Geriatric Nursing Care Plans: 10 Nursing Diagnosis for Older People

Older adults break the rules you learned on younger patients. A normal temperature can be septic. A clear chest can still be pneumonia. A new bout of confusion is a symptom to chase, not a feature of age. Your job is to read the baseline, catch the subtle change early, and keep a frail patient safe while you find the cause.

Geriatric nursing addresses the physiological, developmental, psychological, socioeconomic, cultural, and spiritual needs of the aging adult. Care planning centers on the aging process, promotion and restoration of health and function, increased safety, prevention of illness and injury, and facilitation of healing. Older patients carry overlapping chronic conditions and long medication lists, so the work is collaborative: family, community, and the rest of the care team all feed the plan.

Nursing Problem Priorities

1. Assess each older adult and build an individualized plan.
2. Manage chronic conditions and protect cognitive health.
3. Administer medications and treatments safely.
4. Teach and support healthy aging.
5. Assist with ADLs and promote mobility.
6. Coordinate with interdisciplinary teams and community resources.
7. Prevent falls and keep the environment safe.
8. Provide emotional support and counseling.

Nursing Assessment

Assess for the following subjective and objective data:

• Decreased mobility
• Balance issues
• Changes in cognition or memory
• Increased fatigue
• Changes in appetite
• Weight loss
• Sleep disturbances
• Mood changes
• Decreased vision or hearing
• Increased vulnerability to infection and slower wound healing

Nursing Diagnoses

Common diagnoses in older adult care include:

• Impaired Physical Mobility related to muscle weakness and joint stiffness, evidenced by limited range of motion and difficulty moving independently.
• Risk for Falls evidenced by balance issues, decreased vision, and unsteady gait.
• Activity Intolerance related to decreased muscle mass and low endurance, evidenced by shortness of breath and fatigue with minimal exertion.
• Impaired Memory related to age-related cognitive changes, evidenced by forgetfulness, difficulty recalling recent events, and disorientation to time.
• Self-Care Deficit (Bathing and Hygiene) related to decreased strength and limited joint flexibility, evidenced by inability to wash independently.
• Risk for Impaired Skin Integrity evidenced by immobility, thin fragile skin, and reduced subcutaneous tissue.
• Chronic Pain related to joint inflammation and stiffness, evidenced by persistent discomfort and guarding during movement.
• Disturbed Sleep Pattern related to frequent urination and decreased melatonin production, evidenced by waking multiple times during the night.
• Risk for Infection evidenced by decreased immune response, recent hospitalization, and invasive devices.
• Risk for Ineffective Coping evidenced by loneliness, recent loss of a spouse, and lack of social support.

Nursing Goals

• The patient stays free from falls.
• The patient and caregiver put safety and fall-prevention measures in place at home.
• The patient's respiratory pattern and mental status return to their normal.
• Pulse oximetry or ABG results stay within the patient's normal limits.
• Temperature and mental status stay within normal limits, or return to them at 1°F/hr after interventions.
• The patient gets adequate rest and mental status stays intact.
• The patient's bowel habit returns to normal within 3 to 4 days of diagnosis.
• Stool appears soft and the patient does not strain.
• The patient shows improvement in at least one of: functional ability, hopefulness, weight gain, appetite, or a peaceful death.
• The patient swallows independently without choking.
• The airway stays patent and lungs stay clear before and after meals.
• Mental status, vital signs, and urine output stay within the patient's normal limits.
• Mucous membranes stay moist with no skin tenting.
• Mentation returns to the patient's normal within 3 days of therapy.
• The patient stays free from injury related to mental status.
• The patient stays free of infection: oriented to person and place, respiratory rate and pattern at baseline, clear straw-yellow urine, core temperature and heart rate at baseline, clear-to-whitish sputum, and intact skin of normal color and temperature.
• Skin stays non-erythemic and intact.

Nursing Interventions and Actions

1. Promoting Safety and Preventing Falls and Injuries

Fall prevention runs on assessment plus environment: gauge mobility, strength, and balance; clear tripping hazards and improve lighting; supply assistive devices; teach safe ambulation; build strength and flexibility with regular exercise; review medications for fall-risk side effects; and keep eye and hearing exams current.

Identify factors that raise fall risk. These drive your interventions. Risk factors include age, illness, sensory and motor deficits, medication use, and improper use of mobility aids.

