basis of risk undernutrition and malnutrition are significant prob- assessment. The more risk factors present, the greater lems for the older adult population. Statistics show the likelihood of the older person experiencing nutri- that a large number of older adults are at risk for mal- tional inadequacy. Overall nutritional status will be nutrition, whether they are living independently or are affected if any of these problems persists for a signifi- institutionalized. Malnutrition is defined as a disorder cant period of time. of nutrition resulting from unbalanced, insufficient, or excessive diet or from impaired absorption, assimila- Physiologic risk factors include the following: tion, or use of food. The risk for developing nutritional • Chronic health factors such as chronic obstructive deficiencies increases with aging, but determining nutritional status can be challenging. Older adults who pulmonary disease, chronic heart failure, arthritis, appear to be healthy may have unhealthy nutritional dementia, and many others can interfere with practices. An obese older adult may be malnourished, obtaining and preparing adequate nutritional food. whereas someone thin may be well nourished. Studies Shopping requires physical exertion. Acts that a have shown that a majority of older Americans believe young, healthy person does not think about, such that nutrition is important for good health but that as lifting cans from a top shelf, reaching for some- they do not always follow good nutritional practices. thing near the floor, or moving groceries in to Information from the National Council on Aging and out of a store cart, can physically exhaust an Nutritional Assessment Self-Test reveals that older infirm or older adult. Although store personnel or adults have a disproportionately high risk for poor other shoppers would probably help with these nutrition, which, in turn, has a negative effect on activities (Figure 6-4), older adults are often too their health. Poorly nourished older adults are more embarrassed or proud to ask for help. Once food is likely to experience functional impairments, fatigue, purchased and taken home, the task of food prepa- decreased muscle strength, poor tissue healing, pres- ration remains. Opening cans, unsealing jars, and sure ulcers, and infections. They are likely to develop dealing with the ubiquitous plastic wrappers on more postoperative complications, spend a longer food all present daunting obstacles to the aging time in the hospital, and are at increased risk for death. individual. Think of the problems that a young, healthy person may have with current packaging, Estimates of the number of malnourished older and then imagine performing the same tasks with adults vary depending on the screening tool used, but decreased muscle strength, arthritis, or other age- generally fall within the following ranges: related problems. • Older adults in the community: 45% • Older adults cared for at home: 45% to 51% FIGURE 6-4 Shopping for groceries. • Hospitalized older adults: 54% to 82% • Older adults in residential care facilities: 84% to 100% These data reveal the magnitude of the problem that needs to be addressed by health care providers and demonstrate greater malnutrition as one becomes more frail and dependent on others. Symptoms of nutritional problems include uninten- tional weight loss, lightheadedness, disorientation, lethargy, and loss of appetite. Similar symptoms occur with a variety of illnesses, making it difficult to deter- mine whether the primary problem is medical or nutri- tional in origin. Weight loss is one of the signs of frailty syndrome in older adults, a syndrome characterized by increased susceptibility to stressors that can lead to negative health outcomes and functional impair- ment. The associated nursing diagnosis Frail Elderly Syndrome can be used to address this complex
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 111 • Alcoholism is suspected to be a risk factor in a chain supermarkets have forced many smaller larger percentage of older adults than is commonly neighborhood grocery stores to close. These large recognized. Although small amounts of alcohol stores are often located in shopping plazas that are may stimulate the appetite, consumption of large far away from home. Even if there is a nearby neigh- amounts of alcohol suppresses appetite, interferes borhood grocery or convenience store, its prices with the absorption of essential nutrients, and all must be higher for it to stay in business. Either situ- too often takes the place of meals. ation presents problems for the older adult. Without a car, a homebound older adult may find it difficult • Sensory changes can cause problems with safe to obtain groceries, medicine, or other necessities. preparation and storage of food. Reading small Many times, family members or friends drive the print on labels can be difficult for an individual with older adult to the store to shop or pick up groceries. presbyopia, cataracts, or other vision problems seen As a courtesy to busy or older customers, more with aging. This can be problematic for someone on stores now offer call-in and delivery services for an a restricted diet who needs to read the label to added fee. Some communities offer scheduled choose foods that are permitted. Older adults with transportation from senior citizen housing to altered senses of taste and smell may not be able to grocery stores. Others provide volunteers to shop detect the changes that indicate spoilage. If spoiled for homebound older adults. food is eaten, the risk for GI infection or upset is • Obtaining an appropriate variety and sufficient increased. amount of food can be difficult for older adults. Most foods are packaged in sizes appropriate for • Pain, whether it is chronic or acute, can interfere families of four or more. Although some manufac- with an older person’s appetite and desire to turers are responding to the needs of single adults procure, prepare, and consume food. and older adults by packaging smaller servings, the cost is often higher per serving. Older adults • Medications can cause an unpleasant change in the must decide whether thrift or variety is more taste of food; suppress appetite; or cause nausea and important. vomiting. Many older adults complain of a “metal- Social risk factors include the following: lic taste” that interferes with the enjoyment of food. • Depression is a common reason for decreased Other medications, such as antihypertensives, drugs appetite in older adults. Grief, failing health, loss of used to treat Parkinson disease, bronchodilators, independence, and many other factors can cause and antidepressants can cause a dry mouth, which depression. Malnutrition can also be a cause of makes chewing and swallowing more difficult. depression. Often the problem is unrecognized until the person has lost significant weight or develops • Problems with chewing, swallowing, or digesting other health problems. are common causes of impaired nutrition. Poor oral • Loneliness or social isolation is one of the more hygiene, lost teeth, cavities, poorly fitted dentures, common risk factors for nutritional problems in and decreased oral secretions affect the taste of food older adults. Eating is usually more pleasant with and can interfere with the ability of the older person company. Widowed or single older adults are less to chew foods. This is particularly a problem with likely to prepare and consume nutritious meals than protein-rich foods, such as meat, unless they are are seniors who have more social contact. cooked to a very tender consistency or provided in • Lack of motivation to cook is commonly an issue a chopped or ground form. for older adults. Preparing food for one or two people can be more difficult. Most recipes are • Malabsorption caused by decreased production of intended for four or more servings. Food often must digestive enzymes can interfere with protein break- be either eaten as leftovers for several days or down and absorption of vitamin B12, calcium, and wasted. Some older adults prepare their favorite folate. meals and then package and freeze individual serv- ings so that they can have variety and avoid waste. Economic risk factors include the following: Unfortunately, not everyone has a freezer and not • Cost of food is a concern for many older adults with all foods can be frozen. Since the effort of cooking can be overwhelming for the aging person, meal limited income. Foods rich in protein, such as meats after meal may consist of sandwiches or cereal. and dairy products, tend to be more expensive than Many communities have established programs starchy carbohydrates. Fresh vegetables and fruits designed to help older adults meet their nutritional that are rich in vitamins and minerals may also be needs. Senior citizen meal programs provide costly, depending on the season and locale. Many both reasonably priced meals and companionship. older adults have limited budgets and may not pur- Meals-on-Wheels programs deliver a variety of chase these more costly items, although they know well-balanced meals to the homebound, allowing the nutritional value and importance of these foods. They may skip meals or consume inadequate por- tions to save money. • Difficulty getting transportation to obtain food is a serious problem for older adults, particularly those who live alone. The simple act of getting to a store may be difficult. Trends toward large
112 UNIT II Basic Skills for Gerontologic Nursing Critical Thinking FIGURE 6-5 A Meals-on-Wheels recipient. (From U.S. Air Force photo/Airman 1st Class Katrina Heikkinen.) Nutritional Assessment them to maintain some degree of independence (Figure 6-5). An 84-year-old woman has been living in a long-term care Problems related to poor nutrition are not limited to facility for six months. It is noted that she has been losing older adults residing in the community. Nutritional weight at a rate of approximately 3 to 5 lbs a month. This was problems are also an area of concern for institutional- not immediately evident because she had been moderately ized seniors. As previously identified, 84% to 100% overweight. Now her clothing is loose. She is 66 inches tall of nursing home residents may be undernourished. and weighs 150 pounds. She never complains about being Although most institutions maintain well-staffed hungry, and her chart reveals that she eats 50% to 75% of the dietary departments under the supervision of trained food at each meal. Her hemoglobin is 9.6 g/dL, and her hema- dietitians, many older adults do not consume the tocrit is 32%. nutrients that are available. This may be related to the • Is her weight loss desirable? physiologic or emotional risk factors discussed previ- • What are possible reasons for the weight loss? ously or to institutional factors outside the control of • What other information do you need to obtain? the older adult. Some institutional factors that influ- ence nutrition include the following: SOCIAL AND CULTURAL ASPECTS • The repetitive nature of institutional meals OF NUTRITION • Problems maintaining the temperature and appear- ance of food while serving many people Food is more than a means of meeting nutritional • Environmental concerns, such as the type of back- needs. Food is also used as part of religious ceremo- ground music being played, staff conversations, or nies, in social interactions, and as a means of cultural overhead announcements expression. Throughout history, food has been linked • Problems related to being fed by others to the gods. Many major religions, such as Islam, • Behavior, appearance, or odors of tablemates Judaism, and Catholicism, include some dietary restric- • Inability of an institution to meet the specific cul- tions. These religions may require avoidance of certain tural preferences or general likes and dislikes of a foods, fasting, or special methods of food preparation large number of people for all members of the faith. Although most religions have more lenient restrictions for older adults and the Coordinated Care infirm, many older adults, especially those with great religious faith, want to comply with their religious teachings. Violating dietary rules may deeply upset them. This presents a challenge to caregivers, who Collaboration are more concerned about adequate nutrition than NUTRITION about religious beliefs. If such a situation arises, it is • Nursing assistants or dietary aides are most likely to be appropriate to consult with a dietitian or with the rabbi, minister, priest, or spiritual leader of the specific aware of the amount and types of food consumed by religious group to seek clarification and guidance. older residents. Many times, the spiritual counselor can provide reas- • Data that are more specific than the typical good/fair/poor surance to the older adult and guidance to the health ratings or even percentages are important for good care care team. planning. • Assistants need to report the types of food consumed Cultural influences in food are also significant. The (e.g., the amount of meat and vegetables versus the foods we eat in our homes from early in life reflect our amount of applesauce and dessert). culture. Some people are happy to eat a variety of foods; others prefer to eat only foods with which they are familiar. Various cultures ascribe certain powers to foods. The culture may dictate what, when, or how foods should be eaten. An older adult from such a cultural background may find it difficult to understand or accept mainstream American nutrition practices. It is important to remember that good nutri- tion can be achieved within any culture (Table 6-3). Special planning with the dietitian is often necessary to achieve adequate nutrition and meet cultural preferences within an institutional setting. Family members and significant others from the same culture may be willing to provide special foods and assist in meeting the nutritional needs of the institutionalized older adult.
