Oral and Vision Health in Elderly Patients, Exams of Nursing

Download Oral and Vision Health in Elderly Patients and more Exams Nursing in PDF only on Docsity! Exam 1 Review (week 1-3) MOUTH: Normal findings in elderly mouth/pharynx: ■ The lips have increased vertical markings and appear dryer. ■ The buccal mucosa is thinner, less vascular, and less shiny ■ Tongue may appear more fissures, and veins on its ventral surface ■ Oral tissues may be dryer (xerostomia) especially with medications ■ Natural teeth may be worn down, shortening the crown, and altering enamel thickness. General findings in elderly mouth/pharynx:  Chronic disease increases the burden of oral disease, predisposing older adults to oral microbial infections, pain, altered taste, difficulty chewing and speaking, and dysphagia.  Poor oral health can lead to weight loss ○ Periodontal disease is the 6th leading complication of diabetes and can inhibit glycemic control and poor glycemic control can contribute to periodontal disease ○ Xerostomia (dry mouth) impairs oral function, promotes tooth decay, exacerbates periodontal disease which can be caused by many medications. ○ Oral cancer is the 8th most common cancer in men and 7x more likely in older adults ○ Aspiration pnumonia is a major cause of hospitalization and results in 20-50% mortality, oral hygiene can decrease this incidence. ○ 23% have untreated cavities and 70 % periodontal disease ○ 1/3 are fully edentulous (missing all their natural teeth) or average 19 or less remaining teeth ○ 17% have orofacial pain, facial, oral sores, burning mouth, and toothache Abnormal findings in elderly mouth/pharynx: ■ Gingivitis: which is associated with plaque, hormonal changes, or foreign-body response ■ Periodontal disease is associated with DM, PVD, cerebrovascular disease, & CV disease which could be due to inflammation. This is marked by loss of alveolar bone around teeth: Oral abx and chlorhexidine can slow it but may need root surface debridement. ■ 59% of those 60-69 and 72% of those 70+ have less than 20 teeth remaining which can impact nutritional status. Dentures does not decrease the malnutrition. ■ Dental caries is an infection. This can spread to other organs. The use of high-fluoride toothpaste can be beneficial. Dental caries may be present or deterioration of dental restorations present. ■ Teeth may appear longer due to reabsorption of the gum and bone progresses which reveals the teeth root. ■ Dental malocclusion may be caused by the migration of remaining teeth after extractions. EARS: Otitis Media with Effusion : ■ Initial symptoms: sticking or cracking sound on yawning or swallowing; no signs of dizziness ■ Pain: discomfort, feeling of fullness ■ Discharge: none ■ Hearing: conductive loss as middle ear fills with fluid ■ Inspection: tympanic membrane retracted or bulging, impaired mobility, yellowish; air- fluid level and/or bubbles EYES: Abnormal findings with elderly Conjunctiva Cataracts Age related macular degeneration Diabetic retinopathy Glaucoma Cataracts: a clouding of the lens Cataracts: opacity in lens  gradual onset of blurred vision and increased sensitivity to glare (especially when driving at dusk or night)  sight-limiting cataract is an insensitivity to subtle color differences such as those caused by food stains on clothing in an otherwise neatly dressed patient  white haze in the pupil during pupil testing suggests a moderate or worse cataract  With the pupil dilated, the red eye reflex may exhibit focal or diffuse areas of darkness when viewed with the direct ophthalmoscope or a slit lamp Cataracts Pathophysiology: o Most commonly from denaturation of lens protein caused by aging o With aging, cataracts are generally central o Peripheral cataracts may occur in hypoparathyroidism o Medications such as steroids can cause cataracts o Congenital cataracts can result from a number of genetic defects, maternal infections such as rubella, or other fetal insults during the first trimester of pregnancy Subjective Data: o Cloudy or blurry vision o Faded colors o Headlights, lamps, or sunlight may appear too bright o Halo may appear around lights o Poor night vision or double vision o Frequent prescription changes Objective Data: o Cloudiness of the lens, often obvious without special viewing equipment Age related macular degeneration (AMD): disease that progressively destroys the macula, impairing central vision  In its early stages, AMD has no symptoms  As dry AMD progresses, patients note a gradual blurring of central vision, and increased difficulty reading fine print, recognizing faces or seeing street signs ○ In dry AMD, drusen—cream colored lesions that represent a build-up of metabolic waste products within the retina—are seen in the macula  wet AMD often presents as a rapid loss of central vision, with metamorphopsia (images that appear distorted) or central scotomas ○ In wet AMD, abnormal blood vessels grow and hemorrhage, causing macular swelling, loss of retinal function and scarring  Other signs include pigmentary changes or chorioretinal atrophy of the macula Diabetic retinopathy: is characterized by a progressive series of abnormal changes in the retinal microvasculature ■ may be asymptomatic in its early more treatable stages ■ Blurred vision may occur if there is macular edema, but if the contralateral eye is unaffected or the vision loss is subtle, patients may not notice changes ■ proliferative retinopathy, new blood vessels can bleed extensively, causing blurred vision, or visual field scotomas, extensive laser photocoagulation for treatment of proliferative disease may have an overall constriction of the visual field ■ dilated fundoscopy, and can include hemorrhages, exudates or neovascularization; fundus photographs reviewed via telemedicine can be a sensitive and effective screening tool for identifying patients with diabetic retinopathy who need to be prioritized for referral to specialty eye care ■ Specialty diabetic eye examinations typically include retinal examination for subtle signs of macular edema, assessing