Case+Study+Unit+V


 * Please have questions 1-3 answered for Wednesday, 2/10/10 and the remaining questions completed by 2/17/10. Online posts made after 2/17/10 will no be counted towards your participation for this case study.**

1. Describe the changes you would expect to find during a physical exam of the older adult patient.

Head:- A mild rhythmic tremor of the head is normal. Senile tremors are benign and include head nodding ( as if saying yes or no) and tongue protrusion. Eyes: Eyes-Eyebrows may show a loss of the outer one third to one half of hair, remaining hair is course. Atrophy of elastic tissue will present as crows feet and wrinkles. Upper lid may be so elongated as to rest on the lashes. Eyes may appear sunken because of the weakening of orbital fat, it may also herniate causing bulging at the lower lids and inner third of the upper lids. Tear production may decrease causing eyes to look dry and lusterless( may report burning sensation). Pingueculae on sclera( yellowish elevated nodules due to thickening of the bulbar conjuctiva from prolonged exposure to sun, wind and dust. Cornea may look cloudy. Arcus senilis is commonly seen around the cornea. Xanthelasma are soft raised yellow plaques occurring on lids of the inner canthus ( happens around 50 and more frequently in women). Pupils are small and pupillary light reflex may be slowed. Lens loses transparency and appear opaque.

Ears: "outer ear: increased production of and drier cerumen increased hair growth loss of elasticity in cartilage. Middle ear: atrophic changes of tympanic membrane/conductive hearing loss Inner ear: hair cell degeneration, neuron degeneration in auditory nerve and central pathways, reduced blood supply to cochlea, calcificaiton of ossicles. Less effective vestibular apparatus in semicircular canals." Lewis p. 410

Throat and mouth:"gingival retraction. loss of teeth, presence of dentures, difficulty chewing decreased taste buds, decreased sense of smell diminished sense of taste decreased volume of saliva" Lewis p.933

Cardiovascular:Cardiovascular--Gradual increase in systolic blood pressure, diastolic blood pressure stays fairly constant. May be experiencing orthostatic hypotension. Chest often increases in anteroposterior diameter making making it difficult to palpate the apical pulse. Ectopic beats are common. Dorsalis pedis and posterior tibial pulses are difficult to find. Trophic changes associated with arterial insufficiency( thin, shiny skin, thick- ridged nails, loss of hair on lower legs.)

Respiratory--- Increased anteroposterior diameter giving a barrel shape and kyphosis or an outward curvature of the thoracic spine. Patient compensates by holding the head extended and tilted back. Chest expansion decreases but still symmetric. Coastal cartilages become calcified with age resulting in a less mobile thorax. Elderly patient may fatigue easily, especially during auscultation when deep mouth breathing is required.

GI: "digestive juices diminish and nutrient absorption decreases. malnutrition and anemia become common due to reduced muscle tone and deccreased peristatsis, constipation and indigestion are common." p. 453 Taylor

Musculoskeletal: malnutrition and anemia become common due to reduced muscle tone and deccreased peristatsis, constipation and indigestion are common." p. 453 Taylor

Neurological:Neurological system--- slow response. A decrease in muscle bulk is apparent in the hand, seen by guttering between the metacarpals. Dorsal hand muscle often look wasted. Senile tremors occasionally. Gait slower, more deliberate and deviates from midline path. > than 65 loss of sensation of vibration at the ankle. Malleolus is common loss of ankle jerk. Tactile sensation impaired, need stronger stimuli for light touch and especially pain. Deep tendon reflexes are less brisk. Planter reflex may be absent or difficult to interpret.

Genitourinary:genitourinary: "blood flow to kidneys decreases with diminished cardiac output. Nephron function decreases, urine is excreted more slowly. Bladder capacity decreases by 50%. Voiding becomes more frequent. A decrease in bladder and sphincter muscle control may result in stress incontinence or incomplete bladder emptying. Hypertrophy of the prostate gland. Atrophy, decrease of secretions, and thinning of older woman's genital tract." Taylor p 453

Psychological:psychological: loss of many loved ones retirement: loss of identity, direction, self esteem alcohol abuse suicide risk dementia

2. Discuss three cognitive changes seen in a number of elderly patients. "Loss of memory in old age is not general, but specific to certain kinds of memory. Episodic memories are most affected, while semantic and implicit memories are mostly unaffected. Short term memory declines gradually until age 70, then deteriorates quickly." Feldman, Robert. "Development Across the Life Span." p.601 Three cognitive changes: 1) Acuity of abstract non verbal reasoning diminishes with the normal aging process. 2) Depression can result in psychomotor retardation, memory and concentration impairment and other idiosyncratic alterations in cognition. 3) Normal aging is accompanied by behavioral slowing.

