During ICU Stay

There are many anatomic and physiologic changes that occur with aging (see Table 30.1 in the original guideline document).
The interaction of these changes with the acute pathology of a critical illness, comorbidities, and the ICU environment leads
not only to atypical presentation of some of the most commonly encountered ICU diagnoses, but may also elevate the older
adult's risk for complications. The older adult must be systematically assessed for the following:
Comorbidities and Common ICU Diagnoses
Respiratory: chronic obstructive pulmonary disease, pneumonia, acute respiratory failure, adult respiratory distress

syndrome, rib fractures/flail chest

Cardiovascular: acute myocardial infarction, coronary artery disease, peripheral vascular disease, hypertension,

coronary artery bypass grafting, valve replacements, abdominal aortic aneurysm, dysrhythmias
Neurologic: cerebral vascular accident, dementia, aneurysms, Alzheimer's disease, Parkinson's disease, closed head

injury, transient ischemic attacks

Gastrointestinal (GI): biliary tract disease, peptic ulcer disease, GI cancers, liver failure, inflammatory bowel disease,

pancreatitis, diarrhea, constipation, and aspiration

Genitourinary (GU): renal cell cancer, chronic renal failure, acute renal failure, urosepsis, and incontinence

Immune/hematopoietic: sepsis, anemia, neutropenia, and thrombocytopenia

Skin: necrotizing fasciitis, pressure ulcers

Acute Pathology
Thoracic or abdominal surgery, hypovolemia, hypervolemia, hypothermia/hyperthermia, electrolyte abnormalities, hypoxia,
arrhythmias, infection, hypotension/hypertension, delirium, ischemia, bowel obstruction, ileus, blood loss, sepsis, disrupted
skin integrity, multisystem organ failure
ICU/Environmental Factors
Deconditioning, poor oral hygiene, sleep deprivation, pain, immobility, nutritional status, mechanical ventilation,
hemodynamic monitoring devices, polypharmacy, high-risk medications (e.g., narcotics, sedatives, hypnotics, nephrotoxins,
vasopressors), lack of assistive devices (e.g., glasses, hearing aids, dentures), noise, tubes that bypass the oropharyngeal
airway, poorly regulated glucose control, Foley catheter use, stress, invasive procedures, shear/friction, intravenous (IV)
catheters
Atypical Presentation
Commonly seen in older adults experiencing the following: myocardial infarction, acute abdomen, infection, and hypoxia
Nursing Care Strategies
Preadmission
Based on their preadmission assessment findings, nurses should consider the following:
Obtaining appropriate consults (i.e., nutrition, physical/occupational/speech therapist)

Implementing safety precautions

Using pressure-relieving devices
Organizing family meetings
Providing the older adult with a consistent primary nurse

During ICU
Nursing interventions that may benefit:
Multiple Organ Systems
Encouraging early, frequent mobilization/ambulation

Providing proper oral hygiene

Ensuring adequate pain control
Reviewing/assessing medication appropriateness
Avoiding polypharmacy/high-risk medications (see Table 30.2 in the original guideline document)
Securing and ensuring the proper functioning of tubes/catheters
Actively taking measures to maintain normothermia
Closely monitoring fluid volume status

Respiratory
Encourage and assist with coughing, deep breathing, incentive spirometer use; use alternative device when

appropriate (e.g., positive expiratory pressure [PEP]).

Assess for signs of swallowing dysfunction and aspiration.

Closely monitor pulse oximetry and arterial blood gas results.

Consider the use of specialty beds.
Advocate for early weaning trials and extubation as soon as possible.
Exercise standard ventilator-associated pneumonia (VAP) precautions (American Association of Critical Care Nurses,
2004[Level I]; American Thoracic Society & Infectious Diseases Society of America, 2005 [Level I]; Dezfulian et al.,
2005 [Level I]; Institute for Healthcare Improvement & 5 Million Lives Campaign, 2008 [Level VI]; Krein et al.,
2008 [Level IV]):

Keep the head of the bed elevated to more than 30 degrees.

Provide frequent oral care.
Maintain adequate cuff pressures.
Use continuous subglottic suctioning devices.
Do not routinely change ventilator circuit tubing.

Assess the need for stress ulcer and deep venous thrombosis (DVT) prophylaxis.

Turn the patient as tolerated.

Maintain general hygiene practices.

Cardiovascular
Carefully monitor the older adult's hemodynamic and electrolyte status.

Closely monitor the older adult's electrocardiogram (ECG) with an awareness of many conduction abnormalities seen
in aging. Consult with physician regarding prophylaxis when appropriate.
Advocate for the removal of invasive devices as soon as the patient's condition warrants. The least restrictive device

may include long-term access.

Recognize that both preexisting pulmonary disease and manipulations of the abdominal and thoracic cavities may lead

to unreliability of traditional values associated with central venous pressures (CVPs) and pulmonary artery occlusion
pressures (PAOPs) (Rosenthal & Kavic, 2004 [Level VI]).
Because of age-related changes to the cardiovascular system, the nurse should acknowledge (Rosenthal & Kavic,

2004 [Level VI]):

Older adults often require higher filling pressures (i.e., CVPs in the 8 to 10 cm range, PAOPs in the 14 to 18 cm

range) to maintain adequate stroke volume and may be especially sensitive to hypovolemia.
Overhydration of the older adult should also be avoided because it can lead to systolic failure, poor organ perfusion,

and hypoxemia with subsequent diastolic dysfunction.

