geriatric nurse

["Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 283 PAIN Dental caries and periodontal disease are the most common reasons for oral pain, but oral lesions such as stomatitis or altered sensations in the mouth are frequently reported. Pain may be limited to the oral cavity or may affect the face and jaw. In one study, 7% of older adults reported oral pain within the previous 6 months. Oral pain can cause loss of appetite and decreased food intake and can have a negative effect on the overall quality of an older person\u2019s life. FIGURE 17-10\u2003 Extensive dental caries in an older adult. (In Fillit: Safety Alert Brocklehurst\u2019s textbook of geriatric medicine and gerontology, ed 7, Philadelphia, 2010, Saunders. [Reprinted with the permission of \u2002 Mirriam Robbins, DDS, New York University College of Dentistry.]) Carefully Assess Jaw Pain and decreased appetite in older adults can often be Jaw pain can be an \u201catypical presentation\u201d of a myocardial attributed to dental problems. Decay, or caries, is infarction, a medical emergency! Take into consideration the caused by the action of bacteria that penetrate through patient\u2019s medical and dental history, carefully assess the entire the enamel shield of the tooth and cause destruction patient, and report the jaw pain to the RN or primary care (Figure 17-10). If caries is not recognized early, a provider for follow-up. significant amount of the tooth structure may be destroyed. If the caries extends deep into the tooth, a DENTURES nerve may be exposed, and painful neuritis (tooth- If only a few teeth are missing, the dentist may attempt ache) may result. Replacement of the lost tooth to bridge the gaps by attaching artificial teeth to the material with amalgam restorations (fillings) can help good teeth. If too many teeth are missing, a partial rebuild the tooth, but this leaves a weakened structure plate may be required. When all of the upper or lower that remains susceptible to problems. Lost restorations teeth are removed, a complete set of dentures is needed. leave rough edges that cause irritation of the oral Both partial plates and dentures can cause problems mucous membranes, particularly the cheek and tongue. for the wearer. Partial plates tend to catch particles of food and may weaken the healthy teeth to which they PERIODONTAL DISEASE are attached. Complete dentures are expensive and Food debris and plaque accumulate in the mouth and difficult to fit. on the teeth when oral hygiene is inadequate. Activity of bacteria on this debris, especially the tongue, causes Dentures that fit properly at one time may not halitosis, or bad breath, which is often disturbing to the fit properly if the older person loses or gains a signifi- older person and to anyone who has close contact. cant amount of weight. Fit is also a problem when Periodontal disease is a less obvious but potentially dentures are left out of the mouth for a prolonged more serious complication of poor oral care. One form period. Many older adults refuse to wear their den- of periodontal disease is gingivitis, or inflammation of tures because of the discomfort caused by an improper the gums. Gingivitis causes gum swelling, tenderness, fit. This is because the arch of the jaw changes to com- and bleeding and eventually leads to recession of the pensate for the edentulous state. Professional dental gum tissue away from the tooth. As the gums recede, attention is needed to repair or rebuild the dentures in the teeth lose support, become loose in the sockets, these cases. and eventually fall out. When a tooth is lost, a gap is created. Healthy teeth shift position or move into the Dentures can cause irritation, inflammation, and space, resulting in an uneven bite. Chewing becomes ulceration of the gums and oral mucous membranes. increasingly difficult when significant numbers of Older adults should inspect their mouths regularly teeth, particularly the molars needed for chewing and promptly report any problems to the dentist. and grinding food, become loose or lost. Periodontal Sometimes, a minor adjustment of the denture or use disease is suspected to play a role in thromboembolitic of a fixative agent or cushion is all that is required to disorders, bacterial endocarditis, and myocardial prevent painful problems. infarction. Individuals with a cardiac history are typi- cally given prophylactic antibiotics before or following DRY MOUTH any dental work. Xerostomia, or dry mouth, is common with aging. Dryness may result from the normal age-related reduc- tion in saliva secretion, inadequate hydration, or dis- orders such as diabetes. Medications such as diuretic agents, antidepressants, sedatives, hypnotic agents, antihistamines, and anticholinergic medications also contribute to xerostomia. In turn, xerostomia makes","284\t UNIT IV\u2003 Physical Care of Older Adults The main risk factors for oral cancer are a history of chewing and swallowing more difficult, promotes alcohol and tobacco use or the presence of HPV-16 tooth decay, and alters the sense of taste. (human papilloma virus, version 16), the same virus LEUKOPLAKIA responsible for most cervical cancers. Inspection of the mouth can reveal a number of abnor- malities. White patches in the mouth, called leukopla- DISORDERS CAUSED BY VITAMIN DEFICIENCIES kia, often are precancerous and require prompt medical Vitamin deficiencies, particularly deficiencies of ribo- attention (Figure 17-11). Lesions on the posterior third flavin, niacin, and vitamin C, can affect the oral mucous or the sides of the tongue often are abnormal and membranes. A smooth, purplish, sore tongue may should be brought to the attention of the primary care be related to riboflavin deficiency. Complaints of a provider. burning sensation or soreness of the mouth may be CANCER related to niacin deficiency. Multiple painful ulcers of According to the Oral Cancer Foundation, as many as the oral mucous membranes with enlargement of the 45,750 people are diagnosed with oral or pharyngeal cervical lymph glands, difficulty swallowing, and foul cancer each year (Oral Cancer Foundation, 2015b). The odor may indicate Vincent angina. Vincent angina is a incidence of this cancer increases with age. These condition caused by opportunistic microorganisms forms of cancer have a poor prognosis, primarily that normally live in the mouth but cause infection because they are often discovered late. Early recogni- only when the individual becomes malnourished. tion and treatment before the cancer has metastasized to other tissues offer the best hope. Symptoms of oral SUPRAINFECTIONS cancer are listed in Box 17-3. Suprainfections of the mouth are relatively common in older individuals who receive broad-spectrum FIGURE 17-11\u2003 Leukoplakia. Note the formation of white spots, which antibiotic therapy for some other infection. Antibiotics may become malignant. (From White GM, Cox NH: Diseases of the destroy the normal mouth flora and allow opportun- skin: A color atlas and text, 2000, St. Louis: Mosby.) ists or yeast colonies to become established and grow. Candidiasis, a yeast infection (also known as thrush), Box 17-3\u2003 Symptoms of Oral Cancer appears as white patches that adhere to the tongue, lips, and gums. Attempts to remove these patches may \u2022\t A mouth lesion that does not heal within 2 weeks result in sore, bleeding tissue. A hairy tongue is the \u2022\t A lump or thickening in the cheek result of enlargement of the papillae on the tongue; \u2022\t Red or white patches on the gums, tongue, tonsil, or this often follows antibiotic therapy. Black or brown discoloration on the tongue may be caused by tobacco oral mucosa use or by a chromogenic (color-producing) bacterium. \u2022\t Sore throat or sensation of something being caught in These conditions are more commonly observed in malnourished older adults and those with poor oral the throat hygiene practices. Yeast infections are usually treated \u2022\t Difficulty chewing or swallowing by direct oral application or swishes of prescription \u2022\t Difficulty moving the tongue or jaw medication. Hairy tongue usually resolves without \u2022\t Numbness in the mouth medical treatment. \u2022\t Swelling of the jaw; uncomfortable fit of dentures \u2022\t Chronic hoarseness ALCOHOL AND TOBACCO-RELATED PROBLEMS Alcohol and tobacco, even in small amounts, can harm Data from Oral Cancer Foundation. Diagnosis. 2012. \t mucous membranes. Alcohol is chemically irritating http:\/\/oralcancerfoundation.org\/diagnosis\/index.htm and drying to the mucous membranes. Tobacco, whether smoked, chewed, or taken as snuff, increases the risk for oral cancer. PROBLEMS CAUSED BY NEUROLOGIC CONDITIONS Good oral hygiene practices are part of routine health maintenance, but meeting oral hygiene needs may be difficult for older individuals who have lost strength, coordination, or cognitive processes. Neurologic con- ditions such as stroke, multiple sclerosis, or Parkinson disease decrease coordination and strength, making it difficult for the person to manipulate the equipment needed for oral hygiene. Individuals with severe arthritis may not only find the equipment difficult to","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 285 manipulate, but they may also find it difficult to open NURSING GOALS\/OUTCOMES IDENTIFICATION their mouth adequately for good, thorough cleaning. Older people who take medication for epilepsy or \u2002 other seizure disorders need to use special precautions because these medications often cause hyperplasia of The nursing goals for older individuals diagnosed the gingiva. Oral hygiene with soft toothbrushes or with impaired oral mucous membrane are to (1) obtain swabs is recommended to prevent excessive trauma regular professional dental care; (2) demonstrate tech- and bleeding from the tender, swollen tissues. niques for maintaining or restoring the integrity of the Providing oral hygiene to persons with Alzheimer mucous membranes; (3) inspect the oral cavity regu- disease can be a challenge because affected people do larly and seek care promptly if any symptoms occur; not understand the need for oral hygiene and are likely (4) experience no complaints such as irritation, inflam- to resist care. mation, or ulceration; (5) ingest foods and fluids without discomfort; and (6) verbalize specific actions NURSING PROCESS FOR IMPAIRED ORAL to promote healthy oral mucous membranes. \u2002 NURSING INTERVENTIONS\/IMPLEMENTATION MUCOUS MEMBRANE \u2002 ASSESSMENT\/DATA COLLECTION The following nursing interventions should take place in hospitals or extended-care facilities. Encourage indi- \u2002 viduals who are able to provide their own oral hygiene to do so. When individuals are not capable of meeting \u2022\t Does the person have his or her own teeth? If so, their own oral hygiene needs, nurses or nursing assis- how many? tants must provide the care. When performing oral hygiene, wear gloves and other appropriate protective \u2022\t What is the condition of the teeth? Any teeth loose devices to maintain universal precautions. or decayed? 1.\t Complete a thorough assessment of the oral \u2022\t Does the person have halitosis? mucous membranes. Individuals who require \u2022\t Does the person wear dentures? If so, are they intermediate or skilled nursing care are likely to have more oral hygiene problems and greater oral uppers, lowers, or both? Partial plates or bridges? hygiene needs. If one wishes to judge the quality of \u2022\t Are dentures worn during meals or removed? How nursing care provided in an extended-care facility, the first place to look is in the mouths of the patients do they fit? or residents. For whatever reason, oral hygiene \u2022\t Are there any signs of irritation in the mouth? Any seems to be the area of hygiene that is most often neglected. This is troubling, because oral care is a bleeding? very important component of nursing care. Good \u2022\t Are food particles trapped under the dentures at oral hygiene promotes comfort, enhances appetite, and fosters a sense of well-being. meals? 2.\t Initiate referral to a dentist or dental hygienist. \u2022\t Is any residual food or debris evident in the mouth? If any problems with the teeth or oral mucous \u2022\t How good is the person\u2019s appetite? What types and membranes are observed, the individual should be seen by a dentist. Hospitals may have outpatient consistency of food does he or she prefer to eat? dental clinics that will see in-house patients if \u2022\t What is the condition of the oral mucous mem- necessary. If the problem is not urgent, encourage the individual to make an appointment with his branes? Are they moist or dry? or her own dentist after discharge. Extended-care \u2022\t What is the condition of the tongue? Is it coated, facilities should have a clinic or dentist on staff that sees residents on a scheduled or referral basis. If pale, red, or irritated? there is no dentist on the premises, arrange trans- \u2022\t Does the person use tobacco or have a history of portation with the family or a transport service. It is important to refer individuals as soon as a tobacco use? problem is detected to prevent the development of \u2022\t What medications is the person receiving? more serious conditions. Patients with problems \u2022\t Does the person have any physical conditions that related to ill-fitting dentures should be referred to the dentist for prompt follow-up. Nurses must be interfere with performing oral hygiene? sure to send the improperly fitting dentures along Box 17-4 lists risk factors for problems with oral on the visit. Dental hygienists can perform more mucous membranes in older adults. detailed oral assessment, provide cleanings and other preventive treatments, and assist the nurse NURSING DIAGNOSIS in developing strategies for providing effective oral hygiene. \u2002 Impaired oral mucous membrane Box 17-4\u2003 Risk Factors for Problems With Oral Mucous Membranes in Older Adults \u2022\t Impaired cognitive, neurologic, or musculoskeletal function \u2022\t Inadequate fluid intake \u2022\t Medication that affects the oral mucous membranes \u2022\t Complete or partial artificial teeth \u2022\t Tobacco use (smoking or chewing) \u2022\t Poor health-maintenance practices","286\t UNIT IV\u2003 Physical Care of Older Adults caution because of the potential risk for aspira- 3.\t Provide oral hygiene. Provide thorough oral tion and resulting pneumonia. 4.\t Promote adequate intake of nutrients and fluids. hygiene a minimum of twice a day. Brushing after If the individual is avoiding certain foods or fluids each meal and at bedtime is more desirable for because of dental problems, contact the primary individuals suffering from halitosis, xerostomia, or care provider or dietary department to obtain a gingivitis. Individuals who have poor nutritional change in food consistency. Soft, chopped, or pur\u00e9ed intake because of dysgeusia (funny tastes in the foods may be necessary for persons who are unable mouth) should have additional oral hygiene before to chew because of loose teeth or improperly fitting meals. Frequent oral hygiene is also necessary dentures. If food tends to become trapped under the for individuals with upper respiratory infections. dentures, remove and cleanse them promptly after Excessive respiratory secretions coat the mouth and each meal. Excessively hot or cold foods may irri- tongue, leaving a bad taste; in addition, the infec- tate the mucous membranes or teeth and should be tious agent can easily be aspirated. The frequency avoided if they cause problems. Document any tem- of oral hygiene should be determined by the nurse perature modification in the care plan so that con- and stated specifically in the care plan (e.g., \u201coral sistent approaches can be used. For example, if the hygiene q2h and prn\u201d). Use toothbrushes, not foam individual tolerates beverages at room temperature, swabs to clean the teeth, as swabs are ineffective in all fluids, including the water at the bedside, should removing plaque. Swabs should only be used to be provided this way. Keep fluids at the bedside and clean oral mucosa in someone who is edentulous. offer to the individual at planned intervals through- Dentures should be cleansed using warm water out the day. 5.\t Provide lozenges or topical analgesics as pre- and a nonabrasive cleanser. Brush dentures scribed. If severe or painful lesions are present in over a basin of water or over a towel to prevent the mouth, the primary care provider may order the breakage. Ultrasonic cleaning devices are avail- use of topical analgesics in lozenge or viscous form able in some facilities and are very effective at (viscous lidocaine). Drinking and eating should be removing particles of debris, particularly from avoided for 1 hour after administration of these the wire clasps on partial plates. Clean the oral preparations. cavity thoroughly and inspect before reinserting 6.\t Communicate suspected oral side effects of medi- dentures. cation therapy to the primary care provider and Older denture wearers should be discouraged dentist. If a drug is suspected of causing untoward from removing and wrapping their dentures in side effects on the oral mucous membranes, paper napkins or tissue. Many dentures wrapped promptly communicate this information to the pro- this way have been accidentally thrown away. vider so that any necessary adjustments in dosage It is also wise for anyone who wears dentures or drugs can be made. to have his or her name etched into each plate. The following interventions should take place in This can prevent permanent loss of these costly the home: items if, for some reason, the owner is separated 1.\t Complete a thorough assessment of the oral from them. Remove dentures from the mouth mucous membranes. A thorough assessment is before sleep to prevent slippage, which could necessary to detect the presence and severity of result in trauma to the mouth or problems with any problems. Specific interventions are based on breathing. the information gathered. When performing oral hygiene on an unconscious 2.\t Stress the importance of regular dental visits. patient, take special care to prevent aspiration. Dental hygiene is essential for older adults. Place unconscious individuals in a side-lying Periodic dental visits should be part of ongoing position, and use adequate towels to protect the health-maintenance practice, even for edentulous bedding and clothes. Prop the mouth open with individuals. Encourage and remind those living at gauze or padded tongue blades. Cleanse all sur- home to make and keep regular dental appoint- faces of the teeth, tongue, and oral mucous mem- ments. If cost is prohibitive, dental clinics and branes with a soft brush; damp gauze; sponge-tip schools of dentistry and dental hygiene may offer swab; or clean, moistened washcloth. Special care at reduced rates. Some dentists also give price toothbrushes that attach to suction machines are reductions to older people if requested. available in some facilities. Use lemon and glyc- 3.\t Review the person\u2019s oral hygiene practices. Teach erin swabs with caution because they may be older adults who have their own teeth to brush, irritating to open areas on the mucous mem- floss, and irrigate the mouth at least once daily. branes and because they may ultimately cause If problems of halitosis, plaque formation, bad drying (glycerin tends to draw moisture away taste, or gingivitis are present, more frequent from tissues). brushing may be required. Brushing is best done Dry lips may require application of Vaseline, mineral oil, or a lip balm such as Burt\u2019s Bees. Petroleum- based products should be used with extreme","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 287 with a soft to moderate bristle brush. Too firm a FIGURE 17-12\u2003 Adaptive aids for brushing. (From Daniel: Mosby\u2019s bristle may scratch or irritate the oral cavity. dental hygiene, ed 2, 2008, St. Louis: Mosby.) Commercial fluoridated toothpastes are available at a reasonable cost. Special toothpastes are avail- or transportation services in getting to dental able for individuals with sensitive teeth and gums. appointments. Family and friends can also help by Older adults who have been in the habit of using purchasing and setting up oral hygiene equip- salt or baking soda as a dentifrice should be coun- ment. A family member or friend can be shown seled to avoid ingesting these products, because how to modify a toothbrush or prepare floss for they are high in sodium. Flossing between the use by the older person. teeth helps remove trapped food and maintain 6.\t Explain the need to avoid alcohol and tobacco healthy gums. If the older adult has difficulty use. Because alcohol and tobacco are likely to holding the floss, a loop tied at each end of the irritate the mucous membranes and cause signifi- string can help provide a better grip, or pre- cant health problems, it is important to stress the threaded flossers may be a better choice importance of eliminating, or at least restricting, Irrigation of the mouth is best accomplished with their use. 7.\t Promote adequate intake of nutrients and fluids. a commercial irrigator. If a commercial irrigator Nurses should explain how nutrients, particularly is too costly, a bulb syringe can be used. Even vitamins, can contribute to healthy mucous mem- the swish-and-swallow technique of rinsing the branes. Instruction about diet may be necessary if mouth with water is better than doing nothing. inadequacies are detected. Stress the importance Teach the person to gently brush the tongue to of fluid intake for saliva formation and for use as prevent halitosis, and to inspect the entire oral a rinse for the mucous membranes. Encourage cavity for signs of irritation. older adults to keep a glass of water by the chair Individuals who wear dentures should also be or bedside as a reminder to drink adequate fluids. instructed in proper oral hygiene. Dentures Highly sugared beverages should be avoided should be cleaned thoroughly every day. In because they encourage tooth decay. Many older some people, food debris tends to become adults with altered mucous membranes prefer to trapped under the dentures. If this is a problem, avoid ice in beverages, which can stimulate tooth- instruct the person to remove the denture and ache. If the individual has difficulty chewing food rinse it after each meal to prevent irritation. because of loose or missing teeth, a food processor, Thorough cleansing can be done by brushing grinder, or blender can be used to change the with a commercial dentifrice or by using a food\u2019s consistency. soaking cleanser. Some people choose to use 8.\t Discuss the benefits of adequate moisture in the both. Many individuals use a powder or pad to environment. If the environment is dry or if help the dentures adhere to the gums. It is the individual is a mouth-breather, an additional important that all of the fixative be removed at source of moisture may be needed. A freestanding each cleansing. If it is not removed, an uneven humidifier or one attached to the furnace increases surface may result and irritate the gums. Cleanse and store dentures in tepid water, because hot water may cause them to warp. When the den- tures are out of the mouth, cleanse the entire oral cavity with a soft to moderate-bristle brush and inspect the entire oral cavity for signs of irritation. If signs of irritation from the dentures are present, the individual should see the dentist. Dentures can be reworked until they fit comfortably. 4.\t Provide assistive devices as needed. If the indi- vidual has difficulty holding the toothbrush because of arthritis or a weakened grip, modifica- tions may be needed. Wrapping tape, aluminum foil, a small sponge, a polystyrene ball, or other padding around the handle of the brush may make it easier to grasp. Handle extenders made of a ruler or dowel rod may help those who are unable to reach the mouth easily (Figure 17-12). 5.\t Obtain the assistance of family members, friends, or community agencies. Some older adults may require the assistance of family members, friends,","288\t UNIT IV\u2003 Physical Care of Older Adults 10.\t Discuss the relationship between medications and oral hygiene. If the individual is receiving any the moisture present in the air so that less is drawn medications that could affect the mucous mem- away from the mucous membranes. branes, teach the person any necessary observa- 9.\t Suggest use of hard candy, chewing gum, or arti- tions or precautions. For example, people who are ficial saliva to increase moisture in the mouth. taking phenytoin (Dilantin) for epilepsy or people Sucking on hard candy or chewing gum stimulates who are on antibiotic therapy should know the the production of saliva. If a sugar-based candy or possible side effects that indicate the necessity to gum is used, the teeth must be brushed more fre- contact the primary care provider. quently to prevent tooth decay. Individuals on sugar-restricted diets should use only sugar-free 11.\t Use any appropriate interventions that are used candy or gum. Artificial saliva preparations may in the institutional setting. be used according to package directions if there is no medical contraindication. Get Ready for the NCLEX\u00ae Examination! 3.\t An older female patient complains that her skin feels dry and itchy. What advice should the nurse offer? Key Points 1.\t Advise her not to scratch, and trim her nails so she is less likely to break the skin and get an infection. \u2022\t Under normal conditions, the aging skin and mucous 2.\t Suggest that she drink more fluids, use cool water membranes are more susceptible to damage than the when bathing, and wear cotton clothing only. comparable tissues of younger individuals. When 3.\t Direct her to ask her primary care provider for an disease factors are present, the risk for damage is even antihistamine prescription to decrease the itching. greater. 4.\t Suggest that she bathe less often, use soap sparingly, and apply a skin emollient after each bath. \u2022\t Careful assessment allows nurses to recognize normal changes and identify any abnormalities that may 4.\t The nurse notices that an older adult is using a large indicate problems that are more serious. amount of denture fixative paste. The patient states this is because the denture hurts, otherwise. What is the \u2022\t Nursing interventions are designed to reduce the risk most important nursing action? for damage or trauma to fragile tissues. 1.\t Make a note about this practice in the patient\u2019s care plan and make a note to tell the dentist. Additional Learning Resources 2.\t Check that the denture does not have rough spots and that all of the old fixative has been removed. \u2002 Go to your Evolve website at http:\/\/evolve.elsevier 3.\t Assess the patient\u2019s oral cavity to make sure there is .com\/Williams\/geriatric for the additional online resources. no irritation or breakdown. 4.\t Assist the patient with oral hygiene and request an Review Questions for the NCLEX\u00ae Examination order for a topical anesthetic to reduce oral discomfort. 1.\t A 71-year-old immobile patient has been in his wheelchair for 2 hours. When repositioning him, the 5.\t Family members are caring for their aging mother at nurse observes a reddened area at the base of the home. Which statement by the daughter indicates the buttocks. How would this observation be best need for further teaching? documented? 1.\t \u201cI change Mom\u2019s diaper whenever it is really wet.\u201d 1.\t Stage 2 at greater trochanter 2.\t \u201cI make sure Mom eats good meals and extra 2.\t Stage 1 at ischial tuberosity snacks.\u201d 3.\t Stage 1 on iliac crest 3.\t \u201cWe try to change Mom\u2019s position at least every two 4.\t Stage 0 on posterior superior iliac spine hours.\u201d 4.\t \u201cI try to use lotion on Mom\u2019s skin every morning and 2.\t What is the most appropriate nursing diagnosis for an evening.\u201d older adult who is bedridden because of progressed Parkinson disease? 6.\t In helping the RN perform an admission and 1.\t Risk for impaired skin integrity related to immobility assessment of a new patient, you mutually recognize 2.\t Immobility related to Parkinson disease this patient is at risk for skin tears. Which of the 3.