4.4 Gerontological Nursing & Chronic Disease Management

Gerontological Nursing & Chronic Disease

Gerontological nursing focuses on the care of older adults, aiming to promote health, maximize independence, and manage chronic illnesses effectively. As populations age, this area of nursing is increasingly critical for the MOH examination.

Normal Physiological Changes of Aging

It is essential to differentiate between normal age-related changes and pathological disease processes.

• Cardiovascular: Decreased cardiac output, stiffening of blood vessels leading to increased systolic blood pressure, and slower recovery from tachycardia.
• Respiratory: Decreased chest wall compliance, decreased vital capacity, and weakened cough reflex, increasing the risk of respiratory infections (pneumonia).
• Gastrointestinal: Decreased peristalsis (leading to constipation), reduced gastric acid secretion, and delayed gastric emptying.
• Renal/Genitourinary: Decreased Glomerular Filtration Rate (GFR) and renal blood flow, leading to slower excretion of medications (higher risk for drug toxicity). In men, benign prostatic hyperplasia (BPH) causes urinary retention. In women, weakened pelvic floor muscles lead to stress incontinence.
• Neurological/Sensory: Slower reaction times. Presbyopia (difficulty focusing on near objects) and presbycusis (sensorineural hearing loss, especially high-frequency tones).
• Integumentary: Thinner, less elastic skin, decreased subcutaneous fat (predisposing to hypothermia), and decreased sweat gland activity.

Cognitive Impairment in Older Adults

The "3 Ds" of cognitive impairment—Delirium, Dementia, and Depression—must be carefully distinguished, as their management differs significantly.

Delirium

• Onset: Acute, sudden onset (hours to days).
• Course: Fluctuating over 24 hours; often worse at night (sundowning).
• Characteristics: Impaired attention, altered level of consciousness, disorganized thinking, hallucinations/illusions.
• Reversibility: Usually reversible. It is typically a symptom of an underlying physical illness or toxicity.
• Common Causes: Infections (e.g., UTI, pneumonia), medication side effects/toxicity, dehydration, electrolyte imbalances, and hypoxia.
• Nursing Action: The priority is to identify and treat the underlying cause while maintaining patient safety.

Dementia

• Onset: Insidious, gradual onset (months to years).
• Course: Slowly progressive and chronic.
• Characteristics: Memory loss, impaired judgment, aphasia (language difficulty), apraxia (inability to perform purposeful movements), and agnosia (inability to recognize objects).
• Reversibility: Irreversible.
• Alzheimer's Disease: The most common form of dementia. Care focuses on providing a safe, structured, and consistent environment; supporting caregivers; and managing behavioral symptoms without relying solely on chemical restraints.

Depression

Often underdiagnosed in the elderly, as somatic complaints (fatigue, pain) may mask mood symptoms. Can coexist with dementia (pseudodementia). Assess for suicide risk and refer for treatment.

Chronic Disease Management

Nurses play a pivotal role in educating patients to manage chronic conditions to prevent acute exacerbations and long-term complications.

Diabetes Mellitus (Type 1 and Type 2)

Diabetes is a chronic disorder of impaired glucose metabolism.

• Monitoring: The target HbA1c for most non-pregnant adults is < 7.0%. Fasting blood glucose target is 70-130 mg/dL.
• Hypoglycemia (Blood glucose < 70 mg/dL):
  • Signs: Tachycardia, diaphoresis, shakiness, confusion, irritability.
  • Treatment: If conscious, provide 15g of fast-acting carbohydrate (e.g., 4 oz juice, glucose tablets). Recheck in 15 minutes. If unconscious, administer IM glucagon or IV Dextrose 50%.
• Complication Prevention:
  • Foot Care: Crucial due to peripheral neuropathy and decreased circulation. Teach patients to inspect feet daily, wash with warm (not hot) water, dry carefully between toes, apply lotion (but not between toes), wear well-fitting shoes, and cut toenails straight across.
  • Annual Screenings: Dilated eye exam (retinopathy), microalbuminuria test (nephropathy), and comprehensive foot exam (neuropathy).

Chronic Obstructive Pulmonary Disease (COPD)

COPD includes emphysema and chronic bronchitis. It is characterized by progressive, mostly irreversible airflow limitation.

• Pathophysiology: Destruction of alveoli (emphysema) and chronic inflammation with mucus hypersecretion (bronchitis). Patients chronically retain CO2 (hypercapnia).
• Nursing Interventions & Education:
  • Smoking Cessation: The most important intervention to slow disease progression.
  • Breathing Techniques: Teach pursed-lip breathing (inhale through nose, exhale slowly through pursed lips) to keep airways open longer and facilitate exhalation of trapped CO2. Teach diaphragmatic (belly) breathing.
  • Oxygen Therapy: Use with caution. The hypoxic drive (low oxygen levels) stimulates breathing in chronic COPD patients. Giving high-flow oxygen can suppress their respiratory drive. Maintain SpO2 generally between 88% - 92%.
  • Nutrition: Encourage small, frequent, high-calorie, high-protein meals. Eating takes energy; large meals can cause fatigue and shortness of breath.

Heart Failure (HF)

Heart failure occurs when the heart cannot pump sufficient blood to meet the body's metabolic needs.

• Left-Sided HF: Fluid backs up into the lungs. Symptoms: Dyspnea, orthopnea, crackles in lung bases, frothy pink sputum (in severe pulmonary edema), fatigue.
• Right-Sided HF: Fluid backs up into the systemic circulation. Symptoms: Peripheral edema, ascites, jugular venous distention (JVD), hepatomegaly.
• Nursing Management:
  • Monitor daily weights (report a gain of >2 lbs in a day or >5 lbs in a week).
  • Administer diuretics as prescribed and monitor potassium levels (loop diuretics cause hypokalemia).
  • Enforce fluid and sodium restrictions (usually < 2g/day).
  • Elevate head of bed to facilitate breathing.