4. Causes or contributing factors Nursing Diagnosis
Teeth have Various degree of erosion; Imbalance Nutrition
Abrasions of crown and root structure Less than body requirements related
High prevalence of tooth loss to limited ability to chew food
Reduction in saliva to approximately Imbalanced Nutrition
one-third the volume of earlier years Less than body requirements related
to less efficient mixing foods
Inefficient digestion of starch due to Imbalanced Nutrition
decreased salivary ptyalin Less than body requirements related
to reduced breakdown of starches
Atrophy of epithelial covering in oral Impaired oral mucous membrane
mucosa
Increased taste threshold Disturbed Sensory Perception:
Approximately one-third of number of gustatory.
functioning taste buds per papilla of Imbalanced Nutrition:
earlier years More than body requirements related
to excessive intake of salts and
sweets to compensate for taste
alterations
5. Causes or contributing factors Nursing Diagnosis
Decreased thirst sensation; reduced Imbalanced Nutrition
hunger contractions Less than body requirements related
to reduced ability to sense hunger
sensations
Deficit fluid volume related to
decreased thirst.
Decreased esophageal peristalsis Risk for injury from aspiration
Reduced stomach motility
Less hydrochloric acid, pepsin, and Imbalanced Nutrition
pancreatic acid produced stomach Less than Body requirements related
motility to in effective break down of food
Lower fat tolerance Pain related to indigestion
Decreased colonic peristalsis Imbalanced Nutrition
Reduced sensation for signal to Less than Body requirements related
defecate. to reduced appetite
7. Hydration
• Hydration needs of older adults
To a reduced fluid intake or increased loss
that would be only a minor problem in a
younger person could be life –threatening
to an older person.
8. Nurses evaluate older adults for factors
that can cause them to consume less
fluid, such as
Hydration ① Age related reductions in thirst
sensation
② Fear of incontinence(physical
condition and lack of toileting
opportunities
③ Lack of accessible fluids
④ Inability to obtain or drink fluids
independently
⑤ Lack of motivation
⑥ Altered mood or cognition
⑦ Nausea, Vomiting, gastrointestinal
distress,
9. Dry skin Dehydration
Sunken Concentrated
cheeks urine
Blood urea
value <60
mg/dl
Confusion
Brown
tongue
10. Promotion of oral health
Poor dental Changes in gingival tissue
care ① Periodontal disease
a. Bleeding gums(when
teeth are brushed)
b. Red swollen, painful
Environmental gums
influences c. Chronic bad breath
② Tooth loss
Inappropriate
nutrition
11. Key Concept
Dental problems can affect virtually every system of
the body:
Therefore, they must be identified and corrected
promptly.
12. Nutrition
A variety of Physical, psychological, and
socioeconomic factors influence nutritional status.
13. Threats to Good Nutrition
1. Indigestion and Food intolerance
① Decreased stomach motility Nurse can suggest
② Less gastric secretion eating several
③ Slower gastric emptying time small meals
2. Anorexia- anorexia can be related to a variety of conditions
① Medication side effects
② Inactivity
③ Physical illness or age related changes(such as decreased taste and
smell sensations)
④ Reduced production hormone leptin.
⑤ Gastric change
⑥ Losses and stresses(e.g.; death of love ones, loneliness, financial
worries) could cause anxiety and depression that could effect
appetete.
14. Threats to Good Nutrition
3. Dysphagia
Difficulty moving food from the mouth to the esophagus(transfer
Dysphagia), down the esophagus(transport dysphagia) from the
esophagus into the stomach(delivery dysphagia)
① Neurologic condition such as a strock
② Most cases result from gastro esophageal reflux disease(GERD)
*Having the person sit upright whenever food or fluid is being consumed
*Allowing sufficient time for eating
*Ensuring there is no residual food in the mouth before feeding additional food
.
4. Constipation
① Slower peristalsis
② Inactivity
③ Side effects of drugs(codein)
④ Tendency toward less fiber and fluid in the diet.
