Nursing Care of the Hospitalized Older Patient
Edited by Terry Mahan Buttaro and Kate A. Barba
Nursing Care of the H
ospitalized Older Patient
Nursing Care of the Hospitalized Older PatientNursing Care for the Hospitalized Older Patient is a comprehensive, quick-reference for nurses and advanced practice nurses working with older patients in a hospital setting. Organized in a user-friendly format, the book provides vital information on all aspects of hospital care and the full range of health issues encountered by elderly patients.
Nursing Care for the Hospitalized Older Patient is organized into four major sections. The first section provides an overview of the aging patient, including demographics, normal aging changes, and the general impact of hospitalization. The second section covers proper health assessment, providing guidance on history taking and evaluating laboratory values. The third section is the largest part of the book and consists of short, similarly structured chapters dedicated to individual clinical issues ranging from burns to depression. These chapters are organized by body system to maximize ease of use. The fourth section covers special considerations that cross common clinical areas, such as palliative care, pain management, fall prevention, and discharge planning.
Special Features • Focuses on care of older patients in a hospital setting • Provides fundamental chapters on aging and health assessment • Clinical section organized by body system in a structured format for easy reference
EditorsTerry Mahan Buttaro, PhD, ANP-BC, GNP-BC, FAANP, is Assistant Clinical Professor at Simmons College, Lecturer at the University of Massachusetts Boston, and Nurse Practitioner with Coastal Medical Associates in Salisbury, Massachusetts.
Kate A. Barba, RN, MS, GNP-BC, is Clinical Nurse Specialist at Massachusetts General Hospital in Boston, Massachusetts.
Titles of InterestCase Studies in Gerontological Nursing for the Advanced Practice NurseEdited by Meredith Wallace Kazer and Leslie Neal-BoylanISBN: 9780813823782
Clinical Case Studies in Home Health CareEdited by Leslie Neal-BoylanISBN: 9780813811864
Buttaro and
Barba
Buttaro Complete Cover BC.indd 2-3 8/16/2012 6:21:06 AM
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Nursing Care of the Hospitalized Older Patient
Nursing Care of the Hospitalized Older Patient
Edited by
Terry Mahan Buttaro and Kate A. Barba
A John Wiley & Sons, Inc., Publication
This edition first published 2013 © 2013 by John Wiley & Sons, Inc
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Library of Congress Cataloging-in-Publication Data
Nursing care of the hospitalized older patient / edited by Terry Mahan Buttaro and Kate A. Barba. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8138-1046-1 (pbk. : alk. paper) I. Buttaro, Terry Mahan. II. Barba, Kate A. [DNLM: 1. Geriatric Nursing–methods. 2. Aged. 3. Hospitalization.WY 152] 618.970231–dc23 2012004865
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover design by Buffy Clatt
Set in 9/12.5pt Interstate by SPi Publisher Services, Pondicherry, India
1 2013
Dedication
We dedicate this book to our husbands and children who have supported us
throughout this endeavor. We always have and always will cherish the love you
have shown us.
