Geriatric Care Nursing Diagnosis: Comprehensive Guide for Optimal Elderly Care

What is Gerontology Nursing?

Gerontology nursing, also known as geriatric nursing, is a specialized field dedicated to providing care for older adults. This nursing specialty addresses the multifaceted needs of aging individuals, encompassing their physiological, developmental, psychological, socio-economic, cultural, and spiritual well-being. As individuals advance in age, they often encounter unique health challenges that necessitate specialized care and attention. Geriatric nursing recognizes aging as a natural and fundamental part of life, advocating for a collaborative care approach that integrates the expertise and support of the elderly person’s family, community, and a multidisciplinary healthcare team. This collaborative model ensures that nurses can effectively leverage diverse resources to optimize and sustain the quality of life for older adults. Geriatric nursing care planning is fundamentally centered on promoting healthy aging, restoring and optimizing health and functional abilities, enhancing safety, preventing illness and injury, and facilitating the healing process.

Geriatric Nursing: Specialized Care for Older Adults

Nursing Care Plans and Management in Geriatric Care

Nursing care plans and management for geriatric patients are specifically designed to foster optimal health, independence, and an enhanced quality of life during the aging process. This involves conducting thorough and holistic assessments to understand the unique needs of each older adult. A key focus is addressing age-related physiological changes and managing chronic health conditions that are prevalent in the elderly. Geriatric nursing care prioritizes maintaining and improving functional abilities and mobility, as these are crucial for independence and well-being. Medication management and safety are also paramount, given the increased likelihood of polypharmacy and age-related pharmacokinetic and pharmacodynamic changes. Educating older adults and their families about healthy aging practices is another essential component, empowering them to actively participate in maintaining their health. Furthermore, creating a safe and supportive environment is vital to prevent falls and injuries, ensuring the physical and emotional security of geriatric patients.

Prioritizing Nursing Problems in Geriatric Care

Nursing care for geriatric patients involves a distinct set of priorities aimed at addressing their unique needs and promoting their well-being. These priorities guide nursing interventions and ensure comprehensive care:

• Conducting thorough assessments to identify specific needs and developing individualized care plans tailored for older adults.
• Effectively managing chronic conditions such as diabetes, heart disease, and arthritis, which are common in the geriatric population, and promoting cognitive health to maintain mental acuity and independence.
• Safely administering medications and treatments, considering age-related pharmacokinetic and pharmacodynamic changes to prevent adverse drug events.
• Providing comprehensive education and support for healthy aging, empowering older adults to make informed decisions about their health and lifestyle.
• Assisting with activities of daily living (ADLs) such as bathing, dressing, and eating, while also promoting mobility and functional independence to maintain quality of life.
• Collaborating effectively with interdisciplinary teams, including physicians, therapists, social workers, and dietitians, and connecting patients with appropriate community resources to ensure holistic and coordinated care.
• Implementing proactive fall prevention strategies and creating a safe environment to minimize the risk of injuries in older adults, both at home and in healthcare settings.
• Offering compassionate emotional support and counseling to address the psychological and emotional challenges that may accompany aging, such as loneliness, depression, and anxiety.

Comprehensive Geriatric Nursing Assessment

A comprehensive nursing assessment is the cornerstone of effective geriatric care. It involves gathering both subjective and objective data to gain a holistic understanding of the older adult’s health status.

Assess for the following subjective and objective data:

• Decreased mobility: Observe for difficulties in walking, transferring, or performing other physical activities.
• Balance issues: Assess for unsteadiness, swaying, or falls, which are significant risk factors for injury in older adults.
• Changes in cognition or memory: Evaluate for confusion, disorientation, memory loss, or difficulty with problem-solving, which may indicate cognitive impairment or dementia.
• Increased fatigue: Note complaints of persistent tiredness or exhaustion, which can be a symptom of various underlying conditions in older adults.
• Changes in appetite: Assess for decreased interest in food or altered eating habits, which can lead to nutritional deficiencies.
• Weight loss: Monitor for unintentional weight loss, which can be a sign of malnutrition, illness, or failure to thrive.
• Sleep disturbances: Inquire about insomnia, frequent awakenings, or changes in sleep patterns, as sleep disorders are common in older adults.
• Mood changes: Assess for symptoms of depression, anxiety, or irritability, as mental health is closely linked to overall well-being in the elderly.
• Decreased vision or hearing: Evaluate for visual or auditory impairments, which can affect safety and communication.
• Increased vulnerability to infections and slower wound healing: Observe for signs of infection, such as fever or redness, and assess the healing of any wounds, as older adults may have compromised immune responses and slower tissue repair.

Geriatric Care Nursing Diagnosis Examples

Formulating accurate nursing diagnoses is crucial in geriatric care, as it provides a framework for addressing the specific health challenges faced by older adults. These diagnoses are derived from a comprehensive assessment and reflect the nurse’s clinical judgment. While nursing diagnoses serve as valuable tools for organizing care, their application may vary across different clinical settings. The nurse’s expertise and clinical reasoning are paramount in tailoring the care plan to prioritize each patient’s unique needs.

Here are examples of nursing diagnoses commonly used in geriatric nursing, reflecting typical concerns associated with older adult care:

• Risk for Falls
• Acute Confusion
• Impaired Gas Exchange
• Hypothermia
• Disturbed Sleep Pattern
• Constipation
• Failure to Thrive
• Risk for Aspiration
• Fluid Volume Deficit
• Risk for Infection
• Risk for Impaired Skin Integrity

Establishing Nursing Goals for Geriatric Patients

Setting realistic and measurable goals is an integral part of geriatric nursing care planning. These goals and expected outcomes are patient-centered and aim to improve the older adult’s health, safety, and quality of life.

Goals and expected outcomes may include:

• Fall Prevention: The patient will remain free from falls during their care period.
• Home Safety Measures: The patient and caregiver will implement specific measures to enhance safety and prevent falls within the home environment.
• Stable Respiratory Function: The patient’s respiratory rate, depth, and pattern will remain within normal limits for their age and health condition, and their mental status will be consistent with their baseline.
• Adequate Oxygenation: The patient’s pulse oximetry readings or arterial blood gas results will be maintained within the patient’s normal range, indicating sufficient oxygenation.
• Normothermia: The patient’s body temperature and mental status will remain within their normal limits, or will return to their normal baseline within a specified timeframe (e.g., 1°F/hr) following nursing interventions.
• Restorative Sleep: The patient will achieve adequate rest and demonstrate improved sleep patterns, and their mental status will remain intact and consistent with their baseline.
• Regular Bowel Elimination: The patient will report a return to their normal bowel habits within a specified timeframe (e.g., 3 to 4 days) of nursing interventions, and their stool consistency will be soft and easily passed without straining.
• Improved Nutritional Status: The patient will exhibit or verbalize improvement in at least one indicator of nutritional status, such as increased functional ability, a sense of hopefulness, weight gain (if underweight), increased appetite, or peaceful acceptance in end-of-life care.
• Safe Swallowing: The patient will swallow independently without coughing, choking, or aspirating, ensuring safe oral intake.
• Clear Airway: The patient’s airway will remain patent, and lung sounds will be clear to auscultation both before and after meals, indicating effective airway management.
• Fluid and Electrolyte Balance: The patient’s mental status, vital signs, urine specific gravity, color, consistency, and concentration will remain within normal limits for the patient, reflecting adequate hydration and electrolyte balance.
• Moist Mucous Membranes: The patient’s mucous membranes will remain moist, and skin turgor will be elastic without tenting, indicating proper hydration.
• Restored Mentation: The patient’s mental status will return to their normal baseline within a specified timeframe (e.g., 3 days) of therapeutic interventions, particularly for conditions like acute confusion or delirium.
• Freedom from Injury: The patient will remain free from injury or harm resulting from altered mental status or cognitive impairment, ensuring a safe environment.
• Absence of Infection: The patient will remain free of infection, as evidenced by orientation to person, place, and time within their normal limits; respiratory rate and breathing pattern within normal limits; clear, straw-yellow urine with characteristic odor; core temperature and heart rate within normal limits; clear to whitish sputum; and intact skin with normal color and temperature for the patient.
• Intact Skin Integrity: The patient’s skin will remain non-erythemic and intact, without signs of pressure ulcers or breakdown, reflecting effective skin care and pressure ulcer prevention strategies.

