Page 86 nursing.elitecme.com Complete Your CE Test Online - Click Here ● ● Meticulous foot care: Educate individuals to examine their feet for any open areas, cracks, or evidence of compromised skin integrity. Feet should be washed and carefully dried every day. Attention should be given to the areas between the toes, which are harder to keep dry. Socks should be changed daily and be kept clean and dry. Referral to a podiatrist is appropriate. ● ● Older persons with DM should not cut their own toenails because of the risk of cutting the skin of the feet, thus increasing the risk of infection. Older adults with DM should visit a podiatrist regularly to have their toenails cut and feet evaluated. ● ● Shoes should be fit by someone who is familiar with the problems of DM. If cost is an issue, refer patients for financial counseling. Nurses should be aware of podiatrists in the community who make special arrangements for older persons in financial difficulty. Educate patients to never walk barefoot. ● ● Checking blood glucose: Evaluate the older adult’s ability to perform blood glucose monitoring and evaluate the results. As necessary, teach other family members or caregivers to perform this task. ● ● Medications: Teach patients, families, and/or caregivers about the medications the patient is taking and the potential for side effects. ● ● Diet: Involve a nutritionist to assist patients and families to better understand dietary restrictions. ● ● Signs and symptoms: Teach patients, family members, and/or caregivers the signs of hyperglycemia and hypoglycemia, and what to do in the event of occurrences. ● ● Blood pressure: Help patients to adhere to blood pressure management regimens. If they are not hypertensive, teach them ways to avoid developing high blood pressure. ● ● Exercise: In conjunction with the patient’s physician, initiate physical therapy or help to design an exercise program appropriate for patients’ states of health and wellness. Management of DM is a life-long endeavor. Nurses must help the patient, family, and/or caregivers to adapt to the lifestyle modifications necessary for the maintenance (or achievement) of a maximum state of health and well-being. The older adult may have difficulty adjusting to some aspects of the on-going nature of DM management. Nurses must assist in providing adequate resources and support systems to help older adults manage their care. Thyroid problems Janice is 65 years old and is looking forward to an active retirement. She and her husband are making extensive travel plans. Lately, Janice has lost a few pounds even though she is not dieting. She complains of unusual fatigue and a rapid, pounding heart. Her husband insists she see a doctor. Janice does so and is diagnosed with hyperthyroidism. The incidence of thyroid disorders increases with age. As a person ages, the thyroid slowly loses its ability to function and begins to atrophy. It becomes more nodular, and the occurrence of thyroid nodules and hypothyroidism increases significantly with age. Thyroid antibody levels rise with age, making it difficult to determine if such elevation is pathological or part of the aging process. Hyperthyroidism rates are similar for younger persons and older adults, but the disease may produce less obvious symptoms in older adults, making diagnosis problematic. The incidence of hypothyroidism is quite a bit higher in women compared to men in all age groups, and is higher in older adults who live in long-term care facilities compared to those who do not [9,13,53]. Some important points about hyperthyroidism in the older adult are [9,13,53]: ● ● Hyperthyroidism is harder to diagnosis in the older adult compared to younger people because older adults present fewer signs and symptoms. Additionally, their symptoms may be different than those of younger persons. ● ● The predominant symptoms of hyperthyroidism in older people are rapid heart rate (even new onset of atrial fibrillation), weight loss, fatigue, apathy, changes in sleep patterns, mood changes, changes in bowel movements, visual disturbances, and weakness. The thyroid is usually not enlarged nor is it easy to palpate. By contrast, the predominant symptoms in younger persons are nervousness, anxiety, heat intolerance, sweating, and an enlarged thyroid. ● ● About 27% of older persons who have hyperthyroidism present with some type of cardiac symptoms such as atrial fibrillation, chest pain, angina, and even heart failure. These symptoms may be mistaken for active cardiac disease and the actual cause, hyperthyroidism, may be overlooked or not even considered. EBP alert! About 25% of patients over the age of 65 and who have hyperthyroidism display “classic symptoms” such as goiter, nervousness, weight loss, sweating, heat intolerance, tremors, and palpitations [9,13]. In most older adults, the common presenting signs and symptoms include sleep disturbances, vision changes, appetite changes, fatigue, muscle weakness, cardiac arrhythmias and tachycardia, and tremors [9]. It is important that nurses be alert to the possibility of hyperthyroidism and how the disease presents in older adults. Nurses also need to be aware of conditions, such as hyperthyroidism, that mimic other conditions common in the older adult population. Treatment of hyperthyroidism in older adults generally consists of ingesting radioactive sodium iodide. If treatment results in hypothyroidism, thyroid replacement therapy is initiated [9,13]. Hypothyroidism is rather common. Here are some points about hypothyroidism in the older adult population [9,11,13]: ● ● The older adult who is diagnosed with hypothyroidism is typically a female over the age of 50. ● ● Older adults who have hypothyroidism present with fewer symptoms than do younger people. Generally, these symptoms are rather non- specific and can be attributed to a variety of other health problems. ● ● The symptoms of hypothyroidism most often noted in older adults include mental deterioration, new patterns of incontinence, reduction in mobility, and difficulty coping. ● ● Untreated hypothyroidism may lead to hypertension and hyperlipidemia, both of which are common in the older adult population. A life-threatening complication of untreated hypothyroidism is myxedema coma, a life-threatening medical emergency. In myxedema coma, mental confusion deteriorates to stupor, coma, and significant electrolyte imbalances. Emergency intensive care hospitalization is required if this potentially lethal complication develops. The goal of hypothyroidism treatment in the older adult is to alleviate symptoms and return the thyroid stimulating hormone (TSH) level to normal. However, TSH replacement must be done with caution as an increase in levels may trigger significant cardiac problems [9]. In summary, thyroid problems in the older patient are often difficult to diagnose. Presenting signs and symptoms may be subtle and mimic a variety of diseases and disorders commonly found in this population. It is important to rule out conditions such as heart disease and/or to determine if two or more problems exist simultaneously. Nursing consideration: Unfortunately, because of the vagueness of clinical presentation, thyroid disorders are often overlooked in the older adult patient. Nurses have excellent opportunities to serve as advocates for patients and to remain aware of the possibility of thyroid disease when they perform an assessment. If thyroid disease is suspected, nurses should advocate for laboratory assessment of thyroid hormone levels. The hematologic system Monica is a professor of nursing in the geriatric master’s degree program at a large urban university. She is preparing to teach a series of classes on the hematologic system. Monica decides to focus on several disease entities including anemia, lymphomas, and blood malignancies. She knows that several of her students are particularly interested in the field of geriatric oncology.