Physical Care Of Older Adults PDF

PHYSICAL CARE OF OLDER ADULTS OBJECTIVES At the end of the lesson, the students will be able to: 1. Review the specific anatomy related to nursing care. 2. Identify the nursing diagnosis that requires specific implementation of care 3. Apply the nursing management in the physica...

PHYSICAL CARE OF OLDER ADULTS OBJECTIVES At the end of the lesson, the students will be able to: 1. Review the specific anatomy related to nursing care. 2. Identify the nursing diagnosis that requires specific implementation of care 3. Apply the nursing management in the physical care of older adults.  IMPLEMENTATION Physical Care of Older Adults – Aging Skin and Mucous Membrane – Elimination – Activity and Exercise – Sleep and Rest Introduction As the largest organ of the body, comprising 15% of the body’s weight, the skin reflects the individual’s emotional and physical wellbeing. The skin varies in thickness from 0.5–4.0 mm, depending on which part of the body is involved (Stephen-Haynes, 2005). The skin consists of three main layers; the outer epidermis, the middle dermis and the subcutaneous tissue. Combined, these three layers of tissue provide the following functions: Combined, these three layers of tissue provide the following functions: 1. Protection 2. Barrier to infection 3. Pain receptor 4. Maintenance of body temperature 5. Production of vitamin D 6. Production of melanin 7. Communication, through touch and physical appearance Combined, these three layers of tissue provide the following functions: 1. Protection: the skin acts as a protective barrier, preventing damage to internal tissues from trauma, ultraviolet (UV) light, temperature, toxins and bacteria (Butcher and White, 2005) Combined, these three layers of tissue provide the following functions: 2. Barrier to infection: part of this barrier function is the physical barrier of intact skin; the other is the presence of sebum, an antibacterial substance with an acidic pH which is produced by the skin (Günnewicht and Dunford, 2004). Combined, these three layers of tissue provide the following functions: 3. Pain receptor: nerve endings within the skin respond to painful stimuli. They also act as a protective mechanism Combined, these three layers of tissue provide the following functions: 4. Maintenance of body temperature: to warm the body, the vessels vasoconstrict (become smaller), thus retaining heat. If the vessels vasodilate (become wider), this leads to cooling (Timmons, 2006). Combined, these three layers of tissue provide the following functions: 5. Production of vitamin D in response to sunlight: this is important in bone development (Butcher and White, 2005). 6. Production of melanin: this is responsible for skin colouring and protection from sunlight radiation damage. Combined, these three layers of tissue provide the following functions: 7. Communication, through touch and physical appearance: this gives clues to the individual’s state of physical well- being (Flanagan and Fletcher, 2003). Combined, these three layers of tissue provide the following functions: 1. Protection 2. Barrier to infection 3. Pain receptor 4. Maintenance of body temperature 5. Production of vitamin D 6. Production of melanin 7. Communication, through touch and physical appearance The changes in the skin that occur as an individual ages affect the integrity of the skin, making it more vulnerable to damage. The epidermis gradually becomes thinner, (Baranoski and Ayello, 2004) and thus more susceptible to the mild mechanical injury forces of moisture, friction and trauma (pp. 6–7). In the dermis, there is a reduction in the number of sweat glands and in the production of sebum. These changes add vulnerability to the skin, and, when this is coupled with an increased necessity to cleanse the skin, damage will occur. Most soaps increase the skin’s pH to an alkaline level, thus putting the skin’s surface at risk of the effects of dehydration and altering the normal bacterial flora of the skin, which allows colonisation with more pathogenic species (Cooper and Gray, 2001).  The most dramatic loss that the skin experiences during the ageing process is a 20% reduction in the thickness of the dermis (Bryant, 1992). This gives the skin its paper thin appearance, commonly associated with the elderly (Kaminer and Gilchrist, 1994). This thinning of the dermis sees a reduction in the blood vessels, nerve endings and collagen, leading to a decrease in sensation, temperature control, rigidity and moisture retention (Baranoski and Ayello, 2004). This lesson aims to provide clinicians with best practice guidance in five key areas of skin care for older persons, namely: 1. dry, vulnerable tissue 2. pressure ulcers 3. Incontinence 4. Maceration 5. skin tears.  DRY, VULNERABLE TISSUE As already said, with the ageing process, the skin undergoes a number of changes. Not only is there a significant reduction in the skin’s thickness, but because of the changes within the epidermis and dermis, there is also a reduction in the number of sweat glands, leading to dryness of the skin. Once the skin becomes dry, it is more vulnerable to splitting and cracking, exposing it to bacterial contamination, and further adding to the likelihood of breakdown from infection DRY, VULNERABLE TISSUE DRY, VULNERABLE TISSUE PRESSURE ULCERS A pressure ulcer is an area of localized damage to the skin and underlying tissue, due to the occlusion of blood vessels which leads to cell death (Collier, 1996). Pressure ulcers are believed to be caused by direct pressure, shear and friction (Allman, 1997; EuropeanPressure Ulcer Advisory Panel [EPUAP] Review, 1999). PRESSURE ULCERS The forces of pressure are further exacerbated by moisture, and factors relating to the individual’s physical condition, such as altered mobility, poor nutritional status, medication, and underlying medical conditions. Pressure ulcers are also referred to as pressure sores, decubitus ulcers and bedsores (Beldon, 2006). PRESSURE ULCERS The forces of pressure are further exacerbated by moisture, and factors relating to the individual’s physical condition, such as altered mobility, poor nutritional status, medication, and underlying medical conditions. Pressure ulcers are also referred to as pressure sores, decubitus ulcers and bedsores (Beldon, 2006). PRESSURE ULCERS Pressure ulcers usually occur over a bony prominence, such as the sacrum, ischial tuberosity and heels. However, they can appear anywhere that tissue becomes compressed, such as under a plaster cast or splint.  