Jill C. Cash, MSN, APRN, FNP-BC, a family nurse practitioner (NP) for over 27 years, currently practicesatVanderbiltUniversityMedicalCenterfortheVanderbiltMedicalGroupatWesthaven Family Practice in Franklin, Tennessee. She is a faculty member for the School of Nursing at Vanderbilt University. She has been a clinical preceptor for NPstudents for a variety of programs over the past several years. Her previous experience includes high risk obstetrics as a clinical nursespecialistinmaternal–fetalmedicine,aswellaspracticingasanNPinwomen’shealth,family practice, and rheumatology. In 2017, Ms. Cash was awarded the 2017AmericanAssociation of NursePractitionersStateAwardforExcellenceinIllinois.Ms.Cashhasauthoredseveralchapters inavarietyofnursingandNPtextbooks.Sheisthecoauthorof Family Practice Guidelines (first,second, third, fourth, and fifth editions) and Adult-Gerontology Practice Guidelines (first, second, and third editions). Ms. Cash is an active member of theAmericanAssociation of Nurse Practitioners and Sigma Theta Tau International Honor Society.
ADULT-GERONTOLOGY CONSULTANTS
Ann McQueen Blair, DNP, FNP, WHNP, GNP, is board-certified as a nurse practitioner in both women’shealthandfamilynursepractitioneraswellasgerontologicnursepractitioner.Withover 30 years of NP experience, her clinical practice has included women’s health and reproductive endocrinology, integrative family practice, and geriatric practice including geriatric assessment focused on dementia care. She currently practices at the University of Virginia Student Health andWellnessinCharlottesville,Virginia.SheteachesattheSchoolofNursingattheUniversityof Virginia. Geriatrics and family medicine are her areas of experience as a clinical professor and an expert lecturer. Her doctoral evidence-based practice initiative focused on celiac disease awarenessforhealthcareproviders,andsheaimstoimplementmoreeducationalprogramsonthistopic intootherhealthcaresettings.Dr.McQueenBlairisanactivememberoftheAmericanAssociation of Nurse Practitioners, Nurse Practitioners in Women’s Health, and Gerontological Advanced Practice NursesAssociation.
L. Douglas Smith Jr., DNP, APRN, ACNP-BC, CCRN, CNRN, SCRN, FCCM, is an acute care nurse practitioner at HCA TriStar Centennial Medical Center and a faculty member in the Adult-Gerontology Acute Care Nurse Practitioner program at Vanderbilt University School of Nursing. He has 15+ years of experience caring for aged adults in various inpatient settings. Doug is published in multiple journals and textbooks and regularly speaks at conferences. He is an active member of several national organizations, including the American Association of Critical-Care Nurses, theAmericanAssociation of Nurse Practitioners, and the Society of Critical Care Medicine. Doug is a Fellow in theAmerican College of Critical Care Medicine.
ADULT-GERONTOLOGY PRACTICE GUIDELINES
THIRD EDITION
Jill C. Cash, MSN, APRN, FNP-BC Editor
Ann McQueen Blair, DNP, FNP, WHNP, GNP
L. Douglas Smith Jr., DNP, APRN, ACNP-BC, CCRN, CNRN, SCRN, FCCM
First Springer Publishing edition 978-0-8261-2762-4 (2016); subsequent edition 2019.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright.com or on the Web at www.copyright.com.
Springer Publishing Company, LLC
11 West 42nd Street, New York, NY 10036 www.springerpub.com connect.springerpub.com/
Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for any errors or omissions or for any consequence from application of the information in this book and make no warranty, expressed or implied, with respect to the content of this publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market.
Library of Congress Control Number: 2022949754
Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components.
Printed in the United States of America.
This book is dedicated to my family and friends for always understanding and being there during the development of this book.
To Kaitlin and Carsen—Reach confidently towards your dreams and never look back!
