Transcript Physiological basis of the care of the elderly client

The Integument;
Sensation: Hearing, Vision, Taste, Touch
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You are assigned to care for MX, an 87 year old
obese (264 lbs) woman.
 She arose from a sitting position and
experienced severe low back pain 3 weeks ago.
 Diagnosis: herniated disks
L4-5 and L5-S1.
 She states her legs feel like
“noodles” and she can’t feel
them very well.
 Her temperature has increased
from 98.2 to 100.6.
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What additional information do you need?
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Subjective information
Objective information
Psychosocial information
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Regulation of body fluids—prevent loss from
deeper layers
 Regulation of temperature—blood vessels in
dermis
 Regulation of immune function—prevent
microbe invasion
 Production of vitamin D
activated by UV light
 Sensory reception—detect
touch, pressure,
temperature, pain
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Fine and coarse wrinkles
Rough, leathery texture
Mottled hyperpigmentation
Telangiectasia (dilated red splotches)
Actinic keratoses
Facial expression
Body image
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Pigmentation changes—photoaging
 Decrease in eccrine (total body), apocrine
(armpits, genital, areolar, anal), sebaceous
glands → dry skin
 Decrease in number of blood vessels
 Loss of eyelid elasticity
 Decreased elastin, wrinkling
 Adipose tissue redistributes
to waist & hips
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Changes in pigmentation
 Decreased melanocytes with decreased
photoprotection
 Delayed wound healing
 Onychomycosis common
 Decreased touch receptors,
corresponding slowing of
reflexes and pain sensation
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Contains less moisture
Epidermal mitosis slows, healing takes longer
Manufacture of vitamin D less efficient
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Vitamin D promotes anti-inflammatory
actions systemically to reduce the risk of
coronary heart disease
Vitamin D level is inversely correlated with
coronary artery calcification
Vitamin D promotes
absorption of calcium and
phosphorus by bone
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Skin
cancers
Pressure
ulcers
Skin tears
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Avoid drying of the skin in the elderly!
Promote skin nutrition and hydration through
bath oils, lotions and massage
Vitamins and vitamin supplements
Avoid excessive bathing
Early treatment of pruritis
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Elastin decreases in quality but increases in
quantity leading to wrinkles
Vascularity decreases
Capillaries become thinner and more easily
damaged
Decline in touch and pressure sensations
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Subcutaneous tissue thinner in the face, neck,
hands and lower legs
More visible veins
Fat distribution more obvious in abdomen
and thighs in women, the abdomen in men
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Gray or white hair
Hair becomes more coarse and thin
Gradual loss of pubic and axillary hair
Facial hair in women
Ear and nose hair in men
Hair loss, men > women
Nails duller, yellow or grey
Nail growth slows
Longitudinal striations
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Decreased sweating and thermoregulation
 Amount of sebum decreases, causing less
water in stratum
corneum resulting in
xerosis
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Most common dermatologic complaint in the
elderly
 Drying of the skin by any means
 Diabetes, atherosclerosis, hyperthyroidism,
urea, liver disease,
cancer, pernicious
anemia, some
psychiatric diseases
 Problem: traumatizing
scratching
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Bath oils, massage
Moisturizing lotions
ZnO2 may be applied topically
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Photoaging—long-term UVR damage
 Exposed areas of the face, neck, arms, and
hands
 Freckling, loss of elasticity,
damaged blood vessels,
weathered appearance
 May result in actinic keratosis,
a precancerous lesion
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Avoid tanning and
sunburn
 Sunscreen daily, SPF 30
 Moisturize
 Protective clothing
 Protective accessories
that block UV rays:
umbrellas, sunglasses,
window shades and
car window tints
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Antibiotics: Doxycycline, tetracycline,
quinolones
Antidepressants: tricyclic antidepressants
Antihistamines: diphenhydramine
Nonsteroidal anti-inflammatories: ibuprofen
Diuretics: furosemide, hydrolorothiazide
Antihypertensives: Cardizem, diltiazem
Cholesterol drugs: simvastatin, lovastatin
Hypoglycemics: glipizide, glyburide
Sulfonamides: sulfadiazine, sulfamethoxazole
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Most common precancerous lesion
 More common in men
 1 in 1000 will progress to skin cancer (usually
squamous cell
carcinoma) within
1 year
 Ill-defined border
 Back of hands, face,
forearm, V of neck,
nose, ears, bald scalp
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Basal cell carcinoma—waxy,
pigmented, may be
erythematous, papular or
scaly macular
 Squamous cell carcinoma—
firm to hard, erythematous,
nodular or ulcerated nodular,
especially on dorsum of hands,
forearms and face
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Those who have had one nonmelanoma skin
cancer is at risk for future skin cancers
Any suspicious lesion should be biopsied
Risk for skin cancer associated with total
amount of time spent in the sun
Basal cell rarely metastasizes
Squamous cell can metastasize
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Occur easily in frail elderly
Classification
◦ Category 1: linear or flap type without tissue loss
◦ Category 2: partial tissue loss
◦ Category 3: full thickness tissue loss
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Fragile skin that damages easily
Poor nutritional status
Reduced sensations of: pressure and pain
Elderly have more frequent encounters with
conditions that contribute
to skin breakdown
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Serum albumin—indicator of protein stores
◦ 3.5-5.0 g/dl is normal
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Prealbumin—indicator of protein deficiency
◦ >15 mg/dl is normal
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Lymphocyte count—indicator of protein
malnutrition
◦ 2000-3500 µL is normal
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Can develop on any part of the body
 Caused by tissue anoxia and ischemia
 Most common sites:
Sacrum (most distal portion of spine)
Greater trochanter (head of femur)
Ischial tuberosities
(protuberance of proximal
hip)
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Risk of developing pressure ulcers based on
evaluation of six areas:
1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and shear