5. Malnutrition
16. Rest and Sleep
• Age-related changes in Sleep
1. Circadian sleep-Wake cycles
2. Sleep Stages
3. Sleep Efficiency and quality
• Sleep disturbances
1. Insomnia
2. Nocturnal Myoclonus and Restless leg Syndrome
3. Sleep Apnea
4. Medical Conditions that Affect Sleep
5. Drugs that affect Sleep
• Promoting rest and Sleep in Older adults
1.Pharmacologic measures to promote Sleep
2.Nonphamacologic measures to promote sleep
3.Pain control
17. Age-related Change in Sleep
• Insomnia, daytime sleeping, and napping are all
highly prevalent among the older adults.
• These experiences results from age-related
changes in circadian sleep-wake cycles
18. Age-related Change in Sleep
• Circadian Sleep-Wake Cycles
① To fall asleep earlier in the evening
② To awaken earlier in the morning
③ The quantity of sleep does not change but the
hours in which it occurs may
19. Age-related Change in Sleep
• Sleep Stage
Stage Characteristics Difference in Older Adulthood
NREM I Begins nodding off More time spent in this stage, most
Can be easily awakened likely due to frequent awakening
II Deeper stage of relaxation reached No significant change
III Early phase of deep sleep Decreased
Reduced temperature and heart rate,
Muscle relaxed.
More difficult to be awakened.
IV Deep sleep and relaxation May disappear completely in extreme
All body functions reduced old age
Considerable stimulation needed to be
awaken
Insufficient stage IV sleep can cause
emotional dysfunction.
REM Rapid Eye Movement(REM) occurs Decreased due to reduced amount of
increased vital signs sleep time in general
Will enter REM sleep approximately once ( Certain drugs can also decreased
every 90 minutes of stage IV sleep REM sleep, including alcohol,
Insufficient REM sleep can cause barbiturates, and phenothiazine
emotional dysfunction, including psychosis derivatives.
20. Age-related Change in Sleep
Nurses need to be aware that older adults can be easily
awakened by noise and lighting associated with caregiving
and other staff activities during the night
21. Sleep disturbance
• Sleep disturbance
① Insomnia
a. Difficulty falling asleep
b. Do not sleep soundly
c. Travel to the bathroom several times during the night.
d. Can be short term problem associated with change environmemtal,
illness, added stress, or anxiety.
e. Chronic insomnia(lasting 3 or more weeks) can be related to
physical or mental illnesses, substance abuse, or medications
22. Sleep disturbance
• Sleep disturbance
② Nocturnal Myoclonus and Restless Leg Syndrome
Jerking leg movements during sleep can cause awakenings during
the night.
* Associated with Tricyclic antidepressants and chronic renal failure
③ Sleep Apnea
④ Medical conditions that affect sleep.
a. Hypnotics interfere with REM and deep sleep stages and can
cause daytime drowsiness
23. Sleep disturbance
• Sleep disturbance
⑤ Drugs that affect Sleep
characteristics Drug Affecting results
Antidepressents MAOI, SSRI Inhibited with REM
Antipsychotics Haloperidol Change with REM
Risperidon
Hypotonics, sedatives Barbiturate Interfere with REM and deep
Benzodiazepine. sleep stage and can cause
daytime drowsiness
Diuretics Acetazolamide bathroom several times
during the night.
Anticholinergics Scopolamine
Β-adrenoreceptor Propranolol
antagonists Metopronol
α-adrenoreceptor agonists Clonidine
Methydopa
Smooth muscle relaxants Hydralazine Sleeping disturbance.
24. •diphenhydramine HCL
(Benadryl capsules)
•Nicotine(NicoDerm Nicotine Nonprescription
Transdermal System) sleep aids
•Theophilline
•Alprazolan(xanax)
Contain
dephenydramamine
(Benadryle)
Should
be
avoided
High cholinergic side
effects in older adults
25. Caffeine as Contributor to poor Sleep
Source: National Sleep Foundation. Caffeine calculator.
http://www.sleepfoundation.org
Cappuccino 120mg/8-ounce serving
Coffee 85-110
Tea 46-60
Shasta Cola 45
Pepsi ONE 37
Mountain Dew 34
Diet Coke 31
Sunkist Orange Soda 28
Iced tea 25
Diet Pepsi 24
Coca cola 23
Decaf espresso 10
26. Promoting Rest and Sleep in old adults
• Pharmacologic measures to promotes Sleep.