List of Client Teaching Guides xiii
Contributors xv
Acknowledgments xvii
Instructor Resource xix
SECTION I: GUIDELINES
1. NORMAL PHYSIOLOGIC CHANGES IN THE AGING ADULT 3
L. Douglas Smith Jr.
Introduction 3
Brain and Nervous System 3
Ears 4
Smell and Taste 4
Cardiovascular System 4
Respiratory System 4
Gastrointestinal System 5
Metabolism and Body Weight 5
Endocrine System 5
Musculoskeletal 5
Genitourinary System 5
Reproduction and Sexuality 5
Blood and Blood Components 5
Skin, Hair, and Nails 6
2. HEALTHY LIVING FOR THE ADULT-GERIATRIC
CLIENT 7
Ann McQueen Blair and Kathleen Bradbury-Golas
Health Maintenance During the Life Span 7
Adult RiskAssessment Form 7
Adult Preventive Healthcare 8
Adult-Geriatric Screening Recommendations 8
AbdominalAorticAneurysm 8
Bone Mass Density Measurement for Osteoporosis 15
Cardiovascular Disease and Cardiac Screening (Cardiac Calcium Score) 16
Colorectal Screening 18
Dental Care 18
Depression Screening 19
Diabetes Screening 19
Hepatitis C Screening 20
HIV Screening 20
Immunizations 20
Mammography 22
Pap Smear/Pelvic Examination 24
Prostate Cancer Screening 24
Sexually Transmitted Infection Screening 25
Vision Screens 25
Pretravel Health Screenings 25
3. ADULT-GERIATRIC ASSESSMENTS 27
L. Douglas Smith Jr.
ComprehensiveAssessment in Gerontology 27
Polypharmacy 28
FunctionalAbility 32
Psychological Well-Being 36
Socioenvironmental Status 40
Advanced Care Planning 45
Client Teaching Guides 47
4. CAREGIVER AND END-OF-LIFE ISSUES 53
Ann McQueen Blair
Caregiver Support Issues 53
Formal and Informal Caregivers 53
Informal Caregiver Demographics 53
Care Recipient Demographics 54
Informal Caregiver Concerns 54
Providers’Assistance With the Caregiver 55
Caregiver Resources 55
Advance Directives 56
Palliative Care 58
Special Considerations: Hospice Care 59
Key Factors of Care in the Elderly Client at the End of Life 59
PhysicalAspects of Care 61
Symptom Management 63
SocialAspects of Care 70
Spiritual, Religious, Cultural, and Existential Aspects 71
Ethics 72
5. GERIATRIC SYNDROMES 77
Wesley Cook
Introduction 77
Frailty and Sarcopenia 79
Functional Dependence 79
Falls 79
Dementia, Depression, and Delirium 81
PoorAppetite and Unintentional Weight Loss 82
Pain 84
Incontinence 85
Conclusion 86
6. PAIN MANAGEMENT GUIDELINES 89
Kathleen Bradbury-Golas
Acute Pain 89
Chronic Pain 91
PainAssessment and Management in theAging Population 96
Low Back Pain 99
Client Teaching Guides 102
7. DERMATOLOGY GUIDELINES 105
Jill C. Cash and Amy C. Bruggemann
Acne Rosacea 105
Acne Vulgaris 106
Atopic Dermatitis 108
Benign Skin Lesions 110
Bites 111
Bullous Pemphigoid 114
Candidiasis 115
Cellulitis andAbscess 117
Contact Dermatitis 119
Erythema Multiforme 121
Folliculitis 122
Herpes Simplex Virus Type 1 123
Herpes Zoster (Shingles) 125
Lice (Pediculosis) 126
Lichen Planus 127
Pityriasis Rosea 129
Precancerous or Cancerous Skin Lesions 130
Psoriasis 131
Scabies 133
Seborrheic Dermatitis 134
Tinea 136
Tinea Versicolor 137
Warts 138
Wound Care: Lower Extremity Ulcer 139
Wound Care: Pressure Injuries/Ulcers 141
Wounds of The Skin 143
Wound Healing: High-Protein Nutrition 145
Xerosis (Winter Itch) 146
Client Teaching Guides 147
8. EYE GUIDELINES 173
Jill C. Cash and Nancy Pesta Walsh
Blepharitis 173
Cataracts 174
Chalazion 176
Conjunctivitis 177
CornealAbrasion 179
Dacryocystitis 180
Dry Eyes 181
Excessive Tears 183
Eye Pain 184
Glaucoma,AcuteAngle Closure 186
Hordeolum (Stye) 187
Macular Degeneration 189
Refractive Disorders 190
Retinopathy 191
Subconjunctival Hemorrhage 192
Uveitis 193
Client Teaching Guides 194
9. EAR GUIDELINES 199
Jill C. Cash and Emily Y. Brignola
Acute Otitis Media 199
Cerumen Impaction (Earwax) 200
Hearing Loss 201
Otitis Externa 203
Otitis Media With Effusion 205
Presbycusis 206
Tinnitus 208
Client Teaching Guides 210
10. NASAL GUIDELINES 215
Jill C. Cash and Sarah Hendershott Taylor
Allergic Rhinitis 215
Epistaxis 217
Nonallergic Rhinitis 219
Sinusitis 220
Client Teaching Guides 223
11. THROAT AND MOUTH GUIDELINES 229
Jill C. Cash and Kathleen Bradbury-Golas
DentalAbscess 229
Dysphagia 230
Epiglottitis 232
Oral Cancer, Leukoplakia 233
Pharyngitis 235
Stomatitis, RecurrentAphthous Stomatitis 237
Thrush 239
Client Teaching Guides 240
12. RESPIRATORY GUIDELINES 245
Audra Malone Cave
Asthma 245
Bronchitis,Acute 251
Bronchitis, Chronic 252
Chronic Obstructive Pulmonary Disease 254
Common Cold/Upper Respiratory Infection 259
Cough 260
Dyspnea 262
Emphysema 264
Influenza (Flu) 268
Obstructive SleepApnea 272
Bacterial Community-Acquired Pneumonia 274
Pneumonia (Viral) 277
Tuberculosis 279
Client Teaching Guides 282
13. CARDIOVASCULAR GUIDELINES 301
Debbie A. Gunter and Laura A. Petty
Acute Myocardial Infarction 301
Arrhythmias 303
Atherosclerosis and Hyperlipidemia 306
Atrial Fibrillation 310
CarotidArtery Stenosis 314
Chest Pain 316
Chronic Venous Insufficiency and Varicose Veins 321
Deep Vein Thrombosis 324
Heart Failure 326
Hypertension 334
Lymphedema 338
Murmurs 340
Palpitations 343
PeripheralArterial Disease 344
Superficial Thrombophlebitis 347
Syncope 350
Client Teaching Guides 352
14. GASTROINTESTINAL GUIDELINES 363
L. Douglas Smith Jr., Ann McQueen Blair, and Justin Calabrace
Abdominal Pain 363
Appendicitis 367
Bowel Obstruction 369
Celiac Disease 372
Cholecystitis 375
Cirrhosis of the Liver 377
Colorectal Cancer Screening 381
Constipation 383
Crohn’s Disease 387
Cyclosporiasis 394
Diarrhea 395
Diverticulosis and Diverticulitis 398
Elevated Liver Enzymes 400
Fecal Incontinence 404
Gastroenteritis, Bacterial and Viral 407
