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Physiologic Changes of Aging

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1 Physiologic Changes of Aging
Gerontological & Community Based Nursing: Physiologic Changes of Aging

2 Age related changes affecting nutrition & hydration in older adults
Reduced need for caloric intake r/t ↓body mass & ↑adipose tissue Basil metabolism rate ↓ 2 % q decade of life General ↓ 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)

3 Other factors affecting nutrition
Socialization- eating alone Income- strong relationship between poor nutrition & low income Transportation –access to shopping Housing- substandard housing (SRO) Dentition (see box 8-3 text) – poor oral health – risk factor for dehydration & malnutrition; ↑risk oral cancers

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5 Nutrition concerns Two major concerns:
Obesity – exacerbates age related health issues> type II diabetes, CAD, osteoarthritis, ↓ mobility, Malnutrition – often unrecognized Precursor to frailty

6 Malnutrition in older adults
Protein – Calorie Malnutrition PCM most common type of malnutrition c/b muscle wasting, low BMI; ↓albumin /serum proteins 50% nursing home; 50% hospitalized 44% home health elders - malnourished

7 Malnutrition - Risk factors
Psychosocial Mechanical Box 8-14 text Psychosocial- limited income Alcohol abuse CNS depressants Loneliness Removal of usual cultural patterns ( long-term care- hosp) Memory loss (dementia) Depression Mechanical risk factors Dec. strength/mobility Neuro deficits, arthritis, inability to feed self, lack of assistance, difficulty swallowing, chewing, breathing, Poor fitting dentures, Polypharmacy NPO status

8 “I’m Dying of Thirst!” In young, water makes up about 2/3 of our body weight The brain is composed of about 95% water The blood is about 82% water The lungs are about 90% water In 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 lubricant Water forms the base for saliva Water 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 metabolism In 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. 

9 Hydration Small changes in water content make a big difference in the elderly because: Kidneys lose their ability to concentrate urine as effectively There is a decreasing sense of thirst in the elderly Recommended daily fluid intake for the elderly is ml of non-caffeinated fluids

10 Dehydration Dehydration is one of the most common fluid and electrolyte problems experienced by the elderly Most 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 Types Isotonic - Fluid has the same osmolarity as plasma Hypotonic -Fluid has fewer solutes than plasma Hypertonic-Fluid has more solutes than plasma Isotonic Dehydration Prevention of Isotonic Dehydration Most Common form of Dehydration Occurs when fluids and electrolytes are lost in even amounts There are no intercellular fluid shifts in isotonic dehydration Common Causes diuretic therapy excessive vomiting excessive urine loss hemorrhage decreased fluid intake Assessment of Isotonic Dehydration Weight Loss Hypotension and Orthostatic Hypotension Rapid, weak pulse Oliguria - (dark, concentrated, scanty urine) Decreased skin turgor Dry mucous membranes Elevated urine specific gravity Altered Level of Consciousness Increased Hematocrit (except in hemorrhage), serum protein and BUN Severe Isotonic Dehydration can lead to SHOCK Interventions for Isotonic Dehydration Monitor daily weight, I&O, Skin turgor, LOC and V.S. Check Skin turgor on forehead or sternum on elderly Monitor Lab values - Urine SpG, BUN, CBC and Lytes Replace fluid loss using ISOTONIC fluids Treat the underlying cause Hypertonic Dehydration Second most common type of dehydration. Occurs when water loss from ECF is greater than solute loss Prevention of Hypertonic dehydration Prevent Insensible Fluid Loss - Hyperventilation, pure water loss with high fevers, and watery diarrhea. Control Disease Processes - Diabetic Ketoacidosis and Diabetes Insipidus Prevent Iatrogenic Causes - Prolonged NPO, excessive administration of hypertonic fluids, sodium bicarbonate, or tube feedings with inadequate amounts of water Assessment of Hypertonic Dehydration Hypertonicc Dehydration causes fluid to be pulled from the cells into the blood stream, leading to cellular shrinkage. Thirst Decreased Skin Turgor Dry Mucous Membranes Increased Serum Sodium and Serum Osmolarity Increased Urine Specific Gravity Signs of Shock are usually not present Interventions for Hypertonic Dehydration Prevent Hypertonic Dehydration by diluting tube feedings with adequate amounts of water. Monitor I&O, daily weight, skin turgor, LOC, Serum Sodium and Serum Osmolarity Administer 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 Dehydration Relatively 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 shock Seen in Heat Exhaustion Increased cellular swelling -causes increased intercranial pressure - H/A and Confusion. Seen in Heat Stroke Prevention of Hypotonic Dehydration Avoid over Administration of Hypotonic Fluids - Most common cause of Hypotonic Dehydration Replace fluid lost during exercise with isotonic fluids to patients with Isotonic dehydration. Select the correct IV fluid and rate to meet patients rehydration needs Watch for low serum osmolarity and serum sodium Persons at Risk -Persons on hypotonic IV fluids, Persons with Chronic Renal Failure, Persons with Chronic Malnutrition Assessment of Hypotonic Dehydration Hypotension Tachycardia Changes in LOC Low Serum Sodium Low Serum Osmolarity Low Urine Specific Gravity Increased Urine Volume Interventions for Hypotonic Dehydration Rehydrate orally with hypertonic fluids IV administration of N/S to restore sodium balance. In rare instances hypertonic Sodium (N/S 3%) may be used.

