METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY

CONCEPT: GERIATRICS

INSTRUCTOR: CHARMAINE GEM A. PEREGRINO, R.N.,R.M.

NONALYNNE M. ANDRES, R.N.,M.A.N.

I.Introduction

a. Definition

1. Late adulthood

2. Geriatric (Aging and Lifespan)

3. Geriatric nursing

4. Gerontology

5. Gerontologic nursing

6. Senescence

7. Senility

8. Aging

b. Normal Physiologic and Pathologic Changes with Aging( per system)

c. Stage of Growth and development

II. Aging Changes and Health Deviations

1. Integumentary System

• Alterations in Structure and Function and Common Disorder

1.1.Pruritus

1.2. Nursing Interventions

1.3. Psoriasis

1.4. Nursing Intervention

2. Musculoskeletal System

• Changes in Structure and Fuction and Common Diorders

2.1. Osteoporosis

2.2. Nursing Interventions

2.3 Osteoarthritis

2.4. Nuring Interventions

2.5. Rheumatoid Arthritis

2.6. Nursing Interventions

3. Cardiovascular System

• Cardiovascular Changes: Caused By Age or Disuse and Common Disorders

3.1. Hypertension

3.2. Nursing Interventions

3.3. Myocardial Infarction

3.4. Nursing Interventions

 3. 5. Angina Pectoris

3. 6. Nursing Interventions

4. Respiratory System

• Alterations in structure and Common disorders

4.1. Asthma

4.2.Nursing Interventions

4.3. COPD

4.4. Nursing Interventions

5. Neurological System

• Changes in Functional Abilities of the Neurological System and Common

Disorders

5.1. Dementia

5.2. Alzheimer’s disease

5.3. Nursing Interventions

5.4. Parkinson’s Disease

5.6. Nursing Intervetions

6. Gastrointestinal System

• Common Disorders (Changes with Aging)

6.1. Peptic and Gastric Ulcer

6.2. Nursing Interventions

7. Genitourinary System

• Implications of Genitourinary Changes with Age and Common Disorders

7.1. Dysfunctional voiding patterns

7.2. Urinary retention

7.3. Urinary Tract Infection

7. 4. Nursing Intervetions

8. Endocrine System

• Pathological Changes and Common Disorders

8.1. Hyperthyroidism and Hypothyroidism

8.2. Nursing Intervetions

9. Immune System

• Changes and Common Disorders

9.1. Pernicious Anemia

9.2. Nursing Intervetions

9.3. HIV/AIDS in older patients

9.4. Nursing Interventions

10. Sensory- changes and common disorders

III. Ethical Considerations

IV. Health Promotion for the Elderly

References:

Adrianne Dill Linton & Helen W. Lack, Matteson&McConnell’s Gerontological Nursing Concepts and Practice 3rd
edition, Saunders 2007

Udan, Medical and Surgical Nursing: Concepts and Clinical Application” First Edition, 2002

Suzanne C. Smeltzer & Brenda G. Bare, Brunner & Suddarth Medical and Surgical Nursing, 10th edition

Lippincott & Williams &Wilkins 2004

Geriatrics

Definition of terms:
Late adulthood- extends from above 65 years of age

1. Geriatrics -is a sub-specialty of medicine that focuses on health care of the elderly. It aims to promote
health and to prevent and treat diseases and disabilities in older adults; the science and the study of the
physiologic and pathologic problems of individuals in their later maturity

2. Geriatric nursing- care for the elderly regardless of whether they are diseased or not

3. Gerontology- the science and study of aging process

4. Gerontologic nursing – the care and attention to individuals undergoing the aging process with emphasisi
in the developmental stages of aging

5. Senescence- the normal aging process

6. Senility- aging process characterized by severe mental deterioration

7. Aging- physiologic, behevioral, and social changes that occur with increasing chronoligical age;a normal
progressive process, not a disease; norms:normal physiological changes, have not been cpmpletely
identified

General changes:
1. general tissue desiccation and slowed cell vision

2. slowed, weakened speed of response to stimuli

3. slowed rate of tissue repair

4. decreased metabolism

5. mechanisms of homeostasis less rapid and less efficient

6. rate of change is individual

7. high incidence of health problems

Primary changes of aging ( Physiological changes)