Gastroesophageal Reflux Disease and Dyspepsia 410
Giardia Intestinalis 414
Hemorrhoids 416
HepatitisA 418
Hepatitis B 422
Hepatitis C 427
Hernias,Abdominal 431
Hernias, Pelvic 433
Hiatal Hernia 436
Irritable Bowel Syndrome 438
Jaundice 441
Malabsorption 444
Nausea and Vomiting 447
Pancreatitis 450
Peptic Ulcer Disease 453
Postbariatric Surgery Long-Term Follow-Up 457
Ulcerative Colitis 463
Client Teaching Guides 467
15. GENITOURINARY GUIDELINES 487
Kristina A. Potts and Nancy Pesta Walsh
Benign Prostatic Hyperplasia 487
Chronic Kidney Disease 491
Epididymitis 495
Hematuria 498
Interstitial Cystitis 500
Nocturia 503
Prostatitis 506
Proteinuria 510
Pyelonephritis 513
Renal Calculi, or Kidney Stones (Nephrolithiasis) 516
Sexual Dysfunction, Male: Erectile Dysfunction 519
Sexual Dysfunction, Male: Premature Ejaculation 525
Sexual Health Issues in theAging Population 527
Sexuality and Chronic Health Conditions 532
Sexuality and End of Life 533
Sexuality and Physical Disabilities 533
Testicular Torsion 535
Urinary Incontinence 536
Urinary Retention 541
Urinary Tract Infection (Acute Cystitis) 544
Varicocele 548
Client Teaching Guides 549
16. OBSTETRICS GUIDELINES 565
Penny Wortman
Prepregnancy Counseling: Identifying Clients at Risk 565
Prenatal Care: Initial Prenatal Visit 568
Prenatal Care: First Trimester Overview 568
Prenatal Care: Second Trimester Overview 569
Prenatal Care: Third Trimester Overview 570
Postpartum Overview 571
Anemia, Iron-Deficiency 573
Gestational Diabetes Mellitus 575
Hypertensive Disorders 578
Preterm Labor 582
Pyelonephritis in Pregnancy 585
Vaginal Bleeding: First Trimester 586
Vaginal Bleeding: Second and Third Trimesters 589
Postpartum Breast Engorgement 591
Endometritis 592
Mastitis 594
Postpartum Depression 595
Secondary Postpartum Hemorrhage 599
Wound Infection 601
Postpartum Exam 602
Client Teaching Guides 603
17. GYNECOLOGIC GUIDELINES 617
Rhonda Arthur and Jill C. Cash
Amenorrhea 617
Bacterial Vaginosis (Gardnerella) 619
Bartholin Cyst orAbscess 621
Breast Pain 622
Cervical Cancer Screening Guidelines and Interpretation 624
Associate Professor Frontier Nursing University Floyd, Virginia
Ann McQueen Blair, DNP, FNP, WHNP, GNP
Assistant Clinical Professor School of Nursing University of Virginia Student Health and Wellness
University of Virginia Charlottesville, Virginia
Kathleen Bradbury-Golas, DNP, RN, FNP-C, ACNS-BC
Family Nurse Practitioner
Recovery Centers ofAmerica at Lighthouse
Mays Landing, New Jersey
Associate Clinical Professor Graduate Nursing
Drexel University Philadelphia, Pennsylvania
Emily Y. Brignola, DNP, APRN, FNP-C
Division of Otology
Department of Otolaryngology—Head and Neck Surgery
Vanderbilt University Medical Center
Nashville, Tennessee
Amy C. Bruggemann, MS, APRN-BC, CWS
Director of Clinical Operations
Specialized Wound Management
Chesterfield, Missouri
Justin Calabrace, RN, MSN, ACNP-BC
Lead Neurocritical Care Nurse Practitioner
Assistant inAnesthesiology
Department ofAnesthesiology Division of Critical Care
Vanderbilt University Medical Center Nashville, Tennessee
Carsen Cash, MD
Resident Physician
Department of Physical Medicine and Rehabilitation
Vanderbilt University Medical Center
Nashville, Tennessee
Jill C. Cash, MSN, APRN, FNP-BC
Nurse Practitioner
Department of Medicine
Vanderbilt Medical Group
Westhaven Family Practice
Franklin, Tennessee
Vanderbilt University Medical Center
Nashville, Tennessee
Audra Malone Cave, DNP, FNP-BC
Assistant Professor Department of Family Nursing
Frontier Nursing University Versailles, Kentucky
Wesley Cook, DNP, APRN, FNP-BC
Medical Director
Family Nurse Practitioner
District Primary Care Washington, DC
Doncy J. Eapen, PhD, MSN, APRN, FNP-BC
Assistant Professor, Clinical,AVAScholar Department of Undergraduate Studies
Cizik School of Nursing
UTHealth Houston Houston, Texas
LaDawna Goering, DNP, APRN, ANP-BC, BC-ADM
Cizik School of Nursing
The University of Texas Houston Health Science Center Houston, Texas
Debbie A. Gunter, APRN, FNP-BC, ACHPN
Nurse Practitioner
Neurology and Palliative Care
Emory University Atlanta, Georgia
Dana N. Hughes, MPH, MSN
Assistant in Medicine
NPAmbulatory Department of Medicine
Division of Infectious Diseases
Vanderbilt University Medical Center
Nashville, Tennessee
Hsiao-Hui “Joyce” Ju, DNP, APRN, FNP-BC, CNE
Cizik School of Nursing at UTHealth Houston, Texas
Lauren E. Kimbrell, BS, MSN
Critical Care Nurse Practitioner
HCAPhysician Services Group
Intensive Care Consortium
Centennial Medical Center
Nashville, Tennessee
Kristin K. Ownby, PhD, RN, ACHPN, AOCN, ANP-BC
Associate Professor of Clinical Nursing
Department of Undergraduate Studies
Cizik School of Nursing
UTHealth Houston Houston, Texas
Laura A. Petty, MSN, GNP-BC
Gerontological Nurse Practitioner
Lebanon, Tennessee
Kristina A. Potts, MSN, FNP-BC Nurse Practitioner
St. Luke’s Fenton Family Physician Fenton, Missouri
L. Douglas Smith Jr., MSN, APRN, ACNP-BC, CCRN, CNRN, SCRN
Instructor
Vanderbilt University School of Nursing Nashville, Tennessee
Sarah Hendershott Taylor, MSN, FNP-C
Otolaryngology Nurse Practitioner
Vanderbilt University Medical Center Nashville, Tennessee
Nancy Pesta Walsh, DNP, MSN, FNP
Assistant Professor
Frontier Nursing University Versailles, Kentucky
Family Nurse Practitioner
Glacial Ridge Health System Glenwood, Minnesota
Penny Wortman, DNP, CNM, CNE
Assistant Professor
Department of Midwifery and Women’s Health
Frontier Nursing University Cedar Falls, Iowa
ACKNOWLEDGMENTS
It has been a pleasure to work with the editorial staff and production team at Springer Publishing Company.