3. Identify six patient behaviors in the elderly you would associate with depression. Pt behaviors associated with depression: social isolation not keeping clean--body, clothing, home. not eating balanced meals, and/or not eating enough calories not moving around enough; mostly sitting in one spot angry, irritable attitude that might further isolation from neigbors or family.

4. What medical conditions in the elderly could present with symptoms of depression? Symptoms of depression are often ignored or confused with other ailments such as: Alzheimer's, arthritis, cancer, dementia, heart disease, Parkinson's disease, stroke and thyroid disorder. symptoms such as fatigue, appetite loss and trouble sleeping can be part of the normal aging process making the diagnosis of depression difficult. Medline plus-- www.nim.nih.gov. A number of medical conditions may result n symptoms of depression.Many metabolic a endocrine disorders such as serum glucose abnormalities,elevated blood urea nitrogen, pernicious anemia, hypo or hyper-thyroidism present symptoms that mimic depression.(Sutherland & Skar 1999)

5. What patient behaviors would you associate with delirium? The inability to focus and maintain attention. causes fluctuations in consciousness and changes in cognition ( over a short period of time) Patients become agitated and hypervigilant, sleep- wake patterns are altered. Can experience hallucinations of the visual, auditory or tactile type. Extremes of delirium range from simple confusion to anxious, agitated and hyperactive. can experience one end to the other in a short period of time. The behavioral manifestations of dementia vary and can include disorientation to place and time,or person, disorganized thinking,decreased alertness, agitation, delusions or emotional lability.

6. What patient behaviors would you associate with dementia? behaviors of dementia: Deterioration in intellectual functioning, memory, ability to solve problems and learn new skills Decline in ability to carry out ADL's deterioration of personality accompanied by impaired judgement aphasia,apraxia sexual disinhibition Foundations of psychiatric Mental Health Nursing Pages 379 &656 Dementia is a syndrome characterized by 1) decreased cognition from a previously higher level, 2)emergence of behavioral disturbances, 3)interference with daily function and independence.

7. What neuroanatomic changes are seen in individuals with Alzheimer’s disease? Ct scans and MRI's reveal brain atrophy along with enlargement of cortical sulci and cerebral ventricles. Alzheimer's disease is characterized by the formation of neurofibrillary tangles and senile plaques.

8. Write three priority nursing interventions for the patient with delirium. 1)provide a safe and therapeutic enviroment 2) identify etiological ( causation) factors causing delirium. If underlying causes of delirium are not treated permanent brain damage may ensue. 3) initiate therapies to reduce or eliminate factors causing delirium

pysch book page 377

1. diagnose and treat the cause. eliminate suspicious medications, cure infections, treat electrolyte imbalances. 2.Older adults should be reoriented and shielded from unnecessary stimuli. 3. reassuring the family that delirium is reversible in most cases will ease fears as the family copes. Reorientation to place ,time, and procedures. Clocks and calendars help. Be sure the patient has access to eyeglasses and hearing aids because sensory deprivation can precipitate delirium. Lewis p 1577

9. Write three priority nursing interventions for the patient with dementia. 1) provide a modified environment ensuring safety first 2) Include family members/ support system in the planning, providing and evaluating care. Only to the extent that it involves them. 3) provide a low stimulation environment.( soothing music, dining in small groups, performance expectations that do not exceed cognitive ability. provide anticipatory support and guidance. provide frequent health assessments. provide caregiver information. Involve the patient by giving choices where reasonable and possible, to encourage cooperation. Provide tasks such as folding towels to encourage feelings of usefulness and control. With advanced dementia, medications might be indicated for extreme agitation, for patient safety. Gulanick p.544-547