 Skin

• Loss of subcutaneous supporting tissues

• Sensititive to pressure and ulcer

• Wrinkle and sag

• Dry, wrinkled , loss elasticity

• Decreased perspiration and sebum

• Fragile, easily injured

• Decrased skin tugor

• Decreased sebaceous secretions

• Dry, flabby, prone to itching

 • Atrophy of tiny arterioles near epidermis

• Impired vasomotor homeostatic mechanism

• Poor temperature regulation (feels cold even in warm climate)

• HAIR- decreased number of hair follicles, scant, fine, graying, hirsutism, possible hereditary
baldness

• NAILS- dry, thick, brittle

 Musculoskeletal

• Increase fat substitution for muscle

• Muscle atrophy

• Decreased muscular strength and function

• Loss of Calcium from bones

• Deterioration of cartilage

• Wear, friction, stiffness of joints

• Easily tired, less stamina

• Impaired range of motion resulting from stiff joints

• Generalized loss of 6-10 cm in stature because of: flexion of knee and hip joint, narrowing of
intervertebral disks

• Body takes on bony angular apperance

• Osteoporosis is common

 Cardiovascular

• Thickened cardiac valves

• Decreased myocardial contractability

• Decreased elasticity of blood vessels

• Decreased elasticity and increased stiffness of the arterial wall

• Loss of atrial pacemaker

• Reduction of hemapoietic activity

• Increased blood coagulability

• Decreased efficiency of baroreceptors

 Respiratory

• Reduced chest compliance

• Increased AP diameter of thorax

• Reduced breathing capacity

• Reduced vital capacity

• Increased residual volume

• Decreased cough reflex

• Decreased ciliary activity

• Decreased elasticity of tissue

 Nervous

1. general

a. slow speed of impulse transmission

b. progressive decrase in number of functioning neurons in CNS and sense organs

c. normal neurological functioning possible because of tremendous reserve number of neurons

2. mental and cognitive function

a. altered capacity to retain new information and learn new tasks

b. some impairment of memory and metal endurance

3. sensory

a. some impairment of sensory perception

b. gradual decrease of visual and auditory acuity

4. motor

a. slowed reaction to stimuli; lenthening of reaction time

b. decreased coordination and balance

• Degeneration and atrophy of neurons

• Decreased nerve acuity and sensation

• Loss of memory

• Reduced concentration ability

• Decrased attention span

• Decision-making and judgement ablility remain intact

• Ability to learn is possible up to 200 years of life

• Decreased muscle coordintaion

 Gastrointestinal

• Minimal loss of digestive enzymes

• Decreased absorption

• Decreased peristalsis

• Slowed digestion;increased food intolerance

• Decreased metabolism: caloric requirement approximately 1000 calories per day

• Redistribution of body fat; increased fat in trunk, especially in abdomen

• Teeth and gum problems common

• Atonia constipation in common

 Renal/Genitourinary

• Decrased blood flow

• Reduced GFR

• Reduced nephrons

• Decrased creatinine clearance

• Increased propensity to toxic effects of drugs

 • decrased renal capacity to concentrate urine at night

1. genital

a. ability to function sexaully may continue well in older years

b. female: menopause secondary to decreased estrogen

c. male: decreased testosterone, spermatogenesis, and size of testes, increase in size of prostate

 Endocrine

• Decrased utilization of insulin

• Cessatiomn of progesterone

• Decreased then plateau of estrogen

• Gradual decline in testosterone

• Reduced BMR

 Sexual

• Minimal change in amount of sexual response

• Increased in time for full sexual response

• Reduced vaginal lubrication

• Increased refractory peroids in male

• Decreased cell mass and weight

 Immunity

• Reduced humoral and cellular immunocompetence

• Slowed, less efficient, response to antigens increases susceptibility to infections

 Sensory

 Vision

• Loss of accomodation

• Loss of color sensitivity

• Decreased dark adaptation

• Decreased peripheral vision

• Reduced sensitivity to glare

• Slowed accomodation to light

• Decreased visual acuity-farsightedness d/t slow lens accomodation, narrowed field of

vision (tunnel vision)

 Hearing

• Decreased threshold for high frequencies

• Decreased auditory acuity

• Sesorineural hearing deficit (presbycusis) gradual loss of ability to discriminate to high

frequensy tools

 Taste and smell

• Lack of appetite

• Prefer salty diet

 Touch

• Safety hazard
  Dental

• Gums becomes less elastic;less vascular

• Recede from remaining teeth, exposing areas of teethe not covered with enamel

Stages of growth and development

Older adulthood

Young adult-65-74 years old

Adaptation to retirement and changing is often necessary.Chronic illness may develop