To Joe Morita, ExecutiveAcquisitions Editor: Thank you for being a steadfast proponent of this work.
To Taylor Ball, Director, Content Development: Thank you for your energy, enthusiasm, and support that you always shared on our Friday afternoon Zoom calls when planning the development of this textbook.
To Kris Parrish, Production Manager, and Joanne Jay, Vice President, Production: Thank you for your talent and support for finalizing the material and guiding this book toward publication.
ToDr.AnneMcQueenBlairandDr.DougSmith:Ithasbeenapleasuretoworkwithyou.Thank you for sharing your expertise in caring for our older adult clients.
—Jill
INSTRUCTOR RESOURCE
■ Mapping to AACN Essentials: Core Competencies for Professional Nursing Education are available to qualified instructors by emailing textbook@springerpub.com
SECTION GUIDELINES
1. Normal Physiological Changes in the Aging Adult
2. Healthy Living for the Adult-Geriatric Client
3. Adult-Geriatric Assessments
4. Caregiver and End-of-Life Issues
5. Geriatric Syndromes
6. Pain Management Guidelines
7. Dermatology Guidelines
8. Eye Guidelines
9. Ear Guidelines
10. Nasal Guidelines
11. Throat and Mouth Guidelines
12. Respiratory Guidelines
13. Cardiovascular Guidelines
14. Gastrointestinal Guidelines
15. Genitourinary Guidelines
16. Obstetrics Guidelines
17. Gynecologic Guidelines
18. Sexually Transmitted Infections Guidelines
19. Infectious Disease Guidelines
20. Systemic Disorders Guidelines
21. Musculoskeletal Guidelines
22. Rheumatological Guidelines
23. Neurologic Guidelines
24. Endocrine Guidelines
25. Psychiatric Guidelines
CHAPTER 1
NORMAL PHYSIOLOGIC CHANGES IN THE AGING ADULT
L. Douglas Smith Jr.
INTRODUCTION
A. As we age, our bodies progress through a continuum of predictable changes to basic biologic processes affecting our ability to interact with the environment. Aging is a complex process that begins at conception and progresses through death. Aging is a heterogeneous process; no person ages the sameasanother,andorganswithinthesameindividualexperienceage-relatedchangesatdifferenttimesduetotheunique confluence of genetic makeup, lifestyle choices, and environmental exposure through the life span. No singular theory adequately explains the holistic nature of the aging process— aging is the result of the complex interplay of many factors (e.g., biologic, psychologic, sociologic).
B. Routine age-related change is not synonymous with pathology. Ongoing discoveries suggest that many chronic maladies historically associated with aging (e.g., joint pain) may result from long-lived lifestyle choices more than changes related to age. The concept of successful aging considers an aged individual with good physical and cognitive function free of chronic disease. Still, aging is an inevitable process that results in predictable changes in physiologic function; the following is a brief discussion of common changes with age.
BRAIN AND NERVOUS SYSTEM
A. Anatomic changes in the central and peripheral nervous systems result in functional alterations in the autonomic and somatic nervous systems. Cerebral blood flow decreases, and there is a loss of compensatory mechanisms for normal fluctuation in blood pressure. Neuronal shrinkage and loss (most notable in the cerebellum and cerebral cortex) decrease overall brain volume. Accumulation of neurofibrillary tangles and neuritic plaques occurs routinely—although less than in Alzheimer disease. Significant decreases in the ability to synthesize and degrade neurotransmitters and a loss of myelin sheath result in impaired electrical transmission.
B. Observable effects due to anatomic changes in the nervous system vary between individuals. Muscular atrophy and strength decreases are seen due to decreased innervation and resting neurologic tone. Fine motor coordination and agility decrease; tremors may develop, making it difficult to perform activities of daily living. Changes to autonomic sensory neurons result in impaired proprioception, balance, and
coordination, leading to a higher risk of falls. As a result of decreased nerve conduction speed, autonomic and somatic reflexes slow and contribute to delayed reactions times to touch and pain.
COGNITION
A. Cognitive impairment has long been thought normal in the aging process; however, this paradigm provides an overly simplistic understanding of aging on cognition. In a successfully aged person, parameters of cognitive function, including performance of well-practiced skills, retention of general knowledge, and recognition of familiar objects, remain stable over the lifetime. Changes in cognitive function associated with normal aging begin near the seventh decade of life and include decline in executive function, decreased attention span, difficulty reasoning in unfamiliar situations, and reduced processing of new information; still, successfully aged adults remain capable of functioning in society well beyond their 70th birthday.
SLEEP
A. Aging alters circadian patterns, resulting in changes in sleep and wakefulness. Changes in the thalamus, limbic, and reticular activating systems controlled by the hypothalamus result in a shift in normal rhythmic functions, creating sleep latency (delay in onset of sleep), reduced sleep efficiency (more time in bed when not asleep), increased nocturnal and early morning awakenings, and increased daytime sleepiness and napping. In addition, time spent in the deep and rapid eye movement stages of sleep decreases. These changes occur due to normal aging but may indicate underlying pathology (e.g., snoring or sleep apnea) or adverse drug effects.
