Presentation on theme: "Physiologic Changes of Aging"— Presentation transcript:
1Physiologic Changes of Aging Gerontological & Community Based Nursing:Physiologic Changes of Aging
2Age related changes affecting nutrition & hydration in older adults Reduced need for caloric intake r/t↓body mass & ↑adipose tissueBasil metabolism rate ↓ 2 % q decade of lifeGeneral ↓ in activity level∆’s in taste (sweet intact & ↓Sour, salt, bitter)∆’s in sense of smell believed to be related to other factors (∆’s in CNS function, medications, smoking)
3Other factors affecting nutrition Socialization- eating aloneIncome- strong relationship between poor nutrition & low incomeTransportation –access to shoppingHousing- substandard housing (SRO)Dentition (see box 8-3 text) – poor oral health – risk factor for dehydration & malnutrition; ↑risk oral cancers
5Nutrition concerns Two major concerns: Obesity – exacerbates age related health issues> type II diabetes, CAD, osteoarthritis,↓ mobility,Malnutrition – often unrecognizedPrecursor to frailty
6Malnutrition in older adults Protein – Calorie Malnutrition PCMmost common type of malnutritionc/b muscle wasting, low BMI;↓albumin /serum proteins50% nursing home; 50% hospitalized 44% home health elders - malnourished
7Malnutrition - Risk factors PsychosocialMechanicalBox 8-14 textPsychosocial- limited incomeAlcohol abuseCNS depressantsLonelinessRemoval of usual cultural patterns ( long-term care- hosp)Memory loss (dementia)DepressionMechanical risk factorsDec. strength/mobilityNeuro deficits, arthritis, inability to feed self, lack of assistance, difficulty swallowing, chewing, breathing,Poor fitting dentures,PolypharmacyNPO status
8“I’m Dying of Thirst!”In young, water makes up about 2/3 of our body weightThe brain is composed of about 95% waterThe blood is about 82% waterThe lungs are about 90% waterIn the elderly total body water drops to about 50% of the body’s weight“I’m dying of thirst!” Well. We just might. It sounds so simple. H20. Two parts hydrogen, one part oxygen. But this element, better known as water, is the most essential, next to air, to our survival. Water truly is everywhere, still most take it for granted.Water makes up more than two thirds of the weight of the human body, and without it, humans would die in a few days. The human brain is made up of 95% water, blood is 82% and lungs 90%. A mere 2% drop in our body’s water supply can trigger signs of dehydration: fuzzy short-term memory, trouble with basic math, and difficulty focusing on smaller print, such as a computer screen. (Are you having trouble reading this? Drink up!) Mild dehydration is also one of the most common causes of daytime fatigue. An estimated seventy-five percent of Americans have mild, chronic dehydration. Pretty scary statistic for a developed country, where water is readily available through the tap or bottle.Water is important to the mechanics of the human body. The body cannot work without it, just as a car cannot run without gas and oil. In fact, all the cell and organ functions made up in our entire anatomy and physiology depend on water for their functioning.Water serves as a lubricantWater forms the base for salivaWater forms the fluids that surround the joints.Water regulates the body temperature, as the cooling and heating is distributed through perspiration.Water helps to alleviate constipation by moving food through the intestinal tract and thereby eliminating waste- the best detox agent.Regulates metabolismIn addition to the daily maintenance of our bodies, water also plays a key role in the prevention of disease. Drinking eight glasses of water daily can decrease the risk of colon cancer by 45%, bladder cancer by 50% and it can potentially even reduce the risk of breast cancer. And those are just a few examples! As you follow other links on our website, you can read more in depth about how water can aid in the prevention and cure of many types of diseases, ailments and disorders that affect the many systems of our bodies.
