Unit D Outline
Middle Age/Aged
I. Middle Age = 45-65
A.Tasks (psychosocial concepts)
1. Assume a civic & social responsibility - become more politically active, do volunteer work
2. Establish an economic standard of living (prepare for retirement)
3. Assist children w/growth & development
4. Develop leisure time activities
5. Relationship w/spouse/significant other
6. Accepting & adjusting to physical changes - chronic illness begins in 40’s
7. Responding to/& assisting aging parents
B. Physiological Changes
1. Weight gain & redistribution of fat (women = hips/butt/thighs, men = gut)
2. Changes in bone & connective tissue (less collagen & elastin, bone density loss)
3. Skin changes - wrinkles d/t loss of subQ fat, age spots, dry skin, hair loss
4. Facial feature changes
5. Reproductive system changes (menopause)
6. Mental status changes (forgetfullness)
C. Problems
1. Divorce (currently at 50%) (changes in household now that kids are gone)
2. Economic/employment security
3. Mid-life crisis
II. Aged = 65 - death
A. Tasks (psychosocial concepts)
1. Adjusting to retirement (feelings or worthlessness, emptiness, uselessness)
2. Adjusting to death of spouse/friends/family
3. Establishing affiliation w/one’s own age group
4. Assuming new pattern of social & civic responsibilities - now receiving help from volunteers
5. Maintaining satisfying living arrangements
6. Coping w/physical changes
7. Loss of independence - have day staff, move to assisted living, move in w/family
B. Physiological changes
1. Decline in energy - circulation is less efficient, whole body is less efficient
2. Chronic health problems - HTN, CHF, DM
3. Disabled/frail - get hurt easier, need more assistance, less agile, less flexible
C. Problems
1. Financial Distress - paying for healthcare, living off Social Security, lack of planning
2. Elder Abuse:
- Physical
- Emotional/Verbal
- Financial
- Sexual
D. Perceptions/Misconceptions about aging
1. The aged should be in Erikson’s Integrity vs.
Despair, but d/t illness may be in Trust vs. Mistrust or Autonomy vs. Shame & Doubt
2. “Old people aren’t productive”
3. “Old people belong in a nursing home”
4. “Old people are confused/senile”
5. “Old people are hard of hearing & can’t
see anything”
6. “Old people are set in their ways & cannot
learn new things”
7. “Health promotion is wasted on old people”
- The facts are that employment is not the only measure
of a person’s contribution to society, only 5% of America’s elderly are in nursing homes, some elderly people
have chronic illness but still function quite well, older people should be challenged to stay mentally active, older people
who learn to play an instrument or learn a new language are less likely to get Alzheimer’s, it’s never too late
to start good lifestyle habits like eating well & exercising & it’s never too late to quit bad habits.
III. Cardiovascular System
A. Changes that come w/age:
1. Young adult through middle age - physiological effects influenced by:
- heredity
- environment: first 15 yrs of life is more important in physiological health/development
- lifestyle
- stress
B. Middle Age - physiological changes
- blood vessels less elastic = poor circulation, exercise is important
- vessels may be obstructed by Ca+ deposits or fatty acids (heredity makes this happen early)
- cardiac output diminishes, as does exercise tolerance- heart has to work harder & becomes enlarged
- chronic illness begins: HTN, Ischemia, HD, PVD, DM, etc...
C. Older Adult - physiological changes
- stroke volume & cardiac output decrease as much as 30-40%, it’s important to keep a healthy body weight
- resting heart rate is unchanged but it takes longer to return to normal after exertion
- vessels continue to lose elasticity
- Ca+ & fibrosis of arteries = decreased blood flow which decreases O2 to:
- heart
- brain; leads to confusion
- liver; leads to rapid drug toxicity
- lung; decreased lung capacity results in inability to take deep breaths
- kidneys; results in kidney failure
- decreased O2 supply is a common cause of death in patients
D. Assessment:
1. Hx:
- smoking? How long? How much? What?
- D&A? How long? How much? What?
- family hx - HD, circulatory problems?
- occupation - stress, chemicals, toxins...
- diet - ask details - “what did you eat for dinner last night? How about breakfast yesterday?”
- medications - many pts don’t know what they take; OTC & herbal remedies, “do you take these every day?” “When was your last flu shot?”
- illnesses - DM? Chronic illness? Liver/kidney problems? “Have you been exposed to chicken pox?” or other illness?
2. Physical
- on observation, what do you see that would indicate a CV problem?
- SOB, accessory muscle use, tripod posture, diaphoresis
- grimacing, cyanosis
- edema (feet, legs, hands, face)
- jugular distention
- during physical assessment what findings are relevant?