Nursing Interventions and Actions in Geriatric Care

Therapeutic interventions and nursing actions in geriatric care are diverse and tailored to address the specific nursing diagnoses and patient needs. These interventions are crucial for promoting safety, managing health conditions, and enhancing the overall well-being of older adults.

1. Promoting Safety and Preventing Falls & Injuries

Preventing falls and injuries in geriatric patients is a paramount concern due to age-related physiological changes that increase vulnerability. Effective strategies encompass comprehensive risk assessments, environmental modifications, assistive devices, education, medication review, and sensory impairment management.

Identify factors that increase fall risk.
Risk factors such as advanced age, presence of chronic illnesses, sensory or motor deficits, medication use (especially polypharmacy and medications with side effects like dizziness or orthostatic hypotension), and inappropriate use of mobility aids significantly elevate the risk of falls in older adults. Identifying these specific factors for each patient is crucial for tailoring effective prevention strategies.

Assess the patient’s environment for hazards.
A thorough environmental assessment is essential to identify and mitigate potential fall hazards. This includes evaluating lighting adequacy, presence of tripping hazards (e.g., loose rugs, cords), furniture placement, and accessibility of frequently used items. Modifying the environment to remove or minimize these hazards is a key step in fall prevention.

Monitor baseline LOC and neurologic status.
Regular monitoring of the patient’s level of consciousness (LOC) and neurological status is vital, particularly upon admission and throughout hospitalization. Evaluating mental status and pre-existing cognitive or functional abilities provides a baseline for detecting changes that may indicate acute confusion or delirium, which are significant fall risk factors. Tools like the Mini-Mental State Examination (MMSE) and the Confusion Assessment Method (CAM) can be used for standardized assessments.

Utilize the confusion assessment method (CAM).
The Confusion Assessment Method (CAM) is a validated, standardized tool designed specifically for rapid and accurate detection of delirium in hospitalized older adults. Delirium is a serious condition that significantly increases fall risk and is often underdiagnosed. Regular use of CAM by bedside clinicians can improve early identification and management of delirium, leading to better patient outcomes.

Determine the cause of acute confusion.
Acute confusion or delirium in older adults is rarely caused by age alone and typically arises from underlying physical or psychosocial factors. Identifying the specific cause is crucial for effective management. Potential causes include hypoxia (low oxygen levels), hypoglycemia or hyperglycemia (abnormal blood glucose), electrolyte imbalances, infections (e.g., urinary tract infections, pneumonia), dehydration, pain, medication side effects, and environmental stressors. Diagnostic tests such as pulse oximetry, arterial blood gas (ABG) analysis, serum glucose, electrolytes, complete blood count (CBC), and hydration status assessments are essential to determine the underlying cause.

Test short-term memory.
Assessing short-term memory is important for evaluating cognitive function and safety awareness. A simple test involves demonstrating how to use the call light, having the patient demonstrate it back, and then re-testing after a brief delay (e.g., 5 minutes). Inability to recall and repeat the demonstration indicates impaired short-term memory, which can affect the patient’s ability to seek assistance and maintain safety.

Assess apical pulse and monitor for dysrhythmias.
Cardiac dysrhythmias and other cardiac abnormalities can compromise brain oxygenation, leading to confusion and increased fall risk. Regular assessment of the apical pulse and monitoring for irregular rhythms or dysrhythmias, especially using cardiac monitors or telemetry when indicated, is crucial for early detection and management of cardiac issues that may contribute to confusion and falls.

Monitor pain using a rating scale.
Pain, especially acute pain, can be a significant cause of confusion in older adults. Regular pain assessment using a validated pain rating scale (e.g., 0-10 numeric scale) is essential. For patients unable to use a pain scale, observe for nonverbal pain cues such as facial expressions (frowning, grimacing), body language (restlessness, guarding), and changes in behavior. Input from family or caregivers can be valuable in identifying pain behaviors in patients with cognitive impairment.

Treat pain and monitor behaviors.
Effective pain management is crucial, as pain can contribute to confusion and agitation, increasing fall risk. Administer pain medications as prescribed and closely monitor the patient’s response, observing for changes in behavior and confusion levels. If pain is the underlying cause of confusion, appropriate pain relief should lead to improved mental clarity and reduced agitation.

Monitor intake and output every 8 hours.
Maintaining fluid balance is essential for cognitive function and overall health in older adults. Dehydration is a common cause of acute confusion. Monitor fluid intake and output (I&O) at least every 8 hours to assess hydration status. Output should ideally be roughly equivalent to intake. Significant discrepancies or signs of dehydration (e.g., decreased urine output, concentrated urine, dry mucous membranes) should be promptly addressed.

Assess kidney function by reviewing creatine clearance.
Kidney function plays a critical role in fluid and electrolyte balance and medication clearance. Age-related decline in renal function is common. Serum creatinine and blood urea nitrogen (BUN) levels alone may not accurately reflect kidney function in older adults. Creatine clearance is a more sensitive measure of glomerular filtration rate and should be assessed to evaluate renal function and guide medication dosing adjustments, especially for drugs excreted by the kidneys.

Review current medications with a pharmacist.
Polypharmacy and drug interactions are major contributors to acute confusion and falls in older adults. A comprehensive medication review by a pharmacist is essential. This review should include all prescribed medications, over-the-counter (OTC) drugs, and supplements. Certain medications, such as digoxin, anticholinergics, benzodiazepines, and opioids, are particularly associated with confusion and falls in the elderly. The pharmacist can identify potential drug interactions, side effects, and medications that may be inappropriate or require dose adjustments for older adults.

Toilet patient every 2 hours if short-term memory problems.
Older adults with short-term memory impairment may not reliably use the call light to request toileting assistance, increasing the risk of falls if they attempt to get to the bathroom independently. Proactive, scheduled toileting every 2 hours while awake and every 4 hours at night can help prevent falls related to urgency and incontinence. Establishing a toileting schedule and communicating it clearly in the care plan and at the bedside is important.

Keep urinal and routinely used items within reach.
Ensuring that frequently used items, such as the urinal, call light, glasses, and hearing aids, are within easy reach minimizes the need for the patient to reach, stretch, or get out of bed unassisted, thereby reducing fall risk. A confused patient may delay requesting assistance until urgency becomes overwhelming, increasing the likelihood of a fall.

Patient to wear glasses and hearing aid.
Sensory impairments, such as vision and hearing loss, significantly increase fall risk in older adults. Ensuring that patients wear their glasses and hearing aids, or keeping them readily accessible at the bedside, optimizes sensory input and reduces sensory confusion. Regular eye and hearing exams are also important to address and manage sensory deficits.

Encourage familiar items from home.
Familiar objects from home, such as a blanket, bedspread, family photos, or pet pictures, can promote orientation, reduce anxiety, and provide comfort, especially for patients experiencing confusion or disorientation in an unfamiliar hospital environment. These items can help create a more calming and less disorienting atmosphere, indirectly reducing agitation and fall risk.