EYES
A. Age-related changes to the eye and vision are typical and well-documented. Atrophy of periorbital fatty tissue and decreased resting tone result in ptosis or other malposition of the eyelids. Lacrimal gland changes result in reduced quantity and quality of tear production. The conjunctiva thins and may become yellow. In some adults, the cornea develops a noticeably yellow ring of fatty deposits known as arcus senilis. The iris stiffens, affecting its ability to change size, resulting in pupils that are smaller and more sluggishly responsive to light. The lens yellows and becomes opaque, scattering available light, while the retina becomes thinner due to changes
in retinal photoreceptors and retinal nerve fiber thickening. Examination with the ophthalmoscope reveals narrowed and straightened blood vessels and gray and narrowed spots near the macula.
B. These anatomic differences result in commonly cited changes in vision. Dry and burning eyes result from reduced tear production, while the displacement of the lacrimal punctum may result in ineffective tear drainage and complaints of watery eyes. Changes to the iris and lens may result in difficulty reading up close (presbyopia) and other decreases in visual acuity. In addition, aged adults often experience reduced color and contrast discrimination and glare sensitivity.
C. Aging adults are at risk of three particular eye-related conditions due to normal aging. First, cataracts may develop from excessive protein accumulation in the lens over time. Cataracts appear as an opacity in the lens and interfere with the red reflex. Glaucoma results from increased intraocular pressure and may result in the gradual loss of peripheral vision. Finally, macular degeneration results from the breakdown of cells in the macula and leads to central vision loss and blindness while leaving the peripheral vision intact.
EARS
A. Ears are complex sensory organs responsible for input to the brain for hearing and balance. The ear’s anatomy consists of three parts (external, middle, and inner), all of which experience changes during aging.
HEARING
A. Age-related changes affecting hearing include narrowing of the auditory canal, thickening of canal-lining hairs, and atrophy of the cerumen glands, resulting in thicker cerumen. Conductive hearing loss occurs as the tympanic membrane stiffens and calcification of ossicular joints occurs in the middle ear. Sensorineural hearing loss results from the loss of cochlear and auditory center innervation and stiffening of the basilar membrane. These age-related changes result in presbycusis, the gradual loss of hearing in both ears. Hearing loss occurs gradually and often presents as reduced ability to hear high-frequency sounds or impaired speech recognition in noisy settings. While hearing impairments may not be life-threatening, they can be disabling and negatively impact the quality of life.
BALANCE
A. The vestibule and semicircular canals of the inner ear, along with proprioceptive neurons of the central and peripheral nervous systems, coordinate balance. Sensory hair cell loss in the vestibule and changes in semicircular canal innervation impact balance in the aged adult. Aged adults often present with postural sway, complaints of vertigo, and have an increased risk of injury due to falls.
SMELL AND TASTE
A. Taste and smell are highly integrated senses allowing for sensory evaluation of the environment. Changes in their function carry significant implications for ingestion of food, personal safety, and personal hygiene. Age-related changes to these senses are incompletely understood but typically attributed to changes in the oral mucosa and nasal cavity (decrease in olfactory nerve fibers and taste buds), damage to cells
throughout the life span (viral infections or environmental toxins), medication use, and diminished levels of neurotransmitters. The loss of smell impedes distinguishing spoiled foods, determining body odor, and identifying smoke in the environment. In addition, taste changes are likely to decrease interest in food and lead to weight loss.
CARDIOVASCULAR SYSTEM
A. As the cardiovascular system ages, expected changes in structureandfunctionoccur,includingmodestleftatrialenlargement and hypertrophy and stiffening of the left ventricle, resulting in prolonged contraction time. Time in diastole lengthens to allow the stiffened ventricle longer to relax. Calcification and annular thickening of the aortic and mitral valves occur. There is a loss of pacemaker cells and fibrosis along the cardiac conduction system, leading to decreased responsiveness to adrenergic stimulation. Composition of the blood vessel changes to include increased collagen and decreased elastin, resulting in stiffer, less responsive blood vessels and coronary arteries.
B. Functional changes result from these structural changes. In general, the aged heart takes more time to recover systolic and conduction function between each beat. This is not significant while at rest; however, when stressed or at exercise, aged adults experience a decrease in maximum heart rate, cardiac output, and activity tolerance. While heart chambers enlarge, the overall heart size does not change. Valvular changes may result in nonconcerning systolic murmurs on auscultation. Due to differences in cardiac conduction, the aged adult may experience a higher rate of premature ectopic beats and are at a higher risk for atrial fibrillation. As the blood vessels stiffen, they become less responsive to baroreceptor signals and adrenergic stimulation, and the systolic blood pressure increases over time while the diastolic blood pressure remains consistent, resulting in widening pulse pressure.
RESPIRATORY SYSTEM
A. It is difficult to distinguish changes in the respiratory system solely linked to advanced age from those connected to environmental exposures over time. Changes in the respiratory status result from both changes in the lung and its ability to perform gas exchange and changes in structures assisting in ventilation. Rib and vertebrae osteoporosis and rigidities of the costal cartilage lead to limitations in thoracic movement and decreased chest wall compliance. The diaphragm flattens and becomes less efficient, resulting in pulmonary overdistention, and the recruitment of accessory muscles for adequate ventilation increases metabolic demands. Muscle weakness leads to a less vigorous cough. Age-related reductions in tracheobronchial cilia and immunoglobulin A reduce the ability to filter inhaled air and neutralize inhaled viruses.
