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

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 100.6.

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

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

Structure of the skin

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lab indicators of pressure ulcer risk Serum albumin—indicator of protein stores 3.5-5.0 g/dl is normal Prealbumin—indicator of protein deficiency >15 mg/dl is normal Lymphocyte count—indicator of protein malnutrition 2000-3500 µL is normal

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)

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

Example of Braden Scale Form

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

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

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

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

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

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

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

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

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

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

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

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

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

Macular degeneration

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

Cataracts

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

Glaucoma

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)

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

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

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

Methods of Removing Cerumen

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

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

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?

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!

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

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

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.

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.

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.