- arrythmia, tachycardia, increased BP, increased respirations, pain
- activity intolerance (moving from bed to chair)
- cool clammy skin, low O2 saturation, weak pulse, poor capillary refill
- pitting/non-pitting edema, seeping edema, irregular breath sounds
- discoloration of feet, weak pulses in feet, cold feet
- neuropathy in feet: injuries to feet pt doesn’t know are there (as a result of DM or poor circulation)
E. Arteriosclerosis - broad term applied to any pt w/thickening, hardening, & loss of elasticity of arteries (causes:
heredity, diet, smoking)
1. Atherosclerosis - thickening & hardening of vessels caused by plaques
- Diet changes can be incredibly hard for pts who are used to eating the same way all of their lives
- cessation of smoking - will lower BP, increase circulation, increase activity tolerance
- medications: Vasodilators (hyralazine, aspirin), Hyperlipidemics [tend to work better when body is at rest,
take at night] (Zocor, Lipitor, Tricor, Crestor)
F. Hypertension - more prevelant in blacks, the elderly, obese - 1 in 6 people have HTN (causes: heredity, arteriosclerosis, diet, stress, increased workload of heart, kidney disease)
1. New AMA guidelines:
Pre-HTN = SBP of 120-139 or DBP of 80- 89
- Systole: the part of the heart cycle where the heart is in contraction
- Diastole: period of relaxation alternating w/systole
2. BP assessment: use proper sized cuff!!!!!!!
- some BP meds will also require a pulse
- check kardex for ordered parameters (DBP < 90 don’t give med) if no parameter, must use judgement
- assess for: HA, epistaxis, blurred vision, dyspnea, dizziness, flushing of the face (especially in men)
3. Pt teaching - diet (make lifestyle changes, not just fad dieting), daily weight to check for edema, medication
teaching (take meds daily, orthostatic HTN is a possible side effect, warn the pt!)
4. HTN meds:
- ACE inhibitors - angiotensin converting enzyme inibitors
- blocks the conversion of angiotensin I to angiotensin II, reduces aldosterone levels,
results in vasodilation
- captopril (Capoten)
- benazepril (Lotensin)
- enalapril (Vasotec)
- quinepril (Accurpil)
- ramipril (Altace)
- lisinopril (Prinivil, Zestril)
- Angiotensin II receptor blockers - blocks vasoconstriction, blocks secretion of aldosterone, effects are seen
on vascular smooth muscle & adrenal glands
- losartan (Cozaar)
- irbesartan (Avapro)
- valsartan (Diovan)
- Beta-adrenergic blockers - reduces myocardial stimulation, decreases O2 demand on heart, decreases
myocardial contractility
- propranolol (Inderal)
- atenolol (Tenormin)
- metoprolol (Lopressor)
- nadolol (Corgard)
- timolol
- it is crucial to check pulse since this drug effects (decreases) the pulse - must be at least 50 or higher, all Beta-blockers should have parameters
- Ca+ channel blockers - inhibits transport of Ca+ into the myocardial & vascular smooth muscle cells; too
much serum calcium = arrythmias
- diltiazem (Cardizem)
- verapamil (Calan)
- nifedipine (Procardia)
- amlodipine (Norvasc)
- Vasodilators - first BP meds ever, relax smooth muscle in arterioles resulting in dilation
- hydralozine (Apresoline)
- minoxidil (Loniten)
- Other CV meds:
- Diuretics
- furosemide (Lasix) & bumetenide (Bumex) inhibit reabsorption of Na & Cl in the
loope of Henle (hence the name “loop diuretic”)
- HCTZ - hydrocholothiazide - relatively weak, cheap, inhibits reabsorption of Na in distal tubule (thiazides
decrease BP & edema)
- aldactone - potassium sparing diuretic - causes loss of sodium bicarb & Ca+ but saves potassium & hydrogen ions
- Antiplatelet agents
- plavix (not an anticoagulant) inhibits platelet aggregation
- aspirin - inhibits platelet aggregation
- Trental - increases flexibility of RBC’s to decrease viscosity
- Antiarrythmics - increase force of myocardial contraction, increase cardiac output, decrease heart rate by decreasing
conduction through SA & AV nodes
- lanoxin (Digoxin) must take apical pulse first - must be 60 or higher for adult
G. Common Cardiovascular Tests
1. EKG - measures electrical impulses across the heart muscle
2. Echocardiogram - ultrasonic waves directed to heart detects valve disorders, congenital disorders, fluid around
the heart, heart tumors
3. Cardiac Catheterization - determines BP & blood flow into chambers, looks for blockage, can draw blood, take pictures, get blood gasses
IV. Respiratory System
A. Changes that come with age
- influenced by: heredity, environment, lifestyle (smoking destroys cilia)
B. Middle Age & Aged physiological changes - changes are gradual
- spinal deformities = compression & barrel chesting
- calcification = increased thoracic cage stiffness
- changes in alveolocapillary membrane structure - air sacs die
- decreased muscle strength: decreased cough reflex, decreased lung expansion
- cilia die - can’t cough up fluid/mucous
C. Assessment
1. Hx:
- smoking
- family hx
- occupation, esbestos, garages, painters, chemicals, welders
- last chest x-ray
- medications: do you use inhalers? Allergy meds?