9HydrationSmall changes in water content make a big difference in the elderly because:Kidneys lose their ability to concentrate urine as effectivelyThere is a decreasing sense of thirst in the elderlyRecommended daily fluid intake for the elderly is ml of non-caffeinated fluids
10DehydrationDehydration is one of the most common fluid and electrolyte problems experienced by the elderlyMost often r/t disease process NOT access to water (Thomas et.al. 2008)Result of - fluid loss + ↓ fluid intake r/t↓ thirst & ↓kidney function (↓creatinine clearance)Dehydration is one of the most common fluid and electrolyte problems experienced by older adults. The three types of dehydration are isotonic, hypertonic, and hypotonic.Assessment can be challenging because the clinical signs may not appear until dehydration is advanced. Risk factors for dehydration for long-term care residents are taken from the Minimum Data Set and given in Box Measures to prevent dehydration of institutionalized elderly persons are found in Box 11-2.3 Major TypesIsotonic - Fluid has the same osmolarity as plasmaHypotonic -Fluid has fewer solutes than plasmaHypertonic-Fluid has more solutes than plasmaIsotonic DehydrationPrevention of Isotonic DehydrationMost Common form of Dehydration Occurs when fluids and electrolytes are lost in even amounts There are no intercellular fluid shifts in isotonic dehydrationCommon Causesdiuretic therapyexcessive vomitingexcessive urine losshemorrhagedecreased fluid intakeAssessment of Isotonic DehydrationWeight LossHypotension and Orthostatic HypotensionRapid, weak pulseOliguria - (dark, concentrated, scanty urine)Decreased skin turgorDry mucous membranesElevated urine specific gravityAltered Level of ConsciousnessIncreased Hematocrit (except in hemorrhage), serum protein and BUNSevere Isotonic Dehydration can lead to SHOCKInterventions for Isotonic DehydrationMonitor daily weight, I&O, Skin turgor, LOC and V.S.Check Skin turgor on forehead or sternum on elderlyMonitor Lab values - Urine SpG, BUN, CBC and LytesReplace fluid loss using ISOTONIC fluidsTreat the underlying causeHypertonic DehydrationSecond most common type of dehydration. Occurs when water loss from ECF is greater than solute lossPrevention of Hypertonic dehydrationPrevent Insensible Fluid Loss - Hyperventilation, pure water loss with high fevers, and watery diarrhea.Control Disease Processes - Diabetic Ketoacidosis and Diabetes InsipidusPrevent Iatrogenic Causes - Prolonged NPO, excessive administration of hypertonic fluids, sodium bicarbonate, or tube feedings with inadequate amounts of waterAssessment of Hypertonic DehydrationHypertonicc Dehydration causes fluid to be pulled from the cells into the blood stream, leading to cellular shrinkage.ThirstDecreased Skin TurgorDry Mucous MembranesIncreased Serum Sodium and Serum OsmolarityIncreased Urine Specific GravitySigns of Shock are usually not presentInterventions for Hypertonic DehydrationPrevent Hypertonic Dehydration by diluting tube feedings with adequate amounts of water.Monitor I&O, daily weight, skin turgor, LOC, Serum Sodium and Serum OsmolarityAdminister Hypotonic fluids orally or SLOWLY by IV.Be aware that rapid administration of hypotonic IV fluids can cause swelling of the brain cells, and increased intercrainal pressure.Hypotonic DehydrationRelatively Uncommon - Loss of more solute (usually sodium) than water.Hypotonic Dehydration causes fluid to shift from the blood stream into the cells, leading to decreased vascular volume and eventual shockSeen in Heat ExhaustionIncreased cellular swelling -causes increased intercranial pressure - H/A and Confusion.Seen in Heat StrokePrevention of Hypotonic DehydrationAvoid over Administration of Hypotonic Fluids - Most common cause of Hypotonic DehydrationReplace fluid lost during exercise with isotonic fluids to patients with Isotonic dehydration.Select the correct IV fluid and rate to meet patients rehydration needsWatch for low serum osmolarity and serum sodiumPersons at Risk -Persons on hypotonic IV fluids, Persons with Chronic Renal Failure, Persons with Chronic MalnutritionAssessment of Hypotonic DehydrationHypotensionTachycardiaChanges in LOCLow Serum SodiumLow Serum OsmolarityLow Urine Specific GravityIncreased Urine VolumeInterventions for Hypotonic DehydrationRehydrate orally with hypertonic fluidsIV administration of N/S to restore sodium balance.In rare instances hypertonic Sodium (N/S 3%) may be used.
