Development, Safety

I. Aging and Gerontology

A. Aging is the biopsychosocial process of change that occurs in a person between birth
and death.
B. Gerontology is the study of the aging process.
II. Physiological Changes and Nursing Considerations
A. Integumentary system
1. Loss of pigment in hair and skin
2. Wrinkling of the skin

3. Thinning of the epidermis and easy bruising and tearing of the skin
4. Decreased skin turgor, elasticity, and subcutaneous fat, which may result in
lower tolerance to thermal extremes
5. Increased nail thickness and decreased nail growth
6. Decreased perspiration
7. Dry, itchy, scaly skin
8. Seborrheic dermatitis and keratosis formation (overgrowth and thickening of
certain areas of the skin)
9. Inspect nails of all older adults; cut toenails straight across.
10. Encourage a well-balanced diet with protein and adequate hydration.
11. Teach clients to dress for the environmental temperatures.
B. Neurological system

1. Slowed reflexes
2. Slight tremors and difficulty with fine motor movement

3. Loss of balance
4. Increased incidence of awakening after sleep onset
5. Increased susceptibility to hypothermia and hyperthermia
6. Short-term memory decline possible
7. Long-term memory usually maintained
8. Assess the need for an ambulatory aid, such as a cane or walker.
 9. Daytime napping is especially common in older adults of advanced age.
10. Do not rush older clients; they may become frustrated if hurried and could
sustain a fall.
C. Musculoskeletal system
1. Decreased muscle mass and strength and atrophy of muscles

2. Decreased mobility, range of motion, flexibility, coordination, and

stability
3. Change of gait, with shortened step and wider base
4. Posture and stature changes, causing a decrease in height, also known as
kyphosis (Fig. 20.1 )
5. Increased brittleness of the bones due to demineralization. Postmenopausal
persons experience a greater rate of bone demineralization than older men;
however, older men with poor nutrition and decreased mobility are also at risk
for bone demineralization.
6. Deterioration of joint capsule components
7. Kyphosis and a widened gait cause a shift in the center of gravity, which
could lead to an imbalance and falls; teach proper body mechanics.

The older client is at risk for falls because of the changes that occur in the neurological
and musculoskeletal systems.

D. Cardiovascular system
1. Diminished energy and endurance, with lowered tolerance to exercise
2. Decreased compliance of the heart muscle can be due to remodeling of the
heart after myocardial infarction or long-standing hypertension, with heart
valves becoming thicker and more rigid due to calcification.
3. Decreased cardiac output and decreased efficiency of blood return to the
heart

4. Decreased compensatory response, so less able to respond to increased

demands on the cardiovascular system

5. Decreased resting heart rate, which may be medication-related

6. Peripheral pulses can be weak due to lower cardiac output.
7. Increased blood pressure but susceptible to postural hypotension, especially
with certain cardiac medications such as diuretics
 8. Assess heart rate and rhythm and heart sounds for murmurs.
E. Respiratory system
1. Decreased stretch and compliance of the chest wall

2. Decreased strength and function of respiratory muscles

3. Decreased size and number of alveoli
4. Respiratory rate usually unchanged
5. Decreased depth of respirations
6. Decreased ability to cough and expectorate sputum
7. Respiratory infections may be more severe and last longer.
F. Hematological system
1. Hemoglobin and hematocrit levels average toward the low end of normal.
2. Prone to increased blood clotting

3 Decreased protein available for protein-bound medications

Pigment loss and skin yellowing are common changes associated with aging.

G. Immune system
1. Tendency for lymphocyte counts to be low with altered immunoglobulin
production
2. Decreased resistance to infection and disease
3. Older clients are less able to make new antigens; they need to receive flu
shots, pneumococcal vaccination, and the shingles vaccination.
H. Gastrointestinal system
1. Decreased caloric needs because of lowered basal metabolic rate
2. Decreased appetite, thirst, and oral intake
3. Decreased lean body weight
4. Slowed gastric motility

5. Increased tendency toward constipation due to poor oral intake and

slowed motility
6. Increased susceptibility for dehydration
 7. Tooth loss
8. Poor-fitting dentures
9. Difficulty in chewing and swallowing food
10. Decreased taste buds, decreased sense of smell, decreased volume of saliva
I. Endocrine system
1. Decreased secretion of hormones, with specific changes related to each
hormone's function
2. Encourage the use of skin moisturizers.
3. Decreased metabolic rate
4. Decreased glucose tolerance, with resistance to insulin in peripheral tissues
5. Assess family history for obesity and diabetes mellitus.
6. Teach clients to dress warmly in cool or cold weather.
J. Renal/urinary system
1. Decreased kidney size, function, and ability to concentrate urine
2. Decreased glomerular filtration rate
3. Decreased capacity of the bladder

