Care Of Adults And Older Adults Exam 4

Front 1

What is the purpose of the mini nutritional assessment Part 1 and Part 2?

Whose responsibility is it to obtain the assessment and how long does JCo allow?

Back 1

Part 1: Designed to detect acute disease, psychological stress, current mobility status, and a decrease in BMI

Part 2: Determines the presence of pressure ulcers, polypharmacy, number of full meals eaten daily, method of feeding, whether the person lives independently, and the amount and frequency of specific foods and fluids.

- RN's responsibility and they have 24 hours to complete the assessment

Front 2

What do the scores mean in the first part of the MNA?

At what point does the the second part need to be completed and why?

Back 2

Screening score can be as high as 14 pts.
Score of 12 to 14 = normal nutritional status
Score of 8 to 11 = at risk for malnutrition
Score of 0 to 7 = malnourished

-Score of 11 or less-proceed to Part II
-More assessment required to determine nutrition status

Front 3

What are the 2 limitations of the MNA?

Back 3

1. BMI scores may be outdated; nurses do not usually perform mid-arm and calf measurements
2. No standardized assessment tool for finding malnutrition in older adults

Front 4

What are the 5 supplements used with the MNA?

Back 4

1. data re. culture
2. preferences, social needs
3. lab values
4. 72-hour food diary to give more information and data about what the patient has taken in, including 5. strict I and O’s

Front 5

What are the 3 categories of the updated beers criteria?

Back 5

- 53 medications or medication classes divided into 3 categories:
1.Potentially inappropriate medications and classes to avoid in older adults (Table #2)
2.Potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes (Table #4)
3.Medications to be used with caution (Table #2)

Front 6

What are the 4 goals of the updated beers criteria?

Back 6

1. Decrease adverse drug events in older adults
2. Improve health outcomes in older adults
3. Apply an evidence-based approach utilizing Institute of Medicine standards
4. Integral part of policy and practice in CMS regulations, Medicare Part D

Front 7

What are the 4 characteristics of Potentially Inappropriate Medications (PIMS)?

Back 7

1. Many have minimal effectiveness in older adults
2. Associated with falls, delirium, G.I. bleeding, fracture
3. “Less-is-more approach”
4. Starting to be incorporated into electronic health records

Front 8

What are the 3 types of dehydration and what causes it?

Back 8

1. Isotonic: results from the loss of sodium and water (G.I. illness)
2. Hypertonic: water loss exceeds sodium loss (fever, reduced fluid intake): most common form due to poor oral intake and/or fever
3. Hypotonic: sodium loss exceeds water loss (diuretic use)

Front 9

What are the labs 9 related to dehydration?

Back 9

1. Serum sodium: Elevated the most sensitive measurement of hydration status
2. Hemoglobin and hematocrit: elevated, increased viscosity
3. Blood urea nitrogen (BUN) High means that the kidneys are not filtering properly
4. Creatinine
5. BUN/creatinine ratio
6. Urine specific gravity: Elevated
7. Osmolarity
8. Glucose
9. Bicarbonate

Front 10

At what rate does re-hydration usually occur?

What are we trying to prevent?

Back 10

- Rehydration usually occurs at 1L/12 hours

- Slow rate to prevent CHF and edema
- Mortality rate due to inability to regulate fluids and electrolytes

Front 11

What are the 10 risk factors of dehydration?

Back 11

1. Acute or chronic illness
2. Diminished thirst perception
3. Functional impairment
4. Decrease in loss of total body water (TBW) with aging
5. Loss of muscle mass-fat cells contain less water
6. Reduced creatinine clearance with age
7. Diuretics, laxatives
8. Psychotropics with anticholinergic properties
9. Other medications, i.e., ACE inhibitors
10. Social isolation

Front 12

What are the 14 consequences of dehydration?

