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163 Cards in this Set
- Front
- Back
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What is considered visual impairment?
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worse than 20/40 but better than 20/200
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What is normal vision of the eye?
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20/40 or better
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What is considered legal blindness?
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= or worse than 20/200
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Normal age - related changes in the eye
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-lens becomes less flexible
-lens becomes opaque so it absorbs more light. -decrease ability to adjust to changes in illumination r/t pupil losing ability to adapt size and changes in retinal-neural pathway |
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Effects of age related changes in vision
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-mild visual impairments are common.
-environment can exacerbate. -most perform usual activities with decreased vision aids and non glare light. |
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What is presbyopia?
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When the lens is less able to chane shape (accomodate) to focus on objects held near the eye.
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Decreased activity
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affects ability to detect and discern details
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What is cataracts?
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-Lens opacity r/t changes in proteins in lens, progressively interferes w/vision by allowing less light to the retina.
-More common in elders but not usual aging. |
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What causes chronic (open-angle) glaucoma?
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Abnormal production of aqueous fluid.
-abnormal trbecular network -abnormal Schlemm cells. |
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What is the treatment for chronic glaucoma?
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-eye drops to decrease aqueous humor or to increase it's outflow or a combination.
-Laser tx also helps. *routine eye exam...screening is important!!!!! |
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Symptoms of chronic (open-angle) glaucoma?
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-decrease vision in dim light.
-increased sensitivity to glare. -decreased peripheral vision. |
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Nursing interventions to aid the visually impaired
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-preventative teaching.
-routine exams -floors, lighting, color contrasts or coding -signage: red on yellow, white on green, black on yellow or white.**No glossy paper. -clock face to locate items. -encourage use of hats and sunglasses. |
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Symptoms of acute (closed angle) glaucoma?
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- sudden onset
-intense pain -n/v -halos, blurred vision -dilated pupils |
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What is acute (closed-angle) glaucoma?
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-sudden blockage of aqeuos flow r/t anterior chamber obstructed by thikened iris or enlarged lense, causing optic nerve damage.
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What is chronic (open-angle) glaucoma?
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-slow, insiduous onset
-dilated pupil -90% of cases |
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What is treatment for acute (closed-angle) glaucoma?
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-immediately treat with meds to reduce pressure followed by laser surgery.
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Age-related macular degeneration
"WET" |
-abnormal vessels around drusen leak (wet), causing hemorrhage and scarring.
-sudden onset -10 % of cases -more severe visual loss |
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What are the risk factors for glaucoma?
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-African American
-Age -Family history -Diabetes -certain medications |
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What is glaucoma?
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- increased intraocular pressure from abnormal build up of aqueous humor r/t occlusion or plugging of drainage system.
-loss of peripheral vision -can ead to blindness due to damage to optic nerve. |
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What is the treatment for age-related macular degeneration?
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-Laser treatment to seal leaking blood vessels for wet ARMD.
-*anti-oxidant vitamins & zinc...slows down progression. -Injection into eye w/ macugen...also slows it down. |
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What are the symptoms of cataracts?
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-increased sensitivity to glare, blurred vision, distorted images, double vision, decreased color perception, loss of depth and distance perception, loss of contrast, freq. change in glasses, film over eye.
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What is the leading cause of visual impairment?
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Cataracts
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What are the risk factors for cataracts?
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-age
-diabetes -smoking, ECOH -prolonged exposure to sun -eye trauma -malnutrition -certain medications |
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What is the leadig cause of blindness in white Americans?
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Macular Degeneration
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What is the treatment for cataracts?
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- surgical removal of lens with intraocular lens placed.
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What is macular degeneration?
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- breakdown of cells in macula causes yellow deposits (drusen) to form under the retina
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What are the risk factors for macular degeneration?
