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Impaired gas exchange in the elderly
Impaired Gas Exchange in the Elderly Many factors work to lower respiratoi T function in the elderly. Are there steps a nurse can take to e n h a n c e the function of aging lungs? BY MERRY M O S l E R
FOYT
n any discussion of the functional changes associated with longevity, it is difficult to separate the effects of age from the effects of disease. The environment and other complicating factors--immobility, smoking, surgery, polypharmacy, and poor n u t r i t i o n - - m a y have a profound effect on functional capacity. 1"6 Despite this problem in etiologic distinction, it is generally agreed that
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MERRY MOSIER FOYT, RN, MS, is an assistant professor/ coordinator at the School of Nursing, CreightonUniversity,Omaha, Nebraska. 34/1/39194
physiologic reserve declines with age. This decline in reserve places older adults at greater risk for pathologic responses when confronted with disease, environmental factors, and other complicating and stressful influences. The respiratory system is certainly not spared alteration in function in old age. Indeed, full lung maturity is achieved by age 20 to 25; decline begins thereafter. 7 This article examines the normal phenomena of impaired gas exchange in the elderly and discusses other influences that produce deterioration in pulmonary function. In addition, a nursing care plan addressing impaired gas exchange in the elder is presented.
NORMAL AGE-RELATED CHANGES OF THE RESPIRATORY SYSTEM
Entrapulmonary
Cause
Effect
Degeneration of cartilage and calcificationof
Decreased flexib, of vetebral column; shortened thorax; kyphoscoliosis; chest rigidity; decr. resp. excursion; underventilatlon in bases; improved ventilation in apices; dependance on diaphragm and abdominal muscles; increased A-P diameter; decreased exercise capacity; TLC remains the same; Deer. VC; Incr. RV; Incr. FRC Reduced available blood flow Reduced surface area for exchange Alveolar rigidity; decreased recoil; decr. lung compliance; changes in lung volumes (previously mentioned) Incr. dead space~ airways close prematurely
joints and costal cartilage Osteoporosis of vetebrae Softening and compression of intervertebrol disks Weakening of diaphramatic, intercostal, and accessory muscles Prolonged contraction and relaxation of muscles Changes in ventilation and perfusion
Oecr. distensib, of pulmonary vosculature Mucosal wall thickening Deer. number of alveoli Crosslinkages within collagen fibers of lung tissue Enlarged alveolar wall (senile emphysema)
Ventilation control
Deer. response to hypoxio and hypercarbio Few cilia; weakened muscles Tendency toward dehydration Loss of laryngeal/protective reflexes Decreased immune function
Lung defense mechanisms
TLC,Total lung capacity; VC, vital capacily;RV,residualvolume,FRC,funcllonalresidualcapacity.
262 Geriatric Nursing September/October1992
Reduced ab~ity to respond to stress Oecr. mucociliary escalator Weaker and less effective cough Viscous/diff. to expectorate mucus Incr. chance of aspiration Diff. to treat and/or prevent resp. infec
Causes o f Change Certain extrapulmonary and intrapulmonary changes that occur with increasing age affect respiratory function (see "Normal Age-related Changes"). These changes affect lung support structure, muscle strength, lung volume, alveolar function, ventilation control, and lung defense mechanisms. 1-7 Other factors Immobility. Elders may develop crackles after only a few hours of bed rest. Immobility, especially in the recumbent position, precludes full lung expansion. Lungs that do not completely expand, and thus collect fluid, are prone to infection; in addition, the respiratory muscles become rapidly deconditioned as a result of decreased movement, s When presented with physiologic stressors while lying flat, the elderly person's respiratory system cannot adequately respond. Ventilation actually decreases with the increasing effort needed when trying to take adequate breaths while in this position, and cough is less effective. Airways close, and as a result ventilationperfusion mismatch becomes greater when eiders are lying down. Immobility encourages the development of other body stressors, such as pressure sores and urinary tract infections. These complications increase the body's need for oxygen. An increase in oxygen requirements stresses an already stressed respiratory system to increase the rate of gas exchange. The aged system has a limited ability to increase this on demand. One can see that this rapidly may become a downward spiral toward respiratory failure and resultant multisystems threat. Smoking. Cigarette smoking is a major health hazard. In addition to the promotion of chronic lung disease and lung and other cancers, smoking generally decreases ciliary action, increases mucus production, causes bronchoconstriction, and decreases airflow. 2, 9 Breathing is more difficult and the need for a strong cough is more apparent in a smoker; because of changes in structure and strength, these activities are difficult for the eider to accomplish. Even in those who do not develop frank lung disease, smoking will exacerbate the adverse effects of aging on lung mechanics and clearance capacity. Carbon monoxide, a gaseous by-product of smoking, competes with oxygen at the hemoglobin molecule, l° As a result of impaired gas exchange, cardiovascular function and tissue perfusion may become inadequate. When an elder who smokes is restricted to bed rest, the gas exchange problems are compounded. In addition, smoking alters the action of many medications commonly taken by the elderly. 11 These drugs include propanoloI, lidocaine, antidepressants, pentazocine hydrochloride, phenylbutazone, theophylline, aminophylline, oxytriphylline, and insulin. I1, 12 Surgery. Elective surgery has certain risks, but emergency surgery poses the greatest risk to the elderly client. 13 Rarely does an elderly patient undergo emergency surgery in optimal condition. Because of losses in Iaryngeal reflexes, elders have an increased chance of aspira-
tion, a tendency enhanced by preoperative depressants and residual anesthetic. 14 Gastric emptying is delayed in the elderly, but of course the risk of having a full stomach is most likely in an emergency situation. In either case, aspiration with resultant pneumonia is a threat. Incisions that compromise full chest and abdominal movement impair compensatory breathing and clearing mechanisms. Such incisional sites include the upper abdomen and chest. Splinting caused by pain tends to produce shallow breathing, and this, combined with poor cough, increases the likelihood of airway closure, atelectasis, decreased mucus expectoration, and decreased gas exchange) 4 Perioperative and postoperative hypovolemia thickens secretions. Decreased metabolism and delayed excretion of anesthetic and preoperative drugs produce decreased respiratory drive, as well as promoting diminished or absent gag reflex and inadequate deep breathing. 2, 14 In addition, postoperative immobility is particularly dangerous to the elderly because it decreases ventilation and increases stasis of secretions. Eiders who are adequately prepared and mobilized early have a very good chance of survival from elective surgery)a, 14 Endotracheal intubation for elective and emergency surgery, before induction, may reduce perioperative and postoperative aspiration; mechanical ventilation with positive end-expiratory pressure (PEEP) may prevent shallow breathing, atelectasis formation, and pneumonia. 14, 15
Medications must be carefully monitored to prevent negative effects on the respiratory system. Polypharmaey. Because they take a great number of medications, the elderly have more drug-drug interactions, including those interactions that affect lung function. Certain drugs may contribute to decreased gas exchange. Unmonitored, diuretics may produce dehydration that thickens secretions and cause electrolyte imbalance. Laxatives may produce fluid and electrolyte disturbances. Sedative/hypnotic, antiepileptic, antidepressant, and antiparkinsonian agents may produce decreased levels of consciousness and respiratory depression, especially in combination with recreational drugs. 12 Beta-blockers may cause bronchoconstriction. 12 Respiratory drugs. Drug dosages of prescribed respiratory agents may be inadequate for respiratory therapy. Poor tolerance of drug side effects may hamper compliance. Many drugs prescribed for the treatment of chronic obstructive pulmonary disease (COPD) may produce anorexia or nausea which adversely affects nutritional intake. Many bronchodilators may produce cardiac arrhythmias. 12 Corticosteroids may produce such serious side effects as myopathy, cataracts, secondary infection, vertebral collapse, and a host of other adverse reactions) 2
Geriatric Nursing September/October 1992 263