Kate A. Barba
Terry Mahan Buttaro
vii
Contents
Contributors xiii
Preface xix
Acknowledgments xxi
1 Introduction 1
Terry Mahan Buttaro
2 Health Assessment 9
Kate A. Barba
3 Clinical Issues 22
Unit 1 Skin Disorders 22
Part 1 Overview 22
Terry Mahan Buttaro
Part 2 Burns 24
Terry Mahan Buttaro
Part 3 Cellulitis 27
Terry Mahan Buttaro
Part 4 Contact Dermatitis 31
Terry Mahan Buttaro
Part 5 Herpes zoster 33
Terry Mahan Buttaro
Part 6 Purpura 37
Terry Mahan Buttaro
Part 7 Pruritus 41
Terry Mahan Buttaro
Part 8 Acne Rosacea 44
Terry Mahan Buttaro
Part 9 Seborrheic Dermatitis 46
Terry Mahan Buttaro
Part 10 Thrush 50
Terry Mahan Buttaro
viii Contents
Part 11 Tinea 52
Terry Mahan Buttaro
Part 12 Pressure Ulcers 56
Linda Olson
Part 13 Lower Extremity Ulcers 64
Linda Olson
Part 14 Skin Tears 74
Linda Olson
Unit 2 Cardiovascular Disorders 79
Part 1 Acute Coronary Syndrome 79
Sharon Zisk
Part 2 Atrial Fibrillation 86
Theresa E. Evans
Part 3 Venous Thromboembolism 92
Eva Beliveau
Part 4 Heart Failure 99
Theresa E. Evans
Part 5 Hypertension 105
Chelby Cierpial and Susan Stengrevics
Part 6 Peripheral Vascular Disease 112
Ashley Moore Gibbs
Part 7 Heart Valve Disease 117
Theresa E. Evans
Unit 3 Respiratory Disorders 124
Part 1 Asthma 124
Marian Jeffries and Rosemarie Marks
Part 2 Chronic Obstructive Pulmonary Disease (COPD) 128
Marian Jeffries and Rosemarie Marks
Part 3 Influenza 134
Marian Jeffries and Rosemarie Marks
Part 4 Pneumonia 138
Marian Jeffries and Rosemarie Marks
Unit 4 Gastrointestinal Disorders 148
Part 1 Appendicitis 148
Patricia Fitzgerald
Part 2 Diverticular Disease 152
Patricia Fitzgerald
Contents ix
Part 3 Ischemic Bowel 158
Patricia Fitzgerald
Part 4 Pancreatitis 162
Patricia Fitzgerald
Part 5 Constipation 167
Patricia Fitzgerald
Part 6 Diarrhea 173
Patricia Fitzgerald
Part 7 Gastroesophageal Reflux Disease 178
Patricia Fitzgerald
Unit 5 Genitourinary Disorders 183
Part 1 Acute Kidney Injury 183
Carol A. Tyksienski
Part 2 Chronic Kidney Disease 191
Carol A. Tyksienski
Part 3 Urinary Tract Infections 197
Terry Mahan Buttaro
Unit 6 Neurologic Disorders 202
Part 1 Dementia 202
Constance Cruz, Sara A. Fisher, Mary Lussier-Cushing
and Jennifer Repper-DeLisi
Part 2 Delirium in the Older Hospitalized Adult 209
Mary Lussier-Cushing, Jennifer Repper-DeLisi,
Sara A. Fisher and Constance Cruz
Part 3 Ischemic Stroke 221
Marion Phipps
Part 4 Dizziness 230
Jean B. Fahey
Part 5 Normal Pressure Hydrocephalus 236
Jean B. Fahey
Part 6 Parkinson’s Disease 241
Marion Phipps
Part 7 Seizures 249
Susan R. Gavaghan
Unit 7 Endocrine 255
Part 1 Diabetes 255
Susan L. Wood
x Contents
Part 2 Hypo/Hyperthyroidism 269
Susan L. Wood
Part 3 Hyperparathyroidism/Hypoparathyroidism 275
Susan L. Wood
Part 4 Syndrome of Inappropriate Antidiuretic
Hormone Secretion 283
Susan L. Wood
Unit 8 Musculoskeletal 288
Part 1 Septic Arthritis 288
Susan Bardzik
Part 2 Gout 292
Sharon R. Smart
Part 3 Joint Replacement 296
Nichole Spencer
Part 4 Osteomyelitis 303
Lesley Caracci
Part 5 Metabolic Bone Disease: Osteoporosis
and Paget’s Disease 308
Nichole Spencer
Unit 9 Hematology/Oncology 316
Part 1 The Oncology Patient 316
Kristina N. Wickman
Unit 10 Infectious Disease 324
Part 1 HIV/AIDS 324
Caroline Sturm-Reganato
Part 2 Sepsis and ARDS 337
Vince M. Vacca, Jr.