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 113 Food is often tied to social events. When people visit Many older adults like to go out to eat in restau- friends’ homes, they are often served food. Food is rants. Eating out has many benefits, including a change served at parties, weddings, and wakes. People on of scenery, a wider choice of foods, and the opportu- dates go out to eat. Eating alone is often described as nity for social interaction. Many older adults prefer one of the worst things about being single or widowed. restaurants with table service rather than buffets or A common notion is that food eaten alone does not fast-food establishments, because they tend to be less even taste the same. Nurses should remember this noisy and do not require a person to balance trays of when working with older adults. food. Eating out is an occasional treat for some older Table 6-3 Popular Foods of Various Cultural and Ethnic Groups CULTURAL OR FOOD GROUPS ETHNIC GROUP OR EATING PATTERN GRAINS VEGETABLE FRUIT MILK MEAT AND BEANS Queso blanco Chorizo (sausage)* Mexican Tortilla Other vegetables: Avocado Chicken, beef, goat, Taco shell Chayote (Mexican Mango (white Posole (corn soup) squash) Papaya Mexican or pork Rice Plantano cheese) Beans, dried, Postres (pastries)* Jicama (root Custard (1 vegetable) (cooking cup = 1 cooked banana) cup milk Nopales (cactus Zapote (sweet, serving) Pork (cured ham leaves) yellowish Leche (milk) and uncured fruit) Buttermilk cuts), chicken, Tomato beef, fish Corn Milk and cheese Peas or beans African American Biscuit Dark green: Collard, Blackberries (lacto- (black-eyed, soul food Cornbread kale, mustard, or Melons vegetarians) crowder, purple- (Southern- Grits, rice, macaroni, turnip greens Muscadines hull, or cream) style cooking) Soy milk, or noodles Orange: (grapes) calcium- Cooked dried beans Hominy Sweet potatoes Peaches fortified or peas Crackers Hush puppies Other: Soy cheese Tofu (soybean curd) Okra Cheeses or tempeh Snap, pole (green), (fermented soy) (mozzarella, lima, and butter Parmesan, Nuts or seeds beans Romano, Peanut butter Turnips ricotta, etc.) Egg (ovovegetarians) Summer squash Gelato (Italian Veal or beef (yellow or zucchini) ice cream) Fish Coleslaw Soy milk Sausage* Luncheon meats* Vegetarian Whole-grain bread All All Lentils Cereal, cooked or Squid Almonds, pistachios ready-to-eat Pork, fish, chicken Brown rice Shrimp, crab, Whole-grain pasta Bagel lobster Tofu or tempeh Italian Breadsticks, breads Dark green: Berries Chinese Gnocchi (dumplings) Spinach Figs Continued Polenta (cornmeal Other: Pomegranate Artichoke mush) Eggplant Guava Risotto (creamy rice Mushrooms Lychee Marinara sauce Persimmon dish) Pummelo Pastas Other: Kumquat Pea pods Star fruit Rice or millet Yard-long beans Rice vermicelli (thin Baby corn Bamboo shoots rice pasta) Straw mushrooms Cellophane noodles Eggplant Bitter melon (bean thread) Steamed rolls Rice congee (soup) Rice sticks
114 UNIT II Basic Skills for Gerontologic Nursing Table 6-3 Popular Foods of Various Cultural and Ethnic Groups—cont’d CULTURAL OR FOOD GROUPS ETHNIC GROUP OR EATING PATTERN GRAINS VEGETABLE FRUIT MILK MEAT AND BEANS Yogurt Dal (lentils, mung Indian (south Breads: roti (chapati), Dark green: Mango Asia) naan, paratha, Saag (mixed greens Dates beans, other dried batura, puris, Raisins beans) dosa, idli and potatoes) Melons Beef, chicken (some Spinach Figs are vegetarian) Rice or rice pilau Fruit juices Pooha, upma, Other: Wild game (deer, Green peppers and nectars rabbit, elk, sabudana Cabbage beaver) Eggplant Green beans Lamb Methi (fenugreek Salmon and other leaves) fish Cucumbers Clams, mussels Chutney or vegetable Crab Duck or quail pickles Lamb, goat, fish Almonds Native Bread Orange: Berries Pistachio nuts American† Fry bread Winter squash (hard Cherries Dried beans and Wild rice or oats Plums Popcorn outer shell) Apples peas, lentils Tortilla Peaches Eggs Mush (cooked Starchy: Potato cereal) Corn Other: Rhubarb Middle Eastern Rice or bulgur Yellow: Apricots Yogurt (cracked wheat) Pumpkin or winter Grapes Melons Couscous squash (butternut) Dried fruits: Bread Pita Other: dates, Peppers raisins, Tomatoes apricots Grape leaves Cucumbers Fava beans Eggplant *High fat; use sparingly. †Varies widely depending on tribal grouping and locale. Modified from Lowdermilk DL, Perry SE, Cashion MC, Alden KRA: Maternity & women’s health care, ed 11, St. Louis, Elsevier, 2016. adults, but it is a way of life for others. Older adults NURSING PROCESS FOR RISK FOR who eat out regularly should choose carefully and try to avoid the high-fat, high-sodium items that are common restaurant fare. Many restaurants that cater to older adults offer heart-healthy items and senior IMBALANCED NUTRITION portions, often at discounted prices. Changes in BMI may be an early indication of actual Older adults who live in long-term or assisted living or potential nutritional problems in older adults. BMI settings are usually served one or more meals in can be determined using a chart (see Figure 6-1) or an a dining room. Independent older adults can obtain online calculation tool. The height used should reflect low-cost, nutritious meals and participate in social the person’s current height, not the height from a activities at congregate meal centers funded by the younger age commonly reported by aging individuals Elderly Nutrition Program. Most people tend to eat and recorded on their charts. If the individual appears better when dining with others than when they are well-proportioned and BMI falls within recommended left to eat alone. Nourishing snacks served during norms, then the person is probably receiving adequate group or social activities can supplement an older per- calories. A slow increase or decrease in BMI indicates son’s intake and tend to be consumed more readily an imbalance between caloric intake and energy expen- (Figure 6-6). diture. A decrease in activity with static caloric intake normally results in gradual increase in BMI, whereas an increase in activity with consistent caloric intake normally results in decrease in BMI. Nurses should
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 115 FIGURE 6-6 Good nutrition at any age. (From Ebersole: Toward its normal range of 70 to 100 mg/dL. Individuals who healthy aging: Human needs and nursing response, ed 7, St. Louis, have diabetes, are receiving steroid therapy or total 2008, Mosby.) parenteral nutrition, or are experiencing high levels of stress are likely to experience problems with control of investigate changes in intake or activity that could blood sugar levels. account for changes in BMI. Electrolyte imbalances may be a result of inade Adequate caloric intake is not enough. It is also quate electrolyte intake or excessive loss. Abnormal essential that older adults obtain adequate amounts of levels of calcium, sodium, and potassium are most essential nutrients. To determine whether these nutri- commonly observed. Assess the diet to determine tional needs are being met, nurses must gather addi- whether the patient has adequate intake of the tional information. necessary electrolytes. Medications that may cause electrolyte depletion should be considered. Vomiting, Laboratory values may help support other observa- diarrhea, and gastric suction may contribute to electro- tions. Review the hemoglobin level, hematocrit level, lyte imbalances. RBC count, blood urea nitrogen (BUN) level, creatinine ASSESSMENT/DATA COLLECTION level, albumin level, and other nutritional indices to assess for specific nutritional deficiencies. These labo- ratory values do not routinely change with aging. • Does the person appear noticeably overweight or Hemoglobin is a complex protein-iron molecule underweight? responsible for the transport of oxygen and carbon dioxide within the bloodstream. If adequate iron is not • Does clothing appear abnormally loose or tight? available, the hemoglobin level and the RBC count will • What are the person’s current height and weight? fall below the normal levels. Low hemoglobin levels • Is the BMI within normal limits? (See Figure 6-1.) may result from anemia or blood loss. Common • Has the weight significantly increased or decreased forms of anemia, discussed in Chapter 3, include iron-deficiency anemia and pernicious anemia. Iron- in the past 3 to 6 months? If so, how much has it deficiency anemia may result from blood loss. In older changed? adults, this rarely takes the form of a massive hemor- • How long has this weight change been occurring? rhage, although a significant amount of blood may be APPETITE CHANGES lost from frequent nosebleeds or recent surgery. More common in older adults is subtle blood loss from bleeding gastric or duodenal ulcers, diverticulitis, tumors, or pathologic lower gastrointestinal tract • How does the person describe his or her appetite? conditions. • Does the person feel that his or her appetite has A healthy person’s blood glucose level changes changed? If yes, why does the person think this is throughout the day. It is low during periods of fasting, happening? but rises after a meal and then peaks approximately 30 • How does food taste to the person? to 60 minutes after eating. Within 3 hours, it returns to • What does the person like or dislike about the meals he or she eats (or is served)? • What would the person prefer to eat? • Are there any cultural food preferences that are not being recognized? • Are there any dietary restrictions? Are they understood? • Does the person complain of any of the following before, during, or after meals: nausea or hyperacid- ity? Strange taste in the mouth? Eructation or flatu- lence? Chest pain? • Does the person show an unusual reaction to any foods (e.g., dairy products, nuts, and shellfish)? • Is the person depressed? NUTRITIONAL INTAKE • Are the hemoglobin, hematocrit, and RBC param eters within normal limits? • Has the blood sugar level been taken? Was this a fasting blood sugar? If taken at a nonfasting time, was it before or after a meal? How long before or after? • Are electrolyte levels (e.g., sodium, potassium, and calcium) within normal limits? • Is the serum albumin level within the normal range?