Check on patient every 30 minutes.
Frequent monitoring, at least every 30 minutes and whenever passing the room, is crucial for patients at high risk for falls or confusion. Placing the patient closer to the nurses’ station facilitates closer observation. A safe, non-stimulating environment minimizes potential triggers for agitation and confusion. Regular checks allow for prompt intervention if the patient becomes restless, confused, or attempts to get out of bed unassisted.

Reorient the patient as needed.
Reorientation is a key intervention for managing confusion. Regularly reorient the patient to their surroundings, time, and situation. Use orienting cues such as a clock with large numerals, a large-print calendar, and verbal reminders of the date, day, and reason for hospitalization. Reorientation can help improve awareness and reduce confusion, though its effectiveness may vary depending on the underlying cause and severity of confusion.

Provide music but not TV.
Music can have a calming and therapeutic effect for confused patients. However, television may be disorienting, as patients with confusion may misinterpret TV content as happening in their immediate environment. Music can provide a soothing and familiar auditory stimulus without the potential for misinterpretation and increased confusion.

Use simple terms to explain events.
When communicating with a confused patient, use simple, clear, and concise language. Avoid complex sentences or medical jargon. Explain procedures and events in straightforward terms, such as “I am going to check your blood pressure on your arm” or “This food is good for you.” Simple communication enhances understanding and reduces anxiety and confusion.

Leave room if hostile, return, re-introduce.
If a patient becomes hostile, agitated, or misinterprets the nurse’s role, it’s often best to temporarily withdraw from the situation. Leave the room and return after a short interval (e.g., 15 minutes). Re-enter and re-introduce yourself as if it’s the first encounter. Acutely confused patients often have poor short-term memory and may not recall the previous interaction, allowing for a fresh start and de-escalation of the situation.

Stop reorientation if patient becomes aggressive.
If attempts at reorientation escalate patient agitation or aggression, discontinue the reorientation approach. Avoid directly challenging the patient’s perception of reality or arguing with them. Instead, acknowledge their feelings and perspective by saying something like, “I understand why you might think that.” This approach avoids further escalating anger and agitation in a confused individual.

For permanent cognitive deficit, check every 30 minutes.
Patients with permanent cognitive deficits, such as dementia or Alzheimer’s disease, can also experience acute confusional states (delirium). For these patients, regular checks every 30 minutes are still essential. Reorient to their baseline mental status as needed, but avoid repeatedly questioning their understanding of reality, as this can cause frustration and agitation. Focus on maintaining safety and comfort and managing any acute delirium superimposed on their chronic cognitive impairment.

Walk with patient if they try to leave hospital.
If a confused patient attempts to leave the hospital, do not restrain or physically block them initially. Instead, walk with them and attempt distraction. Engage them in conversation, asking about their intended destination. Use a friendly and conversational tone. Gradually redirect them away from exits and towards safer areas within the unit. After a few minutes, attempt to lead them back to their room, offering snacks or rest. Distraction is often effective in redirecting behavior in confused patients.

Have family talk or sit with patient.
Involving family members or significant others can greatly enhance patient safety and comfort. If a patient requires more frequent monitoring than every 30 minutes, having a family member stay with them or talk to them by phone can provide additional supervision and reassurance. Familiar voices and faces can have a calming effect and reduce agitation and confusion.

Offer urinal or bedpan if patient tries to climb out of bed.
Restlessness and attempts to get out of bed, especially in confused patients, may be due to unmet needs, such as the need to urinate. If a patient tries to climb out of bed, first offer a urinal or bedpan or assist them to the commode. Addressing basic needs can often reduce agitation and prevent falls associated with attempts to get to the bathroom unassisted.

Place patient in chair at nurses’ station if not on bedrest.
If the patient is not on bedrest, placing them in a chair or wheelchair at the nurses’ station provides enhanced supervision and promotes safety while also offering social stimulation and reducing isolation. Increased visibility allows for prompt intervention if the patient becomes agitated or attempts to get up unassisted. Social interaction with staff can also have a calming effect.

Bargain with the patient to stay for a fixed period.
For patients who are agitated and trying to leave, bargaining or establishing a short-term agreement to stay can be a useful delaying tactic. For example, suggest they stay until the doctor comes, until mealtime, or until a family member arrives. Due to poor short-term memory and attention span, the patient may forget their urge to leave in the interim. This approach can help de-escalate the immediate situation and allow time for further intervention.

Hide tubes if patient tries to pull them out.
Patients who are confused or agitated may attempt to pull out tubes, such as IV lines or feeding tubes. To minimize this, try to conceal tubes from view. Use stockinette mesh dressings over IV lines. Secure feeding tubes to the side of the face with paper tape and drape them behind the ear. “Out of sight, out of mind” can be an effective strategy for reducing tube pulling in confused patients.

Use medications carefully for behavior management.
Medications for managing behavior in confused older adults should be used judiciously and with caution. The principle of “start low and go slow” is crucial, as older adults are more sensitive to medication side effects. Neuroleptics like haloperidol may be used for severe agitation in patients with dementia or psychiatric illness (but are contraindicated in Parkinsonism). For acute confusion or delirium, short-acting benzodiazepines (e.g., lorazepam) may be more effective for managing anxiety and fear, which often contribute to disruptive behaviors. Neuroleptics can cause akathisia (restlessness) as a side effect.

Use restraints with caution and according to policy.
Physical restraints should be used as a last resort and only when necessary to prevent immediate harm to the patient or others. Restraints can paradoxically increase agitation in some patients. Use restraints cautiously, according to hospital policy and with appropriate physician orders. Regularly assess the need for continued restraint and release restraints as soon as it is safe to do so.

Evaluate continued need for interventions.
Continuously evaluate the ongoing need for various interventions. Some interventions may become irritating or unnecessary over time. For example, if the patient is now tolerating oral fluids well, discontinue IV fluids. If they are eating adequately, remove the feeding tube. If an indwelling urinary catheter is in place, reassess the need and consider removal and bladder training if appropriate. Discontinuing unnecessary interventions reduces potential irritants and promotes patient comfort and independence.

Secure a wristband identification for fall precautions.
Use a wristband identification system to clearly indicate patients who are at high risk for falls. This visual cue alerts all healthcare providers to implement fall precautions consistently and proactively. Standardized fall precaution protocols should be followed for all patients identified as high fall risk.

Place assistive devices and items within reach.
Ensure that assistive devices (e.g., walkers, canes) and personal care items (e.g., call bell, phone, water) are readily accessible to the patient. This promotes independence and reduces the need to reach or call for assistance, minimizing fall risk.

Review hospital protocols for patient transfers.
Hospital facilities should have clear protocols and procedures for patient transfers to ensure safety and prevent falls during transfers. All staff involved in patient transfers should be trained in proper transfer techniques and adhere to established protocols. Using assistive devices like gait belts and ensuring clear communication during transfers are essential.

Keep bed in lowest position at all times.
Keeping the patient’s bed in the lowest position at all times significantly reduces the distance to the floor in case of a fall from bed. This is a simple yet effective measure to minimize injury severity if a fall does occur.

Answer call light as soon as possible.
Promptly responding to call lights is crucial, especially for patients at risk for falls. Delayed response may lead patients to attempt to get out of bed unassisted, increasing fall risk. Answering call lights quickly allows staff to assess the patient’s needs and provide timely assistance, preventing falls.