Part 3 Tuberculosis 343
Melissa Donovan
Unit 11 Multisystem Disorders 351
Part 1 Fever 351
Monica G. Staples
Part 2 Polymyalgia Rheumatica 359
Monica G. Staples
Part 3 Rheumatoid Arthritis 364
Monica G. Staples
Part 4 Systemic Lupus Erythematosus 369
Kate Roche
Contents xi
Part 5 Temporal Arteritis 376
Kate Roche
Part 6 Vasculitis 379
Kate Roche
Unit 12 The Surgical Patient 386
Part 1 The Surgical Patient 386
Deanne C. Munroe
Unit 13 Fluid and Electrolytes 403
Part 1 Dehydration and other Hypovolemic Fluid
Disorders 403
Terry Mahan Buttaro
Part 2 Hypercalcemia and Hypocalcemia 408
Nancy A. Kelly
Part 3 Hyperkalemia and Hypokalemia 416
Grace A. Good
Part 4 Hyponatremia and Hypernatremia 423
Grace A. Good
Part 5 Hypomagnesemia and hypermagnesemia 432
Nancy A. Kelly
Unit 14 Psychological Issues 440
Part 1 Anxiety Disorders 440
Constance Cruz, Sara A. Fisher, Mary Lussier-Cushing
and Jennifer Repper-DeLisi
Part 2 Depression 445
Jennifer Repper-DeLisi, Constance Cruz, Sara A. Fisher
and Mary Lussier-Cushing
4 Special Considerations 454
Part 1 Nosocomial Infections 454
Hallie S. Greenberg
Part 2 Elder Abuse and Neglect 461
Margaretta Byrne
Part 3 Advance Directives 469
Anita M. Coppola-Ash
Part 4 Nutrition and Older Adults 474
Deborah A. D’Avolio
Part 5 Fall Prevention 480
Deborah A. D’Avolio
xii Contents
Part 6 Pain and Older Adults 488
Deborah A. D’Avolio
Part 7 Palliative Care 494
Jennifer R. Howard
Part 8 Medications and Older Adults 501
Deborah A. D’Avolio
Part 9 Sleep Disorders 506
Donna M. Glynn
Part 10 Urinary Incontinence 511
Mary L. McDonough
Part 11 Discharge Planning and Teaching 518
Arlene J. Lowenstein
Part 12 SBAR Communication 525
Eva Beliveau
Glossary 531
Selected Websites for Geriatric Information 536
Index 537
xiii
Contributors
Editors
Terry Mahan Buttaro, PhD, ANP-BC, GNP-BC, FAANP, DPNAP
Assistant Clinical Professor
Simmons College
Boston, Massachusetts
Lecturer
University of Massachusetts Boston
Boston, Massachusetts
Nurse Practitioner
Coastal Medical Associates
Salisbury, Massachusetts
Kate A. Barba, RN, MS, GNP-BC
Clinical Nurse Specialist
Massachusetts General Hospital
Boston, Massachusetts
Contributors
Susan Bardzik, RN-BC, MSN
Massachusetts General Hospital
Boston, Massachusetts
Eva Beliveau, RN, MSN
Associate Professor
Department of Nursing
Northern Essex Community College
Lawrence, Massachusetts
Margaretta Byrne, MPH, MS, FNP-BC
Master’s in Nursing Student
Simmons College
Boston, Massachusetts
Lesley Caracci, RN, MSN, ACNS-BC
Massachusetts General Hospital
Boston, Massachusetts
xiv Contributors
Chelby Cierpial, RN, MSN, ACNS, BC
Clinical Nurse Specialist/Ellison 11
Cardiac Interventional Unit
Massachusetts General Hospital
Boston, Massachusetts
Anita M. Coppola-Ash, RN, BSN, MSN, ANP-BC, LCSW, MSW
Anna Jacques Hospital
Newburyport, Massachusetts
Constance Cruz, RN, MSN, PMHCNS
Psychiatric Clinical Nurse Specialist
Inpatient Psychiatric Unit
Massachusetts General Hospital
Boston, Massachusetts
Deborah A. D’Avolio PhD, BC-ACNP, ANP
Associate Professor
School of Nursing
Northeastern University
Boston, Massachusetts
Melissa Donovan, MSN, RN
Massachusetts General Hospital
Boston, Massachusetts
Theresa E. Evans, MS, ANP-BC
Clinical Nurse Specialist
Massachusetts General Hospital
Boston, Massachusetts
Jean B. Fahey, MSN, RN, ACNS-BC, CCRN, CNRN, CWS
Neuroscience Clinical Nurse Specialist
Massachusetts General Hospital
Boston, Massachusetts
Sara A. Fisher, MSN, RN, PMHCNS-BC
Psychiatric Clinical Nurse Specialist
Massachusetts General Hospital
Boston, Massachusetts
Patricia Fitzgerald, RN, MSN, ACNS, BC
Clinical Nurse Specialist
Massachusetts General Hospital
Boston, Massachusetts
Susan R. Gavaghan, ACNS-BC
Clinical Nurse Specialist
Massachusetts General Hospital
Boston, Massachusetts
Contributors xv
Ashley Moore Gibbs, RN, MSN, ANP/GNP-BC, CHFN
Faculty, School of Nursing
University of Southern Maine