Medications must be carefully monitored to prevent negative effects on the respiratory system as well as the entire organism. Malnutrition. Malnutrition in the aged population is a serious problem that affects the respiratory and other systems. Inadequate nutrition affects immunocompetence, muscle strength, corpuscle oxygen-carrying capacity (anemia), drug-binding, hydration status, and electrolyte balance. These issues affect respiratory mechanics, clearance of secretions, respiratory drive, the development of respiratory infections, and, ultimately, gas exchange. Poor nutrition may or may not be accompanied by obesity. Obesity impairs breathing patterns and increases the work of breathing, especially when obese patients are on bed rest. Diseases
Several respiratory conditions are seen primarily in the elderly population. COPD, pneumonia, influenza, pulmonary embolism (PE), interstitial disease, tuberculosis (TB), lung cancer, cardiac disease with pulmonary involvement, and disordered breathing during sleep---these are the conditions that most commonly produce a serious threat to the gas exchange of the elder with declining lung function. It is beyond the scope of this article to discuss each disorder in detail. A conceptual discussion of how these diseases may alter elderly respiratory structure and function--and therefore alter gas exchange--is more useful. Respiratory diseases common to the aged tend to accentuate or redouble the adverse effects of aging on pulmonary function. There is also a great deal of overlap/ interconnectedness to these disorders, that is, COPD predisposes to pneumonia, pneumonia predisposes to PE, and so on. COPD produces a further decrease in expiratory air flow and further increases in residual volume. This contributes to air trapping and inefficient and slow gas exchange. Respiratory muscle training is necessary to attempt to overcome muscle atrophy and fatigue and increased residual volume. 16 Chronic bronchitis, one aspect of COPD, produces increases in mucus production. Diseases like pneumonia, influenza, and chronic bronchitis increase the physiologic thickness of alveolar membranes. This reduces the effectiveness of gas exchange. The COPD patient is more vulnerable to pneumonia and influenza. Decreased muscle strength and poor cough combined with increased secretions and decreased clearance ability produces mucus stasis and increases potential for respiratory infection for the COPD patient. Poor immunocompetence of old age 7 predisposes the development of pulmonary infections in old, diseased lungs. Such infections often lead to the demise of older and other COPD patients. Lower respiratory tract infections, such as pneumonia and influenza, account for 78% of elderly deaths. 2 Elders who do not have COPD are also at risk, and a nonspecific presentation may delay prompt diagnosis and treatment. Pulmonary hypertension may develop in a person with
264 Geriatric Nursing September/October 1992
COPD as a result of hypoxemia, polycythemia, and respiratory acidosis. 16 This change may ultimately produce right-sided heart failure. Decreased cardiac output adversely affects oxygen-carbon dioxide exchange. Other complications of COPD that may compound respiratory problems are sleep apnea, arrhythmias, spontaneous pneumotborax, and PE. Pulmonary embolism is a fairly common occurrence in elderly patients with pneumonia and in those who are bedfast. PE produces ventilation-perfusion mismatch, lung infarction, and may produce right-sided heart failo ure. 17 Major PE may cause death. It is difficult to diagnose PE on the basis of physical examination alone; the elder is more likely to have a nonspecific clinical picture. Goldhaber et al. 18 suggest increasing awareness of the possibility of PE in susceptible patients. Their research concludes that the frequent use of lung scanning and pulmonary angiography may increase accurate diagnosis of PE, because the clinical picture in the elderly (and others) is nonspecific. Interstitial diseases are associated with uncontrolled inflammatory reactions in the lung. These inflammatory reactions may or may not be associated with a systemic disease. Whatever theunderlying cause, interstitial diseases produce alveolitis, damage the alveoli, and ultimately produce loss of alveolar-capillary units. 19 Lung compliance will decrease, and a reduced number of functioning alveolar-capillary units produces chronic hypoxia and cor pulmonale. 19 Corticosteroid agents are the therapy of choice for this disorder, but these drugs may aggravate some of the typical nonpulmonary diseases of aging, like osteoporosis and peptic ulcer disease. 12, 19 More important to this discussion, steroids increase the chance of infection and mask its signs and symptoms. Steroids may delay diagnosis and treatment of such pulmonary infections. Pneumonia in the patient with interstitial disease is likely to be fatal. Tuberculosis or reactivation of tuberculosis is more likely in those over 45 years of age. 2 Reactivation is more usual, but institutionalized elderly are at great risk for primary tuberculosis.2° Malnutrition and reduced immunocompetence especially predisposes a person to reactivation. Airway obstruction and loss of functional alveolar tissue for gas exchange may result from tuberculosis. 17 Tuberculosis may predispose a person to the development of pneumonia and respiratory failure. Lung cancer is more likely to occur in smokers than in nonsmokers; it is one of the most commonly occurring cancers in the elderly population. TM21 Lung cancer produces increased cough, wheeze, stridor, dyspnea, obstructive pneumonitis, pleural effusion, pain, and other symptoms.17. 21 Lung cancer increases the work of breathing, decreases lung clearance capability, and predisposes a person to lower respiratory infections. These effects severely compromise aged breathing mechanics, reduce mucus clearance, and hamper gas exchange. Cardiac disease with pulmonary involvement usually indicates pulmonary edema caused by left-sided heart failure. The accumulation of fluid that occurs in pulmo-
nary edema produces ventilation-perfusion defects and gas exchange defects that produce severe hypoxemia. 17 Clearly, aged structures involved in gas exchange would be stressed to produce adequate blood oxygen tension under these circumstances. Disordered breathing during sleep is described as apnea or periodic breathing during sleep that may be associated with underventilation and oxygen desaturation.2, 22, 23 The breathing disorder may be central or obstructive in origin; however, it is suspected that usually such disorders are central because most of respiration and respiratory drive is controlled by the central nervous system. 22 The relationship between old age, cognitive dysfunction, and sleep-disordered breathing is unclear. 22"24 It does seem, however, that obese elderly are more at risk. 22 The pulmonary diseases of old age seriously impair baseline pulmonary function. Most commonly, pulmonary disease causes increased work of breathing, increased mucus with impaired mucus clearance, air trapping, reduced alveolar integrity, reduced cardiae output,
and ventilation-perfusion defects. These are all the normal age-related changes compounded by disease. Impaired gas exchange results from direct pulmonary inefficiencies or because of decreased cardiac output to the lungs.
Nursing Care Plan How do we enhance function of these aged lungs? How can nurses assist the elder to optimize pulmonary function and avoid pulmonary threat? The following outlines a plan of care for maintaining adequate gas exchange in the elderly. Assessment. Prevention of pulmonary problems in the elderly must begin at the level of assessment of baseline function (see "Assessment of Pulmonary Status" box). If the normal age-related level of function is found, an excellent foundation for primary/preventive care exists. Each abnormal finding should be thoroughly investigated. In general, elders exhibit less specific symptoms for many disorders than those exhibited by the younger client. Each complaint should provoke detailed question-
ASSESSMENT OF PULMONARY STATUS OF THE ELDER HISTORY-TAKING (involve family if necessary) Past or recent history of respiratory disease TB COPD PE Pollutant exposure High smog Asbestos Living with smoker Smoking history Packs/year Recent or respiratory (or hypaxio) symptoms Cough SOB DOE PND ADLs toh Other Chronic or acute disease, other than respiratory Past or recent surgery PHYSICAL ASSESSMENT General assessment Vffal signs, including temperature Weight Inspection Cyanosis Capillary refill Barrel-chest of COPD Kyphasls
Cold Flu Pneumonia
Sleep apnea Pul. edema
Interstitial disease Pul. hypertension Lung cancer
Wheezing Bloody sputum Chest Pain Decr. mobility Incr. WOB
Confusion Disturbed sleep Restlessness Activity intol. Rapid heart beat
Weakness Falling Pleurltic pain Irreg. heart beat Recent loss/gain wt.