N.I.- assist clients to keep physically and socially active and to maintain per group interactions

Middle old- 75 to 84 years old

Adaptation to decline in speed of movement, reaction time and increasing dependence on others may be necessary

N.I. Assist clients to cope with loss, provode necessary safety measure

Old-old- 85 and above

Increasing physical problems may develop

N.I. Assist clients with self care as required and with maintaining as much independence as possible

Havighurts’s age periods and developmentakl tasks

Late maturity

1. adjusting to decreasing physical stregth and health

2. adjusting to retirement and reduced income

3. adjusting to death of spouse

4. establishing an explicit affiliation with one’s group

5. meeting social and civil obligations

6. establishing satisfactory physical living arrangements

Freud’s stages of development

Genital- puberty and after

Energy is directed toward full sexual maturity and function and development of skills needed to cope with the
environment

N.I. encourage separation from parents, achievement of independence and decision making

Psychosocial Development

-Developmental task of the older adult

1. adjusting to decreasing physical strenght and health

2.Adjusting to retirement and reduced income

3.Adjusting to the death of one’s spouse

4.Establishing an explicit affiliation with one’s age group

5. Meeting social and civil obligations

6.Establishing satisfactory living arrangements

7.Establishing satisfactory relationships with adult children

8. Finding meaning in life

Erik Erikson ego integrity vs. Despair

Ego integrity 65 years to death

- Views life with a sense of wholeness and desires satisfaction from part accomplishments

- Views death as an acceptable completion of life

- Accept one’s and only life cycle

- Bringing serenity and wisdom

Despair

- Believes they have made poor choices during life and wish they live life loner

- Inability to accept one’s fate

- Gives rise to feeling with frustration, discouragement, and a sense that one’s life has been worthless

Acceptance of worth and uniqueness of one’s own life, acceptance of death

Indicators of negative resolution

-sense of loss, contempt to others

A.Integumentary system

1. Pruritus or generalized itcching is an extremely common geriatric disorder. It is one of the most common
s/sx of patients with dermatologic disorders. Pruritus may be the first indication of a systemic internal internal
disease such as diabetes mellitus, blood dioserders, or cancer. It mas also accompany renal, hepatic, and thyroid
dses. Some common oral medications such as aspirin, antibiotics, hormones, and opioids may cause pruritus
directly or by increasing sensitivity to ultraviolet light. Certain soaps and chemicals, radaiation therapy, prickly
heat, and contact with woolen garments are also associated with pruritus. It may also be caused by psychological
factors, such as excessive stress in family or work situations.

-washing with soap and hot water is avoided

-bath oils containing a surfactant that makes the oil mix with bath water may be sufficient for cleaning

-a warm bath with mild soap followed by application of a bland emolient to moist skin can control xerosis

-applying a cold compress, ice cube, or cool agents that contain methol and camphor may also help relieve
pruritus

Pharmacologic therapy:
 Topical cortecosteroids(anti inflammatory)

Oral antihistamines-diphenhydramine(Benadryl)

hydorxyzine (atarax)

Nursing management: 1.) nurse reinforces the reasons for the prescribed therapeutic regimen and counsels
patient on specific points of care,

2.)remind patient to use tepid water and to shake off the excess water and blot between interriginous areas with
a towel,

3) rubbing vigorously with towel is avoided,

4) instruct to avoid situations that causes vasodilation,

5) vigorous scratching should be avoided,

6) room should be kept coll and humidified

2.) Psoriasis- is a chronic non infectious inflammatory disease of the skin in which epidermal cells are
produced at a rate that is about six to nine times faster than normal

S/Sx: lesions are as red, raised patches of skin covered with silvery scales

Medical management: Oils or coal tar preaparations can be added to bath water and a soft brush used to scrub the
psoriatic plaque gently; application of emolient creams containing alphahydroxy acids or salicylic acid will continue
to soften thick scales

Pharmacologic theraphy:

1.) topical agents-tar preparations, athralin, salicylic acid and cortecosteroids-Calcipotriene (dovonex) and
tazoretene (tazorac)