11 Dehydration 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 blood With ↓H2O in extracellular space –fluid continues to shift into extracellular space-dry cells become dysfunctional ->dehydration

12 Dehydration Dehydration in elderly can cause: Delirium UTI URI
Urinary incontinence Constipation Pressure ulcers Cardiovascular symptoms Death

13 Factors that contribute to Dehydration
Medications Diuretics Sedatives Antipsychotics ETOH abuse Dementia Self feeding defecits Immobility Fever Diarrhea

14 Physiologic Signs of Dehydration
Acute weight loss (> 2 pounds in a few days) 2.2 pounds (1 Kg) = 1 liter of water Orthostatic hypotension BUN/creatinine ratio >25:1 Tachycardia Poor skin turgor On the forehead or sternum, not the hand or arm Sunken eyes Dry mucus membranes Irritability Confusion Dizziness Muscle weakness ↓UOP ↑ HR

15 Diagnosing Dehydration
All must be present to diagnose clinical dehydration: Suspicion of decreased intake or increased output Two physiologic signs of dehydration

16 Dehydration Prevention preferable to treatment!
Adequate water intake Remember: dehydration and malnutrition often go hand in hand Oral hydration Water Sports drinks

17 Treatment for dehydration
Goal – replace missing fluid Avoid hypertonic solutions Encourage 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

18 Hypovolemia – isotonic fluid loss (loss of fluids + solutes) from extracellular space.
r/t excessive fluid loss (bleeding) + reduced fluid intake Third space fluid shift (eg. Ascites- fluid shifts to abdominal cavity) Check orthostatic B/P

19 Bladder Function in the Elderly
Diminished bladder control Warning period between desire to void and micturation is shortened or lost Nocturnal frequency is common in men and women Bladder 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.

20 Urinary Incontinence One of the most common conditions in the care of older adults Related to Cognitive impairments Difficulty in walking Difficulty manipulating clothing Medications Diuretics Sedatives Hypnotics (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.

21 Incontinence Generates feelings of shame, fear, guilt, dependence
Psychological consequences include anxiety, embarrassment =>depressive symptoms Social restriction/isolation Avoidance of sexual activity Physical consequences include Skin problems Pressure ulcers UTIs Falls

22 Types of Urinary Incontinence
Categorized based on symptoms Stress Urge Overflow Iatrogenic Mixed Functional Types 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.

23 Stress Incontinence (Anatomic Incontinence)
Involuntary leaking of urine while exercising, coughing, sneezing, laughing or lifting Most common type in women Often develops after child birth In 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 itself Weakening of the urethral sphincter muscles In men, benign prostatic hyperplasia (a noncancerous overgrowth of the prostate gland) prostate cancer or from prostate surgery In women, a hormone imbalance or a decrease in estrogen following menopause, which can weaken the sphincter muscle Damage 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 chemotherapy Pressure on bladder causes leaking

24 Urge Incontinence (Overactive Bladder)
Frequent, sudden urge to urinate with little control of the bladder Especially when sleeping, drinking, or listening to running water May also be a sign of UTI or kidney infection Urge 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: Stroke Diseases of the nervous system, such as multiple sclerosis, Alzheimer's or Parkinson's Tumors or cancer in the uterus, bladder or prostate Interstitial cystitis (inflamed bladder wall) Prostatitis (inflamed prostate) Prostate removal, cesarean section, hysterectomy, or surgery involving the lower intestine or rectum Problems caused by oversensitive bladder

25 Overflow Incontinence
Incomplete emptying of bladder Frequent urination and/or constant dribbling of urine Generally caused by weakened bladder muscle d/t nerve damage including diabetes Patients 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.

26 Functional Incontinence
Unable to control bladder before reaching the BR R/t limitations of moving, thinking or communicating Iatrogenic Associated with medication side effects Mixed Incontinence More than one type of incontinence Typically stress incontinence and urge incontinence Functional incontinence Functional 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 incontinence Some 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.

