(Wk # 5: February 2 to February 9 – Main post under Assignment by Wed, February 5 at 11:59 PM EST).
Chapter 9 – Safe Medication Use.
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Chapter 10 – Nutrition.
Question(s): The gerontological nurse working in a long-term care facility is responsible to administer psychoactive medications for older adults for conditions such as depression, anxiety, bipolar disorder or psychosis. After reading your textbook, select one class of drug or 1 medication used for the treatment of the mentioned conditions and discuss important nursing considerations (at least three) when given this medication due to its side effects, drug interaction or food interaction.
Guidelines: The answer should be based on the knowledge obtained from reading the book, no just your opinion.
Grading Criteria: Mention one class of drug or one medication used for the treatment of conditions such as depression, anxiety, bipolar disorder or psychosis mentioned in the textbook (30%). Discuss important nursing considerations (at least 3) when given this medication due to its side effects, drug interaction or food interaction (70%). APA FORMAT.
Chapter 10
Nutrition
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The key element is preserving the health of older adults
The quality and quantity of a diet will help prevent, delay the onset of, and manage chronic disease processes
Fulfillment of nutritional needs in aging is often affected by numerous factors
Nutrition
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Generally, older adults need fewer calories
Still require same or higher levels of nutrients
Limit intake of saturated fat and trans fatty acids
Fiber intake is generally lacking in older adults
Vitamin intake is generally good for older adults; they should increase the consumption of the crystalline form of vitamin B12
U.S. Dietary Guidelines
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Usually, older adults are viewed as underweight and frail; however, the concern of obesity in older adults is increasing
Obesity is associated with increased health care costs, functional impairments, disability, chronic disease, and nursing home admission
Weight loss recommendations for older adults must be carefully considered on an individualized basis
Obesity
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Recognized geriatric syndrome
Rising incidence in all settings
Has serious consequences, including infections, pressure ulcers, anemia, hypotension, impaired cognition, hip fractures, prolonged hospital stays, institutionalization, and increased morbidity and mortality
Malnutrition
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Complex syndrome that develops along two primary trajectories
One occurs when the person does not consume sufficient micronutrients and macronutrients to maintain organ function and healthy tissue
Inflammation-related malnutrition develops as a consequence of injury, surgery, or disease that triggers inflammatory mediators that increase metabolic rate and impair nutrient use
Characteristics of Malnutrition
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Lifelong eating habits
Acute and chronic illness
Medication regimens
Ethnicity and culture
Ability to obtain and prepare food
Mood
Socialization
Socioeconomic deprivation
Transportation and housing
Food knowledge
Factors Affecting Fulfillment
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Are developed out of tradition, ethnicity, and religion
Reflects the individual’s dietary history and present food practices
Older adults may fall prey to advertisements that claim specific foods can reverse aging or rid them of chronic conditions
Essential nutrients should be obtained from food sources rather than supplements
Lifelong Eating Habits
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Older adults may be isolated from social events during which food is provided
Effects of medications or a disease process may cause a disinterest in food
Excessive drinking decreases eating habits
Socialization
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Functional and cognitive impairments associated with chronic disease interfere with the ability to shop, cook, and eat independently
Medication side effects may further impair nutritional status
Dysphagia can be the result of behavioral, sensory, or motor problems and is common in those with neurologic disease and dementia
Chronic Diseases
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Obtain a history of the response to dysphagia
Observe the person during mealtime
Determine risk for aspiration
Assume those referred for a dysphagia evaluation (“swallowing study”) are at risk for aspiration
Maintain NPO status until the evaluation is completed
Nutrition and hydration needs can be met by intravenous, nasogastric, or gastric tubes
Assessment of Dysphagia
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Goal: Safe oral intake to maintain optimal nutrition and caloric needs
Compensatory interventions include
Postural changes and proper positioning
Modification of bolus volume, consistency, temperature, and rate of presentation
Modified diets
Neuromuscular electrical stimulation
Interventions for Dysphagia
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The nurse is feeding an older adult patient with dysphagia after a stroke. Which intervention is most important when feeding this patient?
Serve only pureed foods
Offer small sips of fluid with each bite
Place food on the impaired side of the mouth
Have the patient swallow twice between each mouthful
Question
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D—Have the patient swallow twice between each mouthful. If facial weakness is present, place food on the nonimpaired side of the mouth. Alternate solids and liquid boluses. Not all persons require pureed foods.