Portland, Maine
Donna M. Glynn, PhD, RN, ANP-BC
Assistant Clinical Professor
Simmons College
School of Nursing and Health Sciences
Boston, Massachusetts
Grace A. Good, APRN, BC
Acute Care Nurse Practitioner
Massachusetts General Hospital
Boston, Massachusetts
Hallie S. Greenberg, MS-PREP, BSN, BC
Adjunct Faculty,
Simmons College
Nurse Educator
Brigham and Women’s Hospital
Boston, MA
Jennifer R. Howard, MSN, APRN, BC
Clinical Instructor
Simmons College
Boston, Massachusetts
Marian Jeffries, MSN, ACNS, BC, FNP-C
Clinical Nurse Specialist, Thoracic and Laryngeal Surgery
Massachusetts General Hospital
Boston, Massachusetts
Nancy A. Kelly, GNP-BC, DNP
Patient Care Services
Massachusetts General Hospital
Boston, Massachusetts
Arlene J. Lowenstein PhD, RN
Professor and Director
Health Professions Education Doctoral Program
School of Nursing and Health Sciences
Simmons College
Boston, Massachusetts
Mary Lussier-Cushing, MS, RN/PC, PMHCNS
Psychiatric Clinical Nurse Specialist
Psychiatric Nursing Consultation Service
Massachusetts General Hospital
Boston, Massachusetts
xvi Contributors
Rosemarie Marks, RN, MSN
Clinical Nurse Educator
Signature Healthcare
Brockton, Massachusetts
Mary L. McDonough, RN, MSN
Clinical Practice Manager
Department of Urology
Massachusetts General Hospital
Boston, Massachusetts
Deanne C. Munroe, JD, MSN, APRN-BC
Risk Management Coordinator
The Queen’s Medical Center
Honolulu, Hawaii
Linda Olson, RN, BSN, CWON
Wound, Ostomy Nurse
UMass Memorial Medical Center
Worcester, Massachusetts
Marion Phipps, RN, MS, CRRN, FAAN
Clinical Nurse Specialist, Neuroscience
Massachusetts General Hospital
Boston, Massachusetts
Jennifer Repper-DeLisi, RN, MSN, PMHCNS-BC
Clinical Nurse Specialist
Psychiatric Nursing Consultation Service
Massachusetts General Hospital
Boston, Massachusetts
Kate Roche, MS, RN, ANP-BC
Clinical Nurse Specialist
Massachusetts General Hospital
Boston, Massachusetts
Sharon R. Smart, MS, APRN, FNP
Vital Care Services
New England Community Medical Services
Methuen, MA
Nichole Spencer, MSN, ARNP-C
Assistant Professor
Department of Nursing
William Jewell College
Liberty, Missouri
Adult Nurse Practitioner
Shawnee Mission Internal Medicine
Overland Park, Kansas
Contributors xvii
Monica G. Staples, RN-BC, MSN
Clinical Nurse Specialist
General Medicine
Massachusetts General Hospital
Boston, Massachusetts
Susan Stengrevics, MSN, RN, ACNS, BC, CCRN
Clinical Nurse Specialist/Ellison 10
Cardiac Arrhythmia Stepdown Unit
Massachusetts General Hospital
Boston, Massachusetts
Caroline Sturm-Reganato, RN, BSN, ACRN
AIDS Clinical Trial Unit
New York School of Medicine
New York, New York
Carol A. Tyksienski, RN, DNP, APRN, BC
Clinical Nurse Specialist
Nurse Practitioner
Hemodialysis Unit
Massachusetts General Hospital
Boston, Massachusetts
Vince M. Vacca, Jr., RN, MSN, CCRN
Clinical Nurse Educator
Neuroscience Intensive Care Unit
Brigham & Women’s Hospital
Boston, Massachusetts
Kristina N. Wickman, MSN, RN
Adjunct Faculty
Simmons College
Boston, Massachusetts
Susan L. Wood, RN, MSN, ANP, BC
Clinical Nurse Specialist, Adult Medicine
Massachusetts General Hospital
Boston, Massachusetts
Sharon Zisk, MSN, RN, ACNS-BC
Clinical Nurse Specialist
Cardiac Surgery and Interventional Cardiology
Beth Israel Deaconess Medical Center
Boston, Massachusetts
xix
Preface
Worldwide, older adults constitute the fastest growing demographic cohort
and comprise a large percentage of all hospitalized patients. Compared to
younger patients, older adult patients have higher acuity, use more healthcare
resources, experience more complications, and have longer length of stay
when hospitalized. Older patients are also at higher risk for experiencing an
iatrogenic event such as an adverse reaction to medication, falls, functional
decline, delirium, malnutrition, dehydration, pressure ulcers, urinary inconti-
nence, constipation and depression.