\t Impaired skin integrity related to incontinence following would be appropriate to include in the care 4.\t Ischemia related to disuse syndrome plan? 1.\t Apply lotion after the daily bath to moisten the skin. 2.\t Dress patient in short sleeves to allow for better visualization of skin. 3.\t Apply steri-strips if a skin tear appears. 4.\t Move and position the patient gently and carefully.","Elimination chapter 18\u2003 Objectives http:\/\/evolve.elsevier.com\/Williams\/geriatric 1.\t Describe the normal elimination processes. 4.\t Discuss methods for assessing elimination practices. 2.\t Examine age-related changes in bladder and bowel 5.\t Choose selected nursing diagnoses related to elimination elimination. problems. 3.\t Identify the older adults who are most at risk for problems 6.\t Describe interventions used to prevent or reduce with elimination. problems related to elimination. Key Terms fecal impaction\u2002 (F\u0112-k\u0103l\u012dm-P\u0102K-sh\u016dn, p. 291) incontinence\u2002 (\u012dn-K\u014eN-t\u012d-n\u0115ns, p. 289) catheterization\u2002 (k\u0103-th\u0115-t\u0115r-\u012d-Z\u0100-sh\u016dn, p. 297) laxatives\u2002 (L\u0102K-s\u0103-t\u012dvs, p. 290) constipation\u2002 (k\u014fn-st\u012d-P\u0100-sh\u016dn, p. 289) parasitic\u2002 (p\u0103r-\u0103-S\u012c-t\u012dk, p. 295) defecation\u2002 (d\u0115f-\u0115-K\u0100-sh\u016dn, p. 289) retention\u2002 (r\u0113-T\u0114N-sh\u016dn, p. 297) diarrhea\u2002 (d\u012b-\u0103-R\u0112-\u0103, p. 289) sphincter\u2002 (SF\u012cNGK-t\u0115r, p. 289) diuretics\u2002 (d\u012b-\u016d-R\u0114-t\u012dks, p. 292) enemas\u2002 (\u0114N-\u0115-m\u0103s, p. 290) To function properly, the body must be able to rid itself elimination. Attempts to change these habits late in life of waste products effectively. The two major systems can create problems. involved in waste elimination are the urinary system and the gastrointestinal (GI) system. Small amounts of Urine elimination in adults also follows patterns. urea (a by-product of protein metabolism) and sodium The typical adult experiences the urge to urinate chloride can be eliminated through the skin, but the when the bladder contains approximately 300\u202fmL skin is not considered a major site of elimination. of urine. Voluntary control of the external sphincter muscles enables healthy adults to hold larger amounts NORMAL ELIMINATION PATTERNS within the bladder until urination is convenient. Most adults void between 6 and 10 times per day, but this Every adult develops unique patterns for bowel and may vary greatly, depending on fluid consumption, bladder elimination. As long as the pattern is within personal habits, and emotional state. For example, normal limits and is effective for the individual, no urinary frequency can be a physical response to emo- special intervention is required. Diet, fluid intake, tional stress. activity, and lifestyle influence these patterns. Even in young adults, elimination patterns can be disrupted by ELIMINATION AND AGING illness, medications, or changes in daily routine. A large percentage of the older adult population suffers The typical adult bowel movement consists of a from problems with elimination. The most common moderate amount of formed brown stool that is passed elimination problems experienced by older adults without difficulty. The normal frequency of bowel are constipation, diarrhea, and incontinence of bladder elimination varies from several stools per day to only and\/or bowel. These problems may result from two or three per week. Most adults experience bowel changes in the function of the GI system or the urinary elimination every 1 to 2 days. The urge to defecate system, or they may be related to changes in other most commonly occurs 30 to 45 minutes after a meal, body systems such as the musculoskeletal and nervous when the gastrocolic and defecation reflexes stimulate systems. peristalsis. Another common time for defecation is first thing in the morning after consumption of a warm Incontinence of bladder and\/or bowel is one of the beverage. Many people develop a daily routine or most common reasons that older adults are institution- establish rituals over their lifetimes to promote normal alized. Many families who can cope with other prob- lems are often unable to deal with incontinence. 289","290\t UNIT IV\u2003 Physical Care of Older Adults slower rate of peristalsis, results in stools that are drier, harder, and more difficult to pass. Fluid volume deficit CONSTIPATION also leads to a decrease in urine production. Constipation is not a disease but rather a symptom of some other problem. Constipation is defined as hard, Dietary fiber plays an important role in promoting dry stools that are difficult to pass. Because bowel normal bowel elimination, because this indigestible elimination patterns can differ widely from person to substance is effective at trapping moisture and provid- person, the frequency of elimination is not a good ing bulk to the wastes. Foods such as whole grains, measure. For some people, regularity means more than fruits, vegetables, and lean meats are high in fiber. one bowel movement a day; for others, it means three Fiber-rich foods are often lacking in the older person\u2019s bowel movements a week. Other people who were diet because these foods are more difficult to chew, reared with the idea that a daily bowel movement is particularly when teeth are loose or missing. Foods essential to health tend to spend undue amounts of such as dairy products, eggs, refined breads, desserts, time worrying about their bowels. The Rome Criteria and many convenience foods consumed by older have been developed as an objective way to classify adults contain very little fiber. When the diet lacks functional GI disorders. The most recent Rome Criteria adequate fiber, a decreased amount of stool is pro- for constipation can be found in Box 18-1. Constipation, duced. This smaller amount of stool moves more both real and perceived, is a common complaint of slowly through the intestine, further contributing to older adults. Studies show that up to 27% of older excessive dryness. The small mass of stool produced adults experience constipation and that it is more com- without fiber is inadequate to stimulate the normal monly a problem for women. The following changes defecation reflex, resulting in infrequent elimination related to aging or chronic illness increase the risk for with as many as 4 or more days between bowel constipation: decreased abdominal muscle tone, inac- movements. tivity, immobility, inadequate fluid intake, inadequate dietary bulk, disease conditions, medications, depen- The risk for constipation is increased with a number dence on laxatives or enemas, and various environ- of disease processes, including stroke, diabetes, hypo- mental conditions. thyroidism, uremia, lupus, scleroderma, multiple sclerosis, Parkinson disease, dementia, and depres- Peristalsis normally slows somewhat with aging. sion. Cancerous tumors located in the GI tract can Loss of abdominal muscle tone and inadequate result in a partial or total obstruction that can be mis- physical activity contribute to even slower peristalsis. taken for constipation or impaction. Medications often About half of those with chronic constipation contribute to constipation in older adults. The more have delayed intestinal transit time. Older individuals medications an older person takes, the greater the with weak abdominal muscles and those who are risk of medication-induced constipation. Medications inactive or immobile are highly likely to become that increase the risk for constipation include the constipated. following: \u2022\t Narcotic analgesics, particularly those containing Water is absorbed as waste products pass through the large intestine. Inadequate fluid intake or excessive codeine fluid loss through perspiration, emesis, or wounds \u2022\t Anticholinergics, including many tricyclic antide- increases the body\u2019s need to recover as much fluid as possible. Because many older adults suffer from some pressants and antipsychotics degree of fluid volume deficit, their bodies attempt to \u2022\t Diuretics reabsorb as much fluid from the stool as possible. The \u2022\t Iron supplements physiologic need to absorb water, combined with a \u2022\t Calcium-channel blockers \u2022\t Antacids containing calcium or aluminum Box 18-1\u2003 Rome III Criteria for Constipation \u2022\t Anticonvulsants \u2022\t Antidepressants A diagnosis for constipation must include two or more of \u2022\t Antiparkinson medications the following symptoms for the past 3 months. Symptoms \u2022\t Nonsteroidal antiinflammatory agents must have an onset at least 6 months before the diagnosis \u2022\t Antihypertensives, such as the ACE inhibitors and be present at least 25% of the time. Many older individuals who have had problems with \u2022\t Straining constipation over the years may have developed a \u2022\t Hard or lumpy stools habit of taking laxatives or enemas. In fact, laxatives \u2022\t Sensation of incomplete evacuation or of anorectal are one of the most frequently purchased over-the- counter products sold in the United States. Some older blockage adults started taking laxatives when they were quite \u2022\t Fewer than three defecations per week young because absolute regularity (having a daily \u2022\t Loose stool rarely present without use of laxatives bowel movement) was at one time considered impor- \u2022\t Use of manual maneuvers such as digital stimulation tant for good health. Thus, some people have been taking laxatives or enemas daily for 50 to 60 years. We to facilitate defecation now recognize that this is dangerous because the body Modified from Rome Criteria for Functional Constipation. www.romecriteria.org\/ assets\/pdf\/19_RomeIII_apA_885-898.pdf","Elimination\u2003 CHAPTER 18\t 291 can become dependent on laxatives and require this assistance to stimulate elimination. Chronic laxative FECAL IMPACTION use has other risks as well: it has even been associated Fecal impaction, the presence of a mass of hardened with increased risk of falls (Haring et\u202fal, 2013). feces that is trapped in the rectum and cannot be Reestablishing normal bowel elimination in a laxative- expelled, is a result of unrelieved constipation. In dependent older person is almost impossible because severe cases, the fecal mass may extend up into the the body has forgotten how to work on its own. sigmoid colon. Individuals who have a history of chronic constipation are most at risk for impaction. Repeatedly ignoring the urge to defecate can lead to suppression or even extinction of the defecation Symptoms of impaction include a longer-than-usual reflex. Changes in neurologic sensitivity or fear of pain delay in defecation. More than 3 days without a bowel may cause older adults to ignore or delay defecation. movement warrants close attention. Passage of small Those with neurologic disorders may not be aware of amounts of liquid stool without any formed fecal the need to defecate, because the strength of nerve material can also indicate impaction. This liquid stool impulses transmitted to and from the sphincter muscles is fecal material from higher in the colon that is able to is decreased. With no urge to defecate, individuals pass around the hardened mass. It typically oozes may go for many days unaware of the fact that their from the rectum and differs from a diarrheal stool, bowels have not emptied. Older individuals who which passes with normal force. encounter pain with defecation are more likely to avoid or deliberately delay what they know will be Older adults suffering from fecal impaction are a painful experience. Pain can originate from the likely to complain of cramping or rectal pain, abdomi- decreased production of mucus in the intestine that nal distention, and loss of appetite. Digital examina- is typical with aging. Without the lubrication pro- tion of the rectum typically reveals the presence of a vided by mucus, the stool becomes excessively dry hardened mass of feces. Perform this procedure with and irritating to the rectal tissues. The presence of extreme caution because it is uncomfortable and trau- hemorrhoids or anal fissures further contributes to matic to the rectal tissues. Use particular caution when the likelihood of pain. Delaying defecation creates a examining older persons with a history of cardiac vicious circle. When defecation is delayed, the stool problems, because rectal examination can stimulate the becomes harder, drier, and more difficult to pass. This, vagus nerve, resulting in a sudden decrease in heart in turn, leads to more painful defecation, which results rate accompanied by syncope and loss of conscious- in further avoidance of defecation. Active interven- ness. Some facilities require written orders before a tions are needed to break this cycle. Untreated consti- digital rectal examination. Sometimes the impacted pation can result in fecal impaction. mass is higher in the intestinal tract and cannot be detected by digital examination. In these cases, abdom- Delays in defecation are not always chosen by the inal x-rays may be necessary. Before deciding that an older person. An older adult who requires assistance older adult has a problem with bowel elimination, may need to suppress the defecation reflex while nurses should thoroughly assess the total situation, waiting for help getting to the bathroom. If this occurs including the frequency, amount, and consistency of repeatedly, the individual may lose sensitivity to the stools. Assessment should also include identification urge to defecate and become constipated. If unable to of factors that contribute to the development of bowel suppress the urge, the person runs the risk of being elimination problems. This enables the development considered incontinent. of a plan that promotes sound elimination patterns. Environmental factors can play a role in constipa- Patient Teaching tion, particularly with institutionalized older adults. The older adult may be embarrassed by the sounds or \u2002 odors involved with bowel elimination. Lack of privacy may cause anxiety or may result in the person\u2019s ignor- When It May Be More Than Constipation ing or suppressing the urge to defecate. Older adults should be taught to contact their primary care provider when: Difficulty assuming an anatomically suitable or \u2022\t There is severe vomiting or abdominal pain. comfortable position can also interfere with effective \u2022\t The frequency of bowel movements slows dramatically. bowel elimination. Sitting upright or squatting are the \u2022\t Blood is present with bowel movements. preferred positions for defecation, because it is easier \u2022\t There is a continuous sensation of pressure, fullness, or to bear down in these positions (bearing down straight- ens out the anorectal angle, necessary for bowel pain in the rectal area, but they are unable to pass stool. elimination) and gravity assists elimination when the \u2022\t They pass only small amounts of loose stool or leaking \t entire body is upright. People confined to bed find that bedpans are uncomfortable and difficult to use. of stool. Although sometimes necessary, bedpans should be avoided whenever the use of a toilet or commode chair NURSING PROCESS FOR CONSTIPATION is possible. \u2002 ASSESSMENT\/DATA COLLECTION \u2002 \u2022\t How often does the person have a bowel movement?","292\t UNIT IV\u2003 Physical Care of Older Adults NURSING INTERVENTIONS\/IMPLEMENTATION \u2022\t Is there any pattern to when bowel elimination \u2002 occurs? The following nursing interventions should take place \u2022\t Is the person continent or incontinent of stool? in hospitals or extended-care facilities: \u2022\t What is the amount, consistency, and color of the 1.\t Assess bowel elimination patterns and contribut- stool? ing factors. It is important to determine whether the \u2022\t Is there evidence of blood, mucus, undigested food, older adult actually has a problem with constipa- tion or only perceives a problem. Because many or other unusual substances in the stool? older people cling to the idea that daily bowel elimi- \u2022\t Has the stool been checked for occult blood? nation is necessary, they may consider themselves \u2022\t Does the person have to strain to have a bowel constipated when no real problem exists. If this is the case, explain the normal range of variation. movement? If the person is truly experiencing constipation, \u2022\t Is the stool expelled with excessive force, or does it determine the causes and direct the plan of care toward eliminating or reducing the causative ooze from the body? factors. Regularly assess older adults with a history \u2022\t Does the person report or has the nurse observed of constipation or risk factors for constipation to avoid fecal impaction. any particular foods that affect bowel movements? 2.\t Increase physical activity. Physical mobility, even \u2022\t Do these foods cause diarrhea or constipation? as little as twisting the body, turning from side to \u2022\t Does the person\u2019s diet have adequate bulk? side, flexing the trunk, or lifting the legs to the \u2022\t Does the person rely on any aids for bowel elimina- abdomen, can help stimulate peristalsis. If possible, encourage older adults to participate in activities tion (e.g., suppositories, laxatives, and enemas) or that are more vigorous such as walking, bending, bulk enhancers? and stretching. \u2022\t How long has the person been using this aid? 3.\t Increase intake of dietary fiber and fluids. Fluid \u2022\t Is the abdomen distended? and dietary bulk enhance the normal process of \u2022\t If the person cannot speak, does he or she rub the defecation. The recommended amount of fiber is abdomen? 12\u202fg\/day. Cereal fiber is more effective at prevent- \u2022\t Has the person\u2019s appetite decreased? ing constipation, and older adults typically find it \u2022\t If the person cannot sense rectal fullness, what does palatable. Some foods such as bran or prunes have a digital examination of the rectum reveal? bulk and a natural laxative effect. Many older adults \u2022\t What does the person say about his or her bowel accept these foods if they are offered as part of the habits? Have they changed recently? breakfast meal. Some people find that other foods, \u2022\t Does the person report any concerns related to such as cabbage or licorice, are helpful in stimulat- bowel elimination? ing bowel elimination. Adequate fluid intake (2L\/ Box 18-2 lists risk factors for constipation in older day is recommended) reduces the risk for constipa- adults. tion from excessive absorption in the large intestine. Additional fluid is necessary during hot summer NURSING DIAGNOSIS months or when illness results in excessive fluid loss. Older people who take diuretics should be \u2002 encouraged to consume adequate fluids as long as their cardiovascular status is stable. Constipation 4.\t Schedule or encourage toileting at times when the person\u2019s defecation urge is strongest. If the indi- NURSING GOALS\/OUTCOMES IDENTIFICATION vidual suppresses the urge to defecate, he or she is at greater risk for constipation. Encouraging older \u2002 adults to use the toilet (or taking them there) at a time when defecation is likely enables a healthy The nursing goals for older individuals diagnosed pattern to develop. The most likely times are early with constipation are to (1) exhibit regular patterns of in the morning, after drinking the first warm bever- bowel elimination; (2) identify behaviors that promote age of the day, and shortly after meals. Some older normal bowel functioning; and (3) modify behaviors people go through established rituals that support to enhance regular bowel elimination. normal elimination. Determine the existence and nature of these rituals by talking with the person, Box 18-2\u2003 Risk Factors Related to Constipation and use this information in care planning. in Older Adults 5.\t Position the person to facilitate ease of elimina- tion. Use of a toilet is best for normal elimination. \u2022\t Neurologic problems that decrease the ability to sense the need for elimination or to control the sphincter muscles \u2022\t Reduced mobility \u2022\t Inadequate intake of dietary bulk \u2022\t Tube feedings \u2022\t Gastrointestinal obstructions or disease (e.g., Crohn disease and diverticulosis) \u2022\t Inadequate fluid intake \u2022\t Cognitive impairment (e.g., Alzheimer disease and dementia)","Elimination\u2003 CHAPTER 18\t 293 If this is not possible, a bedside commode is the 8.\t Administer prescribed osmotic agents, stimulant next best option. Position a small footstool under laxatives, or enemas if other methods have not the feet of the older person to increase intraabdomi- been effective, as ordered. If other methods of stim- nal pressure and facilitate defecation. A bedpan is ulating defecation have not been effective, it may be the least desirable option. Bedpans are uncomfort- necessary to administer osmotic agents, which draw able, and their use makes it difficult for the person fluid into the colon through osmosis, either orally to achieve the normal bearing-down force needed (e.g., magnesium hydroxide) or via suppository for defecation. (glycerin suppositories). Stimulant laxatives, such 6.\t Provide privacy for elimination. Privacy reduces as bisacodyl, stimulate peristalsis but may produce the risk for constipation that results from suppress- cramping. Bisacodyl can be given orally or via sup- ing elimination to prevent embarrassment. To pository. Older adults are more apt to accept sup- prevent unpleasant odors, promptly remove soiled positories because they are generally less traumatic bedpans and use air freshener. and less invasive than are enemas. Enemas should be used with caution because they can lead to Coordinated Care damage of the rectal mucosa and contribute to elec- trolyte imbalance. If performed incorrectly, enemas \u2002 increase the risk for rectal perforation. Supervision Did You Know? PATIENT PRIVACY \u2022\t The supervisory nurse should ensure that all older \u2002 patients are given adequate privacy for elimination and New Medications for Chronic Constipation that cultural modesty standards are observed. Two newer categories of constipation medications have shown \u2022\t This is particularly important when the nurse is assisting promising results: an incontinent patient. \u2022\t Prokinetic drugs increase intestinal peristalsis. The main 7.\t Administer stool softeners or bulk-forming laxa- one, prucalopride, is being used in Europe but has not tives as prescribed. Stool softeners keep fecal mate- yet been FDA-approved in the U.S. rial moist and reduce the chance of anal irritation \u2022\t Intestinal secretagogues increase intestinal chloride, when stool is passed. Bulk-forming substances thereby moving fluid into the bowel. Lubiprostone has such as psyllium (Metamucil) expand and trap been FDA-approved for narcotic-related constipation in moisture in the feces. Take care to administer these patients with chronic, noncancerous pain. bulk-forming laxatives with adequate amounts of fluid. If adequate fluid is not ingested, these sub- 9.\t Perform digital rectal examination and impaction stances can cause constipation or bowel obstruc- removal as ordered or according to agency poli- tions (Table 18-1). cies. Provide privacy and emotional support. Verify Table 18-1\u2003 Considerations Related to Certain Laxatives TYPE CONSIDERATIONS Stimulant Laxatives Use with caution in older adults; can cause cramping or vomiting; may lead to electrolyte imbalance (loss of potassium), altered fat absorption, fat-soluble vitamin deficiency, and Castor oil dependency; less expensive than some other forms Bisacodyl Senna Bulk Laxatives Work effectively; safe for long-term use in older adults; can cause flatulence; resistance or noncompliance is common because of taste; risk for worsened constipation or impaction if fluid Psyllium intake is inadequate Calcium polycarbophil Methylcellulose Wheat dextrin Osmotic Agents Most are safe and effective even in frail older adults; magnesium salts should only be administered after consulting with patient\u2019s primary care provider, because they interact with numerous Polyethylene glycol medications and are contraindicated for certain medical conditions (e.g., kidney disease, seizure Lactulose disorder) Sorbitol Magnesium hydroxide Glycerin suppositories Fecal Softeners Do not have a laxative action so are not effective for chronic constipation; result in softer stool, Docusate sodium allowing easier passage when straining is dangerous","294\t UNIT IV\u2003 Physical Care of Older Adults amounts of concentrated tube feedings often experi- ence diarrhea. that there are no preexisting conditions that con\u00ad traindicate digital manipulation. Perform digital Many older people with diarrhea complain of examination with a well-lubricated gloved hand. nausea, vomiting, and abdominal cramps in addition Some agencies use a lubricant containing a topical to frequent stools. Rectal pain and skin irritation of the anesthetic to reduce discomfort. When an impaction anus and buttocks are common because fecal material is detected, oil-retention enemas may be ordered to is very irritating. soften the mass, followed by large-volume enemas to evacuate the mass. If this is not successful, digital Diarrhea can easily result in excessive fluid loss. removal may be necessary. With the patient posi- This is a major concern in older adults, who are already tioned in a side-lying position, manually break the at risk for deficient fluid volume. Because diarrhea can fecal mass into smaller pieces and remove. Use quickly result in dehydration, notify the primary care caution to prevent trauma to the rectal tissues. This provider promptly so that the cause can be isolated process may need to be done in increments to reduce and treatment begun. the risk for damage. The following interventions should take place in NURSING PROCESS FOR DIARRHEA the home: 1.\t Provide information regarding high-fiber foods, \u2002 and encourage increased consumption of these. Many older individuals prefer processed foods that ASSESSMENT\/DATA COLLECTION are easy to prepare and chew. Provide information about the value of foods that are easily obtained \u2002 such as cereals, whole wheat breads, bran muffins, and prunes to help older adults select foods that See the assessment for constipation on pages 291\u2013292. may reduce the incidence of constipation. If family NURSING DIAGNOSIS members prepare the meals, discuss the importance of fiber in preventing constipation. \u2002 2.\t Encourage adequate fluid intake. Approximately 2000\u202fmL of fluid should be taken each day. This Diarrhea should include approximately six glasses of water, NURSING GOALS\/OUTCOMES IDENTIFICATION juice, and other beverages. Some individuals drink senna tea, which has laxative properties. \u2002 3.\t Encourage adequate activity and exercise. Activity enhances peristalsis and, along with good dietary The nursing goals for older individuals diagnosed practices, is most important in preventing constipa- with diarrhea are to (1) exhibit regular patterns of tion. Walking after meals may effectively stimulate bowel elimination; (2) identify behaviors that promote the urge to defecate. Older adults should stay near normal bowel functioning; and (3) modify behaviors toilet facilities so that they can act immediately to enhance regular bowel elimination. when the urge arises. Suppressing the urge to def- NURSING INTERVENTIONS\/IMPLEMENTATION ecate increases the risk for constipation. 4.\t Discuss the risks involved with the use of laxa- \u2002 tives without medical supervision. Many older adults are unaware of the side effects and problems The following nursing interventions should take place related to laxative use. Discuss these concerns, and in hospitals or extended-care facilities: encourage older adults to discuss any bowel elimi- 1.\t Assess the elimination pattern and suspected nation problems with the primary care provider before using laxatives. causative factors. Diarrhea in older adults can result 5.