NURSING CARE OF CHRONICALLY-ILL AND THE OLDER PERSONS y Deals with concepts and principles of nursing management of chronically-ill

and older persons with alterations in human functioning using the Nursing Process. y To apply basic knowledge, skills and attitude in the care of chronically-ill and the older persons.

Overview of Gerontological Nursing 1. Factors affecting the normal functioning in the older persons. -Demographics of Aging Stages of growth and development y Older adulthood y Young adult-65-74 years old y Adaptation to retirement and changing is often necessary.Chronic illness may develop y N.I.- assist clients to keep physically and socially active and to maintain per group interactions y Middle old- 75 to 84 years old y Adaptation to decline in speed of movement, reaction time and increasing dependence on others may be necessary y N.I. Assist clients to cope with loss, provode necessary safety measure

Definition of terms: y Geriatrics -is a sub-specialty of medicine that focuses on health care of the elderly. It aims to promote health and to prevent and treat diseases and disabilities in older adults; the science and the study of the physiologic and pathologic problems of individuals in their later maturity y Late adulthood- extends from above 65 years of age y Geriatric nursing- care for the elderly regardless of whether they are diseased or not y Gerontology- the science and study of aging process

y Senescence- the normal aging process y Senility- aging process characterized by severe mental

deterioration y Aging- physiologic, behevioral, and social changes that occur with increasing chronoligical age;a normal progressive process, not a disease; norms:normal physiological changes, have not been completely identified

Theories of Aging Havighurts s age periods and developmental tasks Late maturity 1. adjusting to decreasing physical strength and health 2. adjusting to retirement and reduced income 3. adjusting to death of spouse 4. establishing an explicit affiliation with one s group 5. meeting social and civil obligations 6. establishing satisfactory physical living arrangements

Freud s stages of development Genital- puberty and after Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment Nursing Intervention: encourage separation from parents, achievement of independence and decision making

Psychosocial Development Developmental task of the older adult 1. adjusting to decreasing physical strength and health 2.Adjusting to retirement and reduced income 3.Adjusting to the death of one s spouse 4.Establishing an explicit affiliation with one s age group 5. Meeting social and civil obligations 6.Establishing satisfactory living arrangements 7.Establishing satisfactory relationships with adult children 8. Finding meaning in life

Erik Erikson : Ego integrity vs. Despair

Ego integrity 65 years to death y Views life with a sense of wholeness and desires satisfaction from part accomplishments y Views death as an acceptable completion of life y Accept one s and only life cycle y Bringing serenity and wisdom

Despair y Believes they have made poor choices during life and wish they live life loner y Inability to accept one s fate y Gives rise to feeling with frustration, discouragement, and a sense that one s life has been worthless y Acceptance of worth and uniqueness of one s own life, acceptance of death y Indicators of negative resolution y sense of loss, contempt to others

General changes: 1. general tissue desiccation and slowed cell vision 2. slowed, weakened speed of response to stimuli 3. slowed rate of tissue repair 4. decreased metabolism 5. mechanisms of homeostasis less rapid and less efficient 6. rate of change is individual 7. high incidence of health problems

Primary changes of aging ( Physiological changes) Skin y Loss of subcutaneous supporting tissues y Sensititive to pressure and ulcer y Wrinkle and sag y Dry, wrinkled , loss elasticity y Decreased perspiration and sebum y Fragile, easily injured y Decrased skin tugor y Decreased sebaceous secretions y Dry, flabby, prone to itching y Atrophy of tiny arterioles near epidermis y Impired vasomotor homeostatic mechanism y Poor temperature regulation (feels cold even in warm climate) y HAIR- decreased number of hair follicles, scant, fine, graying, hirsutism, possible hereditary baldness y NAILS- dry, thick, brittle

The deep wrinkles, age spots, and leathery skin indicate premature aging caused by years of unprotected exposure to the sun.

Smoker's lines

Solar lentigo

Senile purpura

Musculoskeletal y Increase fat substitution for muscle y Muscle atrophy y Decreased muscular strength and function y Loss of Calcium from bones y Deterioration of cartilage y Wear, friction, stiffness of joints y Easily tired, less stamina y Impaired range of motion resulting from stiff joints y Generalized loss of 6-10 cm in stature because of: flexion of knee and hip joint, narrowing of intervertebral disks y Body takes on bony angular apperance y Osteoporosis is common

New research may explain the ongoing loss of muscle in older people, whose arms and legs become thinner as they age.

Cardiovascular y Thickened cardiac valves y Decreased myocardial contractability y Decreased elasticity of blood vessels y Decreased elasticity and increased stiffness arterial wall y Loss of atrial pacemaker y Reduction of hemapoietic activity y Increased blood coagulability y Decreased efficiency of baroreceptors

of the

Respiratory y Reduced chest compliance y Increased AP diameter of thorax y Reduced breathing capacity y Reduced vital capacity y Increased residual volume y Decreased cough reflex y Decreased ciliary activity y Decreased elasticity of tissue

Nervous 1. general a. slow speed of impulse transmission b. progressive decrase in number of functioning neurons in CNS and sense organs c. normal neurological functioning possible because of tremendous reserve number of neurons 2. mental and cognitive function a. altered capacity to retain new information and learn new tasks b. some impairment of memory and metal endurance 3. sensory a. some impairment of sensory perception b. gradual decrease of visual and auditory acuity

4. motor a. slowed reaction to stimuli; lenthening of reaction time b. decreased coordination and balance Degeneration and atrophy of neurons y Decreased nerve acuity and sensation y Loss of memory y Reduced concentration ability y Decreased attention span y Decision-making and judgement ablility remain intact y Ability to learn is possible up to 200 years of life y Decreased muscle coordintaion