Answer
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Comprehensive nutritional screening and assessment are essential in identifying older adults at risk for nutrition problems or who are malnourished
The role of nursing assessment and intervention should be comprehensive and include
Increased attention to the process of eating and the entire ritual of meals
Assessment of nutritional status
Thorough medication review
Implications for Gerontological Nursing and Healthy Aging
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Nutrition Screening Initiative Checklist
Mini Nutritional Assessment (MNA)
Both a screening tool and a detailed assessment
Only valid for those older than age 65 years
Intended for use by professionals
Minimum Data Set (MDS)
Food and nutrient intake
24-Hour dietary recall
3-Day dietary history
Nutrition Screening Tools
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Interview
History
Physical examination
Anthropometric data
Laboratory data
Food and nutrient intake
Functional assessment
Nutrition Assessment Components
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Anthropometric measurements
Height and weight
Midarm circumference
Triceps skinfold thickness
There is no single biochemical marker of malnutrition
Serum albumin level
Nutrition Data
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Goal: Increase food intake and enhance and manage the environment to promote increased food intake
Feeding assistance
Environment enhancements
Calorie supplements
Pharmacological therapy
Patient education
Interventions to Increase
Food Intake
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Knowledge of nutritional needs and the many factors contributing to inadequate nutrition is essential
Use of evidence-based practice protocols is important in determining nursing interventions to support and enhance nutritional status
Preventing undernutrition, malnutrition, and the maintenance of dietary needs are ethical responsibilities
Implications for Gerontological Nursing and Healthy Aging (Cont.)
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Which action should the nurse take first when teaching a widowed older patient living with his son about ways to improve nutrition?
Recommend a liquid caloric supplement
Determine who shops and prepares meals
Arrange for weekly transportation to the store
Collaborate with a social worker for food stamps
Question
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B—Assessment is the first step in determining nutrition interventions.
Answer
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Chapter 9
Safe Medication Use
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Older adults who are 65 years and older are the largest user group of prescription and over-the-counter medications
Prescription medications can afford survival or enhance quality of life for those with chronic conditions and disabilities
Older Adults and Medications
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Pharmacokinetics is the movement of a drug throughout the body from the point of its administration as it is
Absorbed
Distributed
Metabolized
Excreted
Pharmacokinetics
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Amount of time between drug administration and absorption depends on
Bioavailability
Amount of drug that passes into the body
Route of administration
Routes of administration include intravenous, oral, parenteral, transdermal, and rectal methods
Absorption
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Physiological changes and effect of other drugs can alter absorption
Increased gastric pH retards acid-dependent drugs
Delayed stomach emptying diminishes the effectiveness of short-lived drugs
Increased motility in the small intestine diminishes drug effect because of shortened contact time
Slowed intestinal motility increases the contact time, amount absorbed, and effect
Absorption (Cont.)
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Medication must be transported to the receptor site on the target organ to have an effect
Distribution depends on the availability of plasma protein in the form of lipoproteins, globulins, and albumin
Age-related changes in distribution are related to changes in body composition, increased body fat, and decreased total body water
Distribution
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Process by which the body modifies the chemical structure of the drug
Primarily occurs in the liver
Normal age-related physiological changes can affect metabolism
Liver’s activity, mass, volume, and blood flow are normally reduced
Hepatic clearance of medication is decreased by 30% to 40%
Metabolism
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Medications are excreted in sweat, saliva, and other secretions, as well as mainly by the kidneys
Normal age-related physiological changes can affect metabolism
Kidney function decreases with aging (up to 50% by 80 years of age)
Prolongs the half-life of a drug or the amount of time required to eliminate the drug
Cockcroft-Gault equation estimates creatinine clearance
Excretion
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Interaction between a drug and the body
The older a person gets, the more likely there will be an altered or unreliable response of the body to the drug
Several known mechanisms
Decreased response to beta-adrenergic receptor stimulators and blockers
Decreased baroreceptor sensitivity
Increased sensitivity to anticholinergics, benzodiazepines, opioid analgesics, warfarin, and the cardiac drugs diltiazem and verapamil
Pharmacodynamics
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Relationship between biological rhythms to the variations in the body’s response to drugs
A developing science that may lead to a more effective drug therapy
Biorhythmic variations occur in
Gastric acid pH
Gastrointestinal tract motility and blood flow
Albumin levels
Glomerular filtration and urine acidity
Chronopharmacology
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Before administering a drug to an older adult, the nurse should understand that the dose may be impacted which age-related physiological change?
Older adults have increased liver metabolism
Gastric emptying often occurs more rapidly
Older adults have reduced glomerular filtration rates
The sensitivity to baroreceptors is often reduced
Question
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C—The decreased glomerular filtration rate prolongs the half-life of drugs, adding to the risk for accumulation and increasing the potential for toxicity or other adverse events.