Use side rails on bed as needed.
Side rails can be used selectively to enhance patient safety, especially for confused or restless patients. However, side rails should not be used routinely for all older adults, as they can sometimes increase agitation or risk of injury if patients attempt to climb over them. Use side rails judiciously, based on individual patient needs and risk assessment, and in accordance with hospital policy.

Advise non-slip footwear.
Advise patients to wear shoes or slippers with non-slip soles when ambulating. Non-slip footwear significantly reduces the risk of slips and falls, especially on smooth hospital floors or at home.

Orient patient to surroundings.
Orienting the patient to their surroundings is essential, especially upon admission to a new environment. Familiarize them with the location of the bed, bathroom, furniture, and any potential environmental hazards. Avoid rearranging furniture in the room, as this can disorient the patient and increase fall risk.

Ensure room is well-lit.
Adequate lighting is critical for fall prevention. Ensure the patient’s room is well-lit, especially at night. Consider using a bedside lamp that is left on at night to improve visibility and reduce tripping hazards during nighttime ambulation.

Encourage family to stay with patient.
Encouraging family members or significant others to stay with the patient, especially if they are at high risk for falls or confusion, provides an extra layer of safety and supervision. Family presence can help prevent falls, reduce agitation, and provide emotional support.

Ensure regular eye exams and use of glasses/hearing aids.
Regular eye exams and proper use of eyeglasses and hearing aids are crucial for fall prevention. Sensory impairments significantly increase fall risk. Ensure patients have regular vision and hearing checks and consistently use prescribed corrective devices to optimize sensory input and environmental awareness.

Instruct on safe ambulation at home, including handrails.
Before discharge, provide patients and caregivers with detailed instructions on safe ambulation techniques at home. Emphasize the importance of home safety modifications, such as installing handrails in bathrooms and hallways, removing tripping hazards, and ensuring adequate lighting. Home safety evaluations by occupational or physical therapists may be beneficial.

Encourage regular exercise and gait training.
Regular exercise programs, including gait training, can improve muscle strength, balance, coordination, and reaction time in older adults. Physical conditioning reduces the incidence of falls and minimizes injury severity if a fall does occur. Encourage participation in appropriate exercise programs, tailored to individual abilities and health conditions.

Collaborate to review medications contributing to falls.
Collaborate with physicians and pharmacists to review the patient’s medication regimen and identify medications that may contribute to fall risk. Pay particular attention to medications with side effects such as dizziness, orthostatic hypotension, sedation, or confusion. Consider dose adjustments or alternative medications if appropriate. Polypharmacy is a major risk factor for falls in older adults.

Evaluate need for physical and occupational therapy.
Evaluate the need for physical therapy (PT) and occupational therapy (OT) consultations. PT can assist with gait training, balance exercises, and strengthening programs. OT can assess functional abilities and recommend assistive devices for transfer and ambulation, as well as conduct home safety evaluations and recommend modifications. Assistive devices such as walkers, canes, wheelchairs, and raised toilet seats can significantly improve safety and independence.

2. Improving Gas Exchange and Respiratory Function

Age-related changes in the respiratory system can compromise gas exchange in geriatric patients. Nursing interventions focus on monitoring respiratory status, promoting effective breathing and coughing, ensuring adequate hydration, and managing underlying conditions.

Monitor respiratory rate, depth, pattern, breath sounds, cough, sputum, and mental status.
Regular monitoring of respiratory parameters provides baseline data and allows for early detection of respiratory compromise. Assess respiratory rate, depth, and pattern; auscultate breath sounds for adventitious noises (e.g., wheezes, crackles); evaluate cough effectiveness and sputum production; and monitor mental status changes, which can be an early indicator of hypoxia.

Assess subtle changes in behavior or mental status.
Subtle changes in behavior or mental status, such as increased anxiety, restlessness, disorientation, or hostility, can be early signs of decreasing oxygen levels (hypoxia). Monitor oxygen saturation using pulse oximetry (SpO2 should ideally be >92%) or review arterial blood gas (ABG) values (PaO2 optimally 80-95 mmHg or higher). However, be aware that pulse oximetry readings can be falsely elevated in patients with anemia (low hemoglobin), as there may be less hemoglobin available to carry oxygen despite a high saturation percentage.

Auscultate lungs for adventitious sounds.
Auscultate lung sounds regularly to detect adventitious sounds. Crackles (rales) are common in older adults due to age-related decrease in lung elasticity and reduced aeration of lower lung fields. Benign crackles in the absence of other respiratory symptoms (e.g., fever, increased respiratory rate, changes in mental status) may not indicate pathology. However, new or worsening crackles, especially if accompanied by other symptoms, warrant further investigation.

Encourage breathing and coughing exercises.
Breathing exercises (e.g., deep breathing, diaphragmatic breathing) and coughing exercises promote alveolar expansion, mobilize secretions, and improve airway clearance, thereby optimizing gas exchange. Incentive spirometry can be used to encourage deep inspiration and lung expansion.

Encourage increased fluid intake.
Adequate hydration is essential for maintaining respiratory function. Encourage increased fluid intake (at least 2.5 liters daily), unless contraindicated by renal or cardiac conditions. Hydration helps to thin respiratory secretions, making them easier to cough up and clear from the airways.

Treat hyperthermia, reduce pain, lessen pacing, and decrease anxiety.
Conditions that increase metabolic demand and oxygen consumption, such as fever (hyperthermia), pain, restlessness (pacing), and anxiety, can exacerbate respiratory compromise. Treat hyperthermia promptly, manage pain effectively, reduce pacing by addressing underlying causes of agitation, and implement anxiety-reducing measures to decrease oxygen demand and improve respiratory function.

Teach use of support devices like nasal cannulas or oxygen masks.
If supplemental oxygen is prescribed, educate the patient and caregivers on the proper use of oxygen delivery devices, such as nasal cannulas or oxygen masks. Provide clear instructions on flow rates, safety precautions, and equipment maintenance to promote adherence and effective oxygen therapy.

3. Managing Hypothermia

Geriatric patients are at increased risk for hypothermia due to age-related changes in thermoregulation. Nursing interventions focus on temperature monitoring, preventing heat loss, and implementing rewarming measures when necessary.

Monitor temperature using a low-range thermometer.
Accurate temperature monitoring is crucial for detecting hypothermia in older adults. Use a low-range thermometer, if available, as normal body temperature in older adults may be lower than the standard 98.6°F (37°C), often around 96°F (35.5°C). Hypothermia is defined as a core body temperature below 95°F (35°C).

Monitor oral temperature accurately.
When taking oral temperatures, ensure accuracy by placing the thermometer tip far back in the patient’s mouth, under the tongue, to obtain a reliable reading of core temperature.

Assess and record mental status.
Changes in mental status, such as increased disorientation, altered sensorium, or atypical behavior, can be early signs of hypothermia, even before significant temperature drop is detected. Assess and document mental status changes as part of hypothermia monitoring.

Watch for sedatives, muscle relaxants, and hypnotics.
Certain medications, including sedatives, muscle relaxants, and hypnotics (including anesthetics), can impair thermoregulation and increase the risk of hypothermia. These medications can suppress shivering, the body’s natural mechanism for generating heat. Be particularly vigilant for hypothermia risk in patients receiving these medications, especially in cooler environments. Older adults are at risk for environmental hypothermia even at moderately cool ambient temperatures (72°-75°F or 22.22°-23.89°C).

Give blankets during tests or x-rays.
Provide warm blankets to patients undergoing procedures or examinations, such as x-rays, especially in radiology departments which may be cooler. This simple measure helps prevent heat loss and reduces the risk of hypothermia, particularly during prolonged or repeated exposures.