Character of respirations Cough strength Grimacing Accessory muscle use Weakness
Sputum Posture Restless A-P Diameter
Palpation Tenderness of ribs Tracheal deviation Masses or lumps Percussion (Resonance or hyperresonance in the very thin is normal) Auscultation (Softer vesicular sounds and diminished sounds in the bases is normal) PE, Pulmonaryembolus;SOB,thorl~ss of brec:dh;ADLs,activitiesof daily living;DOE,dyspneaon exertion;PND,paroxysmalnocturnaldyspnea;WOB,work of brecht.
Geriatric Nursing September/October 1992 265
ing of the specific aspects. Sudden onset and severe symptoms are abnormal. If disease is present, secondary intervention may need to be initiated before rehabilitation may be instituted. Nurses who detect acute disease or exacerbation of chronic disease should rapidly refer the patient to a physician. Many older persons suffer from memory impairment and therefore might not be good historians. The family may be better able to report such things as exercise tolerance and other signs of oxygenation status. They may recall the patient's symptom complaints more accurately than the patient may recall them. Interventions Smoking. Cigarette smoking must be stopped. Sachs 25 suggests that there are substantial benefits to the elder who quits smoking. He outlines several strategies to assist the older client to stop smoking and feels that simple and direct advise by caregivers may be one of the best motivators. Eliminating any environmental pollutants, along with the elimination of cigarette smoking by the client, may prevent the development of serious compromise in oxygenation status. Vaccines. Vaccines are available that offer some protection against influenza and pneumoccocal pneumonia. 26 TB testing is also necessary. Nurses should assist the elder in making financial and transportation arrangements to get this preventive treatment. Diagnostic tests. Schedule any diagnostic tests carefully to avoid exhaustion and dehydration. Whenever possible nurses should accompany the elder to any diagnostic testing. This moral support may help prevent stress and facilitate toleration.
PEEP may not be used with COPD patients because of their friable alveolar walls. Surgery. Careful management of the pulmonary status of elders undergoing surgery may lessen complications. Nasogastric suction should be judiciously used to reduce risk of aspiration. Neutralizing stomach contents with antacids and histamine antagonists may decrease the severity of pulmonary damage if aspiration does occur. 14 Elective preoperative intubation and perioperative and postoperative management with mechanical ventilation and PEEP may prevent decreased gas exchange in the elder who has undergone anesthesia exposure. 14 PEEP may not be used with COPD patients because of the friable nature of their alveolar walls. Mechanical ventilation may produce pulmonary complications. Nursing care of the patient receiving ventilatory support must involve careful attention to prevention of nosocomial infection, barotrauma to the lungs, and other machine-induced hazards. The elder must be weaned from the ventilator as soon as possible to avoid causing more harm than good. COPD patients are particularly prone to ventilator complications, especially ventilator dependence. Therefore
266 Geriatric Nursing September/October 1992
intervention with mechanical ventilation should only be instituted and continued when necessary. Sometimes all that is needed to assist elders postoperatively is supplemental oxygen by mask or prongs to assist with excretion of anesthetic, z4 Carefully analyze confusion in the elderly client. Unexplained confusion postoperatively and at other times should be considered a result of hypoxia until it is ruled out. Medicate for pain to prevent discomfort and restlessness that may increase oxygen requirements; but, again, investigate first whether the restlessness is a result of hypoxia before medicating with potential respiratory depressants.
If such activity alterations are viewed as taking control of the disease, the patient will gain a sense of power. Medication for pain, semi-Fowler's position, incentive spirometry, turning, coughing with incision splinting, deep breathing, and early and frequent mobilization are necessary to prevent pulmonary complications as a result of surgery or other immobilizing events. Evaluate toleration of these activities to avoid exhaustion. An exercise regimen before the onset of immobility may help the patient's toleration postoperatively. Hill et al. 27 studied immobility in a geriatric setting. They found fewer professional staff on wards that had a higher proportion of immobile patients. They suggest that more registered nurses are needed to ensure appropriate mobilization of patients and prevention of the-hazards of immobility. Careful hydration, to assist with anesthetic excretion and optimal thinning of secretions, is an important intervention as well. Prophylactic antibiotic therapy may be indicated to help prevent postoperative pneumonia. Medication and nutrition. Medication management of the elder involves monitoring by many health care disciplines. Nurses must intervene by teaching older adults about their medications (including over-the-counter drugs), the importance of adequate nutrition for proper drug action, the need to avoid recreational drugs with certain prescribed medications, and the importance of consulting an expert when their medications no longer seem therapeutic. Adequate hydration and nutrition is vital to the proper action of medications; this must be emphasized when teaching older clients. COPD patients should avoid caffeinated beverages because caffeine may potentiate the side effects of drugs like theophylline. Milk tends to thicken mucus and make expectoration more difficult. Extremely hot or cold liquids may provoke coughing spells that are unnecessary and inefficient and that exhaust the elder. Large quantities of gas-forming foods should be avoided. Excessive bloating
may impinge on the diaphragm and deleteriously affect tient who has chronic lung disease. Energy conservation lung performance. teaching is undertaken to reduce exhaustion, but also to Exercise. Exercise prescription is important to the well clarify methods to maintain a reasonably normal lifeelderly.2, 5 Older adults should have improvements in car- style. All activities of daily living must be evaluated carediovascular performance, respiratory muscle strength, fully, and energy-efficient ways for performing them ventilation, tissue use of oxygen, and body weight com- must be explored. 28 The need for such modifications may position as a result of exercise. 5 The be a source of frustration and depression for the elder. 28, 29 If, however, exercise program should be carefully monitored to avoid cardiovascular such activity alterations are viewed complications and musculoskeletal as taking control of the disease, injuries and to ensure that a training rather than submitting to it, the palevel has been achieved. 5 Mahler et tient will gain a sense of power. All al. s suggests aerobic exercise every elders have to develop some energy other day for 15 to 30 minutes as a expenditure modifications as they goal. As side benefits, the older athgr.ow older; with that in mind, the lete should feel an enhanced sense of elderly patient with chronic lung diswell-being and sense of p o w e r / ease may more easily accept limitacontrol over their lives as a result of tions. Patients need to realize that regular exercise. Nurses may be inchronic lung disease is not curable. volved in the planning, implementaSuch disease is managed and contion, and/or evaluation of exercise trolled by compliance with therapy programs for the elderly. regimens and modification of lifeExercise prescription in elderly pastyle. tients with lung disease (in addition Evaluation. Prevention of pulmonary to the well elderly) is often possible. disease or prevention of exacerbation The prescription and usefulness will of pulmonary disease is the expected depend on the level of restriction. Diresult of primary assessment and inaphragmatic breathing exercises tervention. Evaluation involves reasshould also be taught. When persessing, for the elimination of enviOlder athletes feel an enhanced sense forming exercises like walking and ronmental hazards and cigarette of control over their own lives. bicycle riding, the patient with lung smoking: F o l l o w - u p e v a l u a t i o n (Courtesy of the St. Louis Senior disease may benefit from concurrent checks understanding and compliOlympics.) oxygen therapy. 