HEALTH ASS 305 ASSESSING THE OLDER ADULT,100% CORRECT

HEALTH ASS 305 ASSESSING THE OLDER ADULT As you well know, the population of the US is aging. The percentage of older patients (always high) is even higher now. Older adults present with unique needs as well as a more complex health picture. The old-old (85) is the fastest growing segment of the population. 82% have at least one chronic condition. Age-associated changes are most pronounced in advanced age of 85 years or older, may alter the older person’s response to illness, show great variability among individuals, are often impacted by genetic and long-term lifestyle factors, and commonly involve a decline in functional reserve with reduced response to stressors. Age Related Changes: Cardiovascular • 1. Arterial wall thickening and stiffening, decreased compliance. • 2. Left ventricular and atrial hypertrophy. Sclerosis of atrial and mitral valves. • 3. Strong arterial pulses, diminished peripheral pulses, cool extremities. • Hartford Institute for Geriatric Nursing Gerontological changes: Are important in nursing assessment and care because they can adversely affect health and function. Must be differentiated from pathological processes to allow development of appropriate interventions; Predispose to disease, thus emphasizing the need for risk evaluation of the older adult; Can interact reciprocally with illness, resulting in altered disease presentation, response to treatment, and outcomes. Implications of the above changes: Decreased cardiac reserve. a. At rest: No change in heart rate, cardiac output. b. Under physiological stress and exercise: Decreased maximal heart rate and cardiac output, resulting in fatigue, shortness of breath, slow recovery from tachycardia. c. Risk of isolated systolic hypertension; inflamed varicosities. d. Risk of arrhythmias, postural and diuretic-induced hypotension. May cause syncope. Implications for assessment 1. ECG; heart rate, rhythm, murmurs, heart sounds (S4 common - The fourth heart sound can be detected occasionally by inspection, commonly by palpation and auscultation, Commonly, its presence indicates increased resistance to filling of the left or right ventricle because of a reduction in ventricular wall compliance; S3 in disease [can be normal in younger adults]) -). Third heart sound is a very important clue to heart failure or volume overload, it does not appear until the problem is relatively far advanced. The left lateral position is of critical importance because the S3 and S4 are often heard only with the patient turned to the side. 2. Palpate carotid artery & peripheral pulses for symmetry.1 2. Assess BP (lying, sitting, standing) and pulse pressure. 2 Age Related Changes: Pulmonary • 1. Decreased respiratory muscle strength; stiffer chest wall with reduced compliance. • 2. Diminished ciliary & macrophage activity, drier mucus membranes. Decreased cough reflex. • 3. Decreased response to hypoxia and hypercapnia. B. Implications 1. Reduced pulmonary functional reserve. a. At rest: No change. b. With exertion: Dyspnea, decreased exercise tolerance. 2. Decreased respiratory excursion and chest/lung expansion with less effective exhalation. Respiratory rate 12-24 breaths per minute. 3. Decreased cough and mucus/foreign matter clearance. 4. Increased risk of infection and bronchospasm with airway obstruction. C. Parameters of Pulmonary Assessment 1. Assess respiration rate, rhythm, regularity, volume, depth,1 and exercise capacity. 3 Auscultate breath sounds throughout lung fields.4 2. Inspect thorax appearance, symmetry of chest expansion. Obtain smoking history. 3. Monitor secretions, breathing rate during sedation, positioning,1,5 arterial blood gases, pulse oximetry.6 4. Assess cough, need for suctioning.7 Age Related Changes: Genitourinary • Decreases in kidney mass, blood flow, GFR (10% decrement/decade after age 30). Decreased drug clearance. • 2. Reduced bladder elasticity, muscle tone, capacity. • 3. Increased postvoid residual, nocturnal urine production. • 4. In males, prostate enlargement with risk of BPH. Implications 1. Reduced renal functional reserve; risk of renal complications in illness. 2. Risk of nephrotoxic injury and adverse reactions from drugs. 3. Risk of volume overload (in heart failure), dehydration, hyponatremia (with thiazide diuretics), hypernatremia (associated with fever), hyperkalemia (with potassium-sparing diuretics). Reduced excretion of acid load. 4. Increased risk of urinary urgency, incontinence (not a normal finding), urinary tract infection, nocturnal polyuria. Potential for falls. Parameters of Renal and Genitourinary Assessment Assess renal function (GFR through creatinine clearance). Assess choice/need/dose of nephrotoxic agents and renally cleared drugs.14(Assess for fluid/electrolyte and acid/base imbalances. 