In this day of cost containment and regulation of resources, it becomes increasingly important to articulate clearly the substance of our services as professional nurses. In addition to monitoring the status of various illnesses, giving physical care, providing health education, and lending psychosocial support, we extend carefully considered cognitive services to those in our care. Often there is little visible, and therefore quantifiable, evidence of such care. An example of this situation can be found in our efforts to promote holistic health and prevent illness in the elderly population, especially those living in their own homes.
One way of validating our cognitive services could be the use of nursing diagnoses, specifically potential nursing diagnoses. In our busy work situations, potential problems are often thought of as nonpriority items; yet assessing for, documenting, and acting on potential problems may substantiate the reason why a person requires professional nursing services. The American Nurses' Association Social Policy Statement gives credence to potential problems in its definition of nursing as, ". . . the diagnosis and treatment of human responses to actual or potential health problems."1 Carpenito2 states that the focus of nursing intervention, when a potential problem is diagnosed, is to prevent the development of the problem. If problems can be prevented, the elderly may stay well longer, healthcare costs may be curtailed, and our unique role in promoting wellness may be more readily recognized.
This article provides a guide using certain potential nursing diagnoses from the North American Nursing Diagnosis Association (NANDA) listing,3 with which to focus the nurses' assessments of the elderly. The goal is to prevent problems from becoming active or to limit their consequences through appropriate interventions. Within each diagnosis, common etiologies or contributing factors are specified, ranging from physiologic changes of aging to psychosocial and environmental factors.
Because of individual differences in the aging process, persons will vary in their level of risk potential for the problem and in the etiology (or etiologies) which contribute to the cause of the problem. It will be noted that certain etiologies given are also present on the NANDA listing as nursing diagnoses. There are interrelationships, overlaps, and interchangeable features within the diagnostic list which make this phenomenon unavoidable. One must also consider that persons will have different combinations of chronic and/or acute illnesses superimposed on age-related changes. The difference between agerelated changes and the development of disease is sometimes difficult to distinguish and continues to be clarified through research. No attempt will be made in this article to deal with disease processes.
The factors included within each diagnosis were synthesized and generalized from several texts and articles on aging and reformulated into a nursing diagnosis framework.4-8
Potential for Activity Intolerance
The cardiovascular system, which is responsible for pumping nutrients, hormones, antibodies, and oxygen to all body cells, loses its efficiency with age. The cardiac muscle strength is diminished, and the stroke volume decreases. There may be less circulation to the coronary arteries. The cardiac rate, under stress, does not increase as readily, and then takes longer to return to a normal level. The cardiac valves may become rigid and the blood vessels less elastic. The end result of changes is that more energy is to do the heart's work, and it may be at a less than optimal level.
Cardiovascular and respiratory systems work together as a unit, therefore, the physiologic changes of each system affect the other. Alterations of the respiratory tract have to do with a reduction of maximum breathing capacity. With time, the lungs become more fibrotic and the rib cage less flexible, causing a decreased vital capacity. The alveoli enlarge and decrease in number, and the bronchioles dilate. There is also decreased strength of the respiratory muscles. Because of these and other changes, there is less efficient ventilation and a decreased surface area for gas exchange with a resultant decrease of oxygen in the blood. If the patient's nutritional requirements are not being met, a decreased level of oxygen-carrying hemoglobin may compound the situation. The combination of a less efficient pump and hypoxemia may cause characteristic signs of activity intolerance.
The musculoskeletal system may also contribute to activity intolerance. With aging, the muscle cells become smaller and fewer. As a result, there is a gradual loss of muscle mass and, perhaps, strength, fatigue is common with less effort. A deconditioned status may occur from the combined problems of all three systems.
Potential for Impaired Mobility
Problems related to mobility can affect activity tolerance and vice versa; however, the elderly person may have mobility problems related to other factors as well. With normal aging, there is a general slowing of nerve conduction. A decrease in the number of functioning neurons occurs, along with myelin sheath degeneration. There is a slowing of reaction time, as motor neurons work less efficiently and have a reduced ability to send messages to and from the central nervous system. Therefore, coordination may be impaired.