B. Changes in the lung affect both ventilation and gas exchange. Enlargement of alveolar ducts from loss of elastic tissue results in a one-third decrease of surface area available for gas exchange. Lessened elasticity results in decreased vital capacity and increased residual volume. Changes in cardiovascular function and enlargement of the pulmonary artery lead to ventilation–perfusion mismatch; the weakened respiratory muscles become less able to move air into dependent alveoli where perfusion is greatest. Reduced effectiveness of gas exchange leads to rising carbon dioxide levels
and decreasing oxygen levels in the blood, predisposing the aged adult to hypoxia and hypercapnia with less respiratory reserve capacity than when younger.
GASTROINTESTINAL SYSTEM
A. Age-related changes in the gastrointestinal (GI) system occur, although the effect on well-being is minimal. The GI tract includes all organs responsible for ingestion, digestion, absorption of nutrients, and excretion of solid waste from the body. GI-specific alterations exist; however, many changes associated with the GI system result from changes in other systems. For example, changes in the nervous system impact peristalsis and transit time, while changes in the cardiovascular system decrease mesenteric blood flow and absorption of nutrients. Specific age-related changes in the GI tract include gingival retraction and loss of teeth, decreased volume of saliva, decreased tone at the lower esophageal sphincter, reduced motility, atrophy of gastric mucosa, reduction of digestiveenzymeexcretion,decreasedanalsphinctertone,and increased transit time (ingestion to excretion). Constipation and reflux gastritis are common complaints associated with age-related changes of the GI system.
METABOLISM AND BODY WEIGHT
A. Nutrients absorbed by the gastrointestinal system nourish the body’s cells and provide energy for normal metabolic functions. As we age, the metabolism slows and the body requires less energy. In addition, hormonal changes cause the body to increase body fat stores and create less muscle mass, further decreasing the metabolic rate and increasing the chance for obesity. Throughout life, adults are encouraged to exercise most days of the week and monitor daily dietary intake to maintain a healthy body mass index between 18.5 and 24.9 kg/m2
ENDOCRINE SYSTEM
A. The endocrine system is a complex array of interlinked organs and glands closely linked to the nervous system. Because of the interconnectedness, it is challenging to identify gland-specific changes that occur over time. Decreases in endocrine function result in problems associated with metabolism, electrolytes, glucose, water, and minerals. Diabetes mellitus, hypothyroidism, osteoporosis, adrenal insufficiency, and various forms of hypopituitarism are some of the most common disease states associated with decreased endocrine function.
MUSCULOSKELETAL
A. The bones, muscles, and joints experience age-related changes. Calcium and mineral loss, in addition to inadequate intake of calcium and vitamin D, excessive alcohol and tobacco use, and decreased weight-bearing activity, lead to weakening of bones over time. Aging increases the chance of fracture and reduces repair speed when a fracture occurs. Joint stiffness and pain result from structure change, inflammation, and space narrowing. Muscle mass and strength decline due to hormonal changes and lack of physical activity. Muscle weakness, poor posture, joint compression, and brittle bones often reduce height by as much as 2 in. by the eighth decade of life.
GENITOURINARY SYSTEM
A. Aging of the renal system generally results in decreased efficiency of the urinary system. Kidney mass decreases and fibrotic changes occur in the parenchyma. Loss of nephrons in the renal cortex primarily affects those nephrons most important to maximal urine concentration and results in about 50% decrease in functional glomeruli in adults aged into the seventh decade of life. The nephrons remaining suffer a reduced filtering ability. Renal blood flow decreases in response to stiffened and thickened blood vessels. The loss of nephrons and decrease in blood flow result in reductions in glomerular filtration rate and creatinine clearance, leading to decreased ability to concentrate urine, manage electrolyte balance, and excrete toxic waste products. The ureters, bladder, and urethra also undergo age-related changes and include decreases in tone, elasticity, capacity, and sphincter tone, contributing to frequent urination, urinary urgency, and urinary incontinence. Females are at increased risk of urinary infections and males often experience difficulty with urination secondary to prostate enlargement.
REPRODUCTION AND SEXUALITY
SEXUALITY
A. Sexuality and intimacy are essential aspects of health and well-being throughout the life span. Decreasing hormones in both aged adults create significant and distressing changes to sexuality. There is a less rapid and extreme vascular arousal response to stimulation for both sexes. Time to orgasm increases, as does the refractory period after orgasm. Males may experience erectile dysfunction, premature ejaculation, less forceful ejaculations, and enlarging prostates. Females may experience anorgasmia, problems with arousal, and painful intercourse.
MENOPAUSE
A. Females reach menopause, the cessation of menses, commonly between their mid-40s and late 50s, with the average age at 51 years. Before menopause, the ovarian function declines, and irregular and lighter menses occur. These changes occur when the ovaries cease producing progesterone and estrogen. When this happens, reproduction is no longer possible. In addition, the hormonal changes decrease blood supply to the vagina and contribute to decreased vaginal secretion and lubrication during intercourse. Other changes associated with menopause include weakened pelvic muscles, thinning of the vaginal epithelium, and alkalinization of the vagina. These changes may lead to pain during sexual activity and increase the risk of infection.
BREAST
A. Changes to breast tissue occur as both males and females age. Postmenopausal females experience breast tissue atrophy due to decreases in sex hormones. Fibrous connective tissue replaces thinning tissue. As breast elasticity decreases, the breast decreases in size and may sag. Declining testosterone levels in males may lead to gynecomastia.
BLOOD AND BLOOD COMPONENTS
HEMATOPOIESIS
A. Outside the influence of pathology, the hematopoietic system maintains adequate function through the life span.
Baselineproductionandturnoverofredbloodcellsandplatelets do not change significantly; however, as with other systems, the hematopoietic ability to compensate for a loss (e.g., from phlebotomy) is less robust. Notably, platelets become hyperresponsive to thrombotic stimulators and several clotting factors increase, resulting in a slight but consistent decrease in bleeding time.