28 ance with medication, nutrition, and Puhnonary disease therapy. Specific care of the pa- exercise programs. Much support and praise must be tient with pulmonary disease, acute or chronic, is depen- given; any effort put forth to meet goals is positive. Predent on the type and extent of disease. It is beyond the vention of decline in pulmonary status is easier and more scope of this article to discuss such therapy in detail. successful than treatment of pulmonary disease. Assessment of the effectiveness of teaching and theraThese therapies may include bronchial hygiene with intermittent positive-pressure breathing, oxygen therapy, pies aimed at treatment of disorders of gas exchange is exercise and breathing retraining, nutritional support, part of secondary evaluation. Many of the strategies used sympathomimetic drugs, theophylline preparations, cor- in primary prevention, such as environment and smoking ticosteroids, anticholinergic drugs, pulmonary vasodila- modification, are used and evaluated in secondary intertor therapy and diuretics. Patients with sleep disorders vention. Goals at this level are to maintain or improve exmust be referred to a sleep laboratory for specific diag- ercise tolerance by keeping the airway as clear as possible nosis and treatment. Lung cancer may be treated surgi- and optimizing gas exchange. For these goals to be accally, with chemotherapy or radiation, or both. Pulmo- complished, acute infections must be eradicated. nary infections may be treated with antimicrobial therGoals for pulmonary rehabilitation are dependent on apy, oxygen, fluids, and bed rest) 6 Postural drainage and the level of pulmonary function or dysfunction. The goals percussion may be indicated: the elderly patient with un- are also dependant on general functional and cognitive derlying lung, heart, or bone disease may not tolerate status. Evaluation of pulmonary rehabilitation is an onchest physical therapy) 6 Such activity must be instituted going process that may present the need for reteaching cautiously, and the nurse must continuously assess the and retraining. Some degree of pulmonary rehabilitation elder's toleration. and improved gas exchange is likely with all but the most Patient education. Teaching is needed. Significant oth- severely affected patient with progressive chronic lung ers should be included in any teaching session. Nurses disease. It takes time, effort, and careful planning. should provide psychosocial support along with the teaching; treatment of depression may be necessary for psy- Conclusion chologic and physical improvement. Teaching regarding energy conservation is fundamenAging, disease, the environment, and other influences tal to any educational program undertaken with the pa- affect gas exchange. Impaired gas exchange may severely
Geriatric Nursing September/October 1992 267
impair functional status and alter an older adult's sense of well-being. Such disability may impair the older client's ability to perform self-care, and self-care is a crucial a s p e c t of f u n c t i o n i n g i n d e p e n d e n t l y or s e m i independently in the community. Nurses affect all levels of care: primary prevention, secondary intervention, and tertiary rehabilitation. Assessment, implementation, and evaluation by nurses is basic to any successful plan for promoting optimal gas exchange in the elderly. =
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REFERENCES
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G e r i a t r i c N u r s i n g September/October 1992
1. Burggraf V, Donlon B. Assessing the elderly system by system. Am J Nuts 1985;85:974-84. 2. ttarrell J. Age-related changes in the respiratory system. In: Matteson MA, blcConnell ES, eds. Gerontological nursing: concepts and practice. Philadelphia: WB Saunders, 1988:219-239. 3. Henderson M. Altered presentations. Am J Nurs 1985;85:1104-1 !. 4. biahler D, Rosiello R, Loke J. The aging lung. Clin Geriatr Med 1986;2:21523. 5. Mahler D, Cunningham L, Curfman G. Aging and exercise performance. Clin Geriatr Med 1986;2:433-52. 6. Rebenson-Piano M. The physiological changes that occur with aging. Crit Care Nurs Q 1989;12:1-14. 7. Kenney R. Physiology of aging: a synopsis. Chicago: Year Book Medical Publishers, 1989:49-65. 8. McConnell E. Nursing diagnosis related to physiologicalalterations. In: blatteson blA, bfcConnell ES, eds. Gerontological nursing: concepts and practice. Philadelphia: WB Saunders, 1988:379-81. 9. Burnside I. Nursing process and the elderly client. In: Burnside IM, ed. Nursing in the aged: a self-care approach. St. Louis: McGraw-ttill, 1988:145-89. 10. Donovan E. Essentials of pathophysiology. New York: M a c m i l l a n , 1985:331-8. 11. Rimer B, Orleans T, Keintz M, Cristianzo S, Fleisher L. The older smoker: status, challenges, and opportunities for intervention. Chest 1990;97:547-53. 12. Deglin J, Vatlerand A, Russin M. Davis's drug guide for nurses. Philadelphia: FA Davis, 1991. 13. Keller S, Markovitz L, Wilder J, Aufses A. Emergency and elective surgery in patients over age 70. Am Surg 1987;53:636-40. 14. Stein J, Hedley-Whyte J. Anesthesiology. In: Calkins E, Davis P J, Ford AB, eds. The practice of geriatrics. Philadelphia: WB Saunders, 1986. ! 5. Djokovie J, Hedley-Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80. JAMA 1979;242:2301-6. 16. Mahler D, Barlow P, Matthay R. Chronic obstructive pulmonary disease. Clin Geriatr bled 1986;2:285-312. 17. Budd bf, McCance K. Alterations of pulmonary function. In: McCance K, Huether S. Pathophysiology: the biologic basis for disease in adults and children. St. Louis: CV Mosby, 1990:1053-95. 18. Goldhaber S, Hennekens C, Evans D, Newton E, Godleski J. Factors associated with correct antemortem diagnosis of major pulmonary embolism. Am J Med 1982;73:822-6. 19. Young K, Merrill W. Interstitial diseases in the elderly patient. Clin Geriatr Med 1986;2:385-410. 20. Niederman M, Fein A. Pneumonia in the elderly. Clin Geriatr Med 1986;2:241-68. 21. Filderman A, Shaw C, Matthay R. Lung cancer in the elderly. Clin Geriatr bled 1986;2:363-84. 22. Smith P, Bleecher E. Ventilatory control during sleep in the elderly. Clin Geriatr Med 1986;2:227-40. 23. Aber W, Block J, Hellard D, Webb W. Consistency of respiratory measurements from night to night during the sleep of elderly men. Chest 1989;96:74751. 24. Berry D, Phillips B, Cook Y, et al. Sleep-disordered breathing in healthy aged persons: possible daytime sequelae. J Gerontol 1987;42:620-6. 25. Sachs D. Cigarette smoking: health effects and cessation strategies. Clin Geriatr bled 1986;2:337-62. 26. Thompson bl. Is routine influenza immunization indicated for people over 65 of age? J Fam Pract 1988;26:211-14. 27. Hill S, blilnes J, Rowe J, et al. Nursing the immobile: a preliminary study. Int J Nurs Stud 1987;24:123-7. 28. Paine R, blake B. Pulmonary rehabilitation for the elderlY. CIin Geriatr Med
1986;2:313-35. 29. Shekleton M. Coping with chronic respiratory difficulty. Nurs Clin North Am 1987;22:569-81.
FOYT
n any discussion of the functional changes associated with longevity, it is difficult to separate the effects of age from the effects of disease. The environment and other complicating factors--immobility, smoking, surgery, polypharmacy, and poor n u t r i t i o n - - m a y have a profound effect on functional capacity. 1"6 Despite this problem in etiologic distinction, it is generally agreed that
I
MERRY MOSIER FOYT, RN, MS, is an assistant professor/ coordinator at the School of Nursing, CreightonUniversity,Omaha, Nebraska. 34/1/39194
physiologic reserve declines with age. This decline in reserve places older adults at greater risk for pathologic responses when confronted with disease, environmental factors, and other complicating and stressful influences. The respiratory system is certainly not spared alteration in function in old age. Indeed, full lung maturity is achieved by age 20 to 25; decline begins thereafter. 7 This article examines the normal phenomena of impaired gas exchange in the elderly and discusses other influences that produce deterioration in pulmonary function. In addition, a nursing care plan addressing impaired gas exchange in the elder is presented.