Gastrointestinal y Minimal loss of digestive enzymes y Decreased absorption y Decreased peristalsis y Slowed digestion;increased food intolerance y Decreased metabolism: caloric requirement approximately 1000 calories per day y Redistribution of body fat; increased fat in trunk, especially in abdomen y Teeth and gum problems common y Atonia constipation in common

Renal/Genitourinary y Decrased blood flow y Reduced GFR y Reduced nephrons y Decreased creatinine clearance y Increased propensity to toxic effects of drugs y decreased renal capacity to concentrate urine at night

Genital ability to function sexually may continue well in older years female: menopause secondary to decreased estrogen male: decreased testosterone, spermatogenesis, and size of testes, increase in size of prostate

Endocrine y Decreased utilization of insulin y Cessation of progesterone y Decreased then plateau of estrogen y Gradual decline in testosterone y Reduced BMR

Sexual y Minimal change in amount of sexual response y Increased in time for full sexual response y Reduced vaginal lubrication y Increased refractory peroids in male y Decreased cell mass and weight

Immunity y Reduced humoral and cellular immunocompetence y Slowed, less efficient, response to antigens increases susceptibility to infections

Sensory Vision y Loss of accomodation y Loss of color sensitivity y Decreased dark adaptation y Decreased peripheral vision y Reduced sensitivity to glare y Slowed accomodation to light y Decreased visual acuity-farsightedness d/t slow lens accomodation, narrowed field of vision (tunnel vision)

Hearing y Decreased threshold for high frequencies y Decreased auditory acuity y Sensorineural hearing deficit (presbycusis) gradual loss of ability to discriminate to high frequensy tools

Taste and smell y Lack of appetite y Prefer salty diet Touch y Safety hazard

Dental y Gums becomes less elastic;less vascular y Recede from remaining teeth, exposing areas of teeth not covered with enamel

A.Integumentary system: 1. Pruritus or generalized itching is an extremely common geriatric disorder. It is one of the most common s/sx of patients with dermatologic disorders. Pruritus may be the first indication of a systemic internal disease such as diabetes mellitus, blood diosrders, or cancer. It mas also accompany renal, hepatic, and thyroid diseases. Some common oral medications such as aspirin, antibiotics, hormones, and opioids may cause pruritus directly or by increasing sensitivity to ultraviolet light. Certain soaps and chemicals, radiation therapy, prickly heat, and contact with woolen garments are also associated with pruritus. It may also be caused by psychological factors, such as excessive stress in family or work situations.

y washing with soap and hot water is avoided y bath oils containing a surfactant that makes the oil

mix with bath water may be sufficient for cleaning y a warm bath with mild soap followed by application of a bland emolient to moist skin y applying a cold compress, ice cube, or cool agents that contain methol and camphor may also help relieve pruritus

Pharmacologic therapy:
y Topical cortecosteroids(anti inflammatory) y Oral antihistamines-diphenhydramine(Benadryl) y Hydorxyzine (Iterax)

Nursing management: 1. Nurse reinforces the reasons for the prescribed therapeutic regimen and counsels patient on specific points of care, 2. Rremind patient to use tepid water and to shake off the excess water and blot between interriginous areas with a towel, 3. Rubbing vigorously with towel is avoided, 4. Instruct to avoid situations that causes vasodilation, 5. Vigorous scratching should be avoided, 6. Room should be kept cool and humidified

2. Psoriasis- is a chronic non infectious inflammatory disease of the skin in which epidermal cells are produced at a rate that is about six to nine times faster than normal Clinical Manifestation: lesions are as red, raised patches of skin covered with silvery scales Medical management: Oils or coal tar preaparations can be added to bath water and a soft brush used to scrub the psoriatic plaque gently; application of emolient creams containing alphahydroxy acids or salicylic acid will continue to soften thick scales

Pharmacologic therapy: 1. Topical agents-tar preparations, athralin, salicylic acid and cortecosteroids-Calcipotriene (dovonex) and tazoretene (tazorac) 2. Intralesional agents- triancinolone acetonide(aristocort, kenalog 10, trymex) 3. Systemic agents- hydroxeurea(hydrea), cyclosporine A (CyA) Photochemotherapy- one treatment for severe dbilitating psoriasis is a porsalen medication combined with ultraviloet light-A (PUVA) light therapy Nursing Interventions: 1. Promote understanding 2. Increase skin integrity 3. Improving self-concept and body image 4. Monitoring and managing potential complications 5. Promoting health and community based care

ANALYSIS/NURSING DISGNOSIS: a. Impaired skin integrity related to itching; physical immobilization; alterations in turgor b. Risks for impaired skin integrity related to physical immobilization; pressure; skeletal prominence. c. Impaired tissue integrity related to altered circulation. d. Disturbed sleeping pattern related to pain or itching. e. Risks for infection related to impaired tissue integrity.