Assess the environment for fall risk. Unfamiliar furniture placement and inadequate lighting both raise the risk.

Establish a baseline level of consciousness and neurologic status on admission, and assess the caregiver's report of pre-confusion function. Ask the patient to complete a three-step task, for example "put your right hand on your chest, wave with your left hand, then raise your eyebrows." A component of the Mini-Mental Status Examination, this gives a baseline for tracking confusion. The task is complex, tests attention, and screens for delirium.

Use the Confusion Assessment Method (CAM) to detect delirium. Delirium is a serious, frequently missed problem in hospitalized older adults. CAM is a short, standardized, validated tool that bedside clinicians can use from medical-surgical units to the ICU.

Find the cause of acute confusion. Acute confusion comes from physical and psychosocial conditions, not age alone. Oximetry or ABG values may show low oxygenation; serum or fingerstick glucose may show high or low glucose; electrolytes and CBC reveal imbalances and an elevated WBC count pointing to infection. Check hydration by pinching skin over the sternum or clavicle (tenting means fluid volume deficit), and look for dry mucous membranes and a furrowed tongue.

Test short-term memory: show the patient how to use the call light, have them demonstrate it back, then wait at least 5 minutes and have them demonstrate again. Record the behavior in concrete terms. Inability to retain information beyond 5 minutes signals poor short-term memory.

Assess the apical pulse and report any new irregular pulse. On a cardiac monitor or telemetry, watch for dysrhythmias and report them. Dysrhythmias and other cardiac problems cause poor brain oxygenation, which can drive confusion.

Rate pain on a 0-10 scale. If a scale is not possible, watch for nonverbal cues: frowning, grimacing, rapid blinking, clenched fists, fidgeting. Ask the caregiver to help identify pain behaviors. Acute confusion can be a sign of pain.

Treat pain as indicated and watch behavior. If pain drove the confusion, behavior changes when the pain is controlled.

Monitor intake and output every 8 hours. Output should equal intake. Dehydration causes acute confusion.

Assess kidney function through creatinine clearance. Renal function governs fluid balance and clears most drugs. BUN and serum creatinine shift with hydration and tell only part of the story in older adults, so creatinine clearance is the fuller measure.

Review all current medications, including OTC drugs, with the pharmacist. High levels of drugs like digoxin and anticholinergic agents, plus drug interactions, cause acute confusion.

With short-term memory problems, offer the urinal or bedpan every 2 hours while awake and every 4 hours at night. Post a toileting schedule on the care plan and discreetly at the bedside. A patient with memory problems cannot be counted on to use the call light.

Keep the urinal and routinely used items within easy reach. A confused patient may wait too long to ask for help toileting.

Keep glasses and hearing aids on the patient or within reach. They cut sensory confusion.

Have the family bring familiar items: a blanket, bedspread, photos of family and pets. Familiar objects aid orientation and comfort.

Check the patient at least every 30 minutes and every time you pass the room. Place them near the nurses' station and keep the environment nonstimulating and safe. A confused patient needs extra safety precautions.

Reorient as needed. Keep a large-numeral clock and large-print calendar at the bedside, and state the date and day. Reorientation lessens confusion.

Provide music, not TV. Confused patients often think the action on TV is happening in the room.

Explain what you are doing in simple terms, for example "I will take your blood pressure on your left arm." Complex sentences are hard to follow.

If the patient turns hostile or misreads your role, leave and return in 15 minutes. Reintroduce yourself as if meeting for the first time and start over. Acutely confused patients have poor short-term memory and may not retain the prior encounter.

If the patient becomes aggressive or argumentative during reorientation, stop. Do not question their grasp of the environment. Say "I get why you might think that." This avoids escalating anger.

With a permanent or severe cognitive deficit, check at least every 30 minutes and reorient to baseline, but do not challenge the patient's reality. Arguing makes a cognitively impaired person hostile and combative. Note: patients with Alzheimer's disease or dementia can also develop acute delirium and can be returned to baseline.

If the patient tries to leave, walk with them and distract. Ask about the destination, keep your tone conversational, and steer the walk away from doors and exits. After a few minutes, lead them back. Offer snacks and naps. Distraction reliably reverses the behavior in a confused patient.

