Nursing Care of the Elderly Client

CHAPTER 15


Nursing Care of the Elderly Client


Persons who are 65 and older are the fastest growing segment of the population, making the elderly a major portion of the health care consumer population. Older persons are in the final stage of development during which many adaptations need to be made by the client because of the physiological changes that occur with aging. The extent or degree of the changes that take place depends on genetic and environmental factors as well as on the client’s previous attention to health maintenance. As a client reaches old age, there may also be many changes in roles, relationships, and ability to maintain his/her usual lifestyle. These factors create psychosocial concerns that need to be addressed.


This care plan focuses on the elderly client needing health care. It includes the nursing diagnoses that reflect the biopsychosocial changes that commonly occur with old age and are intensified with the stressors of illness. This care plan can be used in conjunction with the care plans in this text that are appropriate to the client’s specific medical diagnosis(es) or surgery and is intended for use in an acute or extended care facility or in a home setting.



Nursing Diagnosis INEFFECTIVE TISSUE PERFUSION NDx


Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level


Related to:













Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION*


Definition: Inability of an individual to maintain adequate ventilation of the respiratory tract and perfusion of oxygen (O2) and carbon dioxide (CO2) between the lungs and vascular system to maintain adequate tissue oxygenation


Ineffective breathing pattern (NDx)


Related to:



Ineffective airway clearance (NDx) Related to stasis of secretions associated with decreased activity during illness and an age-related decrease in ciliary activity and cough effectiveness


Impaired gas exchange (NDx)


Related to:







Nursing Diagnosis RISK FOR DEFICIENT FLUID VOLUME NDx


Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.


Related to:













Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODYREQUIREMENTS NDx


Definition: Intake of nutrients insufficient to meet metabolic needs


Related to:













Nursing Diagnosis IMPAIRED COMFORT NDx (DYSPEPSIA, GASTRIC FULLNESS, AND/OR GAS PAIN)


Definition: Perceived lack of ease, relief, and transcendence in the physical, psychospiritual, environmental, and social dimensions


Related to:







Nursing Diagnosis DISTURBED SENSORY PERCEPTION NDx


Definition: Change in the amount of patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli


Visual Related to: the lens becoming more opaque, losing elasticity, and yellowing; loss of ciliary muscle tone; decreased pupil size; and changes in the cornea, retina, macula, and vitreous humor.


Auditory Related to: degenerative changes in the inner ear and eardrum and cerumen accumulation


Gustatory Related to: a diminished sense of smell and atrophy of the taste buds (there is usually only a modest, quality-specific loss of taste in healthy elderly clients)


Olfactory Related to: a decreased number of sensory cells in the nasal lining and atrophy of the olfactory bulb at the base of the brain


Kinesthetic Related to: a decrease in vestibular sensitivity and ability to perceive movement


Tactile Related to: a decreased number of sensory receptors in the skin












Nursing Diagnosis RISK FOR IMPAIRED SKIN INTEGRITY NDx


Definition: At risk for skin being adversely altered


Related to:







Nursing Diagnosis IMPAIRED ORAL MUCOUS MEMBRANE NDx


Definition: Disruption of the lips and soft tissue of the oral cavity


Dryness Related to decreased saliva production associated with a gradual decline in salivary gland activity


Irritation and breakdown Related to dryness and thinning of the oral mucosa






Nursing Diagnosis RISK FOR ACTIVITY INTOLERANCE NDx


Definition: Verbal report of fatigue or weakness; abnormal heart rate or B/P response to activity; exertional discomfort or dyspnea, ECG changes reflecting dysrhythmias or ischemia


Related to:


Stay updated, free articles. Join our Telegram channel

Feb 11, 2017 | Posted by in NURSING | Comments Off on Nursing Care of the Elderly Client

Full access? Get Clinical Tree

Get Clinical Tree app for offline access