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** : balding becomes common, women also experience thinning of hair, hair looses pigmentation (presence of gray hair), wrinkling and sagging occur, skin pigmentation,

loss of hair/thinning hair. moles. **Eyes** : visual acuity diminishes; more common "near sighted", sensitivity to glare and decreased ability to adjust to darkness, decreased color discrimination and depth perfection. Difficulty reading small print and daytime or night driving may be compromised. Cataracts may further obscure vision. overall decreased visual acuity. Tear production can either increase or decrease : hearing acuity diminishes, especially for high-pitched noises. Difficulty in distiguishing backround from forground noise.

pt's loose acuity for high pitches sounds. **Throat and mouth** : Tooth decay and loss (may result in a change in eating habits), drier mucous membranes, greater risk for aspiration due to slower GI motility and loss of muscle strength mucous membranes drier resulting in tooth decay. The sense of taste and smell are decreased. Sensitivity to odors might be reduced. Problems c nutrition may be result. Xerostomia (dry mouth) Cardiovascular ** : blood vessels become less elastic. venus return becomes less efficient. Fatty plaque deposits continue to occur in the linings of the blood vessels. Lower extremities may have edema and perphrial pulses may not always be palpable (poor perfusion). Aorta & branches dilate and elongate, Heart valves also thickening

cardiac output begins to decrease, blood vessels less elastic, body is less able to increase heart rate and cardiac output with activity. **Respiratory** : decreased elastic recoil of lungs, expiration requiring use of accessory muscles, fewer functioal capillaries and more fibrous tissue in alveoli, decreased skeletal muscle in thorax, reduction in vital capacity and increase in residual volume, drier mucous membranes, impaired mobility and inactivity (effects of medication) Pulmonary elasticity and ciliary action decrease, so that clearing of the lungs becomes less efficient. Respiratory rate may increase, accopanied by disminished depth.

digestive juices dimish - less ability to absorb nutrients. malnutrition and anemia is more common. Greater risk for constipation and indegestion. With reduced muscle tone and decreased peristalsis, constipation and indigestion are common complains. **Musculoskeletal** : muscle mass, strength, and agility gradually decrease. Decrease in subcutaneous tissue. Bone demineralization occurs and bones become more brittle. Joints tend to stiffen and loose flexibility. ROM may decrease. Mobility slows and posture tends to stoop.
 * GI ** : gastric PH is less acidic because of a reduction in production of HCL in stomach, gastric emptying decreased because of a decline in smooth muscle tone and motor activity, movement is decreased (peristalisi) because of decreased muscle tone and activity, blood flow reduced because of decreased cardiac output, nutrient absorption decreases,

decreased subQ tissue, decreased muscle mass and strength, posture stoops, height decreases, mobility slows down. Fractures are more common because of bone demineralization.

**Neurological** : CNS responds more slowly to stiumli. Rate of reflexes decreases. Temp/Pain regulation and pain/pressure perception become less efficient. Loss of sensation in the extremeties and difficulty with balance, coordination, fine movements resulting in a risk for falls. Sleep at night shorts and the older adult may awaken more easily. delayed reactions to stimuli, reflexes slow, may be a loss of sensation in extremities. **Genitourinary** : blood flow to the kidneys decreases with diminished cardiac output, number of function nephrons decrease by 50%, fluid and electrolyte balance is fragile, bladder capacity decreases by 50%, voiding becomes more frequent, decrease in bladder and sphincter muscle control may result in stress incontinence or incomplete bladder emptying.

may loose control of sphincter muscle resulting in loss of bladder control. more frequent voiding.


 * Integumentary System**: skin becomes thin tissue paper like, easily broken, loss of subcutaneous tissue (Elderly feel temperature more cold/hot) and atrophy of the sweat glands. Discoloration (age spots)

pt may also become depressed from outliving friends. Patient may also become depressed no longer being the caretaker but having to be taken care of. Loss of independence
 * Psychological **: risk of developing depression (r/t deterioration of physical health, financial problems, death of a loved one, living arrangements), patient may abuse substances or feel suicidal. Patients tend to seem more forgetful.

2. Discuss three cognitive changes seen in a number of elderly patients. Longer time to respond to stimulis, espically in new surroundings. Longer time to react to stimulis. Mild short-term memory loss/Forgetfulness. short term memory loss can be remedied by an older adult using notes. Orient patient to new surroundings. Long term memory usually remains intact.