11Dehydration How it happens ↓body fluids ->↑’s concentration of solutes in the blood (increased osmolality)Na levels ↑To regain balance between intracellular & extracellular-H2O molecules shift out of cells into more concentrated bloodWith ↓H2O in extracellular space –fluid continues to shift into extracellular space-dry cells become dysfunctional ->dehydration
12Dehydration Dehydration in elderly can cause: Delirium UTI URI Urinary incontinenceConstipationPressure ulcersCardiovascular symptomsDeath
13Factors that contribute to Dehydration MedicationsDiureticsSedativesAntipsychoticsETOH abuseDementiaSelf feeding defecitsImmobilityFeverDiarrhea
14Physiologic Signs of Dehydration Acute weight loss (> 2 pounds in a few days)2.2 pounds (1 Kg) = 1 liter of waterOrthostatic hypotensionBUN/creatinine ratio >25:1TachycardiaPoor skin turgorOn the forehead or sternum, not the hand or armSunken eyesDry mucus membranesIrritabilityConfusionDizzinessMuscle weakness↓UOP↑ HR
15Diagnosing Dehydration All must be present to diagnose clinical dehydration:Suspicion of decreased intake or increased outputTwo physiologic signs of dehydration
16Dehydration Prevention preferable to treatment! Adequate water intakeRemember: dehydration and malnutrition often go hand in handOral hydrationWaterSports drinks
17Treatment for dehydration Goal – replace missing fluidAvoid hypertonic solutionsEncourage salt-free oral fluids(serum Na level elevated)IV fluids (hypotonic low-sodium fluids eg. D5W)Avoid hypertonic solutions in pt’s with dehydration because blood is concentrated
18Hypovolemia – isotonic fluid loss (loss of fluids + solutes) from extracellular space. r/t excessive fluid loss (bleeding) + reduced fluid intakeThird space fluid shift (eg. Ascites- fluid shifts to abdominal cavity)Check orthostatic B/P
19Bladder Function in the Elderly Diminished bladder controlWarning period between desire to void and micturation is shortened or lostNocturnal frequency is common in men and womenBladder control in older adults may be diminished. The warning period between the desire to void and actual micturition is shortened or lost. Nocturnal frequency is common in two thirds of women and men older than 65 years who do not take medications and in more than 80% of those with three chronic illnesses.
20Urinary IncontinenceOne of the most common conditions in the care of older adultsRelated toCognitive impairmentsDifficulty in walkingDifficulty manipulating clothingMedicationsDiureticsSedativesHypnotics(Risk factors – Box 9-4 text)Incontinence is one of the most common conditions encountered in the care of older adults. Cognitive impairments, difficulty in walking, and problems manipulating clothing along with drugs that increase urinary output and sedatives and hypnotics may increase the risk for incontinence. Risk factors for incontinence are presented in Box 11-3.
21Incontinence Generates feelings of shame, fear, guilt, dependence Psychological consequences includeanxiety, embarrassment =>depressive symptomsSocial restriction/isolationAvoidance of sexual activityPhysical consequences includeSkin problemsPressure ulcersUTIsFalls
22Types of Urinary Incontinence Categorized based on symptomsStressUrgeOverflowIatrogenicMixedFunctionalTypes of urinary incontinence, categorized by symptoms, are stress, urge, overflow, mixed, and functional. Iatrogenic causes are also discussed. Expected professional competencies for continence care are presented in Box The elements of an incontinence assessment are given in Box 11-6 and include a complete voiding history, a physical examination, a functional assessment, an environmental assessment, a bladder diary, and medical problems that might be contributing to incontinence.