NORMAL AGE-RELATED CHANGES OF THE RESPIRATORY SYSTEM
Entrapulmonary
Cause
Effect
Degeneration of cartilage and calcificationof
Decreased flexib, of vetebral column; shortened thorax; kyphoscoliosis; chest rigidity; decr. resp. excursion; underventilatlon in bases; improved ventilation in apices; dependance on diaphragm and abdominal muscles; increased A-P diameter; decreased exercise capacity; TLC remains the same; Deer. VC; Incr. RV; Incr. FRC Reduced available blood flow Reduced surface area for exchange Alveolar rigidity; decreased recoil; decr. lung compliance; changes in lung volumes (previously mentioned) Incr. dead space~ airways close prematurely
joints and costal cartilage Osteoporosis of vetebrae Softening and compression of intervertebrol disks Weakening of diaphramatic, intercostal, and accessory muscles Prolonged contraction and relaxation of muscles Changes in ventilation and perfusion
Oecr. distensib, of pulmonary vosculature Mucosal wall thickening Deer. number of alveoli Crosslinkages within collagen fibers of lung tissue Enlarged alveolar wall (senile emphysema)
Ventilation control
Deer. response to hypoxio and hypercarbio Few cilia; weakened muscles Tendency toward dehydration Loss of laryngeal/protective reflexes Decreased immune function
Lung defense mechanisms
TLC,Total lung capacity; VC, vital capacily;RV,residualvolume,FRC,funcllonalresidualcapacity.
262 Geriatric Nursing September/October1992
Reduced ab~ity to respond to stress Oecr. mucociliary escalator Weaker and less effective cough Viscous/diff. to expectorate mucus Incr. chance of aspiration Diff. to treat and/or prevent resp. infec
Causes o f Change Certain extrapulmonary and intrapulmonary changes that occur with increasing age affect respiratory function (see "Normal Age-related Changes"). These changes affect lung support structure, muscle strength, lung volume, alveolar function, ventilation control, and lung defense mechanisms. 1-7 Other factors Immobility. Elders may develop crackles after only a few hours of bed rest. Immobility, especially in the recumbent position, precludes full lung expansion. Lungs that do not completely expand, and thus collect fluid, are prone to infection; in addition, the respiratory muscles become rapidly deconditioned as a result of decreased movement, s When presented with physiologic stressors while lying flat, the elderly person's respiratory system cannot adequately respond. Ventilation actually decreases with the increasing effort needed when trying to take adequate breaths while in this position, and cough is less effective. Airways close, and as a result ventilationperfusion mismatch becomes greater when eiders are lying down. Immobility encourages the development of other body stressors, such as pressure sores and urinary tract infections. These complications increase the body's need for oxygen. An increase in oxygen requirements stresses an already stressed respiratory system to increase the rate of gas exchange. The aged system has a limited ability to increase this on demand. One can see that this rapidly may become a downward spiral toward respiratory failure and resultant multisystems threat. Smoking. Cigarette smoking is a major health hazard. In addition to the promotion of chronic lung disease and lung and other cancers, smoking generally decreases ciliary action, increases mucus production, causes bronchoconstriction, and decreases airflow. 2, 9 Breathing is more difficult and the need for a strong cough is more apparent in a smoker; because of changes in structure and strength, these activities are difficult for the eider to accomplish. Even in those who do not develop frank lung disease, smoking will exacerbate the adverse effects of aging on lung mechanics and clearance capacity. Carbon monoxide, a gaseous by-product of smoking, competes with oxygen at the hemoglobin molecule, l° As a result of impaired gas exchange, cardiovascular function and tissue perfusion may become inadequate. When an elder who smokes is restricted to bed rest, the gas exchange problems are compounded. In addition, smoking alters the action of many medications commonly taken by the elderly. 11 These drugs include propanoloI, lidocaine, antidepressants, pentazocine hydrochloride, phenylbutazone, theophylline, aminophylline, oxytriphylline, and insulin. I1, 12 Surgery. Elective surgery has certain risks, but emergency surgery poses the greatest risk to the elderly client. 13 Rarely does an elderly patient undergo emergency surgery in optimal condition. Because of losses in Iaryngeal reflexes, elders have an increased chance of aspira-
tion, a tendency enhanced by preoperative depressants and residual anesthetic. 14 Gastric emptying is delayed in the elderly, but of course the risk of having a full stomach is most likely in an emergency situation. In either case, aspiration with resultant pneumonia is a threat. Incisions that compromise full chest and abdominal movement impair compensatory breathing and clearing mechanisms. Such incisional sites include the upper abdomen and chest. Splinting caused by pain tends to produce shallow breathing, and this, combined with poor cough, increases the likelihood of airway closure, atelectasis, decreased mucus expectoration, and decreased gas exchange) 4 Perioperative and postoperative hypovolemia thickens secretions. Decreased metabolism and delayed excretion of anesthetic and preoperative drugs produce decreased respiratory drive, as well as promoting diminished or absent gag reflex and inadequate deep breathing. 2, 14 In addition, postoperative immobility is particularly dangerous to the elderly because it decreases ventilation and increases stasis of secretions. Eiders who are adequately prepared and mobilized early have a very good chance of survival from elective surgery)a, 14 Endotracheal intubation for elective and emergency surgery, before induction, may reduce perioperative and postoperative aspiration; mechanical ventilation with positive end-expiratory pressure (PEEP) may prevent shallow breathing, atelectasis formation, and pneumonia. 14, 15
Medications must be carefully monitored to prevent negative effects on the respiratory system. Polypharmaey. Because they take a great number of medications, the elderly have more drug-drug interactions, including those interactions that affect lung function. Certain drugs may contribute to decreased gas exchange. Unmonitored, diuretics may produce dehydration that thickens secretions and cause electrolyte imbalance. Laxatives may produce fluid and electrolyte disturbances. Sedative/hypnotic, antiepileptic, antidepressant, and antiparkinsonian agents may produce decreased levels of consciousness and respiratory depression, especially in combination with recreational drugs. 12 Beta-blockers may cause bronchoconstriction. 12 Respiratory drugs. Drug dosages of prescribed respiratory agents may be inadequate for respiratory therapy. Poor tolerance of drug side effects may hamper compliance. Many drugs prescribed for the treatment of chronic obstructive pulmonary disease (COPD) may produce anorexia or nausea which adversely affects nutritional intake. Many bronchodilators may produce cardiac arrhythmias. 12 Corticosteroids may produce such serious side effects as myopathy, cataracts, secondary infection, vertebral collapse, and a host of other adverse reactions) 2
Geriatric Nursing September/October 1992 263
Medications must be carefully monitored to prevent negative effects on the respiratory system as well as the entire organism. Malnutrition. Malnutrition in the aged population is a serious problem that affects the respiratory and other systems. Inadequate nutrition affects immunocompetence, muscle strength, corpuscle oxygen-carrying capacity (anemia), drug-binding, hydration status, and electrolyte balance. These issues affect respiratory mechanics, clearance of secretions, respiratory drive, the development of respiratory infections, and, ultimately, gas exchange. Poor nutrition may or may not be accompanied by obesity. Obesity impairs breathing patterns and increases the work of breathing, especially when obese patients are on bed rest. Diseases