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-age
-white -family hx of ARMD -CV disease -HTN -hyperlipidemia -smoking -overexposure toUV light and meds. |
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Age related Macular Degeneration
"DRY" |
-progresses slowly
-90% of cases |
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Symptoms of death to photoreceptor cells
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-gradual loss (progressive) of central vision
-distorted straight lines -blurred vision -loss of depth and contrast cues. |
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Central hearing loss
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-degenerative changes on auditory nerve pathway or CNS.
-may be unable to interpret language. -auditory processing compromised at level of brain; ear infection may be ok.(?) |
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Meniere's Disease
aka endolymphatic hydrops |
-episodic disorder r/t fluctuating pressure and volume of fluid in inner ear (endolymph & perilymph)
-75% 1 ear infected -25% both ears infected |
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Symptoms of Meniere's Disease
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vertigo (2-4 hrs), may have n/v
-tinnitus -fullness.pressure in ear -fluctuating hearing loss -mild disequilibrium b/t episodes -gradual sensorineural hearing loss -post episode tiredness -may develop perm. tinnitus |
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What is sensorineural loss?
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-loss of hair cells and neurons in cochlea.
-decreased blood supply and endolymph -gradual onset, bilateral, high frequency loss |
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What causes sensorineural loss?
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-genetic
-systemic disease -ototoxic substances -exposure to loud noises |
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What is Mixed hearing loss?
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- both conductive and sensorineural impairment
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With a patient w/ sensorineural hearing loss, what do they have difficulty with?
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-understanding speech and consonants.
* May say they can hear but they don't understand really. |
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Assistive devices
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-magnifiers
-talking watch -large print -audio reader -red carpet service at public library |
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Assessment acuity tests
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-Snelling
-Cardiff Acuity Test: cards A to K, increasingly aint targets. "G" card threshold for impairment. *Poor performance on acuity test may be due to uncorrected refractory error |
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Rsk factors for functional decline?
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-acute illness/hospitalization
-exacerbation of chronic illness -injuries -drug interactions/SE -depression, dementia,delirium -Altered nutrition/hydration -immobility while in hospital -hospital environment |
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Assessment observation
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-how well do they navigate environment?
-ask how doing in ADL's such as reading news and signs -does pt complain about excessive glare, color distortion, changes in social function? |
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What is functinal status/
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the capacity to safely perform daily tasks that enable a person to live and function.
* sensitive indicator of health or illness of an elder. |
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What is functional decline?
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-consequences of physiological changes
-predictable decline in functional reserve capacity of each organ system -results in inability to perform activities that ensure a person's independence |
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What % have functional decline during hosital stay?
Why is this? |
- 20-40%
-B/C forcus of care is to treat acute illness. -factors that affect independence are overlooked |
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What happens to those with greatest loss of ADL's in hospital?
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will likely go to care facility
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What is deconditioning?
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-decrease in muscle mass and other physiologic changes tat result from aging or immobility or both and contribute to overall weakness
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What is "cascade to dependency"?
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process that leads to disability in person who has normal aging changes and is on bedrest in hospital.
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What is the "cascade" with immobility
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results in loss of muscle mass and strength
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How much muscle strength is lost when immobile?
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5 % each day!!!
-with repeated episodes may lose ability to restore muscle mass |
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What is the "cascade" in CV system?
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-blood vessels stiffen
-BP rises -valves calcify affecting blood flow -reduced total body water, blood and plasma volume, dehydration- can lead to syncope. |
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If a person is on bedrest for 24-48 hours, how much blood volume is decreased?
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about 500 mL
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What are iatrogenic events?
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things that happen during hospital stay (falls, fx, adverse drug reactions, nosocomial infections, use of chemicals and physical restraints, diagnostic tests.
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Frailty is?
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a clinical syndrome
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Is decline preventable?
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Some may be or improved with prompt and aggressive nursing interventions; some may be progressive and not reversible.**Begin with functional assessment.
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What is functional assessment?
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- a comprehensive evaluation of physical and cognitive abilities required to maintain independence in daily life
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What does functional assessment emphasize?