The complexity of caring for older adults, especially in the hospital setting,
cannot be understated. In addition to their presenting acute process, many
elders have multiple comorbid illnesses and are confronted with aging changes
that include visual and hearing impediments as well as cognitive, functional,
and health literacy challenges. At the same time, there are ongoing societal
and medical care changes. Today, children can live far away from their older
parents. Hospital care is often provided by hospitalists rather than the patient’s
primary care provider. In addition, patients are often quickly discharged from
the acute care setting to home or to rehabilitation, sub-acute care or long-term
care facilities.
The changes in health care delivery also present challenges for health care
providers and particularly so for nurses caring for older adults. Despite the
growing emphasis on geriatric care, many healthcare providers are not attuned
to the atypical presentation of illness in elders, nor are all providers skilled
in assessing the impact of illness on function and well–being in elders. Illness
presentations in this cohort can be subtle and precipitate a cascade of events
that result in temporary or permanent functional and cognitive changes.
Elders have complex needs and the nursing care of older adults is highly spe-
cialized. The care of the hospitalized older adult requires not only focus and
attentiveness, but also a working knowledge of the common geriatric syndromes
and illnesses affecting older adults.
This book was primarily designed for nurses caring for older patients in
hospitals and acute care settings, but it is a valuable reference for nurses
caring for older patients across varied health care environments. The orga-
nized format provides easy access to the common disorders encountered
when caring for ill elders and provides nurses with specific information related
to geriatric care. The text is organized into four sections. The first section
describes normal aging changes and the impact of illness and hospitalization
on older adults. The second section is concerned with health assessment in
xx Preface
the geriatric patient. Guidance on obtaining an accurate patient history and a
review of laboratory values are discussed in this chapter. The third and major
section of the book provides an overview of the commonly encountered health
issues that can affect the older patient during a hospitalization. These health
issues are organized by systems and the format of these chapters is consis-
tent. The sections are often bulleted affording the reader quick and easy
access to pertinent information. Each chapter gives a brief description of the
illness or disorder. Risk factors, clinical presentation, physical examination,
common diagnostics, differential diagnosis and physician consultation are
discussed to aid the nurse in the collaborative care of each patient. In addition,
the common treatment modalities and patient/family education concerns
for patients will these illnesses or disorders are described, though we realize
that organizations may have specific guidelines for the management of some
disorders and that research and evidence are continually evolving affecting
patient care management.
The final section of this book is concerned with those considerations that
commonly concern nurses caring for older patients. These include palliative
care, pain management, safety issues, and discharge planning.
xxi
Acknowledgments
Each patient teaches us more about the best way to care for ourselves and
our patients. Through them, we become better clinicians. Our colleagues
generously contributed their time, experience and wisdom in writing chapters.
In addition, many other clinicians collaborated with us on this text. Their
knowledge and experience are evident and we appreciate their expertise and
guidance. Without them, this book would not be complete.