Several respiratory conditions are seen primarily in the elderly population. COPD, pneumonia, influenza, pulmonary embolism (PE), interstitial disease, tuberculosis (TB), lung cancer, cardiac disease with pulmonary involvement, and disordered breathing during sleep---these are the conditions that most commonly produce a serious threat to the gas exchange of the elder with declining lung function. It is beyond the scope of this article to discuss each disorder in detail. A conceptual discussion of how these diseases may alter elderly respiratory structure and function--and therefore alter gas exchange--is more useful. Respiratory diseases common to the aged tend to accentuate or redouble the adverse effects of aging on pulmonary function. There is also a great deal of overlap/ interconnectedness to these disorders, that is, COPD predisposes to pneumonia, pneumonia predisposes to PE, and so on. COPD produces a further decrease in expiratory air flow and further increases in residual volume. This contributes to air trapping and inefficient and slow gas exchange. Respiratory muscle training is necessary to attempt to overcome muscle atrophy and fatigue and increased residual volume. 16 Chronic bronchitis, one aspect of COPD, produces increases in mucus production. Diseases like pneumonia, influenza, and chronic bronchitis increase the physiologic thickness of alveolar membranes. This reduces the effectiveness of gas exchange. The COPD patient is more vulnerable to pneumonia and influenza. Decreased muscle strength and poor cough combined with increased secretions and decreased clearance ability produces mucus stasis and increases potential for respiratory infection for the COPD patient. Poor immunocompetence of old age 7 predisposes the development of pulmonary infections in old, diseased lungs. Such infections often lead to the demise of older and other COPD patients. Lower respiratory tract infections, such as pneumonia and influenza, account for 78% of elderly deaths. 2 Elders who do not have COPD are also at risk, and a nonspecific presentation may delay prompt diagnosis and treatment. Pulmonary hypertension may develop in a person with
264 Geriatric Nursing September/October 1992
COPD as a result of hypoxemia, polycythemia, and respiratory acidosis. 16 This change may ultimately produce right-sided heart failure. Decreased cardiac output adversely affects oxygen-carbon dioxide exchange. Other complications of COPD that may compound respiratory problems are sleep apnea, arrhythmias, spontaneous pneumotborax, and PE. Pulmonary embolism is a fairly common occurrence in elderly patients with pneumonia and in those who are bedfast. PE produces ventilation-perfusion mismatch, lung infarction, and may produce right-sided heart failo ure. 17 Major PE may cause death. It is difficult to diagnose PE on the basis of physical examination alone; the elder is more likely to have a nonspecific clinical picture. Goldhaber et al. 18 suggest increasing awareness of the possibility of PE in susceptible patients. Their research concludes that the frequent use of lung scanning and pulmonary angiography may increase accurate diagnosis of PE, because the clinical picture in the elderly (and others) is nonspecific. Interstitial diseases are associated with uncontrolled inflammatory reactions in the lung. These inflammatory reactions may or may not be associated with a systemic disease. Whatever theunderlying cause, interstitial diseases produce alveolitis, damage the alveoli, and ultimately produce loss of alveolar-capillary units. 19 Lung compliance will decrease, and a reduced number of functioning alveolar-capillary units produces chronic hypoxia and cor pulmonale. 19 Corticosteroid agents are the therapy of choice for this disorder, but these drugs may aggravate some of the typical nonpulmonary diseases of aging, like osteoporosis and peptic ulcer disease. 12, 19 More important to this discussion, steroids increase the chance of infection and mask its signs and symptoms. Steroids may delay diagnosis and treatment of such pulmonary infections. Pneumonia in the patient with interstitial disease is likely to be fatal. Tuberculosis or reactivation of tuberculosis is more likely in those over 45 years of age. 2 Reactivation is more usual, but institutionalized elderly are at great risk for primary tuberculosis.2° Malnutrition and reduced immunocompetence especially predisposes a person to reactivation. Airway obstruction and loss of functional alveolar tissue for gas exchange may result from tuberculosis. 17 Tuberculosis may predispose a person to the development of pneumonia and respiratory failure. Lung cancer is more likely to occur in smokers than in nonsmokers; it is one of the most commonly occurring cancers in the elderly population. TM21 Lung cancer produces increased cough, wheeze, stridor, dyspnea, obstructive pneumonitis, pleural effusion, pain, and other symptoms.17. 21 Lung cancer increases the work of breathing, decreases lung clearance capability, and predisposes a person to lower respiratory infections. These effects severely compromise aged breathing mechanics, reduce mucus clearance, and hamper gas exchange. Cardiac disease with pulmonary involvement usually indicates pulmonary edema caused by left-sided heart failure. The accumulation of fluid that occurs in pulmo-
nary edema produces ventilation-perfusion defects and gas exchange defects that produce severe hypoxemia. 17 Clearly, aged structures involved in gas exchange would be stressed to produce adequate blood oxygen tension under these circumstances. Disordered breathing during sleep is described as apnea or periodic breathing during sleep that may be associated with underventilation and oxygen desaturation.2, 22, 23 The breathing disorder may be central or obstructive in origin; however, it is suspected that usually such disorders are central because most of respiration and respiratory drive is controlled by the central nervous system. 22 The relationship between old age, cognitive dysfunction, and sleep-disordered breathing is unclear. 22"24 It does seem, however, that obese elderly are more at risk. 22 The pulmonary diseases of old age seriously impair baseline pulmonary function. Most commonly, pulmonary disease causes increased work of breathing, increased mucus with impaired mucus clearance, air trapping, reduced alveolar integrity, reduced cardiae output,
and ventilation-perfusion defects. These are all the normal age-related changes compounded by disease. Impaired gas exchange results from direct pulmonary inefficiencies or because of decreased cardiac output to the lungs.
Nursing Care Plan How do we enhance function of these aged lungs? How can nurses assist the elder to optimize pulmonary function and avoid pulmonary threat? The following outlines a plan of care for maintaining adequate gas exchange in the elderly. Assessment. Prevention of pulmonary problems in the elderly must begin at the level of assessment of baseline function (see "Assessment of Pulmonary Status" box). If the normal age-related level of function is found, an excellent foundation for primary/preventive care exists. Each abnormal finding should be thoroughly investigated. In general, elders exhibit less specific symptoms for many disorders than those exhibited by the younger client. Each complaint should provoke detailed question-
ASSESSMENT OF PULMONARY STATUS OF THE ELDER HISTORY-TAKING (involve family if necessary) Past or recent history of respiratory disease TB COPD PE Pollutant exposure High smog Asbestos Living with smoker Smoking history Packs/year Recent or respiratory (or hypaxio) symptoms Cough SOB DOE PND ADLs toh Other Chronic or acute disease, other than respiratory Past or recent surgery PHYSICAL ASSESSMENT General assessment Vffal signs, including temperature Weight Inspection Cyanosis Capillary refill Barrel-chest of COPD Kyphasls
Cold Flu Pneumonia
Sleep apnea Pul. edema
Interstitial disease Pul. hypertension Lung cancer
Wheezing Bloody sputum Chest Pain Decr. mobility Incr. WOB
Confusion Disturbed sleep Restlessness Activity intol. Rapid heart beat
Weakness Falling Pleurltic pain Irreg. heart beat Recent loss/gain wt.
Character of respirations Cough strength Grimacing Accessory muscle use Weakness
Sputum Posture Restless A-P Diameter
Palpation Tenderness of ribs Tracheal deviation Masses or lumps Percussion (Resonance or hyperresonance in the very thin is normal) Auscultation (Softer vesicular sounds and diminished sounds in the bases is normal) PE, Pulmonaryembolus;SOB,thorl~ss of brec:dh;ADLs,activitiesof daily living;DOE,dyspneaon exertion;PND,paroxysmalnocturnaldyspnea;WOB,work of brecht.