116 UNIT II Basic Skills for Gerontologic Nursing Box 6-2 Risk Factors Related to Imbalanced Nutrition in Older Adults • Is there a history of diabetes mellitus, anemia, or electrolyte imbalances? • Metabolic disorders (diabetes, thyroid disturbances) • Neurologic or musculoskeletal problems that • Are there any other observations such as pallor, dizziness, or easy fatigue that may indicate interfere with food preparation, eating, or anemia? swallowing • Disturbances of the gastrointestinal tract • Are there any signs of hyperglycemia or hypo • Inadequate resources to obtain food glycemia? • Loss of nutrients as a result of medications, hemorrhage, vomiting, or diarrhea • Are there any signs of electrolyte imbalance? • Inadequate or excessive energy because of exercise • Are the electrolyte levels within normal levels (espe- patterns or disease processes • Living alone cially potassium and sodium)? • Selective eating habits related to culture or habit • Is the person on a prescribed diet that restricts • Grief or other emotional difficulties sodium, calorie, sugar, or fluid intake? Are there any • Are there adequate financial resources to buy food? other dietary restrictions? • Can the person get to a store to purchase food? • Are calcium supplements taken? Iron supplements? • Are there family or friends who will assist with • Does the person drink milk and eat dairy products? (Is the person lactose intolerant?) going to the grocery store? • Are medications taken that can alter electrolyte • Does the individual have adequate vision, stamina, levels (e.g., diuretics and cardiotonics)? • Have there been any recent episodes of vomiting? or coordination to prepare food? • Are there certain foods that are never consumed? • Does fatigue occur so easily that by the time the (Look particularly at meats or vegetables that may require more chewing, and compare this informa- food is prepared, he or she is too tired to eat? tion with the person’s dental status.) • Is there adequate equipment for refrigeration and • What types of foods are consumed most? First? Not at all? cooking? • What percentage of each type of food is actually • Is the person aware of community resources for consumed? How much food in general? • What fluids are consumed during and between nutrition (e.g., Meals-on-Wheels and senior citizen meals? center meal programs)? Does the person consume • Are snacks or supplements consumed between alcoholic beverages? How much? How often? meals? If so, are these prescribed? Box 6-2 lists risk factors for imbalanced nutrition. • Is the person sneaking snacks that are not allowed on a therapeutic diet? NURSING DIAGNOSES • Does the person receive any medications that could alter the taste of food? If so, when are these medica- tions given? • Is the person receiving any drugs that require a Imbalanced nutrition: Less than body requirements restricted diet (e.g., monoamine oxidase inhibitors)? Overweight SOCIAL AND CULTURAL FACTORS Risk for overweight Readiness for enhanced nutrition NURSING GOALS/OUTCOMES IDENTIFICATION • Are meals consumed alone in his or her room or in the dining room? • Does the individual socialize with others during The nursing goals for older individuals diagnosed meals? with some form of nutritional imbalance are to (1) maintain BMI within normal limits; (2) obtain • Does the family ever bring favorite foods from adequate nutrients to maintain healthy tissue; (3) home? identify internal and external cues that influence eating patterns; and (4) adhere to a prescribed thera- • How do these favorite foods meet the individual’s peutic diet. nutritional needs? NURSING INTERVENTIONS/IMPLEMENTATION • Do the favorite foods violate any dietary restrictions (e.g., sodium or calorie restrictions)? HOME CARE OR DISCHARGE PLANNING The following nursing interventions should take place in hospitals or extended-care facilities: 1. Assess the individual carefully to determine the • What is the living situation: alone or with causes of a problem (e.g., dental problems, depres- others? sion, cultural factors, and activity level). The types of approaches used must be tailored carefully • What are the person’s health-management and based on the type and extent of the problem. health-maintenance abilities? • If the person lives at home, is there adequate food in the house?
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 117 Cultural Considerations 6. Monitor laboratory values. RBC parameters, hematocrit, and hemoglobin values help in deter- mining whether iron intake is adequate. Monitor electrolyte levels to verify that they are within Educating the Caregiver normal limits. A low serum albumin level may indicate malnutrition. • Because nursing assistants are typically assigned to assist older patients during mealtime, they need to be 7. Assess the condition of the skin, hair, nails, and aware of how their cultural biases influence what they mucous membranes. Signs of nutritional inade- communicate verbally and nonverbally. quacy can be detected by the observation of exter- nal surfaces. Cracks at the corner of the mouth, • Home health aides who actually prepare meals for changes in the appearance of the tongue, loss or someone from another culture or ethnicity need additional change in consistency of the hair, and slow tissue education and training in how to prepare culturally healing provide clues to nutritional status. appropriate meals that are acceptable to their aging patients. 8. Consult with the dietitian. Dietitians are spe cially trained to assess nutritional needs, and 2. Schedule weekly weight checks. Weight changes they have in-depth knowledge of the nutritional related to nutritional intake do not occur as rapidly value of foods. If an aging individual has serious as with fluid imbalance, when daily fluctuations nutritional problems or medical conditions with often occur. Weighing an older person too often nutritional implications, it is essential that the can cause frustration. Weekly weight checks are dietitian be actively involved in the nutritional more reliable indicators of success. plan of care. 3. Keep a dietary record of the amount, type, and 9. Institute measures to increase or decrease nutri- frequency of food intake. A careful dietary record tional intake. The following measures can be helps determine problem areas, which helps taken to increase the patient’s intake: nurses and dietitians develop a dietary plan that • Provide a selection of nutritious foods. Nurses is most likely to have the desired outcome. When should attempt to provide choices for those possible, actively involve older adults in this who are most in need of nutrients. Many institu- record-keeping. tions, particularly long-term care facilities, have limited menus for each meal. If the meal served 4. Explain the importance of nutrition to overall does not appeal to aging individuals, they may health or disease control. Many older individuals eat very little, if at all. Most institutions have are already aware of normal nutritional needs. If alternatives that do not appear on the menu, the changes related to aging or disease require usually including simple foods such as eggs, dietary modifications, it is important to carefully cheese sandwiches, or soup. The older individ- explain the modifications and the reasons behind ual may not be aware of these choices or may them to the individual. If older adults understand not wish to cause additional work for the staff. the rationale of dietary changes, they are more It is your responsibility to explore these options likely to cooperate with the new plan. with the individual. • Limit excess intake of fluids during meals. Too much Critical Thinking low nutritional fluid can create a sense of full- ness that takes the place of more nutritious food. • Supplement food intake with nutritious snacks. It is often difficult for older adults to consume ade- Culture and Food Preferences quate calories and nutrients within the three routine daily meals. If allowed within the pre- Examine your own cultural food beliefs and practices. scribed diet, offer nutritious snacks that are high • What are your food preferences? in calories and nutrients (e.g., bananas, graham • What foods should be included in a healthy diet? crackers, dried fruits, and milkshakes) between • Are there any foods that you must include or avoid in meals. Schedule these snacks so that they do not interfere with the person’s appetite for regular your daily diet? meals. Many older individuals may stash snacks • Are there foods that cannot be combined or served in the bedside stand or closet. Ensure that snacks are not stored where they can spoil or attract together? insects. Promptly discard any snacks that are • Are any foods recommended or prohibited for special age not consumed promptly. • Ask family members to bring the person’s favorite groups across the life span? dishes from home. Family favorites are rarely on • What foods are served for celebrations? the menu in an institutional setting. Special • What is your reaction when you are served foods that are culturally unfamiliar? 5. Determine food likes and dislikes. People tend to seek the things they like and avoid what they do not like. Food preferences should be considered when selecting nutritious yet acceptable foods for older adults. Many older individuals are set in their likes and dislikes and are unwilling to change late in life.