If behavior needs checking more often than every 30 minutes, have family phone or sit with the patient. Family presence helps keep the patient safe.

If the patient climbs out of bed, offer a urinal, bedpan, or commode. They may need to toilet.

If not on bedrest, seat the patient in a chair or wheelchair at the nurses' station. This adds supervision while providing stimulation and limiting isolation.

Bargain for a fixed delay, such as staying until the provider, a meal, or family arrives. Poor memory and attention mean the patient may forget they wanted to leave.

If the patient pulls at tubes, hide them. Cover IV lines with stockinette mesh, secure feeding tubes to the side of the face with paper tape, and drape the tube behind the ear. Out of sight, out of mind.

Use behavior medications carefully, starting low and going slow. Older patients respond to small doses. Neuroleptics such as haloperidol calm patients with dementia or psychiatric illness, but are contraindicated in Parkinsonism. For acute confusion or delirium, short-acting benzodiazepines such as lorazepam work better on the anxiety and fear that drive dangerous behavior. Watch for akathisia, a neuroleptic reaction marked by restlessness.

Use restraints cautiously and per hospital policy. Patients tend to grow more agitated when wrist and arm restraints go on.

Reassess the continued need for each device. Some become irritating stimuli. If the patient is drinking, stop the IV; if eating, remove the feeding tube; if continent, remove the catheter and start bladder training.

Apply a fall-risk wristband. It warns the team to keep fall precautions in place.

Keep assistive devices and used items within reach. Call bells, telephones, and water should stay close so the patient does not overreach.

Review the facility transfer protocol. Clear transfer procedures protect the patient.

Keep the bed in its lowest position. A bed near the floor prevents fall injury.

Answer the call light promptly. This keeps an unstable patient from ambulating alone.

Use side rails as needed. Raised rails reduce the risk of falling out of bed during transport.

Have the patient wear nonslip footwear. It prevents slips and falls.

Orient the patient to the room and avoid rearranging furniture. Familiarity with the bed, bathroom, and hazards prevents trips and falls.

Keep the room well lit and use a bedside lamp at night. Good lighting reduces fall risk.

Encourage family to stay with the patient. They prevent falls and tube pulling.

Keep eyesight checked and glasses and hearing aids in use. Visually impaired patients are at high risk for falls; correct aids reduce the hazard.

Teach safe home ambulation, including bathroom handrails. This eases anxiety and cuts fall risk at home.

Encourage regular exercise and gait training. Exercise improves strength, balance, coordination, and reaction time, reducing falls and the injuries they cause.

Coordinate with the team to review fall-risk medications and identify their peak effects. More medications mean more side effects and interactions: orthostatic hypotension, dizziness, confusion, incontinence, altered gait. Polypharmacy is a major fall risk factor in older adults.

Evaluate the need for physical and occupational therapy for gait and assistive devices, and arrange a home safety evaluation. Gait belts make transfers safer; wheelchairs, canes, and walkers add stability; high toilet seats ease transfer on and off the toilet.

2. Improving Gas Exchange and Respiratory Function

Aging lowers lung elasticity, chest wall compliance, and respiratory muscle strength, cutting lung capacity, weakening the cough reflex, and raising infection risk.

Record respiratory rate, depth, and pattern; breath sounds; cough; sputum; and mental status on admission and routinely. This sets the respiratory baseline.

Watch for subtle changes in behavior or mental status (anxiety, disorientation, hostility, restlessness). Check pulse oximetry (higher than 92%) or ABG values (ideally PaO2 80%-95% or higher). Sensorium changes can signal falling oxygen. Read oximetry against hemoglobin: a low-hemoglobin patient can show a higher oximetry number yet still be confused or restless because there is less hemoglobin to carry oxygen.

Auscultate for adventitious sounds. Lung elasticity drops with age and the lower lobes aerate poorly, so crackles are common in individuals 75 years and above. Alone, this is not disease. Crackles (rales) that do not clear with coughing, with no fever, anxiety, sensorium change, or increased respiratory depth, are benign.

Encourage breathing and coughing exercises and incentive spirometry if applicable. These expand alveoli and clear bronchial secretions for better gas exchange.

Encourage fluid intake greater than 2.5 liters daily unless a renal or cardiac condition contraindicates it. Hydration mobilizes secretions.