\t Use any appropriate interventions that are used in from many factors. Pay close attention to the fre- the institutional setting (Nursing Care Plan 18-1). quency and nature of stools. Assess the time of day when diarrhea occurs and any factors that appear DIARRHEA related to the onset of loose stools. For example, a Diarrhea is defined as the frequent passage of liquid, loose stool that follows a meal, a tube feeding, or unformed stools. The stools are liquid because they administration of a medication is significant and pass through the large intestine too rapidly and are should be reported. Assess for additional com- expelled before sufficient water is absorbed in the large plaints such as pain, cramping, fever, and force of intestine. Diarrhea is a symptom and can have many expulsion. If the liquid stool seeps from the rectum, causes, such as malabsorption syndromes, tumors of fecal impaction must be suspected. Removal of the the GI tract, lactose intolerance, diverticulosis, and impaction corrects this problem. pathogenic organisms. Older adults who receive large 2.\t Maintain adequate fluid intake. Diarrheal stools lead to an excessive loss of body fluid. Fluid replace- ment to prevent dehydration is essential. In addi- tion to simple fluid balance, electrolyte levels may be disturbed if the episodes of diarrhea are severe or prolonged. Provide oral fluids within dietary restrictions. Offer fluids that are rich in electrolytes (e.g., juices, Gatorade, and broth) instead of plain water. Avoid offering fluids high in fiber, caffeine, and milk because they tend to induce diarrhea. If the individual is unable to take fluids orally, intra- venous infusions may be necessary. Monitor older adults carefully for signs of dehydration, such as","Elimination\u2003 CHAPTER 18\t 295 \u2002 Nursing Care Plan\u2002 18-1\u2003 Constipation Mrs. Port is an 85-year-old woman who resides at Shady Grove Nursing Home. She has mild osteoarthritis, and she prefers to sit and visit or do crafts. She can move about using a walker. When her osteoarthritis pain is severe, she takes acetamino- phen combined with 30\u202fmg of codeine. She eats with friends in the dining room and prefers to eat meat, white bread, and desserts. She eats very little of the fruits or vegetables served, and she consumes about 1200\u202fmL of fluid per day. Mrs. Port reports that she has bowel movements about every 2 or 3 days. \u201cI used to have a bowel movement every other day. Now I really have to push, and it hurts.\u201d The nursing assistant reports that the stool is hard and dry. NURSING DIAGNOSIS Constipation DEFINING CHARACTERISTICS \u2022\t Two to three days between bowel movements \u2022\t Complaints of straining at stool \u2022\t Hard, dry stools \u2022\t Less than normal frequency of bowel movements PATIENT GOALS\/OUTCOMES Mrs. Port will have regular bowel movements at 1- to 2-day intervals, experience no difficulty passing stool, and describe diet changes that promote regular elimination. NURSING INTERVENTIONS 1.\t Assess bowel elimination pattern for the frequency, amount, consistency, and effort required. 2.\t Explain the importance and effect of adequate fluid intake on bowel elimination. 3.\t Design a plan for increasing fluid intake to 2000\u202fmL per day, including beverages favored by Mrs. Port. 4.\t Encourage consumption of fruits, vegetables, and whole grain breads or cereals. 5.\t Discuss alternative measures for pain control to decrease reliance on codeine-based medication. 6.\t Encourage increased physical activity. EVALUATION Mrs. Port has increased her fluid intake to 1800\u202fmL\/day. She reports eating bran cereal, whole-wheat toast, and prune juice for breakfast and a fruit or vegetable with lunch and dinner. Formed, soft bowel movements have been reported every other day and documented in Mrs. Port\u2019s chart. She states, \u201cIt feels so much better when I don\u2019t have to strain.\u201d You will continue the plan of care. CRITICAL THINKING QUESTIONS Mrs. Port has decided that the high-fiber foods and prune juice are upsetting her stomach and has stopped eating them. She reports that problems with elimination have returned. 1.\t What else could she do to help stimulate regular elimination? 2.\t What teaching does Mrs. Port require if she chooses to use a bulk-forming preparation such as psyllium? decreased skin turgor, postural hypotension, tachy- that its origin can be determined. The provider cardia, and altered laboratory values. will probably prescribe fluid maintenance and 3.\t Institute measures to maintain skin integrity. medications to decrease the rate of intestinal Cleanse the skin immediately after each episode of motility and increase water absorption. The timing diarrhea. Diarrheal stool is very irritating to the skin for administering these medications is usually and can rapidly lead to skin breakdown. Wash the related to the frequency of diarrheal stools. It is anal area after each stool, and apply a protective important to administer the medications as pre- ointment or lotion to provide a barrier against the scribed. If diarrhea persists, diagnostic tests on stool caustic body wastes. If the skin becomes excessively specimens may be ordered to determine whether irritated and tender to touch, sitz baths followed the diarrhea is parasitic or bacterial in origin. by air-drying or heat-lamp treatments may help Standard precautions and proper handwashing promote healing. Take care to prevent further must be followed when obtaining or handling stool trauma to the tissue. Keep bed linens clean and dry specimens. at all times. The following interventions should take place in the 4.\t Promptly report observations to the primary care home: provider, and follow up on care provider\u2019s orders 1.\t Explain the importance of seeking medical atten- regarding medications that decrease intestinal tion if the person is experiencing diarrhea. Many motility. Diarrhea in older adults is a serious older people become severely dehydrated from concern. Because it can have many causes, report diarrhea before they seek medical attention. Teach diarrhea to the primary care provider promptly so the importance of calling the primary care provider","296\t UNIT IV\u2003 Physical Care of Older Adults NURSING DIAGNOSIS if diarrhea is severe or lasts more than one day. Any \u2002 additional complaints such as abdominal pain, cramping, or fever also indicate the need to call Bowel incontinence a provider immediately. Many prescription and nonprescription medications can cause diarrhea. NURSING GOALS\/OUTCOMES IDENTIFICATION Because many older adults have prescriptions from multiple providers, it is important that they tell \u2002 each provider every medication they are taking, including over-the-counter preparations. The nursing goals for older individuals diagnosed 2.\t Explain the importance of proper food prepara- with bowel incontinence are to (1) exhibit regular pat- tion and storage in preventing bacterial diarrhea. terns of bowel elimination; (2) identify behaviors that Many cases of diarrhea are related to improper food promote normal bowel functioning; and (3) modify preparation or storage. Some older adults allow behaviors to enhance regular bowel elimination. food to sit out longer than it should. If unrefriger- ated, food becomes a good medium for the growth NURSING INTERVENTIONS\/IMPLEMENTATION of bacteria, many of which can cause diarrhea. Teach the importance of refrigerating all dairy \u2002 products, meats, and other prepared foods immedi- ately after purchase or after the meal, and to not The following nursing interventions should take place allow food to warm up on the counter before in hospitals or extended-care facilities: preparation. 1.\t Assess patterns of elimination and causative 3.\t Use any appropriate interventions that are used in the institutional setting. factors. It is important to know how often and when BOWEL INCONTINENCE the individual is incontinent. If these episodes Bowel incontinence is most common among older have a regular pattern, use this information to plan adults who are unable to recognize and respond to nursing care. For example, many individuals have normal sensations because of mental impairment or a pattern of defecating 30 to 45 minutes after a meal. problems with mobility. Less frequently, colon or rectal If the person is taken to the bathroom at that time, disorders such as cancer, inflammatory bowel disease, an episode of incontinence will be prevented. diverticulitis, or weak rectal muscle cause or contrib- Unfortunately, not all individuals have such a ute to incontinence. Fecal incontinence is more common regular pattern of defecation. than suspected and is the second leading cause for 2.\t Establish a toileting schedule. If a defecation nursing home admission. Exact incidence of inconti- pattern is detected, take the person to the bathroom nence is unknown because of varying definitions and at the time he or she is most likely to defecate. If no underreporting, but studies reveal numbers varying detectable pattern is present, the care provider may from 2% to 18%. In some cases, incontinence is slight, order the use of digital stimulation or glycerin sup- consisting of just a small leakage of stool. In other positories. When repeated daily or every other day, cases, incontinence is a daily occurrence. Frequent these measures may establish a regular pattern of bowel incontinence is a significant problem, because defecation. When planning a toileting schedule, fecal wastes are very irritating to tissues and can con- consider the older adult\u2019s daily routines and sched- tribute to skin breakdown. Inability to control bowel uled appointments (e.g., physical therapy). To be elimination is also psychologically disturbing and effective, all individuals and departments that have embarrassing for older adults. Many community- contact with the individual should be aware of the dwelling older adults are unwilling to bring up con- plan and follow through with it. cerns regarding this problem with health caregivers. 3.\t Take measures to prevent or reduce episodes of They attempt to manage the problem themselves by constipation. It is difficult to prevent incontinence using incontinence pads or briefs. In severe cases, they when an individual is constipated. Measures used may stop participating in social activities for fear of to prevent constipation increase the likelihood of embarrassment. Identification of underlying health regular elimination. problems and planning additional preventive strate- 4.\t Use appropriate aids or garments. It is best if epi- gies can help affected older adults maintain a more sodes of incontinence are prevented by regular comfortable lifestyle. toileting or other methods discussed previously. If these measures are not completely successful, use NURSING PROCESS FOR BOWEL INCONTINENCE special pads or garments to reduce the embarrass- ment of soiling the bed or clothing. However, do not \u2002 use these aids in place of other nursing measures that promote bowel control. ASSESSMENT\/DATA COLLECTION 5.\t Clean the person promptly after each episode of incontinence. Incontinence can easily lead to skin \u2002 breakdown. It is essential to remove any soiled linens or garments as soon as possible to reduce See assessment for constipation on pages 291\u2013292. skin irritation. Provide this care tactfully to reduce damage to the self-esteem of older adults, most of whom are acutely embarrassed by their inconti- nence and are sensitive to any negative verbal or","Elimination\u2003 CHAPTER 18\t 297 nonverbal communication from the nursing staff. Box 18-3\u2003 Risk Factors Associated with Urinary Remove all soiled materials from the room and put Incontinence in Older Adults into appropriate containers to reduce environmen- tal odors. \u2022\t Advanced age 6.\t Use any appropriate interventions that are used in \u2022\t Caffeine intake the institutional setting. \u2022\t Immobility\/functional limitations URINARY RETENTION \u2022\t Diuretics\/other medications Urinary retention is an abnormal accumulation of \u2022\t Obesity urine in the bladder because the bladder is unable to \u2022\t Smoking empty completely. Normally, no more than 50\u202fmL of \u2022\t Fecal impaction\/fecal incontinence urine remains in the bladder after voiding. The person \u2022\t Malnutrition experiencing urinary retention often has several \u2022\t Depression\/delirium hundred milliliters remaining after voiding. Urinary \u2022\t Treatment for prostate cancer retention in older adults can result from decreased \u2022\t Hearing or visual impairment muscle tone in the bladder wall, decreased fluid intake, \u2022\t Low fluid intake prostate gland enlargement, trauma to the muscles \u2022\t Environmental barriers of the perineum, neurologic damage, medications, or \u2022\t Disorders: Diabetes, Parkinson disease, stroke, anxiety. Symptoms of retention include a feeling of fullness, COPD, arthritis\/back problems discomfort or tenderness in the bladder, restlessness, \u2022\t Estrogen depletion and diaphoresis. People experiencing urinary reten- \u2022\t Pelvic organ prolapse tion may complain of a total inability to void or of \u2022\t Institutionalization passing small amounts (between 25 and 50\u202fmL) of urine at frequent intervals. This pattern is called reten- Adapted from Dowling-Castronovo A, Bradway C: Urinary incontinence (Table tion with overflow. Severe retention results in bladder 18-1), 2012. In Boltz M, Capezuti E, Fulmer T, Zwicker D: Evidence-based distention that can be detected by inspecting or palpat- geriatric nursing protocols for best practice, New York: Springer. ing the area over the symphysis pubis. Treatment of urinary retention depends on the cause. If retention is ulcers; it can lead to guilt, frustration, and psychologi- caused by perineal trauma or anxiety, noninvasive cal distress; it can lead to social isolation; and it can be measures such as medications or a sitz bath may be costly because of the need to purchase expensive enough to stimulate effective voiding. If severe reten- undergarments and replace or launder clothing more tion is caused by an obstruction such as an enlarged frequently. Ultimately, it can lead to the emotional, prostate, catheterization or surgery may be necessary social, and economic costs of institutional care. to prevent serious bladder damage that may result from persistent or excessive bladder distention. Home Health Considerations URINARY TRACT INFECTION UTIs are a common problem, particularly for older \u2002 women (see Chapter 3). URINARY INCONTINENCE Community Education Programs Urinary incontinence (UI) is the involuntary loss of Community education programs can be helpful in reducing the urine in sufficient amount or frequency to be a social extent and severity of urinary incontinence (UI) among or hygiene problem. UI is not a normal part of aging, community-dwelling older adults, particularly women. These but it is a major problem in the aging population. More programs should stress that UI is not a part of normal aging than 17 million adults in the United States are affected and emphasize behavioral management of UI, including the by UI, women twice as often as men. Up to 46% of use of incontinence diaries, identification of dietary triggers, community-living older adults experience UI, and recognition of signs and symptoms of urinary tract infections, institutionalized older adults have even higher rates of and performing pelvic muscle strengthening exercises. UI. Prevalence of UI in persons with dementia is as great as 90% (Box 18-3). The national cost of urinary Older adults may hesitate to discuss UI problems with incontinence currently exceeds 16 billion dollars a year care providers because they are embarrassed or because in the United States. UI is among the leading causes of they think that incontinence is simply a problem of long-term institutional placement. aging that they must endure. Therefore, the topic must UI has medical, emotional, social, and economic be introduced in a sensitive manner by caregivers. In consequences for older adults. It can result in skin some cases, UI is curable using surgery, medications, irritation or breakdown and can contribute to pressure or other treatments. In other cases, it can be better managed, thus allowing the older person a more normal lifestyle. Coordinated Care \u2002 Collaboration PREVENTION OF URINARY INCONTINENCE Urinary incontinence (UI) can be reduced if there is a commit- ment to success rather than a defeatist attitude. Stressing the","298\t UNIT IV\u2003 Physical Care of Older Adults excessive fluid intake or increased use of diuretics, the problem of urinary frequency is magnified. In addi- benefits to the patient and identifying the benefits to caregivers tion, many older adults experience involuntary spasms can help motivate the process. All members of the health care of the muscles of the bladder wall, called detrusor team are essential to reduce UI. The physician, nurses, nursing spasms. These spasms can occur even when the assistants, physical therapists, occupational therapists, and bladder contains small volumes, resulting in a sense of facility management need to be actively involved in the devel- urgency to empty the bladder. When the need to void opment, communication, and implementation of the plan. A is frequent and urgent, the result is urge UI. staffing system designating specially trained certified nursing assistants to implement restorative interventions to prevent Urge UI is likely to occur after the removal of an incontinence has been shown to be effective. However, no\t indwelling catheter. When an indwelling catheter is staff members should consider themselves \u201ctoo important\u201d to placed the result is diminished bladder capacity. respond to the needs of patients. A successful plan can Frequency, urgency, and incontinence are likely to improve the self-esteem of residents and enhance the percep- occur when a catheter is removed suddenly without tions of the level of care held by family members and the incremental clamping, which allows the bladder community. muscles to stretch gradually to accommodate larger volumes. A number of normal age-related physiologic changes or common diseases seen with aging can cause or con- Reflex Urinary Incontinence tribute to UI. Different forms of incontinence (i.e., Reflex UI is the involuntary loss of urine at a fairly stress, urge, overflow, functional, and mixed UI) are predictable interval after a certain bladder volume has recognized as problems in older adults. been reached. When this level is reached, the bladder empties, like a reflex. This type of UI occurs when Stress Urinary Incontinence there is an exaggerated reflex of a bladder muscle in Stress UI is leakage of urine during conditions that patients with neurologic disorders such as spinal cord increase intraabdominal pressure, such as exercise, injury. The patient may or may not (e.g., with spinal lifting heavy objects, laughing, coughing, or sneezing. cord injury) feel the urge to void, or have any sensation When a full bladder is compressed against weakened of bladder fullness. urinary sphincters, incontinence occurs. This problem is most commonly observed in women, particularly Overflow Urinary Incontinence those who have weakened perineal muscles resulting Overflow UI is defined as leakage of small amounts of from aging and childbearing. Generally, the amount of urine from an overly full bladder. The bladder cannot urine lost is small. hold the amount of urine being produced, so it over- flows. Overflow UI is a common problem for people Urge Urinary Incontinence with diabetes suffering from loss of bladder muscle Urge UI is caused by involuntary contraction of the tone because of neuropathy or those experiencing detrusor muscle of the bladder. It is characterized by polyuria related to hyperglycemia. Overflow UI is also a sudden, strong urge to void. Individuals suffering common in older men with benign prostate hyperpla- from urge incontinence are often unable to hold back sia. Enlargement of the prostate restricts the flow of the urine long enough to reach a commode or toilet. urine, so the bladder never empties completely. This Urge UI is often seen in older individuals who suffer contributes to overflow problems (see the section on from diseases that affect nerve transmission to the urinary retention). Women who have an obstruction at bladder (e.g., Parkinson disease, multiple sclerosis, the outlet of the bladder resulting from a prolapsed stroke, and dementia). Urge UI is also observed when uterus, cystocele, or rectocele may experience similar there is increased bladder stimulation caused by lower problems. Those with neurologic disorders, such as UTIs, concentrated urine, and irritating chemicals such multiple sclerosis or spinal cord injuries above the as caffeine or alcohol. Atrophic urethritis, uterine pro- sacral area, are also prone to overflow UI. Anticholin\u00ad lapse, fecal impaction, or prostate enlargement also ergic medications may also cause excessive relaxation increases the likelihood of urge UI. Even healthy older of smooth muscle. adults with no known medical problems may experi- ence occasional episodes of urge UI. People who expe- Functional Urinary Incontinence rience urge UI once or more per week are at greater Functional UI is seen in older adults who have normal risk of falls and fractures, most likely caused by the urethral and bladder function. It is caused by a poor individual rushing to the restroom to avoid an incon- relationship between the aging person\u2019s abilities and tinent episode. his or her environment. Changes in functional ability may be cognitive or physical in nature. The inability The basis of urge UI is in the physiologic changes to recognize a toilet and perform simple tasks such as seen with aging. With aging, the bladder decreases in using a zipper or pulling down underwear, walk to the size; it can hold less volume (often 200\u202fmL or less) and bathroom, transfer to the toilet, or ask for assistance needs to be emptied more often. This results in the increased urinary frequency seen with aging. When larger volumes of urine are produced in response to","Elimination\u2003 CHAPTER 18\t 299 \u2002 Table 18-2\u2003 Medications That Affect Continence Box 18-4\u2003 Risk Factors Related to Impaired Urinary Elimination in Older Adults MEDICATION POTENTIAL EFFECT \u2022\t Neurologic problems that decrease the ability to sense Diuretics Cause rapid filling of the bladder the need for elimination or to control the sphincter resulting from the rapid increase in muscles urine production \u2022\t Endocrine disorders Anticholinergics Interfere with normal contraction of \u2022\t Altered structures that interfere with elimination the muscles of the bladder wall Sedatives and (prostate enlargement or tumors) hypnotics Interfere with alertness and \u2022\t Decreased mobility (especially people on bed rest) recognition of the need to urinate \u2022\t Inadequate or excessive fluid intake \u2022\t Cognitive impairment (Alzheimer disease, dementia) Narcotics Interfere with normal contraction of \u03b1-Adrenergic the muscles of the bladder wall; \u2022\t Does the person have a history of any medical decrease awareness of sensations condition that would decrease awareness of the agonists from the bladder need to void? Increase tone of the internal sphincter \u2022\t What is the volume of a typical voiding? muscle \u2022\t How much urine is produced each day? \u2022\t What is the odor, color, and consistency of urine? \u03b1-Adrenergic Decrease tone of the internal \u2022\t Are there any signs of a urinary tract infection antagonists sphincter muscle (burning, pain with urination, frequency)? Calcium-channel Decrease tone of the muscles of the \u2022\t Has a urinalysis been done recently? What are the blockers bladder wall results? can result in functional UI. Environmental factors con- \u2022\t What is the person\u2019s normal pattern of voiding? tribute to the problem of functional UI and increase its \u2022\t Does the person experience any difficulty in starting likelihood. Functional UI is likely to occur when there are not enough toilets, when toilets are difficult to to urinate? access because of their location or height, when there \u2022\t Does the person experience any involuntary loss of are not enough caregivers to provide needed assis- tance, and when physical restraints prevent free move- urine when he or she coughs, laughs, or sneezes? ment. Weakness, changes in dexterity, and decreased \u2022\t Does the person complain of any pain or burning ability to manipulate clothing contribute to problems. Medications that interfere with cognition or mobility, with urination? alter bladder tone, and increase urine production often \u2022\t What is the person\u2019s pattern of fluid intake? contribute to functional UI (Table 18-2). Box 18-4 lists risk factors for impaired urinary elimina- tion in older adults. Mixed urinary incontinence.\u2002 Some incontinent older adults appear to have more than one form of UI. This NURSING DIAGNOSES problem is sometimes called mixed UI. For example, many older adults report that when they have the \u2002 urgent need to urinate, they cannot respond quickly enough because of decreased functional ability and \u2022\t Functional urinary incontinence environmental limitations. UI can be a continuous and \u2022\t Reflex urinary incontinence ongoing problem or may occur only occasionally. \u2022\t Stress urinary incontinence Careful history taking and medical examination are \u2022\t Urge urinary incontinence needed to determine the specific type of UI and the \u2022\t Impaired urinary elimination underlying causes so that appropriate medical treat- \u2022\t Urinary retention ment and nursing interventions can be initiated. NURSING GOALS\/OUTCOMES IDENTIFICATION NURSING PROCESS FOR IMPAIRED \u2002 \u2002 The nursing goals for older individuals diagnosed URINARY ELIMINATION with impaired urinary elimination are to (1) exhibit a reduction in episodes of urinary incontinence or reten- ASSESSMENT\/DATA COLLECTION tion; (2) urinate at acceptable times in acceptable places; (3) identify measures that reduce episodes of \u2002 urinary incontinence or retention; and (4) establish a routine to reduce or prevent the occurrence of bladder \u2022\t Is the person continent or incontinent? elimination problems. \u2022\t Is the person incontinent at any specific time of day NURSING INTERVENTIONS\/IMPLEMENTATION or under any special conditions? \u2022\t Does the person have a history of any medical con- \u2002 ditions that would interfere with urine elimination The following nursing interventions should take place (neurogenic bladder)? in hospitals or extended-care facilities: 1.\t Assess elimination patterns. Older adults may experience a variety of urinary problems. Careful assessment of elimination patterns and problems","300\t UNIT IV\u2003 Physical Care of Older Adults Box 18-5\u2003 Modified Kegel Exercises enables nurses to develop a plan of care that The purpose of the following exercises is to strengthen the addresses the unique needs of a specific person. pelvic floor muscles and the squeezing action that helps Determine how often the person voids and how hold back the flow of urine. It is important that these exer- much is voided each time. If the older person is cises be done faithfully for 3 to 4 months to see improve- incontinent, investigate how often and when ment. If no improvement is seen in this time, consultation incontinence occurs. Consider whether the person with a urologist is suggested. is receiving medications that affect continence. A.\t Follow these instructions to identify the muscles you For example, if incontinence occurs only at night when the older person is receiving diuretic medi- will be exercising. cations, the timing of administration should be 1.\t Sit or stand. Without tensing the muscles of your considered. 2.\t Assess fluid intake patterns. Fluid intake has a legs, buttocks, or abdomen, imagine that you are direct effect on urine elimination. Many older indi- trying to hold back a bowel movement by viduals with urination problems attempt to correct tightening the ring of muscle around the anus. Do the problem by drinking less. This is likely to this exercise only until you identify the back part of increase problems with incontinence because the the pelvic floor. more-concentrated urine that is produced is more 2.