3. Identify six patient behaviors in the elderly you would associate with depression. Changes in sleep patterns (insomnia, hypersomnia) Sudden changes in occupational status (retirement) Feelings of hopelessness, uselessness and despair Patient loosing interest in activities that typically would bring them pleasure Alcohol or substance abuse Sudden decrease in ADL's  Patient begins to isolate self from family and friends. No longer participating in social outings. Fixation on death.

talk about depression, lack of motivation, no longer enjoying previous hobbies, lethargy, changes in eating habits and sleep, hopelessness. High risk of suicide in eldery. 4. What medical conditions in the elderly could present with symptoms of depression?

Depression, drug abuse, alcoholism, substance abuse, and eating disorders. .< Some medical conditions in the elderly could present with symptoms of depression. Medical conditions included are epilepsies, Parkinson’s disease, MS, Alzheimer’s, IBS, Chronic Liver Disorders, CNS Tumors,

5. What patient behaviors would you associate with delirium?
 * Anger
 * Anxiety
 * Apathy
 * Depression
 * Euphoria
 * Irritability

Rapid mood swings, anxious or fearful, hallucinations or delusions, increased or reduced restlessness, sun downing, impaired memory or judgment, reduced attention span physical behaviors: strike out from fear/ anger/ may cry, call for help, curse, moan. lack of concentration and disorientation

6. What patient behaviors would you associate with dementia? memory loss is most easily recognized. Denial common; fears. Return to primitive (infantile) reflexes. Some types of dementia cause key symptoms:
 * Having difficulty recalling recent events.
 * Not recognizing familiar people and places.
 * Having trouble finding the right words to express thoughts or name objects.
 * Having difficulty performing calculations.
 * Having problems planning and carrying out tasks, such as balancing a checkbook, following a recipe, or writing a letter.
 * Having trouble exercising judgment, such as knowing what to do in an emergency.
 * Having difficulty controlling moods or behaviors. Depression is common, and agitation or aggression may occur.
 * Not keeping up personal care such as grooming or bathing.
 * Changes in alertness (usually more alert in the morning, less alert at night)
 * Changes in feeling (sensation) and perception
 * Changes in Level of Consciousness.
 * Changes in movement (for example, may be inactive or slow moving)
 * Changes in sleep patterns, drowsiness
 * Confusion (disorientation) about time or place
 * Decrease in short-term memory and recall
 * Unable to remember events since delirium began
 * Unable to remember past events
 * Disrupted or wandering attention
 * Inability to think or behave with purpose
 * Problems concentrating
 * Disorganized thinking
 * Speech that doesn't make sense
 * Inability to stop speech patterns or behaviors


 * Lack of motivation
 * Difficulty concentrating
 * Also frustration & crying.
 * Showing confusion

7. What neuroanatomic changes are seen in individuals with Alzheimer’s disease? The neurons that control memory and thinking are impaired, disrupting the passage of messages between them. These cells develop discrete changes: senile plaques and neurofibrillary bundles, which, over time, cause deterioration of brain tissue.The cortex of the brain waste and shrink, and the spaces in the center of the brain become distended, consequently reducing its surface. Additionally, a high concentration of protein is found, called “beta amyloid”, which forms patches called neuritic plaques.

8. Write three priority nursing interventions for the patient with delirium. reality orientation, behavior modification to reduce/control dangerous behaviors ( safety ) ensure pt has hearing aids in and on or aids such as glasses. -Ensure safety of patient’s environment (clutter-free, no loose tubing/wires/clothing, call bell within reach). -Verbally acknowledge patients fears and feelings -Monitor neuro status on an ongoing basis. Avoid demands for abstract thinking, if pt can only think in concrete terms. Provide optimistic but realistic reassurance. Use environmental cues (signs, pictures, clocks, calendars, and color codingof environment) to stimulate memory, reorient, and promote appropiate behavior. Use short direct directions Establish ADL routine easily able to follow (Write it down) 9. Write three priority nursing interventions for the patient with dementia.

Ensure safety of surroundings. ( uncluttered, handrails if ness. ) promote independence ( with remaining abilities, step by step instructions ) help the pt avoid confusion ( labeling, ect) -Provide patient with safe environment (clutter-free, no loose tubing/wires/clothing, call bell within reach) -ID usual patterns of behavior (sleep pattern, elimination, food intake, med’s, self care) -Reorient patient as needed Provide a consistent physical environment and daily routine. Give one simple direction at a time. Use distraction, rather than confrontation, to manage behavior.