Presentation on theme: "Physiological basis of the care of the elderly client"— Presentation transcript:
1 Physiological basis of the care of the elderly client The Integument;Sensation: Hearing, Vision, Taste, Touch
2 Patient scenarioYou 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 disksL4-5 and L5-S1.She states her legs feel like“noodles” and she can’t feelthem very well.Her temperature has increasedfrom 98.2 to
3 What additional information do you need? Informal evaluationWhat additional information do you need?Subjective informationObjective informationPsychosocial information
4 Normal functions of the skin Regulation of body fluids—prevent loss from deeper layersRegulation of temperature—blood vessels in dermisRegulation of immune function—prevent microbe invasionProduction of vitamin Dactivated by UV lightSensory reception—detecttouch, pressure,temperature, pain
6 What the skin does with age…. Fine and coarse wrinklesRough, leathery textureMottled hyperpigmentationTelangiectasia (dilated red splotches)Actinic keratosesFacial expressionBody image
7 Normal changes of aging Pigmentation changes—photoagingDecrease in eccrine (total body), apocrine (armpits, genital, areolar, anal), sebaceous glands → dry skinDecrease in number of blood vesselsLoss of eyelid elasticityDecreased elastin, wrinklingAdipose tissue redistributesto waist & hips
8 Normal changes of aging Changes in pigmentationDecreased melanocytes with decreased photoprotectionDelayed wound healingOnychomycosis commonDecreased touch receptors,corresponding slowing ofreflexes and pain sensation
9 Specific changes in epidermis Contains less moistureEpidermal mitosis slows, healing takes longerManufacture 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 diseaseVitamin D level is inversely correlated with coronary artery calcificationVitamin D promotesabsorption of calcium andphosphorus by bone
11 Risks of age related changes in skin Skin cancersSkin tearsPressure ulcers
12 Facilitating integumentary health Avoid drying of the skin in the elderly!Promote skin nutrition and hydration through bath oils, lotions and massageVitamins and vitamin supplementsAvoid excessive bathingEarly treatment of pruritis
13 Specific changes in the dermis Elastin decreases in quality but increases in quantity leading to wrinklesVascularity decreasesCapillaries become thinner and more easily damagedDecline in touch and pressure sensations
14 Specific changes in the subcutaneous layer Subcutaneous tissue thinner in the face, neck, hands and lower legsMore visible veinsFat distribution more obvious in abdomen and thighs in women, the abdomen in men
15 Changes in hair and nails Gray or white hairHair becomes more coarse and thinGradual loss of pubic and axillary hairFacial hair in womenEar and nose hair in menHair loss, men > womenNails duller, yellow or greyNail growth slowsLongitudinal striations
16 Changes in eccrine and apocrine glands Decreased sweating and thermoregulationAmount of sebum decreases, causing less water in stratumcorneum resulting inxerosis
17 Pruritis Most common dermatologic complaint in the elderly Drying of the skin by any meansDiabetes, atherosclerosis, hyperthyroidism, urea, liver disease,cancer, perniciousanemia, somepsychiatric diseasesProblem: traumatizingscratching
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 handsFreckling, loss of elasticity,damaged blood vessels,weathered appearanceMay result in actinic keratosis,a precancerous lesion
22 Actinic keratosis Most common precancerous lesion More common in men 1 in 1000 will progress to skin cancer (usually squamous cellcarcinoma) within1 yearIll-defined borderBack of hands, face,forearm, V of neck,nose, ears, bald scalp
23 Skin cancer—major types Basal cell carcinoma—waxy,pigmented, may beerythematous, papular orscaly macularSquamous 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 cancersAny suspicious lesion should be biopsiedRisk for skin cancer associated with total amount of time spent in the sunBasal cell rarely metastasizesSquamous cell can metastasize
25 Skin tears Occur easily in frail elderly Classification Category 1: linear or flap type without tissue lossCategory 2: partial tissue lossCategory 3: full thickness tissue loss
26 Risk factors for decubitus ulcers Fragile skin that damages easilyPoor nutritional statusReduced sensations of: pressure and painElderly have more frequent encounters with conditions that contributeto skin breakdown
27 Lab indicators of pressure ulcer risk Serum albumin—indicator of protein storesg/dl is normalPrealbumin—indicator of protein deficiency>15 mg/dl is normalLymphocyte count—indicator of protein malnutritionµL is normal
