1. Physiological basis of the care of the elderly client
The Integument;
Sensation: Hearing, Vision, Taste, Touch

2. Patient scenario
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

3. What additional information do you need?
Informal evaluation
What additional information do you need?
Subjective information
Objective information
Psychosocial information

4. Normal functions of the skin
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

5. Structure of the skin

6. What the skin does with age….
Fine and coarse wrinkles
Rough, leathery texture
Mottled hyperpigmentation
Telangiectasia (dilated red splotches)
Actinic keratoses
Facial expression
Body image

7. Normal changes of aging
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

8. Normal changes of aging
Changes in pigmentation
Decreased melanocytes with decreased photoprotection
Delayed wound healing
Onychomycosis common
Decreased touch receptors,
corresponding slowing of
reflexes and pain sensation

9. Specific changes in epidermis
Contains less moisture
Epidermal mitosis slows, healing takes longer
Manufacture of vitamin D less efficient

10. Sidebar: What Vitamin D Does!
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

11. Risks of age related changes in skin
Skin cancers
Skin tears
Pressure ulcers

12. Facilitating integumentary health
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

13. Specific changes in the dermis
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

14. Specific changes in the subcutaneous layer
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

15. Changes in hair and nails
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

16. Changes in eccrine and apocrine glands
Decreased sweating and thermoregulation
Amount of sebum decreases, causing less water in stratum
corneum resulting in
xerosis

17. Pruritis 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

18. Treatment—pruritis Bath oils, massage Moisturizing lotions
ZnO2 may be applied topically

19. Damage due to sun 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

20. Sun protection 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

21. Sun sensitizing drugs
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

22. Actinic keratosis 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

23. Skin cancer—major types
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

24. Education regarding skin cancers
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

25. Skin tears 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

26. Risk factors for decubitus ulcers
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

27. Lab indicators of pressure ulcer risk
Serum albumin—indicator of protein stores
g/dl is normal
Prealbumin—indicator of protein deficiency
>15 mg/dl is normal
Lymphocyte count—indicator of protein malnutrition
µL is normal

28. Pressure ulcers 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)

29. Use of the Braden scale
Risk of developing pressure ulcers based on evaluation of six areas:
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear

30. Example of Braden Scale Form

31. Preventing Pressure ulcers
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

32. Skin health promotion and recovery requires:
High protein, vitamin rich diet
Good skin care
Bath oils and lotions
Keep skin dry
Massage bony prominences
Range of motion at least daily

33. Stage 1—signs/symptoms
Persistent redness (erythema or hyperemia)
Ischemia (erythema with edema and induration)
Skin is still intact
Erythema does not
blanch when
pressure applied

34. Stage 2—signs and symptoms
Partial skin thickness loss
Appearance of an abrasion, a blister, a shallow ulcer

35. Stage 3—signs and symptoms
Full skin thickness loss
Subcutaneous tissue
is exposed
Appearance of deep ulcer
May or may not be
undermining of
surrounding
tissue

36. Stage 4—signs and symptoms
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

37. Interventions 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

38. Principles of pressure ulcer healing
Debridement of nonviable (necrotic) tissue
Keep wound clean
Dress to keep moist wound bed
Prevent and treat infection

39. Cellulitis
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
The most common
location is the
lower leg

40. Age related changes of the eye
Skin surrounding eye becomes thinner
Eyelid musculature decreases
Ectropion
Entropion
Decreased visual acuity, color discrimination
Atrophy of lacrimal glands
Increase intraocular pressure (IOP)
Arcus senilis

41. Light sensitivity ↓ Ability to see in dark
More light required to see clearly
↓ Ability to see in dark
↓ Ability to recover from glare

42. Common visual impairments
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

43. Risks for macular degeneration
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

44. Macular degeneration

45. Risks for cataracts Increased age Smoking and alcohol Obesity
Diabetes, hyperlipidemia, hypertension
Eye trauma
Exposure to sun
Long term use of corticosteroid medications
Caucasian race

46. Cataracts

47. Risks for glaucoma Increased IOP Age > 60 years
Family history of glaucoma
Myopia, diabetes, hypertension, migraines
African American ancestry

48. Glaucoma

49. Medications that can affect vision in the elderly
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)

50. Hearing changes 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

51. Types of hearing loss
Conductive hearing loss—process of the external or
middle ear canal
Sensorineural hearing
loss—process of the
inner ear

52. Promoting hearing health
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

53. Methods of Removing Cerumen

54. Effects of specific drugs on hearing
Ototoxicity—gentamycin,
erythromycin, cisplatin,
furosemide
Tinnitus—gentamycin,
erythromycin, baclofen,
propanolol, aspirin

55. Speaking to the hearing impaired
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

56. Hearing aids… Check surface of ear mo mold Check the battery
Do the dials work?
Are the dials
functioning?
Is the tubing patent
and connected
properly?

57. Tactile impairment 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!

58. Nursing considerations
Frequent monitoring of skin for intactness
Note and educate regarding safety risks
Teach patient to assess skin regularly

59. Formal evaluation What is your nursing diagnosis for MX?
What is your desired outcome?
What are appropriate interventions pertinent to your desired outcome?

60. Risk for imbalance body temperature
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.

61. Risk for injury
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.

62. Risk for impaired skin integrity
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.