\t When you are passing urine, try to stop the flow, likely to irritate the bladder, increasing the risk for then restart it. This helps you identify the front part an episode of incontinence. Fluid restriction also of the pelvic floor. Now you are ready to do the increases the risk for problems with fluid balance complete exercise. and bowel elimination. Encourage older adults to B.\t Do this exercise for 2 minutes at least three times consume most of the day\u2019s fluids early in the day daily (at least 100 repetitions). and to reduce fluid intake after 7 P.M. to reduce the Working from back to front, tighten the muscles while incidence of incontinence during sleep. Fluids that counting to four slowly, and then release them. You irritate the bladder, such as alcohol or caffeine, can do this exercise anywhere; sitting or standing, should be avoided. while watching television, or waiting for a bus. 3.\t Explain measures that help improve tone of the There is no need to interrupt your normal daily sphincter muscles. Kegel exercises are helpful in activity. To feel only the pelvic muscles, do not improving the tone of the sphincter muscles (Box tighten the abdominal, thigh, or buttock muscles, 18-5). These exercises include starting and stop- or cross your legs. Their movement is distinct and ping the stream of urine when voiding. Improved separate from that of the other muscles and can muscle tone can help the person hold the urine be checked by women while they are in the bath until he or she can reach a toilet or obtain assis- or shower by placing one finger inside the vagina tance. Biofeedback has also shown promise as a and contracting the muscles. Men can check method of reducing stress and urge incontinence. success only through improved urine control. 4.\t Modify clothing to make toileting easier. The C.\tDo this exercise every time you urinate. time that is wasted manipulating buttons or zip\u00ad Start and stop your stream five times each time you pers may be long enough to cause incontinence. urinate (i.e., start the flow of urine, squeeze to hold Use of Velcro closures and elastic waists with loops back, then let go to resume the flow). Repeat this may speed undressing and reduce functional sequence several times. Remember, do this every problems related to toileting. time you urinate. You probably will notice that you 5.\t Reduce environmental barriers by providing have much more control of the flow of urine in the grab bars in the bathroom, installing toilet risers, morning than you do in the afternoon. That is keeping the urinal or bedpan readily available, because your muscles are not so tired. and providing a call signal for assistance. Mini\u00ad mizing environmental barriers to safe elimination From National Association for Continence (NAFC), PO Box 1019, Charleston, can help older adults function more effectively and SC 29402. will reduce the incidence of incontinence caused by mobility problems. frustrating to all involved because it need not 6.\t Answer call signals promptly. Decreased muscle happen. Routine scheduling of trips to the bath- tone and neurologic changes hinder the ability of room at regular intervals throughout the day helps many older adults to delay urination. An older reduce the need for the person to call for assistance adult cannot wait as long as a younger person for (Table 18-3). assistance to the bathroom. Respond promptly to 7.\t Develop a toileting schedule. Planning a regular call signals or other requests for assistance with toileting schedule encourages emptying of the toileting, or an episode of incontinence is likely. An bladder at regular intervals. This reduces the occurrence of incontinence caused by lack of staff likelihood of urgency and incontinence. The sched- response is embarrassing for the older adult and ule should be based on the individual\u2019s urinary elimination patterns; there is no absolute best time schedule. If the person is frequently inconti- nent, begin by scheduling toileting at 2-hour intervals. Because urine is produced at a rate of","Elimination\u2003 CHAPTER 18\t 301 Table 18-3\u2003 Promoting a Continence-Friendly Environment ASSESSMENTS MODIFICATIONS OR INTERVENTIONS Accessibility Schedule activities in locations with convenient restrooms. Are restrooms close to bedrooms and activity centers? Are restrooms clearly identified? Use signs that contrast with walls and have large, bold, dark lettering. Can older adult recognize restrooms? Show residents where restrooms are located. Can resident read signs regarding restroom locations? Use universal picture symbols for restrooms in addition to words. Is the resident able to ask for assistance to the Watch for nonverbal signs of discomfort. restroom? Assist resident to toilet on a 2-hour schedule. Does the older adult ask for assistance to the Assist resident to restroom before start of activities. restroom? Answer call lights promptly. Are adequate staff assistants available? Plan to have adequate staff available based on number of residents with continence issues. Are there any physical barriers or restraints that restrict Minimize use of restrictive devices or other barriers to movement. mobility? Safety Verify presence of safety devices. Develop plan for acquisition if not in place. Are the restrooms equipped with call signals and grip bars? Are floors level, dry, and nonskid? Check condition of floors regularly. Post safety signs during cleaning sessions. Are restrooms free from clutter? Remove all clutter from restroom floors promptly. Is there adequate lighting in restrooms? Use adequate wattage in restroom. Leave lights on in restroom at night. Does the older adult have and wear appropriate Remind older adult to wear shoes or slippers when going to footwear? restroom. Does the older adult require assistive devices, such as Consult with physical therapist regarding need for assistive walkers or wheelchairs? devices. Encourage older adult to use recommended devices. Does the older adult need help transferring from Verify that resident and staff are both aware of proper transfer wheelchair to toilet? techniques between wheelchair and toilet. Privacy Be aware that more than one person may need to use the Does the resident share a restroom with other people? restroom at the same time. Have an alternative restroom identified. Do restrooms have doors and locks? Doors with safety locks that can be released by staff promote a sense of privacy. Are toileting requests handled tactfully? Ask resident tactfully if they need to use the toilet. Don\u2019t shout. Is modesty protected during toileting? Close curtains and doors. Make sure resident is adequately dressed when moving in room or public spaces. Comfort Check regularly for chips or cracks and check cleanliness on a regular basis. Are toilets and toilet seats in good condition, clean, and secure? Report any need for cleaning or repairs promptly. Are special needs addressed? Consult with a physical therapist and\/or occupational therapist regarding the need for seat riser or padded seat based on resident needs. Are residents assisted off of the toilet promptly? Assist older adult off of toilet when finished. Excessive waiting time is uncomfortable and can result in unsafe actions. Does the resident have the opportunity to wash hands Assist to sink or provide washcloths or hand sanitizer after toilet after toileting? use.","302\t UNIT IV\u2003 Physical Care of Older Adults A approximately 50 to 75\u202fmL\/hour and the older person\u2019s bladder capacity is approximately 150 to B 200\u202fmL, this frequency will reduce episodes of incontinence. Toileting too frequently can actually FIGURE 18-1\u2003 Disposable garment protectors. A, Complete decrease the ability of the bladder to hold an ade- incontinence brief. B, Pant liner and undergarment. (From Kostelnick quate amount of urine, increasing the risk for C: Mosby\u2019s textbook for long-term care nursing assistants, ed 7, incontinence. When a 2-hour schedule is success- 2015, St. Louis: Mosby.) ful, the time should be increased gradually to retrain the bladder to accommodate larger volumes Adhesive strip of urine. A regular schedule of every 3 to 4 hours is desirable. Monitor the patient\u2019s response to Adult absorbent pad Male drip collector scheduled toileting and praise successes. FIGURE 18-2\u2003 Disposable incontinence pads. (From Gray M: 8.\t Familiarize older adults with the locations of Genitourinary disorders, 1992, St. Louis: Mosby.) bathrooms throughout the facility. Many older adults who experience urgency or incontinence are such as sulfonamides, are often used to treat UTIs. afraid to leave their rooms because they fear being Always check for allergies to sulfa before admin- unable to reach a bathroom when necessary. This istering these medications. Medications such as may result in isolation and withdrawal from oxybutynin (Ditropan) or imipramine may be pre- others. Even a short distance may be too far for scribed to reduce bladder spasms that cause incon- an older person with an urgent need to urinate. tinence. Nurses must administer these medications Reassurance that toilets are available can reduce as prescribed and assess the patient for signs of these fears. medication effectiveness. Many of the medications prescribed to treat incontinence cause side effects 9.\t Provide support and encouragement. Incontinence such as dry mouth, dry eyes, confusion, constipa- is disturbing to alert older adults. Episodes of tion, orthostatic hypotension, and tachycardia. incontinence are embarrassing and can lead to Comfort measures and safety precautions are nec- frustration and loss of self-esteem. Even those essary if these side effects occur. involved in bladder training programs are likely 13.\t Insert catheter as prescribed by primary care pro- to have accidents. It is essential to focus on suc- vider. Catheterization requires an order by a phy- cesses and minimize failures. sician or care provider with prescriptive authority (Figure 18-3). Insertion of an indwelling catheter is 10.\t Initiate actions to maintain skin integrity. Aging not recommended for treating incontinence. The skin is particularly susceptible to damage from risk for UTIs increases dramatically with this inva- moisture and the waste products in urine. Remove sive procedure. Catheters should be used only wet clothing and linens immediately to prevent when the benefits to the patient outweigh the risks maceration and irritation. Thoroughly wash and dry the skin after each episode of incontinence. 11.\t Provide incontinence pads or garments when appropriate. Incontinence pads or garments reduce the need to completely change the bed linens or clothing after an episode of incontinence (Figures 18-1 and 18-2). Use these items with caution, however, because they tend to trap mois- ture next to the skin. Some of the newer inconti- nence garments are constructed with a barrier that keeps moisture away from the skin. Because newer incontinence garments are also smaller and less conspicuous, they are more acceptable to older people than are the bulkier diaper-type garments. The newer garments allow wearers more freedom to move about without fear of embarrassing them- selves. These pads and garments should not be used as a replacement for toileting, however. The cost of incontinence supplies can be significant for people with limited financial resources. When incontinence pads or garments are soiled, change and dispose of them promptly to reduce environ- mental odors. 12.\t Administer medications as prescribed by the primary care provider. Uroseptic medications,","Elimination\u2003 CHAPTER 18\t 303 Single lumen Condom catheter Straight, rounded tip Connected to drainage tube Malecot tip (retention catheter) B Mushroom tip (dePezzer) retention catheter Double lumen (retention catheter with rounded tip) Drainage Sterile water for balloon inflation Triple lumen Alcock (retention catheter with coude tip) Drainage Sterile water for Irrigation balloon inflation A FIGURE 18-3\u2003 Examples of catheters. A, Single, double, and triple lumen catheters. B, Condom catheter. (From deWit SC and O\u2019Neill P: Fundamental concepts and skills for nursing, ed 4, 2014, St. Louis: Saunders.) involved. Sterile technique must be used when 3.\t Encourage discussion of concerns with the primary inserting an indwelling catheter. When the cathe- care provider. Nurses working in a home setting ter is in place, thorough perineal care is essential may be aware of urinary problems that have not to reduce the possibility of ascending UTI. Many been shared with the medical team. Older adults older adults who have had an indwelling catheter should be encouraged to reveal their problems and even for a limited time are at increased risk for concerns with their care provider so that an appro- incontinence once it is removed. When the catheter priate diagnosis can be made and treatment initi- is in place, the bladder is decompressed. Once the ated. Document all observations regarding urine catheter is removed, the bladder is unable to adapt elimination in the person\u2019s record and notify the to holding a significant volume of urine. Before primary care provider. removing the catheter, a procedure in which the catheter is clamped intermittently to increase 4.\t Provide encouragement during treatment for bladder capacity can reduce this problem. urinary problems. Problems with urinary retention The following interventions should take place in or incontinence do not usually respond quickly to the home: treatment. Weeks or months of treatment may be 1.\t Encourage the individual to establish a pattern required before any improvement is noticed. This of urine elimination. A pattern of voiding on awak- can easily result in noncompliance with the plan of ening, after meals, before leaving home, before care. Encourage older adults to take medications, becoming interested in a lengthy activity, before practice exercises, or follow through with other exercise, and before bed can reduce the risk for medical recommendations. incontinence. 2.\t Stress the importance of good skin care and hy- 5.\t Discuss methods for coping with incontinence. giene after episodes of incontinence. Poor hygiene Older adults are more likely to become socially increases the risk for skin irritation or breakdown isolated rather than embarrass themselves in and increases the risk for urinary tract infections. public. Developing strategies for coping (e.g., use Teach the importance of changing soiled clothing of incontinence garments and learning the loca- promptly, careful handwashing after toileting, and tion of toilets in stores or theaters) can help (for women) proper wiping from front to back. prevent this. 6.\t Use any appropriate interventions that are used in the institutional setting.","304\t UNIT IV\u2003 Physical Care of Older Adults 3.\t When caring for an older adult who has a history of cardiac problems, the nurse recognized that it is most Get Ready for the NCLEX\u00ae Examination! important to institute measures to prevent which outcome? Key Points 1.\t Constipation 2.\t Diarrhea \u2022\t Bladder and bowel elimination is essential for normal 3.\t Urinary tract infection body functioning. 4.\t Bladder incontinence \u2022\t Unless waste products are removed effectively from the 4.\t Your patient Mrs. Fawcett has been diagnosed with body, serious consequences will result. urge urinary incontinence. Which of the following \t are appropriate nursing interventions? (Select all \t \u2022\t Aging results in less effective removal of waste that apply.) products, but a problem more significant to older adults 1.\t Avoid placing throw rugs in her room is any alteration in the ability to control the elimination 2.\t Offer her a cup of tea to reduce detrusor muscle process. spasms 3.\t Place her close to the restroom, and remind her of \u2022\t Problems related to elimination are serious concerns for its location older adults, and a great deal of physical and mental 4.\t Secure her pants with safety pins to keep them energy is devoted to dealing with changes in secure elimination function. 5.\t An older woman has begun to stay in her apartment, Additional Learning Resources avoiding socializing with her peers in the independent living center. She states that she cannot wait when she \u2002 Go to your Evolve website at http:\/\/evolve.elsevier needs to urinate. She is afraid that she will have an .com\/Williams\/geriatric for the additional online resources. accident. It is most appropriate for the nurse to: 1.\t Tell her not to worry because many of the other Review Questions for the NCLEX\u00ae Examination ladies have the same problem. 2.\t Suggest that she begin to wear an adult 1.\t While caring for an older adult the nurse determines incontinence garment when she goes out. that further teaching regarding bowel elimination is 3.\t Recommend that she restrict her fluid intake so the needed when the patient states: problem does not occur as often. 1.\t \u201cI\u2019ll do some exercise and increase my daily fluid 4.\t Provide encouragement and discuss Kegel exercises intake.\u201d and other approaches to cope with incontinence. 2.\t \u201cI\u2019ll give myself an enema if I don\u2019t have a bowel movement every day.\u201d 3.\t \u201cI\u2019ll increase my intake of fruits and vegetables.\u201d 4.\t \u201cI\u2019ll try to eat more whole grain foods, like bran, daily.\u201d 2.\t An older adult who recently has had small watery bowel movements, complains of pressure in the rectal area and abdominal cramping. Which is the most appropriate initial nursing action? 1.\t Administer an oil retention enema. 2.\t Notify the primary care provider of these observations. 3.\t Digitally stimulate the rectal sphincter. 4.\t Administer the prn laxative medication.","Activity and Exercise chapter 19\u2003 http:\/\/evolve.elsevier.com\/Williams\/geriatric Objectives 7.\t Select nursing interventions that are appropriate for older individuals experiencing problems related to activity and 1.\t Describe normal activity and exercise patterns. exercise. 2.\t Examine how activity and exercise patterns change with 8.\t Differentiate between a custodial focus and a aging. rehabilitative focus in nursing care. 3.\t Discuss the effects of disease processes on the ability to 9.\t Discuss the impact of nurses\u2019 attitudes on care participate in exercise and activity. planning. 4.\t Describe methods of assessing changes in the ability to 10.\t Identify the benefits of a rehabilitative focus on older participate in activity or exercise. adults. 5.\t Identify older adults most at risk for experiencing 11.\t Identify the goals of rehabilitation nursing. problems related to activity and exercise. 6.\t Select appropriate nursing diagnoses related to activity hemiparesis\u2002 (h\u0115m-\u0113-p\u0103-R\u0112-s\u012ds, p. 310) hemiplegia\u2002 (h\u0115m-\u0113-PL\u0112-j\u0103, p. 310) and exercise problems. isometric\u2002 (\u012b-s\u014d-M\u0114T-r\u012dk, p. 310) isotonic\u2002 (\u012b-s\u014d-T\u014eN-\u012dk, p. 310) Key Terms rehabilitation\u2002 (r\u0113-h\u0103-b\u012dl-\u012d-T\u0100-sh\u016dn, p. 308) rehabilitative\u2002 (r\u0113-h\u0103-b\u012dl-\u012d-T\u0100-t\u012dv, p. 327) agility\u2002 (\u0103-J\u012cL-\u012d-t\u0113, p. 306) tachycardia\u2002 (t\u0103k-\u0115-K\u0102R-d\u0113-\u0103, p. 316) alignment\u2002 (\u0103-L\u012aN-m\u0115nt, p. 310) arthritis\u2002 (\u0103hr-THR\u012a-t\u012ds, p. 308) coordination\u2002 (k\u014d-\u014fr-d\u012d-N\u0100-sh\u016dn, p. 306) custodial\u2002 (k\u016d-ST\u014c-d\u0113-\u0103l, p. 327) dexterity\u2002 (d\u0115k-ST\u0114R-\u012d-t\u0113, p. 306) diversional activities\u2002 (d\u012d-V\u016cR-zh\u0103n-\u0103l, p. 323) dyspnea\u2002 (D\u012cSP-n\u0113-\u0103, p. 318) NORMAL ACTIVITY PATTERNS Although the amount and type of exercise one per- forms changes over the life span, exercise and activity The activity-exercise health pattern deals with behav- remain an essential part of life. People who were not iors related to exercise, activity, leisure, and recreation. physically active as young adults can become more Nurses must consider the wide range of behaviors physically active as they age, but it must be increased within this pattern that fall under the general term gradually to avoid injury. A healthy pattern of activity activity. Activity is anything that requires the expen- and exercise is best established early in life, however, diture of energy. Some activities require only a small to ensure that these behaviors become habitual and are expenditure of energy, whereas others require a great carried into old age. deal of energy. Exercise helps people look and feel better. Physical Basic body functions such as breathing, temperature activity is necessary to maintain joint mobility and control, and metabolism expend the least amount of muscle tone. When people do not participate in regular energy. Sitting, resting, watching television, reading, activity, all body systems suffer. Preventing mobility and playing cards or bingo are sedentary activities that problems is easier than trying to overcome the prob- require little energy. Activities of daily living (ADL), lems once they develop. Older adults should be such as dressing, grooming, eating, bathing, and toilet- encouraged to be as active and independent as possi- ing require a greater expenditure of energy. Cooking, ble. Because existing medical conditions may restrict cleaning, driving, and shopping require still more activity, nurses should be aware of any problems that effort and expend more energy. Walking can be a mild may affect someone\u2019s ability to participate in activities or vigorous activity, depending on the pace. Running, and assist them to do as much as is permitted. swimming, dancing, aerobics, and other forms of active exercise require the greatest energy expenditure. Many older adults remain physically active. It is common to see individuals in their sixties, seventies, 305","306\t UNIT IV\u2003 Physical Care of Older Adults transmission of nerve impulses, but it does slow the and older, leading active, self-sufficient lives. Aging speed of nerve transmission. does not imply that a person must sit in a recliner and vegetate. Visit a park or shopping mall early A loss of muscle mass can interfere with activities in the morning, and you will see many older adults that require muscular strength. Activities such as walking for their health. Golf courses are filled with moving furniture, lifting bags of groceries, shoveling older adults teeing up. Activity is good for people of snow, and vacuuming may become increasingly all ages. Aging may change the type and amount difficult. of participation, but active participation in a variety of activities is the best way to maintain high-level Loss of cushioning cartilage can result in arthritic function. joint pain, which inhibits motion and makes a person less likely to exercise. Ligaments and tendons become Physical activity requires a complex interaction of stiff, contributing to decreased joint flexibility. This can physiologic processes, primarily those of the neuro- result in problems with performing ADLs. Reaching logic, musculoskeletal, cardiovascular, and respiratory for objects on shelves, dressing, bending to put on systems. Anything that interferes with the coordination shoes, and even washing the feet or back may be of these systems can alter the ability to participate in difficult. physical activity. Agility, the ability to move quickly and smoothly, Of major importance is the function of the nervous decreases with age. This may cause difficulty when system, which is the primary coordinating system of older adults try to climb ladders or avoid hazards the body. The brain controls the involuntary activities while walking. Dexterity, the ability to perform fine of the body, including metabolism, respiration, and manipulative skills, is also likely to decrease with age. temperature control. Areas of the brain control the Gross motor skills remain intact longer than do fine high-level processes of perception and cognition. motor skills. However, skills that were perfected when Before any voluntary activity occurs, individuals must younger, such as playing a musical instrument or be able to recognize that a need for action exists. Once sewing, may be maintained at a high level if used the need is recognized, the individual must have the regularly. desire and the ability to perform that action. The brain is also the motor control center of the body, and it com- Decreased stamina is typically seen with aging. This municates with the somatic peripheral nervous system. is most often a result of decreased oxygen supply to Any physiologic age- or disease-related change that body tissues. Impaired oxygen exchange may be alters the function of the brain\u2019s motor centers or caused by a loss of elasticity in the lungs and a smaller interferes with the transmission of impulses from the chest cavity. The decreased availability of oxygen may brain to the musculoskeletal system can interfere with lead to the need for frequent pauses during activity or activity. a slower pace when performing activities. The musculoskeletal system must then be able to Coordination of multiple activities is likely to respond to these messages from the brain. Normal and decrease with aging. Activities that require simultane- pathologic changes in muscles or bones can interfere ous perception of many stimuli and quick physical with normal activity. Even if the nervous and the mus- response (such as driving) are often affected. Older culoskeletal systems are intact, problems in the cardio- adults with impaired vision and hearing, decreased vascular and respiratory systems can lead to alterations strength, slow reaction time, and decreased coordina- in activity. Muscles, including the heart muscle, require tion may not be able to safely perform this type of an adequate supply of oxygen and nutrients to func- complex activity. tion properly. Anything that interferes with the oxygen supply to tissues affects a person\u2019s ability to perform Because these changes appear gradually, older indi- activity. viduals generally learn to compensate for or cope with them. Many strategies such as pacing activities, finding ACTIVITY AND AGING alternative methods of performing activities, and sim- plifying activities demonstrate the capacity of older With advancing age, most people experience some adults to adapt and adjust. changes in the ability to perform or tolerate activity, and this ability varies widely among older adults. In EXERCISE RECOMMENDATION general, the more active of a lifestyle a person has FOR OLDER ADULTS lived, the more active he or she remains with aging. Regular, planned exercise is of benefit to all ages, and it is of particular benefit as we age. Scientific evidence The first change noticed by most aging people is a indicates that regular physical activity can extend decrease in the rate or speed of activity. Things that years of active independent life, reduce disability, and could be done quickly in the past now take longer. improve the quality of life for older adults. Exercise Many older individuals complain that it now takes promotes muscle mass, strength, balance, coordina- them much longer to dress, shop, or do other simple tion, and joint flexibility. It helps decrease stress and activities. Normal aging does not interfere with the promotes normal sleep. Exercise does not have to be demanding to be beneficial. Moderate exercise done","Activity and Exercise\u2003 CHAPTER 19\t 307 for 30 minutes a day is more beneficial than strenuous for these exercises, but caution should be used when exercise done infrequently. Because there may be doing standing exercises if someone has balance prob- medical reasons why certain activities are contraindi- lems. Balance training is particularly important for cated, older people should check with their primary older adults. Studies have demonstrated that strength care provider before starting an exercise program. Care and balance training improve physical fitness and providers often refer older patients to a physical thera- reduced fall risk in community-dwelling older adults pist, who can develop a plan specific to their needs. (Zhuang et\u202fal, 2014). Older adults with physical limitations will need an individualized plan developed to meet their unique Technologic innovations such as the Nintendo Wii needs. The proper exercise plan for a frail older adult and other interactive games appear to have the poten- will be quite different from the plan most suited to a tial of stimulating interest in activity within the aging high-functioning 65 year old. Physical therapists can population. They have the added benefit of being able recommend exercise programs designed for use by to be performed at home. wheelchair-bound individuals or anyone with special needs. Before starting an exercise program, the older Keeping motivated to exercise is a major problem person should know the importance of acquiring good at any age, perhaps more so as a person gets older. supportive footwear and clothing appropriate for the Nurses should educate older persons about the impor- environment and type of exercise. Because older adults tance of exercise and emphasize the benefits, such are more at risk for thermal imbalance, they should be as weight loss, improved mobility, improved blood aware that it is wise to avoid excessive exercise during glucose control, lower blood pressure, decreased fall extreme weather conditions. risk, and living a longer and healthier life. Here are some guidelines to help older adults make a regular A 94-year-old man was interviewed at a private health exercise program a reality: club where he spends 1 hour a day, 6 days a week. He \u2022\t Keep it simple. Simple exercise programs are more said he started coming to the club when he was in his late seventies to give his wife, who had Alzheimer disease, likely to be successful than complicated ones that some privacy while she received personal care at home. are hard to remember or difficult to perform. He said he thought it would help him decrease his stress \u2022\t Have a plan. Set up a weekly calendar with a and increase his physical strength so that he could help planned time for exercise to keep on track. her. She has since died, but he keeps coming to the club \u2022\t Do it with a friend. Enlisting the company of a to use the treadmill and flexibility machinery. When friend or group of friends who can provide mutual asked why he likes to come to the club to exercise, the encouragement and support is highly motivating. man replied, \u201cIt keeps me young.