As a result of generalized wear and tear on the joints and changes in the ligaments, tendons, and synovial membranes, the development of stiffness and discomfort may occur. In addition, there may be decreased range of motion of the extremities. Posture, which affects the center of balance, may be altered as well. Many elderly persons are less mobile because of their fear of falls. The spinal column shortens, which leads to stooping, and the hips and knees may become more flexed. There is decreased agility. More effort must be expended to move and endurance may be limited. Aside from age-related changes, simple disuse from inactivity will cause a functional decline in mobility.9
With a generalized neurological slow-down comes degenerative changes to the senses. A visual impairment may severely hamper mobility. Visual dysfunction will be covered in a separate nursing diagnosis.
Potential for Alteration in Nutrition: Less Than Body Requirements
Some persons have problems with obesity in their later years because of slowed metabolic processes and overeating. Many other factors combine, however, to make attaining optimal nutritional requirements a potential problem in the general elderly population.
Due to atrophy of lastebuds and inefficient neuro connections to the brain, the taste and smell senses are dulled. There is a decrease in secretion of saliva, and there may be a problem with chewing because of poor dentition or ill-fitting dentures. A slowing of peristalsis and loss of smooth muscle tone exist which delay gastrointestinal emptying. Anorexia may be a logical consequence of this phenomenon: there is gastric mucosal atrophy and a reduced secretion of hydrochloric acid which lead to a decreased absorption of certain vitamins and minerals, and possibly some food intolerances.
Fatigue, discomfort, sensory impairment, activity intolerance, decreased mobility, and other self-care deficits may make food shopping, preparation, and/or eating too much of a chore. Financial constraints may cause the person to make poor nutritional choices. Fresh fruits, dairy products, vegetables, and protein sources may prove too expensive. Excessive alcoholic intake will influence appetite and nutritional status.
Finally, emotional factors may contribute to poor nutrition. Persons who are lonely, depressed, or grieving may find themselves with no appetite and little motivation to eat.
Alteration in Bowel Elimination: Constipation
Because of weak sphincter muscles and possible food intolerances, some older persons may have episodes of diarrhea, but more often constipation is the prevailing problem. Because of decreased bowel motility, there is a slower transit time allowing for more water reabsorption in the large intestine. The intestine secretes less mucous, thus providing less lubrication.
In addition to physiologic changes, a host of other factors could contribute to constipation. There may be inadequate fiber in the diet, either from personal preference, lack of funds for fresh fruits and other sources of fiber, or from uninformed nutritional choices. The older person may not drink enough liquids because the thirst sensation is blunted and, in some cases, because the increased liquids may necessitate more trips to the bathroom. Inactivity and weak abdominal muscles may predispose to constipation, as well as the postponement of bowel urges that come at inconvenient times. Many drugs may cause constipation as a side effect, or there may be a long-term overdependence on laxatives which may result in chronic problems with constipation.
Potential for Impairment of Skin Integrity
An obvious clue to a person's age may be the integumentary system. The skin normally protects us from injuries, limits water loss, prohibits invasion of pathogens, serves as a heat regulator, and as a sensory device. In aging, the skin becomes thinner and less elastic. There is a change in the distribution of subcutaneous fat. It is lost from the face, arms, and legs and deposited over the hips and abdomen.
Because of decreased circulation to the skin, the oil-secreting cells and sweat glands fail to operate optimally, causing dry skin and itching. The loss of supporting structures may cause the capillaries to be more fragile. Poor nutrition, coupled with reduced circulation, which causes slower healing of irritations and injuries, may lead to more serious skin breakdown. Pressure areas are at greater risk.
Potential for Injury: Trauma
Closely aligned with skin integrity, the elderly person is especially at risk for trauma of tissues. There is a reduced tissue perfusion to the periphery. As the arterial and venous structures thicken and fibrosis begins with age, less efficient delivery of nutrients and removal of end products is carried out, A minor bump may cause more than the usual injury. Injuries may occur without awareness because of reduced tactile perception and, perhaps, altered pain perception in general.
The elderly are at particular risk for falls. Falls have been estimated to be the "single greatest cause of accidental death in people over 65 years of age. " 10 The bones become weaker and more porous with age-related changes. There is a decreased absorption of calcium. Women, especially, are at risk for fractures with minimal trauma. The elderly may have a slower reaction time with regard to maintaining balance. To complicate the situation, there may be gait changes and a reduced position sense.
Sensory impairments may cause the elderly more trouble interpreting their environment resulting in exposure to injury. Eye changes, caused by a thickened, yellowing lens, which loses its ability to focus, cause impaired sight and peripheral vision. Color perception is distorted, especially blues, greens, and purples.