Initiate slow rewarming for mild hypothermia.
For mild hypothermia (body temperature between 90-95°F or 32.2-35°C), initiate slow, passive rewarming. Increase room temperature to at least 77.5°F (23.89°C). Use warm blankets, head covers, and warm circulating air blankets to gradually rewarm the patient. Avoid rapid rewarming for mild hypothermia.

Warm internally with fluids for temperature below 95°F.
For moderate to severe hypothermia (body temperature below 95°F or 35°C), internal rewarming is necessary. Administer warm oral or IV fluids, if appropriate. Other internal rewarming methods may include warmed saline gastric or rectal irrigations or warmed, humidified air inhalation. Internal rewarming should be done under medical supervision.

Watch for signs of excessive rapid rewarming.
Monitor for signs of excessively rapid rewarming, which can be dangerous. Signs include irregular heart rate, dysrhythmias, and vasodilation causing very warm extremities (which paradoxically leads to core heat loss). Rewarming should be gradual and carefully monitored.

Anticipate labs if temperature doesn’t increase by 1°F/hr.
If the patient’s temperature does not increase by at least 1°F (0.56°C) per hour with rewarming measures, suspect underlying medical conditions contributing to hypothermia. Anticipate laboratory tests, such as white blood cell count (WBC) for sepsis, serum glucose for hypoglycemia, and thyroid function tests for hypothyroidism, as these conditions can impair thermoregulation.

Administer antibiotics, glucose, or thyroid therapy as prescribed.
Treat underlying medical conditions identified as contributing to hypothermia. Administer antibiotics for sepsis, glucose for hypoglycemia, or thyroid hormone replacement therapy for hypothyroidism, as prescribed. Addressing the underlying cause is essential for restoring normal thermoregulation and resolving hypothermia.

4. Promoting Adequate Sleep and Improving Sleep Patterns

Sleep patterns are often disturbed in geriatric patients. Nursing interventions aim to assess and address sleep disturbances, promote a conducive sleep environment, and implement non-pharmacological sleep aids.

Assess and record sleeping pattern.
Conduct a thorough assessment of the patient’s sleep patterns, including usual bedtime, wake time, sleep duration, frequency of nighttime awakenings, and daytime napping habits. Gather information from the patient and, if possible, from family members or caregivers to obtain a comprehensive sleep history.

Gather inquiries regarding activity level and naps.
Assess the patient’s daily activity level and napping habits. Low activity levels and frequent daytime napping can disrupt nighttime sleep. Inquire about the timing, duration, and frequency of naps, as well as the patient’s overall activity level throughout the day.

Monitor patient’s activity level.
Monitor the patient’s activity level and response to activity. If the patient reports fatigue after activities or exhibits signs of tiredness, irritability, or restlessness, encourage a nap after lunch or early afternoon. However, discourage late afternoon or evening naps, as these can interfere with nighttime sleep. Balance activity and rest throughout the day.

Identify and follow typical nighttime routine.
Identify the patient’s typical nighttime routine at home and try to replicate it as much as possible in the healthcare setting. Familiar routines promote a sense of normalcy and can facilitate sleep. This may include bedtime rituals like reading, listening to music, or having a warm drink.

Arrange activities together to lessen interruptions.
Minimize nighttime disruptions by clustering nursing activities whenever possible. Group vital sign measurements, medication administration, and toileting assistance together to reduce the frequency of awakenings during sleep hours. Coordinate care to allow for longer periods of uninterrupted sleep.

Refrain from caffeinated drinks after 6 pm.
Advise patients to avoid caffeinated beverages (coffee, tea, cola, chocolate) after 6 pm, as caffeine is a stimulant that can interfere with sleep onset and maintenance. Caffeine can increase alertness, cause insomnia, and lead to frequent nighttime awakenings for urination.

Provide calm and quiet environment.
Create a calm, quiet, and dark sleep environment. Minimize noise and light exposure in the patient’s room, especially during sleep hours. Use white noise machines or earplugs to reduce noise disturbances. Ensure a comfortable room temperature and adequate ventilation. Reduce unnecessary interruptions during sleep hours.

Administer pain medications, back rub, pleasant conversation at sleep time.
Promote comfort and relaxation before bedtime. Administer pain medications as prescribed to manage pain that may interfere with sleep. Offer a back rub to promote relaxation. Engage in a brief, pleasant conversation to reduce anxiety and create a calming bedtime atmosphere. These measures enhance comfort and facilitate sleep onset.

5. Restoring Bowel Function and Managing Constipation

Constipation is a common concern in geriatric patients. Nursing interventions focus on assessing bowel patterns, promoting dietary and lifestyle modifications, and using pharmacological interventions judiciously.

Assess and record normal bowel elimination pattern.
Obtain a detailed bowel history upon admission, including the patient’s normal bowel elimination pattern: frequency, time of day, associated habits, and previous methods used to manage constipation. If the patient cannot provide this information, consult with family members or caregivers. This baseline assessment is essential for identifying deviations from the patient’s norm and guiding interventions.

Quantify roughage intake.
Assess the patient’s dietary fiber (roughage) intake. While fiber is important for bowel regularity, excessive roughage intake, especially if introduced too rapidly, can cause gas, bloating, and diarrhea. Gradually increase fiber intake as tolerated and monitor for adverse effects.

Assess hydration status and promote routines.
Assess hydration status for signs of dehydration, as dehydration is a major contributor to constipation. Maintain adequate fluid intake, dietary fiber, activity levels, and consistent toileting routines. If bowel movements do not occur within 3 days, initiate mild laxatives cautiously to re-establish a normal bowel pattern. Be mindful that osmotic laxatives can cause dehydration if fluid intake is insufficient.

Inform patient hospitalization increases constipation risk.
Educate the patient that hospitalization and changes in routine can increase the risk of constipation. Encourage them to continue effective non-pharmacological methods they use at home to manage constipation, both preventively and when constipation occurs. Early preventive measures are more effective than treating established constipation.

Educate about fluid intake and constipation.
Educate the patient about the strong link between fluid intake and constipation. Encourage a daily fluid intake of 2500 ml (unless contraindicated by medical conditions), as adequate hydration softens stool and promotes bowel movements. Monitor and record bowel movements, including amount, date, time, and consistency.

Instruct to include roughage in every meal.
Instruct the patient to include fiber-rich foods (roughage) in every meal, if possible. For patients who have difficulty tolerating raw fruits and vegetables, suggest alternative sources of fiber, such as bran cereals, whole-grain bread, and muffins. Dietary fiber adds bulk to the stool, facilitating bowel movements and preventing constipation.

Educate about activity level and constipation.
Educate the patient about the connection between physical activity and bowel function. Encourage optimal activity levels for all patients, as tolerated. Implement and encourage participation in an activity program to promote mobility and independence. Regular exercise stimulates peristalsis and helps prevent constipation.

Encourage gastrocolic/duodenocolic reflex use.
Utilize the gastrocolic and duodenocolic reflexes to promote colonic emptying. If the patient typically has a bowel movement in the morning, schedule interventions that stimulate these reflexes, such as offering warm liquids in the morning and encouraging ambulation after breakfast. Digital stimulation of the inner anal sphincter may also trigger a bowel movement in some individuals.

Use previously effective measures, start low, go slow.
When addressing constipation, start by using the patient’s previously effective methods, if known and appropriate. Follow the principle of “start low, go slow,” beginning with the least invasive and most natural interventions and gradually progressing to more potent interventions if needed. Aggressive measures can lead to rebound constipation and hinder future bowel movements.