27 Nursing Interventions
Understanding type of incontinence Goal setting Curing incontinence versus Minimizing effects Attitude Nurses should not demonstrate: Acceptance of inevitability of incontinence Disgust—decreases self-worth of elder and increases dependence Nurses should: Treat incontinence as curable Adopt a teaching role

28 Nursing Interventions
Environmental Dietary changes Bowel training Sphincter training exercises Biofeedback training Medication Surgery (see Box9-6 text)

29 Nursing Care All health care providers should strive to understand the causes of incontinence, risk factors and evidence-based interventions Failure to address continence promotion has enormous consequences in terms of economics and burden of care In 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.

30 Fecal Incontinence Inability to control passage of stool
Devastating social implications for individuals and families Multifactorial Intestinal transit time Pelvic floor and sphincter tone Pelvic musculature Rectal sensitivity Accessibility of toilet Presence of urge Medications Use of laxatives Bulk in diet Fluid intake Exercise Presence of hemorrhoids When 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.

31 Nursing Intervention Fecal incontinence is symptom, nurses should seek out cause Attitude Goal setting Planned Realistic Consistent

32 Maslow’s Hierarchy Elimination is key to maintenance of physiologic and biologic integrity What other implications does it have?

33 Healthy Skin and Aging Skin is the largest organ in the body
Many purposes Protects underlying structures Heat-regulating mechanism Sense organ Metabolism of salt and water Stores fat Gas exchange Conversion of vitamin D The 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-melanomatype skin cancer, but there is no evidence that it is effective in preventing melanoma. Actinic keratoses are precancerous lesions, which should be removed.

34 Skin Subject to damage Photo aging Skin cancers
Development of skin cancer Sunscreen Skin cancers Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma Skin 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.

35 Other Skin Problems Seborrheic Keratosis Candida albicans
Benign growths mainly on trunk, face, scalp Candida albicans Fungal infection Usually found in folds of skin R/t antibiotics, steroid use Other 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.

36 Carcinomas of the skin Basal cell –most common malignant skin cancer
Squamous cell 2nd most common skin cancer

37 Vascular Insufficiency
Leads to complications of skin: mild dermatitis  ulcerations  gangrene Arterial insufficiency r/t atherosclerotic plaques  ischemia Symptoms: Pain with exercise Pain at rest Susceptible to infections 2o to even mild trauma Affects 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.

38 Lower Extremity Arterial Disease
Claudication discomfort, cramps or pain in the hips, thighs or calves with walking The 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.

39 LEAD Risk Factors Same as those associated with coronary artery disease Smoking High blood pressure (hypertension) High levels of blood cholesterol or triglycerides (hypercholesterolemia, hyperlipidemia) Obesity Sedentary lifestyle Diabetes Family history of heart disease or arterial disease Risk 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: Smoking High blood pressure (hypertension) High levels of blood cholesterol or triglycerides (hypercholesterolemia, hyperlipidemia) Obesity Sedentary lifestyle Diabetes Family history of heart disease or arterial disease Smoking 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.

40 LEAD 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 foot Temperature 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 extremity Shrinking of calf muscles Presence of thickened toenails Development of gangrene Signs 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 feet Discoloration of the affected leg or foot when dangling (from pale to bluish-red) Diminished or absent pulses in the affected leg or foot Temperature 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 extremity Shrinking of calf muscles Presence of thickened toenails Development of gangrene

41 Venous 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.

42 CVI—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; 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). CAUSES AND RISK FACTORS Venous 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). DIAGNOSIS Physicians 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 APPROACH The 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.

43 Pressure Ulcers Pressure ulcers develop as a result of compression between a bony prominence and another hard surface Serious and costly problems Lead to severe complications and death Pressure 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.

44 Stage I through IV Pressure ulcer

45 Stage I Erythemia within 30 minutes of pressure
Stage II Partial thickness loss of epidermis & dermis Stage III Full thickness loss through to subcutaneous tissue Stage IV Deep tissue destruction

46 Determining Risk for Pressure Ulcers
Important factors Severity of illness Involuntary weight loss Hypoproteinemia Dehydration Vitamin deficiencies Braden Scale—risk assessment tool Sensory perception Skin moisture Activity Mobility Friction and shearing Nutritional status (very important)

47 Nursing Implication Prevention!! Turning schedule Supportive surfaces
An ounce of prevention is worth a pound of cure Turning schedule Supportive surfaces Activity level Meticulous cleaning and skin care Nutrition Avoid sedative medications

48 Feet Number and severity of foot problems increase with age
Nursing assessment can identify potential problems and actual problems needing attention Useful guide for assessment in box 11-6 Guide for comprehensive assessment of the lower extremities (LEs) in figure The 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.

49 Nursing interventions
Proper toenail care Reducing dependent edema Promoting foot massage to stimulate circulation Nursing 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.

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