Family Practice and Adult Gerontology Primary Care Nurse Practitioner Certification Examination Review Questions and Strategies [Print Replica] (Ebook PDF)
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 andSigmaThetaTauInternationalHonorSociety.
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 PracticeNursesAssociation.
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 CareMedicine.DougisaFellowintheAmericanCollegeofCriticalCareMedicine.
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.
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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
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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 reservecapacitythanwhenyounger.
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.