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the elder's ability to fulfill responsibilities and perform tasks for self care
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What is the treatment for Meniere's disease?
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-lay down on firm, motionless surface
-open eyes and fix on object -don't drink any fluids -get up slowly after episode -PT: balance exercises -avoid dizziness triggers |
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What is the treatment to prevent or reduce episodes of Meniere's disease?
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-avoid caffeine, ECOH, smoking
-avoid high carb foods and candy - decrease salt intake to improve fluid balance in inner ear. |
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Other treatments for Meneire's disease
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-use night light
-medication- diuretics -surgery- perfusion of inner ear w/ antibiotics or steroids or endolymphatic chamber decompression. |
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what is the most common cause of dizziness in elders?
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Benign Paroxysmal Positional Vertigo
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What is benign paroxysmal positional vertigo?
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- normal aging change involving degeneration of vestibular system
-paticles of Ca carbonate crystals dislodge and float to the wrong part of the ear canals which stimulate sensors |
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benign paroxysmal positional vertigo
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intense, brief episodes of vertigo after changing head position.
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otoconia
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particles of Ca carbonate crystals in ear
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What are s/s of benign paroxsymal positional vertigo?
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dizziness, imbalance, nausea
-changing head positions |
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How do you assess benign paroxysmal positional vertigo?
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perform Dix-Hallpike's maneuver which would cause nystagmus and vertigo (diagnostic)
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What is conductive hearing loss?
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-reduced ability of sound to be conducted to the middle ear.
-results in decreased intensity of sounds and difficulty w/vowels and low pitched tones. |
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Types of hearing loss
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Normal- 25 dB or lower
Mild Loss- 26-40 dB Moderate- 41-55 dB Moderately Severe- 56-70dB Severe-71-90 dB Profound Loss- higher than 90 |
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What is conductive hearing loss associated with?
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-hx of otosclerosis
* background noise is not a problem! |
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What are the risk factors of hearing loss?
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increased age, male, white, genetic(otosclerosis), occupational, recreational, otoxic meds, ototoxic environment, chemicals, smoking
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What are the systemic effects of hearing loss?
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Diabetes, increased fever, head trauma, HTN, Meniere's, meningitis, measles, mumps, CVD, hypothyroidism, bacterial or viral inf. of middle ear if no tx.
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Functional decline: Immobility
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low mobility in hospital pts; a predictor of poor outcomes at discharge such as ongoing decline in ADL's, new admission to care facility, or death.
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History of Functional Assessment
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-began in the 1920's w. workers' comp.
-1940's emphasis on rehab w/ WWII injuries; 1954 term ADL's 1st used. 1960's instruments developed. |
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Functional Decline: Impaired Cognition
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-dementia or delirium is a predictor of functional decline.
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Elder's Driving
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-adjust driving behaviors by:
*driving shorter distances *driving more slowly *avoid night driving * not driving in inclement weather. |
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What % of patients have functional decline during hospital stay?
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20%-40%
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Why do patients decline functionally during stay in hospital?
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-Focus of care is to treat acute illness. Factors that affect independence overlooked
-Those w/ greatest loss of ADL's in hospital will likely go to care facility. |
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Frailty
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A midpoint between independence and death
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Criteria for Frailty:
*Must have 3 or more of these |
-unintentional wt loss (#10 in last year)
-self report of exhaustion -weakness of grip strength -slow walking speed -low physical activity |
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What is Functional Assessment?
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- a comprehensive evaluation of physical and cognitive abilities required to maintain independence in daily life.
-emphasizes elder's ability to fulfill responsibilities and perform tasks for sefl care. |
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Benign Paroxysmal Positional Vertigo
What is the goal? |
-move particles from the fluid-filled semicircular canals (vestibular labyrinth) back into a tiny bag- like structure (utricle)
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Epley Maneuver follow up on BPPV
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patient is placed in several positions and turns head to promote return of otoconia.