Treat hyperthermia promptly, control pain, limit pacing, and reduce anxiety. These cut oxygen demand.

Teach the use of nasal cannulas or oxygen masks. Understanding the device improves adherence.

3. Managing Hypothermia

Older adults lose heat fast and struggle to hold a stable temperature because of reduced subcutaneous fat, diminished muscle mass, and impaired thermoregulation.

Monitor temperature with a low-range thermometer if available. It detects hypothermia. Normal temperature for an older adult is 35.5°C (96°F).

Take oral temperature with the tip far back in the mouth. This gives the most accurate core reading.

Assess and record mental status. Increasing disorientation, altered sensorium, or atypical behavior may signal hypothermia.

Watch sedatives, muscle relaxants, hypnotics, and anesthetics. They suppress shivering, raising environmental hypothermia risk. Older adults are at risk at ambient temperatures of 22.22°-23.89°C (72°-75°F).

Give blankets to patients going for testing or x-ray. This keeps them warm and prevents hypothermia.

Start slow rewarming for mild hypothermia. Raise the room to at least 23.89°C (77.5°F) and add warm blankets, head covers, and warm circulating-air blankets.

Warm internally with warm oral or IV fluids if temperature drops below 35°C (95°F). This reverses moderate to severe hypothermia, along with warmed saline gastric or rectal irrigations and warmed humidified air to the airway.

Watch for excessive rapid rewarming. Irregular heart rate, dysrhythmias, and very warm extremities from peripheral vasodilation (which dumps core heat) are warning signs.

If temperature fails to rise by 1°F/hr, anticipate a WBC count for sepsis, glucose for hypoglycemia, and thyroid testing for hypothyroidism. Nonenvironmental causes may be at work.

Give antibiotics for sepsis, glucose for hypoglycemia, or thyroid therapy as prescribed. Treating the cause returns the temperature to normal.

4. Promoting Adequate Sleep and Improving Sleep Patterns

Aging changes sleep architecture (less deep sleep, more awakenings), and comorbidities, medications, and environment all interfere.

Assess the sleep pattern, including input from family or caregiver. Older adults usually sleep less than in earlier years and wake more often at night.

Ask about activity level and napping. Low-activity patients who nap often sleep only 4 to 5 hours per night.

Monitor activity level. If the patient tires after activity or grows irritable, encourage a nap after lunch or early afternoon. Otherwise discourage daytime naps, especially late afternoon, since they disrupt nighttime sleep.

Identify and follow the patient's usual nighttime routine. Familiar rituals promote sleep.

Cluster care, combining vital signs, medications, and toileting. Fewer interruptions mean more rest.

Stop caffeinated coffee, cola, and tea after 6 pm. Stimulants increase alertness, cause insomnia, and trigger nighttime awakenings to urinate.

Keep the environment calm and quiet and limit interruptions during sleep hours. Bright lights, noise, snoring roommates, and loud talk cause sleep deprivation. White noise generators can help.

Give pain medication as ordered, offer a back rub, and talk pleasantly at bedtime. These promote comfort and sleep.

5. Restoring Bowel Function and Managing Constipation

Aging slows the digestive system, and comorbidities plus medications make constipation common. Infrequent or difficult stools hit quality of life hard in older adults.

On admission, record the normal bowel pattern (frequency, time of day, associated habits, prior measures). Ask family or caregiver if the patient cannot answer. This sets the baseline.

Match roughage to the severity of constipation. Too much roughage too fast causes gas, bloating, and diarrhea.

Assess hydration. Maintain diet, fluid, activity, and routines. If there is no bowel movement within 3 days, start mild laxatives. Osmotic medications can dehydrate, and fluid volume deficit hardens stool.

Tell the patient hospitalization itself raises constipation risk. Let them use the nonpharmacologic measures that work at home, as needed or prophylactically. Constipation is easier to prevent than to treat once established.

Teach the link between fluid intake and constipation. Encourage 2500 ml/day unless contraindicated, and record bowel movements (amount, date, time, consistency). More fluid softens stool. Renal, cardiac, or hepatic disease may require fluid restriction.

Include roughage at each meal where possible. For patients who tolerate raw foods poorly, give bran through cereals, bread, and muffins. Roughage (raw fruits and vegetables, whole grains, legumes, nuts, fruit with skin) adds bulk and cuts constipation.