IMMUNE SYSTEM
A. The immune system weakens with aging due to a weakened ability to make antibodies to disease. The thymus gland, responsible for T-cell activating hormones, atrophies and weakens. Peripheral T-cells decrease, increasing the risk of developing infections and making infections more severe. Aged clients greatly benefit from adherence to immunization schedules recommended by the Centers for Disease Control and Prevention.
SKIN, HAIR, AND NAILS
A. Normal skin aging leads to atrophy, decreased elasticity, and impaired reparative responses. The epidermis becomes thin, flattens, and loses elasticity, leading to fine lines and wrinkles. The epidermis plays a crucial role in vitamin D
synthesis, and as the epidermis thins the aged person’s ability to synthesize vitamin D decreases. Skin hydration is affected as sweat, oil, and sebaceous glands become less active. The loss of subcutaneous fat tissues throughout the body reduces insulation against cold, and the loss of protective fat pads in the feet increases the risk of a foot injury. Wound healing is delayed with age. Hair changes are related to decreased follicle density and function. Hair growth slows and hair thins. Hair loss occurs most commonly in the scalp, axilla, and pubic areas. Hair color may gray and females may begin to grow facial hair. Fingernails become thin and tear easily, while toenails grow thick.
BIBLIOGRAPHY
Centers for Disease Control and Prevention. (2021a). Healthy weight, nutrition, and physical activity. https://www.cdc.gov/healthyweight/asses sing/bmi/index.html
Centers for Disease Control and Prevention. (2021b). Vaccine information for adults. https://www.cdc.gov/vaccines/adults/index.html
Saxon, S. V., Etten, M. J., & Perkins, E. A. (2021). Physical change and aging: A guide for the helping professions (7th ed.). Springer Publishing. Taffet, G. E. (2021). Normal aging UpToDate. https://www.uptodate.com/ contents/normal-aging#H189995853
CHAPTER 2
HEALTHY LIVING FOR THE ADULT-GERIATRIC CLIENT
Ann McQueen Blair and Kathleen Bradbury-Golas
HEALTH MAINTENANCE DURING THE LIFE SPAN
A. Health maintenance involves identifying individuals at risk for health problems and encouraging behaviors that reducetheserisks.Animportantaspectofhealthmaintenance is client education, including teaching individuals about their risk factors for disease and ways to modify their behaviors to reduce their risks of comorbidities. Client teaching guides maybedownloadedbythepractitioner,filledaccordingtothe client’s evaluation and needs, and given to the client.
BIBLIOGRAPHY
Andrews, M. M., & S, Boyle, J. (Eds.). (2008). Transcultural concepts in nursing care (5th ed.). Lippincott Williams & Wilkins.
Ellis, R. L. (2006, May). Are associate degree nursing graduates adequately prepared to meet the cultural needs of their patients at the end of life? Paper presented at the meeting of thesis presentation. https://research.libra ries.wsu.edu:8443/xmlui/handle/2376/499
Ruddock, H. C., & Turner, D. S. (2007). Developing cultural sensitivity: Nursing students’ experiences of study abroad program. Journal of
Spector, R. E. (2012). Cultural diversity in health and illness (8th ed.). Prentice-Hall.
Wallace, M. P., Weiner, J. S., Pekmezaris, R., Almendral, A., Cosiquen, R., Auerbach, C., & Wolf-Klien, G. (2007). Physician’s cultural sensitivity in African American advanced care planning: A pilot study. Journal of Palliative Medicine, 10(3), 721–727. https://doi.org/10.1089/jpm.2006 .0212
ADULT RISK ASSESSMENT FORM
A. The Adult Risk Assessment Form (Exhibit 2.1) should be used for all adult clients to evaluate their risk for particular diseases. The practitioner should interview the client, assessing for the risk factors listed on the Adult Risk Assessment Form. The family history of first-degree relatives (parents, siblings, and children) should also be discussed because many diseases are related to genetic factors. Keep a copy of the Adult Risk Assessment Form in the front of the client’s chart
3. Elevated cholesterol level.
4. Stroke.
5. Hypertension.
6. Tobacco use.
B. Lung cancer:
1. High-fat/high-cholesterol diet.
2. Tobacco use.
C. Cervical cancer:
1. Early age of first intercourse.
2. Multiple sexual partners.
3. History of human papillomavirus.
D. Breast cancer: 1. Nulliparous.
2. Primigravida after the age of 35.
3. High-fat diet.
E. Colon cancer:
1. History of polyps.
2. High-fat diet.
F. Osteoporosis:
1. Less than 1 g of calcium per day.
2. History of tobacco or alcohol use.
3. Sedentary lifestyle.
4. Thin, Caucasian.
5. Female gender.
EXHIBIT 2.1 Adult Risk Assessment Form (continued )
G. Glaucoma/visual impairment:
1. Family history of glaucoma.
2. Diabetes mellitus.
H. Sexually transmitted infections (STIs)/HIV:
1. Alcohol and drug use or abuse.
2. Multiple sexual partners.
3. Homosexual or bisexual partner.
4. History of intravenous drug use/needle sharing.
5. History of blood transfusion.
6. Exposed to or history of STI.
7. Exchanging sex for drugs or money.
I. Substance abuse:
1. Alcohol or drug use history including “street drugs” and opioids.
2. Family history of substance abuse.
3. Stress or poor coping mechanisms.
4. Administer the CAGE Assessment: Have you ever tried to Cut down on your alcohol/drug use? Do you get Annoyed if someone mentions your use is a problem? Do you ever feel Guilty about your
andupdateyearlyorasneeded.Whencomplete,thistoolcan guidethepractitionerindeterminingtheassessmentneedsof each client. If using electronic medical records, a special section should be identified for risk assessment.