Because of reduced blood supply to the eye and the lens changes, there is a slower visual response to changes in light conditions and less tolerance for glare, especially at night and in bright sunlight. Depth perception also may be altered.
Hearing changes result from auditory nerve degeneration, thickening of the ear drum, decreased functioning of sound transmission pathways, and reduced ability of the central nervous system to interpret sound messages. Difficulty hearing high frequency sounds and consonants is the usual first sign of this impairment. A frequent cause of decreased hearing, however, is impacted cerumen.11 A loss of smell may make an elderly person more vulnerable to injury through accidental poisoning, fire hazards, toxic fume, or smoke inhalation.
Potential for Injury: Poisoning
The elderly have altered drug absorption and excretion which can predispose them to a myriad of problems. Altered absorption in the gastrointestinal tract, because of decreased blood flow and surface changes, may cause absorption difficulties with some drugs.
In the kidneys, the glomerular filtration rate is decreased. There is a reduction in the number of nephrons, and the kidneys lose approximately 45% of their capacity to reabsorb and excrete. 5(P 63)
In addition to the renal changes, there is decreased metabolic functioning of the liver. These factors, plus the fact that the elderly person has a reduced total body water content, and reduced plasma albumin concentration may cause cumulative effects, enhanced effects, and increased risk of drug interactions.12 The possibility of taking several prescribed drugs, plus over-the-counter drugs , may complicate the picture. As a consequence, side effects of depression, dehydration, altered electrolyte balance, and altered thought processes are major possibilities depending on the drugs involved.
Some elderly persons are not aware of what drugs they are taking and why, and may inadvertently take discontinued drugs. Exchanging brand names and generic names on prescriptions may cause the person to take both drugs, thinking they are different. Finally, drugs may be omitted or duplicated because of forgetfulness, difficulties in keeping track of complicated dosage schedules, or because of sensory impairments which may alter drugtaking capabilities.
Potential for Infection
As a person ages, the immune function becomes less effective. Older persons have reduced lymphocytes and impairment of antibody response. Reduced circulation to various areas provides less nutrition, and healing is slower.
The bronchial cilia become less effective in promoting airway clearance.
Physical inactivity causes more pooling of respiratory secretions. Weak respiratory and abdominal muscles may cause an ineffective cough. With generalized reduction in functioning of major organ systems, the elderly person has less reserve with which to tolerate pathogenic invaders and the stress of illness.
Usual signs and symptoms of infection, such as elevated temperature, may be absent.
Potential for Alteration in Body Temperature
Elderly persons are at risk for injury from exposure to excessive heat or excessive cold.
The loss of insulation in the form of a fat layer under the skin makes them more vulnerable to cooling; the metabolic rate may not be able to increase sufficiently to create more internal heat; inactivity would cause less body heat to be produced through skeletal muscle contraction; and the reduction of peripheral circulation causes less delivery of warmth through normal blood flow.
When exposed to excessive heat, vasodilation and normal perspiration may not occur in the older person because of the atrophy of sweat glands and less elastic blood vessels.
Because of decreased thirst perception, the patient may not drink enough to replace insensible fluid loss. The lack of fluids may predispose to postural hypotension and a resultant fall.
Potential for Altered Urinary Elimination Pattern
In the elderly person, the bladder muscles become weaker, and the bladder capacity is reduced. The sensation of having to urinate may be altered because of less astute bladder sensory receptors, leading to the possibility of urge incontinence. The kidneys are unable to concentrate urine as readily, and therefore, urgency, frequency, and nocturia may occur. In the woman, relaxing pelvic musculature and decreased estrogen levels may predispose to stress incontinence. In the man, an enlarging prostate gland may predispose to retention, retention with overflow, or a weak urinary stream. Incomplete emptying of the bladder may cause urinary tract infection from stasis of urine.
