106 ESSENTIALS OF GERONTOLOGICAL NURSING

Normal Changes of Aging 85

lower cholesterol levels, which will reduce athero- and arteriosclerosis.
Moreover, exercise has been shown to lower blood pressure and enhance
weight loss, which will greatly reduce the strain on heart musculature.
Despite these clearly obvious benefi ts of exercise, the majority of older
adults do not exercise. Reasons for the lack of exercise among older
adults lie in habit. Cultural beliefs surrounding exercise are important in
motivating older adults to participate in exercise programs. Reijneveld,
Westhoff, and Hopman-Rock (2003) report that understanding culturally
specifi c exercise choices, are critical to removing exercise barriers
among culturally diverse clients. Environmental barriers (no safe place
to exercise) and the presence of normal changes of aging (such as muscle
aches and pains) are also signifi cant barriers to exercise among older
adults.
It is usually cautioned that older adults should take their slower
cardiovascular status into consideration when exercising or engaging
in heavy labor. This may mean starting new regimens slowly until it is
determined how the body will react physiologically. Frequent assessments
of cardiovascular status are also recommended to detect pathological
changes early, when they are more amenable to treatment. Because
the cardiovascular system is one of the most vital organ systems in the
body, effective functioning is critical. It is essential that nurses assess this
system continually for signs and symptoms of failure. Dizziness, chest
pain, SOB, DOE, headache, sudden weight gain, or changes in function
or cognition should alert the nurse to conduct further assessments for
pathological cardiac function.
Nurses are in an ideal role to teach the interventions necessary to
help older adults to participate in exercise programs. Interventions should
begin by discussing the benefi ts of exercise. The nurse may help older
adults to choose exercise programs that they will enjoy, and encourage
them to do so. Choosing the right exercises and encouragement are key
factors in motivating older adults to exercise. The ideal exercise program
will combine strength training, fl exibility, and balance. One of the most
popular forms of exercise among older adults is walking. Walking is an
exercise that transcends care settings, requires little equipment (except
good shoes), and is accessible 24 hours a day. Other exercises that are
found to be popular among older adults include both weight-bearing and
aquatic exercises. Weight-bearing and muscle-building exercises assist in
maintaining functional mobility, promoting independence, and preventing
falls. In addition, weight-bearing exercises have been shown to be very
effective in reducing bone-wasting related to osteoporosis (Swanenburg,
de Bruin, Stauffacher, Mulder & Uebelhart, 2007). Aquatic exercises are
a pain-free method of promoting health and increasing functional ability,
especially for older adults with arthritis and osteoporosis.

86 ESSENTIALS OF GERONTOLOGICAL NURSING

TABLE 3.2 Common Laboratory Tests Used to Assess Older Adults
Test
Why Used
Cholesterol; total cholesterol (TC), high density lipoprotein (HDL), low density
lipoprotein (LDL)
Normal Ranges
TC <200 mg/dl
HDL >60 mg/dl
LDL <100 mg/dl
Tests the amount of circulating cholesterol levels. Good indicator for risk of
cardiovascular disease, as well as to manage medications to prevent hyperlipidemia.
Complete Blood Count (CBC); hemoglobin (Hg), Hematocrit (Hct), and white
blood cells (WBC).
Normal Ranges
Males
Hg 1017 g/dl
Hct 3854%
Females
Hg 917 g/dl
Hct 3549%
WBC 4,30010,800 cells/mm3
Tests for red blood cell (hg, hct, ESR) function and white blood cell function
(leukocytes) to determine ability of red blood cells to carry oxygen and white
blood cell role in infection.
Drug assays (e.g., digoxin, dilantin, phenytoin, theophyllin, lithium).
See individual tests for reference ranges
A collection of tests used to measure the level of certain medications within the
body. Helpful in managing medication dosing.
Glucose and Hemoglobin A1C (HgA1C)
Normal Ranges
Glucose (fasting) 70105 mg/dl
HgA1C < 8%
Used to evaluate blood sugar levels and effectiveness of glucose management
medications on glucose function among older adults.
Iron (Fe)
The role of diet in reducing the effects of aging on cardiovascular
function is substantial. Lifelong eating habits, such as a diet high in fat
and cholesterol, are among many obstacles that prevent optimal nutrition
and contribute to pathological cardiovascular function. Diets high
in fat and cholesterol are among the leading cause of coronary artery disease.
Nutritional assessment is one of the fi rst steps toward helping older
adults to meet daily nutritional requirements with a diet rich in health
(continued)