15 Evaluate nocturnal polyuria, urinary incontinence, BPH. 13 Assess UTI symptoms Assess fall risk if nocturnal or urgent voiding Age Related Changes: GI • 1 Decreases in strength of muscles of mastication, taste, and thirst perception. • 2. Decreased gastric motility with delayed emptying. • 3. Atrophy of protective mucosa. • 4. Malabsorption of carbohydrates, vitamins B12 and D, folic acid, calcium. • 5. Impaired sensation to defecate. • 6. Reduced hepatic reserve. Decreased metabolism of drugs. Implications 1. Risk of chewing impairment, fluid/electrolyte imbalances, poor nutrition. 2. Gastric changes: altered drug absorption, increased risk of GERD, maldigestion, NSAID-induced ulcers. 3. Constipation not a normal finding. Risk of fecal incontinence with disease (not in healthy aging). 4. Stable liver function tests. Risk of adverse drug reactions. Parameters of Oropharyngeal and Gastrointestinal Assessment 1. Assess abdomen, bowel sounds. 2. Assess oral cavity); chewing and swallowing capacity, dysphagia (coughing, choking with food/fluid intake). 17If aspiration, assess lungs rales) for infection and typical/atypical symptoms. 3. Monitor weight, calculate BMI, compare to standards. Determine dietary intake, compare to nutritional guidelines. 4. Assess for GERD; constipation and fecal incontinence; fecal impaction by digital examination of rectum or palpation of abdomen. Age Related Changes: Musculoskeletal • Sarcopenia with increased weakness and poor exercise tolerance. • 2. Lean body mass replaced by fat with redistribution of fat. • 3. Bone loss in women and men after peak mass at 30 to 35 years. • 4. Decreased ligament and tendon strength. Intervertebral disc degeneration. Articular cartilage erosion. Changes in stature with kyphosis, height reduction. Sarcopenia is the age-related decrease in muscle mass and strength 1. Sarcopenia: increased risk of disability, falls, unstable gait. 2. Risk of osteopenia and osteoporosis. 3. Limited ROM, joint instability, risk of osteoarthritis. Age Related Changes: Neurological • 1. Decrease in neurons and neurotransmitters. • 2. Modifications in cerebral dendrites, glial support cells, synapses. • 3. Compromised thermoregulation. 1. Impairments in general muscle strength; deep-tendon reflexes; nerve conduction velocity. Slowed motor skills and potential deficits in balance and coordination. 2. Decreased temperature sensitivity. Blunted or absent fever response. 3. Slowed speed of cognitive processing. Some cognitive decline is common but not universal. Most memory functions adequate for normal life. 4. Increased risk of sleep disorders, delirium, neurodegenerative diseases. C. Parameters of Nervous System and Cognition Assessments 1. Assess, with periodic reassessment, baseline functional status. During acute illness, monitor functional status and delirium. 2. Evaluate and periodically assess cognitive function. 3. Assess impact of age-related changes on level of safety and attentiveness in daily tasks. 4. Assess temperature during illness or surgery. Age Related Changes: Immune System • Immune response dysfunction with increased susceptibility to infection, reduced efficacy of vaccination, chronic inflammatory state. Follow CDC immunization recommendations for pneumococcal infections, seasonal, influenza, zoster, tetanus, hepatitis for the older adult Atypical Presentation of Disease • 1. Diseases especially infections may manifest with atypical symptoms in older adults. • 2. Symptoms/signs often subtle include nonspecific declines in function or mental status, decreased appetite, incontinence, falls, fatigue, exacerbation of chronic illness. 5 • 3. Fever blunted or absent in very old, frail or malnourished adults. Baseline oral temperature in older adults 40 is 97.4 °F (36.3 °C) versus 98.6 °F (37 °C) in younger adults . 1. Note any change from baseline in function, mental status, behavior, appetite, chronic illness18. 2. Assess fever; Determine baseline and monitor for changes; 2–2.4 °F (1.1–1.3 °C) above baseline16. Oral temperatures above 99 °F (37.2 °C) or greater also indicate fever18. 