118 UNIT II Basic Skills for Gerontologic Nursing FIGURE 6-8 Nursing home residents enjoy a pleasant meal in the dining room. (From Kostelnick C: Mosby’s textbook for long-term care nursing assistants, ed 7, 2015, St. Louis, Mosby.) FIGURE 6-7 Chopsticks and Asian food make the meal enjoyable for FIGURE 6-9 Special dining tables are used for assistive dining this older Japanese woman. programs. Residents are fed three at a time, in the company of others. (From Sorrentino SA: Mosby’s textbook for nursing favorites and foods connected with fond memo- assistants, ed 7, 2008, St. Louis, Mosby.) ries are most likely to be consumed. However, before the family brings food, be sure to discuss without staff interference. If significant others the care plan with them to ensure that these are present at mealtime, they may want to eat foods are permitted. It is frustrating for the with the older individual. Some institutions family to make a special effort, only to have the provide special trays or bag lunches for guests meal rejected at the institution. at a nominal charge. • Serve meals in an attractive manner. Foods that • Prepare food by opening cartons, buttering toast, or are well prepared and served in an attractive performing other activities that may be difficult for manner are more appealing. Taking plates and the older person (Figure 6-10). Problems setting cups off the tray or setting a table with place up food and opening cartons may lead older mats and flowers can improve the appearance adults to skip or avoid certain foods. Many con- of a meal. Serving food on fancier dishes, using tainers are difficult to open; even healthy young a special teacup, or making an effort to reduce adults can have difficulty. Open these with the institutional character of the meal can help minimal fuss so that the aging person does not improve appetite (Figure 6-7). Foods should feel helpless. Assist the individual to get ready always be served fresh and at the appropriate to eat by cutting meats or buttering bread; temperature. perform these tasks unobtrusively. • Provide a social environment for meals by encourag- • Avoid hurrying the individual during meals. If an ing older adults to eat in the dining room. The older person eats too rapidly, indigestion, heart- nature of meals tends to be social (Figure 6-8). burn, or regurgitation may result. If rushed, Aging individuals often have better appetites many older individuals stop eating before they when they eat in groups than when isolated in are truly satisfied. Avoid creating a rushed envi- individual rooms. Alert individuals should be ronment, and allow older adults adequate time grouped with other alert people. Noise and dis- to eat at their own pace. traction from confused patients can be disturb- ing and decrease appetite. Separate seating or rooms can provide the best environment, depending on the needs of the individual (Figure 6-9). Many older individuals living in institutional settings make friends with whom they prefer to sit. Aging individuals should have the opportunity to seek mutually agree- able seating arrangements in dining rooms
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 119 FIGURE 6-10 Nurses open cartons and other containers and oral intake. Make all attempts at oral feeding provide other assistance at mealtimes. (From Kostelnick C: before the supplement is given. If nasogastric Mosby’s textbook for long-term care nursing assistants, ed 7, 2015, feeding is required, take all safety precautions, St. Louis, Mosby.) including checks for tube placement and positioning. • Request a modification in the form of food served if • Time medication administration to not interfere with the individual has difficulty chewing. It may be dif- meals. Some medications leave a bad taste in the ficult for older adults to chew some foods, par- mouth or otherwise upset the individual. If pos- ticularly meats and undercooked vegetables. sible, these medications should be scheduled Chopped or ground meat is easier to eat for away from normal mealtimes. Other medica- people with dentures or missing teeth. Notify tions that may cause gastric upset may be best the dietary department about these modifica- given after a meal. tions, and contact the physician if an order is • Play relaxing music at mealtime. Studies have required. If the person is alert, avoid serving shown that agitated behaviors decrease when puréed foods because of their similarity to baby quiet, melodic, peaceful music, with a steady food (unless the individual has severe trouble tempo yet enough variety for interest, is played chewing). If vegetables are routinely a problem, during mealtime. dicing or additional cooking may help. Contact • Refer individuals for special counseling if emotional the dietary department if problems are detected. difficulties are interfering with appetite. Individuals with extreme grief and emotional disturbances • Provide assistive devices such as plate sides, gripper may require special nutritional approaches. spoons, and adaptive cups. Older adults prefer to Consult therapists trained to deal with eating feed themselves whenever possible. Consult an disorders to determine the most effective occupational therapist regarding utensils to interventions. enable aging individuals to eat without undue The following measures can be taken to decrease difficulty. intake: • Assist in the selection of low-calorie foods. • Provide oral hygiene before meals. Normal decreases Decreasing caloric intake helps the person in taste and saliva production occur with aging. lose weight. Foods high in bulk and low in The decrease in saliva production reduces the calories, such as fresh fruits and vegetables, normal cleansing mechanism within the mouth, provide a sense of fullness without a sense of leading to a buildup of debris and microorgan- deprivation. isms that alters the taste of food and decreases • Plan low-calorie snacks into the daily routine. the appetite. Good oral hygiene freshens the Snacks such as diet beverages and unbuttered mouth and makes food taste better. popcorn are appropriate for older individuals unless they have a medical condition that con- • Assist the individual to the toilet before meals. Many traindicates their inclusion. Check the sodium older adults have less awareness of their need content of diet beverages if the person is on a to eliminate. If the need to eliminate occurs sodium-restricted diet. Individuals with diver- during mealtime, the person may become dis- ticulitis should avoid corn with husks. Planned tracted and lose interest in the meal. snacks can actually prevent mealtime overeat- ing and consumption of high-calorie snacks if • Provide supplemental tube feedings, if ordered. they are part of the aging person’s dietary Supplemental gastric or nasogastric tube feed- habits. ings are ordered for individuals who cannot • Increase diversional activities to decrease snacking. consume adequate nutrients by eating. Admin Some older and younger people snack when ister these supplemental feedings only after the they are bored. Activities that occupy the hands individual has had adequate opportunity for and mind may reduce the urge to eat. • Encourage increased activity levels. Increased activity helps burn calories. Walking is an exer- cise tolerated well by most older individuals, and it is effective as a means of weight reduction. 10. Complete a thorough documentation of nutri- tional status, including assessment, interven- tions, referrals, and patient response. The following interventions should take place in the home:
120 UNIT II Basic Skills for Gerontologic Nursing experience significant problems than would a younger person. A seemingly minor problem with fluid balance 1. Assist the individual in obtaining resources such can quickly become a serious concern in an aging as Meals-on-Wheels, food stamps, a housekeeper, individual. If not detected and treated, dehydration or shopping services. Many community agencies can easily become a significant problem, possibly and programs have been developed to help resulting in death. People with the greatest risk for older adults meet their nutritional needs. Each com- dehydration include those over age 85, African munity has different services available. Social Americans, those residing in skilled facilities, demen- workers often maintain directories of these agencies tia, taking multiple medications, and previous history and can help older adults establish contact with of dementia (Austin, 2012). them. Clarify and explain the available programs and provide the means for older adults or their Older adults have a lower percentage of body fluid families to contact the agencies. (approximately 45% lower) than younger persons have, even when they are well hydrated. Anything Cultural Considerations that restricts adequate intake of fluids or causes the body to lose water excessively can contribute to the risk for dehydration. Dietary Practices Common risk factors for dehydration include: (1) a Older adults may have distinct preferences based on their decreased thirst sensation; (2) decreased effectiveness heritage. These dietary preferences and practices vary widely of the kidney at concentrating urine; (3) hormonal across ethnic and cultural groups and are too extensive to changes, including decreased aldosterone secretion publish in this text, but many informational sites are available and renin activity; (4) side effects of medications; (5) on the Internet. The following are some website addresses for altered level of mentation; (6) altered levels of func- useful information and teaching materials: tional ability; and (7) fear of incontinence or pain, • www.nal.usda.gov/fnic/pubs/ethnic.pdf leading to inappropriate fluid restriction. • http://fnic.nal.usda.gov/professional-and-career-resources/ As at younger ages, older men have a higher per- ethnic-and-cultural-resources/dietary-guidelines-around- centage of body fluid than do older women. The world decrease in the kidneys’ concentrating abilities reduces • http://multiculturalhealth.org the body’s ability to adapt to changes in fluid volume. • http://ohioline.osu.edu/htdigsearch/search.php (Enter The aging body is less able to respond rapidly to fluid search terms “eating in America” for fact sheets on many volume changes. When the many diseases that affect cultures.) fluid balance are added to the normal changes of aging, maintaining fluid balance becomes a challenge. 2. Involve the family in shopping and meal plan- ning. If the older person is unable to meet his or her Body fluids are distributed into two major com nutritional needs without assistance, the family can partments: intracellular and extracellular compart- often provide help. Older individuals are often too ments. Intracellular fluid is found within the cells proud to ask for help, even from their own families. and composes approximately two-thirds of the total With help from a nurse, the older person may be body fluid. Extracellular fluid (ECF) composes approx- willing to accept this assistance. Family members imately one-third of the total body fluid. ECFs are can provide transportation to the store, read labels, further classified as intravascular (plasma) and intersti- and assist with food preparation. Variety can be tial fluids. ECF is in constant motion throughout the provided through meals prepared and then frozen body, carrying nutrients to the cells and removing in family members’ homes for the older person’s waste products. The movement of body fluids is use. Teach family members about their loved one’s affected by the levels of various electrolytes and relevant dietary restrictions so that meals do not proteins in the various compartments. Albumin, endanger his or her well-being. an important plasma protein responsible for maintain- ing adequate intravascular fluid levels, is often defi- 3. Identify senior citizen meal programs available in cient, contributing to tissue edema and orthostatic the community. Many communities offer meals at hypotension. churches or senior citizen centers. These meals are prepared by dietitians who are well versed in the Although the intracellular fluid is affected when the nutritional needs of the aging population. These body experiences fluid imbalance, the ECF changes inexpensive meals provide the opportunity for more rapidly and significantly. ECF deficit, or fluid social interaction. volume deficit, can result in hypovolemia or dehydra- tion. ECF excess, or fluid volume excess, can result in 4. Use any appropriate interventions that are used in hypervolemia (circulatory overload) or edema (exces- the institutional setting. sive fluid in the interstitial spaces). ASSESSMENT/DATA COLLECTION NURSING PROCESS FOR RISK FOR IMBALANCED • What are the vital signs (i.e., blood pressure, pulse, FLUID VOLUME respiration, and temperature)? Fluid balance is not an everyday problem in healthy older adults. However, if there is a sudden change in fluid volume, an older person is more likely to
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 121 • What is the appearance of the skin? Is it moist? Dry? DEFICIENT FLUID VOLUME • Describe the skin turgor? Is the tongue dry and/or furrowed? Skin temperature? • Does the individual complain of thirst? Weakness? Deficient fluid volume occurs when an individual has • Does the individual manifest any mood changes, inadequate intake or excessive loss of fluids. Inadequate fluid intake can easily progress into dehydration, such as restlessness or confusion? which, unless corrected, can result in death. A variety • What is the fluid intake per nursing shift? Per day? of conditions can contribute to deficient fluid volume • Is the person receiving fluids through non-oral in older adults. One author devised an interesting way of identifying older persons who have problems routes, such as nasogastric feeding or intravenous related to fluid intake. They were divided into three fluid therapy? groups: (1) people who can drink, but do not; these • How does the individual’s fluid intake compare are people who are capable of drinking but do not with the recommended intake? know how much fluid is necessary or have cognitive • Is the person’s weight changing rapidly? Is it problems so they forget to drink; (2) people who increasing? Decreasing? can drink, but will not; those who report that they • Is the urine output within normal limits? never drank much or are afraid of incontinence; and • What is the color and consistency of the urine? What (3) people who cannot drink; those who lack the ability is the urine specific gravity? to access fluids independently or have impaired • Is there excessive fluid loss through hemorrhage, swallow or gag reflexes. Each group will benefit from wound drains, gastric suction, diaphoresis, or different nursing approaches. The “don’t drink” people mouth breathing? need to be offered fluids frequently. The “can’t drink” • Are there complaints about the fit of rings, shoes, or people require special approaches, including position- clothing? Are they too loose or too tight? ing, swallowing exercises, thickened fluids, and, if • Is the person receiving medication that is likely to ordered, tube or parenteral feeding. The “won’t drink” cause fluid retention or loss? people need education regarding the importance of • Are laboratory values (hemoglobin, hematocrit, fluids and alternative techniques for dealing with electrolytes, BUN, creatinine) within normal limits? incontinence. Boxes 6-3 and 6-4 list risks for deficient fluid volume or excess fluid volume in older adults. Individuals experiencing deficient fluid volume are likely to manifest dry mucous membranes, thirst, Box 6-3 Risk Factors for Deficient Fluid Volume decreased skin turgor (assessed over the sternum or on in Older Adults the inner thigh), rapid weight loss (>3% of body weight), sunken eyes, weakness, and decreased volume • Altered swallow reflex (patients with stroke) or increased concentration of urine. Vital signs are • Nausea and an unwillingness to eat or drink likely to be affected. An increase in heart rate and • Acute emotional distress and decreased interest in decrease in pulse pressure can indicate a decrease in fluid volume. Hypotension and, particularly, ortho- personal needs static hypotension are common. An increase in body • Inability to obtain adequate fluids without assistance temperature may indicate dehydration. Blood studies are likely to change with deficient fluid volume. (bedridden patients) Hematocrit normally increases as the blood plasma • Altered cognition (Alzheimer disease or dementia) and volume decreases. Electrolyte levels, creatinine, and BUN are likely to be altered. lack of awareness of the need for fluids • Draining wounds, open sores, or ulcers EXCESS FLUID VOLUME • Diuretic medications • Kidney disease • Tube feedings of low-sodium preparations • Diaphoresis Excess fluid volume can result from excessive intake • Intermittent or persistent vomiting or inadequate elimination of fluids. A primary indica- • Intermittent or persistent diarrhea tion of excess fluid volume is edema, which may mani- fest as swelling of dependent extremities and increased Box 6-4 Risk Factors for Excess Fluid Volume abdominal girth. Pulmonary edema may result in in Older Adults shortness of breath, dyspnea, cough, gurgling sounds on respiration, and frothy sputum. Because fluid intake • Increased fluid intake secondary to excess sodium exceeds fluid output, weight gain can be sudden and intake, hyperglycemia, or medications dramatic. The amount of weight gained reflects the amount of fluid being retained. One liter of fluid results • Compulsive water-drinking in a 1-kg weight gain. Skin over edematous areas may • Decreased urine output secondary to kidney appear shiny and taut. The amount and concentration of urine produced are likely to change with excess dysfunction fluid volume. Hematocrit normally decreases as the • Heart failure blood plasma volume increases. Electrolyte levels, cre- • Insufficient protein intake or excessive protein loss atinine, and BUN are also likely to be altered. The • Steroid therapy • History of alcoholism or liver disease • Kidney disease