28 Pressure ulcers Can develop on any part of the body Caused by tissue anoxia and ischemiaMost common sites:Sacrum (most distal portion of spine)Greater trochanter (head of femur)Ischial tuberosities(protuberance of proximalhip)
29 Use of the Braden scaleRisk of developing pressure ulcers based on evaluation of six areas:Sensory perceptionMoistureActivityMobilityNutritionFriction and shear
31 Preventing Pressure ulcers Prevention is based on 6 areas of Evaluation:Avoid unrelieved pressureEncourage activityTurn every hourPillowFlotation padEncourage outside activitiesAvoid shearing forces
32 Skin health promotion and recovery requires: High protein, vitamin rich dietGood skin careBath oils and lotionsKeep skin dryMassage bony prominencesRange of motion at least daily
33 Stage 1—signs/symptoms Persistent redness (erythema or hyperemia)Ischemia (erythema with edema and induration)Skin is still intactErythema does notblanch whenpressure applied
34 Stage 2—signs and symptoms Partial skin thickness lossAppearance of an abrasion, a blister, a shallow ulcer
35 Stage 3—signs and symptoms Full skin thickness lossSubcutaneous tissueis exposedAppearance of deep ulcerMay or may not beundermining ofsurroundingtissue
36 Stage 4—signs and symptoms Full skin thickness lossSubcutaneous tissue lossMuscle and or bone is lostDeep ulcerationMay be accompanied by:•Necrosis•Sinus tractformation•Exudate•Infection
37 Interventions Hyperemia—relieve pressure, use of adhesive foam Ischemia—skin protectant solutions, clean with normal saline at least daily if skin brokenNecrosis—transparent dressing permeable to oxygen and water vapor, irrigate thoroughly, topical antibioticsUlceration—debridement is required
38 Principles of pressure ulcer healing Debridement of nonviable (necrotic) tissueKeep wound cleanDress to keep moist wound bedPrevent and treat infection
39 CellulitisOccurs when one or more types of bacteria enter through a break in the skinMost common types of bacterial causes of cellulitisStreptococcusStaphylococcusMRSA is increasingThe most commonlocation is thelower leg
40 Age related changes of the eye Skin surrounding eye becomes thinnerEyelid musculature decreasesEctropionEntropionDecreased visual acuity, color discriminationAtrophy of lacrimal glandsIncrease 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 blueand UV light, promotingvisual acuity.Macular degenerationaffects central visionand visual acuityCataracts—cloudingof the lens coveringthe eyeGlaucoma--⇧IOP causesoptic nerve damage
43 Risks for macular degeneration Age > 50 yearsCigarette smokingFamily history of macular degenerationIncreased exposure to UV lightCaucasianLight colored eyesHypertension or cardiovascular diseaseLack of dietary antioxidants and zinc
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 interactCerumen tends to be drier,harderPruritis of canalis commonMost hearing changesare attributable toexposure to loud sounds
51 Types of hearing lossConductive hearing loss—process of the external ormiddle ear canalSensorineural hearingloss—process of theinner ear
52 Promoting hearing health Prompt and complete treatment of ear infectionsPrevention of traumaRegular audiometric examsEvaluate for cerumen collectionRemove cerumen by gentle irrigationAvoid cotton applicators in earEducate regarding effects of environmental noise
54 Effects of specific drugs on hearing Ototoxicity—gentamycin,erythromycin, cisplatin,furosemideTinnitus—gentamycin,erythromycin, baclofen,propanolol, aspirin
55 Speaking to the hearing impaired Eliminate extraneous noiseStand 2 to 3 feet from the patientEye contactUse lower pitch of voiceFrequent pausesSpeak slowly and clearlyAsk for validation ofunderstanding
56 Hearing aids… Check surface of ear mo mold Check the battery Do the dials work?Are the dialsfunctioning?Is the tubing patentand connectedproperly?
57 Tactile impairment Slowing of conduction of nerve impulses Causes decreased perception of pain and temperatureCreates risk for injuryContributes to sensation ofisolation and decreasedinteraction with othersRemember the value oftherapeutic touch!
58 Nursing considerations Frequent monitoring of skin for intactnessNote and educate regarding safety risksTeach 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 infectionevery 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 injuryPatient will identify behaviors contributing to her risk for injury and corrective measures by (date).Keep bed locked and in low positionAssess patient safety status every hour and remind of location of call light.Provide night light.Assist patient with transfers andambulation.
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 byoffering water every hour.Maintain good body hygieneusing lotion and massage.
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