In either sex , weak sphincter muscles may lead to urinary incontinence . Functional incontinence may occur because of activity intolerance and/or limited mobility if the patient has a difficult time getting to the bathroom. Urinary incontinence affects 5% to 10% of the elderly in the community.13
Potential for Sexual Dysfunction
Older persons may not be sexually active for a number of reasons, lack of partner being one of them. The desire for sexual expression will vary depending on the individual. It is important to remember, however, that the maintenance of a satisfying sexual relationship may be possible. The belief that the older years are devoid of sexual relationships may perpetuate itself in unnecessary loss of companionship and social support.14
Physiologically, there are changes which can compromise sexual functioning, but not necessarily preclude it. A woman will have less pubic hair, atrophy of breast tissue, and a drying of the vaginal tissues. A man will have a gradual decrease in testosterone function. Muscle strength, virility, and sexual desire may decrease. The prostate enlarges, and changes in ejaculatory pattern may occur.
In either sex, depression and fatigue may reduce libido. There may be anxiety about slower "performance." A threatened body image and weak selfesteem may cause a reticence to sexual functioning. In addition, activity intolerance, discomfort, drug and alcohol side effects, and limited range of motion may limit sexual expression.
Potential for Ineffective Coping
Many elderly persons are reasonably well, content, and able to use effective coping skills. Others, however, are facing multi factorial Stressors which, gradually or precipitously, can become overwhelming. Loss is a significant contributing factor to the possibility of ineffective coping. The elderly person faces many potential sources of loss. Loss of significant others, including friends, spouse, other family members, and/or a beloved pet through death or relocation are likely. Loss of health is a definite possibility, either in increments or through a catastrophic illness. Loss of self-esteem may arise from no longer having a job or career. Feelings of decreased self-worth are possible due to role changes, a reduction in finances, a loss of independence and/or a change in perception of body image. There may be active grieving over these and other losses, or anticipatory grieving.
Depression is a common occurrence in the elderly and can be a result of loss or other causes. The suicide rate for the elderly is triple that of the general population.15 Depression may be masked by somatic complaints, excessive alcohol intake, altered thought processes, and withdrawal. Apathy, feelings of helplessness, hopelessness, and powerlessness may be overwhelming. If there is disruption in long-standing beliefs and values, spiritual distress may occur. Fears of the future are common , as well as fears about day-to-day coping. Anxiety is a possibility. Sensory impairment and/or being placed in unfamiliar situations with little support may escalate these feelings. In general, the elderly adapt less readily to change.
At a time when many of the elderly are making significant adjustments, their support system, both internal and external, may be on shaky ground. Their perceptions of certain Stressors may be unclear and inaccurate and they may have exhausted their previous manners of coping.
Potential for Social Isolation
Social isolation may affect health status and vice versa. When the elderly have limited personal resources, they are at risk for social isolation.
Physical factors may be a contributing factor. Decreased mobility, activity intolerance, discomfort, incontinence, and sensory impairment may make participation in some social activities difficult. In addition, with sensory impairment, important linkages to the outside world may be compromised, such as TV, radio, and newspapers. It is estimated that 30% to 50% of those over 65 alter and limit their socialization because of impaired hearing.16
Former lifestyle may be a factor in the development of social isolation. Some elderly persons have not developed lasting friendships or leisure activities and hobbies that they enjoy, therefore choice of diversional activities may be limited.
Another factor affecting socialization may be emotional status. Depression and grieving may leave a person poorly motivated to socialize. Fear may cause social withdrawal.
One of four Americans over 65 live below the poverty line.6 Many live in crowded urban areas; therefore, financial considerations, transportation limitations, and fear for their safety may keep certain persons from participating in organized socialization networks.
Potential for Altered Thought Processes
Some well-meaning care providers still equate aging with an inevitable gradual slide into senility. Because of this erroneous assumption, reversible causes of impaired thought processes may not be considered for what they are. With normal aging, there may be a reduction of blood flow and oxygen to the brain, and a reduction in number of neurons. It is likely that there may be some normal forgetfulness and an increased length of time necessary for processing information in some situations. Confusion, however, is not a normal age-related change, and should be investigated.
Many other factors could cause problems with thought processes. The elderly person is at risk for altered thought processes from sleep-pattern disturbance. Normally, there is a reduction in the deeper levels of sleep which goes along with the aging process.17 A reduction of activity, improper sleeprest pattern, discomfort, depression, or dependence on sedatives may further reduce sleep quality. Sensory impairment may cause messages to be misinterpreted and perceptions altered which can impede thought processes.
Altered environment and disruption in a routine may cause increased problems with orientation and memory.18 Side effects or untoward reactions to prescribed drug therapies may cause confusion. Dehydration, electrolyte imbalance, nutritional deficits, infections, and other illness may be heralded with confusion. Simple lack of cognitive challenge, another form of disuse, may show itself in excessive forgetfulness and inattention.