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BPPV Treatment
Epley follow up |
sleep in recliner @ 45 degrees for 2 nights.
*Avoid head positions that cause BPPV for at least one week |
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Value of assessment tools
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-functional impairments can be early indication of active illness in elder.
-assist client and family in maintaining highest degree of functional independence. -aids in planning for future care needs. |
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What are important things to remember when assessing an elder?
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-test in stages
-establish rapport -inform about goals of testing (what type of help is needed?) -have family/caregiver validate. |
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Katz assessment measures what?
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ADL's
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Lawton assessment measures what?
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IADL's (higher level ADL's)
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Risk factors for elder driving
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-increased age and # of miles driven
-stroke, dementia, visual impairment, meds, limited ROM of head, neck, extremities, slower motor response, delayed reaction time, difficulty switching attention b/w tasks. |
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Demographics- falls in the elderly
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*75% of nursing home residents fall each year.
*2-10% of hospital admissions fall *1/2 of fallers over age 75 w/ serious fracture die w/in first year after fall |
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Sentinel event
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-serves a signal of acute illness or exacerbation of chronic illness
-falls can be a marker of poor health and declining function. |
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Why do elders with higer level of functional capacity usually fall?
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- hazards in the environment (extrinsic factors)
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Falls in frail elders tend to be related to?
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- functional and physiological changes (intrinsic factors)
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Risk factors of Falls (Intrinsic)
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-sensory impairments, orthostatic hypotension, impaired mobility/gait/balance, foot problems, cognitive impairment, frailty and previous fall hx.
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Risk factors of Falls (Intrinsic)
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Polypharmacy, diuretics, benzo's, opiods, antidepressants, anticholinergics, psychotrophics, antihypertensives, NSAIDS
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Risk factors for Falling (Intrinsic)
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-urinary urgency or incontinence (slip on pee)
-acute.chronic illness; electrolyte imb., arrhythmias, stroke, seizures, Parkinson's, exacerbagtions of COPD, CHF, renal disease. deconditioning |
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Risk factors for Falling (Extrinsic)
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lighting, floor treatments, furniture, room design, unsuitable footwear, use of assistive devices, stairs, unfamiliar environment, clutter, restraints, side rails
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The likelihood of falling increases with what?
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- with the number of risk factors
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What can falls also lead to?
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spontaneous fractures
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Implications of falls
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-greater decline in ADL's and social activities
- 1/4 with hipo fractures die w/in 6 months -50% who survive go to nursing home and half still there a year later -10-15% have decline in life expectancy |
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Fallaphobia
Psychological Implications |
Fear of falling is almost as harmful as falling itself causing lack of confidence, restricted activity/exercise and more falls
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Characteristics of Fearful Elderly
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-Tentative
-reluctant to go places -isolated -deconditioned |
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Serious injury can also result from?
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not being able to get up!
*soft tissue injuries, stiffness, weakness, treatment delay, dehydration, rhabdomyolysis |
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Risk factors: not being able to get up
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-older than 80 years old
-decrease shoulder and knee strength -poor balance, dizziness -dependence on others for ADL -arthritis |
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Evaluating a fall
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-hx, activity, time, pre-fall sx, location, witnessess, hx of similar falls, past medical hx/medications
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Evaluating a fall: Physical Assessment
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-visual acuity
-BP,P, arrhythmia, bruits -extremities: arthritis, edema, foot probs, poorly fitted shoes, ROM, strength -neuro: mental status testing, assess gait/balance |
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Evaluating a fall: Physical Assessment
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continence, Romberg test (just a tool), injuries, use of assistive devices>>are they using them? If no, why not?