2.) intralesional agents- triancinolone acetonide(aristocort, kenalog 10, trymex)

3.) systemic agents- hydroxeurea(hydrea), cyclosporine A (CyA)

Photochemotheraphy- one treatment for severe dbilitating psoriasis is a porsalen medication combined with
ultraviloet light-A (PUVA) light theraphy

Nursing Interventions:

1. Promote understanding

2. Increase skin integrity

3. Improving self-concept and body image

4. Monitoring and managing potential complications

5. Promoting health and community based care

B. Musculoskeletal System

1.) Osteoporosis- is so obiquitous in older age that is generally is considered a normal age realted
phenomenon rather than a disease. It is characterized by a decreased in bone mass per unit volume, producing a
porous-looking skeletal frame that fractures eaqsily when stressed

Risk factors: small framed, nonobese Caucasian women are at greatest risk

Asian women of slight build

Increased age, low weight and body mass index, estrogen deficiency or menaopause, family history, low initial
bone mass, contributing coexisting medcial conditions

Assessment and diagnostic exams:

-routine xrays

Medical Management:
 1. An adequate, balanced diet rich in calcium and vitamin D throughout life with anincreased calcium intake
during adolescence, young adulthood, and the middle years-3 glasses of skim milk or whole Vitamin D
enriched milk orother foods high in calcium

2. Calcium supplement

3. Regular weight bearing exercise

4. Weight training

Pharmacologic treatment:

1. Hormone replacement therapy with estrogen and progeterone

2. Biphosphonates and calcitonin

Nursing intervention:

1. Promoting undersatanding of osteoporosis and the treatment regimen

2. Relieving pain

3. Improving bowel elimination

4. Prevening injury

2.) Osteoarthritis- also known as generative joint disease; non inflammatory disorder of movable joints
Risk factors:

1. Increased age

2. Obesity

3. Previous joint damage

4. Repetitive use

5. Anatomic deformity

6. Genetic susceptibility

Clinical manifestations:

1. Pain, stiffness and gunctional impairment

Assessment and diagnostic findings:

1. X-ray

Medical management:

1. Weight reduction, prevention of injuries, perinatal screening for congenital hip disease and ergonomic
modifications

2. occupational and physical theraphy

Pharmacologic Treatment:

1. Acetaminophen

2. Opioids and intra articular cortecosteroids

3. Topical analgesics – Capsaicin and methylsalicylate

4. Glucosamine and chrondoitin

Surgical Management:

1. Osteotomy

2. Arthroplasty

3. Tidal irrigation of the knee

Nursing intervention:

1. pain management and optimizing functional ability

3.) Rheumatoid arthritis- chronic, systemic, progressive disease of unknown origin.
Clinical manifestations:

1. Joint pain, swelling, warmth, erythema, and lack of function

2. palpation of the joints reveals spongy or boggy tissue

3. joint stiffness

4. deformities oof hands and feet

5. fever, weight loss, fatigue, anemia, lymph node enlargement and raynuads phenomenon stress induced
vasospasm

Assessment and diagnostic findings:

1. history and physical examintaion

2. Increased in Erythrocyte sedimentation rate

3. Arthrocentesis

4. X-ray

Medical Management:

Early stage RA:

1. Education- balance of rest and exercise and referral to community agencies for support

2. therapeutic doses of salicylates or NSAIDS

3. Biologic response –enatercept (enbrel)/infliximab (remicade)

Moderate erosive RA:

1. formal program with occupational and physical theraphy (cyclosporine)

Persistent erosive RA:

1. reconstructive surgery and cortecosteroids(synovectimy/ tenorrhaphy/arthroplasty

Advanced unremitting RA:

1. immunosuppressive agents are prescribed –methotrexate (rheumatrex), cyclophosphamide (cytoxan),

azathioprine (imuran)

Nutrition theraphy

Nursing intervention:

C. Cardiovascular system:

1. Hypertension
-a systolic blood pressure greater than 140mmHg and a diastolic pressure greater that 90mmHg over a sustained
period.