PRESSURE ULCERS Direct pressure is the major causative factor in the development of pressure ulcers. This occurs when the soft tissue of the body is compressed between a bony prominence and a hard surface. This occludes the blood supply, leading to ischaemia and tissue death.  PRESSURE ULCERS Friction occurs when two surfaces move or rub across one another, leading to superficial tissue loss. Prior to the use of lift aids, patients were manually lifted up the bed and, if the sacrum and heels were not clear of the surface, they would be dragged up causing friction to these areas.  PRESSURE ULCERS The majority of pressure ulcers to the heel are caused by a combination of both pressure and friction. Initially, they present as a blister (friction), with purple discoloration to the underlying tissue (pressure)  PRESSURE ULCERS The effects of pressure, shear and friction can be further exacerbated by the individual’s physical condition. These factors should be considered when carrying out a full assessment, including: 1. general health 2. age 3. reduced mobility 4. nutritional status 5. incontinence 6. certain medication PRESSURE ULCERS  INCONTINENCE Some studies have shown that older people are more prone to incontinence. In one study, 29% of older people cared for in a nursing home were incontinent of urine, 65% were doubly incontinent, and 6% were catheterised (Bale et al, 2004). Incontenence is inability of the body to control the evacuative functions of urination or defecation : partial or complete loss of bladder or bowel control fecal incontinence urinary incontinence — see also stress incontinence, urge incontinence.  INCONTINENCE Skin has a mean pH of 5.5, which is slightly acidic. Both urine and feces are alkaline in nature, therefore, if the individual is incontinent there is an immediate change in pH which affects the skin. Ammonia is produced when microorganisms digest urea from the urine. Although urinary ammonia alone is not a primary irritant, urine and feces together increase the pH around the perianal area, causing increased skin irritation (Berg, 1986; Le Lievre, 2000). This is responsible for the dermatitis excoriation seen in individuals with incontinence (Fiers, 1996).  INCONTINENCE Skin has a mean pH of 5.5, which is slightly acidic. Both urine and feces are alkaline in nature, therefore, if the individual is incontinent there is an immediate change in pH which affects the skin. Ammonia is produced when microorganisms digest urea from the urine. Although urinary ammonia alone is not a primary irritant, urine and feces together increase the pH around the perianal area, causing increased skin irritation (Berg, 1986; Le Lievre, 2000). This is responsible for the dermatitis excoriation seen in individuals with incontinence (Fiers, 1996).  INCONTINENCE The increase in moisture resulting from episodes of incontinence, combined with bacterial and enzymatic activity, can result in the breakdown of vulnerable skin, due to an increased friction co-efficient, particularly in those who are very young or elderly. For those individuals experiencing incontinence and the effects of irritation from incontinence, it is important to avoid exacerbating this further through inappropriate methods of cleansing the skin (Whittingham, 1998).  INCONTINENCE A protective barrier, spray or cream can be used to prevent sore skin from breaking down further. Advice on appropriate products to aid management of incontinence can be sought from your local continence advisor.  MACERATION It is accepted that a degree of moisture is essential for moist wound healing to occur (Winter, 1963). However, the correct moisture balance is difficult to define. The wound needs to be moist, but not too moist or too dry, as this may affect the rate of healing.  MACERATION Maceration of the skin may be due to any of the following factors: 1. incontinence 2. excess moisture from sweating in hot 3. environments and induced by waterproof 4. chair and bed surfaces 5. wound exudate 6. peri-stomal exudate.  MACERATION Maceration of the skin may be due to any of the following factors: 1. incontinence 2. excess moisture from sweating in hot 3. environments and induced by waterproof 4. chair and bed surfaces 5. wound exudate 6. peri-stomal exudate.  MACERATION When the skin is in contact with fluid for sustained periods of time, it becomes soft and wrinkled allowing for breaks in the epidermis (White and Cutting, 2003). This softening of the tissue, along with attack from enzymes within urine, feces and wound exudate, can cause the skin to become red, broken and painful. It is important that the skin is protected from these enzymatic onslaughts  SKIN TEARS Skin tears are a common problem in the elderly because the skin becomes thin and fragile (Bryant, 1992). They usually occur on the shin and the arm, and are normally caused by trauma exacerbated by shear and friction (Morris, 2005). Due to the thin nature of the skin, skin tears tend to involve some damage to the epidermis and the dermis, and may take some time to heal. Therefore, to optimise healing, management of these wounds is best carried out at the time of injury SKIN TEARS Each of the sections that follow, contain a table showing: the optimum outcome the reason for, and how best to succeed in reaching this outcome how to demonstrate that best practice is being achieved Thank you for Listening.