Hierarchy of laxatives (oral methods first).
*When pharmacological therapy is necessary, use a hierarchical approach, starting with the most benign oral methods first:

1. Bulk-forming additives (bran, methylcellulose, psyllium)
2. Mild laxatives (apple or prune juice, Milk of Magnesia)
3. Stool softeners (docusate calcium, docusate sodium)
4. Potent laxatives or cathartics (senna, bisacodyl, cascara sagrada)
5. Medicated suppositories (glycerin, bisacodyl)
6. Enemas (tap water, saline, sodium phosphate/biphosphate)

Avoid pharmacological interventions until the patient has not had a bowel movement for three days, unless clinically indicated. Older adults may focus more on changes in bowel habit than stool frequency as indicators of constipation.

Administer laxatives after barium imaging.
Administer laxatives as ordered after diagnostic imaging procedures of the gastrointestinal tract that use barium contrast. Laxatives facilitate barium removal, preventing barium impaction and rebound constipation due to bowel habit disruption during bowel preparation.

6. Failure to Thrive in Older Adults

Failure to thrive (FTT) in older adults is a complex syndrome characterized by weight loss, functional decline, and overall health deterioration. Nursing interventions involve comprehensive assessment, addressing underlying causes, and promoting nutritional and psychosocial support.

Conduct a comprehensive physical assessment.
Perform a thorough physical assessment to establish a baseline and identify any underlying medical conditions contributing to failure to thrive. Evaluate the status of chronic diseases and assess for new or worsening health problems. A comprehensive system assessment provides a basis for comparison and ongoing monitoring.

Examine laboratory and other studies.
Review relevant laboratory and diagnostic studies, such as complete blood count (CBC) with differential, albumin and pre-albumin levels (indicators of nutritional status), thyroid-stimulating hormone (TSH) (to rule out thyroid dysfunction), and basic metabolic panel (BMP) (to assess electrolytes and renal function). These tests help identify nutritional deficiencies, electrolyte imbalances, infection, and thyroid abnormalities that may contribute to FTT.

Gather patient history; involve caregiver.
Obtain a detailed patient history, involving caregivers as needed, to gather essential information about the onset and progression of FTT. Assess critical factors such as recent losses (e.g., death of a spouse), changes in living situation, medications, changes in appetite, and decline in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Focus on the timing of changes in behavior and appetite to identify potential contributing factors like depression, dementia, pain, or sensory impairments (taste, smell).

Allow patient to vent feelings.
Provide emotional support and allow the patient to express feelings of fear, anger, despair, frustration, and concerns about their health and hospitalization. Acknowledge and validate these feelings as normal responses to their situation. Supportive listening and empathy can help reduce feelings of despair and isolation.

Explain age-related changes to patient and others.
Educate the patient and significant others about normal age-related physiological changes and the concept of decreased physiologic reserve in older adults. Explain that failure to thrive can result from the interaction of physical frailty, disability (functional decline), and neuropsychiatric impairment (cognitive or emotional dysfunction). Describe these three components:

• Frailty: Increased vulnerability due to diminished physiologic reserve affecting multiple body systems.
• Disability: Difficulty or decline in performing ADLs.
• Neuropsychiatric impairment: Complex phenomenon arising from life circumstances (depression), physiologic disruption (delirium), or neurologic changes (cognitive impairment).*

Collaborate with healthcare providers.
Collaborate with other healthcare professionals to provide comprehensive care for patients with FTT:

• Speech therapists and dietitians: Address swallowing difficulties and inadequate food and fluid intake.
• Physical and occupational therapists: Assess physical limitations and potential for improvement with rehabilitation programs and assistive devices.
• Social Services: Evaluate support networks, identify social and economic barriers to care, and assess readiness for end-of-life care planning, if appropriate.*

7. Preventing Aspiration

Aspiration is a serious risk in geriatric patients, particularly those with swallowing difficulties or impaired consciousness. Nursing interventions focus on assessing swallowing function, implementing aspiration precautions, and ensuring safe feeding techniques.

Evaluate swallowing reflex and gag reflex.
Assess the patient’s swallowing reflex by palpating the laryngeal prominence and instructing the patient to swallow. Evaluate the gag reflex by gently touching each palatal arch with a tongue blade. Document these findings. Intact swallowing and gag reflexes are essential to prevent aspiration and choking before oral intake.

Monitor food intake and swallowing process.
Carefully monitor the patient during meals. Record food intake, including amount and consistency of food consumed. Observe how the patient places food in their mouth, manipulates food, chews, and the time taken before swallowing. Note any difficulties with chewing or swallowing. This detailed observation provides valuable information for subsequent feedings and care planning.

Monitor patient during swallowing.
Closely observe the patient during swallowing for signs of difficulty, coughing, or choking. This assessment helps evaluate swallowing ability and identify patients who require aspiration precautions. Deficiencies in swallowing function necessitate implementation of aspiration precautions.

Monitor for choking or coughing before, during, or after swallowing.
Monitor for coughing or choking that occurs before, during, or immediately after swallowing. Coughing or choking within minutes of oral intake indicates aspiration of material into the airway.

Check for wet or gurgling speech after swallowing.
Assess the patient’s speech quality after swallowing. Wet or gurgling speech may indicate pulmonary aspiration and suggest impaired gag and swallow reflexes. This finding warrants further evaluation and aspiration precautions.

Assess for breath sound abnormalities.
Auscultate breath sounds for abnormalities such as crackles (rales), rhonchi, or wheezes, which may indicate aspiration pneumonia. Monitor for other signs of aspiration, including shortness of breath, dyspnea, cyanosis, increasing temperature, and deteriorating level of consciousness. These signs may indicate “silent aspiration,” which is more common in older adults due to less effective cough reflexes and sphincter closure.

Watch for food retention in mouth.
Observe for food retention on the sides of the mouth, which can indicate poor tongue movement and impaired oral phase of swallowing.

Check for drooling or inability to close lips.
Assess for drooling of saliva or food, or inability to close the lips tightly around a straw. These signs suggest restricted jaw, lip, or tongue movement, which can impair swallowing efficiency and increase aspiration risk.

Anticipate video fluoroscopic swallowing exam (VFSE) or MBS.
Anticipate the need for a video fluoroscopic swallowing exam (VFSE) or modified barium swallow (MBS) study to comprehensively evaluate the patient’s gag and swallow reflexes and swallowing mechanics. This non-invasive procedure, performed by a radiologist and speech therapist, helps determine if aspiration is occurring, identify the consistencies of food and liquid most likely to be aspirated, and pinpoint the cause of aspiration.

Thickened fluids or diet modifications based on VFSE/MBS.
Based on the VFSE/MBS results, thickened liquids and/or diet modifications may be prescribed by the physician or speech therapist. Thickening agents increase fluid viscosity, improving swallow safety. Mechanically soft, pureed, or liquid diets may be ordered to reduce aspiration risk while ensuring adequate nutritional intake.

Anticipate speech therapist consult.
Anticipate the need for a speech therapy consultation for patients with swallowing difficulties. Speech therapists specialize in evaluating and treating swallowing disorders (dysphagia) and can provide tailored interventions and strategies to improve swallowing safety and efficiency.

Tilt head forward 45° during swallowing.
For patients with impaired swallowing reflexes, instruct them to tilt their head forward at a 45-degree angle during swallowing. This head position helps protect the airway and reduce aspiration risk by directing the bolus towards the esophagus.

Tilt head toward unaffected side for hemiplegia.
For patients with hemiplegia (paralysis on one side of the body, often due to stroke), instruct them to tilt their head towards the unaffected side during swallowing. This head position helps prevent aspiration by directing food and liquid towards the stronger side of the pharynx and esophagus.