B. Musculoskeletal System 1. Osteoporosis- is so obiquitous in older age that is generally is considered a normal age realted phenomenon rather than a disease. It is characterized by a decreased in bone mass per unit volume, producing a porous-looking skeletal frame that fractures eaqsily when stressed Risk factors: small framed, nonobese Caucasian women are at greatest risk y Asian women of slight build y Increased age, low weight and body mass index, estrogen deficiency or menaopause, family history, low initial bone mass, contributing coexisting medcial conditions

Assessment and diagnostic exams: y routine xrays Medical Management: y An adequate, balanced diet rich in calcium and vitamin D throughout life with anincreased calcium intake during adolescence, young adulthood, and the middle years-3 glasses of skim milk or whole Vitamin D enriched milk orother foods high in calcium y Calcium supplement y Regular weight bearing exercise y Weight training

Pharmacologic treatment: y Hormone replacement therapy with estrogen and progeterone y Biphosphonates and calcitonin Nursing intervention: y Promoting understanding of osteoporosis and the treatment regimen y Relieving pain y Improving bowel elimination y Preventing injury

2. Osteoarthritis- also known as generative joint disease; non inflammatory disorder of movable joints Risk factors: y Increased age y Obesity y Previous joint damage y Repetitive use y Anatomic deformity y Genetic susceptibility Clinical manifestations: y Pain, stiffness and functional impairment Assessment and diagnostic findings: 1. X-ray

Medical management: 1. Weight reduction, prevention of injuries, perinatal screening for congenital hip disease and ergonomic modifications 2. occupational and physical therapy Pharmacologic Treatment: 1. Acetaminophen 2. Opioids and intra articular cortecosteroids 3. Topical analgesics Capsaicin and methylsalicylate 4. Glucosamine and chrondoitin Surgical Management: 1. Osteotomy 2. Arthroplasty 3. Tidal irrigation of the knee Nursing intervention: 1. pain management and optimizing functional ability

3. Rheumatoid arthritis- chronic, systemic, progressive disease of unknown origin. Clinical manifestations: 1. Joint pain, swelling, warmth, erythema, and lack of function 2. palpation of the joints reveals spongy or boggy tissue 3. joint stiffness 4. deformities oof hands and feet 5. fever, weight loss, fatigue, anemia, lymph node enlargement and raynuads phenomenon stress induced vasospasm

Assessment and diagnostic findings: 1. history and physical examintaion 2. Increased in Erythrocyte sedimentation rate 3. Arthrocentesis 4. X-ray Medical Management: Early stage RA: 1. Education- balance of rest and exercise and referral to community agencies for support 2. therapeutic doses of salicylates or NSAIDS 3. Biologic response enatercept (enbrel)/infliximab (remicade)

Moderate erosive RA: 1. formal program with occupational and physical theraphy (cyclosporine) Persistent erosive RA: 1. reconstructive surgery and cortecosteroids(synovectimy/ tenorrhaphy/arthroplasty Advanced unremitting RA: 1. immunosuppressive agents are prescribed methotrexate (rheumatrex), cyclophosphamide (cytoxan), azathioprine (imuran) Nutrition therapy

4.) Gouty Arthritis- is a syndrome or collection of metabolic disorders in which uric acid crystallizes in body fluids and is deposited in tissues. Clinical Manifestations: 1.swelling, tenderness, redness, and sharp pain in big toe Assessment and diagnostic findings: 1. Physical exam 2. Arthrocentesis- A sample of fluid from your joint to look for uric acid crystals.

Medical Management: 1.Ibuprofen or another anti-inflammatory medicine 2. adequate fluid intake 3. weight reduction 4. dietary changes, reduction in alcohol consumption, 5. medications to lower the uric acid level in the blood (reduce hyperuricemia)- allopurinol (Zyloprim) or febuxostat(Uloric).

Nursing intervention: 1. resting and elevating the inflamed joint 2. Ice-pack applications can sometimes make the inflammation worse by causing more uric acid to form crystals in the involved area 3. avoid aspirin-containing medications, when possible, because aspirin prevents kidney excretion of uric acid.

ANALYSIS/NURSING DISGNOSIS: a. Activity intolerance related to weakness, stiffness. b. Chronic Pain related to musculoskeletal disease, injury. c. Divertional activity, deficient; related to loss of ability to perform usual or favorite activities secondary to immobility, pain and weakness. d. Risk for injury related to sensory or motor deficits.

C. Cardiovascular system: 1. Hypertension-a systolic blood pressure greater than 140mmHg and a diastolic pressure greater that 90mmHg over a sustained period. Clinical manifestations: 1. High BP 2. Retinal changes such as hemmorhages, exudates, arteriolar narrowing, and cottonwool spots 3. papilledema Major risk factors: 1. smoking 2. dyslipidemia 3. DM 4. age older than 6o years old 5. Gender (men and postmenopausal women) 6. Family history

Assessment and diagnostic evaluation: 1. Health history and physical assessment 2. Urinalysis 3. Blood chemistry 4. 12 lead echocardiogram 5. Creatinine clearance 6. Renin level Medical management: -The goal of hypertension treatment is to prevent death and complications by achieving and maintaining the arterial blood pressure at 140/90 mmHg or lower. -weight loss, reduced alcohol and sodium intake, and regular physical activity

Pharmacologic Therapy: 1. Diuretics, beta nlockers or both Nursing intervention: 1. Increasing Knowledge 2. Promoting Home and community based care

2. Myocardial Infarction-usually caused by reduced blood flow in a coronary artery due to atherosclerosis, and occlusion of an artery by an embolus or thrombus Clinical Manifestations 1. Chest pain occurs suddenly 2. Shortness of breath, dyspnea, tachypnea 3. nausea and vomiting 4. decreased urine output 5. cool, clammy, diaphoretic, pale skin 6. anxiety, restlessness 7. Denial

Assessment and diagnostic Findings 1. Physical assessment and Patient History 2. Electrocardiogram 3. Echocardiogram 4. Laboratory test (Creatine Kinase and its isoenzymes, Myoglobin, Troponin T) Medical management: -the goal of the medical management is to minimize myocardial damage, preserve myocardial function and prevent complications -thrombolytic medications (PTCA) -Emergent Percutaneous Coronary Intervention -cardiac Rehabilitation