Deficits, Alterations and Impairments
The World Health Organization describes the purpose of screening in the geriatric population as preventative care, "to keep the elderly in good health and happiness in their own house for as long as this is possible."19
Accordingly, the last three diagnoses are the problems which take top priority to prevent. It is appropriate that they are discussed together, because they are closely interdependent. Problems leading to these deficits, alterations, or impairments are the significant threats to the elderly 's ability to continue living in their homes. The potential diagnoses which were examined prior to this section are common examples of situations which are amenable to intervention and which, when successfully controlled, can help to keep the elderly population as healthy and independent as possible.
The challenge is in prevention. It is necessary to remember that the elderly tend to underreport their symptoms.20 It may take a higher index of suspicion and a more astute assessment to detect a decreased level of functioning, or more obscure self-care deficit.
So as not to paint an unnecessarily negative picture of the elderly, with risks hovering at every possible turning point, it should be mentioned that, in truth, the vast majority of elderly persons are living in their own homes.7 The elderly, as a group, have developed enviable strengths and wisdom from their years of living. They continue to teach us a great deal. However, in being fully cognizant of the potential Stressors and hazards that the elderly may face, the health-care professional may be more effective in supporting strengths, in providing appropriate intervention, and in linking them with the resources which may help to keep them functioning at their optimal level.
- 1. CarpenitoLJ; Actual, potential, or possible? Am J Nurs 1985; 85(4):458.
- 2. American Nurses' Association Congress for Nursing Practice: Nursing: A Social Policy Statement. Kansas City, American Nurses' Association, 1980, p 9.
- 3. North American Nursing Diagnosis Association, cited by Taylor CM. Cress SS: Nursing Diagnosis Cards. Springhouse, PA, Springhouse Corp, 1987.
- 4. Yurick AG, Spier BE, Robb SS, et al: The Aged Person and the Nursing Process, ed 2. Norwalk, CT, Appleton-Century-Crofts, 1984.
- 5. HudsonMF: Safeguard your elderly patient's health through accurate physical assessment. Nurs 1983; 13(ll):58-64.
- 6. Gioella EC, Bevil CW: Nursing Care of the Aged Client. Norwalk, CT, Appleton-Century-Crofts, 1985.
- 7. Carnevali DL, Patrick M: Nursing Manage - meni for the Elderly, ed 2. Philadelphia, JB Lippincott Co, 1986.
- 8. Burggrat V, Donlon B: Assessing the elderly, Am J Nurs 1985; 85(9):976-985.
- 9. Sullivan M: Atrophy and exercise. J GeronM//v«rj 1987;13(7):27.
- 10. Schwartz G, cited by Kidd PS, Murakami RY: Common pathologic conditions in elderly persons: Nursing assessment and intervention. Journal of Emergency Nursing 1987;13(1):30.
- 11 . Mahoney DF: One simple solution to hearing impairment. Geriatric Nursing 1987; 8<5):243.
- 12. Alien MD: Drug therapy in the elderly. Am J Nurs 1980; 80(8):1475.
- 13. Williams ME, Fitzhugh C: Urinary incontinence in the elderly. Ann Intern Med 1982; 97(12):895.
- 14. Parsons V: Assessment of older clients' sexual health, in Burnside IM (ed): Nursing and the Aged, ed 2. New York, McGraw-Hill Book Co, 1981, p 375.
- 15. Chaisson-Stewart GM: Depression in the Elderly, New York, John Wiley and Sons, 1985, p 6.
- 16. Hays AM, Borger F: A lest in time. Am J Nurs 1985;85(10):II09.
- 17. Eliopoulos C, cited by Bower FN, Patterson J: A theory-based nursing assessment of the aged. Topics in Clinical Nursing 1986; 8(1):26.
- 18. Campbell EB, Williams MA, Mlynarczyk SM: After the fall - confusion. Am J Nurs 1986;86(2):153.
- 19. World Health Organization, quoted by Magenheim, MJ, in Calkins E, Davis P, Ford A (eds): The Practice of Geriatrics. Philadelphia, WB Saunders Co, 1986, p 61.
- 20. Brody E: Mental and Physical Health Practices of Older People. New York, Springer Publishing Co, 1985, p 181.