23Stress Incontinence (Anatomic Incontinence) Involuntary leaking of urine while exercising, coughing, sneezing, laughing or liftingMost common type in womenOften develops after child birthIn men usually related to benign prostatic hyperplasia (BPH)People with stress incontinence involuntarily leak urine while exercising, coughing, sneezing, laughing or lifting. These activities apply sudden pressure to the bladder, causing urine to leak out. Stress incontinence is the most common type of incontinence among women, and may be due to weakened pelvic muscles, weakening in the wall between the bladder and vagina, or from a change in the position of the bladder. In many cases, the condition develops as a result of pregnancy and childbirth. Other causes of stress incontinence include:Weakening of muscles that hold the bladder in place, or of the bladder itselfWeakening of the urethral sphincter musclesIn men, benign prostatic hyperplasia (a noncancerous overgrowth of the prostate gland) prostate cancer or from prostate surgeryIn women, a hormone imbalance or a decrease in estrogen following menopause, which can weaken the sphincter muscleDamage to the nerves controlling the bladder resulting from diseases such as diabetes, stroke, Parkinson's disease and/or multiple sclerosis, or from treatment of gynecologic or pelvic cancers with surgery, radiation or chemotherapyPressure on bladder causes leaking
24Urge Incontinence (Overactive Bladder) Frequent, sudden urge to urinate with little control of the bladderEspecially when sleeping, drinking, or listening to running waterMay also be a sign of UTI or kidney infectionUrge incontinence describes the experience of a frequent, sudden urge to urinate with little control of the bladder (especially when sleeping, drinking, or listening to running water). Urge incontinence is also known as spastic bladder, overactive bladder or reflex incontinence. Marked by a need to urinate more than seven times daily or more than twice nightly, urge incontinence is most common in the elderly. It also may be a symptom of a urinary infection in the bladder or kidneys, or may result from injury, illness or surgery, such as:StrokeDiseases of the nervous system, such as multiple sclerosis, Alzheimer's or Parkinson'sTumors or cancer in the uterus, bladder or prostateInterstitial cystitis (inflamed bladder wall)Prostatitis (inflamed prostate)Prostate removal, cesarean section, hysterectomy, or surgery involving the lower intestine or rectumProblems caused by oversensitive bladder
25Overflow Incontinence Incomplete emptying of bladderFrequent urination and/or constant dribbling of urineGenerally caused by weakened bladder muscle d/t nerve damage including diabetesPatients with overflow incontinence cannot completely empty their bladders, causing either a constantly full bladder requiring frequent urination or a constant dribbling of urine, or both. This type of incontinence is generally caused by weakened bladder muscles as a result of nerve damage from diabetes or other diseases. It can also result from the urethra being blocked due to kidney or urinary stones, tumors, an enlarged prostate in men, or a birth defect.Bladder doesn't empty completely, leading to frequent urination or dribbling.
26Functional Incontinence Unable to control bladder before reaching the BRR/t limitations of moving, thinking or communicatingIatrogenicAssociated with medication side effectsMixed IncontinenceMore than one type of incontinenceTypically stress incontinence and urge incontinenceFunctional incontinenceFunctional incontinence is the most common type of incontinence among elderly patients with arthritis, Parkinson's disease or Alzheimer's disease. Often, these patients are unable to control their bladder before reaching the bathroom due to limitations in moving, thinking or communicating.Mixed incontinenceSome patients have two types of incontinence simultaneously, typically stress incontinence and urge incontinence. Mixed incontinence is the most common type in women, and what causes the two forms may or may not be related.
27Nursing Interventions Understanding type of incontinenceGoal settingCuring incontinence versusMinimizing effectsAttitudeNurses should not demonstrate:Acceptance of inevitability of incontinenceDisgust—decreases self-worth of elder and increases dependenceNurses should:Treat incontinence as curableAdopt a teaching role
28Nursing Interventions EnvironmentalDietary changesBowel trainingSphincter training exercisesBiofeedback trainingMedicationSurgery(see Box9-6 text)
29Nursing CareAll health care providers should strive to understand the causes of incontinence, risk factors and evidence-based interventionsFailure to address continence promotion has enormous consequences in terms of economics and burden of careIn all settings, it is important that nurses understand the risk factors and causes for urinary incontinence and evidence-based protocols for intervention. Failure to address continence promotion has enormous consequences in terms of economics and burden of care. Gerontological nurses have an ethical responsibility to take action to maintain competence in continence care needs. The relationship among maintaining continence, nursing diagnoses, and Maslow’s hierarchy of needs is given.
30Fecal Incontinence Inability to control passage of stool Devastating social implications for individuals and familiesMultifactorialIntestinal transit timePelvic floor and sphincter tonePelvic musculatureRectal sensitivityAccessibility of toiletPresence of urgeMedicationsUse of laxativesBulk in dietFluid intakeExercisePresence of hemorrhoidsWhen fecal incontinence occurs, a complete client assessment is needed to determine the cause and plan interventions to manage and/or restore bowel continence, such as bowel training and diet alterations. Meticulous skin care and an attitude that supports the patient’s self-esteem are essential in caring for patients who experience this condition.