4. Increased residual urine and increased incidence of infection and

possibly incontinence

5. Impaired medication excretion

6. Evaluate prescribed medications for possible contribution to retention.
7. Monitor hydration status.
8. Discourage excessive fluid intake for 2 to 4 hours before going to bed;
encourage emptying the bladder at least every 2 hours on a regular basis to
avoid overflow urinary incontinence.
K. Reproductive system
1. Decreased testosterone production and decreased size of the testes
2. Changes in the prostate gland, leading to urinary problems such as retention,
hesitancy, or stress incontinence, predisposing to urinary tract infections
3. Decreased secretion of hormones with the cessation of menses
4. Vaginal changes, including decreased muscle tone and lubrication; teach
Kegel exercises to strengthen pelvic muscles.
 5. Impotence or sexual dysfunction for both sexes; sexual function varies
and depends on general physical condition, mental health status, and
medications.
6. Discuss normal and expected changes; provide education to help prevent
problems with body image.
L. Special senses

1. Decreased visual acuity

2. Decreased accommodation in eyes, requiring increased adjustment time to
changes in light
3. Decreased peripheral vision and increased sensitivity to glare
4. Presbyopia and cataract formation

5. Possible loss of hearing ability; low-pitched tones are heard more

easily
6. Inability to discern taste of food
7. Decreased sense of smell
8. Changes in touch sensation

9. Decreased pain awareness

III. Psychosocial Concerns

A. Adjustment to deterioration in physical and mental health and well-being
B. Threat to independent functioning and fear of becoming a burden to loved ones
C. Adjustment to retirement and loss of income
D. Loss of skills and competencies developed early in life
E. Coping with changes in role function and social life
F. Diminished quantity and quality of relationships and coping with loss
G. Dependence on governmental and social systems
H. Access to social support systems
I. Costs of health care and medications
J. Loss of independence in living, driving, and other daily functions
K. Not having a youthful look may affect a person's self image.
 IV. Mental Health Concerns
A. Depression: The increased dependency that older adults may experience can lead to
hopelessness, helplessness, lowered sense of self-control, and decreased self-esteem
and self-worth; these changes can interfere with daily functioning and lead to
depression. Depression is a common mental health behavioral problem among older
adults in the community.
B. Grief: Client reacts to the perception of loss, including physical, psychological,
social, and spiritual aspects.
C. Isolation: Client is alone and desires contact with others but is unable to make that
contact.
D. Suicide: Depression can lead to thoughts of self-harm.
E. Depression differs from delirium and dementia (Table 20.1 ).

Any suicide threat made by an older client should be taken seriously.

V. Pain
A. Description
1. Pain can occur from numerous causes and most often occurs from
degenerative changes in the musculoskeletal system.
2. The nurse needs to monitor the older client closely for signs of pain; failure
to alleviate pain in the older client can lead to functional limitations affecting
his or her ability to function independently.
3. Older adults may be more hesitant to report pain due to their inaccurate
assumption that it is part of aging or their fear of further diagnostic testing.
4. Nurses caring for older adults have to advocate for appropriate and effective
pain management with the goal being to maximize and maintain function and
improve quality of life.
B. Assessment
1. Restlessness
2. Verbal reporting of pain
3. Agitation
4. Moaning
5. Crying
C. Interventions
 1. Monitor the client for signs and symptoms of pain.
2. Identify the type and pattern of pain.
3. Identify the precipitating factor(s) for the pain.
4. Monitor the impact of the pain on activities of daily living.
5. Set realistic goals for pain management, and use functional outcome as a
measure of attaining the goal.
6. Provide pain relief through measures such as distraction, relaxation,
massage, biofeedback, ice, heat, and stretching.
7. Administer pain medication as prescribed, and instruct the client in its use.
Opioid use should be avoided as much as possible.
8. Over-the-counter preparations such as acetaminophen, ibuprofen, lidocaine
patches, and creams may be prescribed.
9. Evaluate the effects of pain-reducing measures.