① Barbiturates are general depressants, especially to the central
nervous system
significantly depress some vital body functions
a. Lowering basal metabolic rate
b. Decreasing blood pressure
c. Decreasing mental activity
d. Decreasing peristasis
• Nonpharmacological measures to promote Sleep
① Activity and Rest Schedules.
② Environment
③ Food and supplements
④ Stress management
⑤ Pain control
28. Comfort
• Define comfort
1. Derived from the Latin word “ confortare”which means to
strengthen greatly
2. Webster’s Dictionary :“ to relieve from distress, lessen
misery, have freedom from pain and worry, calm, and
inspire with hope
3. Holistic perspective: “Can be viewed as a sense of
physical, emotional, social, and spiritual peace and well
being.
**Unfortunately, with advancing age, the incidence of factors
that can threaten comfort increase
29. Pain
An unpleasant sensory and emotional experience associated
with actual or potential tissue damage (American Pain Society,
2003)
Prevalence of pain in older Adults (PR Newswire,2000)
① More than 4 of 10 people report experiencing pain on a daily
basis.
② With majority(89%) saying that they experience pain each
month
③ Low back pain is among the most common complaints, along
with migraine or severe headache, and joint pain, aching, or
stiffness
④ The knee is the joint that causes the most pain according to
the report
(Increasingly Knee replacement surgeries have risen
dramatically for people over age 65.
30. The complex phenomenon of pain is a
stressor to physical, emotional, and
spiritual well-being
31. Types of Pain
Pathophysiological mechanism
Nociceptive (Tissue) Pain
Nociceptive pain results from mechanical, thermal,or
Chemical noxious stimuli to the A delta and C afferent
nociceptors
Nociceptive pain can be subdivided into
①somatic : bone and soft tissue masses, localized,
describe as Throbbing or Aching
②visceral (gut) pain.: Generalized or referred pain
Neuropathic (Nerve) Pain
Examples of neuropathic pain include
① diabetic neuropathy,
② trigeminal neuralgia,
③ postherpetic neuralgias.(peripheral pains)
④ thalamic pain syndrome (a central pain).
The pain is Sharp, stabbing, tingling, or burning, which a sudden onset
34. Types of Pain
Onset and Duration
Acute Pain
Abrupt onset, can be severe, but lasts only a short time.
Chronic Pain
Has persisted for three months or longer
35. Assessing pain
• Good rapport with patient and use
therapeutic communication skills
• History and risk factors
• Subjective presentation
• Objective presentation
• Vital sign and hemodynamics
www.themegalllery.com
36. History and risk factors- P Q R S T
Palliating factors:
① What makes the pain better?
② What do you do to get relief?
③ What helps you?
Provocative factors:
① What makes the pain worse?
② What brings it on?
③ What aggravates it?
Quality of pain:
① What does the pain feel like?
② What words would you use to describe it?
.
Radiation: 또는 Region
① Where is the pain?
② Does the pain go anywhere else?
③ Does it spread?
Severity:
① How bad is the pain?
② Mild, moderate, severe
Time:
• On set 등(recent, promote)
www.themegalllery.com
38. Subjective presentation
• Pain is subjective
• Should be asked to describe the nature of pain
• (location, intensity, quality, the timing of the pain,
aggravating/alleviating factors)
• NRS(Numeric scale)
• VAS(Visual analog scale)
• ARS(Adjective rating scale)
www.themegalllery.com
42. Adjective Rating scale
Patient select an adjective that best describes the pain intensity
www.themegalllery.com
43. Objective presentation
*Used self report 또는 의식이 없을 때 가족이나 친지
• Physiologic
ANS stimulation과 관계있는지 사정한다.