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Assessment tools
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SVHC-Morse fall scale
-Tinetti gait and balance assessment -Timed "getr up & go test -Hendrich II Fall Risk Model |
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Interventions for falls
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-discuss falling and fear of
-prevent deconditioning -consider interventions to reduce injury (padding) -assistive devices |
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Interventions for falls: Address causes
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Polypharmacy, visual deficits, confusion/mood state, environmental hazards
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Interventions for falls
Exercise |
-encourage regular exercise
-minimize pain -tai chi- type of balance exercise. |
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Interventions for falls: electronic alerts
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-home monitor: "Lifeline"
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Long term care
Traditional definition |
care provided in nursing homes
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Long term care
Broader definition |
services and support, formal and informal that helps people function as well as possible
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Aging in Place
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range of services that allows older adults to remain in one setting and recieve differnet levels of care as needs change
ex: PACE programs, Continuing Care Retirement Community |
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Acute Care Settings
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-in-patient hospital units
-subacute units (KRH, Select Specialty, aubacute units in nursing homes -ACE units (Acute Care for Elders) in hospitals; recognizes unique needs of elders |
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What is the focus of acute care settings?
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-assisting elders with complex problems to remain at highest functional level
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Reasons for admission for long term care nursing facilities
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-needs assistance w/ several ADL's, living alone w/ no available caregivers, lack of informal hospitalization, female, white, poverty
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Common diagnosis for admission to long term care facilities
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-heart disease
-HTN -dementia |
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Skilled nursing home care
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-post hospital care of elders w/ rehab potential
-medicare and health insurance cover -must meet Medicare criteria for "skilled". |
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Medicare criteria
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-100 days if progressing; many only meet criteria for 32 days
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What do you need to do to qualify for medicare for skilled nursing?
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-you have to stay 3 midnights
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Intermediate Care
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-need on going assistance w/ ADL's
-no medicare coverage -private pay, long term care insurance or medicaid |
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Dementia Units
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-some nursing facilities offer this
-may have units that care for disease according to its stage (early, mid, advanced) |
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"Cultural change" in Nursing Facilities
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-move away from traditional clinical setting to more "homelike" setting
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Regulations of long term care facilities
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-highly regulated by the state and federal government>>result of nursing home reform beginning in 1989
-Kansas Dept of Aging is the agency that enforces the regulations in Kansas |
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2 Types of Ownership
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-many facilities are operated by chains or for-profit organizations
-some are not for profit organizations |
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Assisted Living
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-may be free standing or connected to facility that provides other levels of care
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Assisted living helps elders with?
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-help w/basic ADL's
-medication assistance -meals, activities, transportation -medical needs>>directly or outside services |
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Assisted Living staffing
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-a nurse on staff is NOT required in most states
-likelihood of having to move to nursing home is less if RN on staff |
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Cost of Assisted Living
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-basic fee plus add charges for additional services that are outlined in a service contract.
-generally Medicare/Medicaid do NOT cover unless qualifies for medicaid program (HCBS) |
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What happens if condition of elder deteriorates in assisted living ?
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-most likely have to move to setting that can meet their needs.
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Independent Living
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-senior housing
-may be free standing -may have services and may not -no health services unless resident arranges from outside source -may be rent subsidized |
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Independent Living
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-may be part of services offered in a retirement community
-would include options such as meals, activites, transportation, intermittent nursing services |
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Community Care
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-Independent living
-Group homes ( no requirement for nursing background to operate) -Home Health Care-some is Medicare certified |
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Medicare Certified must have what?
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- a need identified by Medicare as "skilled",
- must be homebound -short term service |
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Home Health Care
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-Medicaid may pay for some
-Grant funding under Older American Act -Out of pocket or private insurance |
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Adult Day Care
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-available in nursing homes or Midland Care Connection
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Parish Nursing
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-in faith communities, holistic approach, assessing, educating, referrals, spiritual counseling
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Risk factors for altered presentation
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-over age 85
-multiple co-morbidities -multiple medications -cognitive or functional impairments |
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Why is presentation altered?