Teach the link between activity and constipation. Support activity for every patient and build a program with whatever devices keep them independent. Exercise stimulates peristalsis.

Use the gastrocolic or duodenocolic reflex: if the usual movement is morning, prompt then; if evening, ambulate just before. Timing interventions to the patient's pattern increases movements. Warm morning liquids also drive peristalsis, and digital stimulation of the inner anal sphincter can trigger a movement.

Use previously effective measures and start low, go slow (lowest non-natural intervention first, escalating gently). Aggressive measures cause rebound constipation and hinder later movements.

For pharmacologic therapy, give the more benign oral methods first, in this order:

• Bulk-forming additives (bran, methylcellulose, psyllium)
• Mild laxatives (apple or prune juice, Milk of Magnesia)
• Stool softeners (docusate calcium, docusate sodium)
• Potent laxatives or cathartics (senna, bisacodyl, cascara sagrada)
• Medicated suppositories (glycerin, bisacodyl)
• Enema (tap water, saline, sodium phosphate/biphosphate)

Older patients judge constipation by loss of their habit, not stool count. Do not intervene pharmacologically until there has been no stool for three days.

Give laxatives as ordered after barium imaging of the GI tract. Laxatives clear the barium and prevent rebound constipation from the prep.

6. Failure to Thrive in Older Adults

Adult failure to thrive is unintentional weight loss, declining function, and falling health status. It is multifactorial (physical, psychological, social) and drives up morbidity and mortality.

Do a comprehensive physical assessment and evaluate chronic disease. It sets a baseline.

Review CBC with differential, albumin, pre-albumin, thyroid-stimulating hormone (TSH), and a basic metabolic panel (BMP). These show nutrient and electrolyte imbalances, protein and thyroid status, and infection.

Take a focused history, involving the caregiver. Note critical events such as the death of a spouse or family member. A history centered on timing of behavior, appetite, medication, and ADL or IADL changes uncovers contributors like depression, dementia, pain, and lost taste or smell.

Let the patient vent fear, anger, despair, frustration, and worries about hospitalization. Acknowledging these feelings as normal eases despair.

Explain age-related changes to the patient and family. Physiologic reserve declines with normal aging across systems. Failure to thrive arises from three components: physical frailty, disability, and impaired neuropsychiatric function. Frailty is increased vulnerability from diminished reserve across multiple systems. Disability is difficulty performing ADLs. Neuropsychiatric impairment runs from life circumstances into depression, physiologic disruption into delirium, or neurologic change into cognitive impairment.

Collaborate with other providers: speech therapists and dieticians for swallowing or inadequate intake; physical and occupational therapists for strength, limitations, and improvement potential; and social services for support networks and end-of-life readiness.

7. Preventing Aspiration

Aspiration happens when food or fluid enters the airway instead of the digestive tract, and it can cause pneumonia and serious harm in older adults.

Test the swallowing reflex: place your thumb and index finger on both sides of the laryngeal prominence and have the patient swallow. Test the gag reflex by touching each palatal arch with a tongue blade. Record both. An intact swallow and gag reflex are essential before the patient takes food or fluid.

Monitor food intake: amount, consistency, where the patient places food, how they chew, and how long before they swallow the bolus. This guides later feedings.

Watch the patient during swallowing. It reveals swallowing ability; deficits may require aspiration precautions.

Watch for choking or coughing before, during, or after swallowing. It can happen within minutes of food or fluid placement and signals material entering the airway.

Listen for a wet or gurgling voice after swallowing. Wet speech may mean pulmonary aspiration and a restricted or absent gag and swallow reflex.

Assess for crackles (rales), rhonchi, wheezes, shortness of breath, dyspnea, cyanosis, rising temperature, and declining consciousness. These signal silent aspiration, a particular risk in older adults whose sphincter fails to close fully between swallows.

Watch for food retained on the sides of the mouth. It signals poor tongue movement.

Watch for drooling of saliva or food, or inability to close the lips on a straw. These signal restricted jaw, lip, or tongue movement.

Anticipate a videofluoroscopic swallowing exam (VFSE) or modified barium swallow (MBS). This noninvasive study shows whether the patient aspirates, which consistencies are aspirated, and the cause. Using four consistencies of barium, the radiologist and speech therapist check tongue function, pharyngeal peristalsis, swallow reflex timing, and the epiglottis's ability to close off the airway.