Normal Changes of Aging 87

Normal Ranges
Serum Iron 35165 ug/L
Plays a role in hemoglobin and red blood cell function. Low iron is diagnostic
for iron-defi ciency anemia.
International Normalized Ratio (INR)
Normal Ranges
INR 23
Tests bodies clotting ability. Often used to evaluate response to warfarin
therapy.
Kidney Function Tests (BUN) and Creatinine
Normal Ranges
Males
BUN 835 mg/dl
Serum CR 0.41.9 mg/dl
Females
BUN 630 mg/dl
Serum CR 0.41.9 mg/dl
Commonly used to evaluate kidney function among older adults.
Liver function tests (LFTs)
See individual tests for reference ranges
Used to evaluate normal and pathological liver functioning
Prostate Specifi c Antigen (PSA)
Normal Ranges
PSA < 4 ug/L
Used to detect early signs of pathological prostate activity, such as benign prostatic
hypertrophy (BPH), or prostate cancer.
Thyroid Function Tests (T3, T4, TSH)
Normal Ranges
T3 75220 ng.dl
T4 4.511.2 ug/dl
TSH 0.44.2 uU/ml
As thyroid problems are prevalent among older adults, these tests are frequently
used to determine thyroid function.
Vitamin Assays
See individual tests for reference ranges
Tests for function of vitamins within the body, such as vitamin X. Vitamins play
an essential role in all bodily system functions.
TABLE 3.2 (Continued)
food choices. Teaching appropriate food choices is essential to changing
nutritional patterns and improving poor dietary patterns among older
adults. Taking small steps toward good nutrition, by slowly replacing
unhealthy food choices with healthier alternatives, is the most appropriate
nursing intervention to help achieve nutritional outcomes.

Normal Changes of Aging 89

The respiratory system is a critical organ system. While changes in
the respiratory system will vary among the older population, smoking
cessation and exercise are two important interventions that will help to
maintain respiratory health.
The benefi ts of exercise are numerous. Among older adults, regular
exercise programs help to increase vital capacity, prevent normal and
pathological changes of aging, and reverse the effects of smoking. As
stated earlier, many older adults do not participate in exercise programs,
despite their obvious benefi ts. Nurses can play an essential role in helping
older adults choose the right exercise and encourage regular exercise
participation. As with cardiovascular status, it is usually cautioned that
older adults should progress slowly when beginning a physically demanding
program.
Cigarette smoking is one of the most critical negative predictors of
longevity. Smoking is well-known as a risk factor for the development
of multiple respiratory diseases including chronic obstructive pulmonary
diseases, such as bronchitis, asthma, emphysema, and bronchiectasis, as
well as cancer of the lung (U.S. Department of Health and Human Services,
2004). Todays older adults are among the fi rst individuals who
have potentially smoked throughout their entire adult lives. The effects
of smoking are silent and often occur slowly over time. Moreover, symptoms
of lung disease are not often experienced until extensive damage
has occurred. Despite the many years older adults may have smoked, it is
possible for older adults to experience the benefi ts of smoking cessation.
It is also important to note that older adults may be more motivated to
quit smoking than their younger counterparts, because they are likely to
experience some of the damage that smoking has caused.
Nurses are in an ideal position to assist older adults to quit smoking
to promote health or while recovering from an acute illness or managing
chronic illnesses. Interventions to stop smoking usually surround
behavioral management classes and support groups, which are available
to community-dwelling older adults. Nicotine-replacement therapy and
anti-depression medications are also helpful in assisting the older adult
to quit smoking.
INTEGUMENTARY SYSTEM
The skin of older adults generally becomes thinner and more fragile as
they age. The decreased amount of subcutaneous tissue allows for less
water, and the skin becomes dry and loses its elasticity. Consequently,
small lines and wrinkles appear on the skin. The appearance of lines and
wrinkles is closely associated with the amount of sun exposure sustained
throughout older adults lives, especially the early years. In fact, the skin