3. Note typical and atypical symptoms of pneumococcal pneumonia16,19,41, tuberculosis33,influenza16,UTI16, peritonitis39, and GERD42. Atypical Presentation of Illness: Infection • Absence of fever • Sepsis without usual leukocytosis and fever • Falls, decreased appetite or fluid intake, confusion, change in functional status Considering the frequency of infections in older adults, more often affecting the urinary tract, the respiratory tract, the skin or the GI tract, an infection should be suspected with any change in condition, including falls, a decrease in food or fluid intake, confusion, and/or a change in functional status For example, a patient with Pneumonia would typically present with fever, cough with sputum production and SOB. Elderly may not have any of these symptoms but present with confusion, malaise, anorexia. UTI typical presentation: burning on urination, frequency, hematuria. Atypical presentation would not have any of these but could present as confusion, incontinence, and anorexia. Atypical Presentation of Illness: MI • Absence of chest pain • Vague symptoms of fatigue, nausea and a decrease in functional status. • Classic presentation: shortness of breath more common complaint than chest pain Most myocardial infarctions in older adults do NOT present with clinical symptoms such as chest pain. Clinicians need to be astute to patients at risk who present with vague symptoms of fatigue, nausea, and a decline in functional status. When patients do present with a more classic picture of an acute event, a more common complaint than chest pain is shortness of breath. Symptoms that may Indicate Impending Major Illness in Older Patients CONFUSION APATHY SELF-NEGLECT ANOREXIA FALLING DYSPNEA INCONTINENCE FATIGUE It is essential to take reports seriously from patients, family and non-professional care providers as to subtle symptoms such as mild confusion, changes in ability to perform activities of daily living (ADL), and decreased appetite. Timely identification of acute illnesses with vague presentation enables early treatment of illness resulting in reduced morbidity and mortality and an enhanced quality of life in older adults. CHALLENGES OF ASSESSING THE OLDER ADULT • Atypical disease presentation • Extensive medical histories • Communication/Sensory deficits Older adults may have more chronic health problems. cluster of health problems may complicate your assessment. Keep in mind that the most frequently occurring conditions reported in older adults are hypertension, arthritis, heart disease, cancer, diabetes, and sinusitis. • Older adults may mistake a health problem for a normal part of aging. Consequently, patients may not report symptoms that they believe to be normal. For example, an older man may assume that frequent nighttime voiding is a normal part of aging when it could indicate benign prostatic hyperplasia (BPH) or another medical condition. Frequent nighttime voiding can also be linked to use of certain medications, such as diuretics. • Older patients are more likely to develop cognitive problems when experiencing acute and chronic illnesses. For example, confusion and cognitive impairment frequently occur with infection and polypharmacy. Never interpret confusion as a normal sign of aging. Any sudden change in cognition (occurring over hours or a few days) may signal an acute, reversible condition. Special Assessment Considerations ▪ Extra time is usually needed ▪ Help patient into the exam room ▪ Dressing and undressing ▪ Address by last name ▪ Ask one question at a time ▪ Allow adequate response time ▪ Repeat questions and confirm answers Special Assessment Considerations ▪ Patient is the primary source of information ▪ Use medical records, family and friends for clarification ▪ Establish a caring relationship ▪ Start with questions that focus on orientation and past information ▪ Use common lay language Subjective data collection • Special needs • Impaired hearing • Visually impaired • Aphasia • Alzheimer’s or related  MMSE FOCUS AREAS • Mobility • Medications • Nutrition • Acute and persistent pain • Sexuality • Urinary incontinence & skin breakdown • Smoking and alcohol • Risk for falls MOBILITY • Activities of daily living • Basic self-care activities • Bathing • Dressing • Toileting • Feeding • Transferring • Instrumental activities of daily living o Higher level functions ▪ Shopping ▪ Preparing food ▪ Housekeeping ▪ Laundry ▪ Taking medicine ▪ Managing money ▪ Driving MEDICATIONS • Experience more side effects from medications due to the smaller size and decreased functioning of the liver and kidneys • Poly-pharmacy • Visual impairment may cause mistakes • Ask if they know why they are taking a medication • OTC-vitamins, herbs, minerals, cold preparations • Should bring meds to clinic or hospital for staff to see RISK FOR FALLS • History • Medications • Gait or muscular weakness • Dizziness, vertigo, or loss of consciousness a time of fall • Visual changes • Environmental problems • Major illnesses Environmental Structure and Hazards • Stairs • Accessibility of the bathroom and kitchen • Help with kitchen and household activities • Assistive devices • Referrals NUTRITION • Assessing for risk • Finances, transportation • Functional & sensory deficiencies  Taste changes  Poor fitting dentures  Weight loss  Depression • 1/3 with deficiencies Acute and persistent pain • 80% of clinic visits • MS, joint, back pain • Less likely to report pain • Fear of extra cost • Extra treatment • Fear of progression