Autonomic Indicators pain
Diaphoresis, pallor
Vasoconstriction
Increased systolic and diastolic BP
Pulse rate> 100회/ min
Papillary dilation
Change respiratory rate( 20회 이상)
Musle tension or spasm
Endocrine imbalance(evidence sodium and water retension and
mild hyperglycemia)
• Behavioral
Social , cultural, ethic, and environmental factors
Nonverval indicators참조.
www.themegalllery.com
44. **Skeletal muscle tension
① Facial grimace, tension
② 아픈 부위의 Guarding
③ Restlessness
④ Decreased motor activity
**Psychic reactions
① Short attention span
② Irritability
③ Anxiety
④ Sleep disturbance
⑤ Anger
⑥ Crying
⑦ Fearfulness
⑧ Withdrawal
45. Signs That Could Indicate pain Persons
with Cognitive Impairments
Splinting or
Grimacing Perspiration guarding body
part
Increased
Crying,
pacing, Agitating
moaning
wandering
Increased Aggressive Changing in
Vital sign behaviors sleep pattern
50. Comforting
Healing is not synonymous being cured.
Rather, it implies living in harmony and peace
with a health condition.
51. Safety
•Aging risks to safety
•Importance of the Environmental Health and
wellness
•Impact of Aging on Environmental Safety
and Function
•The problem of Falls
•Interventions to reduce Intrinsic Risks to
Safety
52. Aging risks to safety
• Age-related changes can reduce the
capacity of older adults to protect
themselves from injury and increase their
vulnerability to safety hazards.
53.
54.
55. Aging and Risks to safety
Decreased intracellular fluid
Loss of subcutaneous tissue: less natural insulation; Lower BMR
Decreased efficiency of heart
Reduced strength and elasticity of respiratory muscle
Reduces oxygen use under stress
Poor condition of teeth
Weak gag reflex
Altered taste sensation Reduced income
Reduction in filtration of wastes by kidneys
Higher prevalence of urinary retention more alkaline vaginal secretions
Decreased muscle strength, Demineralized of bone
Delayed response and reaction time Poor vision and hearing
Reduced lacrimal secretions Distorted depth secretion
Increased threshold for pain and touch
Less elacicity, more dryness, fragility of skin
Poor short-term memory High prevalance of polypharmacy
58. Risk Factors for Falls
• Age related Factors
① History of falls
② Female aged 75 and older
③ Impaired vision
A program to
④ Gait disturbance prevent falls is
⑤ Postural hypotension essential to settings
⑥ TIA that provide services
to older adults
⑦ Cerebrovascular accident
⑧ Diabetes mellitus
⑨ Peripheral vascular disease
⑩ Foot problem
⑪ Multiple diagnosis
59. Risk Factors for Falls
• Health conditions or functional impairments
① Physical disability
② Incontinence, nocturia
③ Delirium, Dementia
④ Mood disturbance
⑤ Dizziness
⑥ Weakness
⑦ Fatigue
⑧ Ataxia
⑨ Paralysis
⑩ Edema
⑪ Use Cane, walker, wheelchair, crutch, or brace
⑫ Presence of IV, indwelling catheter
⑬ Neurologic disease(Parkinsonism)
60. Risk Factors for Falls
• Medication
① Antidepressants
② Antihypertensives
③ Antipsychotics
④ Diuretics
⑤ Sedatives
⑥ Tranquilizers
⑦ Multiple medication
• Environmental Factors
① Newly admitted to hospital/nursing home
② Unfamiliar environmental
⑪ Highly polished floors
⑫ Inadequate environmental lighting
⑬ Absence of railings, grab bars.
61. Interventions to reduce Intrinsic Risks to Safety
= prevention
• Reducing Hydration and Nutrition Risks
• Addressing Risks Associated with Sensory Deficits
• Addressing Risks associated with mobility Limitations
• Monitoring body temperature
• Preventing Infection
• Suggesting Sensible Clothing
• Using medication Cautionusly
• Avoiding Crime.
63. Effect of Aging on Medication Use
• Drug use by older adults has been steadily increasingly every
year ; a majority of older people use at least one drug
regularly, with more typical situation involving the use of
several drugs(Skufca, 2007).
• The most used common drugs by the older population include
• 우리나라 65세 이상 노인의 94%가 약물을 사용하고 있고 처방
약과 비처방약을 함께 사용하고 있는 경우는 66%
처방약물로는 관절염 및 신경계통약, 고혈압약, 당뇨약, 위장관
약 순. 비처방약물로는 영양제, 소염진통제, 소화제 순
재가노인의 경우 94.2%가 평균 4.2개의 약물 복용.