VI. Infection (Box 20.1 )

A. Altered mental status is a common sign of infection in the older adult, especially
infection of the urinary tract.
B. Carefully monitor the older adult with infection because of the diminished and
altered immune response.
C. Nonspecific symptoms may indicate illness or infection (see Box 20.1).
D. Risks associated with the development of infections in older adults include lack of
proper hygiene, poor nutrition and unintentional weight loss, lack of exercise, poor
social support, and low albumin.
E. Teach older adults and their families how to reduce the risk for infections.
VII. Medications
A. Major problems with prescriptive medications include adverse effects, medication
interactions, medication errors, nonadherence, polypharmacy, and cost. See Box
20.2 for information on medications to avoid in the older adult client. This information
is based on Beers Criteria from the American Geriatrics Society. Information on this
criteria and a full list of medications to avoid can be located
at https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-
beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001

B. Determine the use of over-the-counter medications.

C. Polypharmacy
 1. Routinely monitor the number of prescription and nonprescription
medications used and determine whether any can be eliminated or combined.
2. Keep the use of medications to a minimum.
3. Overprescribing medications leads to more side and adverse effects,
increased interaction between medications, duplication of medication
treatment, diminished quality of life, and increased costs.
D. Medication dosages normally are prescribed at one-third to one-half of normal adult
dosages.
E. Closely monitor the client for adverse effects and response to therapy because of the
increased risk for medication toxicity (see Box 20.2).
F. Assess for medication interactions in the client taking multiple medications.
G. Advise the client to use one pharmacy and to notify the consulting primary health
care provider(s) of the medications taken.

A common sign of an adverse reaction to a medication in the older client is a sudden

change in mental status.

H. Safety measures for medication administration (Box 20.3 )

1. The client should be in a sitting position when taking medication.
2. The mouth is checked for dryness because medication may stick and dissolve
in the mouth.
3. Liquid preparations can be used if the client has difficulty swallowing
tablets.
4. Tablets can be crushed if necessary and given with textured food (pudding,
applesauce) if not contraindicated.
5. Enteric-coated tablets are not crushed, and capsules are not opened.
6. If administering a suppository, avoid inserting the suppository immediately
after removing it from the refrigerator; a suppository may take a while to
dissolve because of decreased body core temperature.
7. When administering parenteral solution or medication, monitor the site
because it may ooze or bleed because of decreased tissue elasticity; an
immobile limb is not used for administering parenteral medication.
8. Monitor client adherence with taking prescribed medications.
9. Monitor the client for safety in correctly taking medications, including an
assessment of the ability to read the instructions and discriminate among the
pills and their colors and shapes.
 10. Use a medication case or organizer with checklists/schedules to facilitate
proper administration of medication.
11. Encourage clients to keep a complete and up-to-date list of medications
with them at all times.
12. Educate the client on each medication, common side effects, and when to
notify the primary health care provider.
13. Allow time for the client to ask questions, and use the teach-back method
when appropriate. Include support persons in the teaching.

VIII. Mistreatment of the Older Adult (see Clinical Judgment: Take Action Box)
A. Domestic mistreatment takes place in the home of the older adult and is usually
carried out by a family member or significant other; this can include physical,
psychological, financial, or sexual maltreatment; neglect; or abandonment.
B. Institutional mistreatment takes place when an older adult experiences abuse when
hospitalized or living somewhere other than home (e.g., a long-term care facility).
C. Self-neglect is the choice by a mentally competent individual to avoid medical care
or other services

Clinical Judgment: Take Action

The home care nurse is caring for an older client who lives with her son and is
physically and financially dependent on her son. The nurse notes multiple
bruises on the client's arms and asks the client how these bruises occurred. The
client confides in the nurse that her son takes out anger on her sometimes. The
nurse takes the following actions.

▪ Performs a thorough assessment of physical injuries.

▪ Provides confidentiality during the assessment with an empathetic and
nonjudgmental approach.
▪ Reports the abuse to the appropriate authorities and follows state and agency
guidelines.
▪ Reassures the victim that they have done nothing wrong.
▪ Assists the victim in developing self-protective and problem-solving skills.
▪ Encourages the victim to develop a specific plan for safety (a fast escape if
the violence returns) and for where to obtain help (hotlines, safe houses, and
shelters) or to call the police (an abused person is usually reluctant to call the
police).
 that could improve optimal function, to not care for oneself, or to engage in actions that
negatively affect his or her personal safety; unless declared legally incompetent, an
individual has the right to refuse care.
D. Older adults are a population at risk for being victims of “scams,” in which they are
approached via e-mail, phone, or other means of communication, asking them to send
money for specific causes; teach clients to always verify the legitimacy of the caller
and to never provide any information about self, such as bank information, credit card
information, passwords, or Social Security number.