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Prevention is based on 6 areas of Evaluation:
 Avoid unrelieved pressure
 Encourage activity
 Turn every hour
 Pillow
 Flotation pad
 Encourage outside activities
 Avoid shearing forces
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High protein, vitamin rich diet
Good skin care
Bath oils and lotions
Keep skin dry
Massage bony prominences
Range of motion at least daily
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Persistent redness (erythema or hyperemia)
Ischemia (erythema with edema and
induration)
Skin is still intact
Erythema does not
blanch when
pressure applied
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Partial skin thickness loss
Appearance of an abrasion, a blister, a
shallow ulcer
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Full skin thickness loss
 Subcutaneous tissue
is exposed
 Appearance of deep ulcer
 May or may not be
undermining of
surrounding
tissue
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Full skin thickness loss
Subcutaneous tissue loss
Muscle and or bone is lost
Deep ulceration
May be accompanied by:
•Necrosis
•Sinus tract
formation
•Exudate
•Infection
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Hyperemia—relieve pressure, use of adhesive
foam
Ischemia—skin protectant solutions, clean
with normal saline at least daily if skin broken
Necrosis—transparent dressing permeable to
oxygen and water vapor, irrigate thoroughly,
topical antibiotics
Ulceration—debridement is required
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Debridement of nonviable (necrotic) tissue
Keep wound clean
Dress to keep moist wound bed
Prevent and treat infection
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Occurs when one or more types of bacteria
enter through a break in the skin
Most common types of bacterial causes of
cellulitis
◦ Streptococcus
◦ Staphylococcus
◦ MRSA is increasing
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The most common
location is the
lower leg
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Skin surrounding eye becomes thinner
Eyelid musculature decreases
◦ Ectropion
◦ Entropion
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Decreased visual acuity, color discrimination
Atrophy of lacrimal glands
Increase intraocular pressure (IOP)
Arcus senilis
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More light
required to
see clearly
↓ Ability to
recover from
glare
↓ Ability to see
in dark
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Macula absorbs excess blue
and UV light, promoting
visual acuity.
Macular degeneration
affects central vision
and visual acuity
 Cataracts—clouding
of the lens covering
the eye
 Glaucoma--⇧IOP causes
optic nerve damage
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Age > 50 years
Cigarette smoking
Family history of macular degeneration
Increased exposure to UV light
Caucasian
Light colored eyes
Hypertension or cardiovascular disease
Lack of dietary antioxidants and zinc
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Increased age
Smoking and alcohol
Obesity
Diabetes, hyperlipidemia, hypertension
Eye trauma
Exposure to sun
Long term use of corticosteroid medications
Caucasian race
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Increased IOP
Age > 60 years
Family history of glaucoma
Myopia, diabetes, hypertension, migraines
African American ancestry
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Β-blockers → bradycardia, CHF, syncope,
bronchospasm (Timoptic, Betagan)
Adrenergics → palpitations, hypertension,
tremor (Lopidine)
Miotics/cholinesterase inhibitors →
bronchospasm, N/V, abdominal pain
(pilocarpine)
Carbonic anhydrase inhibitors → renal failure,
hypokalemia, diarrhea (Trusopt, Azopt)
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Hearing impairments and
loss affect communication
and desire to interact
 Cerumen tends to be drier,
harder
 Pruritis of canal
is common
 Most hearing changes
are attributable to
exposure to loud sounds
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Conductive hearing loss—process of the
external or
middle ear canal
 Sensorineural hearing
loss—process of the
inner ear
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Prompt and complete treatment of ear
infections
Prevention of trauma
Regular audiometric exams
Evaluate for cerumen collection
Remove cerumen by gentle irrigation
Avoid cotton applicators in ear
Educate regarding effects of environmental
noise
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Ototoxicity—gentamycin,
erythromycin, cisplatin,
furosemide
Tinnitus—gentamycin,
erythromycin, baclofen,
propanolol, aspirin
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Eliminate extraneous noise
 Stand 2 to 3 feet from the patient
 Eye contact
 Use lower pitch of voice
 Frequent pauses
 Speak slowly and clearly
 Ask for validation of
understanding
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Check surface of ear mo
mold
 Check the battery
 Do the dials work?
 Are the dials
functioning?
 Is the tubing patent
and connected
properly?
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Slowing of conduction of nerve impulses
 Causes decreased perception of pain and
temperature
 Creates risk for injury
 Contributes to sensation of
isolation and decreased
interaction with others
 Remember the value of
therapeutic touch!
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Frequent monitoring of skin for intactness
Note and educate regarding safety risks
Teach patient to assess skin regularly
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What is your nursing diagnosis for MX?
What is your desired outcome?
What are appropriate interventions pertinent
to your desired outcome?
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Patient will have no alteration in body
temperature by (date).
◦ Monitor for signs/symptoms of infection
every 4 hours.
◦ Monitor skin and mucous membrane integrity every
2 hours.
◦ Monitor intake and output every hour.
◦ Provide cooling measures within parameters
described by health care provider.
◦ Collaborate with health care team in identifying
causative organisms.
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Patient will identify behaviors contributing to
her risk for injury and corrective measures by
(date).
◦ Keep bed locked and in low position
◦ Assess patient safety status every hour and remind
of location of call light.
◦ Provide night light.
◦ Assist patient with transfers and
ambulation.
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Patient will exhibit structural intactness of
skin by (date).
◦ Perform active or passive ROM at least once per
shift at time of bathing or position change.
◦ Reduce pressure on skin surfaces by using egg
crate mattress.
◦ Collaborate with dietitian regarding well-balanced
or weight reduction diet.
◦ Facilitate fluid intake by
offering water every hour.
◦ Maintain good body hygiene
using lotion and massage.
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