Nursing Care of the Hospitalized Older Patient
1
Nursing Care of the Hospitalized Older Patient, First Edition. Edited by Terry Mahan Buttaro and Kate A. Barba.© 2013 John Wiley & Sons, Inc. Published 2013 by John Wiley & Sons, Inc.
Chapter 1
Introduction Terry Mahan Buttaro
Demographics
There are currently 39.6 million Americans older than age 65; most are women
(Administration on Aging [AOA], 2010 ). In another 20 years it is expected that
about one fifth of all Americans (72.1 million) will be older than age 65 and by
2050, the number of elders living in this country will likely double (AOA, 2009 ;
Vincent & Velkoff, 2010 ). This seemingly sudden onset of older citizens is
related to the aging of the “baby boomers”. The “boomers” were born between
1946 and 1964 and are a racially and ethnically diverse population that includes
healthy elders, as well as elders with a variety of co-morbidities and disabilities.
Many are foreign born; some are Vietnam War veterans. Many are still working
(AOA, 2011 ).
Older adults are the fastest growing cohort in the US and though these
elders often describe themselves as being in good health, they frequently
have many co-morbid disorders, such as hypertension, arthritis, or hyperlipid-
emia. Almost one-third (30%) live alone (AOA, 2011 ). Some are dependent on
Social Security for income, but some have private or government pensions or
carefully saved for their retirement (AOA, 2011 ).
The average income for older females was $15,282 in 2009; for men $25,877
that same year (AOA, 2011 ).
Other countries are experiencing a similar change in aging demographics. In
some of these countries, the life expectancy, especially of women, is longer
than in the US (Federal Interagency Forum on Age-Related Statistics, 2010 ). It
has been known for some time that women lived longer than men worldwide,
but this, too, is changing as life expectancy for men is projected to improve in
the future (Vincent & Velkoff, 2010 ).
Persons between age 55 and 75 are thought of as “young old” while those
over age 75 are considered “old old”. Some elders are referred to as “frail
elders”. Frail elders are more dependent, because they are less able to care for
themselves and perform their own activities of daily living (ADLs). Frail elders
are often older than 75 years of age, though illness and comorbidity can cause
frailty in any age cohort.
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2 Nursing Care of the Hospitalized Older Patient
Patients over age 65 represent more than one third of all hospital admissions
and more than half of all hospital days (CDC, 2007 ). Men and women in the US
have similar health care disorders, though the percentages for each disorder
are quite different.
Heart disease, malignancy, and cerebrovascular disease are the top three
causes of death for all elders (Xu et al ., 2009 ).
Theories of aging
There are numerous theories about aging. Some are biologic or programmed
theories that address physiological changes that occur over time (Jin, 2010 ).
Biologic theories suggest that aging is programmed in some way. It could be
built in senescence or a gradual decrease in gene or immunologic function
(Jin, 2010 ). Wear and tear theory is an example of damage theory, another
biologic theory of aging. In wear and tear theory, it is proposed that over
time, cells fatigue and eventually cannot function appropriately. This theory
can explain some aging changes (e.g., degenerative bone disorders) and is
another example that considers aging a preprogrammed rather than random
process.
Other common theories associated with aging include psychological and
sociological theories. Psychosocial theories are primarily concerned with
explaining human personality and behavior. Erikson, a developmental theorist,
described human stages of development that ranged from infancy to old age.
In Erikson ’ s theory, at each stage of development there are specific tasks that
individuals must master. Infants learn to trust themselves and others, while at
the opposite end of the life spectrum, elders prepare for the end of life by
reviewing one ’ s life – the achievements and disappointments. This theory is
commonly considered when planning end of life care, but a different theory
(Activity Theory) encourages active, healthy engaged elders (Roy & Russell,
2005 ). There are many other psychosociological theories of aging. Some
theorize that our personalities really do not change as we age (i.e., the
Continuity theory) while other theorists describe how roles and activities
change as we age (i.e., Disengagement theory) (Roy & Russell, 2005 ).
No one theory addresses the complexity of aging, as growing older involves
physiologic changes as well as personality and attitude changes. For nurses,
understanding the interplay of these theories is very important because it
helps understand the many changes that occur with aging.