- respiratory infections? Allergies? Asthma? Brochitis? Cancer? TB?
2. Physical:
- on observation what would indicate a respiratory problem?
- SOB, coughing (wet/dry, non/productive), wheezing, gurgling, pale skin, diaphoresis, cyanosis, activity intolerance,
c/o fatigue*, anxiety, c/o anorexia
- during physical assessment, what findings are relevant?
- increased HR/BP, decreased O2 Sat, abnormal breath sounds, cook skin, fever, poor/sluggish capillary
refill (>3 seconds), mucous membranes are pale/dry
D. Pneumonia- acute infection of the parenchyma of the lungs, most commonly caused by bacteria, very common in
elderly d/t weakened cough, inability to take deep breaths, immobility...
* Parenchyma = functional components of an organ
1. Causes:
- bacteria
- fungi - difficult to treat
- chemical - often work related
- aspiration - d/t dysphagia, g-tubes, j-tubes (very frequent cause d/t not turning off pump ½ hour before lowering
head of bed), reflux
- PCP = HIV pts, cancer pts, anyone with drastically lowered immunity
2. What happens?
- organism enters the alveoli - multiplies & produces an inflammatory response
- outpouring of fluid & accumulation & migration of neutrophils (first defense)
- organism causes rapid progression of infection
3. Assessment:
- increase in temperature (may be very abrupt)
-uncontrolled shaking/chills (abrupt fever & shaking/chills always means infection, may mean
sepsis)
- tachypnea/dyspnea
- pleuritic chest pain (constant cough inflames pleura)
- cough (assess sputum: green, blood tinged, yellow, brown...)
- abdominal pain d/t coughing
- breath sounds: crackers (rales), wheezing
4. Diagnosis:
- symptoms
- chest x-ray
- sputum sample identifies responsible bacteria
5. Nursing Care:
- relieve resp. distress, keep on O2, fowler’s or semi-fowler’s position, check pulse Ox
- promote removal of drainage, encourage coughing, ISP, position upright, hydrate properly (definitely push fluids
to break up mucous)
- control infection, maintain hygiene
- maintain fluid & nutritional intake
- promote rest/comfort/activity, get pts out of bed as often as possible, especially for meals, it’s easier to eat sitting up
- discarding of tissues/sputum, pts will often put dirty tissues in bed, WEAR GLOVES to get them out of bed and
throw them away, keep fresh linens on bed
6. Pneumonia Medications
- IV Antibiotics: Zithromycin, Rocephin, Cipro, Cefobid
- PO meds (on
discharge): Zithromax, Cipro, Biaxin, Ceftin
- Antitussive treatment: Robitussin, Phenergan (caution w/phenergan cough syrup w/codeine w/elderly pts d/t risk of
respiratory suppression), Tessalon Perles (older but effective medication also used in cancer pts), Humabid
- Bronchodilators: Albuterol, Alupent, Aminophylline
E. Tuberculosis (TB) - infectious disease caused by a gram+ bacilli (mycobacterium tuberculosis)
1. Information & Stats
- Strep is the most common cause in the elderly, they get a strep infection & TB as a secondary
infection
- Most often effects the lungs but can occur in other areas - kidneys, bones, etc...most common site is alveloar surface of the lungs
- Most often effects people in closed quarters, it takes frequent prolonged contact to get it, common in prisons,
non-hispanic black males, poor, homeless people are most prone
- Not inherited, increase of nearly 20% in US from 1986-92
- WHO estimates 1/3 of world population is infected w/Mycobacterium tuberculosis (in 1997 there were 8 million new cases & 2 million deaths - the highest rates being in Africa)
- Acquired through droplets; close frequent & prolonged contact w/pt.