Pharmacologic therapy: 1. Thrombolytics 2. Angiotensin converting enzyme inhibitors (ACE-I) Nursing Intervention: 1. relieving pain and other signs and symptoms of ischemia 2. improving respiratory function 3. promoting adequate tissue perfussion 4. reducing anxiety 5. monitoring and managing potential complications 6. promoting home and community based care

3. Angina Pectoris- ususally characterized by episodes or paroxysm of pain or pressure in the anterior chest Clinical manifestations: 1. chest pain 2. choking or strangling sensation 3. weakness or numbness in arms 4. shortness of breath 5. pallor 6. dizziness 7. nausea and vomiting

Medical management: -goal :to decrease the oxygen demand of the myocardium and to increase the oxygen supply -Revasculization procedures Percutaneous coronary interventional (PCI), Pharmacologic treatment: 1. Nitroglycerin 2. Beta-Adrenergic Blocking agents 3.Calcium channel blocking agents 4. anti platelet and anti coagulant medications -oxygen administration -alternative therapies Nursing Intervention: 1. Treating angina 2. Reducing anxiety 3. Preventing pain 4. Promoting home and community based care

ANALYSIS/NURSING DISGNOSIS: a. Acute pain related to cardiac ischemia, impaired circulation in the extremities. b. Ineffective tissue perfusion related to thrombus, compromised circulation, venous congestion, interruption of cerebral blood flow.

D.Respiratory System 1. Asthma- is a clinical syndrome characterized by three phenomena: recurent episodes of airway obstruction that resolve spontaneously or in response to treatment, airway hyperresponsiveness, and iraway inflammation. Clinical manifestations: 1. breathlessness 2. wheezes 3. intermittent cough 4. tightness in chest 5. use of accesory muscles 6. intercostal retractions 7. chest hyperinflation and prolonged expiratory phase of respirations Management: -Drug therapy- beta adrenergic agonists, anticholinergics, Leukotriene modifiers

2.Chronic Obstructive Pulmonary Disease (COPD)makes it hard for you to breathe. Coughing up mucus is often the first sign of COPD. Chronic bronchitis and emphysema are common COPDs. In COPD, less air flows in and out of the airways because of one or more of the following: y The airways and air sacs lose their elastic quality. y The walls between many of the air sacs are destroyed. y The walls of the airways become thick and inflamed. y The airways make more mucus than usual, which tends to clog them.

Clinical manifestations: 1.Chronic, persistent cough 2.Increased mucus 3.Shortness of breath, especially during physical activity 4.Wheezing 5.A tight feeling in the chest

Management: 1.Quit smoking 2. taking medications to dilate airways (bronchodilators) and 3. decrease airway inflammation; 3. vaccination against flu influenza and pneumonia 4. regular oxygen supplementation; and 5. pulmonary rehabilitation.

ANALYSIS/NURSING DISGNOSIS: a. Ineffective airway clearance related to pain, tenacious traacheobronchial ssecretions, weak cough, bronchospasm and increase pulmonary secretions. b. Ineffective breathing pattern related to increased pulmonary secretions, stiff chest wall. c. Impaired gas exchange related to carbon dioxide retention, airway obstruction and excess mucus production.

E. Nervous System Dementia- is charaterized by uneven , downward decline in mental funtion. - Agnosia (inability to identify familiar objects) is a key finding in Dementia. - Sundown Syndrome/Sundowning y is a term that describes the onset of confusion and agitation that generally affects people with dementia or cognitive impairment and usually strikes around sunset.

The early signs of Sundown Syndrome y The earliest signs of the onset of this condition can be subtle and difficult to recognise for those new to Sundown Syndrome. These include paranoid delusions of being criticised or judged. For example, the sufferer may start to feel they are being watched and that their movements are known to neighbours. Hallucinations & Confusion y As the condition progresses, they may become more confused, becoming more agitated towards the end of the day. At its worst, the sufferer may experience hallucinations - possibly caused by the effects of chemical imbalances in the brain affecting the centers that handle visual and auditory processing. Wandering/Screaming

Care of Sundown Syndrome The following are some suggestions that can help minimize the symptoms: y Reassure and keep the sufferer calm y Warm and soothing drinks (warm milk, chamomile tea) at evening time y Avoid over-tiredness y Frequent and regular naps and rest periods y Close the drapes before sunset y Minimize stress y Explain that the things they see/hear are just hallucinations and can t harm them

Management: 1.Cognition 2. Activities of daily living 3. Behavior

2. Alzheimer s disease- is a chronic,progressive and degenerative brain disorder accompanied by profound effects on memory, cognition and ability for self care. Clinical manifestations: 1. forgetfullness and subtle ,memory loss occur 2. small dificulties in work or social activities but has adequate cognitive function to hide the loss and can function independently 3. Depression 4. loss ability to recognize familiar faces, place and things Assessment and diagnostic findings: 1. Assessment and Patient History 2. complete blood count 3. Electroencephalography 4. Magnetic resonance imaging 5. examination of cerebrospinal fluid

Comparison of a normal aged brain (left) and an Alzheimer's patient's brain (right). Differential characteristics are pointed out.

Medical management: 1.tacrine hydrochloride (Cognex) 2. donepezil (Aricept) 3. Rivastigmine (Exelon) Nursing interventions: 1. Supporting cognitive function 2. Promoting physical safety 3. reducing anxiety and agitation 4. Improving communication 5. Promoting independence in self care activities 6. Providing for socialization and intimacy needs 7. Promoting adequate nutrition 8. Promoting balance activity and rest 9. Supporting Home and Community based care

3. Parkinson s Disease-is a slowly progressing neurologic movement disorder that eventually leads to disability Clinical Manifestations: 1. Tremor 2. Rigidity 3. Bradykinesia 4. depression, dementia, sleep disturbances, excessive and uncontrolled sweating Assessment and Diagnostic findings: 1. assessment and history 2. PET scanning

Person with Parkinson's disease displaying a flexed walking posture .