Answer
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Polypharmacy
Drug interactions
Medication–herb/supplement interactions
Medication–food interactions
Drug–drug interactions
Adverse drug reactions
Misuse of drugs
Medication-Related Problems and Older Adults
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Use of approximately five or more medications or the use of multiple medications for the same problem
Major concerns are the increased risk for drug interactions and the increased risk for adverse events
May be unavoidable but can result from fragmented communication
Polypharmacy
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When two or more medications or foods are taken together or close together, they may cause a change in the effectiveness of the other
Effects may be increased, decreased, or variable
Polypharmacy increases the risk for and the frequency of medication–medication interactions
Drug Interactions
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Medication–Medication Reactions
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An unwanted pharmacologic effect
Range from minor annoyances to unwanted pharmacological effects and death
Common in those older than 65 years of age
Commonly observed adverse reactions in older adults include drug-induced delirium, confusion, and lethargy
Adverse Reactions
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Includes
Overuse
Underuse
Erratic use
Contraindicated use
May be accidental or deliberate
Misunderstanding or inability to read labels or understand instructions
Make medication last longer for financial reasons
Believe the dose is either too low or high
Forget to take the medication correctly
Misuse of Drugs
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Their potential for harm is greater than their potential benefits
Beers list (1997)
Identifies drugs that carry a higher-than-usual risk when prescribed for older adults
Incorporated into regulatory policy for long-term care (LTC) facilities and are part of quality measures
Using a “do not use” medication in LTC without documentation of overwhelming benefit is considered medication misuse by the prescriber
Inappropriate Medications
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Alter brain chemistry, emotions, and behaviors
Have a high risk of adverse events
Medications included in this category are
Antidepressants
Antianxiety agents
Mood stabilizers
Antipsychotics
Sedative-hypnotics
Psychoactive Medications
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SSRIs (e.g., Zoloft, Prozac, Lexapro, and Celexa) and SNRIs (e.g., Effexor)
Drugs of choice for use in older adults
Effective, with minimal side effects
May cause nausea, dry mouth, sexual dysfunction
Use with caution in persons with a history of falls because of the potential to produce ataxia or dizziness
Tetracyclic mirtazapine (Remeron) useful in treating sleep problems in older adults
Antidepressants
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Include benzodiazepines, buspirone (BuSpar), and beta blockers
Benzodiazepines
Most frequently used but should be avoided
Older adults slowly metabolize these drugs and have decreased excretion
Side effects include drowsiness, dizziness, ataxia, cognitive deficits, and memory impairment
Antianxiety Agents
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Used to treat bipolar disorder
Include
Lamotrigine (Lamictal)
Lithium
Anticonvulsants—carbamazepine (Tegretol), valproic acid (Depakote), and gabapentin (Neurontin)
Atypical (Abilify, Zyprexa, and Seroquel)
Each has a very individualized drug–drug interaction profile
Mood Stabilizers
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Used for treating psychotic symptoms and for mood stabilizing effects
Pose significant risk of cardiac events
Inappropriate use may mask a reversible cause of a problem
Drugs with the lowest side effects profile and at the lowest dose possible and for the shortest length of time should be prescribed
Antipsychotics
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Risk of serious side effects increases in older adults
Neuroleptic malignant syndrome
Extrapyramidal syndrome (EPS) reactions
Acute dystonia
Akathisia
Parkinsonian symptoms
Tardive dyskinesia
Antipsychotics (Cont.)
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Nurses are responsible for assessing, monitoring, evaluating, and educating persons regarding safe medication use
The nurse and patient must decide together when a PRN, or “as needed,” medication is indicated
Implications for Gerontological Nursing and Healthy Aging
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Comprehensive medication assessment
“Brown bag approach”
24-Hour medication recall
Systems approach
Medication reconciliation with interfacility transfers
Look for discrepancies between the prescribed dosage and the actual dosage, potential drug–drug and food–drug interactions, and potential or actual adverse drug reactions
Assessment
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Key persons
Environment
Timing
Communication
Reinforce teaching
Patient Education
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Difficulties opening bottles as a result of arthritis
Use of pill cutters
Difficulty swallowing medications
Use of accurate medication-measuring devices
Proper administration of enteric-coated, extended-release, or sustained-release medications
Use of transdermal patch
Medication Administration
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Monitor and evaluate the effectiveness of medications and observe for signs of problems
Assess and document changes in physical and functional status
Measure blood levels when needed
Promptly communicate potential problems to the prescriber
Determine severity of side effects
Promote actions necessary to prevent drugs from becoming toxic
Monitoring
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To reduce polypharmacy in an older adult, the nurse should
give all medications to a family member instead of the patient.
encourage the patient to refill all of his or her medications at one time.
transmit prescriptions to the patient’s pharmacy electronically.
obtain a complete medication assessment with each patient encounter.
Question
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D—Conducting a comprehensive drug assessment is the most effective way to reduce polypharmacy. Electronic transmitted prescriptions and filling all prescriptions at once may still involve multiple pharmacies.
Answer
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