Clinical manifestations:

1. High BP

2. Retinal changes such as hemmorhages, exudates, arteriolar narrowing, and cottonwool spots

3. papilledema

Major risk factors:

1. smoking

2. dyslipidemia

3. DM

4. age older than 6o years old

5. Gender (men and postmenopausal women)

6. Family history

Assessment and diagnostic evaluation:

1. Health history and physical assessment

2. Urinalysis

3. Blood chemistry

4. 12 lead echocardiogram

5. Creatinine clearance

6. Renin level

Medical management:

-The goal of hyoertension treatment is to prevent death and complications by achieving and maintaining the
arterial blood pressure at 140/90 mmHg or lower.

-weight loss, reduced alcohol and sodium intake, and regular physical activity

Pharmacologic Theraphy:

1. Diuretics, beta nlockers or both

Nursing intervention:

1. Increasing Knowledge

2. Promoting Home and community based care

2. Myocardial Infarction
-usually caused by reduced blood flow in a coronary artery due to atherosclerosis, and occlusion of an artery by an
embolus or thrombus

Vlincal Manifestations

1. Chest pain occurs suddenly

2. Shortness of breath, dyspnea, tachypnea

3. nausea and vomiting

4. decreased urine output

5. cool, clammy, diaphoretic, pale skin

6. anxiety, restlessness

7. Denial

Assessment and diagnostic Findings

1. Physical assessment and Patient History

2. Electrocardiogram

3. Echocardiogram

4. Laboratory test (Creatine Kinase and its isoenzymes, Myoglobin, Troponin T)

Medical management:

-the goal of the medical management is to minimize myocardial damage, preserve myocardial function and prevent
complications

-thrombolytic medications (PTCA)

-Emergent Percutaneous Coronary Intervention

-cardiac Rehabilitation

Pharmacologic theraphy:

1. Thrombolytics
2. Angiotensin converting enzyme inhibitors (ACE-I)

Nursing Intervention:

1. relieving pain and other signs and symptoms of ischemia

2. improving respiratory function

3. promoting adequate tissue perfussion

4. reducing anxiety

5. monitoring and managing potential complications

6. promoting home and community based care

3. Angina Pectoris
- ususally characterized by episodes or paroxysm of pain or pressure in the anterior chest

Clinical manifestations:

1. chest pain

2. choking or strangling sensation

3. weakness or numbness in arms

4. shortness of breath

5. pallor

6. dizziness

7. nausea and vomiting

Medical management:

-goal :to decrease the oxygen demand of the myocardium and to increase the oxygen supply

-Revasculization procedures –Percutaneous coronary interventional (PCI),

Pharmacologic treatment:

1. Nitroglycerin

2. Beta-Adrenergic Blocking agents

3.Calcium channel blocking agents

4. anti platelet and anti coagulant medications

-oxygen administration

-alternative therapies

Nursing Intervention:

1. Treating angina

2.Reducing anxiety

3. Preventing pain

4. Promoting home and community based care

D.Respiratory System

1. Asthma
- is a clinical syndrome characterized by three phenomena: recurent episodes of airway obstruction that resolve
spontaneously or in response to treatment, airway hyperresponsiveness, and iraway inflammation.
Clinical manifestations:

1. breathlessness

2. wheezes

3. intermittent cough

4. tightness in chest

5. use of accesory muscles

6. intercostal retractions

7. chest hyperinflation and prolonged expiratory phase of respirations

Management:

-Drug theraphy- beta adrenergic agonists, anticholinergics, Leukotriene modifiers

2. COPD

E. Nervous System

1. Dementia- is charaterized by uneven , downward decline in mental funtion.

Management:

1.Cognition

2. Activities of daily living

3. Behavior

2. Alzheimer’s disease- is a chronic,progressive and degenerative brain disorder accompanied by

profound effects on memory, cognition and ability for self care.

Clinical manifestations:

1. forgetfullness and subtle ,memory loss occur

2. small dificulties in work or social activities but has adequate cognitice function tgo hide the loss and can function
independently

3. Depression

4. loss ability to recognize familiar faces, place and things

Assessment and diaqagnostic findings:

1. Assessment and Ptaient History

2. complete blood count

2. Electroencephalography

3. Magnetic resonance imaging

4. examination of cerebrospinal fluid

Medical management:

1.tacrine hydrochloride (Cognex)

2. donepezil (Aricept)

3. Rivastigmine (Exelon)

Nursing interventions:

1. Supporting cognitive fuunction

2. Promoting physical safety

3. reducing anxiety and agitation

4. Improving communication

5. Promotinng independence in self care activities

6. Providing for socialization and intimacy needs

7. Promoting adeqauate nutrition

8. Promoting balance activity and rest

9. Supporting Home and Community based care

3. Parkinson’s Disease-is a slowly progressing neurlogic movement disorder that eventually leads to
disability

Clinical Manifestations:

1. Tremor

2. Rigidity

3. Bradykinesia

4. depression, dementia, sleep disturbances, excessive and uncontrolled sweating

Assessment and Diagnostic findings:

1. assessment and history

2. PET scanning

Medical management:

1. Pharmmacologic theraphy

a. anti parkinsonian medications- Levodopa

2. Anti cholnergic theraphy

3. Anti viral theraphy

4. Dopamine agonists

5. Monoamine oxidase inhibotirs

6. Cathechol-O-methyltransferase inhibitors

7. anti depressants

8. antihistamines

Surgical management:

1. Stereotactic procedures

2. Neural transpalantation

3. Deep brain stimulation

Nursing Intervention:

1. Improving mobility

2. Enhancing self care activities

3. Improving bowel elimination

4. Improving nutrion

5. enhancing swallowing

6. encouraging the use of assistive devices

7.improving communication

8.supporting coping abilities

9. Promoting home and commnity based care

F.Gastrointestinal system:

1. Gastric Ulcer

2. Peptic ulcer

G. Genitourinary system

1.Dysfunctional Voiding patterns

a. Adult voiding dysfunction- both neurogenic and non-neurogenic disorders can cause adult voiding dysfunction.

b. Urinary Incontinence- involuntary loss of urine

Types of incontinence:

a. stress incontinence

b. urge incontinence

c. reflex incontinence

d. overflow incontinence

Assessment and diagnostic findings:

1. Physical Assessment and patient history

2. extensive urodynamic test

3. urinalysis

4. urine culture

Medical Management:

1. Behavioral therapy

2. Pharmacologic therapy

a. Anti cholinergic agents- (oxybutynin);Diclomine (antispas)

b. Tricyclic anti depressants- Imipramine, doxepin, desipramine, nottripyline

c. Oral estrogen

Surgical management:

a. anterior vaginal repair

b. periurethral bulking

c. Tranurethral resection

Nursing Intervention:

1. Provide support and encouragement

2. Patient teaching reagrding the bladder program

2. Urinary retention – is inability to empty the bladder completely during attempts to void

-in adults older than age 60, 50 to 100 ml of residual urine may remain after each each void because of the
decreased contractility of the detrusor muscle

Maniifestationsw:

1. bladder fullness

2. sensation of incomplete bladder emptying

Assessment and diagnostic findings:

1. Assessment and history

Nursing Intervention:

1. Promoting normal urinary elimination

2. Promoting urinary elimination

3. Promoting Home and community based care

3. Urinary Tract Infection-is an infection that begins in your urinary system. Your urinary system is composed of the
kidneys, ureters, bladder and urethra. Any part of your urinary system can become infected, but most infections
involve the lower urinary tract — the bladder and the urethra.

Clinical manifestations:

• A strong, persistent urge to urinate

• A burning sensation when urinating
• Passing frequent, small amounts of urine
• Urine that appears cloudy
• Urine that appears bright pink or cola colored — a sign of blood in the urine
• Strong-smelling urine
• Pelvic pain, in women
• Rectal pain, in men

Types of urinary tract infection

Each type of urinary tract infection may result in more-specific signs and symptoms, depending on which part of your urinary tract is infected.

Part of urinary tract affected Signs and symptoms

• Upper back and side (flank) pain

• High fever
• Shaking and chills
Kidneys (acute pyelonephritis)
• Nausea

• Vomiting

• Pelvic pressure
• Lower abdomen discomfort
Bladder (cystitis) • Frequent, painful urination

• Blood in urine

Urethra (urethritis) • Burning with urination

Assessment and diagnostic findings:

1. assessment and history

2. colony counts

3. cellular studies

4. urine cultures

Medical management:

1. acute pharmacologic therapy

2. lont term pharmacologic theraphy

Nursing Intervention:

1. Relieving pain

2. Monitoring and managing potential complications

3. Promoting home and community based care

H. Endocrine System

1. Hypothyroidism

2. Hyperthyroidism

I.Immune System
1. Pernicious Anemia

2. HIV/AIDS in older patients

J. Sensory Problems