2. What Happens?
- tubercule bacilli is inhaled & passes through the airways & deposits on the alveolar surface where it
thrives - it loves the lungs: warm, moist, & dark
- WBC’s accumulate
- infection spreads to lymph & circulatory systems quickly
- inflammation & bacilli - produces small, firm white nodule; cells gather & blood vessels become compressed
- necrosis can occur = scar tissue
- nodule center has soft/cheesy consistancy; a productive cough can expel pieces of the cheesy looking substance
3. Assessment
- may be asymptomatic early
- low-grade fever
- fatigue
- anorexia & weight loss
- irregular menses
- progression: dry cough to productive, pleuritic pain, hemoptysis, dyspnea, night sweats
* night sweats are drenching, pt needs to change clothes, no real known reason for this; night sweats are also
a classic symptom of lymphoma
4. Diagnosis
- tb test - Mantoux, is not done if pt is presenting w/symptoms
- chest x-ray, will show nodules
- bacteriological studies of sputum (AFB - acid fast bacilli)
- case must be reported to the Department of Health
- treatment usually takes one year, may also treat family & coworkers
5. Medications:
- Ethambutol - action is not clear - appears to inhibit RNA synthesis
- Rifampin - inhibits RNA synthesis by blocking RNA transcription in the susceptible organism
- IHN - Isoniazid - inhibits Mycobacterium cell wall synthesis & interferes w/metabolism (created in the 50’s,
the very first TB med)
- Antibiotics - streptomycin type
- Bronchodilators
* Treatment is usually INH w/Ethambutol or Rifampin
6. Nursing Care
- Respiratory isolation, everyone entering room wears mask
- discard tissues/sputum; WEAR GLOVES, keep linens fresh
- HANDWASHING!!!!!!
- nutrition & hydration
F. Common Respiratory Diagnostic Tests
1. Chest X-ray
2. ABG - arterial blood gas
3. PFT - pulmonary function test - tests lung capacity, inhale & exhale
4. Bronchoscopy - scope to look & biopsy
G. Oxygen Therapy
1. Disadvantages
- Nasal cannula - drys mucous membranes, pts often breath through
mouth d/t cannula, mouth dries out, pt not receiving O2, hospitals don’t always use a humidity device
- Mask - straps irritate ears (straps can cause pressure sores - use cotton or gauze to cushion), interferes w/eating
& talking
2. Mask advantages
- humidity/moisture & high concentration of O2
3. Use water-soluble lubricant only on lips (no vaseline)
V. Neuromuscular System
A. Changes that come with age
- brain shrinks w/age d/t loss of neurons
- blood supply decreases, leads to sluggish motor, sensory & intellectual functioning, sluggish reflexes
- muscle mass shrinks
- circulation impairment - affects peripheral vessels - nervous tissue deteriorates leading to slow responses
- bones decalcify & degenerate - lose flexibility - motor functioning is impaired leading to pain/stiffness
- diminished stage 3-4 sleep, often no REM sleep, pt never feels rested
B. Arthritis (Rheumatoid) RA- very debilitating, inflammation of the synovial membrane of the joints: knees, wrists, fingers, shoulders, hips, elbows, ankles, spine
1. Information & Statistics for all arthritis
- 5 million are affected by some form of arthritis
- affects mostly middle-aged women
- 3 x more common in women than men
2. Cause of RA
- autoimmune response precipitates inflammation
- virus
- environmental factors
- genetics
3. Pathophysiology
- inflammation begins at the synovial membrane
- joint becomes stiff, swollen, red, painful
- as disease progresses the tendon sheath becomes inflamed
- exudate accumulates & spills into the joint capsule - joint continues to swell
*these episodes are called exacerbations
- atrophy of tendon sheath & contractures of joints
4. Assessment
- assess the mobility of the joints, general mobility, ROM, any crippling of joints?
- what relieves the pain?