31Nursing InterventionFecal incontinence is symptom, nurses should seek out causeAttitudeGoal settingPlannedRealisticConsistent
32Maslow’s HierarchyElimination is key to maintenance of physiologic and biologic integrityWhat other implications does it have?
33Healthy Skin and Aging Skin is the largest organ in the body Many purposesProtects underlying structuresHeat-regulating mechanismSense organMetabolism of salt and waterStores fatGas exchangeConversion of vitamin DThe skin, the largest organ in the body, serves many purposes. However, it is subject to damage by a variety of factors, one of which is ultraviolet rays from the sun. Although the use of sunscreen can help prevent some sun damage, normal age-related changes such as thinning of the layers and diminished melanocyte activity can significantly increase the risk for damage. Older adults are at increased risk for skin cancer because of the increased number of years of sun exposure. Sunscreen may reduce the risk of non-melanomatype skin cancer, but there is no evidence that it is effective in preventing melanoma. Actinic keratoses are precancerous lesions, which should be removed.
34Skin Subject to damage Photo aging Skin cancers Development of skin cancerSunscreenSkin cancersBasal Cell CarcinomaSquamous Cell CarcinomaMelanomaSkin cancers are more common in older adults. Basal cell carcinoma is the most common malignant lesion of epidermal tissue, but metastasis is rare. Squamous cell carcinoma is a more aggressive lesion with a high incidence of metastasis. Melanoma, the least common among the skin cancers, has a high mortality rate. Nurses should recommend a dermatology consult to any elder who has a suspicious skin change.
35Other Skin Problems Seborrheic Keratosis Candida albicans Benign growths mainly on trunk, face, scalpCandida albicansFungal infectionUsually found in folds of skinR/t antibiotics, steroid useOther skin problems are also common. These include seborrheic keratosis (benign growths that appear mainly on the trunk, face and scalp) and dry skin (the result of less moisture being retained). Dry skin often leads to pruritus. Candidiasis, usually found in skin folds or in the mouth, may become a pathogen because of antibiotic or steroid use, pruritus, edema, and therapy. Dry skin may be alleviated with the use of lotion or emollients. Efforts to prevent Candida include keeping skin folds dry and giving prompt attention to skin when incontinence occurs. Anti-fungal medications treat Candida.
36Carcinomas of the skin Basal cell –most common malignant skin cancer Squamous cell 2nd most common skin cancer
37Vascular Insufficiency Leads to complications of skin: mild dermatitis ulcerations gangreneArterial insufficiencyr/t atherosclerotic plaques ischemiaSymptoms:Pain with exercisePain at restSusceptible to infections 2o to even mild traumaAffects 10% of those > 65 y.o.Vascular insufficiency, either arterial or venous, can result in skin ulcers. Symptoms of venous insufficiency include pruritus, edema, and stasis dermatitis, which can precede the development of venous ulcers. Nursing interventions for vascular insufficiency focus on relieving edema and treating the venous stasis ulcer, usually with elevation of the limb and compression stockings. Table 13-1 compares the characteristics of arterial and venous insufficiency, and Box 12-3 lists treatments for venous stasis ulcers.