Based on the study, thickened fluids may be prescribed. Thickeners raise viscosity and improve swallow safety. Mechanical soft, pureed, or liquid diets may also be ordered to lower aspiration risk.

Anticipate a speech therapist referral. It addresses gag and swallow problems.

Tilt the head forward 45° during swallowing for impaired swallow reflexes. For hemiplegia, tilt toward the unaffected side. This closes off the airway and prevents aspiration.

Allow rest before meals. Fatigue raises aspiration risk.

Position the patient upright with the chin tilted slightly down while eating or drinking, with pillows to hold position. This closes the airway and lets food and fluid flow by gravity into the stomach.

Make sure dentures fit and stay in place. Good chewing lowers choking risk.

For dementia, cue the patient to chew and swallow each bite and watch for retained food. Dementia patients forget to chew and swallow.

Allow enough time to finish eating and drinking. Patients with swallowing problems often need twice as long.

Stay with the patient during meals. This protects against choking and aspiration.

Encourage breathing and coughing exercises every 2 hours while awake and every 4 hours at night. They expand the lungs and help prevent infection.

Keep suction at the bedside. Suction equipment must be ready, especially for high-risk patients.

If aspiration occurs:

• Assess for complete airway obstruction per American Heart Association (AHA) guidelines: poor air exchange, cyanosis, inability to speak or breathe. Complete obstruction needs immediate intervention.
• Check breathing pattern and respiratory rate every 1-2 hours after suspected aspiration to catch any change.
• For partial obstruction, have the patient cough forcefully to clear the airway.
• For unconscious or nonresponsive patients with partial obstruction, suction with a large-bore catheter (Yankauer or tonsil tip).
• For complete or partial aspiration, notify the provider and request a chest x-ray to confirm whether food or fluid obstructs the airway.
• Keep the patient NPO until a diagnosis is established.
• Anticipate antimicrobial agents for possible aspiration pneumonia.

8. Preventing Fluid Imbalance

Age-related changes, comorbidities, and medications swing older adults toward dehydration or fluid overload, so hydration needs close watching.

Record amount, color, and frequency of all output: urine, diarrhea, emesis, drainage. This lets you compare intake to output. Dark urine signals concentration and dehydration.

Assess skin turgor by gently pinching skin over the forehead, clavicle, sternum, or abdomen. Tenting signals dehydration; a furrowed tongue signals severe dehydration.

Encourage fluid intake of 2-3 liters per day unless contraindicated, with intake goals for day, evening, and night shifts. This ensures adequate hydration. Cardiopulmonary and renal disorders may require restriction.

Assess level of consciousness: orientation, ability to follow commands, behavior. Disorientation and disorderly behavior can mean dehydration.

Weigh daily at the same time (usually before breakfast), same scale, same clothing. Comparable measurements are more valid. A swing of 2.5 kg (5 lb) or more signals a hydration change.

Assess the patient's ability to drink independently. Keep fluids within reach and use lidded cups to ease spill worry. This removes barriers to intake.

Monitor intake and output, especially with tube feedings or contrast medium. Watch for third spacing: increasing peripheral and sacral edema, output well below intake (1:2), and urine output less than 30 ml/hr. These agents pull fluid osmotically into interstitial tissue.

On IV infusions, assess cardiac and respiratory status for overload. Check the apical pulse and auscultate the lungs with vital signs. Fluid overload can cause heart failure or pulmonary edema; rising heart rate, crackles, and bronchial wheezes are warning signs.

In dehydration, anticipate rising serum sodium, BUN, and serum creatinine. These values climb with dehydration.

Ensure easy access to toilet, urinal, commode, or bedpan every 2 hours while awake and every 4 hours at night, and answer the call light immediately. The gap between recognizing the need to void and voiding shrinks with age.

Offer fluids every time you are in the room. Provide preferred liquids but limit caffeine. Aging blunts thirst, so older adults need encouragement to drink; caffeine acts as a diuretic.

9. Promoting Infection Control and Minimizing Infections

Immunosenescence, chronic disease, impaired organ function, fragile skin, reduced mobility, and invasive devices all raise infection risk in older adults.