Medical management: 1. Pharmacologic therapy a. anti parkinsonian medications- Levodopa 2. Anti cholinergic therapy 3. Anti viral therapy 4. Dopamine agonists 5. Monoamine oxidase inhibitors 6. Cathechol-O-methyltransferase inhibitors 7. anti depressants 8. antihistamines Surgical management: 1. Stereotactic procedures 2. Neural transplantation 3. Deep brain stimulation

Nursing Intervention: 1. Improving mobility 2. Enhancing self care activities 3. Improving bowel elimination 4. Improving nutrition 5. enhancing swallowing 6. encouraging the use of assistive devices 7.improving communication 8.supporting coping abilities 9. Promoting home and community based care

ANALYSIS/NURSING DISGNOSIS: a. Impaired adjustment related to negative attitudes toward health behavior, multiple stressors. b. Anxiety related to unmet needs, change in health status. c. Ineffective coping related to uncertainty, inadequate resources available. d. Fear related to separation from support system in potentially stressful situation, sensory impairment. e. Impaired memory related to neurological disturbances, fluid and electrolyte imbalance. f. Hopelessness related to prolonged activity restrictions creating isolation.

F.Gastrointestinal system: 1. Gastric Ulcer-is a break in the normal tissue that lines the stomach Clinical Manifestations: 1.Recurrent abdominal pain - dull and burning type pain usually located in epigastric area (area between belly button and rib cage) 2.Abdominal pain after food 3.Abdominal pain at night 4.Blood in vomit 5.Nausea

Deep gastric ulcer

Medical management: 1. Anti-acid medications: "Proton-Pump" inhibitors (eg omeprazole, lansoprazole), H2 antagonists (eg ranitidine, cimetidine) 2.Eradication of Helicobacter pylori infection: oral antibiotics, proton pump inhibitor 3.Avoidance of NSAID medications (aspirin, ibuprofen (Nurofen, Brufen etc) 4.Surgical partial gastrectomy - only performed if ulcer will not heal using medications or if there is acute hemorrhage or perforation of ulcer

Nursing interventions: 1.Normal activity is encouraged. 2. Antibiotics and other agents are used as adjuvants to treat duodenal ulcer disease associated with H pylori. 3. Instruct patient to avoid NSAIDs. 4.Discourage alcohol consumption and cigarette smoking because these activities impair gastric mucosal protection.

3.Peptic ulcer-is an ulcer (defined as mucosal erosions equal to or greater than 0.5 cm) of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. Clinical Manifestations: 1.abdominal pain, classically epigastric with severity relating to mealtimes, after around 3 hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it)

2.bloating and abdominal fullness 3.waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus) 4.nausea, and copious vomiting 5.loss of appetite and weight loss 6.hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting. 7.melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin) 8.rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis. This is extremely painful and requires immediate surgery.

Medical management: 1.Histamine2 (H2) receptor antagonists such as ranitidine to reduce gastric acid secretions. 2.Antisecretory or proton-pump inhibitor, such as omeprazole, to help ulcer heal quickly in 4 to 8 hours. 3.Cytoprotective drug sucralfate, which protects ulcer surface against acid, bile, and pepsin. 4.Antacids to reduce acid concentration and help reduce symptoms. 5.Anti-biotic as part of a multi-drug regimen to eliminate H. pylori to prevent reoccurrence. 6.Surgery-Gastroduodenostomy /Total gastrectomy
y Removal of stomach with anastomosis of esophagus to

jejunum or duodenum.

Nursing Interventions: y Monitor the patient for signs of bleeding through fecal occult blood, vomiting, persistent diarrhea, and change in vital signs. y Monitor intake and output. y Monitor the patient s hemoglobin, hematocrit, and electrolyte levels. y Administer prescribed I.V. fluids and blood replacements if acute bleeding is present. y Maintain nasogastric tube for acute bleeding, perforation, and postoperatively, monitor tube drainage for amount and color. y Perform saline lavage if ordered for acute bleeding. y Encourage bed rest to reduce stimulation that may enhance gastric secretion.

y Provide small, frequent meals to prevent gastric y y y

y y

distention if not actively bleeding. Watch for diarrhea caused by antacids and other medications. Restrict foods and fluids that promote diarrhea and encourage good perineal care. Advise patient to avoid extremely hot or cold food and fluids, to chew thoroughly, and to eat in a leisurely fashion to reduce pain. Administer medications properly and teach patient dose and duration of each medication. Advise patient to modify lifestyle to include health practices that will prevent recurrences of ulcer pain and bleeding.