Individuals at most risk for abuse include those who are dependent because of their
immobility or altered mental status.

E. For additional information on abuse of the older client, see Chapter 68.
Fig. 20.1 A normal spine at 40 years of age and osteoporotic changes at 60 and 70 years of age.
These changes can cause a loss of as much as 6 inches (15 cm) in height and can result in the so-
called dowager's hump (far right) in the upper thoracic vertebrae.

Table 20.1 Differentiating Delirium, Depression, and Dementia

Characteristic Delirium Depression Dementia

Onset Sudden, abrupt Recent, may relate to life Insidious, slow, over years and often
change unrecognized until deficits are obvious

Course over 24 Fluctuating, often worse at Fairly stable, may be Fairly stable, may see changes with stress;
hr night worse in the morning sundowning may occur

Consciousness Reduced/distorted Awake Awake

Alertness Increased, decreased, or Normal Generally normal

variable

Psychomotor Increased, decreased, or mixed Variable; agitation or Normal; may have apraxia or agnosia;
activity retardation agitation can occur

Duration Hours to weeks Variable and may be Years

chronic

Attention Disordered, fluctuates Little impairment Generally normal but may have trouble
focusing; overwhelmed with multiple
stimuli

Orientation Usually impaired, fluctuates Usually normal, but may Generally normal to person but not to plac
answer “I don't know” to or time; may be impaired and may make u
questions or may not try answers or answer close to the right thing,
to answer or may confabulate, but tries to answer
Speech Often incoherent, slow, or rapid; May be slow Difficulty finding word, perseveration
may call out repeatedly or
repeat the same phrase

Affect Variable but may look Flat Slowed response, may be labile
disturbed, frightened

Box 20.1 Nonspecific Symptoms That Possibly Indicate Illness or Infection

▪ Anorexia
▪ Apathy
▪ Changes in functional status
▪ Altered mental status, including delirium
▪ Tachypnea
▪ Hyperglycemia
▪ Dyspnea
▪ Falling
▪ Fatigue
▪ Incontinence
▪ Self-neglect
▪ Shortness of breath
▪ Blood pressure below baseline

Box 20.2 Medications to Avoid in the Older Client

Analgesics

▪ Indomethacin
▪ Ketorolac
▪ Nonsteroidal antiinflammatory drugs (NSAIDs)
▪ Meperidine

Antidepressants

▪ First-generation tricyclic antidepressants

Antihistamines
 ▪ First-generation antihistamines

Antihypertensives

▪ Alpha1-blockers
▪ Centrally acting alpha 2-agonists

Urge Incontinence Medications

▪ Oxybutynin
▪ Tolterodine

Muscle Relaxants

▪ Carisoprodol
▪ Cyclobenzaprine
▪ Metaxalone
▪ Methocarbamol

Sedative-Hypnotics

▪ Barbiturates

Box 20.3 Administering Oral Medications to a Client at Risk for Aspiration

▪ Check the medication prescription and compare against the medical record. Clarify any
incomplete prescriptions prior to administration. Check the rights of medication administration.
▪ Review pertinent information related to the medication and any related nursing
considerations, such as laboratory parameters.
▪ Assess for any contraindications to the administration of oral medications, such as NPO
(nothing by mouth) status or decreased level of consciousness.
▪ Place the client in a sitting position. Assess aspiration risk using a screening tool or per
agency policy. Check for an ability to swallow and cough on command. Check for the presence
of a gag reflex. Following this assessment, if aspiration is a serious concern, the nurse would
collaborate with the primary health care provider and speech therapist before administering the
medication.
▪ Remember to plan to keep the client in an upright position for 30 minutes to prevent
aspiration after PO intake.
▪ Prepare the medication in the form that is easiest to swallow, checking the rights of
medication administration again. Mix medications whole, or crush medications and mix with
applesauce or pudding if indicated (use sugar-free and low carbohydrate products for clients
with diabetes). Do not crush sustained-release tablets, and use liquid preparations when
possible. Thicken liquids when indicated, and avoid the use of straws.
▪ Check the rights of medication administration one more time, and administer the medications
one at a time in the prepared form, ensuring that the client has effectively swallowed
everything. Ensure that the client is comfortable and safe, and document the medications given
using an electronic system or per agency policy.