38Lower Extremity Arterial Disease Claudicationdiscomfort, cramps or pain in the hips, thighs or calves with walkingThe inner lining of arterial blood vessels is normally smooth, allowing blood to flow easily. In lower extremity arterial disease, the lining becomes damaged, leading to buildup of cholesterol and other lipids, causing the arterial wall inner lining to become rough and thickened. This accumulation is called atherosclerosis, or “hardening of the arteries.” As the atherosclerotic process of the lower extremity arteries increases, the arteries become narrowed or blocked, causing blood flow to decrease. This can lead to discomfort, cramps, or pain in the hips, thighs or calves with walking. This is called claudication.Claudication typically occurs during physical activity such as walking and is promptly relieved by a brief resting period (2-5 minutes). Normally, blood flow can increase up to ten-fold to meet the increased need for additional oxygen in exercising muscles. However, when the leg arteries are blocked, blood flow cannot increase in response to exercise and pain develops. Claudication pain always involves the same muscle groups, usually the calves, and does not change from day to day. The vascular surgeon relates the onset of claudication pain to a particular walking distance in terms of street blocks (e.g. “2-block claudication”) or distance traveled before the symptom occurs. This helps to provide a standard of measuring if there has been any change before and after therapy has been initiated.As atherosclerosis progresses and blockage becomes more severe, pain may occur in the feet even when at rest. This pain, known as rest pain, occurs because the arteries of the leg can no longer deliver adequate blood flow to the feet, even at rest. Rest pain generally worsens when the legs are elevated, such as when lying in bed at night. Relief from this pain may occur only when the feet are dangled. Gangrene or “death of tissue” may occur when nutrition needed for normal growth and repair can no longer be provided because of extensive arterial narrowing (stenosis) or complete blockage (occlusion) of lower extremity arteries.Currently, atherosclerosis affects up to 10% of the Western population 65 years or older. When claudication is used as an indicator of lower extremity arterial disease, estimates are that 2% of the population aged 40 to 60 years and 6% older than 70 years of age are affected. With the elderly population expected to increase to 22% by the year 2040, lower extremity arterial disease will be even more common.
39LEAD Risk FactorsSame as those associated with coronary artery diseaseSmokingHigh blood pressure (hypertension)High levels of blood cholesterol or triglycerides (hypercholesterolemia, hyperlipidemia)ObesitySedentary lifestyleDiabetesFamily history of heart disease or arterial diseaseRisk Factors The risk factors for atherosclerosis affecting the lower extremities are the same risk factors associated with coronary artery disease or cerebrovascular disease. These risk factors include:SmokingHigh blood pressure (hypertension)High levels of blood cholesterol or triglycerides (hypercholesterolemia, hyperlipidemia)ObesitySedentary lifestyleDiabetesFamily history of heart disease or arterial diseaseSmoking is the most influential of all the risk factors. Although the mechanism by which smoking causes or worsens atherosclerosis is unclear, it is known that the degree of damage to the arterial wall lining is directly related to the amount of tobacco used. Quitting smoking is essential in the battle against atherosclerosis progression.
40LEAD Signs & Symptoms Decreased hair growth on the legs and feet Discoloration of the affected leg or foot when dangling (from pale to bluish-red)Diminished or absent pulses in the affected leg or footTemperature difference in affected leg or foot (cooler than other extremity)Change in sensation (numbness, tingling, cramping, pain)Presence of non-healing wound on affected lower extremityShrinking of calf musclesPresence of thickened toenailsDevelopment of gangreneSigns and Symptoms Essential to the management of a patient with leg pain is a comprehensive lower extremity examination including palpation of peripheral pulses. Signs and symptoms that advanced lower extremity arterial disease is causing the leg pain include:Decreased hair growth on the legs and feetDiscoloration of the affected leg or foot when dangling (from pale to bluish-red)Diminished or absent pulses in the affected leg or footTemperature difference in affected leg or foot (cooler than other extremity)Change in sensation (numbness, tingling, cramping, pain)Presence of non-healing wound on affected lower extremityShrinking of calf musclesPresence of thickened toenailsDevelopment of gangrene
41Venous Insufficiency—Signs & Symptoms Symptoms of CVI may include:Varicose veins;Ulceration or skin breakdown;Reddened or discolored skin on the leg;Edema or swelling.WHAT ARE THE SYMPTOMS?Symptoms of CVI may include: · Varicose veins; · Ulceration or skin breakdown; · Lipodermatosclerosis, which may appear as a rash on the skin of the calves or ankles; · Reddened or discolored skin on the leg; and · Edema or swelling.