5. Treatment
- Steroids: cortisone injection into joint, Prednisone
- Anti-inflammatories - Celebrex (Cox II inhibitor), Ibuprofen, Indocin, Naproxyn, Relafen, Bextra
** Do NOT confuse : CELEBREX (Cox II inhibitor), CELEXA (SSRI antidepressant), & CEREBRYX (anticonvulsant)**
- localized heat/ice
- well - balanced diet
- simple exercise
- rest
- surgery - synovectomy (may replace synovial membrane w/silicone), joint replacement (has to be done before the
tendon sheath atrophies
- gold therapy - gold is injected into joint
- may aspirate exudate from joint
- Methotrexate - chemo drug works well in young RA pts, clears inflammation
C. Dementia - very broad term, progressive impairment of orientation, memory, judgement & other intellectual functions;
Includes Pick’s Disease (atrophy of frontal & temporal lobes), OBS Organic Brain Syndrome (dementia of unknown
origin, doesn’t really mean anything as a Dx, just means Dr doesn’t know what’s wrong) & Alzheimer’s
1. Approximately 4 million older adults have some form of dementia
2. Causes: artherosclerosis, degenerative characteristics of aging, autoimmune response
3. Assessment
- decrease in memory
- prone to agitation, quickly irritated
- problems w/perception, afraid of stairs, lack of depth perception, afraid of spraying H2O
4. Interacting w/Dementia pts
- don’t argue w/pts - they will never be in your reality, there is no point in correcting them & trying to
bring them back to reality orientation
- nothing you can say will make them realize that today is NOT Tuesday March
7, 1952
- use Validation - don’t bother to tell a pt her mother’s dead, ask for details about her mother... sometimes
this can help someone orient herself w/much less emotional distress, DO NOT LIE to pts, simply redirect their attention
D. Parkinson’s Disease - disorder of the basal ganglion (a center for voluntary movement) & grey matter in
the cerebral hemispheres characterized by muscle weakness, rigidity, tremors, bradykinesia, & gait disturbances
1. Information & Pathophysiology
- most common among the elderly but may occur any time
- neurons undergo a degenerative process
- decrease in Dopamine (DA), which is necessary for motor reflexes; giving DA eases symptoms but is not a cure
2. Symptoms/Progression
- 1st fine tremor (hand or foot)
- muscle rigidity
- mood swings r/t lucid thinking abilities (realizing what’s happening), imbalance of DA, increased anxiety,
withdrawal, & depression
- mask face - expressionless d/t poor muscle control, weakness, pt can’t smile anymore
- speech slowed - poor communication, ask simple questions to pt
- drooling - d/t muscle weakness in tongue
- swallowing reflex weakens - pt often ends up w/feeding tube
- thumbs turned into palms
- shuffling gait - shuffles fast & can fall forward
- head bowed, body bent forward, increase muscle weakness in neck
- numbness & tingling = parethesia - d/t muscle weakness & poor circulation to nerves
- pts eventually end up wheelchair or bedbound
3. Nursing considerations
- promote safety - promote independent mobility as possible w/walker, cane, assistance of staff but be aware of
safety risks
- promote rest & comfort
- nutrition & hydration are vital
- emotional aspects - very difficult for families
4. Medications
-Stimulate DA production
- Sinemet (1 of the first available drugs)
- Permax
- Mirapex
- Requip
- Eldepryl
- Symmetrel (a very old medication)
- Apokyn (apomorphine) - very new drug, has morphine in it
- Anticholinergics - block cholinergic activity in the CNS - slows CNS activity & relaxes rigidity
- Cogentin
- Prevents breakdown of DA
- Comtan - maintains DA pt still has
- Other medications can help w/mood swings, but only treat symptoms
- Antidepressants
- Zoloft, Prozac, Lexapro
- Antianxiety
- Ativan, Xanax
E. Alzheimer’s Disease - Alois’ Alzheimer is the man the disease is named for - it is a neurological disease
in which nerve cells in the cerebral cortex slowly degenerate, no one really knows why
1. Theories
- increased concentration of Aluminum & Mercury in brain cells
- virus
- old head injury (Mohammad Ali - “punch drunk”)
- hormone deficiencies
- heredity - tends to run in families
- Down’s Syndrome chromosome - pt does not have Down’s Syndrome, but carries the chromosome
2. Information
- approximately 3 million Americans have AD - youngest on record - 28 yrs
3. Diagnosis - no real diagnosis until autopsy
- history, psych tests, MRI, neurological tests, biochemical analysis, CAT scan, level of ACH (AD pts lack ACH
or ACH levels are all over the board)
4. Symptoms (often progress very quickly in young pts)
- starts w/memory loss & disorientation
- subtle personality changes
- lack of spontaneity
- lack of judgement
- restless at night
- inappropriate social behavior
- wandering & sundowning
- extreme irritability
- increase in or unusual swearing
- repetitive behavior
- may tell stories of traumatic events from the past that they never talked about to anyone
- cannot remember how to walk, sit, follow directions - need 1 direction at a time
- difficulty w/communication
- unusual chewing motions, tongue protrusions
- changes in eating, don’t know they’re hungry
- inability to write
- twitching & possibly seizures d/t brain activity as a result of disease
- no longer recognizes family & friends
- incontinence of bowel & bladder
- some will end up in a vegetative state
5. Nursing Care
- remember the family suffers too: they can label items at home, hide car keys!, place locks high on doors
- tasks of ADL’s
- give 1 direction at a time
- keep conversations brief
- diet & hydration - need frequent, short meals - attention span is too short for full meals
- daily activity - walks, etc...