Certain drugs commonly used in the ICU setting may prove to be either not as effective (e.g., isoproterenol and

dobutamine) or more effective (e.g., afterload reducers).

Neurologic/Pain
Closely monitor the older adult's neurologic and mental status.

Screen for delirium and sedation level at least once per shift.
Implement the following interventions to reduce delirium:
Promote sleep, mobilize as early as possible, review medications that can lead to delirium, treat dehydration,

reduce noise or provide "white noise," close doors/drapes to allow privacy, provide comfortable room temperature,
encourage family and friends to visit, allow the older adult to assume their preferred sleeping positions, discontinue
any unnecessary lines or tubes, and avoid the use of physical restraints, using least restraint for minimum time
only when absolutely necessary.
Maximize the older adult's ability to communicate his or her needs effectively and interpret their environment.

Promote the older adult wearing glasses, hearing aids, and other appropriate assistive devices.
Face the patients when speaking to them, get their attention before talking, speak clearly and loud enough for
them to understand, allow them enough time (pause time) to respond to questions, provide them with a
consistent provider (i.e., a primary nurse), use visual clues to remind them of the date and time, and provide
written or visual input for a message (Garrett et al., 2007 [Level IV]).

Provide the older adult with alternate means of communication (e.g., providing him or her with a pen and paper,
using nonverbal gestures, and/or using specially designed boards with alphabet letters, words, or pictures)
(Garrett et al., 2007 [Level IV]; Happ et al., 2010 [Level III]).

Provide translators/interpreters as needed.

Provide adequate pain control while avoiding oversedation or undersedation. For a full discussion, see the National

Guideline Clearinghouse (NGC) summary of the Hartford Institute for Geriatric Nursing guideline Pain management in
older adults.
Gastrointestinal
Monitor for signs of GI bleeding and delayed gastric emptying and motility.

Encourage adequate hydration, assess for signs of fecal impaction, and implement a bowel regimen.
Avoid use of rectal tubes.
Advocate for stress ulcer prophylaxis.

Provide dentures as soon as possible.

Implement aspiration precautions.

Keep the head of the bed elevated to a high Fowler's position, frequently suction copious oral secretions, bedside
evaluate swallowing ability by a speech therapist, assess phonation and gag reflex, monitor for tachypnea.

Advocate for early enteral/parental nutrition.

Ensure tight glucose control.

Genitourinary

Assess any GU tubes to ensure patency and adequate urinary output. If the older adult should experience an acute
decrease in urinary output, consider using bladder scanner (if available), rather than automatic straight
catheterization, to check for distension.

Advocate for early removal of Foley catheters. Use other less invasive devices/methods to facilitate urine collection
(i.e., external or condom catheters, offering the bedpan on a scheduled basis, and keeping the nurse's call bell/signal
within the older adult's reach).

Monitor blood levels of nephrotoxic medications as ordered.

Immune/Hematopoietic

Ensure the older adult is ordered appropriate DVT prophylaxis (i.e., heparin, sequential compression devices).
Monitor laboratory results, assess for signs of anemia relative to patient's baseline.
Recognize early signs of infectionrestlessness, agitation, delirium, hypotension, tachycardiabecause older adults are
less likely to develop fever as a first response to infection.

Meticulously maintain infection control/prevention protocols.

Skin

Conduct thorough skin assessment.

Vigilantly monitor room temperature, make every effort to prevent heat loss, and carefully use and monitor
rewarming devices.

Use methods known to reduce the friction and shear that often occur with repositioning in bed.
In severely compromised patients, the use of specialty beds may be appropriate.
Techniques such as frequent turning, pressure-relieving devices, early nutritional support, as well as frequent
ambulation may not only protect an older adult's skin but also promote the health of their cardiovascular, respiratory,
and GI systems.

Closely monitor IV sites; frequently check for infiltrations and use of nonrestrictive dressings and paper tape.

Potential Benefits
Patient

Restoration of hemodynamic stability

Avoidance/minimization of complications
Maintenance/optimization of preadmission functional ability
Minimization of pain/anxiety
Improvement of communication with the health care team

Provider

Employing consistent and accurate documentation of assessment relevant to the older intensive care unit (ICU)
patient

Provision of consistent, accurate, and timely care in response to deviations identified through ongoing monitoring and
assessment of the older ICU patient

Provision of patient/caregiver with information and teaching related to his or her illness and regarding transfer of care
and/or discharge

Institution (Includes quality assurance/quality assessment)

Evaluation of staff competence in the assessment of older critically ill patients

Utilization of unit-specific, hospital-specific, and national standards of care to evaluate existing practice
Identification of areas for improvement and work collaboratively across disciplines to develop strategies for improving
critical care to older adults