G. Genitourinary system 1.Dysfunctional Voiding patterns a. Adult voiding dysfunction- both neurogenic and nonneurogenic disorders can cause adult voiding dysfunction. b. Urinary Incontinence- involuntary loss of urine Types of incontinence: a. stress incontinence b. urge incontinence c. reflex incontinence d. overflow incontinence Assessment and diagnostic findings: 1. Physical Assessment and patient history 2. extensive urodynamic test 3. urinalysis 4. urine culture

Medical Management: 1. Behavioral therapy 2. Pharmacologic therapy a. Anti cholinergic agents- (oxybutynin);Diclomine (antispasm) b. Tricyclic anti depressants- Imipramine, doxepin, desipramine, nottripyline c. Oral estrogen Surgical management: a. anterior vaginal repair b. periurethral bulking c. Transurethral resection Nursing Intervention: 1. Provide support and encouragement 2. Patient teaching regarding the bladder program

G. Genitourinary system 1.Dysfunctional Voiding patterns a. Adult voiding dysfunction- both neurogenic and nonneurogenic disorders can cause adult voiding dysfunction. b. Urinary Incontinence- involuntary loss of urine Types of incontinence: a. stress incontinence b. urge incontinence c. reflex incontinence d. overflow incontinence

Surgical management: a. anterior vaginal repair b. periurethral bulking c. Transurethral resection Nursing Intervention: 1. Provide support and encouragement 2. Patient teaching regarding the bladder program

Assessment and diagnostic findings: 1. Physical Assessment and patient history 2. extensive urodynamic test 3. urinalysis 4. urine culture Medical Management: 1. Behavioral therapy 2. Pharmacologic therapy a. Anti cholinergic agents- (oxybutynin);Diclomine (antispasm) b. Tricyclic anti depressants- Imipramine, doxepin, desipramine, nottripyline c. Oral estrogen

2. Urinary retention is inability to empty the bladder completely during attempts to void -in adults older than age 60, 50 to 100 ml of residual urine may remain after each void because of the decreased contractility of the detrusor muscle Manifestations: 1. bladder fullness 2. sensation of incomplete bladder emptying Assessment and diagnostic findings: 1. Assessment and history Nursing Intervention: 1. Promoting normal urinary elimination 2. Promoting urinary elimination 3. Promoting Home and community based care

3. Urinary Tract Infection-is an infection that begins in your urinary system. Your urinary system is composed of the kidneys, ureters, bladder and urethra. Any part of your urinary system can become infected, but most infections involve the lower urinary tract the bladder and the urethra. Clinical manifestations: y A strong, persistent urge to urinate y A burning sensation when urinating y Passing frequent, small amounts of urine y Urine that appears cloudy y Urine that appears bright pink or cola colored a sign of blood in the urine y Strong-smelling urine y Pelvic pain, in women y Rectal pain, in men

Assessment and diagnostic findings: 1. assessment and history 2. colony counts 3. cellular studies 4. urine cultures Medical management: 1. acute pharmacologic therapy 2. long term pharmacologic therapy Nursing Intervention: 1. Relieving pain 2. Monitoring and managing potential complications 3. Promoting home and community based care

Types of urinary tract infection-Each type of urinary tract infection may result in more-specific signs and symptoms, depending on which part of your urinary tract is infected. Part of urinary tract affected Signs and symptoms y Kidneys (acute pyelonephritis) y Upper back and side (flank) pain y High fever y Shaking and chills y Nausea y Vomiting y Bladder (cystitis) y Pelvic pressure y Lower abdomen discomfort y Frequent, painful urination y Blood in urine y Urethra (urethritis) y Burning with urination

ANALYSIS/NURSING DISGNOSIS: a. acute/chronic pain b. infection

H. Endocrine System 1. Hypothyroidism-is a condition in which the body lacks sufficient thyroid hormone. Clinical manifestations: 1.Fatigue 2.Weakness 3.Weight gain or increased difficulty losing weight 4.Coarse, dry hair 5.Dry, rough pale skin 6.Hair loss 7.Cold intolerance (you can't tolerate cold temperatures like those around you) 8.Muscle cramps and frequent muscle aches 9.Constipation

(T4) normally produced in 20:1 ratio totriiodothyronine (T3)

10.Depression 11.Irritability 12.Memory loss 13.Abnormal menstrual cycles 14.Decreased libido

Medical Management: 1.Life time thyroid hormone intake

2. Hyperthyroidism-is a condition caused by the effects of too much thyroid hormone on tissues of the body. Clinical manifestations: 1.Palpitations 2.Heat intolerance 3.Nervousness 4.Insomnia 5.Breathlessness 6.Increased bowel movements 7.Fatigue 8.Fast heart rate 9.Trembling hands

10.Weight loss 11.Muscle weakness 12.Warm moist skin 13.Hair loss 14.Staring gaze Medical Management: 1.Radioactive iodine 2. Surgery- Thyroidectomy

(T3) and thyroxine (T4) are both forms of thyroid hormone.

I.Immune System 1. Pernicious Anemia-is a disease where large, immature, nucleated cells (megaloblasts, which are forerunners of red blood cells) circulate in the blood, and do not function as blood cells. Due to an inability to absorb vitamin B-12 (also known as cobalamin or Cbl) from the gastrointestinal tract.

Clinical Manifestations: 1.Feeling tired and weak 2.Tingling and numbness in hands and feet 3.A bright red, smooth tongue Medical Management: 1.high-dose oral vitamin B-12

2.HIV/AIDS in older patients-s a virus that damages the immune system the system your body uses to fight off diseases.There is no cure for HIV/AIDS. Clinical Management: 1.headache 2.chronic cough 3. diarrhea 4. swollen glands 5.lack of energy, loss of appetite and weight loss. 6.frequent fevers and sweats 7. frequent yeast infections, 8.skin rashes 9. pelvic and abdominal cramps 10.sores on certain parts of your body 11. short-term memory loss

People age 50 and older may not recognize HIV symptoms in themselves because they think what they are feeling and experiencing is part of normal aging.