ADULT PREVENTIVE HEALTHCARE
A. Exhibits2.2and2.3helpthepractitioneridentifychanges in the adult client’s risk factor status, make recommendations for health maintenance (e.g., immunizations, laboratory work, physical exams), and educate the client on prevention. The guide can be used as a quick reference for the practitioner to evaluate the client’s adherence to preventive measures. Keep a copy of this flow sheet and guide in the front of the client’s chart where they can be reviewed routinely and updated as necessary. If using electronic medical records, a special section should be identified as routine health maintenance.
BIBLIOGRAPHY
U.S.PreventiveServicesTaskForce.(2021). AandBrecommendations.Aand B Recommendations | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org).
Women’s Preventive Services Initiative. (2016). Recommendations for preventive services for women: Final report to the U.S. Department of Health and Human Services. Health Resources & Service Administration American College of Obstetricians and Gynecologists. https://www. womenspreventivehealth.org/final-report
ADULT-GERIATRIC SCREENING RECOMMENDATIONS
A. Health promotion includes utilization of preventive screen testing. Multiple guidelines are available for clinicians to utilize during guidance and discussion of recommendations with clients. Professional societies, the U.S. Public Health Service, and other organizations evaluate the strength of evidence and the weight of clinical research, statistical analysis, and the risk and benefits of testing to make recommendations for screening. Most of the recommendations for this section are from the U.S. Preventive Services Task Force (USPSTF) guidelines.
B. Eligibility and Medicare coverage for screening are summarized in Table 2.1.
use? Do you ever have an Eye-opener first thing in the morning after you have been drinking or using the night before?
J. Accidents and suicide:
1. Previous suicide attempt.
2. Family history of suicide.
3. Alcohol use.
4. Substance use.
5. History of depression.
6. High-stress or “hot-reactor” personality.
7. Male gender.
8. Poor coping mechanisms or stress.
K. Safety:
1. Does not use seat belt or car seat.
2. Drinks and drives.
3. Drives over the speed limit.
4. Does not wear safety helmet if driving motorcycle.
5. Inadequate number of smoke detectors or none in the home.
BIBLIOGRAPHY
U.S. Centers for Medicare and Medicaid Services. (n.d.[a]). Alcohol misuse screenings & counseling. https://www.medicare.gov/coverage/ alcohol-misuse-screenings-counseling
U.S. Centers for Medicare and Medicaid Services. (n.d.[b]). Nutrition therapy services. https://www.medicare.gov/coverage/nutrition-therapy -services.html
U.S. Centers for Medicare and Medicaid Services. (n.d.[c]). Smoking & tobacco-use cessation counseling. https://www.medicare.gov/coverage /smoking-tobacco-use-cessation-counseling
U.S. Centers for Medicare and Medicaid Services. (n.d.[d]). Yearly “Wellness” visits. https://www.medicare.gov/coverage/ yearly-wellness-visits
U.S. Centers for Medicare and Medicaid Services. (n.d.[e]). Your “Welcome to Medicare” preventative visit. https://www.medicare. gov/information-for-my-situation/your-welcome-to-medicarepreventive-visit
ABDOMINAL AORTIC ANEURYSM
A. The Centers for Disease Control and Prevention (CDC) notes abdominal aortic aneurysms (AAAs) were the primary cause of death in 59% of deaths in 2019. The main risk factors for development of AAAs are age, sex, smoking, and family history. A history of smoking occurs in 75% of those with AAA. About two-thirds of people who have an aortic dissection are male. Older males who have smoked are at the highest risk of developing an AAA. Dissections and ruptures are the cause of most deaths from aortic aneurysms. An AAA is often asymptomatic; however, the symptoms may include a sharp, sudden pain in the chest; throbbing or deep pain in the back or side, and/or pain in the buttocks, groin, or legs; trouble breathing or swallowing; or syncope. Nearly two-thirds of aneurysms leading to surgery were detected as incidental findings on imaging studies performed for other indications. On physical examination, a pulsatile mass in the epigastrium where the aorta bifurcates at the umbilicus may be palpated. B. There are several types of aneurysm: thoracic aneurysms, abdominal aneurysms, peripheral aneurysms, and those that occur in the brain, which may cause a stroke. An AAA is an enlarged ballooning area that is more than 50% of the normal diameter of the aorta. The U.S. Preventive Services Task Force (USPSTF) notes that people who are screened are about twice
EXHIBIT
2.2 Adult Preventive Healthcare Flow Sheet
Immunization Schedule
Immunization or Positive TiterDateDateDateDate
Tdap (tetanus, diphtheria, and pertussis) booster
MMR
TB (yearly as indicated)
HepB
Influenza (yearly)
Pneumococcal (PCV15, PCV20, PPSV 23)
Varicella (14–49y)
Zoster recombinent (>50y)
COVID-19
Other
Assess clients for the following behaviors:
Risk Assessment
Clients should be educated about any behavior modifications that can reduce their risk factors for health problems. The practitioner should note the date as well as the type of counseling given to the client.
as likely to have AAA surgery within 3 to 5 years compared with people who are not screened. The 2019 USPSTF guideline onAbdominalAorticAneurysm: Primary Care Screening recommendations forAAAscreening include the following:
1. Males 65 to 75 years of age who have ever smoked (100 cigarettes in a lifetime) should have a onetime ultrasound screening for AAA even if they are asymptomatic.
2. Males ages 65 to 75 years who have never smoked can be selectively offered screening by clinicians rather than routinely screening all males in this group. Screening
should be based on medical history, family history, other risk factors, and client preferences.
3. The current evidence is insufficient to assess the balance of benefits and harms for the USPSTF to recommend that females ages 65 to 75 who have ever smoked be screened for AAA.
4. The USPSTF recommends that females who smoke or have never smoked should not undergo AAA screening. AAAisuncommoninolderfemalesandisveryrarein females who have never smoked. The Society for Vascular