\u201d He also mentioned Even a pet can be your friend and exercise buddy that he likes the social atmosphere and \u201cwatching the for a walk. youngsters sweat.\u201d \u2022\t Keep it interesting. Join an exercise or dance class as a way to try some new form of exercise that Specific types of exercise provide unique benefits. is more interesting and motivating (see Comple\u00ad Aerobic exercise promotes cardiovascular and respira- mentary and Alternative Therapies box). tory function. Aerobic exercise includes activities that \u2022\t Try music. Upbeat rhythms or waltzes can help increase the heart rate, such as walking, jogging, or coordinate your movements. Music designed spe- bicycling. Many residential facilities, YMCAs, and cifically for exercise is available in music stores senior centers provide additional opportunities for or online. Exercise videos are also available, but aerobic exercise using equipment such as treadmills, choose one that is appropriate for your needs and elliptical trainers, and rowing machines. The individ- abilities. ual must know how to use the equipment properly to \u2022\t Get a coach. A physical therapist can provide addi- avoid injury. Swimming is a pleasurable aerobic exer- tional teaching and motivation and can design a cise for many seniors, and water exercises can help safe workout routine that can be done at home. individuals with sore joints because the water pro- \u2022\t Set a goal. Goals should be realistic but challenging. vides support and eases movement. Even doing Focus on small but measurable gains in the areas of routine household chores and yard work can be con- strength and flexibility, such as increasing strength sidered aerobic if done for a long enough time. Strength to walk an additional block or being able to put on training will help maintain muscle mass and can be shoes more easily. Remember, anything that you can performed at home or at the gym using exercise balls, do now but had trouble with before is a gain. In fact, inexpensive elastic stretch bands, or weights. Weight- not losing function as you age is a significant gain bearing exercise such as walking helps maintain bone in itself. strength. Stretching exercises are important to promote range of motion and joint flexibility. Most aerobic or Complementary and Alternative Therapies strength-training exercises cause muscles to tighten, so stretching major muscle groups after exercising will \u2002 help maintain flexibility. Little equipment is needed Qi Gong and Tai Chi Qi gong and tai chi are forms of exercise from Asia that are gaining popularity, because they are less stressful to the body","308\t UNIT IV\u2003 Physical Care of Older Adults gait), which further limits the ability to participate in normal activities. and yet require more focus and concentration. This makes these exercises beneficial for both body and mind. The major Diseases or injury to the musculoskeletal system components include body posture adjustments, gentle motion, can interfere with the ability to perform some activi- regulated breathing, meditation, and other purposeful relax- ties. Fractures can lead to limited or extensive mobility ation. Some forms also include massage or hand resistance. restriction, depending on the body part affected. These exercises can be done vigorously or gently, making Fracture of a small bone, such as a finger results in them suitable for a variety of individuals. They are typically limited loss of mobility. Fracture of a large bone, such performed while standing but can also be adapted for walking, as the femur, results in severe limitation of mobility. sitting, or lying. These forms of exercise are inexpensive to Not only does the fracture itself restrict mobility, but perform because they require no special equipment or facili- the treatment further limits mobility. Even after surgi- ties. Research conducted abroad and in the United States\t cal repair, the person with a fractured hip is not per- has shown many benefits from these exercises, including the mitted to participate in certain activities (e.g., weight following: increased oxygen consumption; decreased blood bearing on the extremity) until healing has occurred. pressure; improved flexibility; increased lower extremity Preventive nursing interventions are important to pre- strength; increased bone density, improved posture and serve strength and joint mobility. balance; and improved immune system function. Additional reported benefits include decreases in stress, anxiety, and Diseases such as gout and arthritis cause joint pain, depression. which leads to restricted activity. A person with severe gout or arthritis may avoid use of the painful joints These exercise practices have gained some support in\t to reduce discomfort. Unfortunately, this inactivity the United States, but many health care providers and\t can lead to further loss of joint mobility and muscle potential older participants are unaware of them or remain strength, further reducing the person\u2019s ability to skeptical of their benefits. This may be because of lack of perform activities. Joint degeneration with aging familiarity with the techniques and a perception of difficulty. In severely restricts mobility, particularly in the weight- addition, there are not enough teachers who are prepared to bearing joints in the knees and hips. Joint replacement explain the principles and skills of these exercises appropri- surgery is an increasingly common option for older ately. Further research and dissemination of information are adults. After a period of rehabilitation, older adults being funded by the Robert Wood Johnson Foundation and generally achieve a greatly improved activity level. others. Many articles and video training materials are now available. Foot conditions commonly seen in older adults (e.g., bunions, hammertoes, and calluses) may interfere with Focusing on the positive outcomes of exercise is key ambulation, particularly if footwear does not fit prop- to maintaining a regular program. See the Nursing erly. Painful feet are a common reason for decreased Process for Impaired Physical Mobility on pages 309\u2013 activity in older adults. 315 for additional benefits that can increase an older adult\u2019s motivation to continue exercising. Any disease condition that interferes with the intake or distribution of oxygen to body tissue significantly EFFECTS OF DISEASE PROCESSES ON ACTIVITY interferes with a person\u2019s ability to participate in activ- ity and exercise. These conditions include diseases If, in addition to normal changes, the aging person has of the respiratory system that prevent adequate gas health problems that affect the critical body systems, exchange in the lungs (e.g., asthma, emphysema, bron- his or her ability to participate in activity is further chitis, and pneumonia) and diseases of the cardiovas- impaired. Cognitive disorders such as delirium, cular system that prevent adequate distribution of Alzheimer disease, and stroke can affect both the high- oxygen to body tissues and heart muscle (e.g., myocar- level thinking functions and the motor functions of the dial infarction, congestive heart failure, heart block, brain. Severely affected persons may not recognize the arteriosclerosis, and hypertension). need for the most basic activities, such as moving, eating, dressing, bathing, or toileting. Even if they do Inadequate oxygenation places additional stress on recognize these needs, their altered motor function the cardiovascular and respiratory systems. Pulse and may prevent them from meeting basic needs. respiratory rates increase in an attempt to compensate for the decreased amount of oxygen. If additional Neurologic damage resulting from head injury, demands for oxygen occur, as they do with even mod- infection, degenerative disease, Parkinson disease, or erate activity, older adults may experience additional toxic drug reactions can interfere with normal nerve symptoms. Fatigue with minimal activity is common impulse transmission. People suffering from these with oxygen deprivation. Pain may be reported with conditions may recognize a need and have the desire activity. Most common are angina (chest pain which to perform an activity yet are unable to carry out the may radiate down the left arm or present as vague activity. The nervous system does not transmit appro- gastrointestinal discomfort) and intermittent claudi- priate messages to the muscles to enable them to cation (a cramping pain in the legs during or after perform the activity. Abnormal nerve transmission can walking), which are both caused by inadequate tissue result in difficulty getting started with movement or oxygenation. Initially, this pain occurs with activity in uncoordinated muscle activity (e.g., a staggering","Activity and Exercise\u2003 CHAPTER 19\t 309 only; in severe cases of oxygen deprivation, it also Box 19-1\u2003 Risk Factors Related to Impaired Physical occurs at rest. Severe oxygen deprivation can result in Mobility in Older Adults cardiac or respiratory distress. \u2022\t Intolerance of physical activity because of medical To compensate for these symptoms, older adults conditions that decrease endurance or strength spontaneously restrict their activities. Individuals may become housebound because the effort of dressing is \u2022\t Pain too much for them. Some are unable to eat or perform \u2022\t Neuromuscular or musculoskeletal conditions basic hygiene because it is too exhausting. Sometimes \u2022\t Cognitive impairment (Alzheimer disease or dementia) the activity limitation is so severe that individuals are \u2022\t Severe anxiety or depression able to maneuver around the house only by placing \u2022\t Prescribed bed rest chairs at 10-feet intervals. They move that short dis- \u2022\t Restrictive devices (restraints, casts, splints, and tance, then sit and rest until they are able to move to the next chair. immobilizers) Malnourishment can also contribute to the reduced \u2022\t Is the person able to lift his or her feet when walking, ability to perform activities. Inadequate intake of or does the person shuffle? nutrients can result in muscle atrophy. Malnourished individuals lack adequate protein to build muscle \u2022\t Does the person maintain an upright posture when tissue, an adequate supply of glucose to fuel the walking? muscles, and adequate iron to form hemoglobin. Inadequate iron intake can result in anemia, which \u2022\t Do both sides of the body move evenly? leads to a decrease in the oxygen available to tissues \u2022\t How well can the person maintain balance? and further reduces the ability to perform activity. \u2022\t What kind of footwear does the person wear for Although not physiologic in origin, emotional dis- walking? orders such as severe grief, anxiety, or depression can \u2022\t Does the person have any foot problems (e.g., lead to decreased participation in normal activity. Individuals who are emotionally disturbed may be bunions and calluses) that interfere with walking? directing all of their energy inward and may not be \u2022\t How far can the person ambulate without willing or able to summon the energy required for physical activity. It is important to remember that these discomfort? people need to continue to use their bodies to prevent \u2022\t Does the person require any assistive devices loss of physical function. (walkers or canes) for ambulation? Are they used NURSING PROCESS FOR IMPAIRED properly? \u2022\t Does the person feel comfortable and confident \u2002 using these aids? \u2022\t Does the person require the assistance of another PHYSICAL MOBILITY person to ambulate? \u2022\t If the person is not ambulatory, what is his or her Older adults typically experience some changes in activity level? their ability to perform physical activities. These \u2022\t Does the person use a wheelchair? changes may result from the normal changes of aging \u2022\t Can the person operate the wheelchair or from some pathologic changes. independently? ASSESSMENT\/DATA COLLECTION \u2022\t Does the person receive passive range-of-motion exercises? \u2002 \u2022\t Is the environment safe for the individual? Box 19-1 lists risk factors for impaired physical mobil- \u2022\t Does the individual have full range of motion in ity in older adults. the joints? NURSING DIAGNOSIS \u2022\t Does the person have any contractures or deformities? \u2002 \u2022\t Does the person experience any pain or tenderness Impaired physical mobility in the joints? NURSING GOALS\/OUTCOMES IDENTIFICATION \u2022\t Is there any particular motion that aggravates joint pain? \u2002 \u2022\t What relieves pain? The nursing goals for individuals with impaired phys- \u2022\t Describe the muscle tone of the arms and legs? ical mobility are to (1) increase participation in physi- \u2022\t Is muscle strength equal on both sides of the cal activities that maintain strength and mobility; (2) maintain normal anatomic position and function in all body? joints; (3) remain free from joint contractures and foot \u2022\t Is there any muscle tenderness? drop; and (4) maintain or increase strength and mobil- \u2022\t Is the person bedridden, wheelchair-bound, or ity using assistive devices. ambulatory? NURSING INTERVENTIONS\/IMPLEMENTATION \u2022\t If ambulatory, what is the pattern of the gait? \u2002 Steady? Shuffling? Ataxic? Slow? Rapid? The following nursing interventions should take place in hospitals or extended-care facilities:","310\t UNIT IV\u2003 Physical Care of Older Adults will benefit a specific individual. These exercises should become part of the nursing care plan and 1.\t Identify the prescribed activity level. The activity be included in the day\u2019s activities (Figure 19-1). level is established by the primary care provider Passive range-of-motion exercises help keep the based on the older adult\u2019s overall health status. joints flexible, but they do little to maintain muscle The patient should be as active as possible yet not strength. Passive range of motion should be pro- exceed the prescribed activity level. It is particu- vided a minimum of twice a day for immobile larly important to be aware of any weight-bearing older individuals. Active range of motion helps restrictions related to fractures or joint replace- with both joint flexibility and muscle toning. Teach ments. Failure to take proper precautions can lead older people with hemiplegia or hemiparesis to to serious and permanent harm. use the stronger side of the body to exercise the weaker extremities. Many facilities provide exer- 2.\t Continue to assess strength and joint mobility. cise programs that are adapted to meet the ability Strength and joint mobility are not always consis- levels of the residents. Exercise is often done to tent in older adults. Changes may be caused by music because the rhythm encourages motion. something as simple as a change in the weather, Isometric exercises, such as alternately tightening or they may be an early indication of a change in and relaxing the muscles of the arms, abdomen, the older person\u2019s health status. Carefully assess or buttocks, may benefit some older adults by mobility if the older adult has experienced weak- helping them maintain the strength of the abdomi- ness or falls. Promptly report any acute changes in nal and gluteal muscles and quadriceps. Isometric the assessment such as one-sided weakness or exercise does not affect the joints. Isotonic exercise, severe pain to the primary care provider. which helps improve muscle strength, muscle tone, and joint mobility, includes such movements 3.\t Perform physical mobility activities in conjunc- as lifting the body off of the bed with a trapeze tion with daily care. Provide passive range- (Figure 19-2), pressing against a footboard, or of-motion exercise in conjunction with the bath. pushing against the bed to lift the buttocks off Incorporate active exercise as part of dressing, the mattress. Isometric and isotonic exercises meals, grooming, toileting, and other ADL. Even should be used with caution by persons with minimal participation in ADL can increase physi- cardiac problems because these exercises increase cal mobility. Any exercise performed by the older stress on the cardiovascular system. These exer- individual during bathing, hair combing, and oral cises may result in elevation of the blood pressure hygiene that uses the joints and muscles can be and use of the Valsalva maneuver, which can beneficial. slow the heart rate dangerously, even to the point of cardiac arrest in someone with cardiac disease. 4.\t Provide good body alignment and frequent posi- To prevent this problem, older adults should be tion changes. Bedridden older adults are at high instructed to breathe through the mouth while risk for loss of joint mobility. Poor alignment can exercising. result in muscle fatigue, which enhances the likeli- 7.\t Verify that the older adult is appropriately hood of contractures. Flexion contractures of the dressed for activity and has the proper footwear. hip, knee, and foot occur when the stronger flexor Proper clothing and footwear should be selected muscles dominate. These contractures can result in for exercise. Clothing should not be constricting permanent loss of the ability to stand or ambulate. (to allow for freedom of movement) and suitable To prevent this, always provide good alignment to the environment. Many older adults choose and positioning. Use positioning devices (pillows, comfortable footwear instead of footwear that pro- trochanter rolls, and foot supports) when needed vides proper support. Most slippers do not provide to maintain proper alignment. adequate support and are intended for rest, not ambulation. Encourage the wearing of shoes 5.\t Avoid unnecessary restraint that limits physical whenever possible. Shoes should fit well and mobility. By definition, restraints limit mobility. support the foot to decrease the likelihood of falls. Any device that restricts mobility is a restraint, If the individual has foot problems, special foot- including vests, wheelchair tables, foot pedals, wear may be necessary. Gait changes, particularly and even safety bars. Many of these devices the inability to lift the feet freely, increase the risk that historically have been used to protect older for falls. If footwear is too loose or is not support- adults from falls have actually increased the likeli- ive, the fall risk increases. Shoes should fit snugly hood of injury. An older adult who is prevented enough that they do not slip off the heel when by these devices from using joints and muscles walking. Older women, particularly those with loses strength and function and becomes increas- kyphosis, should be encouraged to wear low heels ingly susceptible to injury. Ensure that splints or when walking to provide better balance. other devices do not unnecessarily restrict joint movement. 6.\t Consult with the physical therapist to determine a suitable activity\/exercise plan that maintains muscle strength and joint mobility. The physical therapist may be able to suggest exercises that","Activity and Exercise\u2003 CHAPTER 19\t 311 LYING DOWN With your arms at your sides, bend at the elbow and curl your arms as if making a muscle. Clap your hands directly above your head. Stretch your arms and legs; take a deep breath. Grab each leg with both hands below the Fold your hands on your stomach; Lift each leg off the bed, but try not to knee and pull toward your chest slowly. raise your arms over your bend your knee. Use an arm to help. head toward the headboard. SITTING Touch your elbows together in front of you. Shrug your shoulders forward, Bend forward and let your While still sitting, move each of then move them in a circle, arms dangle; try to touch the your knees up and down as if you raising them high enough to floor with your hands. are walking; each time your right reach your ears. foot hits the ground, count it as one. Lift your knee high. Twist your whole upper body from side to side with your hands on your hips. FIGURE 19-1\u2003 Various exercises that can be done while lying down, sitting, standing up, and walking. (From Johnson-Paulson JE, Koshes R: Exercise is for everyone. Geriatr Nurs, 6(6):322, 1985.) Continued","312\t UNIT IV\u2003 Physical Care of Older Adults Keep your feet planted on the ground and twist your upper body at STANDING UP the waist from side to side with your arms swinging; when you twist to Hold your arms out and turn them in the right, count it as one. big circles. Using your arms, push off While holding onto the edge from the bed and stand up; if of the bed or back of a chair, you get dizzy, sit down and bend your knees slightly. try again. With hands at your side, bend at the waist as far as you can to the right side, then to the left. WALKING PLACES Walking is good exercise. It helps in toning INSIDE OUTSIDE muscles and maintaining flexibility of joints. It is important to maintain walking Wear soft-soled shoes with good support, (i.e., It also is good exercise for the heart and ability. Determine how far you can jogging shoes). When walking, push off from your circulatory system. Walking briskly for 20 walk and each day walk to 3\/4 of toes and land on your heels. Swing arms loosely minutes a day, 3 times a week can be as that distance, building endurance. at your sides. Begin with 10-minute walks and effective a heart conditioner as jogging, but it Wear supportive shoes and use build to 20 to 30 minutes. does take a longer time to achieve the same whatever aids are necessary. effect as jogging. For those who cannot walk Walking up stairs requires effort. Place one foot rapidly for long periods, walking to the point FIGURE 19-1, cont\u2019d flat on a step, push off with the other and shift of muscular fatigue also helps maintain good your weight. Use a railing for balance if necessary. muscle tone. Your body may give you signs to indicate you are overdoing exercise. Stop, rest, and if necessary, call your physician if you experience any of these symptoms: \u2022 SEVERE SHORTNESS OF BREATH \u2022 CHEST PAIN \u2022 SEVERE JOINT PAIN \u2022 DIZZINESS OR FAINT FEELING \u2022 HEART FLUTTERS In all walking exercises, go only as fast as you are able to walk and still carry on a conversation. If you cannot, slow down.","Activity and Exercise\u2003 CHAPTER 19\t 313 FIGURE 19-2\u2003 Patient using a trapeze bar. (From Kostelnick C: Mosby\u2019s textbook for long-term care nursing assistants, ed 7, 2015, St. Louis: Mosby.) FIGURE 19-3\u2003 Quad cane. Note that proper footwear is being worn. FIGURE 19-4\u2003 Patient using a walker. (From Potter PA, Perry AG, (From Potter PA, Perry AG, Stockert PA, Hall AM: Fundamentals of Stockert PA, Hall AM: Essentials for nursing practice, ed 8, 2015, nursing, ed 8, 2013, St. Louis: Mosby.) St. Louis: Mosby.) 8.\t Provide pain medication in a timely manner so remind the older adult to lock the wheels of their that maximal benefits from the medication occur wheelchair before sitting down. In addition, ensure when greatest physical effort is expected. Pain is that assistive devices are kept nearby so that they a common reason for decreased physical mobility. are easily available to the older person. If the indi- Be aware of particular activities that intensify or vidual suffers from one-sided weakness, place the relieve an individual\u2019s pain. Pain increases with device on the stronger side. Many older adults do fatigue; therefore, pace activities so that they do not like to use these devices because they are cum- not overly fatigue the individual. Administer anti- bersome and because they are constant reminders inflammatory medications or analgesics so that the of failing health. Stress the importance of using the older adult is as comfortable as possible when devices if they are needed for safety. physical activity is scheduled. 10.\t Encourage wheelchair-bound patients to move by using their arms or feet whenever possible. If 9.\t Verify that the individual knows the correct they are unable to walk, older adults may still be method for using assistive devices and that he or able to move about in a wheelchair, which involves she does, in fact, use them for activity. Explain using either the arms to turn the wheels or the legs proper use if needed. If assistive devices such as and feet to propel the chair. wheelchairs, walkers, or canes are needed, verify 11.\t Provide adequate assistance during ambulation. that older adults know how to use them properly Gait belts and the assistance of one or two helpers (Figures 19-3 and 19-4). Assess the older adult\u2019s may be needed to provide safety and a sense of ability to use the walker, particularly when climb- security. The loss of balance seen in some older ing stairs. Check that the person holds the cane in people increases the risk for falls. Use a gait belt the correct hand when walking. To prevent falls, when assisting an unsteady person. A gait belt is not a lifting device. Gait belts that are properly secured around the person\u2019s waist allow the care- giver to prevent injury to both the individual and the caregiver. The belt is near the person\u2019s center of gravity; thus, the caregiver can sense subtle balance changes and anticipate problems (Figure 19-5). If the belt is too loose, it may slide up under the rib cage and cause injury. Regular belts on trou- sers or dresses should only be used as a last resort, because they are usually narrower and may not fasten as securely as a proper gait belt. Holding the arm of the older adult to provide support should","314\t UNIT IV\u2003 Physical Care of Older Adults FIGURE 19-5\u2003 Assist with ambulation by walking at the person\u2019s FIGURE 19-6\u2003 Healthy aging. (\u00a9 2010 Photos.com, a division of side. Use a gait belt for the person\u2019s safety. (From Kostelnick C: Getty Images. All rights reserved.) Mosby\u2019s textbook for long-term care nursing assistants, ed 7, 2015, St. Louis: Mosby.) incidence of obesity. Activity also has psychologic benefits, including a decreased incidence of depres- Box 19-2\u2003 Benefits of Exercise for Older Adults sion, improved mood, and an enhanced sense of well-being. \u2022\t Maintain independence 2.