the location and amount of hemorrhages and assessing the vascular abnormalities that help stage the severity of either nonproliferative or proliferative retinopathy. Glaucoma: is a progressive, chronic optic neuropathy in which intraocular pressure (IOP) and GENERAL PATIENT CARE: Know how to ask culturally sensitive questions…..if someone of a different culture comes in with pain how would you address that? By asking them what questions? RESPECT MODEL:  Rapport: o Connect on a social level o See the patient’s point of view o Consciously suspended judgement; recognize and avoid making assumptions  Empathy: o Remember the patient has come to you for help o Seek out and understand the patient’s rationale for his/her behaviors and illness o Verbally acknowledge and legitimize the patient’s feelings  Support: o Ask about and understand the barriers to care and compliance o Help the patient overcome barriers; Involve family members if appropriate o Reassure the patient you are and will be available to help  Partnership: o Be flexible o Negotiate roles when necessary o Stress that you are working together to address health problems  Explanations: o Check often for understanding o Use verbal clarification techniques  Cultural competence: o Respect the patient’s cultural beliefs o Understand that the patient’s view of you may be defined by ethnic and cultural stereotypes o Be aware of your own cultural biases and preconceptions o Know your limitations in addressing health issues across cultures o Understand your personal style and recognize when it may not be working with a given patient  Trust: o Recognize that self-disclosure may be difficult for some patients; Consciously work to establish trust  Do you express your pain to your loved ones?  Does the pain cause you to be afraid?  How do you cope with the pain?  How do you want others to respond to your pain?  What ways do you treat your pain usually?  Do you have any cultural beliefs that will affect how we need to treat your pain? Dr. Parajuli Tips (From soundcloud (Summer 19’) & dropbox (Fall 19’) : Exam layout: 20 questions (10 MC & 10 SA (some ?s have 2 part))- 60 minutes to complete Do MC first and then SA  Focus on how you would collect health history data o Talking to patients from different cultures o Talking to patients where there is a language barrier EYES Know normal and abnormal: example redness or swelling to eyelids Assess eye: assess congunctiva and sclerea What tests would you use to check vision acuity? o Rosenbaum (near-sighted vision) o Snellen (Far-sighted vision) Know some red flags of the eye (send to ED or eye doctor): o Uneven pupils (especially with HA) o Sudden loss of vision o Floaters/ flashes (retinal detachment possible) When a patient has retinal detachment what is their main complaint? “curtain” feeling, floaters or flashes How do you check for glaucoma? Check extraocular pressure/ (can use Tonipen to measure)  Know how to do an external exam of the eyes o Know how to identify bacterial conjunctivitis vs allergic conjunctivitis  Bacterial- starts in one eye and spreads to the other, yellow/ crusty drainage  Allergic- both eyes, puffy and/ or runny What are you looking for when you have a patient follow your finger with their eyes? o Cardinal fields of gaze (testing cranial nerves 3,4, & 6)  When completing an eye exam you want to look at the outside of the eye? Look at eyelids and make sure not swollen, look at the conjunctiva/ sclera, then use ophthalmoscope to look at the inside of the eye, check cardinal gazes (checks cranial nerves 3,4, & 6)  How to use the Ophthalmoscope: o Examine the patient’s right eye with your right eye and the left with your left to reduce unintentional nose to nose contact. o Hold the ophthalmoscope in the hand that corresponds to the examining eye o Change the lens of the ophthalmoscope with your index finger; start with the lens at 0, and stabilize yourself and the patient by placing your free hand on the patient’s shoulder or head o The focus wheel is adjusted by your thumb o With the patient looking at a distant fixation point, direct the light of the ophthalmoscope at the pupil from about 12 in away and visualize the red reflex first. o As you approach the eye the retinal details should become apparent. With a blood vessel being the 1st thing you see at 3-5 cm from the patient.  If your patient is myopic (nearsighted) use the minus (red) lens  If patient is hyperoptic (farsighted) or aphakic (lacks a lens) use the plus lens o Look at the optic disc o Next look at the vascular supply of the retina o Now inspect the optic disc o Next examine the macula (fovea centralis) which may not be visible because of pupillary response. EARS: Know normal and abnormal findings Know differences between Otitis Externa and Otitis Media  Otitis media- middle ear  Otitis externa/ “swimmers ear”- ear canal When doing an ear exam what do you start out looking at? Look at the outer structures of the ear then palpate If you look at the outside of the ear and you see drainage, is this normal or abnormal? ADNORMAL What is your differential diagnoses if you see this? Otitis Externa, Otitis Media, Ear effusion, or foreign body in the ear  What kind of patients get Otitis Externa? Swimmers, breast/ bottle fed children  When you do ear tests, what are other things that you look for? Look at the TM (whether it is perforated or not), look at the light, look at the canal (whether it is swollen or red, look for cerumen impaction)  Exam external ear pull tragus and palpate the preauricular and post auricular lymph nodes and mastoid area  What is the worst differential diagnosis for a patient that comes in with an ear infection? Mastoid infection or meningitis o Mastoid is bone that connects the ear canal with the skull, people with chronic ear infections can get mastoid infections. If patient comes in saying that ear pain has been over 2 weeks make sure that you palpate the mastoid area to make sure that there is no erythema)  What tests do you do to test hearing? o Whisper/ watch test