Monitor baseline vital signs, level of consciousness, and orientation. Watch for a heart rate greater than 100 bpm and a respiratory rate higher than 24 breaths per minute. Auscultate for adventitious sounds, remembering that basilar crackles (rales) can be normal. Acute mental status change is a key infection sign in older adults, along with rising heart and respiratory rates. Adventitious sounds may not appear until late.

Assess skin for tears, breaks, redness, or ulcers, and record on admission and ongoing. Broken skin invites infection.

Take temperature with a low-range thermometer if possible. Older adults may run low from slower metabolism and lose heat easily. A temperature of 35.5°C (96°F) may be normal, while 36.67°-37.22°C (98°-99°F) may be febrile.

Take a rectal temperature if the oral reading does not fit the picture (warm skin, restless, depressed mentation) or if it reads 36.11°C (97°F) or higher. Rectal readings confirm core temperature when oral is unreliable.

Avoid the tympanic thermometer if possible. Improper use makes electronic tympanic readings inconsistent.

Assess urine quality and color, document changes, and report them. Watch for urinary incontinence, which can signal a urinary tract infection (UTI). UTI, shown by cloudy foul-smelling urine without painful urination and by incontinence, is the most common infection in older adults.

Limit urinary catheter insertion. Catheters raise infection risk.

Anticipate blood cultures, urinalysis, and urine culture. Cultures identify the bacteria or fungi causing the infection.

Anticipate a WBC count. A count higher than 11,000/mm3 can be a late sign, since an older immune system responds slowly.

If infection is confirmed, expect IV fluid therapy. Fluids improve hydration, replace fever losses, and loosen secretions.

Anticipate a chest x-ray if lung sounds are not clear. It rules out pneumonia.

Anticipate a broad-spectrum antibiotic regimen, antipyretic, and oxygen if infection is confirmed. These clear infection, reduce fever, and improve brain oxygenation. Fever raises cardiac workload, and with low physiologic reserve, prolonged tachycardia puts older adults at greater risk of heart failure or pulmonary edema.

10. Preventing Pressure Ulcer Formation

Decreased skin elasticity, thinning skin, reduced subcutaneous fat, impaired circulation, immobility, and malnutrition all make older adults prone to pressure ulcers.

Assess skin on admission and regularly. It sets a baseline for skin integrity.

Monitor skin over bony prominences for erythema. Sacrum, scapulae, heels, spine, hips, pelvis, greater trochanter, knees, ankles, costal margins, occiput, and ischial tuberosities take the most external pressure.

Watch for redness, texture change, or breaks. These need aggressive skin care to prevent further breakdown and infection.

Use a lift sheet or roll the patient when repositioning. Sliding, pulling, or dragging causes shear injury.

Turn at least every 2 hours. Turning shifts the pressure point and relieves the skin.

Use waterbeds, airbeds, air-fluidized, alternating-pressure, or other pressure-sensitive mattresses for patients on bedrest. They add comfort and protect skin from prolonged pressure.

Pad bony prominences with pillows or pads, including in a wheelchair or during long sitting. The ischial tuberosities break down in a seated position; gel pads on chair or wheelchair seats disperse pressure.

Apply lotion generously to dry skin. It keeps skin smooth and supple; lanolin-containing lotions help most.

Get the patient out of bed as often as possible, using mechanical lifts for transfers. If out of bed is impossible, change position every 2 hours. Movement promotes blood flow and prevents breakdown.

Post a turning schedule on the care plan and at the bedside. It keeps nurses and family aware of turning times.

Do not place tubes under the head or limbs. Pad between the patient and the tube. Tube pressure causes decubitus ulcers.

Bathe with tepid water (32.2°-40.5°C [90°-105°F]) and superfatted, nonperfumed soap. Hot water burns older adults with reduced temperature sensation; superfatted soap prevents dryness.

Clean the face, axillae, and genital area daily. Full baths dry older skin and are better done every other day.

Record the percentage of food eaten, let family bring preferred foods, offer nutritious snacks, and consult a dietician. A diet high in protein and ascorbic acid protects skin from breakdown.

Limit plastic protective pads. When used, place a layer of cloth between the patient and the plastic, check pads every 2 hours in incontinence, and avoid adult diapers unless the patient is ambulatory, going for a test, or up in a chair. Pads and diapers trap heat and moisture, causing moisture-associated skin damage.