\t Assess the home for safety hazards or conditions \u2022\t Retain mobility that may interfere with mobility. The home may \u2022\t Prevent or reduce depression present conditions that interfere with mobility or \u2022\t Encourage sleep increase the risk for falls. Modifications of the \u2022\t Improve self-esteem environment may be required to prevent accidents \u2022\t Improve appetite or injury. Chapter 9 addresses assessment of home \u2022\t Improve cardiovascular status safety in detail. \u2022\t Maintain or improve musculoskeletal function 3.\t Help older adults develop a schedule for regular \u2022\t Prevent obesity physical activity that is appropriate for their pre- \u2022\t Decrease stress level scribed activity level. The primary care provider \u2022\t Expand social network should be consulted before an older person who \u2022\t Enhance appreciation for life has a chronic disease or has lived a sedentary life- style starts an exercise program. Once an appropri- be avoided, as it can lead to shoulder dislocation ate target level is established, teach the older adult in a fall. to start slowly and build up to the optimal level The following interventions should take place in the over time. Encourage active older adults to partici- home: pate in regular physical activity. Incorporate exer- 1.\t Teach or reinforce the benefits of regular activity cise into the daily activity plan. If exercise is not and exercise. Remind and encourage older adults viewed as important enough to plan for, it will not about the benefits of exercise (Box 19-2). Important be done. Older adults who do not have limiting information to communicate to older adults in- health conditions should participate in 150 minutes cludes the fact that moderate or higher levels of of aerobic physical activity each week plus muscle- physical activity are associated with lower mortal- strengthening activities that work every major ity rates. Physical activity has been associated with muscle group, twice a week (Centers for Disease many beneficial physiologic effects, including Control and Prevention, 2014). The physical activity improved cardiovascular status, decreased risk for can be broken down into small, even 10 minute, colon cancer, beneficial effects on Type 2 diabetes, sessions. Midmorning is a good time for exercise, maintenance of normal muscle strength and joint but afternoon and early evening are also good function, reduced risk for falling, and decreased times. Much of the timing depends on the individ- ual\u2019s peak energy time. Blood supply may be diverted to digestion for up to 2 hours after large meals; therefore, intense physical activity should not be scheduled immediately after meals. Walking is an excellent exercise for older adults. Swimming and cycling are also recommended (Figure 19-6). Exercise programs, including aerobics classes, are sponsored by many senior citizen centers. Before","Activity and Exercise\u2003 CHAPTER 19\t 315 joining an exercise program, older adults should see Box 19-3\u2003 Risk Factors Related to Activity Intolerance their primary care providers to ensure that the in Older Adults program is appropriate and safe for them. In addi- tion to providing exercise, these programs provide \u2022\t Sedentary lifestyle an opportunity for socialization. Exercising with \u2022\t Decreased sense of self-worth, self-esteem, or others provides motivation and makes the effort more worthwhile and pleasant. independence 4.\t Explain the importance of warm-up and cool- \u2022\t Generalized weakness, immobility, restriction to bed down exercise. Before starting an exercise session, the individual should warm up for approximately rest 5 minutes. Simple exercises that make the joints \u2022\t Problems related to oxygenation limber and slowly stretch the muscles are recom- \u2022\t Cognitive impairment (Alzheimer disease or dementia) mended. Older adults better tolerate exercises that \u2022\t Malnourishment do not put undue stress on bones and joints. Explain to older adults the importance of a cool-down ASSESSMENT\/DATA COLLECTION period after exercise. Five minutes of slower activi- ties (similar to the warm-up) help blood return from \u2002 the muscles to the central circulation. If someone stops exercise abruptly, they may experience faint- \u2022\t Does the older adult complain of shortness of breath, ing (syncope) because of inadequate blood flow to fatigue, or weakness? brain tissue. 5.\t Explain the importance of proper dress for envi- \u2022\t How much exertion can the older adult tolerate ronmental conditions and proper footwear for before shortness of breath or fatigue is noticed? safety. Consider environmental conditions, includ- ing heat, cold, high humidity, and air pollution, \u2022\t Has participation in normal or routine activities when planning activity. Older persons should try to decreased? minimize exercise on excessively hot or cold days. On very hot days, activity is best planned for early \u2022\t Does the older adult complain of decreased interest in the day or later in the evening when the tempera- in activities? ture is cooler. Some large cities experience ozone alerts because of excessive air pollution. On ozone \u2022\t What are the vital signs? Do they remain within alert days, it is wise for all individuals, particularly normal limits with activity? older adults, to minimize their activity. On warm days, lightweight, loose clothing should be worn to \u2022\t Does the older adult experience orthostatic allow the body to cool through evaporation. On hypotension? extremely cold days, it is wise for older adults to exercise indoors. Cold weather can be extremely \u2022\t Is the older adult\u2019s nutritional intake adequate? stressful for individuals with cardiac or respiratory See Box 19-3 for a list of risk factors for activity intoler- conditions. If older adults must go outside in cold ance in older adults. weather, clothing should be layered to trap heat. A mask or scarf worn over the face and mouth helps NURSING DIAGNOSIS warm the air before it enters the respiratory tract. 6.\t Review signs and symptoms that necessitate con- \u2002 tacting the primary care provider. Older adults should be aware that any new or unusual pain, Activity intolerance weakness, or other untoward symptoms that are experienced during activity should be reported NURSING GOALS\/OUTCOMES IDENTIFICATION promptly to the care provider. 7.\t Use any appropriate interventions that are used in \u2002 the institutional setting (Nursing Care Plan 19-1). The nursing goals for older adults with activity intoler- NURSING PROCESS FOR ACTIVITY INTOLERANCE ance are to (1) demonstrate an increased ability to tol- erate activity and (2) identify factors that contribute to \u2002 activity intolerance. Activity intolerance is a state in which the aging indi- NURSING INTERVENTIONS\/IMPLEMENTATION vidual has insufficient physiologic or psychological The following nursing interventions should take place energy to accomplish necessary or desired daily activi- in hospitals or extended-care facilities: ties. Activity intolerance is a common problem for 1.\t Identify factors that contribute to activity intoler- older adults who live a sedentary lifestyle. ance. People stop participating in physical activity for a variety of reasons. Plan nursing interventions specific to the reason why the participation stopped. For example, an older person who stops participat- ing in activities because of depression after the death of a spouse has a very different problem from that of the person who has activity intolerance because of cardiac problems. Some older adults have no real reason for declining activity level other than a belief that it is expected and accepted with old age. As they age, older adults become increas- ingly sedentary and consequently lose functional abilities. Determine the specific concerns and prob- lems experienced by the individual so that an effec- tive plan of care can be developed.","316\t UNIT IV\u2003 Physical Care of Older Adults \u2002 Nursing Care Plan 19-1\u2003 Impaired Physical Mobility Mrs. King is a 73-year-old woman who lives at Poplar Bluff Long-Term Care Facility. She was diagnosed three years ago with Parkinson disease. She has bilateral tremors in both arms. She is able to walk but does so very slowly with a rigid, flexed posture. Her coordination and balance are poor. She has experienced occasional falls when ambulating in the hall. She states, \u201cI get tired so easily. My bones and muscles ache all of the time, and recently I\u2019ve noticed that my fingers and toes tingle.\u201d The care provider has ordered physical therapy three times a week to maintain her strength and flexibility. Mrs. King participated in pottery activities until recently. She states that these activities are \u201cjust too hard for me now.\u201d NURSING DIAGNOSIS Impaired Physical Mobility DEFINING CHARACTERISTICS \u2022\t Impaired coordination and balance \u2022\t Muscle rigidity \u2022\t Altered posture \u2022\t Slowed movements \u2022\t Tremors PATIENT GOALS\/OUTCOMES IDENTIFICATION Mrs. King will participate in mobility activities and exercises and maintain mobility at the highest level possible. NURSING INTERVENTIONS\/IMPLEMENTATION 1.\t Provide passive range-of-motion exercises twice daily. 2.\t Encourage Mrs. King to perform active range-of-motion exercises whenever possible. 3.\t Encourage participation in activities of daily living. 4.\t Consult with occupational therapy regarding assistive devices for feeding and dressing. 5.\t Discuss the exercise program with the physical therapist so that exercises can be incorporated into the daily routine on the nursing unit. 6.\t Have Mrs. King ambulate with the help of an assistant using a gait belt. 7.\t Provide massage for tight muscles. 8.\t Schedule daily or every-other-day tub baths for muscle relaxation. 9.\t Provide adequate periods of rest on a scheduled basis. 10.\t Encourage continued participation in activities such as music therapy or other relaxing pastimes. 11.\t Provide positive encouragement for successes. EVALUATION Slight tremors are still noted in both arms, and Mrs. King moves slowly but with slightly less rigidity than noted previously. No falls have been reported in the past two weeks. She states, \u201cI feel stronger since I\u2019ve been getting the therapy and doing exercises. I even helped get myself dressed today.\u201d You will continue the current plan of care. CRITICAL THINKING QUESTIONS 1.\t What other activities that are appropriate for Mrs. King can you identify? 2.\t What modifications in the plan of care are likely to be necessary as the disease process progresses? 2.\t Identify the activities that older adults view as older adults are able to resume near-normal levels essential or desirable. The activities that nurses of activity; others always experience some amount think are important are often different from those of activity intolerance. that older adults value. Consult with and include 4.\t Encourage older adults to pace activities through- older adults in the planning and structuring of out the day, alternating periods of activity with activities. It is easier to motivate people to work periods of rest. Attempting to do too much in too toward goals or activities they consider important. short a period of time is a common cause of activ- ity intolerance in older adults. Older adults often 3.\t Plan activities so older adults can progress from benefit from a planned approach to activity that easier activities to those that are more demanding. includes periods of activity and periods of rest. By Activities should build from the least strenuous to pacing activities, the individual usually finds that most strenuous. Those unable to tolerate low levels he or she can accomplish more and feel better. of activity must progress slowly, because rapid pro- 5.\t Monitor vital signs to assess the physiologic gression leads to exhaustion, a feeling of failure, response to activity. Vital signs are good indicators loss of motivation, and possible injury. Once mild of the older person\u2019s tolerance of activity. Individuals activities are tolerated, then activities that are more who have been immobile or sedentary may experi- physically demanding can be attempted. The pace ence significant changes in vital signs with increased at which activities are introduced depends on the activity. Tachycardia is a common occurrence when specific needs and abilities of the individual. Some","Activity and Exercise\u2003 CHAPTER 19\t 317 an activity program is started. An elevated pulse in under conditions of emotional or physical stress, they an older adult takes longer to return to its normal may not be able to supply the physiologic needs of rate than in a younger person. Changes in blood the body. pressure, particularly orthostatic hypotension, may ASSESSMENT\/DATA COLLECTION pose safety risks to older adults. Those who are sedentary or have been on bed rest often experience \u2002 dizziness or lightheadedness when changing posi- tion, which may result in falls. Changing position \u2022\t Does the person experience excessive fatigue? more slowly and waiting after each position change \u2022\t What level of activity causes this fatigue? helps prevent injuries or falls. \u2022\t Does the person have any complaints of nausea, 6.\t Teach methods of conserving energy. Simple modi- fications in activity can help the older adult con- vomiting, or anorexia? serve energy. Putting on clothing while sitting \u2022\t Does the person complain of dyspnea? Is this worse requires less energy than doing so while standing. Dressing in clothing with Velcro grips and zippers at any specific time of day, such as during the night? is less exhausting than dressing in clothing with \u2022\t Does the person complain of chest pain? small buttons or other difficult fasteners. Slip-on \u2022\t What is the heart rate? respiratory rate? shoes require less energy than do laced shoes. \u2022\t Is the breathing silent and effortless? If not, describe. Occupational therapists can provide assistance in \u2022\t Does the chest expand evenly with respiration? modifying the environment so that a maximal \u2022\t Is breathing deep or shallow? amount of activity can be performed with a minimal \u2022\t Does the person adopt a posture that is more com- amount of exertion. 7.\t Teach older adults and their families methods of fortable for breathing? reducing stress. Both psychological stress and \u2022\t Is a cough present? Is it productive? Describe the physiologic stress place extra demands on the body and decrease the older person\u2019s activity tolerance. sputum. Methods for reducing stress are discussed in \u2022\t Is there an order for supplemental oxygen? Chapter 13. \u2022\t Does (or did) the person smoke? The following interventions should take place in the \u2022\t Is there a history of exposure to air pollution? home: 1.\t Modify the environment to reduce energy expen- Secondhand smoke? diture and promote safety. All frequently used \u2022\t Are any signs of cyanosis present? Cold, clammy objects should be easily accessible. Remote controls for the television, stereo, or lights are desirable. skin? Diaphoresis? Arrange furniture to provide easy access to resting \u2022\t Are the jugular veins distended? At what angle (30 places. Take care to ensure that the environment is safe. Remove hazards such as throw rugs and other degrees, 45 degrees)? clutter on the floor. \u2022\t Are the peripheral pulses palpable? Are pulses 2.\t Identify family or community resources to assist with energy-intensive activities. The family should equal bilaterally? be encouraged to assist the aging person in energy- \u2022\t What color are the nail beds and fingers? intensive activities such as cleaning, cooking, and \u2022\t What is the capillary refill time? laundry. If this is not possible, service agencies such \u2022\t Is there a normal amount of body hair present over as Meals on Wheels may be available. 3.\t Use any appropriate interventions that are used the feet and lower legs? in the institutional setting (See Nursing Care \u2022\t Does the person experience any leg pain with ambu- Plan 19-1). lation? If so, how severe? Is it relieved by rest? NURSING PROCESS FOR PROBLEMS \u2022\t Does the person complain of cold hands and feet? \u2022\t Are signs of peripheral edema present? \u2002 \u2022\t Is the urinary output low despite normal fluid OF OXYGENATION intake? \u2022\t Has there been a rapid weight gain of more than 10 To survive, body tissues and organs must have an adequate supply of oxygen. The respiratory and car- pounds? Over what period of time? diovascular systems work together to meet the oxygen \u2022\t Has the person shown signs of confusion? needs of the body. If either system functions inade- \u2022\t Does the person complain of anxiety, loss of ability quately, a variety of physiologic changes are observed. to concentrate, or insomnia? In general, the aging heart and lungs are able to \u2022\t Are there any changes in relevant laboratory values meet the demands of a normal activity level. However, (e.g., hemoglobin, hematocrit, cardiac enzymes, and electrolytes)? \u2022\t If an electrocardiogram was done, what were the findings? Are these different from the baseline ECG? \u2022\t If chest radiography was done, are there any signs of heart enlargement or congestion? Box 19-4 lists risk factors related to decreased cardiac output in older adults. NURSING DIAGNOSES \u2002 Decreased cardiac output Impaired gas exchange","318\t UNIT IV\u2003 Physical Care of Older Adults can reveal the presence of pulmonary congestion, which could indicate respiratory tract infection Box 19-4\u2003 Risk Factors Related to Decreased Cardiac or pulmonary edema. Other diagnostic tests Output in Older Adults (e.g., electrocardiography) may reveal pathologic conditions of the heart before other symptoms \u2022\t Arteriosclerotic changes in the blood vessels are obvious. Any abnormal test results should \u2022\t Congestive heart failure be reported immediately to the primary care \u2022\t Myocardial infarction provider. \u2022\t Obstructive pulmonary disease 3.\t Observe respiratory effort, including the use of \u2022\t Increased physiologic or psychological stress, accessory muscles. An individual who has diffi- culty breathing appears to labor when breathing. including anxiety and pain Use of the accessory muscles of the abdomen and \u2022\t Severe anemia shoulders is an indication that the individual is working harder than normal to breathe. Ineffective airway clearance 4.\t Evaluate oxygenation by observing for signs of Ineffective breathing pattern cyanosis and by checking capillary refill time. To meet the life-sustaining needs of the body, blood NURSING GOALS\/OUTCOMES IDENTIFICATION flow to the extremities may be reduced. This results in cold, clammy skin; slow capillary refill time \u2002 (> 3\u202fs); pallor; and cyanosis. These changes are most often observed in the lips and fingertips. The nursing goals for older individuals with oxygen- Delayed capillary refill time indicates that blood ation problems are to (1) maintain an open, patent supply to the extremities is restricted. airway; (2) exhibit an effective respiratory pattern; (3) 5.\t Assess the peripheral pulses, particularly in the experience fewer episodes of dyspnea, angina, and lower extremities. Assessment of peripheral pulses cyanosis; (4) demonstrate an increased activity toler- reveals any areas of the body that are not receiving ance; (5) identify methods to reduce physical and psy- adequate oxygen. The lower extremities are most chological stress; and (6) manifest signs of improved at risk because of the arteriosclerotic changes of cardiac function (e.g., stable vital signs, adequate aging. Inadequate oxygen can result in ischemia urinary output, and adequate tissue perfusion). and necrosis. Mild ischemia can result in hair loss from the lower extremities. Severe ischemia may NURSING INTERVENTIONS\/IMPLEMENTATION result in stasis ulcers and in necrosis of the toes, which may necessitate amputation. \u2002 6.\t Position the person to maximize chest expansion, and encourage frequent changes of position. Age- The following nursing interventions should take place related changes tend to reduce the size of the chest in hospitals or extended-care facilities: cavity. To maximize oxygen exchange, the person 1.\t Assess pulse and respiration before, during, and should be encouraged to stand or sit in a position that is as upright as possible. Bedridden individu- after activity. Vital signs are good indicators of als should change position frequently to prevent activity tolerance. These should be assessed while stasis and pooling of respiratory secretions within the individual participates in various levels of the lungs. activity to determine which specific activities cause 7.\t Clear secretions and teach effective coughing. the greatest problems. Tachycardia may be a sign Older adults may find it difficult to cough effec- of decreased cardiac output, although it is an tively because of loss of muscle strength and tone. expected sign of increased demand during vigor- The inability to remove secretions from the respi- ous physical activity. To compensate for the ratory tract can increase the risk for respiratory decreased volume, the heart beats more rapidly. tract infections. If the older person is very weak Once elevated, it takes longer for the heartbeat of and unable to remove secretions, suction may be older adults to return to a normal resting rate. necessary. When suctioning is done, care should Consistent tachycardia or an excessive delay in be used to avoid excessive stimulation of the return to a normal rate indicates serious cardiac respiratory tract, which increases production of problems. The respiratory rate should increase secretions. with the heart rate because the body is attempting 8.\t Administer medication as ordered to promote to meet oxygen needs. With severe cardiac prob- cardiovascular and respiratory function. Medi\u00ad lems, fluid may back up into the pulmonary circu- cations such as cardiotonics may be ordered to lation, interfere with oxygenation, and further strengthen the pumping ability of the heart. Muco\u00ad stress the heart. lytics, bronchodilators, and expectorants may be 2.\t Monitor laboratory values, radiograph reports, and other diagnostic studies. Laboratory tests, including hematocrit and arterial blood gases, provide information regarding the oxygen- carrying capability of the blood. Results of cardiac enzyme studies (e.g., elevated levels of creatinine phosphokinase and troponin) can indicate cardiac damage from a myocardial infarction. Electrolyte levels should be evaluated, particularly if the person is receiving diuretics. Chest radiographs","Activity and Exercise\u2003 CHAPTER 19\t 319 assessed and reported. Determine the location and FIGURE 19-7\u2003 Nasal cannula. (From Potter PA, Perry AG, Stockert severity of the pain, as well as whether it radiates PA, Hall AM: Essentials for nursing practice, ed 8, 2015, St. Louis: or stays in one area. Ask if the pain occurs during Mosby.) an activity or afterward. Anginal pain originates in the heart and occurs when the heart muscle is ordered to enhance the person\u2019s ability to remove deprived of oxygen because of coronary artery respiratory secretions. Observe all precautions narrowing or increased oxygen demand. This pain regarding these medications, and closely monitor classically starts in the upper left chest and radi- vital signs. ates down the left arm. In some individuals, the 9.\t Administer supplemental oxygen as ordered. pain is referred to the jaw; jaw pain of a cardiac Increasing the amount of available oxygen by origin can exist without the chest pain in some using supplemental oxygen may make breathing people, such as women, people with diabetes, easier. Oxygen should be prescribed by the primary and older adults. Coronary vasodilators, such as care provider and administered at the prescribed nitroglycerin, are used to improve blood flow and rate. Low doses are normally used because high decrease the pain. Intermittent claudication is a oxygen concentrations can decrease respiratory specific type of pain that is described by some as effort in some people. Supplemental oxygen is cramping, tightness, or aching. This pain is most most commonly administered through a nasal commonly in the foot or calf, but it may extend to cannula (Figure 19-7). When oxygen is being the thigh or buttock. It typically occurs during administered, good care of the nasal passages is activity and disappears with rest. Intermittent essential. Keep the nares free of secretions, and claudication is an indication of inadequate oxygen inspect the skin regularly for breakdown where supply to the tissues of the leg, and the pain is a the plastic tubing presses at the nares and over the result of ischemia. Most care providers recom- ears. Post \u201cNo Smoking\u201d signs when oxygen is mend daily walking for 60 minutes, pausing when in use. pain occurs. Any activity that causes vasoconstric- 10.\t Use incentive spirometers to improve ventila- tion (e.g., smoking) must be stopped. Cold envi- tion. Incentive spirometers are often ordered to ronments should also be avoided because cold improve respiratory effort. Many older people further aggravates the condition. are unfamiliar with these devices and need clear 12.\t Administer sedatives and painkillers with explanations regarding their use. An older adult caution. Many sedatives and analgesics affect the that is confused or cognitively impaired may have rate or depth of respiration. Assess and document difficulty performing the correct action with the respiratory rate and depth before administering incentive spirometer. Some older adults find these these medications to verify that the initial rate is devices unpleasant and may avoid using them. adequate for safety. Assess and document respira- Reinforce the importance of these devices and tions again after administration. encourage the patient to use them at regular 13.\t Maintain a calm, restful environment and provide intervals. emotional support. Stress places additional oxygen 11.\t Assess for the presence, location, and duration of demands on the body. A calm, restful environment pain. Pain that occurs during activity should be decreases the effects of stress. Decreasing the number of interruptions, closing doors, playing soft music, or making other environmental changes may benefit an individual who is experiencing stress. If the stress is severe or if it is made worse by interaction with unpleasant roommates, a private room may be medically indicated. Take time to listen to the concerns of older adults to reduce their stress. 14.\t Explain stress-reduction techniques. Stress can be controlled by means of nonmedical interventions, including meditation, guided imagery, biofeed- back, and relaxation techniques. These techniques are particularly helpful to older adults because they enable the individuals to control their own behavior and lack the side effects of antianxiety medications. 15.