122 UNIT II Basic Skills for Gerontologic Nursing lytes may precede or may be a result of fluid imbal- ance. Report changes promptly. individual may experience behavioral changes, includ- 5. Weigh the patient daily before breakfast. Weights ing restlessness and anxiety. measured at a consistent time of day are the most NURSING DIAGNOSES accurate for comparison. Weigh the individual each day wearing the same clothing. Use the same scale consistently, and check it for accuracy at regular intervals. Consistency is essential to elimi- Deficient fluid volume nate errors in readings. Record daily weight checks Excess fluid volume promptly on the appropriate record. Risk for deficient fluid volume 6. Measure changes in girth of body parts such Risk for imbalanced fluid volume as legs and abdomen. Take measurements at Readiness for enhanced fluid balance a consistent spot each day. If the person has no NURSING GOALS/OUTCOMES IDENTIFICATION objections, make a small ink mark on the skin so that all staff will measure consistently. Retained fluid (edema) increases girth; fluid loss decreases girth. The nursing goals for older individuals with or at risk 7. Maintain adequate fluid intake. Implement the for deficient fluid volume or excess fluid volume are following measures to increase intake: to: (1) manifest vital signs within normal limits or • Offer smaller amounts of fluid at more frequent limits specified by the physician; (2) evidence moist oral mucous membranes and good skin turgor without intervals. Small amounts of fluids taken fre- evidence of edema; (3) maintain a stable weight within quently add up to significant fluid intake. Offer normal limits; (4) exhibit balanced fluid intake and fluids, or remind the individual to take a drink, output; (5) report no problems related to thirst or every 30 to 60 minutes throughout the day. weakness; (6) exhibit blood studies (hemoglobin, • Keep preferred beverages at the bedside. Many older hematocrit, serum electrolytes, BUN, creatinine) within adults have distinct preferences regarding the normal limits; (7) verbalize an understanding of the type and temperature of beverages they like. recommended dietary and fluid intake; (8) demon- Because people are most likely to consume strate behaviors necessary to maintain appropriate foods and fluids that they like, determine the fluid intake; (9) demonstrate a selection of appropriate individual’s preferences. foods and fluids; (10) verbalize an understanding of • Use smaller containers such as medication cups or prescribed medication(s), including the frequency and small juice glasses when offering beverages. Small any precautions; and (11) verbalize signs and symp- beverage containers are less intimidating than toms that should be reported to the physician. are large containers. An older person often can NURSING INTERVENTIONS/IMPLEMENTATION be coaxed into drinking four or five medicine cups of liquid (120 to 150 mL) far more easily than he or she can be persuaded to drink a glassful. The following nursing interventions should take place • Keep beverages easily available for individuals who in hospitals or extended-care facilities: are not in their rooms (e.g., in day rooms, activity 1. Complete a thorough assessment. A thorough rooms, lounges, or other common areas). Low- sodium, low-sugar beverages are ideal because assessment is necessary to determine the presence individuals on restricted diets can consume and severity of any problems related to fluid them. Making beverages easily accessible intake. reminds and encourages individuals to drink. 2. Monitor vital signs. Vital signs can change in Passing a tray of assorted beverages around response to changes in fluid volume. Orthostatic an area where several older adults are congre- hypotension is more common in individuals who gated can encourage social interchange and have inadequate fluid intake than in individuals provide mutual encouragement for many to who have adequate fluid intake. participate even when they might otherwise 3. Monitor intake and output. Any individual with have refused. an actual or potential fluid imbalance should be • Encourage the intake of foods with a high fluid placed on intake and output (I&O) measurement. content, such as fruits, vegetables, soups, and cooked Calculate shift and daily totals and compare them cereals. Significant amounts of fluid are con- with previous totals. It is essential that all indi- tained in these foods. Individuals who have dif- viduals who provide care know how to measure ficulty drinking liquids can obtain significant intake and output correctly. All caregivers should amounts of fluid through these alternative be aware that the individual is on I&O so that all sources. fluids are recorded. If family members assist with feeding, teach them how to record fluid intake. Keep intake and output sheets in a convenient place to help ensure prompt recording. Too often, I&O are monitored in a careless manner, and the data collected are meaningless. 4. Monitor laboratory values. Shifts in hemoglobin, hematocrit, BUN, creatinine, albumin, or electro-
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 123 • Administer nasogastric, gastric, or parenteral fluids require careful hygiene. Both dry, fragile skin as ordered by the physician. Individuals who and edematous tissue are highly susceptible to cannot drink adequate fluids may need supple- breakdown. The person’s physical position should mental fluids administered by other routes. All be changed frequently. Take care when moving the fluid given by gastric or parenteral route must patient or handling the skin. be counted as fluid intake. 11. Report and document significant findings promptly. The signs and symptoms of fluid volume Implement the following measures to decrease problems rarely occur suddenly. Rather, these intake: problems tend to develop over time. Nurses must • Avoid keeping fluids at the bedside. If fluids are be sure that all changes are documented and reported promptly to the charge nurse and/or the easily available, older adults are likely to physician. consume them too freely. The following interventions should take place in the • Offer frequent oral hygiene. When fluids are home: restricted, saliva production decreases and the 1. Complete a thorough assessment. A thorough mucous membranes feel dry and uncom assessment is necessary to determine the presence fortable. Thick, tenacious secretions can build and severity of any problems. It may be necessary up in the mouth if not removed regularly. to bring a scale, measuring tape, and sphygmo Provide frequent oral hygiene to compensate for manometer to the home to complete a good the lack of oral fluids and diminished saliva assessment. production. 2. Teach the individual and his or her family • Provide lozenges or hard candy. Sucking on a hard members how to monitor fluid intake. The indi- lozenge stimulates the release of saliva. Offer vidual and the family must be aware of methods candy and lozenges only to those who are alert used to keep track of fluid intake and loss. Teach the enough not to swallow or choke on them. Verify family to measure fluid intake using common that there is no dietary prohibition to additional household containers, and teach them to read sugar intake. cartons for fluid content. It is easier for most lay • Plan a schedule to distribute limited fluids through- persons to learn to keep track of fluid intake in out the day. Plan the total fluid volume intake for terms of ounces than in terms of milliliters. Provide the day within the prescribed limitations. Then a specimen pan or urinal to measure output. divide the total into appropriate amounts spaced 3. Promote wellness by reviewing the prescribed throughout the day. For example, a 600-mL dietary and fluid intake with the individual. It is restriction could be divided into 12 servings of important that the individual understands the 50 mL offered at hourly intervals between 8:00 reason for consuming or avoiding certain foods and a.m. and 8:00 p.m. This prevents the person fluids. The importance of adequate fluid intake, from consuming all of the allowance too early particularly during hot weather, should be stressed. in the day and then having to withstand Advise individuals with no acute problems to long periods of thirst or to exceed prescribed consume a minimum of 64 ounces (2000 mL) of limits. fluid each day. Those who live alone may need • Limit the quantity of foods that are high in fluid reminders to consume this amount. Fluid intake content. Fluids contained in solid foods can con- reminders are particularly important during hot tribute to excess fluid volume and edema. Foods weather when increased amounts of fluid are lost such as fresh fruits and vegetables have a high through perspiration. fluid content, whereas foods such as breads, 4. Explain methods of increasing or decreasing fluid dried fruits, and cooked meats have a lower intake. The following measures can be taken to fluid content. increase intake: 8. Administer medications as ordered by the • Develop a schedule for fluid intake. A planned sched- primary care provider. Many individuals with fluid imbalances receive medication to prevent or ule using a time list or clock helps remind older correct this problem. Nurses must ensure that persons, as well as their spouse or caregiver, to these medications are given on time and that the consume fluids at regular times. It also helps patient’s response to the medications is assessed. them keep track of how much fluid is being con- 9. Refer to the dietitian, if appropriate. Individuals sumed. Encourage them to check off or write with medical conditions likely to cause excessive amounts next to the times so that they are aware fluid loss or fluid retention need detailed and spe- of making progress. cific diet modifications and instructions, which are • Post signs in the kitchen and other rooms reminding best provided by a specialist. Nurses should rein- the individual to drink. Reminders help older force this teaching. adults remember the importance of drinking 10. Provide appropriate skin care. Persons with adequate amounts of fluid. excess fluid volume or deficient fluid volume
124 UNIT II Basic Skills for Gerontologic Nursing Box 6-5 Risk Factors for Impaired Swallowing in Older Adults • Encourage friends and family to visit and share a beverage with the individual. Social contact and • Neurologic problems resulting in paralysis or sharing are natural over a cup of coffee, soda, weakness of the face, mouth, or throat juice, or other beverage. This is a pleasant way to promote social interaction and encourage fluid • Altered level of consciousness, awareness, or intake at the same time. sensation • Encourage the use of fruit or other foods with high • Mechanical devices such as a tracheostomy tube fluid content. or nasogastric tube The following measures can be taken to decrease • A narrowing or obstruction of the pharynx or intake: esophagus • Develop a schedule that spreads the limited • Excessive fatigue amount of fluid throughout the day. individuals experiencing dysphagia should always be • Encourage the use of hard candy or lozenges to carefully assessed for possible aspiration. keep the mouth moist. ASSESSMENT/DATA COLLECTION • Recommend frequent oral hygiene. • Discuss the importance of avoiding foods with high fluid content. • Is there any history of stroke or other neurologic 5. Discuss signs and symptoms that should be disease that could interfere with chewing or swallowing? reported promptly to the primary care provider. Fluid imbalance may result in hospitalization and • Is the individual alert and able to follow serious complications. This is particularly impor- directions? tant for older individuals who are receiving medica- tions that influence fluid balance. The individual • Is any facial drooping or difficulty chewing should know what signs and symptoms are observed? important. A written list of symptoms should be given to the individual and his or her significant • Do the caregivers observe or report difficulty others. swallowing? 6. Use any appropriate interventions that are used in the institutional setting. • Does the individual complain of something sticking in the throat? NURSING PROCESS FOR IMPAIRED SWALLOWING • Is there coughing, choking, or drooling when eating? • Does the person complain of hoarseness or dry Chewing and swallowing are complex processes that throat? involve coordinated movements of the oral cavity, • Is there food stored in the cheek pockets? tongue, pharynx, larynx, and esophagus. An individ- • Is the gag reflex weak or absent? ual who is unable to coordinate these movements • Can the individual close his or her lips? experiences difficulty swallowing, or dysphagia. • Are there problems with any particular foods or Dysphagia is often a result of reduced muscle tone in the pharynx and esophagus, laxity of the ligaments fluids? and the age-related slowing of swallowing, infection, Box 6-5 lists risk factors associated with impaired swal- scar tissue, cancer, or dental conditions. Problems lowing in older adults. related to eating, and particularly problems related to swallowing, are serious because they can lead to dehy- NURSING DIAGNOSIS dration, malnutrition, or aspiration. It is reported that as many as 68% of older adults in long-term–care facil- ities have dysphagia (Sura et al., 2012). Impaired swallowing Swallowing problems are commonly a result of neu- rologic damage, trauma that affects the cranial nerves NURSING GOALS/OUTCOMES IDENTIFICATION or facial muscles, or diseases such as Parkinson disease or stroke. Dysphagia can even be a sign of an emer- gency such as aortic aneurysm (Song, 2012). Recent research indicates that heart failure, diabetes, and The nursing goals for an older individual diagnosed general frailty because of age place older adults at risk with impaired swallowing are to: (1) pass food from for impaired swallowing. People with altered level of mouth to the stomach without aspiration; (2) maintain consciousness or severe fatigue are also at risk. Some adequate nutrition and hydration; and (3) maintain or individuals who are capable of swallowing may be achieve appropriate BMI. hesitant to do so because of a lack of desire to eat or because of fear after an episode of choking. Older NURSING INTERVENTIONS/IMPLEMENTATION The following nursing interventions should take place in hospitals or extended-care facilities: 1. Assess the individual to determine his or her unique problems and needs. Not all swallowing disorders are the same. Develop different approaches based on the individual’s specific problems and needs.
