Medical Surgical Nursing

(Tina Sui) #1

Gerontological Considerations



  • Important to distinguish normal aging changes from abnormal changes

  • Determine previous mental status for comparison. Assess mental status carefully to


distinguish delirium from dementia.



  • Normal changes may include:

  • Losses in strength and agility; changes in gait, posture and balance; slowed reaction


times and decreased reflexes; visual and hearing alterations; deceased sense of taste and


smell; dulling of tactile sensations; changes in the perception of pain; and decreased


thermoregulatory ability


Pupil Size



  • Normal range: 2 - 6 mm

  • Drugs: pinpoint pupils

  • Increased intracranial pressure: pupils begin to dilate

  • Dilated and fixed, poor prognosis


Glascow Coma Scale



  • Score BEST response in each category

  • Highest score = 15 (normal)

  • Lowest score = 3 (deep coma)

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