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-diminished physiologic reserve to respond to stress
-organs age @ different rates -illness in elders complicated by age-related changes and multiple chronic health probs. |
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Under-reporting factors of altered presentation
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-symptoms are vague
-onset of symptoms insiduous -symptoms regarded as normal agingl -elder will NOT complain -communication deficits |
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Note on sentinel event
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-fall isn't the main problem; something else caused it (ex: UTI)
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Consequences for altered presentation
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-increased morbidity
-increased mortality -missed diagnosis -unnecessary use of ER |
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Geriatric Syndromes
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-non-specific symptoms that may signify an impending acute illness in an elder
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Non-specific symptoms of geriatric syndromes
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Changes in mental status, dehydration, decrease in appetite, loss of functional ability, incontinence, falls, pain, dizziness ("What's going on behind everything?")
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Possible underlying causes of mental status change
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adverse reaction to drugs, untreated anemia, hypoxia,infections, metabolic disturbances, vitamin/nutrition def., decreased sensory input, dehydration, untreated thyroid disease
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Possible underlying causes of Falls
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environmental or health related?, functional capacity, change in mental status, psychological factors, meds, neurological, continence, cardiac, sensory
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Possible underlying causes for dehydration
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decreased muscle mass so less free water, thirst response blunted, chronic dehydration, acute dehydration
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Chronic Dehydration is risk for?
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acute dehydration
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Acute Dehydration is risk for?
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further dehydration with urine not concentrated by kidneys
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What is one way you can assess for increased water loss?
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-put hands under arm pits. YUCK
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Possible underlying causes: decreased appetite/early satiety
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not classic anorexia
--may indicate worsening CHF or early onset of pneumonia |
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Possible underlying causes for Pain
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-difficulty identifying origin
-difficulty rating on 1-10 scale -non-verbal cues -undertreatment (people don't want to get addicted to meds. |
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Possible undelying causes: Loss of functional ability
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-fatigue and decline in activity may indicate aneiam, thyroid disease, infection, cardiovascular or pulmonary insufficiency
-knowing baseline is helpful-compare the change |
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Possible underlyuing causes: Dizziness
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May be sign of anemia arrhythmias, depression, infection, ear disease, acute MI, CVA, vasovagal response, cerumen impaction, cerebral tumor, adverse drug reactions
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Possible underlying cause: Incontinence
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UTI
Limited mobility Metabolic problems Medications |
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How do you know if it's an altered presentation?
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look for a hanful of s/s which imdicate "atypical" and occur outside the norm of traditional s/s of a disease
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Altered Presentation of Disease: Infection
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-decreased immune function
-lower core body temp -absence of fever -inflammatory response slowed -may not have leukocytosis |
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Altered Presentation of Disease: Infection (Common)
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Pneumonia-increased rr, decreased appetite, and function
UTI- incontinence, increased confusion, falls Skin infections-may be missed becasue of chronic edema, difficulty moving/ undressing |
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Altered Presentation of Disease: GI system
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Obstruction-cramps, dehydration, diarrhea
GI blleding-signs of dehydration; crampy pain, not localized -Diverticulities Appendicitis |
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Altered Presentation of Disease: Pulmonary edema
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-may not have "classic" paroxysmal nocturnal dyspnea or cough
-Onset: change in function, food or fluid intake, confusion, increased edema, fatigue, possible dyspnea |
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Altered Presentation of Disease: Thyroid Disease
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-fatigue or tremor absent or missed
-hyperthyroid- new onset afib, wt. loss, muscle weakness, confusion, fatigue -hypothyroid-few if any s/s; may be confused or agitated -carefully assess reports of fatigue |
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Altered Presentation of Disease: Type II Diabetes
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-with hyperglycemia>>dehydrated, confused, incontinent...not the 3 P's
-hypoglycemia- confusion (early symptoms) |
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Why do elders have increase risk of hyperglycemic episode?
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because some meds stimulate insulin production but elder less able to make and store glycogen to counteract drops in BG
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Altered Presentation of Disease: Depression
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-lack of reports of sadness
-pre-occupation w/ physical complaints -society expects elders to be tired, have little interest in life. |