- may eventually be in ECF (extended care facility) needing 24 hr care
- death occurs from complications
6. Medications - all agents act by increasing the amount of ACH in the CNS inhibiting cholinesterase (which eats
up ACH); Meds temporarily improve cognitive functions
- Aricept
- Reminyl
- Exelon
- Cognex
- Namenda - acts on the CNS to prevent binding of glutamate (an excitatory neurotransmitter - glutamate stimulates
neurons & Namenda keeps glutamate in check)
* these drugs are all very expensive
- Antianxiety & antidepressant meds are also given, but be careful of dosage for elderly pts because of poor
metabolism
VI. Gastrointestinal/Genitourinary System
A. Changes that come w/age
- Middle-age: metabolism decrease 5-8% every 10 years (gain weight if continue to eat the same way), need for calories is not as great
- Aged changes: further decrease in metabolism, GI slows w/age- slow peristalsis, fewer gastric juices, taste
& smell senses decrease, weakening of intestinal walls
B. Constipation/Diarrhea – elderly need good hydration
1. Prolonged constipation causes: decrease in appetite, headache, infection, fecal impaction
2. Diarrhea can cause dehydration & electrolyte imbalance – occurs quickly in the elderly
3. Nursing Care - Constipation
- nutrition & hydration, exercise, stool softeners, remember that narcotics are very constipating
4. Nursing Care – Diarrhea
- nutrition & hydration, I&O accuracy, daily weight, assess stools, meds: Lomotil (narcotic – has atropine in it, drying effect), Imodium
C. Ulcers – Physiological Stress – d/t chronic illness, pain, trauma, infection
1. Why are most pts in the hospital on anti-ulcer or proton pump inhibitors?
BEDREST doesn’t slow the production of HCL in the stomach, pts are also
an a variety of different medications
2. How do these meds work?
- Protonix - $expensive$ - proton pump inhibitor, prevents reflux, prevents GERD
- Pepcid - H2 antagonist, antiulcer
- Reglan - antiemetic, speeds emptying time of stomach, used for chemo pts
- Carafate - antiulcer, forms past in stomach & protects stomach walls
D. Diabetes Mellitus - #1 Cause of CVA
1. Information: 10 million Americans have DM, women more than men, 7th leading cause of death, leads to
other problems: stroke, MI, kidney failure, gangrene; infections in DM pts are extremely hard to get rid of because bacteria
loves glucose & glucose levels rise during infection
- Type I: Insulin Dependent DM
- Type II: Non-Insulin Dependent DM
- Cause: unknown, but heredity is factor; obesity also factor; Gestational DM usually subsides after pregnancy
2. DM Pathophysiology
- Insulin - made by Beta cells of pancreas in Islets of Langerhans; facilitates the transport of Glucose, Amino
Acids, & Fatty acids across cell membrane
- In liver glucose is stored as glycogen
- Absence of insulin: glucose accumulates & circulates in blood & spills into urine; glucose coats/damages
vessel walls (is very sticky) & decreases circulation; glucose in circulation causes limited tubular absorption leading to polyuria & loss of Na & K
- Muscle cells need insulin to incorporate amino acids into muscle protein (leads to fatigue)
- Insulin transports glucose into cells to change fatty acids to triglycerides (increases cholesterol)
- Fatty acids breakdown in ketone & acetone leading to ketoacidosis (fruity breath)
- interruption of metabolism; pts need dietician advice on how to eat CHO, proteins, & fats
3. Clinical Symptoms
- polyuria
- polydipsia
- polyphagia
- other symptoms: glucosuria, fatigue, wt loss or wt gain (sometimes), numbness or tingling leads to neuropathy)
4. DM diagnosis: one of 3 criteria (new guidelines)
- random plasma glucose concentration greater than or equal to 200
- fasting blood glucose concentration greater than or equal to 136 on 2 occassions
- plasma glucose concentrations after oral glucose intake greater than or equal to 200
* urine testing may also be done
5. Oral Hypoglycemic Agents
- decreases hepatic glucose production & decreases intestinal absorption of glucose, does not work in pancreas
- Glucophage
- improves cell sensitivity to insulin; good for Sub Q insulin pts, helps insulin work better
- Actos
- Avandia (expensive)
- stimulates pancreas to release more insulin (some also improve cell sensitivity to insulin)
- Glucotrol (old)
- Glyburide (old)
- Starlix (new, $$)
- Prandin (new, $$)
- delays glucose absorption in GI tract (not often used, glucophage does same thing)
- Precose
- Glyset
6. Insulin Treatment: most common 3: Regular, NPH, 70/30
- Onset - when drug begins to work
- Peak - when drug has most profound effect, glucose will drop
- Duration - how long drug is in system
* 70/30 is its own drug, it is not a substitute for mixing NPH & regular
* fast acting insulin must be followed w/food because glucose will drop!