of disease • Lead to depression, social isolation, physical disability • Use visual analog pain scale Urinary incontinence • Do not report due to embarrassment • May believe is normal part of getting old • Many risk factors • Age, limited mobility, caffeine intake, impaired cognition, prostate enlargement, diuretics, DM, stroke SEXUALITY • “Tell me about your sex life” • Loss of lifetime partner • Sex education • Use of condoms • STD SMOKING AND ALCOHOL • Harmful, risk for heart & pulmonary disease • 10% have alcohol related problems • Increase # of the elderly with drinking problems • Detecting alcohol use • Memory loss • Depression, anxiety, change in hygiene/appearance • Impaired gait • Malnutrition CURRENT HEALTH STATUS • Reason for seeking treatment “chief complaints” • May be over lapping • Set priorities • Use open ended questions PAST HEALTH HISTORY • Obtain a comprehensive medical history • Known problems • Specific diseases • Hospitalizations • Childhood illnesses (missed school or in bed for extended periods) ex. Rheumatic fever COMMON OLDER AGE SURGERIES • Cataract surgery • Joint replacements • Removal of skin lesions • GB, appendix, uterus, or prostate • Obvious scars FAMILY HISTORY • Mortality • Alzheimer’s • Familial conditions • HTN • Heart disease • Diabetes • Cancer • Drug/alcohol addiction • Mental illness Family history will give indications of diseases patient is at risk for. ROS • Perform usual review and focus on problems that are prevalent in the older adult COMMON SYMPTOMS • Incontinence • Sleep • Pain • Cognitive changes • Depression • Injuries caused by elder abuse SUPPORT SYSTEMS • Personal and community support • Types of interactions (phone calls and visits) ADVANCE DIRECTIVES AND PREFERENCES FOR CARE • 1990 Patient –Determination Act • Gives patients choice regarding health care interventions. • Nurses are at the forefront of these discussion. SCREENING AND PREVENTION • Pneumonia • Mammogram • Prostate Exam (Rectal and PSA) • Fecal occult Blood • Cholesterol • Depression “Do you feel sad or depressed” Physical Assessment • Friendly environment • Warm room • Minimum background noise • Higher than standard seating, with arm rests • Broad based- step stools • Minimize position changes • Only uncover the part being examined. • Make safety a priority • Explain what you are doing GENERAL SURVEY • Appearance, hygiene, emotional status • Posture and gait– senile kyphosis • Skin lesions • SOB • Vital signs, ht and weight In oldest patients, subQ tissue is lost, giving a more angular appearance. Posture generally more flexed. Gait may change with wider stance and smaller steps. Pulse rate remains unchanged at rest. Adjustments to activity may be slow. Maximum heart rate is decreased. Returns to normal more slowly. Respirations often slightly higher than for younger adults. Temperature slightly lower than in young adults. Integumentary • Graying of hair • Thinning of hair and balding • Hirsutism • Coarse, dry hair, • Flaky scalp • Nails yellow, dry, ridges, fungal infections • Decreased turgor ,bruising, dermatitis An aging-related decline in melanin production makes the hair less vibrant in color, leading to graying. Also, the hair thins; many older adults lose their hair altogether. Dermal vascular beds diminish with age as well, altering hair distribution patterns. Some men are genetically predisposed to baldness and may experience hair loss at younger ages. Assessing the nails Regardless of the patient’s age, nail surfaces normally are flat or slightly curved. Note their color, length, and cleanliness. Check for abnormalities. Clubbing may indicate a cardiac or pulmonary disorder; pitting and transverse groves may signify peripheral vascular disease, arterial insufficiency, or diabetes. Brittleness may stem from decreased vascular supply, whereas yellow or brown nails may signal a fungal infection. Wrinkled skin results from loss of elasticity and turgor. With age, the skin gradually thins and loses density, making it more susceptible to bruising and tears. Inspect the skin for lesions and moles. Check for pressure ulcers. Pressure ulcers are most common on the sacrum, heels, and trochanters. Preventable and stem primarily from decreased mobility and activity, insufficient caloric intake, and incontinence. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses for care related to hospital-acquired pressure ulcers, so clinicians must be able to quickly identify at-risk patients and implement preventive strategies. COMMON SKIN LESSIONS • Solar Lentigines (liver spots) • Actinic keratosis (rough precancerous) • Seborrheic keratosis (benign pigmented waxy lesions on face and trunk) When examining moles, look for irregular shapes; ask the patient if any moles have gotten bigger or changed color. Positive findings indicate the need for further evaluation by a primary care provider or dermatologist. Keep in mind that excessive sun exposure exacerbates aging-related changes and may lead to skin cancers such as melanoma. LENTIGINES (LIVER SPOTS) ACTINIC KERATOSIS SEBORRHEIC KERATOSIS HEENT • Decreased peripheral vision • Presbyopia • Dry eyes • Arcus senilis • Xanthelasma • Senile ectropion and entropion • Smaller pupils, retina and optic disc paler Note whether the patient’s eyes, eyebrows, nose, and mouth are centered and symmetrical. Asymmetrical features suggest a stroke. Look for appropriateness of affect and behavior. Vision and hearing assessment: Vision can deteriorate with age. Older adults should have 20/40 vision or better. Such conditions as changing eye shape (presbyopia), cataracts, and glaucoma typically worsen with age. Because of structural changes in the eye, older adults may be more sensitive to glare; as a result, shiny surfaces may increase the risk of falls and result in injury. Encourage adults to get annual eye exams. Hearing loss is common in older adults and usually affects both ears. In general, older adults have more trouble hearing high-frequency sounds, such as consonants (especially p, s, and t) than low-frequency sounds, such as vowels. Refer patients with hearing difficulty to an audiologist. /td Arcus Sensilis A gray-white circle that circumscribes the limbus and results from deposition of lipid, is a common cloudiness that appears around the corneas Composed of cholesterol deposits. Often normal. Or may indicate elevated cholesterol in younger patients. XANTHELASMA Deposits of cholesterol on inner eyelids. May be indicative of cardiovascular disease. SENILE ECTROPION SENILE ENTROPION HEENT • Presbycusis, conductive hearing loss • Diminished pitch, discrimination • Ears lobes elongate • Increase ear hair men • Diminished cone of light • Elongated nose • Increased nose hair • Decreased sense of smell Hearing loss is common in older adults and usually affects both ears. In general, older adults have more trouble hearing high-frequency sounds, such as consonants (especially p, s, and t) than low-frequency sounds, such as vowels. Refer patients with hearing difficulty to an audiologist. RESPIRATORY • Increased anterior to posterior diameter – barrel chest • Kyphosis • Decreased respiratory excursion • Breath sounds decreased Assess breath sounds in all fields. In older patients, breath sounds tend to be diminished in the lung bases due to decreased respiratory muscle strength, a stiffer chest wall, and less elastic lung tissue. Pay particular attention to any asymmetrical variations in breath sounds. Although a barrel chest sometimes indicates chronic obstructive pulmonary disease, in older adults it may also signal vertebral collapse due to osteoporosis. Changes associated with aging of the pulmonary system typically don't affect normal ADL. However, an older adult may find exercising or breathing at high altitudes challenging. Cardiovascular • Increase in premature beats • Irregular pulse • Decreased pedal pulses • Slight increase in BP and wider pulse pressure • Orthostatic drops in BP • More vascular disease • Atherosclerotic changes in the arteries (stiffer arteries)- bruits With advancing age, arterial walls tend to thicken and stiffen. Older adults may develop left ventricular and atrial hypertrophy and sclerosis of the aortic and mitral valves. Extra heart sounds are a common assessment finding in older adults, so you may note an S4 and systolic aortic murmurs on auscultation. However, an S3 is a sign of heart failure, volume overload, or ventricular dysfunction, and is always abnormal in older adults. Gastrointestinal • Colorectal cancer peaks between 85 and 92 • Abdominal aortic aneurysms increase with age • Abdomen soft • BS decrease • Listen for bruits Musculoskeletal • Decreased arm swing • Wider base of support • Abnormal gait • Decreased sensory input, • Slower motor responses, • Thoracic curvature, • ROM decreased, • Crepitus, stiffness, • Decreased muscle strength and tone Investigate for abnormalities suggested by the health history data, such as loss of balance, gait disorders, postural abnormalities, or inability to transfer from a chair to a standing position. If the patient is weak, with poor coordination, you may need to allow additional time for the functional examination. Evaluate muscle groups for atrophy, tremors, and involuntary movements. ROM tests in older adults are similar to those used in other age-groups. However, inflamed joints may limit ROM in older adults. Inspect joints of the hands, wrists, knees, hips, and shoulders—areas more prone to arthritis. Note warmth, swelling, tenderness, crepitus, and deformities. Maintaining independent functioning as long as possible improves quality of life—a