J. Sensory Problems 1. VISUAL IMPAIRMENT y normal vision: 20/40 or better y visual impairment ("low vision"): worse than 20/40 but better than 20/200 y legal blindness: equal to or worse than 20/200 y The most common problem is difficulty focusing the eyes (a condition called presbyopia). Management: - eyedrops or artificial tears solutions.

a.Age-related macular degeneration (AMD) is a progressive disease in which light-sensing cells are damaged in the macula, the part of the retina responsible for central vision. Risk factors include advancing age; being white; and having a family history of AMD, cardiovascular disease, smoking, or hypertension.

b.Cataracts can increase in density gradually and eventually may require surgery. In their early stages, cataracts are largely asymptomatic. Risk factors include age, certain diseases (such as diabetes), smoking and alcohol consumption, and prolonged exposure to sunlight (specifically ultraviolet radiation).

c.Glaucoma- another leading cause of blindness, is associated with loss of peripheral vision, often the result of increased intraocular pressure that damages the optic nerve. Risk factors include age, family history, and race: Mexican Americans older than 60 years of age and African Americans older than 40 years of age are especially susceptible.

Acute angle closure glaucoma of the right eye. Note the mid sized pupil, which was non-reactive to light, and injection of the conjunctiva.

d.Diabetic retinopathy damages retinal blood vessels, causing them to leak, grow abnormally, and form scar tissue. According to the American Diabetes Association, "diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20 [to] 74 years." Risk factors include long duration of disease, poor control of blood sugar levels, and elevated blood pressure and cholesterol level

Normal Vision

Same scene viewed by a person with diabetic retinopathy

2.HEARING y Balance (equilibrium) is controlled in a portion of the inner ear. Fluid and small hairs in the semicircular canal (labyrinth) stimulate the nerve that helps the brain maintain balance. y As you age, your ear structures deteriorate. The eardrum often thickens and the bones of the middle ear and other structures are affected. It often becomes increasingly difficult to maintain balance. y Hearing may decline slightly, especially that of highfrequency sounds, particularly in people who have been exposed to a lot of noise when younger. This agerelated hearing loss is called presbycusis.

y Impacted ear wax may be removed in your doctor's

office. y Sensorineural hearing loss involves damage to the inner ear, auditory nerve, or the brain y Surgery or a hearing aid may be helpful for this type of hearing loss, depending on the specific cause. y Persistent, abnormal ear noise (tinnitus) is another fairly common hearing problem, especially for older adults. It is usually a result of mild hearing loss.

3.TASTE AND SMELL y You have approximately 9,000 taste buds. Your taste buds are primarily responsible for sensing sweet, salty, sour, and bitter tastes. y Smell (and to a lesser extent, taste) also play a role in both safety and enjoyment. We detect certain dangers, such as spoiled food, noxious gases, and smoke with taste and smell. -The number of taste buds decreases beginning at about age 40 to 50 in women and at 50 to 60 in men. Each remaining taste bud also begins to atrophy (lose mass). The sensitivity to the four taste sensations does not seem to decrease until after age 60, if at all. If taste sensation is lost, usually salty and sweet tastes are lost first, with bitter and sour tastes lasting slightly longer.

y mouth produces less saliva as you age. This causes dry

mouth, which can make swallowing more difficult. It also makes digestion slightly less efficient and can increase dental problems. y The sense of smell may diminish, especially after age 70. This may be related to loss of nerve endings in the nose. y Regardless of the cause, decreased taste and smell can lessen

4.TOUCH, VIBRATION, AND PAIN y Many studies have shown that with aging, you may have reduced or changed sensations of pain, vibration, cold, heat, pressure, and touch. It is hard to tell whether these changes are related to aging itself or to the disorders that occur more often in the elderly. y It may be that some of the normal changes of aging are caused by decreased blood flow to the touch receptors or to the brain and spinal cord.

y Reduced ability to detect vibration, touch, and

pressure increases the risk of injuries, including pressure ulcers. After age 50, many people have reduced sensitivity to pain. You may develop problems with walking because of reduced ability to perceive where your body is in relation to the floor. This increase your risk of falling, a common problem for older people. y Fine touch may decrease. However, some people develop an increased sensitivity to light touch because of thinner skin (especially people older than 70).

y To increase safety, make allowances for changes in

touch-related sensations: y Limit the maximum water temperature in your house (there is an adjustment on the water heater) to reduce the risk of burns. y Look at the thermometer to decide how to dress rather than waiting until you feel overheated or chilled. y Inspect your skin (especially your feet) for injuries, and if you find an injury, treat it. Don't assume that just because an area is not painful, the injury is not significant.

Psychosocial changes in elderly y Age-related Sociological Changes y Age-related Psychological Changes

Elderly abuse and neglect Signs and symptoms of specific types of abuse Physical abuse Unexplained signs of injury such as bruises, welts, or scars, especially if they appear symmetrically on two side of the body y Broken bones, sprains, or dislocations y Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should) y Broken eyeglasses or frames y Signs of being restrained, such as rope marks on wrists y Caregiver s refusal to allow you to see the elder alone

Sexual abuse y Bruises around breasts or genitals y Unexplained venereal disease or genital infections y Unexplained vaginal or anal bleeding y Torn, stained, or bloody underclothing

Emotional abuse In addition to the general signs above, indications of emotional elder abuse include y Threatening, belittling, or controlling caregiver behavior that you witness y Behavior from the elder that mimics dementia, such as rocking, sucking, or mumbling to oneself

Neglect by caregivers or self-neglect y Unusual weight loss, malnutrition, dehydration y Untreated physical problems, such as bed sores y Unsanitary living conditions: dirt, bugs, soiled bedding and clothes y Being left dirty or unbathed y Unsuitable clothing or covering for the weather y Unsafe living conditions (no heat or running water; faulty electrical wiring, other fire hazards) y Desertion of the elder at a public place