① Cardiovascular agents ②Antihypertensive
③ Analgesics ④ Antiarthritic agents ⑤Sedatives
⑥ Tranqulizers ⑦Laxatives ⑧antaacids
64. Effect of Aging on Medication Use
• Altered Physical mechanism
• Altered Pharmacokinetics
1. Absorption
① No change bioavailability, 그러나 에너지를 요하는 능동
수송은 감소하여 그 결과 일부 약물은 생체 이용률이 감
소한다(예, 칼슘함유 제산제)
2. Distribution
① 수용성 약의 분포 용적은 감소하며 농도는 증가한다.
② 지용성 약물의 분포 용적은 증가하며 반감기는 증가한다.
65. Effect of Aging on Medication Use
• Altered Pharmacokinetics
3. Altered Pharmacodynamics
Pharmacodynamics refers to the biologic and
therapeutic effects of drugs at the site of action or on
the target organ
① Increased myocardial sensitivity to anesthesia
② Increased central nervous system receptor sensitivity to narcotics, alcohol
4. Increased Risk of Adverse Reactions
This risk of adverse drug reactions is high in older adults because of age
related differences in pharmacokinetics and pharmacodynamics
① Signs and Symptoms ②A prolonged time-adverse effect
③ After the drug has been discontinued- Adverse reaction
④ Long period time of without problems- Adverse reaction can develop
suddenly.
66. Effect of Aging on Medication Use
• Altered Pharmacokinetics
4. Increased Risk of Adverse Reactions
Older adults easily may become victims of drug-induced cognitive
dysfunction
① Varying degrees of mental dysfunction
a. Codein
b. Digitalis
c. Methyldopa
d. Phenobarbital
e. L-dopa
f. Diazepam(valium)
g. diuretics
67. Adverse Reaction inappropriate drugs in older populations
1. Postural hypotensionTricyclic-antidepressants,
① 항고혈압성 약물
② α-receptor blocking(수용체 길항체)효과를 나타내는
약물(삼환계항우울제,phenothiazines),
중추신경으로부터 교감신경방출을 감소시키는 약물(barbiturate,
bezodiazephnes, antihistamine, morphine)
2. Unstable position
선조체(corpus striatum)에서 Dopamine(D2)수용체가 감소하기 때문이다.
① 수면제, 진정제 같은 약물은 postural sway를 증가시킴으로 노인이 잘 넘어진다.
3. Hypothermia,
① benzodiazepines, opioids, alcohol 등이 노인들에게 갑자기 체온저하를 유발할 수
있다.
4. cognitive dysfunction
① Anticholinergics, sedatives, H2-antagonist, β-adrenoreceptor blocker등이 혼동 유
발
5. Decreased GI Mortility
① Anticholinergics, tricyclic-antidepressants,antihistamines같은 약물이 변비 또는 장
폐색을 유발하기 쉽다.
69. Reviewing necessity and Effectiveness of
Prescribed Drugs
• Nurse should review all prescription and nonprescription
medications used by patients.
1. Why is the drug ordered?
2. Is the smallest possible dosage ordered?
3. Is the patients allergic to the drug?
4. Can this drug interact with other drugs, herbs or nutritional
supplements that are being used?
5. Are there any special instructions accompanying the drug’s
administration?
6. Is the most effective route of administration being used.
71. 노인의 약물에 관한 간호중재
1. 노인의 특수성
2. 노인의 약물치료원칙
① 가급적 약물을 사용하지 않는다
② 새로운 약물 추가시 기존 약물과 상호작용 가증성이 있는 것은 피한다
③ 적은 용량으로 시작
④ 불필요한약 물 장기간 복용금지
⑤ 약물이 주로 신장 배설약이면 연령과 신기능 감안.
⑥ 약물투여 방법 단순화- 약물복용이행도를 증가
72. 노인의 약물사용 관리는 노인
의 인지기능,기억력,시력,투약
보조자 유무 등 노인의 상황에
근거한 실제적이고 효과적인
투약교육 프로그램의 개발과
약물오용 행위를 예방할 수 있
는 투약계획표, 개별 약상자
등 투약보조방법의 활용 등이
관건이다.