fundamental principle of geriatric nursing. Assess the patient’s ability to perform activities of daily living (ADLs), including bathing, dressing, toileting transfer, continence, and feeding. Also assess more complex functioning skills such as those needed to perform instrumental ADLs (IADLs). These are activities that enable an individual to live independently, such as the ability to use the telephone, travel, shop, prepare meals, do housework, take medication appropriately, and manage money. Neurological • Decrease in olfactory & visual acuity • Presbyopia • Pupils smaller • Reflexes less brisk • Decreased taste • Presbycusis • Decreased gag Should still be at 20/40 with correction Female Reproductive • Breast sag • Decrease and graying of pubic hair • External genitalia decrease in size, skin thinner • Pale vaginal walls • Uterus and ovaries decrease in size • Note prolapsed uterus, cystocele, or rectocele Cystocele RECTOCELE PROLAPSED UTERUS Male Reproductive • Gynecomastia • Decrease and graying of pubic hair • Scrotum and penis decrease in size • Testes hang lower and have fewer rugae Key Points • Older adults heal more slowly because of slower growth of new cells. • Loss of vision can significantly affect ADLs, including dressing, grooming, and ambulating safely. • Allow older adults extra time to answer subjective data questions. • Special challenges to interviewing older adults include hearing, visual, language, and cognitive impairments. • Geriatric syndromes include nutritional changes, mobility impairment, falls, polypharmacy, and skin breakdown. • Common problems of older adults include urinary incontinence, sleep problems, pain, cognitive changes, depression, and elder abuse. • The skin of the older adult has increased wrinkling and is thinner, less elastic, and drier. Pressure ulcers in the sacral and ischial areas, greater trochanteric area, or heels should be staged and interventions begun immediately. • Senile ptosis, dry or red eyes, smaller and slower pupillary responses, and difficulty with glare are common ocular findings. • Loss of hearing is a common finding in the older adult. • Unexpected findings in the mouth include pallor, malodorous breath, poor dentition, and candidiasis. • The older adult has a less elastic chest wall, decreased respiratory muscle strength, loss of alveolar recoil, and increased residual volume. • Arterial walls are less elastic and stiffer, causing increased systolic blood pressure, increased ventricular wall hypertrophy, decreased coronary blood flow, reduced cardiac output, and increased circulating catecholamines. • Arrhythmias, especially atrial fibrillation, are common in older adults but should be considered abnormal. • Gastrointestinal changes include slowed peristalsis, reduced hepatic flow, and decreased metabolism of drugs on the first pass. • Common normal neurological findings include restricted upward gaze, slowed coordination, slowed gait, decreased reflexes, decreased strength, and impaired sensation. • The older adult should be assessed for depression, dementia, Parkinson disease, and signs of cerebrovascular accident. • Older adults often lose height and lean body mass. • Large nodules in the distal interphalangeal joints are Heberden nodes. Enlargements of the proximal interphalangeal joints are Bouchard nodes, a common finding in association with arthritis. • Kidney function decreases with age, causing a decreased glomerular filtration rate, decreased creatinine clearance, and inability to conserve sodium. • Endocrine changes include decreased growth hormone, decreased adrenal hormones, decreased response of the immune system, and increased glucose intolerance. • Common nursing diagnoses for older adults include Risk for falling, Risk for skin breakdown, Urinary incontinence, Altered sleep pattern, Confusion, Adult failure to thrive, Disturbed sensory perception, and Imbalanced nutrition. Review Questions 1. Which of the following findings are considered an expected change in the skin in older adults? A. Solar lentigines (liver spots) B. Actinic keratoses C. Loss of subcutaneous fat D. Photoaging C. Loss of subcutaneous fat. Rationale: The skin normally thins and loses subcutaneous fat with aging, making it more susceptible to tears and breakdown. 2. Which of the following statements is true concerning changes in the older adult? A. The lens becomes smaller and less dense. B. The tympanic membrane becomes more flexible and retracted. C. Changes in the inner ear can interfere with sound discrimination. D. Increased pupillary responses lead to difficulty in light accommodation. C. Changes in the inner ear can interfere with sound discrimination. Rationale: As the older adult ages, sound discrimination is altered, making it difficult to hear voices when around a lot of background noise, such as a television. 