42CVI—Risk Factors CVI can also be caused by: Risk factors may include: A thrombus, or blood clot, that blocks blood flow in a vein, called deep vein thrombosis; orPhlebitis, an inflammation of a superficial vein that causes a blood clot to form.Risk factors may include:Heredity;Obesity;Pregnancy;Sedentary lifestyle;Smoking;Jobs requiring long periods of standing or sitting in one place; andAge and sex (women in their 50s are more prone to developing CVI).CAUSES AND RISK FACTORSVenous hypertension, or high blood pressure inside veins that persists over time, is a primary cause of CVI. CVI can also be caused by: · A thrombus, or blood clot, that blocks blood flow in a vein, called deep vein thrombosis; or · Phlebitis, an inflammation of a superficial vein that causes a blood clot to form.Risk factors may include: · Heredity; · Obesity; · Pregnancy; · Sedentary lifestyle; · Smoking; · Jobs requiring long periods of standing or sitting in one place; and · Age and sex (women in their 50s are more prone to developing CVI).DIAGNOSISPhysicians can diagnose CVI after performing a careful medical history and physical examination. To confirm a diagnosis of CVI, the physician may also order one or more of the following: · Duplex ultrasound; · Plethysmography; and · Venograms.TREATMENT APPROACHThe goals of treatment for CVI are to restore a person to an active life and to minimize pain or disability. Typically, CVI does not pose a serious threat to life or limb, and with proper treatment most people with this condition can continue to lead active lives. In most cases, mild CVI can be treated on an outpatient basis with simple procedures. Treatment methods include: · Elastic compression therapy; · Sclerotherapy; · Vein stripping; · Deep vein surgery; or · Valve repair.
43Pressure UlcersPressure ulcers develop as a result of compression between a bony prominence and another hard surfaceSerious and costly problemsLead to severe complications and deathPressure ulcers, which develop as a result of compression between a bony prominence and another hard surface such as a bed or chair, are serious and costly problems that can lead to severe complications if not addressed. Determining risk for pressure ulcers is a high priority for nurses. Normal changes to aging skin, severity of illness, and involuntary weight loss because of poor nutritional status are important risk factors. The Braden Scale and the Norton Risk Assessment Scale are research-based assessment tools that reliably predict risk for the development of pressure ulcers.Once risk factors have been identified, prevention begins with daily inspection of the skin. Pressure ulcers are classified according to the stages developed by the National Pressure Ulcer Advisory Panel and range from stage I, in which the skin is damaged but still intact, to stage IV, in which tissue death extends through to subcutaneous structures. (See Figure 13-1 for illustrations of pressure ulcer development.) The goal of nursing is prevention, which should focus on eliminating friction, reducing moisture, and displacing body weight from bony prominences. Nutrition should also be monitored. The healing process for pressure ulcers includes keeping wounds clean and moist and using appropriate dressings. Clinical practice guidelines for preventing pressure ulcers are in Box Appendix 13-A presents a pressure sore status tool. The Braden Scale is in Appendix 13-B.
45Stage I Erythemia within 30 minutes of pressure Stage II Partial thickness loss of epidermis & dermisStage III Full thickness loss through to subcutaneous tissueStage IV Deeptissue destruction
46Determining Risk for Pressure Ulcers Important factorsSeverity of illnessInvoluntary weight lossHypoproteinemiaDehydrationVitamin deficienciesBraden Scale—risk assessment toolSensory perceptionSkin moistureActivityMobilityFriction and shearingNutritional status (very important)
47Nursing Implication Prevention!! Turning schedule Supportive surfaces An ounce of prevention is worth a pound of cureTurning scheduleSupportive surfacesActivity levelMeticulous cleaning and skin careNutritionAvoid sedative medications
48Feet Number and severity of foot problems increase with age Nursing assessment can identify potential problems and actual problems needing attentionUseful guide for assessment in box 11-6Guide for comprehensive assessment of the lower extremities (LEs) in figureThe number and severity of foot problems increase with age. These may be related to chronic illness, such as osteoarthritis and rheumatoid arthritis, gout, or diabetes. Corns, calluses, and bunions may occur because of improperly fitting footwear. Hammer toes and metatarsalgia require orthotic or surgical intervention. Unrelieved burning in the feet may be a symptom of a more serious disease and requires management of the underlying cause. Tinea pedis and nail fungus are common infections needing treatment.
49Nursing interventions Proper toenail careReducing dependent edemaPromoting foot massage to stimulate circulationNursing assessment of the feet can identify potential and actual problems needing attention. A helpful guide for foot assessment is given in Box 13-6, and a guide for comprehensive assessment of the lower extremities is in Figure Nursing interventions include implementing proper toenail care, reducing dependent edema, and promoting foot massage to stimulate circulation. Nursing diagnoses to be considered, along with Maslow’s hierarchy and wellness outcomes, are presented.