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Physiological basis of the care of the

elderly clientThe Integument;

Sensation: Hearing, Vision, Taste, Touch

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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.

Patient scenario

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What additional information do you need?

Subjective information Objective information Psychosocial information

Informal evaluation

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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

Normal functions of the skin

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Structure of the skin

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Fine and coarse wrinkles Rough, leathery texture Mottled hyperpigmentation Telangiectasia (dilated red splotches) Actinic keratoses Facial expression Body image

What the skin does with age….

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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

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Changes in pigmentation Decreased melanocytes with decreased

photoprotection Delayed wound healing Onychomycosis common Decreased touch receptors, corresponding slowing of reflexes and pain sensation

Normal changes of aging

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Contains less moisture Epidermal mitosis slows, healing takes

longer Manufacture of vitamin D less efficient

Specific changes in epidermis

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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

Sidebar: What Vitamin D Does!

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Skin cancers

Skin tears

Pressure ulcers

Risks of age related changes in skin

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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

Facilitating integumentary health

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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 dermis

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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

Specific changes in the subcutaneous layer

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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 hair and nails

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Decreased sweating and thermoregulation Amount of sebum decreases, causing less

water in stratum corneum resulting in xerosis

Changes in eccrine and apocrine glands

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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

Pruritis

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Bath oils, massage Moisturizing lotions ZnO2 may be applied topically

Treatment—pruritis

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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

Damage due to sun

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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 protection

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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

Sun sensitizing drugs

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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

Actinic keratosis

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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

Skin cancer—major types

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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

Education regarding skin cancers

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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

Skin tears

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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

Risk factors for decubitus ulcers

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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

Lab indicators of pressure ulcer risk

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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)

Pressure ulcers

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Risk of developing pressure ulcers based on evaluation of six areas:

1. Sensory perception2. Moisture3. Activity4. Mobility5. Nutrition6. Friction and shear

Use of the Braden scale

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Example of Braden Scale Form

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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

Preventing Pressure ulcers

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High protein, vitamin rich diet Good skin care Bath oils and lotions Keep skin dry Massage bony prominences Range of motion at least daily

Skin health promotion and recovery requires:

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Persistent redness (erythema or hyperemia) Ischemia (erythema with edema and

induration) Skin is still intact Erythema does not

blanch when pressure applied

Stage 1—signs/symptoms

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Partial skin thickness loss Appearance of an abrasion, a blister, a

shallow ulcer

Stage 2—signs and symptoms

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Full skin thickness loss Subcutaneous tissue

is exposed Appearance of deep ulcer May or may not be

undermining of surrounding

tissue

Stage 3—signs and symptoms

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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

Stage 4—signs and symptoms

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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

Interventions

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

Principles of pressure ulcer healing

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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

Cellulitis

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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

Age related changes of the eye

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More light required to see clearly

↓ Ability to see in dark

↓ Ability to recover

from glare

Light sensitivity

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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

Common visual impairments

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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

Risks for macular degeneration

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Macular degeneration

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

Risks for cataracts

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Cataracts

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

Risks for glaucoma

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Glaucoma

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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)

Medications that can affect vision in the elderly

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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

Hearing changes

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Conductive hearing loss—process of the external or

middle ear canal Sensorineural hearing loss—process of the inner ear

Types of hearing loss

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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

Promoting hearing health

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Methods of Removing Cerumen

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Ototoxicity—gentamycin, erythromycin, cisplatin, furosemide

Tinnitus—gentamycin, erythromycin, baclofen, propanolol, aspirin

Effects of specific drugs on hearing

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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

Speaking to the hearing impaired

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

Hearing aids…

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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!

Tactile impairment

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

Nursing considerations

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What is your nursing diagnosis for MX? What is your desired outcome? What are appropriate interventions

pertinent to your desired outcome?

Formal evaluation

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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 imbalance body temperature

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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 injury

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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.

Risk for impaired skin integrity