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 125 2. Consult with the speech therapist, occupational flavored beverages to turn them into a gelatinous therapist, and dietitian to develop a dysphagia form that is more easily managed by persons with program. These specialists have unique knowl- impaired swallowing. Water usually is not given edge of the best techniques and methods for to individuals with swallowing disorders. Because dealing with swallowing disorders. It is important water has no texture or taste, the individual may for nurses to use their expertise when developing not be aware of its presence in the mouth and may a feeding plan. Use special adaptive equipment aspirate it. (e.g., special spoons) to deliver food to the back of 8. Place foods into the unaffected or stronger the throat, where it is more easily swallowed. You side of the mouth. The individual will be able may also use special cups that allow the older indi- to detect food more easily on the unaffected or vidual to drink without tipping the head back. stronger side. Teach exercises designed to strengthen the tongue 9. Present foods in an appealing manner. The to improve swallowing ability. appearance of food affects the appetite. Even if its consistency is altered (ground or puréed), food 3. Verify that dentures fit properly and maintain should be served as pleasantly as possible. Do not good oral hygiene. Improperly fitted dentures can stir foods together in an unappealing mixture. slip in the mouth, causing increased problems with Keep each food identifiable and serve them to the swallowing. A dentist should be consulted if this individual in the preferred order. is the problem. Provide good oral hygiene to 10. Select foods based on taste, texture, temperature, enhance the appetite and removes any old food and fluid content. Individuals with swallowing or foreign materials that may interfere with disorders may have altered senses of taste, texture, swallowing. and temperature. Foods that have distinct flavors and textures, such as applesauce, are accepted 4. Position the person with his or her head upright more readily than are nondescript, puréed foods. and the chin flexed slightly forward to facilitate Seasonings and spices can be used to enhance the flavor of many foods. The food should have some swallowing. Help with head control, if necessary. consistency; however, foods that require chewing Whenever possible, assist older adults in a chair are not advised. Always serve food at a tempera- for meals. If they must remain in bed, raise the ture that will not burn the mucous membranes of head of the bed as high as possible. Ensure that the mouth. Many individuals with swallowing the head is not in malposition, as this can inter disorders cannot sense temperature adequately. A fere with swallowing ability. Excessive flexion variety of temperatures will make the person more or hyperextension of the neck can interfere with aware of the presence of food. the passage of food through the pharynx and 11. Ensure that the lips are closed by applying slight into the esophagus. If a pillow is used for position- pressure or stroking. It is almost impossible to ing, it should be placed behind the shoulder, not swallow when the lips are open. To prevent aspira- behind the head, which could interfere with swal- tion, it may be necessary to close the person’s lips lowing. Individuals with swallowing problems mechanically. should remain seated upright for at least 30 12. Stimulate swallowing by stroking the side of the minutes after a meal to reduce the likelihood of neck, and support the weakened side if appropri- aspiration. ate. Stroking the neck stimulates the urge to 5. Encourage rest periods before meals. Eating swallow. Supporting the muscles of the affected requires a great deal of effort from individuals side of the throat can enhance swallowing. with swallowing disorders. Providing rest before 13. Give frequent verbal cues. Individuals with swal- meals helps increase the amount of energy and lowing difficulties may not remember to swallow strength available. when food is in the mouth. Some are able to 6. Allow adequate time for meals. Hurrying a meal swallow if they are reminded to do so. increases the risk for aspiration. Older persons 14. Reduce distractions. The process of eating requires with swallowing difficulties are even more likely the full attention of the affected individual and the to have problems if they try to swallow too quickly. caregiver. Distractions, such as television or visi- 7. Start with small amounts of food and thickened tors, may interfere with concentration and lead to fluids. Provide individuals with swallowing diffi- increased problems. culties a moderate amount of food (approximately 15. Keep suction equipment available in case of 15 to 20 mL) at a time. This amount is enough for problems. When giving oral feedings to an indi- the individual to detect the presence of food, but vidual with a swallowing disorder, it is wise to it is not so much that it is difficult to swallow. keep a suction apparatus nearby. Most of these Individuals with swallowing disorders have a people also have problems with other protective great deal of difficulty controlling and swallowing reflexes, such as the gag and cough reflexes. They liquids. Therefore, foods that have a high fluid content are necessary to ensure adequate fluid intake. Many facilities add a thickening agent to
126 UNIT II Basic Skills for Gerontologic Nursing Box 6-6 Risk Factors for Aspiration in Older Adults may be unable to clear an airway obstruction. • Neurologic problems, particularly those that affect the Keep the suction machine readily available because cough and/or gag reflexes delay may lead to aspiration or more serious consequences. • Reduced level of consciousness 16. Provide oral hygiene before and after feedings. • Continuous supine positioning Individuals with swallowing disorders are likely • Tracheostomy tubes to retain food particles in the mouth, leading to • Gastric tubes altered taste. Good oral hygiene before and after • Decreased gastric motility; excessive amounts of meals removes debris and tenacious saliva and might improve the person’s appetite. residual gastric contents or gas 17. Administer tube feedings as ordered by the phy- sician to individuals who are unable to achieve • Are there signs of abdominal distention? adequate oral intake. Some individuals with swal- • Are the person’s stomach contents more than lowing disorders may not be able to eat enough to meet their nutritional needs. These individuals 150 mL before a scheduled feeding? require feeding through either a nasogastric or a • Is there noisy respiration? gastric feeding tube. Tube feedings may be used to • Is there a productive cough? What is the consistency meet the total nutritional needs of older adults, or they may be given as a supplement for those of the sputum? who need additional fluid or calories. If the feed • Are the pulse and respiratory rates elevated? ing is supplemental, administer it after the indi- Box 6-6 lists risk factors for aspiration in older adults. vidual has had the opportunity to take as much oral nutrition as possible. These feedings are NURSING DIAGNOSIS not meant as a time-saving method to replace oral feedings. Use care to verify placement and absorption of nutrients before each feeding is given. Use medical asepsis when handling all Risk for aspiration nutrients and feeding equipment to reduce the risk for contamination. Irrigation sets should be NURSING GOALS/OUTCOMES IDENTIFICATION replaced every 24 hours. Do not use food dyes in feeding solution because it may be a source of infection and has even been linked to patient death (Ackley et al., 2008). The nursing goals for an older individual at risk for 18. Use any appropriate interventions that are used aspiration are to: (1) remain free from episodes of aspi- in the institutional setting in the home. ration and (2) maintain clear, noiseless breath sounds. NURSING PROCESS FOR RISK FOR ASPIRATION NURSING INTERVENTIONS/IMPLEMENTATION Aspiration, the inhalation of solids or liquids into the The following nursing interventions should take place upper respiratory tract, is a serious problem for many in hospitals or extended-care facilities: infirm older adults. Symptoms of aspiration include: 1. Position the person appropriately. The person (1) a sudden appearance of severe coughing or cyano- sis associated with eating or drinking; (2) voice should be positioned in a Fowler or semi-Fowler changes; and (3) signs of aspiration pneumonia, includ- position before both oral and gastric tube feedings. ing increased respiratory rate, abnormal lung sounds, This position should be maintained for at least 30 fever and behavioral changes, such as confusion or to 45 minutes after each feeding. Elevating the head delirium. Risk for aspiration is increased with dys allows solutions to flow into the stomach and phagia and with gastroesophageal reflux problems. reduces the chance of regurgitation. If the person Symptoms are discussed in Chapter 3. must remain flat in bed, a side-lying position is ASSESSMENT/DATA COLLECTION better than a supine position. 2. Assess for stomach distention. Stomach distention can be an indication of slow gastric emptying, which can lead to regurgitation and aspiration. • Are the cough and gag reflexes intact? Monitor carefully and report continued complaints • Is there a reduced level of consciousness? of gastric fullness or excessive stomach gas. If these • Does the person have a tracheostomy? problems persist, the amount or type of feeding • Is the person in the supine position during may need to be changed. 3. Avoid feeding too rapidly. Rapid ingestion of food feedings? increases the likelihood of regurgitation and aspira- • Are feedings or medications administered through tion. Offer oral nourishment slowly, and allow ade- quate time for chewing and swallowing. a gastric tube? 4. Avoid liquids and puréed foods. Semisolid foods are less likely to be aspirated than are liquids or puréed foods. The consistency of liquids can be modified with commercial preparations that are available in most dietary departments. 5. Monitor respiratory sounds and respiratory rate, and observe the amount and type of sputum