Encourage rest before meals.
Ensure adequate rest periods before meals. Fatigue and exhaustion increase the risk of aspiration. Allow the patient to rest before eating to optimize their energy and focus during meals.

Upright position, chin down during eating.
Position the patient upright (90 degrees) during eating and drinking, with the chin slightly tilted down (chin tuck). Use pillows to support the upright position. This posture minimizes aspiration risk by closing off the airway and promoting gravity-assisted flow of food and liquid into the stomach.

Ensure dentures fit properly.
Ensure that the patient’s dentures fit properly and are securely in place. Properly fitting dentures improve chewing ability, reducing the risk of choking and aspiration. Ill-fitting dentures can impair chewing and increase swallowing difficulties.

Instruct dementia patients to chew and swallow.
For patients with dementia, provide verbal cues and reminders to chew and swallow each bite of food. Dementia can impair awareness of swallowing cues and increase the risk of food retention in the mouth and subsequent aspiration. Monitor for food pocketing in the sides of the mouth.

Allow sufficient time for meals.
Allow ample time for the patient to eat and drink. Patients with swallowing problems typically require twice as much time for meals as those with normal swallowing function. Avoid rushing meals and allow for slow, deliberate eating and drinking.

Have someone stay with patient during meals.
Have someone present with the patient during meals and fluid intake to supervise and provide assistance if choking or aspiration occurs. Supervision promotes safety and allows for immediate intervention if needed.

Encourage breathing and coughing exercises.
Encourage breathing exercises and coughing exercises every 2 hours while awake and every 4 hours during the night. These exercises promote lung expansion, improve airway clearance, and help prevent aspiration pneumonia.

Have suction machine available.
Ensure that suction equipment is readily available at the bedside, especially for patients at high risk for aspiration. Suctioning may be necessary to clear the airway in case of aspiration.

If aspiration occurs, assess airway obstruction.
If aspiration is suspected, immediately assess for signs of complete airway obstruction based on American Heart Association (AHA) guidelines: poor air exchange, cyanosis, inability to speak or breathe. Complete airway obstruction requires immediate intervention (e.g., Heimlich maneuver).

Encourage forceful cough for partial obstruction.
If there is partial airway obstruction, encourage the patient to cough forcefully to try to clear the airway. Effective coughing can often dislodge aspirated material.

Notify provider and get chest x-ray.
For both complete and partial aspiration, notify the healthcare provider immediately and obtain an order for a chest x-ray to confirm aspiration and rule out aspiration pneumonia or other complications.

Institute NPO status until diagnosis established.
Institute nothing by mouth (NPO) status until the diagnosis is established and the patient’s swallowing ability and aspiration risk are fully evaluated. NPO status minimizes further aspiration risk until a safe feeding plan can be determined.

8. Preventing Fluid Imbalance

Maintaining fluid balance is crucial in geriatric patients due to age-related physiological changes that affect hydration status. Nursing interventions focus on monitoring fluid balance, promoting adequate fluid intake, and managing fluid imbalances.

Assess and record fluid output (urine, diarrhea, emesis).
Accurately assess and record all sources of fluid output, including urine, diarrhea, emesis (vomit), and drainage from wounds or tubes. Document the amount, color, and frequency of output. Dark-colored, concentrated urine is a sign of dehydration.

Assess skin turgor and hydration status.
Assess skin turgor to evaluate hydration status. Gently pinch a fold of skin over the forehead, clavicle, sternum, or abdomen and observe for tenting (delayed return to normal). Tenting indicates decreased skin elasticity and dehydration. A furrowed tongue is another sign of severe dehydration. However, skin turgor may be less reliable in older adults due to age-related skin changes.

Monitor fluid intake, encourage 2-3 liters daily.
Monitor fluid intake carefully. Encourage a daily fluid intake of 2-3 liters (unless contraindicated by medical conditions like heart failure or renal disease). Set specific intake goals for each shift (day, evening, night) to ensure adequate hydration throughout the day.

Assess level of consciousness and orientation.
Changes in level of consciousness, including confusion, disorientation, lethargy, or decreased responsiveness, can be indicators of dehydration. Assess the patient’s orientation to person, place, and time, and their ability to follow commands.

Weigh patient daily.
Weigh the patient daily at the same time, preferably before breakfast, using the same scale and wearing similar clothing. Daily weights are a sensitive indicator of fluid status. Significant weight changes (e.g., >2.5 kg or 5 lbs) can indicate fluid gain or loss.

Assess ability to drink fluids independently.
Assess the patient’s ability to take and drink fluids independently. Ensure that fluids are readily accessible, within easy reach. Use cups with lids to prevent spills and make drinking easier, especially for patients with tremors or weakness.

Monitor I&O for tube feedings or contrast medium.
Closely monitor intake and output, especially for patients receiving tube feedings or contrast media (e.g., for CT scans or angiograms). Contrast media and high-protein tube feedings can have osmotic effects, pulling fluid into the interstitial space and potentially causing dehydration. Monitor for signs of third spacing of fluids: peripheral edema (especially sacral), urine output significantly less than intake (e.g., 1:2 ratio), and decreased urine output (<30 ml/hr).

Monitor for fluid overload with IV infusions.
If the patient is receiving intravenous (IV) fluids, monitor closely for signs of fluid overload. Assess cardiac and respiratory status regularly, including apical pulse and lung sounds. Fluid overload can lead to heart failure or pulmonary edema. Signs include increased heart rate, crackles in the lungs, and bronchial wheezes.

Anticipate increased serum sodium, BUN, creatinine in dehydration.
In dehydrated patients, anticipate laboratory findings consistent with dehydration, such as elevated serum sodium, blood urea nitrogen (BUN), and serum creatinine levels. These lab values increase as the blood becomes more concentrated due to fluid deficit.

Ensure easy toilet access every 2 hours.
Ensure easy and timely access to the toilet, urinal, commode, or bedpan, at least every 2 hours during waking hours and every 4 hours at night. Answer call lights promptly. Older adults have decreased bladder capacity and increased urgency, so timely toileting access is crucial to prevent dehydration and incontinence.

Offer fluids frequently.
Offer fluids frequently throughout the day, whenever you are in the patient’s room. Provide a variety of fluids that the patient prefers to encourage intake. Limit caffeine-containing beverages, as caffeine is a diuretic and can promote fluid loss.

9. Promoting Infection Control and Minimizing Infections

Geriatric patients are more susceptible to infections due to age-related immunosenescence. Nursing interventions focus on infection prevention measures, early detection of infection, and prompt treatment.

Monitor baseline vital signs and LOC.
Monitor baseline vital signs, including temperature, heart rate, respiratory rate, blood pressure, level of consciousness, and orientation. Acute changes in mental status, such as confusion or disorientation, are often early indicators of infection in older adults, sometimes even before fever develops. Be alert for heart rate >100 bpm and respiratory rate >24 breaths/min.

Assess skin for tears, breaks, redness, ulcers.
Assess the patient’s skin integrity upon admission and regularly thereafter. Document the condition of the skin. Skin tears, breaks, redness, or ulcers provide portals of entry for infection. Maintain skin integrity through meticulous skin care.

Assess temperature using low-range thermometer.
Assess temperature using a low-range thermometer, if available. Older adults may have lower baseline body temperatures due to reduced metabolism. A temperature of 96°F (35.5°C) may be normal, while 98°-99°F (36.67°-37.22°C) may be considered febrile in an older adult. Fever may be blunted or absent in geriatric patients with serious infections.