7. New Insulins:
- Glulisine (Apidra) onset: w/in 15 mins; peak: 1hr; duration: 2hrs
- Symlin (Pramlintide) onset: RAPID; peak - 20 mins; duration: 3 hrs
- Byetta (Exenatide) onset: within 30 mins; peak: 2.1 hrs; duration: 8 hrs
8. Insulin Considerations
- Why is it important to know the O-P-D? pts need to eat, glucose can drop dangerously low
- When would a pt not receive their entire dose of insulin today? When glucose is low according to sliding scale; if pt’s NPO find out what to do
- Besides DM, what other pts may receive insulin? Pts on steroids because they increase glucose; when pts are on HAL/TPN
- What if pt is going to surgery? Make sure there is an order for AM insulin, call Dr if needed
- Can all insulins be mixed together in a syringe? NO!!!!
- What 2 insulins are in 70/30? 70% NPH, 30% Regular
9. Insulin Coverage/Sliding Scale - giving pt insulin according to his blood sugar (usually ac & hs)
- some may receive both their normal AM dose & coverage - be careful! Check the med kardex
* Pinnacle has several different coverage options, Dr. must choose the option on order
10. DM - Nursing care
1. teaching - diet (get help from dietician & give handouts), Meds (teach injections, use video
aids), family (whole family needs to know what’s going on)
2. Foot care - no sandals, no open toed shoes, no bare feet, always have shoes, inspect feet daily
3. Compliance
4. Coping - this is for the rest of your life
11. Hypo vs Hyperglycemia
- Hypo:
- sudden onset, skin pale/moist, excited, nervous, irritable, confused, breathing normal to rapid & shallow, breath odor = normal, thirst = absent, tongue = moist, numb, tingling; hunger
= present; vomiting = absent; Headache
- Hyper:
- gradual onset, skin flushed/dry, drowsy, breathing = deep/labored, breath = fruity, thirst = present, tongue = dry, hunger = absent, vomiting = present; abdominal pain
E. Hyperalimentation HAL/TPN
1. Contents: H2O, concentrated glucose, amino acids, vitamins & minerals, electrolytes, possibly meds (insulin, Reglan, etc…), usually 1 calorie/mL, can cost $1000-$3000 per bag
2. HAL & Lipids
- most pts will receive both - HAL usually infuses over 24 hrs
- lipids usually infuse over 8, 10, 12 hours
- can infuse together w/lipids plugged into the IV port below the HAL filter
- d/t the concentrated gluose: pts will have BGT ac & hs; REASSURE pt that he is not diabetic
F. N/G tube - feeding tube
G-Tube: inserted surgically into stomach
N/G tube: inserted into nose & ends in stomach
- What will be included as part of your assessment? Placement!!! (in GI assessment “placement confirmed”), check placement w/air auscultation; duodenal tube can’t be heard, must be
x-ray’d
- What is residual & when do you check it? Turn feeding tub off for ½ hr before checking, measure it & put
it back, if >100mL, leave feeding off & check again in ½ hr
- Why should tubes be flushed? To keep patency
VII. Genitourinary System
A. Changes that come w/age:
- renal capacity decreases w/age d/t actual loss of nephrons (they die)
- CV system decreasing in efficiency
- CNS changes
- any cerebral cortex damage (CVA, etc…)
- loss of muscle control (especially in bladder)
- prostatic hypertrophy
B. Benign Prostatic Hypertrophy - enlargement of glandular & cellular tissue of the prostate gland
- cause: unknown, hormone imbalance probable
- most common in middle age & aged men (can happen anytime after 30’s)
- more than 50% of men over 50 will have prostate problem
1. BPH Dx: rectal exam (prostate will be large, tender, hard/firm) & cystoscopy (scope through urethra)
2. Symptoms: pain & swelling on exam, dysuria, urgency, hesitation, dribbling, nocturia, residual urine (bladder not emptying fully, can develop into infection or even stones)
3. Treatment
1. Flomax - decreases contractions in smooth muscle of prostate capsule to decrease symptoms
***Don’t confuse FLOMAX with FLOVENT (for asthma, contains a steroid)***
2. Uroxatral - (new) blocks receptors in lower urinary tract to relax smooth muscle in bladder & prostate
3. Proscar - reduces testosterone levels *women of childbearing age should not touch pill, men taking proscar should not impregnate anyone, will cause gonad defects in male fetus
4. Surgery - TURP - transurethral resection of prostate
- post-op concern: bleeding
- 3 way catheter (urine, balloon, irrigation) LARGE lumen (20 or 22 Fr. Normal Foley is 16 or 18 Fr.)