Healthy aging
Healthy aging is dependent on many factors. Genetics and lifestyle play a
significant role, but people who had fewer acute and chronic illnesses over
their lifetime may also be healthier as they age. Other factors that contribute
to healthy aging include:
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Introduction 3
● Ideal weight for height
● Normal blood pressure, blood sugar, and cholesterol
● Daily exercise
● 10,000 steps per day or 30 minutes a day
● Weight training twice weekly to strengthen abdomen, back, chest, arms,
shoulders, hip and leg muscles
● Balance training each day
● Low fat, low cholesterol, low calorie diet, that includes:
● lean meats
● fruits, fiber, and vegetables
● adequate calcium and vitamin D
● 1 glass red wine per day
● Fewer medications
● Smoking cessation
● Stress reduction
● Breathing exercises
● Meditation
● Yoga
● Socialization
Many of the elements associated with healthy aging are appropriate for elderly
patients. Adults older than age 65 still need exercise, but the physician always
needs to determine if an older patient is healthy enough for exercise. In general,
if a person over age 65 is healthy and has no limiting health disorders, physical
exercise guidelines continue to recommend 150 minutes of moderate intensity
exercise (e.g., brisk walking) each week and exercise that strengthens muscles
twice weekly (CDC, 2011 ). Even for frail elders exercise can be beneficial.
Researchers learned that exercise in these patients improves well being, sleep,
decreases pain, increases mobility and helps prevent falls (Heath & Stuart, 2002 ).
It is also never too late for people to learn about healthier foods, and it is
never too late to begin an exercise regimen. The Nurses’ Health Study and
other research studies provided evidence that proper diet and exercise at
any age are beneficial, maintaining telomere length on chromosomes and
increasing cellular lifespan as well as decreasing the risk of physical or
cognitive problems (Baer et al ., 2011 ; Hu et al ., 2003 ).
In addition to the healthy behaviors described above, there are other
components of healthy or successful aging. Socialization or engagement in
life and a positive outlook on life impact quality of life and possibly cognition.
Elders themselves describe the importance of being adaptable to aging
changes and losses as they grow older.
Normal aging changes
Numerous issues affect aging and not all are physiologic. Financial concerns,
family stressors, and the loss of family and friends are important considerations
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4 Nursing Care of the Hospitalized Older Patient
that impact all of us. Some physiologic changes do occur over time despite proper
diet and exercise, in most, if not all, body systems. These changes are linear, occur-
ring over time and starting around age 45. In addition, co-morbid disorders and
illness can impact aging significantly in some people. Though not all changes
affect all elders, common changes associated with normal aging include:
● Decreased body water
● Increased body weight
● Homeostasis easily affected by illness
● Temperature regulation impacted over time
● Gait changes especially after age 80 may be multifactorial
● Increased double stance time; decreased gait speed
● Cellular changes
● Diminished cell mediated immunity
● Decreased number of receptors and diminished receptor sensitivity impact
medication pharmacodynamics
● Skin: initial aging changes are seen in skin changes
● Epidermis thins, becomes dryer and less elastic
● Decreased subcutaneous fat
● Sweat glands, blood vessels, melanocytes, and nerve cells decrease in number
● Absorption of topical medications is more rapid
● Head, ears, eyes, nose, throat (HEENT)
● Visual and hearing changes
● Decreased thirst
● Diminished sense of smell and taste
● Cardiac
● Cardiac and arterial muscle stiffening results in some cardiac enlarge-
ment, hypertension
● Decreased baroreceptor sensitivity
● Decreased cardiac output affects blood flow to all organs and can affect
medication absorption, distribution, first pass effect, biotransformation,
and elimination
● Respiratory
● Possible increase in AP chest diameter
● Decreased bronchiolar smooth muscle
● Vital capacity decreases, residual volume increases
● Increased risk aspiration
● Gastrointestinal
● Atrophic gastritis
● Decreased absorption medication/nutrients is possible.
● Diminished esophageal motility
● Functional changes in swallowing (usually related to medications or neuro-
logical disorder)
● Decreased hepatic blood flow
● Genitourinary
● Decreased blood flow can cause decreased glomerular filtration and
tubular secretion; diminished creatinine clearance.
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