Back 12

1. Increase in mortality
2. Delirium
3. Thromboembolic complications
4. Infections
5. Kidney stones
6. Constipation, obstipation
7. Drug toxicity
8. Electrolyte imbalance
9. Fecal impaction
10. Renal failure
11. Decreased absorption of nutrients
12. Risk of anemia from reduced absorption of iron and folate, B vitamins
13. Risk of osteoporosis from reduced absorption of calcium and vitamin D
14. Exacerbates underlying conditions, such as urinary tract infection

Front 13

What are the 3 nursing diagnoses for malnutrition and dehydration and what might they be related to?

Back 13

1. Imbalanced nutrition: less than body requirements; more than body requirements
2. Risk for imbalanced nutrition
3. Self-care deficit: feeding
4. Impaired swallowing
5. Risk for aspiration
6. Disturbed sensory perception: gustatory
7. Dysfunctional family processes: alcoholism
8. Deficient fluid volume

Front 14

What are the nursing interventions for dehydration?

Back 14

1. Comprehensive assessment and physical exam; labs
2. Risk identification
3. Oral hydration is preferred
4. Calculate daily fluid goal
5. Strict intake and output
6. Rehydrate according to severity and type of dehydration
7. Assist patient with fluid intake
8. Document, document, document

Front 15

What is dysphagia?

Back 15

• Up to 60% of nursing home residents experience dysphagia
• Risk factors: stroke, Parkinson’s, neuromuscular disorders, head and neck cancers, traumatic brain injury, inadequate feeding techniques, poor dentition, tracheostomy
• Can result in aspiration pneumonia, weight loss, sepsis, dehydration, death

Front 16

What are the 3 types of dysphagia and where is the impairment?

Back 16

1. Transfer (oropharyngeal): difficulty moving bolus from mouth to esophagus
2. Transport: difficulty passing ingested bolus down the esophagus
3. Delivery: difficulty moving bolus of food to the stomach

Front 17

What are the 3 types of malnutrition and what are their characteristics?

Back 17

1. Protein-Energy Malnutrition: Most common form in older adults;“Deficiency, excess or imbalance of energy, protein & other nutrients causing adverse effects on body form, function, and clinical outcome.”; Clinical signs of muscle wasting, low BMI
2. Marasmus: develops gradually over months/years; energy intake is insufficient; skeletal muscle is metabolized; serum albumin can be normal
3. Kwashiorkor: more acute or subacute process; precipitated by acute illness and develops over weeks; serum proteins are depleted with consequent edema; high mortality rate; Seen more often in the acute care setting

Front 18

What are the 9 labs associated with malnutrition?

Back 18

1. albumin,
2. prealbumin (more sensitive indicator than albumin ½ life of 2-3 days)
3. cholesterol
4. transferrin
5. total lymphocyte count
6. CBC, thyroid
7. liver function tests
8. complete metabolic panel
9. stool sample

Front 19

What are the normal levels of Serum albumin?

What are the normal levels of prealbumin?

What are the normal levels of Transferrin?

Back 19

Serum albumin: 3.5g/dL is an indicator of poor nutritional state; greater than 4g/dL is desired (Normal: 3.5-5.5)

Prealbumin: sensitive indicator of current protein status; normal range = 20-40mg/dL; 5-15mg/dL = mild-to-moderate protein depletion; less than 5mg/dL = severe protein depletion

Transferrin: iron transport protein; diminished in protein malnutrition
o Less than 200mg/dL = mild-to-moderate protein depletion
o Less than 100mg/dL = severe depletion
o Normal range = 200-400mg/dL

Front 20

What are the 12 risk factors for nutritional impairment?

Back 20

1. Older adults need to be included in the drive to decrease hunger
2. Poverty
3. Poor quality food choices; more economical for people to go out and eat off the $1 menu
4. Transportation issues; inability to get to a market to purchase food
5. Acute or chronic illness
6. Poor dentition and diet restriction; Medicare will not pay for dental care
7. Functional, mental, cognitive impairment
8. Alterations in diets; Ex. Ensure
9. Involuntary loss or gain of 5% weight in one month, 7.5% in three months, 10% in six months 10. Social isolation is directly associated with malnutrition
11. Polypharmacy
12. Psychiatric illness

Front 21

What are the14 risk factors associated with malnutrition?