- CBI - continuous bladder irrigation - 3rd lumen usually ice cold water to stop bleeding/swelling
- Urine output: immediately post-op bloody urine normal; w/in 24 hrs should be pink
- determine urine output by subtracting from drainage bag the irrigation amount
- PAIN is severe d/t bladder spasms from surgery, large catheter, big balloon (30cc), & cold H2O
- B&O Suppositories work well - B (bella donna - relaxant) O (opiate)
- Demerol - good for pain, not in PCA, morphine in PCA
- Sitz baths
VIII. Reproductive System
A. Changes w/aging:
- Female: changes r/t estrogen, menopause, vagina shortens w/age (less mucous production & atrophy), less
vaginal mucus production, vaginal pH becomes more alkaline (leads to yeast infections), pelvic support structures weaken
(uterine prolapse), breasts lose elasticity (pendulous breasts), hair & skin changes
- Male: skin tone decreases & changes in distribution of body hair, urination problems, ears & nose grow
B. Sexuality
- need for sexual satisfaction continues
- research has found interest doesn’t diminish (but opportunities do)
- sexual response slows
- older adults can & do enjoy sex
C. Attitudes toward sexuality
- rooted in a person’s social environment (sometimes only families can bathe pts)
- be aware of values
- religious beliefs
- ethnic background
- coping behavior & sexuality
- female circumcision is still happening in the middle east
D. Nursing care & Sexuality
- respect privacy
- wear gloves: inspect perineum for lesions, parasites, swelling, etc…
- male - circumcision?? Always clean around foreskin & if retract foreskin PUT IT BACK!
- ask about breast/testicular exams, mammograms…
IX. AIDS Timeline
1981 - “Gay cancer” - GRID - 121 deaths in US - named changed to AIDS
1982 - CDC reports sexual contact & infected blood transmits AIDS. 285 cases worldwide
1983 - NIH identifies virus (HIV) Rock Hudson dies of AIDS, raises public awareness
1985 - congress - $70 million for research; 1st AIDS conference; blood test approved; Surgeon General sends
AIDS info to US households
1986 - scientists locate 2nd virus - HIV-2 in West Africa
1987 - FDA approves AZT - 1st treatment
1988 - WHO begins World AIDS Day; 1st clinical trials on multiple meds
1990 - Ryan White dies of AIDS
1991 - Magic Johnson announces he has HIV
1992 - FDA approves more drugs
1993 - US annual death rate reaches 45,000
1994 - AIDS related illnesses are the leading cause of death in 25-44 year olds
1996 - delay of full-blown diseases d/t multiple drugs
1997 - AIDS related illnesses decreasing; clinical trials for AIDS vaccine
1998 - US deaths decrease to 17,000 yearly - AIDS drops
to 14th leading cause of death in US
- WHO estimate: has caused life expectancy in South Africa
to drop from 59 yrs to 45 yrs
1999 - AIDS infections sharply increase in Southeast Asia; US spends $6.9 billion on AIDS/HIV
treatment; 21.8 million have died worldwide
2000 - Africa: 10% population between 15-49 has HIV/AIDS - infection rates skyrocket
2001 - AIDS spreading more rapidly in eastern Europe & Russian Federation;
lowers life expectancy by 20yrs in Botswana,
Malawi, Mozambique,
& Swaziland to under 40 yrs; worldwide leading cause of
death 15-59
2002 - FDA approves 1st fingerstick AIDS test
2003 - WHO starts initiative to provide AIDS drugs to 3 million people in poor countries in 2005; FDA approves saliva-based test
2004 - 95% of those w/AIDS live in the developing world
2005 - FDA approves generic treatment; # of people living w/AIDS estimated @ 40.3 million
X. Death & Dying
A. Concepts:
- part of the human life cycle
- most dreaded experience by man
- most find ways to avoid it
- society oriented toward the pleasures of life
- causes pain & hurt to many people
- death is often related with lonliness
B. Developmental concepts:
- age 3-4 talks about death
- age 5 - manlike creature that steals life away
- age 9-10 - beginning to understand the biological concept of death
- many young & middle age adults spend little time thinking about death
- influenced by family, media, friends, school, religion, ethnics, culture
C. Elizabeth Kubler-Ross - Stages of Grief
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
D. Nursing Legalities
- What is nurse’s responsibility w/death & dying?
- What is the legal responsibility of the nurse when caring for the dying?
- What are the psychosocial concepts of death & dying?
- What are the physiological concepts of death & dying?
- Physical signs of impending death:
