Lecture 4 & NSC 4

Question 1

What are normal age related changes to the integumentary system ?

Answer 1

—↑ skin dryness

—↑ skin pallor

—↑ skin fragility

—Progressive wrinkling & sagging

—Lentigo senilis (age spots)

—Decreased perspiration

—Thinning & greying of scalp, pubic & axillary hair

—Slower nail growth, ↑ thickening

Women over 60 have increasing facial hair.

Changes may affect psychological well being; feelings of being distinguished to depression due to loss of youth.

In older women breast become smaller & sag due to loss of subcutaneous tissue & muscle tissue- if large or pendulous particular care required for area where skin chaffs.

Loss of subcutaneous tissue: more susceptible to cold, minimize heat loss when performing nursing care.

Exposure to sun: premalignant & malignant skin lesion (basal cell carcinoma, melanoma, squamous cell carcinoma)

Cherry Angiomas: small round red lesions on trunk

Seborrheic lesions: irregular round, or oval, brown watery leasions

—↓ in sebaceous gland activity & tissue fluid

—↓ vascularity

—Reduced thickness & vascularity of dermis; loss of subcutaneous fat

—Loss of skin elasticity, ↑ dryness, ↓ subcutaneous fat

—Clustering of melanocytes-smooth brown irrg spots

—Reduced number & functioning or sweat glands

—Progressive loss of pigment cells from the hair bulb

—Increased risk of skin breakdown

Question 2

What are some strategies to prevent skin breakdown ?

Answer 2

• Reducing skin dryness
• Humidified air, warm water, avoiding irritants/soaps, reducing bathing frequency/time, moisturizers
• Reducing skin injury
• Improving co-morbid conditions
• Falls reduction strategies
• Improving continence
• Adherence to treatments (use of mobility aids, sensory aids, support stockings)

Diabetes: improving glycemic control, ideally HbA1c (blood test which evaluates 3-month blood glucose level) <7% in healthy older client and <8% in a frail older client

Vascular disease: managing risks (smoking, obesity, inactivity, hypertension, diabetes, dyslipidemia, atrial fibrillation)

Other considerations:

Environment: limit excessive furniture, proper lighting, grab bars, padded wheelchair foot & armrests, side rails, support for extremities with pillows/pads

Clothing: skid-free shoes, protective clothing, hi protectors.

Transfers: use of appropriate equipment (mechanical lifts), proper techniques to reduce friction, frequent repositioning.

Nutrition: adequate intake of calories & protein- consult dietician

Wound care: minimize use of tape on skin-stockinette or gauze wrap over dressings.

Question 3

How do Nurses prevent skin breakdown ?

Answer 3

—Assess skin daily, clean soiled skin promptly

—Avoid hot water & irritating agents, use moisturizers on dry skin

—Do not massage bony prominences, use pillows & pads to protect

—Protect skin of incontinent clients from exposure to moisture

—Proper lifting techniques, lifting devices

—Turn and position bed-bound clients every 2 hours, plan a schedule & post it

—Use a 30-degree lateral side lying position; do not place clients directly on their trochanter

—Keep head of the bed at lowest height possible.

—Use pressure-reducing devices (static air, alternating air, gel or water mattresses).

—Reposition chair- or wheelchair-bound clients every hour. In addition, if client is capable, have him or her do small weight shifts every 15 minutes.

Question 4

How does improve continence ?

Answer 4

• Maintain healthy body weight
• Avoid bladder irritants
• Adequate fibre intake
• Empty bladder every 3-4 hours (a schedule)
• Adequate fluid intake
• Smoking linked to overactive bladder
• Kegel exercises
• Manageable clothing
• Consider medications
• Mechanical treatments
• Medical diagnoses ie., impact of cognition, surgical options

Common quality of life issue for women in LTC. ¼ women experience incontinence.

Incontinence is not caused by being a woman it is caused by aging, but an associated stigma exists.

Belief it is an inconvenience rather than an illness. Self-management is emphasized. Renders clients to become secretive, not seek supportive health care & socially isolated.

Institutional culture: care routines, types & quantities of products, de-valuing self-care, lack of decision making, language “diapers”.

Question 5

What are some experiences of clients living with Incontinence ?

Answer 5

—Physical implications:

–Skin irritation & breakdown, bladder infections

–Physical discomfort

–Self-care management: ↓fluid intake, holding urine, using extra pads, frequent toileting, using powders, hyper-vigilance with physical care

—Institutionalized culture:

–Rituals and routines

–Ageism & marginalizing

–Influence of staff

Question 6

What are some cognitive changes that occur in elderly populations ?

Answer 6

• Reduction in the number of brain cells, deposits of lipofuscin & amyloid, changes in neurotransmitter levels
• Forgetfulness is not an expected consequence of aging
• Symptoms of cognitive impairment: disorientation, loss of language skills, unable to calculate, & poor judgement are not normal aging changes

A common misconception about is that cognitive impairments are widespread among older adults

Question 7

What are the three main conditions that affect cognition ?

Answer 7

Delerium: Acute confusional state, potentially reversible, with a physiological cause—Characterized by: fluctuations in cognition, mood, attention, arousal, & self-awareness—Other signs: hallucinations, incoherant speech, disturbed sleep-wake cycles, disorientation—Onset: sudden, symptoms & severity fluctuate rapidly—Tx: promptly assess pt, find the cause, try to prevent in future, medication profile

Dementia: Gradual, progressive, irreversible dysfunction —A syndrome of symptoms: loss of memory, judgement & reasoning, ∆ mood, behaviour & communication abilities—Must assess for possibility of delirium first —5 types of dementia 1.Alzheimer’s2.Lewy body3.frontotemporal,4.Creutzfeldt-Jacob5.vascular

Depression: —Late-life depression occurs in 15-20% of older adults —Contributes to physical & social limitation, complicates tx of medical problems, ↑risk of suicide —Older adults more likely to talk about it, feel blue or down in the dumps, diminished life satisfaction

Question 8

What are some aspects of alzheimers disease ?

Answer 8

—Cause is unknown

—S/S progressive loss of memory (amnesia), loss of ability to recognize objects & people (agnosia), loss of the ability to perform familiar tasks (apraxia), loss of language skills (aphasia)

—Become more dependent on caregivers for ADLs, safety issues are concerns (stove on, getting lost)

—Medication therapy – slow progression

Question 9

What are some functional changes that occur in elderly populations ?

Answer 9

• Functional capacity
• Declines in physical, psychological, cognitive & social function that can occur with aging are usually linked to illness or disease & its degree of chronicity

Some older adults deny changes, others overemphasize & some are fearful of becoming dependent on others for care

The nurse educates the older adult to promote understanding of age related changes, appropriate lifestyle adjustments, & effective coping

Functional capacity: safe performance of ADLs, is a sensitive indicator of health or illness in older adults

It is a complex relationship between many factors

Question 10

What are some psychosocial Changes in elderly populations ?

Answer 10

Involve changes in roles & relationships:

◦Retirement

◦Social Isolation

◦Abuse

◦Sexuality

◦Housing & Environment

◦Death

Retirement: It is a major turning point in your life. Planning is impt. As it can last for 30 yrs. Loss of the work role can be devastating- as this is your identity. 85% work part-time. How well you retire depends upon your health status, having the option to keep working, and having sufficient income.

Social Isolation: & loneliness are significant issues regardless of gender or geographical location. Living alone & having multiple chronic illnesses contribute to the problem

Abuse: elder abuse is the mistreatment of the OA by people of trust or power or who are responsible for the adults care. Neglect is a also abuse, many types of abuse (physical, sexual, psychological/emotional, material, neglect, self-neglect)

Sexuality: all OA whether healthy or frail, need to express sexual feelings. Sexuality involves love, warmth, sharing, touching, not just intercourse. Libido doesn’t decline, but frequency of sexual activity may.

Housing & Environment: most want to stay in their community, but this is dependent upon their ability to live independently. Want to promote independence & functional ability- assess for safety.

Death: hard to come to terms with loss of friends, family, and your own mortality. Know the grieving process, support them.

Question 11

what are the 4 factors that affect good health in advanced ages ?

Answer 11

Genetics

Chance

Good Health Habits

Preventive Measures

2 most common casues of death: Cancer & Heart Disease

• Other health concerns: resp. Diseases, stroke, accidents/falls, diabetes, kidney disease, liver disease
• There are preventive measures for all these causes of death, that could reduce frequency, delay disability, death or both

Question 12

What are some health concerns for older adults ?

Answer 12

—Smoking

—Alcohol Abuse

—Nutrition

—Falls

—Pain

—Medication Use

Cancer: malignant neoplasms most common cause of death. Nurses teach about s/s of cancer, (wt loss, wound doesnt heal, unexpected bleeding, change in bowel habits) screening test for (mamograms, colonoscopy, fecal occult blood, breast self-exam, testicular self exam, smoking cessation, fecal occult blood).

Heart Disease: 2nd leading cause of death in OA. Common are hypertension, coronary artery disease. 45% of Canadians have hypertension. Nurses address weight reduction, exercise, diet changes to reduce salt & fat, stress management, and smoking cessation.

Smoking: cigarette smoking has been recognized as the major preventable cause of death & disease. Older smokers can still benefit from quitting, may help stabilize existing conditions such as COPD, may extend your life or independent functioning. Many programs available.

Alcohol Abuse: 12% consume 14 or more drinks/week. 2 patterns: a lifelong pattern of heavy drinking & a late onset in which heavy drinking begins late in life. Causes could be: depression, loneliness, lack of social support. S/S can be suttle and hard to dx.

Nutrition: lifelong eating habits & situational factors (ability to access food stores, finances, ability to prepare food, a place to prepare and store food) influence how OA meet their needs.

Arthritis: common in OA, esp women- no cure, can cause pain, affect quality of life. Medications for swelling & pain

Falls: cause of functional dependence, 75% deaths from injury, Stand-up program

Pain: 50% suffer at any given time

Medications: take more px drugs, risk of polypharmacy, adverse reactions, managing meds

Question 13

What is SPICES ?

Answer 13

SPICES is an assessment tool

1. Sleep disorders: common problem-stress, being awakened for routine care, pain, effects of medications, change in environment, noise.
2. Problems with eating & feeding: anorexia, unable to feed self, poor pain control, cold food, bedside table out of reach, IV lines or other interventions, difficulty positioning self.
3. Incontinence: bladder or bowel-delirium or dementia, reduced function related to illness, medications which suppress sensation, functional disability, passive restraints, traction devices, associated with longer LOS.
4. Confusion: temporary or long term, 1/3 of older adults suffer delirium within 24 hours after admission (higher rates in ICU)
5. Evidence of falls: risk factors-confusion, gait instability, urinary incontinence, hx of falls, administration of hypnotic/sedative medications
6. Skin breakdown: can be fatal in older adults, major risk factors: older age, bedrest, neuropathy, poor nutrition, cognitive impairment, friction & sheering & urinary incontinence

Example of an assessment tool for assessing older adults on six common ‘marker’ conditions – sleep problems, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown. Provide a snapshot of overall quality of care and health

Question 14

What are some aspects of the skin ?

Answer 14

Skin anatomy

Epidermis: consists of 5 layers, thin & avascular, regenerates every 4-6 weeks, primary function-protection

Dermis: consists of 2 layers, thickest layer, sparsely populated cells, main functions to provide strength, support, blood & O2 to skin. Collagen (strength) & elastin (recoil)-major proteins-synthesized & excreted by fibroblasts.

Basement membrane: dermal-epidermal junction

Under the dermis is a layer of loose connective tissue (subcutaneous tissue), attaches dermis to underlying structures. Consists of adipose & connective tissue, blood & lymphatic vessels & nerves. Functions to supply blood to dermis for regeneration

Epidermis & basement membrane thin

Dermis thins 20%

Loss of subcutaneous tissue

Blood vessels become thin & fragile

Question 15

What is the purpose of the skin ?

Answer 15

—Protection

—Sensation

—Temperature regulation

—Secretion & excretion

An average adult has 2 sq meters of skin weighing approx. 2.7kg The largest organ of the body.

Protection: normal to have bacteria on surface, non disease forming

Weakening of epidermis causes scraping or stripping of surface

Excessive dryness leads to cracks and entry for bacteria

Excessive moisture leads to maceration

Overuse of soaps, detergents, cosmetics can lead to chemical irritation-dermatitis

Cleansing with warm water reduces excessive sweat, oil, dead skin cells & dirt that can promote bacterial growth

Sensation:

Friction causes loss of stratum corneum, can result in development of pressure ulcers

Removal of nurse’s jewellery can reduce accidental injury

Temperature regulation:

Wet linen interferes with conduction & convection

Excess blankets interferes with heat loss by radiation & conduction

Use of coverings can promote heat conservation

Never leave your pt in a wet/soiled bed/or brief, change asap

Excretion & secretion:

Perspiration and oil can harbour micro-organisms

Excessive bathing can cause drying of the skin

Sebaceous glands secrete sebum, and oily odorous fluid into hair follicles

3 Layers of Skin: epidermis: several thin layers of cells, constantly regenerating, Dermis: thick layer, bundles of collagen, elastic fibers, nerves, blood vessels, sweat glands, sebaceous glands, hair follicles, Subcutaneous Layer: has blood vessels, nerves, lymph, fat cells

Question 16

How does one assess the skin ?

Answer 16

—Examine for colour, texture, thickness, turgor, temperature, hydration.

—Skin should be smooth, warm, supple have good turgor

—Pay attention if lesions, dryness, flaking, redness, scaling, cracking

—Assess tattoos & body piercings - risk for hepatitis B, C or HIV, AIDS (contaminated needles)

—Pay special attention to under woman’s breasts, perineal tissues, mans scrotum, foreskin

—Document problems, follow up in rounds, involve the pt.

Question 17

What the risk factors for skin impairment ?

Answer 17

—Immobilization

—Reduced Sensation

—Nutrition & Hydration Alterations

—Secretions & Excretions on the Skin

—Vascular Insufficiency

—External Devices

Question 18

How does one predict pressure ulcers ?

Answer 18

Braden Scale

—SENSORY PERCEPTION: the ability to respond to pressure-related discomfort (1-4:completely limited-no impairment)

—MOISTURE: degree to which skin is exposed to moisture (1-4 constantly moist –rarely moist)

—ACTIVITY: degree of physical activity (1-4: bedfast-walking frequently)

—MOBILITY: ability to change and control body position (1-4: completely immobile- no limitations)

—NUTRITION: usual food intake pattern( 1-4: very poor –excellent)

—FRICTION AND SHEAR: (1-3: problem- no apparent problem)

Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers.

At risk – 15 to 18;

Moderate Risk – 13 to 14;

High Risk – 10 to 12;

Very High Risk – 9 or below.

Question 19

What are the aspects of the oral Cavity ?

Answer 19

Floor of the mouth & underneath of tongue has rich supply of blood vessels, which allows for the absorption of sublingual medications (nitroglycerine, ativan) Ulcerations or trauma can cause significant amount of bleeding

3 pairs of salivary glands supply 1 litre of saliva/day- can be impaired due to medications, radiation & mouth breathing

Teeth are for mastication. Difficulty in chewing may be a result of inflamed or infected gum tissue or tooth loss, poorly fitting dentures, which can result in poor nutritional intake

Assess: regular oral hygiene, & dental apt., inspect oral cavity for colour, hydration, texture, lesions, coating on tongue, receding gums, discolored teeth, missing teeth, carries, pain in the mouth

Problems: gingivitis (gum inflammation) & periodontal disease

Halitosis (bad breathe)

Stomatisis: inflammation of oral mucosal tissues, common with chemotherapy or radiation

Aging:

Several factors can result in poor oral care-age-related changes of the mouth (teeth brittle, drier, darker, gums lose vascularity & tissue elasticity), chronic disease, disabilities involving hand grasp or strength, lack of attention and medications.

Question 20

What are the aspects of the Hair ?

Answer 20

•Growth, distribution & pattern can indicate

general healthA status - healthy hair is clean, shiny, untangled, scalp free of lesions

•Affected by:

–Hormonal changes

–Emotional & physical stress

–Aging

–Infection

–Certain illness

–Nutrient deficits

–Toxic therapies

Ageing: can begin between 20-50 years of age.

Drugs/Medications/Radiation: This cause of hair loss can include anticoagulants, antidepressants, contraceptive pills, amphetamines, some arthritis medications, some antibiotics, some blood thinners, medicines for gout, drugs derived from vitamin-A, certain drugs for ulcers, beta blocker drugs for high blood pressure.

Cancer treatments such as chemotherapy and radiation therapy halt the growth phase of hair follicles which results in a sudden hair loss as those follicles all shed their hair at about the same time.

Heredity: Androgenetic alopecia is the term used to describe a genetic predisposition in men and women for pattern baldness or pattern hair loss. Although there is a dominant tendency for male pattern baldness, female members of a family can be transmitters as well.

Hormonal Imbalance: If the male and female hormones, androgens and estrogens, are out of balance, hair loss may result. Also an overactive or under active thyroid gland can contribute to hair loss.

Illness and Severe Infections: These can include scalp fungal infections, Thyroid disorders, Hyperthyroidism, Hypothyroidism, Diabetes, Lupus.

Immune System Disorder: Alopecia areata is an immune system disorder which causes hair follicles to stop producing hairs. Advanced forms of the disorder are identified by the terms alopecia totalis when all head hair disappears, and alopecia universalis which results in all body hair disappearing.

Menopause: This can be a main cause of hair loss in women. Due to hormonal changes after menopause, some women find their hair begins to thin.

Poor Blood Circulation: Poor blood flow to the scalp, insufficient nutrients in the blood, or poor drainage of waste products through the lymphatic systems can all contribute to hair loss.

Pregnancy: Three to six months after delivering a child, many women notice a degree of hair loss as the hair goes into a resting phase because of the physiological impact of the pregnancy on the body.

Traction Alopecia: is the term used to describe loss of hair from constant pulling, as with tightly braided hair styles such as pony tails.

Sebum Build-up: A basic cause of hair loss is sebum build-up in the follicles which attacks the hair bulb, the rounded area at the end of a hair strand which is rooted in the follicle. Sebum causes the hair bulb to shrink so the hair is not as well rooted. After the hair falls out the new hair strand growing in that follicle is weaker and thinner and the process is repeated until the hair follicle is so damaged it dies.

Stress and Nervous Disorders: Telogen Effluvium is the term used for a slowing down of new hair growth because of sudden or severe stress. The stress triggers a large number of hair follicles to enter the resting stage, so a few months after the stressful event, those follicles shed hair at about the same time.

Question 21

What influences of hygiene ?

Answer 21

—Social practices

—Personal preferences

—Body image

—Socio-economical status

—Health beliefs & motivation

—Cultural variables

—Physical condition

Question 22

What are the benefits of providing client Hygiene ?

Answer 22

—Skin assessment

—Promote client function/assess function

—Enhance circulation

—Promote sense of well-being

—Develop nurse-client interaction

—Reduce infection/skin breakdown

—Promotion of health teaching

Question 23

What are the guidelines for bathing ?

Answer 23

—Provide privacy: close curtain/door, expose only the area bathed

—Maintain safety: side rails up when not present, call bell near if leaving

—Maintain warmth: body cools with bathing by convection, cover pt

—PromAote independence: offer assistance when needed, involve pt

—Anticipate needs: be organized, bring towel, washcloth, change of clothing, hygiene products

—Perineal care

◦Self-care ability of client

◦Reduction of embarrassment

◦Asepsis

—Back rubs

◦Benefits

◦Contraindications

Question 24

What are the guidelines for oral hygiene ?

Answer 24

—Brushing and flossing

—Clients with special needs

◦Presence of stomatitis

◦Use of oxygen therapy

◦Unconscious state

—Denture care

Stomatitis: an inflammation of the mucous lining of any of the structures in the mouth. Causes: poor oral hygiene, poorly fitting dentures, burns from hot liquids or food, conditions that affect other areas of the body such as an allergic reaction, medications, chemotherapy, radiation therapy or infections.

Unconscious client: pooling of saliva due to inability to clear on own, increased risk of aspiration. It may be necessary to provide oral care every 2 hours (q2h). When performing oral care position the client so they are side-lying with head turned toward dependant side.

Question 25

Why keep the bed wrinkle free ?

Answer 25

Prevent irritatio and provide comfort

open sheets - improve acess

Closed sheets - Keep bed clean

—Occupied bed: can be done after a bed bath

—Unoccupied bed: client has left the room for a length of time

—Linen needed:

◦Fitted or bottom sheet

◦Draw/lift/protector sheet (shoulders to below hips)

◦Top sheet

◦Pillow case

◦Additional flannel/cover

—One side of the bed, then the other; or work in pairs

—Do not flap sheets in air

—Body mechanics!