\t Promote good fluid and nutritional intake within medical restrictions. Adequate fluid intake keeps respiratory secretions liquefied, making them","320\t UNIT IV\u2003 Physical Care of Older Adults Box 19-5\u2003 Home Oxygen Systems FIGURE 19-8\u2003 Portable oxygen cylinder used during ambulation. LIQUID OXYGEN (From Kostelnick C: Mosby\u2019s textbook for long-term care nursing Portable* unit can be refilled by patient from reservoir. assistants, ed 7, 2015, St. Louis: Mosby.) Portable unit holds 6 to 8 hours of supply at 2\u202fL\/min; res- ervoir will last approximately 7 to 10 days at 2\u202fL\/min con- easier to expectorate. If the older person has con- tinuously. Patients do not use the reservoir continuously gestive heart failure or other disease processes that because of the high expense. Instead patients use the\t lead to fluid retention, it is important to give fluids O2 concentrator because the cost is much lower. Liquid with caution and assess for signs of fluid overload. system is strictly for portable and emergency use. Not Adequate nutrition, particularly adequate iron available everywhere; generally limited to urban areas. intake, is essential for production of adequate hemoglobin, which is necessary for oxygen COMPRESSED O2 CYLINDERS transport. Cylinders or tanks of varying sizes, e.g., D, M, E, H, J dura- The following interventions should take place in the tion varies with tank size and liter flow, e.g., J tank at 2\u202fL\/ home: min flow lasts about 50 hours. Portability possible with cart 1.\t Explain how to use oxygen equipment safely. and some of the smaller tanks may be refilled from large Teach the older adult and the family how to operate cylinders. Smaller tanks weigh about 10 lbs and can be the equipment. If oxygen is required, teach the carried on shoulder strap, backpack, or fanny pack carried family safety precautions related to its use. Teach\u00ad or placed on a portable cart. ing should include the reasons that smoking and open flames are dangerous. All people having CONCENTRATOR OR EXTRACTOR contact with the oxygen should be familiar with the Because the O2 supply is produced from room air, they various modalities of home oxygen (Figure 19-8) never need to be \u201cfilled.\u201d On wheels, movable from room and know the proper precautions to use when to room, but usually kept centrally located in the dwelling handling oxygen tanks and equipment. They with extension tubing reaching to the furthest area. Patients should know how to verify that adequate oxygen is need to be very cautious to prevent falling over the tubing. available and whom to call if any equipment prob- Compact, excellent system for rural or homebound patient. lems arise (Box 19-5). A power outage may present Convenient, safe, and reliable. Patient will need backup O2 a problem to individuals who use an oxygen con- tank in case electricity fails. Concentrator noise may be centrator. The older adult needs to keep a backup bothersome and should be kept in a room other than tank of oxygen for use in such an emergency, as well bedroom. as a portable oxygen concentrator with several charged batteries. It is also wise to notify the power PORTABLE OXYGEN CONCENTRATOR company in advance that the resident needs power These are lighter-weight devices (8.5 to 17 lbs) that are returned quickly. Persons needing oxygen or other portable via carts or shoulder straps that may provide pulsed or continuous O2. Flow of 5 to 6\u202fL\/min depending on the particular device. Batteries provide up to 8 hours of operation with recharging in AC or DC (e.g., car) and are approved by most airlines. This combined with another stationary system in the patient\u2019s dwelling provides the patient with exceptional freedom and mobility as the system continuously provides a renewable source of O2 outside the home. Systems include EverGo, Inogen One, and Eclipse Oxygen Generator. O2 CONSERVING OR PULSED DEVICES Delivers a pulse of O2 only during inhalation to conserve O2. Allows patient increased mobility. Devices are relatively lightweight; varying from approximately 3 to 6 lbs with a supply of oxygen up to 20 hours. System may clip on belt or be contained in a backpack or shoulder bag. Audible pulses may be annoying. Some devices may require\t batteries. Becomes less efficient at higher O2 flow rates. Usually best for low activity levels. Monitor patient\u2019s O2 saturation during rest and exercise to determine if oxygen- ation is acceptable. *Portable usually refers to units weighing more than 10 lbs. (4.5\u202fkg) and ambulatory units weigh less than 10 lbs. From Lewis SL, Dirkson SR, Heitkemper MM, et\u202fal: Medical-surgical nursing, ed 8, 2011, St. Louis: Mosby.","Activity and Exercise\u2003 CHAPTER 19\t 321 medical equipment are usually a priority for power Box 19-6\u2003 Risk Factors Related to Self-Care Deficits companies. in Older Adults 2.\t Explain the signs and symptoms of possible com- plications and the measures to take if these occur. \u2022\t Decreased strength or endurance resulting from Teach older adults and their families the signs and respiratory or cardiovascular changes symptoms of a change in condition that may indi- cate complications. The telephone number of the \u2022\t Altered neuromuscular or musculoskeletal function care provider and emergency services should be related to disease or aging prominently displayed next to the telephone so help can be summoned rapidly if needed. \u2022\t Pain 3.\t Use any appropriate interventions that are used in \u2022\t Cognitive or perceptual problems (Alzheimer disease the institutional setting. or dementia) NURSING PROCESS FOR SELF-CARE DEFICITS \u2022\t Severe anxiety or depression \u2022\t Impaired mobility \u2002 NURSING DIAGNOSES When a person is partially or totally restricted in his or her ability to perform the most basic ADL (i.e., \u2002 bathing, dressing, grooming, eating, and toileting), a self-care deficit is present. With advanced age or the Feeding self-care deficit onset of disease, many individuals experience some Bathing self-care deficit degree of problem with self-care. Problems related to Dressing self-care deficit self-care can be devastating to older adults because of Toileting self-care deficit their effect on self-esteem. People who cannot meet these needs become dependent on others and lose NURSING GOALS\/OUTCOMES IDENTIFICATION much control over the most basic elements of their lives. Older adults who cannot feed themselves must \u2002 eat what they are fed. Those who cannot dress them- selves must wear what another person chooses. Those The nursing goals for older individuals with self-care who cannot bathe or groom themselves are only as deficits are to (1) perform self-care at the highest clean and well groomed as another person allows. possible level within limitations; (2) demonstrate the Those who cannot go to the bathroom alone are likely use of modified techniques and assistive devices to to become incontinent. Nurses must be able to recog- accomplish self-care; (3) verbalize improved self- nize the individual\u2019s specific difficulties and degree of esteem related to self-care abilities; and (4) identify limitation with self-care so that appropriate nursing resources that are available to provide assistance. interventions can be planned. These interventions should be directed toward maintaining the indi\u00ad NURSING INTERVENTIONS\/IMPLEMENTATION vidual\u2019s functioning at the highest possible level. The previously discussed concepts of rehabilitation form \u2002 the basis for working with older individuals with self-care deficits. The following nursing interventions should take place ASSESSMENT\/DATA COLLECTION in hospitals or extended-care facilities: 1.\t Assess the individual to determine the factors that \u2002 cause or contribute to the deficit, such as age- \u2022\t Can the person feed himself or herself? If not, what related changes, disease processes, medications, level of assistance is required (0-4)? and cognitive or perceptual changes. Each aging 0 = Completely independent individual presents a unique set of problems to 1 = Requires devices or equipment which nurses must respond when planning care. 2 = Requires help, supervision, or teaching from Unless the specific needs of each person are another person identified, the plan of care is meaningless. Some 3 = Requires devices and help from another person individuals are able to regain many skills and 4 = Totally dependent become less dependent; others remain at lower levels of function. A good assessment covers the \u2022\t Can the person toilet himself or herself? If not, what person\u2019s strengths and limitations so that the most level of assistance is required (0\u20134)? appropriate care plan can be developed. 2.\t Include older adults in problem identification and \u2022\t Can the person bathe himself or herself? If not, what care planning. A plan that does not include the level of assistance is required (0\u20134)? individual is likely to fail. Overcoming a self-care deficit requires the person\u2019s total commitment \u2022\t Can the person dress himself or herself? If not, what and cooperation. The only way nurses can hope level of assistance is required (0\u20134)? to ensure this level of commitment is by including the older person in the entire process. If the aging Box 19-6 lists risk factors for self-care deficits in individual is unable to communicate verbally, older adults. nurses should observe nonverbal communication. Many individuals who cannot express their needs verbally will respond to simple directions and posi- tive encouragement.","322\t UNIT IV\u2003 Physical Care of Older Adults either use the riser or be willing and able to remove and replace it when they use the toilet. In some 3.\t Allow adequate time for completion of activities. situations, modification of the environment with With aging, even healthy, active persons require assistive devices may necessitate room changes so more time than younger individuals to accomplish that individuals with common needs are grouped a task. Those experiencing self-care deficits require together. even more time than older adults who are well. The following interventions should take place in Most facilities and nurses are geared toward getting the home: things done as quickly as possible. In many facili- 1.\t Assess the ability of the family or significant ties, older individuals who are perfectly capable of others to provide safe care. Many totally depen- completing self-care activities are not allowed to do dent older adults are being cared for today in so because it takes too long. This practice is in direct the home setting. Nurses may make regular visits, opposition to those of the rehabilitative focus. but much of the responsibility for care falls on Encouraging and allowing older adults to perform spouses or other family members. These care\u00ad self-care does take more time than having the care givers may have little or no training for the tasks provided by the nursing staff. This fact must be involved. Often, the caregiver is older or debili- taken into consideration when staffing and assign- tated. Nurses are responsible for ensuring that ments are made so that adequate time is available. no harm comes from the home care situation. If the If these adjustments are not made, it undermines care needs exceed the ability of the caregivers, any chance of success. nurses may have to contact other family members or social services to ensure the older individual\u2019s 4.\t Develop a plan that moves in stages toward the safety. If the caregiver is capable of providing care, highest possible level of function, and give posi- he or she may need additional teaching related to tive feedback to reinforce positive changes. The providing care. plan to increase self-care ability should be struc- 2.\t Assess the home environment to determine tured in stages so that the individual achieves some safety and the need for modifications such as grip successes. If too much is expected, the individual rails, bath chairs, or toilet risers. Depending on may become frustrated and give up. It is better to the level of self-care deficit, the home may require work toward and build on small successes. For major modification. Individuals with minimal example, if the person has not been doing any self-care deficits may require only a few assistive personal hygiene, successfully washing the face devices to function adequately (Figure 19-12). is a major accomplishment. Success of this nature Those with serious self-care deficits require more should not be ignored but should be reinforced by modifications. a comment such as, \u201cYou did a good job washing 3.\t Identify community resources available to help your face.\u201d Use a simple checklist to enable the obtain the necessary equipment. Special assistive person to see that he or she is making progress. devices can be costly and may require special skill Reinforcing the positives and minimizing the nega- for installation. Many communities have agencies tives is the best way to achieve the desired goals and or volunteer groups that help provide the necessary increase motivation. assistance. 4.\t Inform the families or significant others of the 5.\t Consult with occupational and physical therapists necessity to allow older adults to do as much as to identify alternative methods and equipment possible for themselves. Family members often are that would most benefit the individual. Occu\u00ad too helpful and do not expect the older individual pational and physical therapists are specialists in to do anything for himself or herself, which can lead rehabilitation. They have extensive knowledge of to a loss of functional ability. Teach the family the the techniques and equipment available to improve importance of allowing and encouraging the aging self-care ability. Modification of an activity (such as individual to do as much as possible. Stress that this sitting instead of standing) may enable an individ- is the best thing caregivers can do for their loved ual to perform self-care activities (Figure 19-9). ones and that they are not being thoughtless or Modified clothing or eating utensils may mean neglectful. the difference between complete dependence and 5.\t Discuss respite care and other options with care- independence. givers. Anyone who provides long-term care in the home places himself or herself at risk for both phys- 6.\t Modify the environment with assistive devices ical injury and psychological distress. Home care is designed to meet the specific needs of the indi- often exhausting for the caregivers. Discuss the pos- vidual. Once the need for special assistive devices sibility of some form of respite care so that care\u00ad is identified, make certain these devices are avail- givers are able to maintain their own health and able (Figures 19-10 and 19-11). Identifying the need mental well-being. for a toilet riser, grip rail, or special spoon does no good if the item is not available. The staff may have to wash special eating utensils so that they are not lost. Residents sharing a bathroom may have to adjust to the presence of a toilet riser. They must","Activity and Exercise\u2003 CHAPTER 19\t 323 A C D BE FIGURE 19-9\u2003 A, A button hook is used to button and zip clothing. B, A sock assist is used to pull on socks and stockings. C, \u201cReachers\u201d are helpful to remove items from high shelves. D, A shoe remover is used to take off shoes. E, A door knob turner increases leverage to help turn the knob. (A\u2013C, E, Courtesy Northcoast Medical Inc., Morgan Hill, Calif. D, Courtesy AbilityOne Corporation, Germantown, Wisc.) 6.\t Assist the family with arrangements for hospital- NURSING PROCESS FOR DEFICIENT ization or extended-care placement. When the aging individual becomes completely dependent, \u2002 the spouse or family may have to consider alterna- tive methods of providing care. This is a very dif- DIVERSIONAL ACTIVITY ficult topic, both financially and emotionally. Nurses may be able to provide some guidance or may be Diversional activities play an important role in the lives able to contact other social service agencies that can of older adults. Diversional activities can help fill time help the family through this difficult process. and provide creative outlets, particularly when they are meaningful to the older person. 7.\t Use any appropriate interventions that are used in the institutional setting. (See Nursing Care ASSESSMENT\/DATA COLLECTION Plan 19-1). \u2002 \u2022\t What activities does the person enjoy? \u2022\t How often does the person participate in these activities? \u2022\t Does the person prefer solitary or social activities?","324\t UNIT IV\u2003 Physical Care of Older Adults A BC FIGURE 19-10\u2003 A, Long-handled combs and brushes for hair care. B, Long-handled brushes for bathing. C, Brush with a curved handle. (A\u2013B, Courtesy Northcoast Medical Inc, Morgan Hill, Calif. 19-10, C, Courtesy Sammons Preston: An AbilityOne Company, Bollingbrook, Ill.) FIGURE 19-11\u2003 Eating device attached to a splint. (From Kostelnick FIGURE 19-12\u2003 Bathtub with grab bars. (From Sorrentino SA, C: Mosby\u2019s textbook for long-term care nursing assistants, ed 7, Gorek B: Mosby\u2019s textbook for long-term care assistants, ed 4, 2015, St. Louis: Mosby.) 2003, St. Louis: Mosby.)","Activity and Exercise\u2003 CHAPTER 19\t 325 Box 19-7\u2003 Risk Factors Related to Deficient time seem to pass slowly and may lead to depres- Diversional Activities in Older Adults sion and social isolation. 2.\t Include the individual in selecting and planning \u2022\t Restricted mobility diversional activities. Older adults should have \u2022\t An environment with limited activities the right to choose the activities they find most \u2022\t Anxiety, depression, or grief meaningful. Purposeful activity is good for main- \u2022\t Limited financial or transportation resources taining self-esteem; busywork is not. Older adults \u2022\t Cognitive or perceptual problems who reside in extended-care facilities because of illness or infirmity may have fewer opportunities \u2022\t How much time does the person spend alone? With and diversions available. Nurses can help these others? individuals maintain active interests by exploring those activities that were enjoyed at an earlier age. \u2022\t Does the person interact with other individuals? The nurse\u2019s interest and a little creativity can go a Who? How often? long way toward meeting the social and diver- sional needs of older adults. \u2022\t Can the usual hobbies\/activities be undertaken in 3.\t Provide suitable reading materials such as large- the present setting? print books or audiobooks. Many older persons enjoy books but are not able to read because of \u2022\t Can the person financially afford to participate in visual changes. Books with large print may be the activities he or she enjoys? usable and are available through most libraries. If visual impairments are severe, audiobooks on \u2022\t Is the person able to get to the desired activities? Is tapes or CDs are also available. transportation required? 4.\t Focus on what the individual can do rather than on what he or she cannot do. Successes, even \u2022\t Do sensory or cognitive changes interfere with small ones, are likely to lead to more successes. It interests? is often depressing to older adults to focus on activities that they can no longer do. Directing \u2022\t Do physical changes interfere with interests? attention to accomplishments helps the person \u2022\t Is the person napping because of boredom? If so, maintain a more positive attitude. 5.\t Suggest activities that are occurring in the facil- how often? ity, such as music or discussion groups, occupa- \u2022\t What is the person\u2019s psychological state of mind tional therapy, activity therapy, or religious activities. Many older adults are not able to leave (e.g., depressed)? the care setting to participate in certain activities. Box 19-7 lists risk factors for deficient diversional Physical or economic changes may interfere with activity in older adults. normal diversional activities. Hospitalization or change of living accommodations can lead to a NURSING DIAGNOSIS variety of restrictions and inconveniences. Nurses can help individuals maintain social contacts and \u2002 interests by exploring other activities. Occupational and activ\u00ad ity therapists may suggest activities and Deficient diversional activity provide assistance in learning new skills. Activity and occupational therapy are provided in most NURSING GOALS\/OUTCOMES IDENTIFICATION residential care settings. Therapists can help indi- viduals learn new activities or ways to modify \u2002 existing interests. For example, if physical changes make knitting too difficult, lap weaving may be The nursing goals for older individuals with deficient possible. Music therapy provides another form of diversional activity are to (1) identify activities that diversion and allows individuals to express their might be of interest; (2) express interest in participat- feelings nonverbally. Music is often combined with ing in diversional activities; (3) participate in selected exercise because rhythm seems to enhance activity. diversional activities; and (4) demonstrate socially Inter\u00adestingly, people unable to speak because of a acceptable behaviors while participating in activities. stroke can sometimes sing beautifully because of the different parts of the brain involved. This NURSING INTERVENTIONS\/IMPLEMENTATION author once developed a routine of singing with a stroke patient during morning care. The smile on \u2002 the resident\u2019s face once he realized he could sing words was priceless! The following nursing interventions should take place in hospitals and extended-care facilities: 1.\t Assess current and past hobbies, activities, and interests. The best way to prepare for a good old age is to have as many interests as possible when young. Young adults are so busy raising families and working that they often neglect to develop and nurture hobbies or interests outside of family and work. Individuals who have developed a wide range of interests seem to adjust to aging better than older adults with few interests. After their families have grown and they have retired from work, many men and women finally get the oppor- tunity to participate in favorite hobbies and activi- ties. Some older adults have a steady stream of activities that keep their days full. Others complain of boredom. Lack of interests and diversions makes","326\t UNIT IV\u2003 Physical Care of Older Adults FIGURE 19-13\u2003 Residents enjoying a game of cards. (From Kostelnick FIGURE 19-14\u2003 Pets can be a great comfort to older adults. C: Mosby\u2019s textbook for long-term care nursing assistants, ed 7, (From Kostelnick C: Mosby\u2019s textbook for long-term care nursing 2015, St. Louis: Mosby.) assistants, ed 7, 2015, St. Louis: Mosby.) 6.\t Work with the activities department to plan new to work with older adults is a very rewarding or different activities based on patient input. activity. The resulting intergenerational mix can be Many facilities tend to fall into habits or patterns a learning experience for both old and young. of repeating the same activities. Many older adults 11.\t Display the results of residents\u2019 activities in a are very creative and should have input into deci- prominent place and give recognition to all par- sion making. Some facilities are progressive and ticipants. Displaying what residents have created offer a variety of activities; others do not. Nurses (e.g., craft work, creative writing, and other play a more important role in extended-care facili- achievements) recognizes their positive accom- ties and home care than they do in acute care plishments and enables the staff and visitors to settings. realize that creativity and productivity do not end with old age. 7.\t Encourage social interaction among residents 12.\t Explore the possibility of new activities such as with similar interests. People of all ages find pet therapy to stimulate interest of withdrawn shared activities enjoyable. Those who share individuals. Pet therapy is becoming increasingly common interests are more likely to want to spend common. The benefits of association with animals time together (Figure 19-13). have been documented in many studies. Older individuals who have pets are healthier and able 8.\t Spend time with individuals to demonstrate to live longer than do those without pets. interest in their personal interests. We all need to Institutionalized individuals, even those who have know that we are special. Even a few minutes isolated themselves from most human contact, spent with an older person will help nurses know seem to respond to the unquestioning affection that person better and will elicit responses that are given by animals. Some residential care centers more personal. Commenting on older adults\u2019 latest have pets that live in the home (Figure 19-14). craft projects or asking how they are enjoying a 13.\t Ensure that physical needs are met before and television show demonstrates interest and caring. during diversional activities. Make sure assis- tance is available for toileting, snacks, and trans- 9.\t Change the physical environment to increase fers. Many older adults with physical deficits are stimulation and interest (e.g., use of bulletin reluctant to leave their rooms or care units because boards of currently scheduled activities, seasonal of fear. Many are afraid that they will not get to a themes, and flyers about topics of interest). Lack bathroom in time and will embarrass themselves. of stimulation can lead to loss of interest and dis- Others are afraid that no one will be available to engagement from others. Any device that helps help them move from place to place or meet other maintain interest and contact with the rest of physical challenges. Make certain there is adequate society will help the aging person remain alert and help to meet physical care needs before and during interested. activities. Provide older adults the opportunity to use the toilet before leaving the care unit and 10.\t Enlist the help of volunteers to read, play games, at regular intervals during the activities. Even or just talk with residents. There is not enough diversional activities require increased energy time for nursing staff to meet the needs of all the expenditure, so make snacks available that are in patients in an institution. Many groups such as keeping with the prescribed diets. Scouts, social clubs, and school groups are inter- ested in providing community service. Volunteering","Activity and Exercise\u2003 CHAPTER 19\t 327 The following interventions should take place in REHABILITATION the home: 1.\t Provide information regarding community re- Our attitudes affect our expectations, and our expecta- tions affect our plans. If caregivers do not expect much sources for older adults, including senior citizen from older adults, they will not get much; if caregivers centers, libraries, museums, and volunteer activi- keep their expectations high, much is possible. ties. Many senior citizen centers offer a variety of craft programs, including painting, weaving, The attitudes held by nurses regarding aging and woodworking, and pottery. Participation in these older adults have a significant impact on their plan- activities may provide exposure to crafts that the ning of nursing care. Attitudes about the value of older individual never had the opportunity to try before. persons and about their potential for leading active, Some individuals find real talents that they never meaningful lives influence the priorities, goals, and suspected they had. Travelogs, movies, or speakers interventions selected during the planning process. on topics of current interest help older adults main- Attitudes also influence the extent to which nurses tain interest in world events. Activity centers can include and involve older adults in the planning provide an opportunity for social interaction and a process. chance to meet new friends, reducing the sense of isolation. Some senior citizen centers also offer Low expectations for older adults lead to a low- classes in subjects such as foreign languages, his- level, or custodial, focus in care planning. High tory, and computer skills. Some colleges have Older expectations of older adults lead to a high-level, or Adult Programs that offer free, noncredit courses to rehabilitative, focus. senior citizens as long as they are not already full. NEGATIVE ATTITUDES: THE CONTROLLING The senior citizen benefits from the stimulation of OR CUSTODIAL FOCUS the course, and the younger students benefit from Nurses who take a negative view of aging see aging the different perspective of the older individual. as a process of deterioration and loss. With this nega- Road Scholar (Elder Hostel) is a program through tive perspective, older adults are viewed as helpless, which older adults can travel around the world by passive, dependent, and incapable of making deci- staying in hostels and expanding their knowledge. sions regarding their own care. Nurses who have these There are many volunteer opportunities for older negative attitudes generally see little potential for adults, including being a foster grandparent, work- improvement in older adults. Although this may be ing as a docent\/tour guide, volunteering in one\u2019s true for a small percentage of older adults, it is not former profession, or helping with literacy pro- the norm. grams, humane society, and disaster relief. 