Financial exploitation y Significant withdrawals from the elder s accounts y Sudden changes in the elder s financial condition y Items or cash missing from the senior s household y Suspicious changes in wills, power of attorney, titles, and policies y Addition of names to the senior s signature card y Unpaid bills or lack of medical care, although the elder has enough money to pay for them y Financial activity the senior couldn t have done, such as an ATM withdrawal when the account holder is bedridden y Unnecessary services, goods, or subscriptions

Healthcare fraud and abuse y Duplicate billings for the same medical service or device y Evidence of overmedication or undermedication y Evidence of inadequate care when bills are paid in full y Problems with the care facility: - Poorly trained, poorly paid, or insufficient staff - Crowding - Inadequate responses to questions about care

Death is the cessation of the connection between our mind and our body. Indications of death: y Total lack of response to external stimuli y No muscle movement y No reflexes y Flat ECG- this is the most accurate indicator of death.

Development of concept of death: Infancy to 5 years old y Does not understand concept of death y Believes death is reversible, a temporary departure or sleep 5-9 years old y Understand that death is final y Believes own death can be avoided y Associates death with aggression or violence 9-12 years old y Understands death as the inevitable end of life y Begins to understand own mortality

12-18 years y Fears of lingering death y May fantasize that death can be defied, acting out defiance through reckless behavior y Views death in religious and philosophic terms 18-45 years y Has attitude towards death that is influenced by religious and cultural beliefs 45-65 years y Accepts own mortality y Encounters death of parents and some peers y Experience peak of death anxiety

65 years above yFears prolonged illness yEncounters death of family members and peers ySees death as having multiple meanings.

Dying- approaching death. Care of the dying client: Signs of impending clinical death: y Loss of muscle tone y Relaxation of the facial muscle (the jaw may sag) y Difficulty in speaking y Difficulty of swallowing and gradual loss of the gag reflex y Decrease activity of the gastrointestinal tract y Possible urinary and rectal incontinence y Diminished body movement

Slowing of circulation y diminished sensation y mottling and cyanosis of the extremities y cool skin, first in the feet and later in the hands, ears and nose Changes in vital signs y decelerated and weaker pulse y decreased blood pressure y rapid, shallow, irregular or abnormally slow respirations- Cheyne-stroke respirations; noisy breathing (death rattle); mouth breathing

Sensory impairment y Blurred vision y Impaired sense of taste and smell

Nursing care for the dying client: y Assist the client achieve a dignified and peaceful death y Provide relieve from loneliness, fear and depression y Maintain the client s sense of security, self-confidence, dignity and self-worth y Maintain hope y Help the client accept his or her losses y Provide physical comfort

Maintain physiologic and psychologic comfort y Personal hygiene measures y Pain control y Relief of respiratory difficulties y Assistance with movements, nutrition, hydration and elimination y Measures related to sensory changes Provide spiritual support y Search for meaning y Sense of forgiveness y Need for love y Need for hope

Nursing diagnosis: Dying Clients Fear related to: y Knowledge deficit y Lack of social support in threatening situations y Negative impact on survivors Hopelessness related to: y Prolong restriction of activity resulting in isolation y Deteriorating physiologic condition y Terminal illness y Long-term stress y Perceive significant loss of loved one, youth, influence Powerlessness related to: y Chronic debilitating disease y Terminal illness institutional environment y Interpersonal behavior of others

Care of the body after death: BODY CHANGES AFTER DEATH: y Rigor mortis- the limbs of the corpse become stiff (Latin rigor) and difficult to move or manipulate, occurs about 2-4 hours after death y Results from lack of Adenosine Triphosphate (ATP) which is not synthesized due to lack of oxygen in the body y Position the body, place dentures in the mouth and close the eyes and mouth before rigor mortis sets in y Algor mortis- the reduction in body temperature following death. y When blood circulation terminates and the hypothalamus ceases to function, body temperature falls about 1 C per hour until it reaches room temperature y Livor mortis- discoloration of the skin after death after circulation has ceased. The red blood cells break down, releasing hemoglobin which discolors the surrounding tissues. y Pallor mortis- paleness which happens in the 15 120 minutes after death y Decomposition- the reduction into simpler forms of matter, accompanied by a strong, unpleasant odor.

Nursing interventions for the body after death: y Make the environment as clean and as pleasant as possible. y Make the body appear natural and comfortable. y Remove all equipment and supplies from the bedside. y Remove soiled linens, so the room is free from odors y Place the body in supine position, the arms at the sides, palms down. y Place one pillow under the head and shoulders to prevent blood from discoloring the face. y Close the eyelids, insert dentures and close the mouth. y Place absorbent pads under the buttocks to take up any feces and urine released because of relaxation of the sphincter muscles. y Provide clean gown, brush/comb the hair y Remove all jewelries. All the client s valuables are listed and place in a safe storage area for the family to take away. y Allow the family to view the body. y Apply identification tags, one to the ankle and one to the wrist. y Wrap the body in shroud. Apply another identification tag to the outside of the shroud. y Bring the body to the morgue for cooling (cryonics).

Mela ie is yet a t er actress as attled dr gs a d lis f r c f er life. T is ay e at least artly t alc la e f r s e s aged.

You wouldn t know it now, but looking at pictures of young Marlon Brando one can only guess that he was quite the ladies man at one time.

This is one of the great tragedies of all time. Brigitte Bardot is easily regarded as one of the sexiest women of all time as long as that time ends somewhere in the 1980s.

In his younger days, Jack Nicholson had a hunger for gritty roles and serious acting. In his later years, sadly, he became hungrier for sandwiches.

The End Thank you