Back 21

1. Older adults need to be included in the drive to decrease hunger
2. Poverty
3. Poor quality food choices; more economical for people to go out and eat off the $1 menu
4. Transportation issues; inability to get to a market to purchase food
5. Acute or chronic illness
6. Poor dentition and diet restriction; Medicare will not pay for dental care
7. Functional, mental, cognitive impairment
8. Alterations in diets
9. Ex. Ensure
10. Involuntary loss or gain of 5% weight in one month, 7.5% in three months, 10% in six months
11. Important to get a baseline height and weight when a patient arrives and trend regularly
12. Social isolation is directly associated with malnutrition
13. Polypharmacy
14. Psychiatric illness

Front 22

What are the consequences of malnutrition?

Back 22

1. Longer hospital stays
2. Institutionalization
3. Medical complications: infections, pressure
lcers, anemia, impaired cognition, hip fractures
4. Increase in morbidity and mortality
5. Direct link between malnutrition, socioeconomic status, and social isolation

Front 23

What are the 7 components to the physical exam?

Back 23

1. Height, weight
2. Vital signs
3. Oral mucosa
4. Skin assessment
5. Functional status
6. Weight history: intentional v. unintentional weight loss
7. Anthropometric measurements

Front 24

What are the 4 goals of MyPyramid?

What are the daily recommended calorie ranges for fat, carbs, protein, and fiber?

Back 24

1. Provide recommendations of types and amounts of food for older adult
2. Can modify for vegetarians and culture
3. Specific daily amount of water added for older adults: eight, 8 ounce glasses
4. Vitamin B12, calcium and vitamin D also added to the pyramid for older adults

o Total calories from fat: 20% to 35%
o Total calories from carbs: 45% to 65%
o Total calories from protein: 20% to 25%
o Fiber: 14g per 1000 calories

Front 25

What are the 4 physiologic changes in aging impacting nutritional status?

Back 25

1. Loss of lean body mass and skeletal muscle (sarcopenia)
2. Slowing of G.I. system causing less efficient absorption of nutrients
3. Decline in organ function impacting elimination of waste products
4. After age 50, stomach produces less gastric acid: causes reduced absorption of vitamin B12 and iron
- Lack the acids to break down nutrients
- B6, B12, Ca+, Vit D are now recommended by MyPyramid or older adults

Front 26

What are the 6 physiological changes in aging impacting nutritional status?

Back 26

1. Vitamin B12 deficiency occurs in 12%-14% of community-dwelling older adults; 25% in institutional settings
2. Slowing of metabolism and delayed gastric emptying
3. Decrease in liver size, blood flow, metabolism of drugs
- Decrease in liver size makes it harder for the medications to be excreted
4. Increase in adipose tissue
- Medications are kept in the adipose tissue and therefore, require lower doses of medications
5. Reduction in renal concentration of urine
6. Diminished thirst sensation and saliva

Front 27

What are the 4 characteristics of polypharmacy?

Back 27

1. Occurs when more medication is consumed than is actually needed.
2. Symptoms might be confused with another illness, leading to prescribing more drugs to treat new symptoms (“prescribing cascade”)
3. Occurs in all settings
4. Review patient’s medication profile if there is unexplained fatigue, sleepiness, ALOC, anxiety, depression, dizziness, tremors, falls, weakness, constipation, diarrhea, incontinence, loss of appetite, rashes, and poorly healing wounds.

Front 28

What is the difference between pharmakodynamics and pharmakokenetics?

Back 28

Pharmacodynamics: physiological interaction between drugs and the body

Pharmakokinetics: movement and action of drugs in the body; determines concentration of drugs, which determines the effect.

Front 29

What is the pharmakokinetics of absorption?