Obtain rectal temperature if oral reading inaccurate.
If oral temperature readings are inconsistent with the clinical picture (e.g., warm skin, restlessness, depressed mentation) or if the oral temperature is low (≤97°F or 36.11°C), obtain a rectal temperature reading to ensure accurate assessment of core body temperature. Rectal temperature is generally considered more accurate than oral in older adults, especially when oral readings are questionable.

Avoid tympanic thermometer if possible.
Avoid using tympanic (ear) thermometers if possible, as their reliability may be inconsistent in older adults due to improper technique or ear canal anatomy. If tympanic temperature is used, ensure proper technique and consider verifying with another method if readings are questionable.

Assess urine quality and color; watch for incontinence.
Assess the quality and color of the patient’s urine. Document any changes in urine appearance and report findings to the healthcare provider. Be alert to new onset or worsening urinary incontinence, which can be a sign of urinary tract infection (UTI) in older adults, even in the absence of typical UTI symptoms like dysuria (painful urination).

Limit urinary catheter insertion.
Limit the use of indwelling urinary catheters whenever possible, as catheters significantly increase the risk of catheter-associated urinary tract infections (CAUTIs). Use alternative methods for managing urinary incontinence, such as prompted voiding or external collection devices, whenever appropriate.

Anticipate blood cultures, urinalysis, urine culture.
If infection is suspected, anticipate orders for blood cultures, urinalysis, and urine culture to identify the causative microorganisms (bacteria, fungi, viruses) and guide antibiotic therapy. Cultures help determine the specific pathogen and its antibiotic sensitivities.

Anticipate WBC count request.
Anticipate an order for a white blood cell count (WBC). While elevated WBC count (>11,000/mm3) is a classic sign of infection, it may be a late or less pronounced finding in older adults due to age-related blunting of the immune response. A normal or even low WBC count does not rule out infection in geriatric patients.

IV fluid therapy for proven infection.
If infection is confirmed, expect initiation of intravenous (IV) fluid therapy. IV fluids improve hydration, compensate for fluid losses due to fever, and help liquefy secretions for easier expectoration in respiratory infections.

Anticipate chest x-ray if lung sounds unclear.
Anticipate an order for a chest x-ray if lung sounds are not clear or if pneumonia is suspected. Chest x-ray helps to rule out pneumonia or other pulmonary infections.

Anticipate antibiotics, antipyretics, oxygen for proven infection.
If infection is proven, anticipate orders for a broad-spectrum antibiotic regimen (initially, until culture results guide therapy), antipyretics (fever-reducing medications), and oxygen inhalation if hypoxia is present. Antibiotics treat the infection, antipyretics reduce fever, and supplemental oxygen improves oxygenation to vital organs, especially the brain. Fever increases cardiac workload, and older adults with decreased physiologic reserve are at higher risk for cardiac complications from prolonged tachycardia.

10. Preventing Pressure Ulcer Formation

Geriatric patients are highly susceptible to pressure ulcers due to age-related skin changes and increased risk factors. Nursing interventions focus on meticulous skin assessment, pressure relief, skin care, and nutritional support.

Assess skin upon admission and regularly.
Perform a thorough skin assessment upon admission and regularly thereafter (at least daily). Document the condition of the skin, paying particular attention to bony prominences. Baseline skin assessment is essential for early detection of pressure ulcer development.

Monitor skin over bony prominences for erythema.
Carefully monitor skin over bony prominences (sacrum, scapulae, heels, spine, hips, pelvis, greater trochanter, knees, ankles, costal margins, occiput, ischial tuberosities) for erythema (redness). These areas are at highest risk for pressure ulcer development due to concentrated pressure and reduced tissue perfusion.

Observe skin for redness, texture changes, breaks.
Observe the skin for any areas of redness, changes in skin texture (e.g., induration, bogginess), or breaks in the skin surface. Redness, texture changes, or skin breaks indicate early pressure ulcer development and require immediate and aggressive skin care measures to prevent progression.

Use lift sheet or roll patient during repositioning.
Use a lift sheet or draw sheet when repositioning patients in bed. Avoid dragging or pulling the patient across sheets, as this creates shear forces that can damage the skin and contribute to pressure ulcer formation. Rolling or lifting minimizes shear.

Provide turning schedule every 2 hours.
Implement a regular turning schedule, repositioning the patient at least every 2 hours. Turning redistributes pressure and relieves pressure on vulnerable bony prominences, promoting tissue perfusion and preventing pressure ulcers.

Utilize pressure-sensitive mattresses for bedridden patients.
For patients who are bedridden or unable to reposition themselves, use pressure-redistributing mattresses, such as waterbeds, airbeds, air-fluidized mattresses, or alternating pressure mattresses. These specialized mattresses reduce pressure on bony prominences and promote skin protection.

Pad bony prominences with pillows or pads.
Pad bony prominences (e.g., heels, elbows, sacrum) with pillows or specialized pressure-relief pads, even when the patient is in a wheelchair or sitting for extended periods. Padding cushions bony prominences, reducing pressure and protecting overlying skin. Ischial tuberosities are particularly vulnerable in seated positions; use gel pads for chair or wheelchair seats.

Use lotions generously on dry skin.
Apply lotions generously to dry skin to maintain skin hydration and suppleness. Dry skin is more prone to breakdown. Lanolin-containing lotions are particularly beneficial for moisturizing dry skin.

Assist patient out of bed frequently; use lift devices.
Assist the patient out of bed and encourage mobility as frequently as possible, if medically permitted. Utilize mechanical lifting devices to assist with patient transfers to minimize friction and shear forces on the skin during transfers. If getting out of bed is not possible, provide frequent position changes (every 2 hours) to promote blood flow and prevent skin breakdown.

Establish turning schedule on care plan and bedside.
Document the turning schedule clearly on the patient’s care plan and post it at the bedside. This serves as a reminder for nurses and other caregivers to adhere to the turning schedule consistently.

Discourage tubes under patient; pad tubes.
Avoid placing tubes (e.g., drainage tubes, catheters) directly under the patient’s head or limbs, as these can create pressure points. If tubes must be positioned beneath the patient, place a pad or pillow between the patient and the tube to provide cushioning and prevent pressure ulcer formation.

Use tepid water and superfatted, nonperfumed soaps.
When bathing patients, use tepid (lukewarm) water (90°-105°F or 32.2°-40.5°C) and superfatted, nonperfumed soaps. Hot water can burn older adults with decreased pain and temperature sensation. Superfatted soaps are less drying to the skin than regular soaps.

Clean face, axillae, and genital areas daily.
Cleanse the patient’s face, axillae (underarms), and genital areas daily to maintain hygiene and prevent skin breakdown in these areas. Complete full-body baths may be drying to older adult skin and are preferably done every other day rather than daily, unless medically indicated.

Record food intake percentage; offer snacks; consult dietitian.
Record the percentage of food intake at each meal to monitor nutritional status. Encourage family to bring in foods the patient enjoys to improve appetite and intake. Offer nutritious snacks between meals. Collaborate with a dietitian for nutritional assessment and recommendations, especially for patients with malnutrition risk or existing pressure ulcers. Adequate protein and ascorbic acid (vitamin C) intake are crucial for skin health and wound healing.

Limit plastic pads; use cloth layer; check incontinence pads q2h.
Limit the use of plastic protective pads under the patient, as plastic pads trap heat and moisture, increasing skin maceration and breakdown risk. If plastic pads are necessary, place at least one layer of cloth between the patient’s skin and the plastic pad to absorb moisture. For patients with incontinence, check incontinence pads at least every 2 hours and change them promptly to keep skin clean and dry. Avoid routine use of adult diapers unless the patient is ambulatory, undergoing diagnostic tests, or sitting in a chair, as diapers can trap moisture and heat.

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