90 ESSENTIALS OF GERONTOLOGICAL NURSING

that has not been exposed to the sun (i.e., skin on the underside of the
arm) may be quite free of lines and wrinkles and appear very youthful.
Nurses caring for older adults know that people enjoy the sun. Moreover,
some sun is healthy. The sun produces vitamin D within the body,
which is necessary for calcium metabolism. However, overexposure to
the harmful rays of the sun can accelerate the normal aging changes and
place the older adult at high risk for the development of pathological skin
problems, such as cancer. Nursing interventions to reduce the effects of
sun exposure on the skin and prevent against disease onset include the use
of sun protection. It is presently recommended that older adults should
be counseled to use sun block and avoid over exposure to the sun.
In addition to the wrinkling of the skin, the number of sweat glands
diminishes as people age, leading to less perspiration among older adults.
The subcutaneous fat and muscular layers of the skin also begin to diminish.
These changes have several common and noticeable effects. First,
these changes result in dryness of the skin, which often is uncomfortable
and can lead to skin tears. These skin tears occur under seemingly little
trauma and may be very diffi cult to heal. In addition, the loss of subcutaneous
tissue beneath the skin of older adults results in less padding and
a higher rate of bruising with minimal trauma. The dryness of the skin,
in combination with decreased perspiration, leads to the need to bathe
less frequently. Nurses caring for older adults may recommend that older
adults and caregivers avoid the use of soaps that further dry the skin and
replace moisture lost during bathing with a recommended moisturizer.
Moreover, great care must be taken to prevent the skin from skin tears.
The use of clothing and protection of high risk areas, such as elbows and
heels, with appropriate padding, may be helpful in preventing skin tears.
Preventing older adults from falls and traumas is a substantial issue for
nurses caring for the elderly, and this will be discussed in greater detail
in Chapter 5. Changes in subcutaneous tissue, fat, and muscle among
older adults result in less protection against temperature extremes. Consequently,
older adults exposed to extreme heat or cold are at risk for
developing hyperthermia and hypothermia, respectively. Proper environmental
control and adequate hydration are essential to prevent these devastating
consequences of normal aging changes.
Through the normal aging process, fi ngernails and toenails become
thick and brittle, and thus, nail care may become more diffi cult for the
aging adult to accomplish independently. Changes in vision and pain perception
may further complicate the task of nail care. In some facilities
and care agencies, nurses may assist older adults with nail care. However,
it is generally recommended that older adults enter the care of a podiatrist
when normal and pathological aging changes make independent nail
care diffi cult. Nurses may play an instrumental role in detecting the need

well-being. While nurses may assume that the assessment of older adults is
similar to that of a younger adult, older adult assessments must pay close
attention to the differentiation between normal and pathological changes,
as well as the impact of these changes on functional status. Moreover,
these assessments must consider potential subtle changes in function and
cognition that indicate early signs of disease in this population.
This chapter provides information on health assessment techniques
necessary for the assessment of older adults. Challenges to obtaining
health histories and physical examinations among older adults will be
discussed. Altered presentation of commonly occurring diseases among
the elderly will be identifi ed, and the reader will be provided with material
on appropriate assessment of function and cognition.
SYSTEMATIC GERIATRIC ASSESSMENT
The nurses assessment of older adults requires the ability to actively listen
as well as to use all other senses to gather data. This often draws upon
experience and expertise gained over time in working with the older population.
An inexperienced nurse is often frustrated by the length of time
needed for the geriatric assessment, and the inability of some older adults
to keep focused on providing the necessary information. For example,
consider an 86-year-old woman with mild cognitive impairment (MCI)
who presents to a medical unit with a small bowel obstruction (SBO).
This assessment will probably take a long time, and it may be necessary
to consistently encourage the client to focus on answering the questions.
In an effort not to be rude, the nurse may allow the patient to continue
providing unessential information. Written forms and checklists can help
the nurse to keep the client more focused.
The physical assessment of the older adult demands that the health
care team include special considerations that are unique to the geriatric
population. Environmental adaptations are usually necessary to compensate
for the older adults physiological and psychological changes
of aging. Modifi cations to the physical environment start with a room
that is comfortably warm to the client and not exposing the client any
more than is necessary. Changes in subcutaneous tissue, fat, and muscle
among older adults provide less protection against temperature extremes,
consequently, older adults are more sensitive to temperature changes.
Amella (2004) states that the key to providing appropriate treatment to
older adults is going beyond the usual history and physical parameters
to examine mental, functional, nutritional and social- support status
(p. 43).
The room should be adequately bright but with indirect lighting to
compensate for diminished visual acuity. Fluorescent lighting and window