Back 29

I. Absorption into bloodstream and small intestine impacted by:
A. Diminished GI blood flow and gastric motility which delays onset of analgesic effect
B. Decreased gastric acid slows the action of acid-dependent drugs
1. Absorption through the skin after topical administration may actually increase in the older adult as the skin becomes thin and frail (Beers, 1999).
2. Drying of mucous membranes affects absorption of sublingual medications.
3. However, the more drugs taken, the greater the chance that one drug will interfere with the absorption of another.
II. Reduction in salivary secretion and esophageal motility
III. Delayed stomach emptying can inactivate the effectiveness of short-lived drugs before reaching the small intestine
IV. Slowed intestinal motility can increase drug effect due to prolonged absorption

Front 30

What are the pharmakokinetics of distribution?

Back 30

A. Decrease in total body water=greater concentration of water-soluble drugs with increased serum levels (digoxin, lithium)
B. Diminished plasma albumin=more unbound drug in the body
C. Increase in total body fat=higher concentration from decreased metabolism (Valium)
1. Decrease in total body water=greater concentration of water-soluble drugs with increased serum levels (digoxin, lithium)
2. Diminished plasma albumin=more unbound drug in the body
3. Increase in total body fat=higher concentration from decreased metabolism (Valium)
D. Decrease in lean body mass=increase in serum concentration of digoxin, coumadin, Demerol
E. Route of administration influences the bioavailability of drug
F. Distribution is influenced by nutritional status, acute/chronic illness

Front 31

What are the 4 pharmakokinetics of metabolism?

Back 31

1. Reduced size of liver
2. Decrease in hepatic blood flow-slows metabolism of drugs
3. Liver has less capacity to catabolize drugs and metabolites
4. Outcome = higher concentrations of drugs from decreased metabolism; increase in toxicity with normal dosing

Front 32

What are the pharmakokinetics of Excretion?

Back 32

A. Decreased glomerular filtration rate with reduced renal clearance
B. Reduced renal plasma flow and size of kidneys by 50% at age 75
C. Outcome = higher concentrations of drugs
D. Blood flow through the liver decreases with aging, reducing clearance of certain drugs by 30-40% (Beers, 2005)
1. Cytochrome P450 enzyme system – major enzyme system by which the liver metabolizes drugs – becomes easily overwhelmed in older adults. Certain drugs are metabolized more slowly and not as well
2. Renal clearance of drugs can be reduced by up to 50% as a person reaches age 75

Front 33

What are the 6 drugs that are affected by a patient with a decrease in renal function and what do they all require?

Back 33

- REQUIRE LOWER DOSING
1. Digoxin: toxicity levels
2. Cephalosporins: Decrease dose rec. by davis and can add to nephrotoxicity ABX
3. Allopurinol: Inhibits production of uric acid; cautiously in dehydration
4. Ciprofloxacin: ABX nephron toxic
5. Histamine receptor antagonists: Urinary retention due to anticholinergic effects
6. NSAIDS: can cause renal failure

Front 34

What are 4 drug-food interactions?

Back 34

1. Fiber and digoxin = absorption of drug into fiber, reducing drug action
2. Vitamin K foods and warfarin = inhibits anticoagulation
3. Tyramine foods and MAOIs = hypertensive crisis
4. Grapefruit juice with CC blockers (amiodipine, verapamil, nifedipine, Diltiazem), Statins, = increases concentration of drug

Front 35

What are 4 drug-disease interactions that cause problems?

Back 35

1. ASA, NSAIDs & Gastritis = GI hemorrhage
2. Steroids with Cataracts = increase in cataract formation
3. Anticholinergics with BPH = urinary retention
4. Renal impairment with NSAIDs = acute renal failure
5. Anticholinergics can exacerbate glaucoma (blind as a bat??)

Front 36

What are drug-drug interactions?