2.\t Identify community resources that provide trans- If nurses have predetermined that older adults are portation to desired activities. Lack of transporta- incapable of making their wishes known or that they tion is a common cause for social isolation and are not interested in what happens, then the nurses failure to participate in activities. Many communi- will not consider older adults\u2019 input important or nec- ties have special programs that provide buses or essary for care planning. Preferences or desires often vans to transport older adults to shopping centers go unnoticed merely because the nurse chose not to or activities for a nominal fee. Research these ser- listen to verbal or nonverbal communication. vices and assist the older adult with making contact if they are hesitant to call for help. Once you guide Once nurses predict or anticipate little potential someone the first time, it will be easier for them to for improvement, their expectations are kept low. With use the service for future occasions. a negative attitude toward aging and older adults, 3.\t Encourage participation in new and meaningful priority is given to slowing the process of physical activities and interests. Many older adults need deterioration. Maintenance of function is supported, encouragement to explore new interests and seek but no improvement or higher level of functioning is new possible diversional activities. Many are inter- expected or encouraged. Little, if any, attempt is made ested in participating in new activities but are afraid to reverse or undo any functional losses. Goals are to try because of their age. They often fear that limited to maintaining the existing level of function, or others will not accept them or will laugh at their the status quo. inexperience. Provide information that familiarizes the person with the activity beforehand. Knowledge With maintenance as the goal, the care plan is often about the activity can reduce fear of the unknown. limited to physiologic and safety concerns. In general, Exploration of past successes in facing new or dif- interventions address the lowest level of needs, accord- ferent challenges may provide the necessary encour- ing to Maslow. Older adults are kept clean, groomed, agement to try something new. clothed, and fed. Basic elimination needs are met. 4.\t Use any appropriate interventions that are used in Accommodations are clean and reasonably comfort- the institutional setting. able. Medications are administered, and treatments are performed. However, higher-level needs such as security, love, and a sense of belonging are minimized or ignored.","328\t UNIT IV\u2003 Physical Care of Older Adults \u201con behalf of the families of your soldiers\u2026thank you for putting yourself in danger to keep their sons safe. They Nurses then control all aspects of the planning have no idea what it cost you when you couldn\u2019t.\u201d To process and take total responsibility for determining Diana\u2019s astonishment, he clearly and quietly replied, what is best for the older person. The care plan requires \u201cthank you.\u201d The following week, Diana dropped off a the nurse to be active and the older adult to be passive. book about the war Col. H. had served in; he later returned By its very nature, this type of care plan promotes it to her without saying anything. When she placed it in helplessness, loss of function, and dependence. Little her bookshelf, however, the flap of the dust jacket was is expected; even less is achieved. A few older adults positioned halfway through the book; not how she had are severely impaired and have experienced a pro- left it. Had he placed it there intentionally? The following found loss of mental and physical capabilities because week, she brought a different book written by a soldier of aging and disease. Some are so severely affected that who had made several mistakes during his time in the they are truly unable to communicate their wishes or war. When Col. H. returned it to Diana at the end of the do anything for themselves. However, it is amazing day, he said, \u201cThey promoted him too quickly and he never how much even severely impaired persons can and learned from his mistakes.\u201d This man, previously \u201cwritten will communicate about their care, often nonverbally, off\u201d by careg\u00ad ivers, could read, think, understand, critique, if nurses pay attention. and speak quite clearly, and had evaluated the young soldier through the eyes of a commanding officer. If functional losses are so severe that the person is unaware of reality or is absolutely unable to function, Why did the nurses underestimate Col. H.\u2019s cognitive then and only then should all needs be anticipated and abilities? Is it possible that when we expect very little provided by nurses or other caregivers. However, this from someone, they deliver very little? Was Diana\u2019s determination should not be made quickly. Many \u201cbreakthrough\u201d because of the fact that she spoke to seemingly hopeless and helpless older adults have him with the assumption that he could understand more ability and potential than we give them credit for. everything and others did not? Nurses with a positive Often, the potential remains hidden because we do not attitude toward aging recognize that most older adults expect to find it. want to retain control of their lives. A rehabilitative care focus addresses both the actual and potential Negative attitudes that older adults themselves problems older adults are likely to experience. A reha- have may lead to declining function. They may feel bilitative focus does not wait until problems occur. It helpless, hopeless, or afraid to try. If nurses reinforce is a proactive approach to nursing care planning that these negative feelings, nothing positive will occur. deals with the prevention of problems, not just reac- Older adults who have potential for improvement but tions to them. Always speak to someone as if they fully are given only custodial care are likely to lose hope. understand you, even if you believe they may not. Loss of the will to fight and of the ability to strive for something better is the most destructive attitude. All older adults benefit from a rehabilitative focus in care planning. To plan care with a rehabilitative POSITIVE ATTITUDES: focus, nurses must (1) acknowledge that older adults THE REHABILITATIVE FOCUS have intrinsic worth greater than their limitations; (2) accept that older adults have the right to make When nurses have a positive attitude toward aging informed decisions regarding their care; (3) recognize and believe that older adults are able and willing to that loss of function or disability has a serious impact participate in their care, the outcome is very different. on older adults, their families, and significant others; These nurses recognize that, as older adults experience and (4) recognize that older adults, their families, and the normal physiologic changes of aging or the impact significant others are important members of the health of disease, they are more likely to require nursing care. team and should play a role in decision making. This care may be given in the home, in the hospital, or in an extended-care facility. Nurses who have a posi- The long-term goal of rehabilitative nursing care is tive attitude toward aging recognize that older adults to help older adults achieve and maintain maximal often have a great deal of unused and unrecognized physical, psychosocial, and spiritual health. When potential. Consider the following anecdote: planning care with a focus on rehabilitation, nurses must (1) attempt to prevent complications of physical Diana and the Colonel disability, restore optimal functioning, and help the Diana, a nursing instructor at a long-term care facility, individual adjust to alterations in lifestyle; (2) attempt to minimize the impact of physical changes or disease was checking on her students\u2019 assignments when she met processes that interrupt or alter functioning and life a resident who had had several strokes. His chart read \u201c\u2026 satisfaction; (3) focus on maintaining the highest dementia; cannot speak or understand.\u201d Diana began achievable level of independent function; (4) provide reading the greeting cards above the resident\u2019s bed. He for comfort needs and adjustments in lifestyle that had been a highly decorated colonel in the military. There are conducive to health; (5) support the ability of were letters from soldiers formerly under his command, older adults to adapt to change; (6) help older adults and cards from world dignitaries. When the resident noticed Diana reading his memorabilia, he stared at her. Diana decided to assume he could understand and chose to speak to the man he had been before the strokes, saying,","Activity and Exercise\u2003 CHAPTER 19\t 329 reestablish and maintain control over their lives; therapists, dentists, podiatrists, chaplains, and social and (7) work to reduce the impact of societal factors workers. For older individuals residing in their own that restrict the older adult\u2019s ability to maintain homes, consider the environmental impact of the sur- independence. roundings and the community services available. Under these guiding principles, nurses work with All of these specialists, along with the older adult older adults and establish priorities based not on the and his or her family, should have input into the devel- nurse\u2019s values, but on the older adult\u2019s values. It is opment of the care plan. When a formal meeting is vital for nurses in acute care settings to not neglect the held in a hospital or extended-care facility, it is com- rehabilitative focus while focusing on more urgent monly referred to as a staffing. Schedule regular reviews medical problems. If the older adult is discharged from of the care plan to determine if modifications are nec- acute care in a less independent state than he or she essary. Information should be shared by all concerned was admitted, unless it is directly related to the reason parties and communicated clearly. Clearly document for hospitalization (e.g., hip fracture), a disservice has interventions in enough detail so all parties are aware been done to that older adult. Establish goals that are of their roles. Remind older adults of their right to challenging yet realistic with the older adult. Select change or modify the plan of care. and communicate nursing interventions most likely to help these persons achieve their goals in the plan A rehabilitation focus is not limited to the care pro- of care. vided in institutional settings. Rehabilitation is also directed toward improving or maintaining the capabil- When planning care with a rehabilitative focus, look ity of disabled older adults to function in society. Like beyond the nursing interventions and act as coordina- other healthy, capable adults, nurses are often unaware tor for all of the various disciplines that enable the of environmental barriers that prevent the disabled older adult to achieve the highest level of physical, from accessing goods and services. Box 19-8 provides mental, psychosocial, and spiritual functioning. Seek a good way of assessing the world through the eyes of input from a wide range of specialists, including a disabled person. Nurses who believe that older physicians, pharmacists, dietitians, physical therapists, adults have the desire and ability to maintain high- occupational therapists, speech therapists, activity level function at home and in the community must Box 19-8\u2003 Accessibility of Public Places \u2022\t Are reception areas well-marked and lit with desk space available at a suitable height for wheelchair users? The term accessible means that public transportation and public places (as well as objects therein) are approachable \u2022\t Are steps leading to the restrooms? Are restroom \t and usable by someone with a physical disability. The list of doors at least 32 inches wide? Do they swing outward questions below can be used as a guideline to help deter- with 32 inches of clearance? Is there a wider stall \t mine accessibility. (56 inches wide \u00d7 60 inches deep)? Are grab bars \u2022\t Does public transportation allow entry and appropriate installed? space for people who use wheelchairs? \u2022\t Are walkways and hallways at least 36 inches wide and \u2022\t Do streets have crosswalk signals for people with \t free of obstacles? vision loss? \u2022\t Do directional signs and menus use large print and\/or \u2022\t Does the facility have access to someone who can use Braille? sign language? \u2022\t Are any ramped or steep areas sloped 1\u2009:\u200910 to 1\u2009:\u200912 \u2022\t Are there parking spaces reserved for the disabled? If with handrails on either side? so, are these parking spaces clearly marked? Are they \u2022\t Are drinking fountains no higher than 48 inches from the near the entrance? floor? If not, are drinking cups provided? \u2022\t Is there an unobstructed path from the parking area to the curb cut to the front door? \u2022\t Do elevator doors open at least 32 inches wide? \t \u2022\t If the front door is not at ground level, are there What are the internal dimensions of the elevator? Are alternative entrances (e.g., ramp, side door at ground elevator buttons set lower? Are there Braille elevator level)? Alternate methods of entry (e.g., restaurant buttons? personnel willing and able to assist)? Are doorways to public areas at least 32 inches wide? \u2022\t Are public telephones set no higher than 48 inches from \u2022\t Is the doorway threshold no higher than half an inch? the ground? Do they have sound amplifiers? \u2022\t How many doors are at the entrance? The restroom entrance? If there are consecutive sets of doors, how \u2022\t Are there clear routes to emergency exits? much space is between them? \u2022\t Are alarm and alert systems both audible and visible? \u2022\t Are entrance doors easily opened (automated, opened \u2022\t Are telephones no higher than 48 inches from the floor with a button or levered handles and a minimum of force)? and equipped with sound amplifiers? \u2022\t Is there a TDD (telephone device for the deaf)? \u2022\t Are guide dogs allowed? Is there an outside area where they can relieve themselves? Data from Centers for Disease Control and Prevention, Disability and Health: Accessibility, 2012. www.cdc.gov\/ncbddd\/disabilityandhealth\/accessibility.html; and Work Group for Community Health and Development at University of Kansas, Tool 3: Accessibility checklist, 2014. http:\/\/ctb.ku.edu\/en\/table-of-contents\/implement\/ access-barriers-opportunities\/increase-access-disabilities\/tools","330\t UNIT IV\u2003 Physical Care of Older Adults incredibly well. We cut the queue and were escorted onto the London Eye in record time. We were immediately become social activists and work to make others aware seated at a popular new restaurant, while others were of the needs of the disabled. Much work is needed to turning back because of the long wait time (felt guilty make the everyday world accessible to them. about that). We toured Buckingham Palace and were directed to have our taxi driver deliver us to a private I have traveled extensively with my 89-year-old mother- entrance; at the end of our tour we were taken to a special in-law, along with her wheelchair and oxygen; I can attest gift shop, with items placed at a lower level where to an enormous range in accessibility throughout the someone in a wheelchair could properly view them! world. We found a shortage of elevators in restaurants in Touring with my mother-in-law certainly made me look France and at an American ski resort we followed the at the accessibility of the world very differently. signage for \u201cwheelchair route\u201d to the outdoor caf\u00e9, only \u2014Patricia Williams to hear the door close and lock behind us, leaving us on an actual ski run! Other cities, such as London, do Get Ready for the NCLEX\u00ae Examination! 3.\t The nurse is caring for an older adult with a history of severe cardiac problems. The goal is to use exercise to Key Points maintain the highest level of function possible. Which directions should be included in the teaching to prevent \u2022\t The ability to perform activity and exercise requires that hypertension or use of the Valsalva maneuver? the musculoskeletal, respiratory, cardiovascular, and 1.\t Breathe through your mouth while exercising. nervous systems work together effectively. 2.\t Start slowly and work up until you feel short of breath. \u2022\t Age- and disease-related changes in these systems 3.\t Limit exercises to range of motion and stretching. contribute to the decreased level of activity common 4.\t Perform isotonic and isometric exercise frequently. with aging. 4.\t A diagnosis of activity intolerance related to \u2022\t Difficulty with activity and exercise can result in lifestyle oxygenation problems was made. Which statement changes for older adults. made by the patient would indicate to the nurse that the patient needs more teaching? \u2022\t Assessment and prompt initiation of appropriate 1.\t \u201cI\u2019ll need to rest if my pulse rate gets too fast.\u201d nursing interventions help older adults achieve and 2.\t \u201cI need to do my activities quickly to get everything maintain the highest level of function possible. done.\u201d 3.\t \u201cI need to work on strategies that reduce my stress.\u201d Additional Learning Resources 4.\t \u201cI\u2019ll use my oxygen so I can breathe easier.\u201d \u2002 Go to your Evolve website at http:\/\/evolve.elsevier 5.\t An older adult residing in a community-based .com\/Williams\/geriatric for the additional online resources. residential facility states, \u201cI just don\u2019t know what to do except sleep. I worked hard all my life; I never had the Review Questions for the NCLEX\u00ae Examination time or money to do lots of things.\u201d Which is the most appropriate nursing intervention? 1.\t Which healthy older adults meet the current 1.\t Schedule the patient to join a museum trip with the recommendations for physical activity? (Select all \t local senior center. that apply.) 2.\t Select books and videos from the library to occupy 1.\t Tom, a former marathon runner, power walks his time. 30 minutes every weekday 3.\t Refer him to occupational therapy for evaluation. 2.\t Marge, a retired nurse, swims 25 minutes every day 4.\t Explore the variety of activities that are now except Sundays, and does strength training with available to him. weights on Tuesdays and Fridays 3.\t Jose lifts weights in his home gym every day, and walks to the grocery store twice a week 4.\t Yi-Lin plays video fitness three times each day, 10 minutes each time, and performs weight lifting three times a week 2.\t Identify five benefits of exercise for older adults. 1.\t ____________________________________________ 2.\t ____________________________________________ 3.\t ____________________________________________ 4.\t ____________________________________________ 5.\t ____________________________________________","Sleep and Rest chapter 20\u2003 Objectives http:\/\/evolve.elsevier.com\/Williams\/geriatric 1.\t Describe normal sleep and rest patterns. 6.\t Choose selected nursing diagnoses related to sleep or 2.\t Describe how sleep and rest patterns change with aging. rest problems. 3.\t Examine the effects of disease processes on sleep. 4.\t Describe methods of assessing changes in sleep and rest 7.\t Describe nursing interventions that are appropriate for older individuals experiencing problems related to patterns. disturbed sleep patterns. 5.\t Identify older adults who are most at risk for experiencing hypnotic\u2002 (h\u012dp-N\u014eT-\u012dk, p. 334) disturbed sleep patterns. insomnia\u2002 (\u012dn-S\u014eM-n\u0113-\u0103, p. 333) nocturnal\u2002 (n\u014f-T\u016cR-n\u0103l, p. 333) Key Terms orthopnea\u2002 (or-TH\u014eP-n\u0113-\u0103, p. 336) phase advance\u2002 (p. 332) apnea\u2002 (\u0102P-n\u0113-\u0103, p. 333) sedative\u2002 (S\u0114D-\u0103-t\u012dv, p. 335) boredom\u2002 (p. 338) circadian\u2002 (s\u012dr-K\u0100-d\u0113-\u0103n, p. 331) cognitive behavioral therapy (CBT)\u2002 (p. 334) diurnal\u2002 (d\u012b-\u016cR-n\u0103l, p. 331) fatigue\u2002 (p. 331) SLEEP-REST HEALTH PATTERN medications, and changes in the circadian rhythm. Nurses must understand normal sleep patterns and be The sleep-rest health pattern describes the patterns of able to identify common age-related changes in sleep sleep, rest, and relaxation that are exhibited through- patterns and common sleep disorders to assess, plan, out the 24-hour day. Individual perceptions, rituals, and intervene appropriately and effectively. and aids used to promote sleep and rest are included in the sleep-rest health pattern. NORMAL SLEEP AND REST Periods of sleep and wakefulness occur in regular and No one knows exactly why we sleep, but we all somewhat predictable cycles. Most humans develop a require sleep to function normally. Sleep apparently pattern that repeats approximately every 24 hours. allows the body time to rejuvenate and to respond to This cycle occurs in response to the day-night cycle of life\u2019s daily stresses. Lack of adequate sleep can affect the sun and is referred to as circadian (from the Latin health and behavior. Studies have connected sleep word meaning \u201cabout a day\u201d) or diurnal (from the deprivation and insomnia to altered appetite; fatigue; Latin word meaning \u201cdaily\u201d) rhythm. Within this decreased ability to perform tasks that require high- cycle, individuals develop their own unique patterns level coordination; increased traffic accidents, home for waking and sleeping. accidents, falls, and irritability; emotional instability; decreased immune response; difficulty with memory The usual times that people go to bed and rise differ and concentration; pain; and impaired judgment. widely among individuals. Some go to sleep at 10 PM and rise at 6 AM; others go to sleep at midnight and Many older people experience problems related rise at 8 AM. These sleep-wake patterns can be dis- to sleep. It is estimated that as many as half of all turbed by shift work, time-zone changes, illness, emo- independent-living older adults and two-thirds of tional stress, medications, and numerous other factors. institutionalized older adults have sleep disturbances. The amount of sleep needed also varies among indi- Sleep-related problems can be troubling to the aging viduals. Some individuals function normally with less individual and are often the basis of visits to the than 6 hours of sleep, whereas others require 9 hours primary care provider and complaints to the nurse. of sleep or more to feel rested. The average amount of Some of these problems result from changes that nor- sleep required for people ages 20 to 60 years is 7.5 mally occur with aging, but they are more likely a hours per day. result of things that accompany aging, such as illnesses, 331","332\t UNIT IV\u2003 Physical Care of Older Adults Box 20-1\u2003 Stages of Sleep Cycle Sleep is under the control of the central nervous STAGE 1: NREM system. Current research indicates that wakefulness is Stage includes lightest level of sleep. regulated by the neurotransmitter norepinephrine. Stage lasts a few minutes. Sleep appears to be controlled by the release of sero- Decreased physiologic activity begins with gradual fall in tonin within the brainstem. Melatonin, which is pro- duced by the pineal gland, is released when the level vital signs and metabolism. of light decreases. Older adults receive, on average, 60 Person is easily aroused by sensory stimuli, such as minutes of bright light each day; institutionalized older adults receive virtually none (Neikrug & Ancoli- noise. Israel, 2010). Levels of cortisol and growth hormone Awakened, person feels as though daydreaming has also affect sleep. Sleep is not a uniform state of uncon- sciousness; rather, it is divided into a series of cycles occurred. of lighter and deeper stages of sleep. Immediately before falling asleep, most adults experience a stage of STAGE 2: NREM increased relaxation and drowsiness lasting from 10 to Stage is period of sound sleep. 30 minutes. This is followed by four to six complete Relaxation progresses. sleep cycles lasting between 1 and 2 hours each. Each Arousal is still relatively easy. cycle consists of four nonrapid eye movement (NREM) Stage lasts 10 to 20 minutes. stages and one rapid eye movement (REM) stage (Box Body functions continue to slow. 20-1 and Figure 20-1). As the night\u2019s sleep progresses, REM periods increase in length and NREM periods STAGE 3: NREM decrease in length. If sleep is interrupted at any time, Stage involves initial phases of deep sleep. the individual goes back to stage 1 of NREM sleep and Sleeper is difficult to arouse and rarely moves. begins a new cycle. Muscles are completely relaxed. SLEEP AND AGING Vital signs decline but remain regular. As a person ages, the levels of hormones associated Stage lasts 15 to 30 minutes. with sleep change. Decreases in melatonin (which regulates the sleep-wake cycle) and growth hor\u00ad STAGE 4: NREM mone (which promotes sleep) lead to a shifting in This is deepest stage of sleep. circadian rhythm, causing many older adults to feel It is very difficult to arouse sleeper. sleepy earlier in the evening and to awake earlier If sleep loss has occurred, sleeper will spend in the morning, a phenomenon known as \u201cphase advance.\u201d considerable portion of night in this stage. Vital signs are significantly lower than during waking Because sleep efficiency decreases as age increases, many older adults complain that they do not feel hours. refreshed after sleep. Although the amount of time Stage lasts approximately 15 to 30 minutes. spent in bed may increase with age, the amount of time Sleepwalking and enuresis may occur. actually spent sleeping may decrease. The average 70-year-old sleeps for 7 hours per night, about the REM SLEEP same as reported by younger adults; however, the Vivid, full-color dreaming may occur. Less vivid dreaming nature of the sleep changes. Older individuals experi- ence more stage 1 and fewer stages 3 and 4 of (deeper) may occur in other stages. NREM sleep and somewhat less REM sleep. REM Stage usually begins about 90 minutes after sleep has sleep occurs earlier in the sleep cycle than seen in younger adults. These changes result in less deep begun. restorative and refreshing sleep. The phase advance It is typified by autonomic response of rapidly moving in circadian rhythm also appears to change with age, resulting in earlier bedtime and earlier rising. eyes, fluctuating heart and respiratory rates, and (Not surprisingly, this is the opposite of the \u201cphase increased or fluctuating blood pressure. delay\u201d observed in teenagers, who easily sleep until Loss of skeletal muscle tone occurs. noon.) It is suspected that this alteration in circadian Gastric secretions increase. rhythm in the older adult results from earlier drop in It is very difficult to arouse sleeper. core body temperature, decreased light exposure, or Duration of REM sleep increases with each cycle and genetic factors. In addition, sleep interruption and noc- lasts an average of 20 minutes. turnal awakening are common because older adults are more easily aroused by environmental noise or Presleep sleepiness stimuli. NREM NREM NREM NREM Stage 1 Stage 2 Stage 3 Stage 4 REM sleep NREM NREM Stage 2 Stage 3 FIGURE 20-1\u2003 The adult sleep cycle. (From Potter PA, Perry AG, Stockert PA, Hall AM: Fundamentals of nursing, ed 8, 2013, St. Louis: Mosby.)"]