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 127 produced. Aspiration of food or fluids may result applied will simply cause the tube to collapse on in coughing, choking, dyspnea, and respiratory dis- itself, resulting in the possibly false impression that tress. Increased amounts of frothy sputum are often no residual is present. If the volume of stomach noted. Elevated heart rate and respiratory rate contents exceeds 50 to 100 mL, the physician should (tachycardia and tachypnea) are usually present be notified and the feeding withheld. Stomach con- with aspiration. tents should be replaced through the tube to main- 6. Keep suction equipment available. Aspiration can tain electrolyte balance. result in respiratory distress. Keep suction equip- 3. Maintain clean technique for all feeding tubes, ment on hand whenever an individual at risk for equipment, and formula. Bacterial contamination aspiration is being fed. of formula increases over time and when breaks in 7. Consult with specialists such as speech therapists clean technique occur. Be sure to wash your hands and dietitians. A team approach to swallowing before pouring formula or checking placement. disorders and potential aspiration can help reduce Wash the top of the formula can before opening. the likelihood of problems. Speech therapists often Cleanse ports before and after manipulation. have special training in swallowing disorders and Change feeding bags and irrigation sets according can suggest modifications in feeding practices. to agency policy, at least every 24 hours. Clean Dietitians are specially trained to meet the needs of equipment between uses and store properly. Avoid these individuals and can provide a nutritionally use of food dyes, which have been shown to increase sound diet in a form modified to meet the needs of the risk for contamination and even death. the person at risk for aspiration. The following interventions should take place in the The following interventions should be taken for home: persons receiving tube feedings: 1. Explain safety precautions to the individual and 1. Check placement of the nasogastric tube using the the family or caregiver. Explain the importance of approved method. Nasogastric tubes can become proper positioning, proper rate of feeding, and displaced into the lungs, resulting in aspiration. modifications to food consistency that reduce the Tube placement should be verified before any solu- likelihood of aspiration. tion is instilled. This should be done routinely 2. Encourage enrollment in a home safety course that according to institutional policy. If available, x-ray includes the Heimlich maneuver and cardiopul- confirmation is recommended (Ackley et al., 2008). monary resuscitation. Aspiration of solids can 2. Measure stomach contents before starting inter- sometimes be relieved by the use of the Heimlich mittent feeding; then replace stomach contents. maneuver. Respiratory distress related to aspiration Stomach distention, which is related to decreased may require other emergency interventions until gastric emptying time, increases the risk for regur- medical assistance arrives. The family should be gitation and aspiration. If possible, measure the prepared to provide these lifesaving measures if volume of stomach contents before intermittent they plan to provide care in the home. tube feedings. This may not be possible if a small- 3. Use any appropriate interventions that are used in bore tube is used, because the negative pressure the institutional setting (Nursing Care Plan 6-1). Nursing Care Plan 6-1 RISK FOR ASPIRATION Mr. Thomas is a 74-year-old man who recently suffered a stroke. His level of consciousness is decreased, he has no gag reflex, and the left side of his face shows some paralysis. His physician has ordered intermittent feedings (every 4 hours) of a commercial nutrient solution through a nasogastric tube. NURSING DIAGNOSIS Risk for aspiration DEFINING CHARACTERISTICS • Decreased level of consciousness • Facial paralysis • Absence of gag reflex PATIENT GOALS/OUTCOMES IDENTIFICATION Mr. Thomas will remain free from episodes of aspiration. NURSING INTERVENTIONS/IMPLEMENTATION 1. Assess for signs of stomach distention, cough, or excessive respiratory secretions during each feeding. 2. Position Mr. Thomas in the Fowler position before feeding. Continued
128 UNIT II Basic Skills for Gerontologic Nursing Nursing Care Plan 6-1 3. Verify placement of the nasogastric tube using approved methods before each feeding. 4. Measure the stomach contents before beginning feeding. Withhold feeding and notify the primary care provider if the volume of stomach contents is greater than 50 to 100 mL. 5. Return the stomach contents through nasogastric tube. 6. Allow adequate time (approximately 30 minutes) for instillation of 250 mL. 7. Keep the head elevated for 30 to 45 minutes after feeding. 8. Keep suction equipment at the bedside. Check at regular intervals to verify that this equipment is functioning properly. EVALUATION Physical assessment reveals no signs of stomach distention. The residual stomach contents before feedings range from 25 to 70 mL. No episodes of coughing or silent tearing are noted with feedings. His lungs are clear on auscultation. You will continue the plan of care. CRITICAL THINKING QUESTIONS The patient’s family thinks that the feeding tube is unnecessary and that he should be offered food and fluids by mouth. 1. How would you explain the risks to them? 2. How would you modify the plan of care if continuous feedings were ordered? Get Ready for the NCLEX® Examination! Additional Learning Resources Key Points Go to your Evolve website at http://evolve.elsevier .com/Williams/geriatric for the additional online resources. • Nutritional and fluid problems are common in the aging population. Online Resources: • Knowledge of a wide range of facts and concepts • Dietary Reference Intakes (DRIs): Recommended about nutrition and the nutritional needs of older adults Intakes for Individuals: http://fnic.nal.usda.gov/dietary- is important. This text addresses the basics only. For guidance/dietary-reference-intakes/dri-tables greater understanding, consult texts that specialize in geriatric nutrition. • Older Adult Nutrition Programs: Senior Farmers’ Market Nutrition Program (SFMNP), Elderly Nutrition Program: • A wide range of factors increases the risk for www.nutrition.gov/food-assistance-programs/ malnutrition in the older adult population. Take these elderly-nutrition-program into account when assessing the nutritional status of older adults. Review Questions for the NCLEX® Examination • Sensory or cognitive changes, weakness, activity 1. A male older adult who resides in a long-term care intolerance, and loss of interest in food as a result of facility recently began to refuse food and will not open depression or other emotional disturbances contribute his mouth for solids. He does take liquids by mouth. He to these problems. repeatedly says, “Leave me alone.” He has lost a total of 5 lbs over the past month. What is the best initial • Signs and symptoms of poor nutrition, such as nursing intervention? confusion, weight loss, lethargy, and lightheadedness, 1. Obtain an order from the primary care provider to may be mistakenly attributed to an illness or medication insert a feeding tube. reaction rather than to the underlying nutritional 2. Assess to identify changes in physical or emotional problem. status. 3. Discuss use of high nutrient liquid feedings with the • Indicators of nutritional and metabolic alteration dietitian. are most commonly observed in the skin, mucous 4. Request assistance with feeding from the family. membranes, hair, and nails. Assessment of these structures can tell nurses a great deal about an aging 2. An older woman recently moved to the United States person’s nutritional status and fluid balance. from the Middle East. She does not like to drink cow’s milk or eat most cheeses. What is a culturally • Good nutrition has been shown to be one of the most acceptable food that would best help meet the need for significant factors in the prevention of skin breakdown. calcium? 1. Yogurt • Nurses play an important role in the recognition of 2. Broccoli nutritional and fluid balance problems, identification of 3. Sardines contributing factors, and development of an appropriate 4. Tofu plan of care. • Nurses should recognize the importance of consultation with the dietitian and referral to community agencies that can provide nutritional support.
Maintaining Fluid Balance and Meeting Nutritional Needs CHAPTER 6 129 3. An older man who lives alone in an apartment is 5. An older adult is taking furosemide (Lasix) to reduce placed on a sodium-restricted diet because of heart edema. Dietary teaching for this person would best failure. He asks you to help him make good diet include directions to increase dietary intake of which choices. Which foods should he avoid? (Select all of the following foods? (Select all that apply.) that apply.) 1. Bananas 1. Canned tomato soup 2. Apple juice 2. Deli bologna or ham 3. Tomatoes 3. Grilled steak 4. Oranges 4. Frozen spaghetti dinner 5. Grapes 5. Pancakes 6. Milk 6. Boiled eggs 6. An older nursing home resident has poor skin turgor, 4. An 85-year-old woman was admitted to the hospital. dry mucous membranes, and very concentrated urine. Clinical indicators of inadequate nutrition include which What are the best directions to give to the nursing of the following? (Select all that apply.) assistant? (Select all that apply.) 1. Thin, brittle hair 1. Make sure the resident eats everything served at 2. Hgb 10.2; Hct 33 each meal. 3. Thin, dry skin 2. Offer small amounts of fluids frequently during 4. Slow reflexes the day. 5. Pale conjunctiva 3. Provide good oral hygiene. 4. Identify the beverages that the resident prefers. 5. Keep a large container of iced water in the resident’s room. 6. Give the resident hard candy to suck on.