Geriatric Nursing September/October 1992 265
ing of the specific aspects. Sudden onset and severe symptoms are abnormal. If disease is present, secondary intervention may need to be initiated before rehabilitation may be instituted. Nurses who detect acute disease or exacerbation of chronic disease should rapidly refer the patient to a physician. Many older persons suffer from memory impairment and therefore might not be good historians. The family may be better able to report such things as exercise tolerance and other signs of oxygenation status. They may recall the patient's symptom complaints more accurately than the patient may recall them. Interventions Smoking. Cigarette smoking must be stopped. Sachs 25 suggests that there are substantial benefits to the elder who quits smoking. He outlines several strategies to assist the older client to stop smoking and feels that simple and direct advise by caregivers may be one of the best motivators. Eliminating any environmental pollutants, along with the elimination of cigarette smoking by the client, may prevent the development of serious compromise in oxygenation status. Vaccines. Vaccines are available that offer some protection against influenza and pneumoccocal pneumonia. 26 TB testing is also necessary. Nurses should assist the elder in making financial and transportation arrangements to get this preventive treatment. Diagnostic tests. Schedule any diagnostic tests carefully to avoid exhaustion and dehydration. Whenever possible nurses should accompany the elder to any diagnostic testing. This moral support may help prevent stress and facilitate toleration.
PEEP may not be used with COPD patients because of their friable alveolar walls. Surgery. Careful management of the pulmonary status of elders undergoing surgery may lessen complications. Nasogastric suction should be judiciously used to reduce risk of aspiration. Neutralizing stomach contents with antacids and histamine antagonists may decrease the severity of pulmonary damage if aspiration does occur. 14 Elective preoperative intubation and perioperative and postoperative management with mechanical ventilation and PEEP may prevent decreased gas exchange in the elder who has undergone anesthesia exposure. 14 PEEP may not be used with COPD patients because of the friable nature of their alveolar walls. Mechanical ventilation may produce pulmonary complications. Nursing care of the patient receiving ventilatory support must involve careful attention to prevention of nosocomial infection, barotrauma to the lungs, and other machine-induced hazards. The elder must be weaned from the ventilator as soon as possible to avoid causing more harm than good. COPD patients are particularly prone to ventilator complications, especially ventilator dependence. Therefore
266 Geriatric Nursing September/October 1992
intervention with mechanical ventilation should only be instituted and continued when necessary. Sometimes all that is needed to assist elders postoperatively is supplemental oxygen by mask or prongs to assist with excretion of anesthetic, z4 Carefully analyze confusion in the elderly client. Unexplained confusion postoperatively and at other times should be considered a result of hypoxia until it is ruled out. Medicate for pain to prevent discomfort and restlessness that may increase oxygen requirements; but, again, investigate first whether the restlessness is a result of hypoxia before medicating with potential respiratory depressants.
If such activity alterations are viewed as taking control of the disease, the patient will gain a sense of power. Medication for pain, semi-Fowler's position, incentive spirometry, turning, coughing with incision splinting, deep breathing, and early and frequent mobilization are necessary to prevent pulmonary complications as a result of surgery or other immobilizing events. Evaluate toleration of these activities to avoid exhaustion. An exercise regimen before the onset of immobility may help the patient's toleration postoperatively. Hill et al. 27 studied immobility in a geriatric setting. They found fewer professional staff on wards that had a higher proportion of immobile patients. They suggest that more registered nurses are needed to ensure appropriate mobilization of patients and prevention of the-hazards of immobility. Careful hydration, to assist with anesthetic excretion and optimal thinning of secretions, is an important intervention as well. Prophylactic antibiotic therapy may be indicated to help prevent postoperative pneumonia. Medication and nutrition. Medication management of the elder involves monitoring by many health care disciplines. Nurses must intervene by teaching older adults about their medications (including over-the-counter drugs), the importance of adequate nutrition for proper drug action, the need to avoid recreational drugs with certain prescribed medications, and the importance of consulting an expert when their medications no longer seem therapeutic. Adequate hydration and nutrition is vital to the proper action of medications; this must be emphasized when teaching older clients. COPD patients should avoid caffeinated beverages because caffeine may potentiate the side effects of drugs like theophylline. Milk tends to thicken mucus and make expectoration more difficult. Extremely hot or cold liquids may provoke coughing spells that are unnecessary and inefficient and that exhaust the elder. Large quantities of gas-forming foods should be avoided. Excessive bloating
may impinge on the diaphragm and deleteriously affect tient who has chronic lung disease. Energy conservation lung performance. teaching is undertaken to reduce exhaustion, but also to Exercise. Exercise prescription is important to the well clarify methods to maintain a reasonably normal lifeelderly.2, 5 Older adults should have improvements in car- style. All activities of daily living must be evaluated carediovascular performance, respiratory muscle strength, fully, and energy-efficient ways for performing them ventilation, tissue use of oxygen, and body weight com- must be explored. 28 The need for such modifications may position as a result of exercise. 5 The be a source of frustration and depression for the elder. 28, 29 If, however, exercise program should be carefully monitored to avoid cardiovascular such activity alterations are viewed complications and musculoskeletal as taking control of the disease, injuries and to ensure that a training rather than submitting to it, the palevel has been achieved. 5 Mahler et tient will gain a sense of power. All al. s suggests aerobic exercise every elders have to develop some energy other day for 15 to 30 minutes as a expenditure modifications as they goal. As side benefits, the older athgr.ow older; with that in mind, the lete should feel an enhanced sense of elderly patient with chronic lung diswell-being and sense of p o w e r / ease may more easily accept limitacontrol over their lives as a result of tions. Patients need to realize that regular exercise. Nurses may be inchronic lung disease is not curable. volved in the planning, implementaSuch disease is managed and contion, and/or evaluation of exercise trolled by compliance with therapy programs for the elderly. regimens and modification of lifeExercise prescription in elderly pastyle. tients with lung disease (in addition Evaluation. Prevention of pulmonary to the well elderly) is often possible. disease or prevention of exacerbation The prescription and usefulness will of pulmonary disease is the expected depend on the level of restriction. Diresult of primary assessment and inaphragmatic breathing exercises tervention. Evaluation involves reasshould also be taught. When persessing, for the elimination of enviOlder athletes feel an enhanced sense forming exercises like walking and ronmental hazards and cigarette of control over their own lives. bicycle riding, the patient with lung smoking: F o l l o w - u p e v a l u a t i o n (Courtesy of the St. Louis Senior disease may benefit from concurrent checks understanding and compliOlympics.) oxygen therapy. 