3. When speaking with a frail older adult, it is best to A. fill in silences to avoid discomfort. B. address all questions to the patient's family. C. rely on the patient's memory when gathering all information. D. ask questions using lay terms rather than medical terms. D. ask questions using lay terms rather than medical terms. Rationale: The older adult needs more time to answer questions. It is best to talk directly with the patient and use the family as a resource as needed. Information from the chart can be validated with the patient, but it is best to gather information ahead of time to avoid asking unnecessary questions and fatiguing the patient. 4. The nurse assesses for geriatric syndromes, which are A. the interaction of multiple diagnoses that contribute to problems in the older adult. B. the exacerbation of chronic conditions such as congestive heart failure or chronic obstructive - pulmonary disease. C. conditions in which older adults may not mount an immune response. D. decreases in growth hormones and steroids that reduce functional status. A. the interaction of multiple diagnoses that contribute to problems in the older adult. Rationale: Although no agreement exists on which clusters of symptoms are geriatric syndromes, agreement exists that they are syndromes that involve multiple systems and diagnoses. 5. Nutritional screening is an assessment of risk factors that A. indicate that the patient is at high nutritional risk. B. identify older adults who may require a more comprehensive assessment. C. calculate BMI and classify patients as obese versus malnourished. D. describe food frequency and microelements that may be lacking in the diet. B. identify older adults who may require a more comprehensive assessment. Rationale: Although the DETERMINE is a screening tool, it is less reliable than other methods. Thus, more comprehensive assessment should be performed, which includes a calorie count, food diary, or food frequency questionnaire. 6. Which question or questions should you ask to assess medication use in the older adult living in the - community? Select all that apply. A. “What medications are you taking?” B. “What is the schedule for your medications? C. “Do you understand why you are taking all of your medications? D. “What is the dose of the medication that you take?” A. “What medications are you taking?”; B. “What is the schedule for your medications?”; C. “Do you understand why you are taking all of your medications?”; D. “What is the dose of the medication that you take?” Rationale: All of the above. It is best to have the patient demonstrate how he or she takes medications. The nurse can see which medications that the patient is taking correctly, those that he or she might be skipping, and those that he or she might be taking too much. 7. As part of the Mini Mental Status Examination, you ask the patient to immediately state three words. This is a measure of which of the following? A. Orientation B. Registration C. Recall D. Attention B. Registration. Rationale: Registration indicates that the brain has processed the information and that the patient has heard the information correctly. Recall is the ability to remember it at a later time. 8. Which of the following patients should the nurse see first? A. A patient with unilateral changes in vision B. A patient with ectropion of the lower lid C. A patient with presbyopia D. A patient with senile ptosis A. A patient with unilateral changes in vision. Rationale: Unilateral changes in vision might indicate a stroke, which should be treated as an acute situation. 9. You auscultate a loud murmur in an older adult patient. You should also assess for which of the following? A. Coarse rhonchi and purulent sputum B. Irregular heartbeat and pulse deficit C. Crackles in the lungs and leg edema D. Abdominal distention and liver tenderness C. Crackles in the lungs and leg edema. Rationale: A loud murmur indicates that there may be backflow of blood through the valve (regurgitation) or difficulty with the blood moving forward over the valve (stenosis). Either of these conditions may result in symptoms of heart failure. Right heart failure causes leg edema; left heart failure causes pulmonary congestion. 10. The patient has findings of cognitive decline, minimal to no intake of nutrition, and neglect of the home - environment and finances. Which of the following is the appropriate nursing diagnosis? A. Disturbed sensory perception B. Impaired individual coping C. Imbalanced nutrition, less than body requirements D. Adult failure to thrive D. Adult failure to thrive. Rationale: These findings are some defining characteristics of adult failure to thrive. Although some data may support the other diagnoses, this is the best diagnosis based on the symptoms.