chapter 7 Medications and Older Adults http://evolve.elsevier.com/Williams/geriatric 7. Discuss how medications fit into the nursing plan of care. 8. Describe specific nursing interventions and modifications Objectives in technique that are related to medication administration 1. Identify factors that increase the risk for medication- to older adults. related problems. 9. Describe the older person’s rights as they relate to medication administration. 2. Discuss the reasons each of these factors increases 10. Identify information that should be provided to older health risks for the older adult. adults regarding medications. 11. Discuss the impact of age-related changes on self- 3. Describe how pharmacokinetics is altered with aging. administration of medications. 4. Discuss the pharmacodynamic changes observed in the 12. Describe nursing interventions that can reduce problems related to self-administration of medication in the home. older adult. 5. Explain specific precautions that are necessary when geropharmacology (jĕr-ō-făr-mă-KŌL-ŏ-jē, p. 131) half-life (p. 131) administering medication to older adults in an metabolism (mĕ-TĂB-ō-lĭzm, p. 132) institutional setting. pharmacokinetics (făr-mă-kō-kĭ-NĔT-ĭks, p. 131) 6. Identify the risks related to aging and pertinent nursing polypharmacy (pŏ-lē-FĂR-mă-sē, p. 132) observations for specific drug categories. Key Terms absorption (ăb-SŎRP-shŭn, p. 131) adverse drug reaction (p. 130) distribution (dĭs-trĭ-BŬ-shŭn, p. 131) excretion (ĕks-KRĒ-shŭn, p. 132) first pass effect (p. 131) Problems related to medications are common in older consulting their primary care provider. Studies show adults, and they are costly in terms of both time and that older adults purchase 40% of the OTCs sold money. Medications can alter an older adult’s ability (Wilhelm & Ruscin, 2009) and that 90% of this group to perform normal functions, can result in behavior use OTC drugs at least occasionally. changes, and can be life threatening. Adverse drug reactions (ADR) are common in older adults. Studies Considering these numbers, it is no surprise that have revealed that 15% or more of hospitalizations of use, misuse, and abuse of medications present serious older persons were related to ADRs, and that about threats to the aging population. Medications are potent half of these are potentially preventable (Pretorius substances. For every desired effect, many side effects et al., 2013). In addition, older people are more likely and adverse effects are likely to occur. Although often to develop iatrogenic (treatment-related) complica- useful or necessary to maintain health, medications tions secondary to medications taken during a hospital present risks to people of all ages, and older adults stay. The greatest risks for ADR-related death include are at even greater risk than the younger population people over age 75, African Americans, men, and (Box 7-1). people living in extremely rural areas (Shepherd et al., 2012). ADRs also have been linked to an increased risk RISKS RELATED TO DRUG-TESTING METHODS for falls and automobile accidents. Hospitalizations from ADRs cost older adults and taxpayers several In general, methodologies used to test drugs and to billion dollars each year. establish therapeutic dosages do not take into account the unique characteristics of older adults. Most drug On average, people over age 65 years of age take 14 testing is performed on people who are healthier, or more prescription medications each day. This younger, and have been exposed to fewer medical number jumps to 18 after age 80. As a group, older interventions than the older adult who might actually adults consume 40% of all prescription drugs in be prescribed the medication. Because older adults America (American Society of Consultant Pharmacists, normally have had some changes in body function and 2014). Many older adults prefer to try self-treatment are more likely to suffer from at least one disease with over-the-counter (OTC) medications before process, they are not physiologically the same as young 130
Medications and Older Adults CHAPTER 7 131 Box 7-1 Factors That Increase the Risk for Drug Absorption Medication-Related Problems Most medications are taken orally and are absorbed through the gastrointestinal (GI) tract. First pass effect • Drug-testing methodology is a phase of drug absorption that is altered in the older • Physiologic changes related to aging adult. In first pass effect, oral medications take a first • Use of multiple medications, OTC medications, and pass through the liver before entering the systemic circulation, greatly reducing the drug concentration. herbal supplements Because of decreased liver mass and blood flow, there • Cognitive and sensory changes is reduced first pass metabolism in the older adult, • Knowledge deficits which can lead to a significant increase in the effects • Financial concerns of certain medications like propanolol and labetalol. Other medications need to be “activated” by the liver, Table 7-1 Factors Affecting Drug Response such as angiotensin-converting-enzyme (ACE) inhibi- in Older Adults tors (e.g., enalapril); therefore, the effect of these medi- cations can be reduced in the older adult. EFFECT CAUSE It was a long-held belief that gastric acid secretion Absorption: decreased Reduced liver mass and blood decreases as we age, resulting in an increased gastric first pass effect flow pH and reduced drug absorption. Newer research has shown this so-called age-related change to only be Distribution: altered Storing of fat-soluble drugs in present in certain disease states and not true for healthy fatty tissue; decreased serum older adults (Zwicker & Fulmer, 2012). Likewise, albumin for binding of drugs decreased gastric motility and a slower emptying rate of the stomach can occur, but again, usually only in the Metabolism: altered Decreased enzyme activity in presence of disease. When they do occur, these can liver increase the amount of time that the medication is in contact with the gastric mucosa and lead to increased Excretion: decreased Decreased renal blood flow; absorption. Decreased peristalsis can slow the speed at decreased glomerular which enteric medication reaches the intestine, there- filtration rate; decreased fore delaying its onset of action. Changes in the ability number of functional renal of the cells in the GI tract to absorb and transport the tubules drug can further influence its absorption. If medication is not transferred effectively through the cell mem- adults. It seems obvious that an 80-year-old, 94-lb brane, the amount of absorption will be decreased. woman with heart disease should not be expected to respond in the same way that a healthy 35-year-old, Drug Distribution 200-lb man would. The drugs and dosages that are With aging, there is typically a decrease in total body appropriate for one may be unsuitable for the other. mass, lean body mass, and total body water and an No medical professional would think of giving an increase in total body fat. These changes can signifi- adult dose of medication to a child, yet the same con- cantly alter the distribution of medications. Because sideration is not always given to the unique situation there is less total body water, water-soluble drugs presented by older adults. Geropharmacology, the such as gentamicin, histamine-receptor blockers, and study of how older adults respond to medication, is a lithium tend to remain in higher concentrations in the new but growing area. Until all care providers recog- bloodstream. This results in increased blood concen- nize the uniqueness of older adults and modify treat- tration levels of these drugs. An older person who is ment accordingly, overmedication is likely to occur. dehydrated is at even greater risk for reaching exces- sive blood levels of water-soluble drugs. RISKS RELATED TO THE PHYSIOLOGIC CHANGES OF AGING As muscle mass decreases and the percentage of adipose tissue increases, fat-soluble drugs such as phe- People do not experience age-related physiologic nobarbital and the benzodiazepines become trapped changes at the same rate. When considering an older in the fatty tissue, resulting in abnormally low blood adult’s response to medication, it is more important levels. If the dosage is increased based on these blood to consider physiologic age than chronologic age. The levels, an excessive amount of medication may be more physiologic changes experienced, the greater administered. Because fat-soluble drugs continue to be the risk will be of an altered response to medications. released slowly from the fat into the bloodstream, Even the most common physiologic changes of aging older persons may exhibit delayed or hangover effects. can have a significant effect on pharmacokinetics A drug’s half-life is the amount of time required for half and pharmacodynamics (Table 7-1). of the medication to be eliminated or metabolized. The half-life of a single dose of diazepam, which is 36 hours PHARMACOKINETICS Pharmacokinetics is the study of drug actions within the body, including absorption, distribution, metabo- lism, and excretion.
132 UNIT II Basic Skills for Gerontologic Nursing affect the response to medications. Receptor sites on the target organs may respond more or less sensitively in a young adult, may extend to as much as 100 hours to medications. The receptors may respond normally in an older individual. to some medications but not to others. Receptors often may be more sensitive to medications, placing older A decrease in hemoglobin and the plasma protein adults at increased risk for toxic responses. Brain albumin is common with aging. This results in fewer receptors are particularly sensitive, thus older adults available sites for protein-bound drugs, such as war- typically respond strongly to psychotropic medica- farin, phenytoin, theophylline, salicylates, and tolbu- tions. When the receptor sites are less sensitive, the tamide. The danger of adverse or toxic reactions is individual may require larger-than-normal doses to high even with smaller doses, because an unbound achieve therapeutic effects. If receptor sites in the myo- active drug still circulates in the bloodstream. The risk cardium are affected, older people may require higher for toxicity is greater in malnourished older adults. doses of common medications such as propranolol Older adults who consume high-carbohydrate, low- and lidocaine. Administration of these higher doses protein diets are more likely to develop toxicity than increases the risk for toxicity. Additionally, receptors are older adults who consume a well-balanced diet. may respond in unpredictable ways. For example, the Because not all of the serum drug assays can distin- wildly successful erectile dysfunction medication guish between free and bound medications, these tests sildenafil citrate (Viagra) began as a cardiac medica- may not provide reliable measures of toxicity. Because tion that was performing poorly in clinical trials for the of this, nursing assessment for symptoms of toxicity intended effects of reducing hypertension and angina, becomes more important than ever. but instead seemed to consistently demonstrate an unusual side effect in the clinical trial participants. Drug Metabolism Polypharmacy The liver is the primary site of drug metabolism. Aging Polypharmacy, the prescription, administration, or use often results in decreased activity of liver cells, of more medications than are clinically indicated, is a decreased metabolic enzymes, and decreased cardiac common problem in older adults (Figure 7-1). As men- output, which results in reduced blood flow to the tioned previously, older adults ingest far more medica- liver. By 65 years of age, the liver has only 55% to 65% tions than do younger people in addition to OTC of the perfusion of a young adult. This reduction in medications, herbs, and supplements that may be perfusion decreases the liver’s effectiveness in metabo- taken with or without the primary care provider’s lizing drugs. When drugs are not metabolized effec- recommendation or knowledge. It is estimated that tively by the older adult’s liver, the risk for toxicity older adults purchase 40% of all nonprescription increases. Toxicity is always a concern with medica- tions commonly prescribed for older adults, including FIGURE 7-1 Older adults’ concurrent use of many prescription digoxin, β-blockers, calcium-channel blockers, and tri- medications can lead to polypharmacy. (From deWit SC, O’Neill P: cyclic antidepressants. Fundamental concepts and skills for nursing, ed 4, 2013. Philadelphia: Saunders.) Drug Excretion Aging kidneys are significantly less effective at remov- ing waste products, including the by-products of med- ications. As the kidneys become less effective in the excretion of drugs, in part because of reduced renal perfusion, more drug remains in the circulation, leading to elevated drug levels and symptoms of drug toxicity. Because the changes in kidney function are accompanied by changes in lean body mass, serum creatinine levels often remain constant, masking the decline in function. When the risks for toxicity are assessed, creatinine clearance tests provide a more effective measure of kidney function than does the serum creatinine level. Medications such as aminoglycosides, digoxin, lithium, procainamide, and cimetidine are likely to reach toxic levels because of poor renal excretion. Nonprescription drugs, such as alcohol and nicotine, can also affect kidney function and cause changes in drug elimination in older persons. PHARMACODYNAMICS Responses to medications are less predictable in the aging person. Pathologic changes in target organs may
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