28 ance with medication, nutrition, and Puhnonary disease therapy. Specific care of the pa- exercise programs. Much support and praise must be tient with pulmonary disease, acute or chronic, is depen- given; any effort put forth to meet goals is positive. Predent on the type and extent of disease. It is beyond the vention of decline in pulmonary status is easier and more scope of this article to discuss such therapy in detail. successful than treatment of pulmonary disease. Assessment of the effectiveness of teaching and theraThese therapies may include bronchial hygiene with intermittent positive-pressure breathing, oxygen therapy, pies aimed at treatment of disorders of gas exchange is exercise and breathing retraining, nutritional support, part of secondary evaluation. Many of the strategies used sympathomimetic drugs, theophylline preparations, cor- in primary prevention, such as environment and smoking ticosteroids, anticholinergic drugs, pulmonary vasodila- modification, are used and evaluated in secondary intertor therapy and diuretics. Patients with sleep disorders vention. Goals at this level are to maintain or improve exmust be referred to a sleep laboratory for specific diag- ercise tolerance by keeping the airway as clear as possible nosis and treatment. Lung cancer may be treated surgi- and optimizing gas exchange. For these goals to be accally, with chemotherapy or radiation, or both. Pulmo- complished, acute infections must be eradicated. nary infections may be treated with antimicrobial therGoals for pulmonary rehabilitation are dependent on apy, oxygen, fluids, and bed rest) 6 Postural drainage and the level of pulmonary function or dysfunction. The goals percussion may be indicated: the elderly patient with un- are also dependant on general functional and cognitive derlying lung, heart, or bone disease may not tolerate status. Evaluation of pulmonary rehabilitation is an onchest physical therapy) 6 Such activity must be instituted going process that may present the need for reteaching cautiously, and the nurse must continuously assess the and retraining. Some degree of pulmonary rehabilitation elder's toleration. and improved gas exchange is likely with all but the most Patient education. Teaching is needed. Significant oth- severely affected patient with progressive chronic lung ers should be included in any teaching session. Nurses disease. It takes time, effort, and careful planning. should provide psychosocial support along with the teaching; treatment of depression may be necessary for psy- Conclusion chologic and physical improvement. Teaching regarding energy conservation is fundamenAging, disease, the environment, and other influences tal to any educational program undertaken with the pa- affect gas exchange. Impaired gas exchange may severely
Geriatric Nursing September/October 1992 267
impair functional status and alter an older adult's sense of well-being. Such disability may impair the older client's ability to perform self-care, and self-care is a crucial a s p e c t of f u n c t i o n i n g i n d e p e n d e n t l y or s e m i independently in the community. Nurses affect all levels of care: primary prevention, secondary intervention, and tertiary rehabilitation. Assessment, implementation, and evaluation by nurses is basic to any successful plan for promoting optimal gas exchange in the elderly. =
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REFERENCES
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::i::i{i!i!i!i::i::i::i GeriatricNurse Practitioner.We are seeking an independent and creative sell" ::i::i::ili::iiiiiiiii starter to assume this exciting new Positicm within the Depaament of ::i::i::iiiiiii~ili~ Nursing of our 382 bed general acute care facilitylocateA in the residentlal northeast section Of the d~s~'~ct.
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iii::i::i::iii::iiiiiiCoo~i~at~the develops=t,~p~=.enutio.andevmatio,of th, p~o:::::::::::::::::::::::::::: gram of health care services for our geriatric population. Collaborate ::::::::::::::::::::::::::::::: closely with our new Geriatrician to develop clinical programs geared to both in and out patients. This position offers an excellentoppoaunlty to design creativeappreaches to interventions for the care of the dderly. National Certification as a Nurse Practitioner, current D.C. ~censure, and a minimum of 1 year of experience as a Geriatric Nurse Practitioner are requi.md. An blSN or a degree in a n:lated field is preferred. .............::. Excellent salary and benefits package. Please send iiiiiiiiiiiiili!ii PROVIDENCE 1,'our resume to Carol Lleberman, Nurse Re. cruller, 1150 Varnum Street, N.E., Washing. iiiiiiiiiiiiiiiill HOSPITAL iii!ii}i!i~fWash|ngton, D.C. ton, D.C. 20017. (202) 269-7925. EEO. ................,
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G e r i a t r i c N u r s i n g September/October 1992
1. Burggraf V, Donlon B. Assessing the elderly system by system. Am J Nuts 1985;85:974-84. 2. ttarrell J. Age-related changes in the respiratory system. In: Matteson MA, blcConnell ES, eds. Gerontological nursing: concepts and practice. Philadelphia: WB Saunders, 1988:219-239. 3. Henderson M. Altered presentations. Am J Nurs 1985;85:1104-1 !. 4. biahler D, Rosiello R, Loke J. The aging lung. Clin Geriatr Med 1986;2:21523. 5. Mahler D, Cunningham L, Curfman G. Aging and exercise performance. Clin Geriatr Med 1986;2:433-52. 6. Rebenson-Piano M. The physiological changes that occur with aging. Crit Care Nurs Q 1989;12:1-14. 7. Kenney R. Physiology of aging: a synopsis. Chicago: Year Book Medical Publishers, 1989:49-65. 8. McConnell E. Nursing diagnosis related to physiologicalalterations. In: blatteson blA, bfcConnell ES, eds. Gerontological nursing: concepts and practice. Philadelphia: WB Saunders, 1988:379-81. 9. Burnside I. Nursing process and the elderly client. In: Burnside IM, ed. Nursing in the aged: a self-care approach. St. Louis: McGraw-ttill, 1988:145-89. 10. Donovan E. Essentials of pathophysiology. New York: M a c m i l l a n , 1985:331-8. 11. Rimer B, Orleans T, Keintz M, Cristianzo S, Fleisher L. The older smoker: status, challenges, and opportunities for intervention. Chest 1990;97:547-53. 12. Deglin J, Vatlerand A, Russin M. Davis's drug guide for nurses. Philadelphia: FA Davis, 1991. 13. Keller S, Markovitz L, Wilder J, Aufses A. Emergency and elective surgery in patients over age 70. Am Surg 1987;53:636-40. 14. Stein J, Hedley-Whyte J. Anesthesiology. In: Calkins E, Davis P J, Ford AB, eds. The practice of geriatrics. Philadelphia: WB Saunders, 1986. ! 5. Djokovie J, Hedley-Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80. JAMA 1979;242:2301-6. 16. Mahler D, Barlow P, Matthay R. Chronic obstructive pulmonary disease. Clin Geriatr bled 1986;2:285-312. 17. Budd bf, McCance K. Alterations of pulmonary function. In: McCance K, Huether S. Pathophysiology: the biologic basis for disease in adults and children. St. Louis: CV Mosby, 1990:1053-95. 18. Goldhaber S, Hennekens C, Evans D, Newton E, Godleski J. Factors associated with correct antemortem diagnosis of major pulmonary embolism. Am J Med 1982;73:822-6. 19. Young K, Merrill W. Interstitial diseases in the elderly patient. Clin Geriatr Med 1986;2:385-410. 20. Niederman M, Fein A. Pneumonia in the elderly. Clin Geriatr Med 1986;2:241-68. 21. Filderman A, Shaw C, Matthay R. Lung cancer in the elderly. Clin Geriatr bled 1986;2:363-84. 22. Smith P, Bleecher E. Ventilatory control during sleep in the elderly. Clin Geriatr Med 1986;2:227-40. 23. Aber W, Block J, Hellard D, Webb W. Consistency of respiratory measurements from night to night during the sleep of elderly men. Chest 1989;96:74751. 24. Berry D, Phillips B, Cook Y, et al. Sleep-disordered breathing in healthy aged persons: possible daytime sequelae. J Gerontol 1987;42:620-6. 25. Sachs D. Cigarette smoking: health effects and cessation strategies. Clin Geriatr bled 1986;2:337-62. 26. Thompson bl. Is routine influenza immunization indicated for people over 65 of age? J Fam Pract 1988;26:211-14. 27. Hill S, blilnes J, Rowe J, et al. Nursing the immobile: a preliminary study. Int J Nurs Stud 1987;24:123-7. 28. Paine R, blake B. Pulmonary rehabilitation for the elderlY. CIin Geriatr Med
1986;2:313-35. 29. Shekleton M. Coping with chronic respiratory difficulty. Nurs Clin North Am 1987;22:569-81.