Back 36

1. Warfarin and ginkgo biloba increases INR: can cause cerebral hemorrhage
2. SSRIs and St. John’s wort increase availability of serotonin
3. Inadequate labeling requirements for supplements and herbal remedies
4. Warfarin (blocks clotting factors) and ASA (deceases platelet aggregation) = risk of bleeding
5. Digitalis (increased CO by slowing HR) and quinidine (suppression of arrhythmias, increases serum digoxin levels) = risk of toxicity
6. Levodopa (dopamine replacement) and clonidine (anti HTN and ADHD) = decrease in antiparkinsonian effect (less affective) and B/P; Davis- Adverse CNS affects and increases orthostatic hypotension
7. Thiazides and long-acting antidiabetics = risk of hypoglycemia
8. Diuretics and NSAIDs = renal impairment (both are nephrotoxic)

Front 37

What are the 3 adverse reactions to consider when giving Benzos?

Back 37

1. Negative impact of drugs on cognition, emotional status, ambulation, continence, balance
2. Client’s goals regarding quality of life (function vs. pain)
3. Overall avoidance of benzos is advised due to 24% increase in hip fractures

Front 38

What are the 4 adverse reactions associated with Benzodiazepines?

Back 38

1. Use of short-life benzos found fracture rate highest in the 2 weeks after starting treatment
2. Likelihood of toxicity, impaired memory, impaired psychomotor performance, balance problems
3. Harder time metabolizing and/or excreting medication when there is hepatic or renal damage
4. Avoid benzos for the treatment of delirium or agitation because it will worsen the delirium

Front 39

What are the 3 considerations when giving Antihistamines to older adults?

Back 39

1. Cough and cold remedies
2. Significant anticholinergic effects: dry mouth, urinary retention, delirium, sedation, constipation, falls, blurred vision,
3. Confusion, and dizziness

Front 40

What are the 3 adverse reactions associated with Sedatives-hypnotics?

Back 40

1. Cause confusion and excessive sedation in the older adult
2. Try alternative therapies
3. Gradual dose reductions

Front 41

What are the 3 considerations when giving Antipsychotics to older adults?

Back 41

1. Must show evidence of appropriate indications for use --> may be prescribed too freely for convince of nurses
2. Haldol has a high EPS profile: tremors, akinesia, akathisia, rigidity; tardive dyskinesia
3. Atypicals can cause diabetes, weight gain, increase risk of stroke and death in older adults with dementia

Front 42

What are the 3 adverse reactions associated with Tricyclic Antidepressants?

Back 42

1. TOO SEDATING
2. ANTICHOLINERGIC EFFECTS
3. ORTHOSTASIS

Front 43

What are the 4 considerations when giving Cardiovascular agents to older adults?

Back 43

1. Increase risk of orthostatic hypotension, dehydration, especially with volume-depleting drugs and vasodilators (nifedipine)
2. Beta-blockers for ischemic heart disease can cause severe fatigue; found to be ineffective for hypertension in elderly
3. Assess for adverse effects of antihypertensive treatment
4. Important to be aware that a BP that is too low can cause a patient to fall

Front 44

What are the 4 characteristics of the Armor tool?

Back 44

1. A tool to evaluate polypharmacy in Elderly persons
2. Takes into account the patient’s clinical profile and functional status.
3. Use of a medication is weighed against the impact on biological functions
4. Research outcomes include a decline in falls and behaviors related to self-harm or harm to others in a long-term care setting

Front 45

What are the 5 steps of the Armor tool?

Back 45

1. ASSESS for total number of meds & groups of meds that have potential for adverse outcome
2. REVIEW for drug-drug interactions, drug-disease interactions, drug-body interactions, impact on functional status; weigh risks and benefits
3. MINIMIZE: non-essential meds, meds that lack evidence for use, risks outweigh benefits
4. OPTIMIZE by addressing duplication; adjust dosing
5. REASSESS: vital signs, oxygen saturation at rest & activity; ADLs, IADLs; cognition; medical adherence

Front 46

What is the MASTER and what are its 5 components?

Back 46

- Rules for rational drug therapy
1. Minimize number of drugs used.
2. Alternative therapies, drugs, and dosage forms for older adults should be considered.
3. Start low, and go slow.
4. Titrate therapy and adjust dosages.
5. Educate the client.
6. Review and monitor responses.