Examination of the skin should take place in good, natural light. 

Compare both sides of the body and touch should be used to determine skin temperature or the presence of rashes/irritation.

Color changes, including pallor, cyanosis, jaundice, or erythema can indicate a variety of problems.

One of the most common problems of aging.

Can result in itching(pruritus), burning, and cracking of the skin.

Many older people develop a habit of scratching or picking at dry/cracked skin, increasing their risk for further tissue damage and infection.

Medications, communicable diseases and contact with chemical substances are common causes of skin rashes & pruritus.

Allergic response to medications can manifest as diffuse rashes all over the body.

superficial infection caused by a parasitic mite that burrows under the skin.

It's 1st seen inside webs of fingers and toes.

Changes in this is common with aging.

Acne rosacea can be tx with topical medications.

Changes in size/pigmentation of moles are of greater significance b/c it may indicate prescence of a precancerous/cancerous condition.

Breaks in tissue integrity increase the older person's risk for infection and often result in timely, costly treatments.

Skin tears, abrasions, lacerations, and ulcers most often result from friction, shearing force, moisture and pressure.

Make sure to hydrate skin and educate the staff!

Older adults who suffer from compromised circulations, restricted mobility, altered level of consciousness, fecal/urinary incontinence, or nutrional problems are at a greater risk.

Excessive pressure on tissues, particularly over boney prominences can quickly lead to skin breakdown.

Use a rohoe cushion for pt to sit on. Has a wavy buttom to prevent any breakdown.

Immobility

Inactivity

Incontinence

Malnutrition

Diminished sensation/decreased mental status

Impaired skin integrity

The Braden Scale takes into consideration the following factors when assessing for pressure ulcer risk:

Sensory perception

Moisture

Activity

Mobility

Nurition

Typically becomes thinner and has a finer consistensy with advanced age.

men tend to lose more hair than women do although some men retain a full head of hair throughout life.

Male pattern baldness typically results in progressive loss of hair at the temples and back of the head.

Sudden and excessive hair loss or breakage is likely to indicate a systemic problem. 

It could be autoimmune or because of chemo.

Diminished/absent hair in the lower legs/feet especially combined with dry, scaley skin and weak absent pedal pulses indicate a decreased blood supply to lower extremites.

Aging results in hyperkeratosis (thickening of nails...it's normal) particularly the toenails.

Thick hard nails become difficult to cut.

Fungi cause the nails to become thick, brittle, misshapen, and discolored (such as black/brown)

Tooth decay, loose teeth, and lost teeth (false teeth) are ongoing problems.

Poor nutrition and decreased appetite can be attributed to dental problems.

Decay/caries is caused by the action of bacteria that penetrate through the enamel shield of the tooth and cause destruction.

Food debris and plaque build up in the mouth and on the teeth when oral hygiene is inadequate.

Activity of bacteria on this debris causes bad breath/halitosis

Gingivitis causes gum swelling, tenderness, and bleeding and eventually leads to recession of the gum tissue away from the tooth.

Check for abscesses under dentures

Dental caries and periodontal diease are the most common reasons for oral pain, but oral lesions such as stomatitis in the mouth can occur.

Pain can also affect the face and jaw.

Oral pain can cause loss of appetite, decreased food intake.

B12/riboflavin deficient people have a sore tongue.

Dementia people will pain will often be agitated, acting out, more confused, they're pain will not always be visible.

Make sure they fit.

They're expensive and difficult to fit.

A significant amount of weight can be lost if they're not fitted correctly.

Dentures can cause irritation, inflamm, and ulceration of gums and oral mucous membranes.

If patient doesn't wear dentures they're gums will "firm up"

Xerostomia/dry mouth. Is common with aging.

Causes increased cavities and risk for aspiration.

Makes chewing and swallowing more difficult, promotes tooth decay, and alters sense of taste.

Give them something to drink before they start eating.

White patches in the mouth.

Often are precancerous and require prompt medical attention.

Lesions on the posterior third/sides of tongue.

Often are abnormal.

Usually have been smokers/chew tobacco.

People with mouth cancers have very poor prognosis.

Oral/pharyngeal cancer has a poor prognosis

Symptoms of oral cancer include leukoplakia, or erythroleukoplakia, sores in the mouth that do not heal, oral bleeding, pain or diff swallowing, diff wearing dentures, swollen lymph nodes in neck, chronic earache.

Possibly previous alcholic, tobacco use or enviornmental factor

Deficiences of riboflavin, niacin, and vitamin C affect oral mucous membranes

Smooth purplish sore tongue may be related to riboflavin deficiency

COmplaint of a burning sensation or a soreness of the mouth may indicate niacin deficency

Of the mouth are relatively common who recieve broad spectrum antibiotic therapy for another infection.

Antibiotics destroy the normal flora and allow opportunist bacteria or yeast colonies to become established and grow.

Doctor's try to wait to give antibiotics

Is the result of an enlargement of the papillae on the tongue. This often follows antibiotic treatment.

Black or brown discoloration on the tongue may be caused by tobacco use or by a chromogenic (color producing) bacterium

Superinfections

Alcohol & tobacco even in small amts can harm the mucous membranes.

Alcoholis chemically irritating and drying to the mucous membranes.

Tobacco whether smoked, chewed or taken as snuff increases the risk for oral cancer.

Neurologic conditions such as stroke, MS, or Parkinson's decrease coordination & strength making it difficult for the person to manipulate equipment as needed for oral hygiene.

Older person with epilepsy may take medications (such as dilantin) and need to take special precautions b/c these medications often cause hyperplasia (thickening of the gums)

Complete a thorough assessment of the oral mucous membranes

Inititate referral to a dentist

Provide oral hygiene

Promote adequate intake of nutrients & fluids

Provide lozenges/topic analgesics as prescribed

Communicate suspected oral side effects of medication therapy to physician and dentist.

Many factors influence how many calories will be used by a person:

Activity patterns

Gender

Body Size

Age

Body Temp

Emotional Status

Temp of the climate in which the person lives

Foods high in nurtitional value and relatively low in calories must be sleected to maximize the amount of nutrients the body recieves while reducing the number of calories.

Vital nutrients needed by all people include carbs, protein, fats, vitamins, minerals, and fluids.

Factors affecting Nutrition in the elderly

physiologic risk factors

Chronic health factors

Alcoholism

Sensory changes

Pain

Meds

Problems with chewing/swallowing/digesting

Malabsorption

Factors affecting Nutrition in the elderly

Economic Risk Factors

Cost of food

Diff getting transportation

Obtaining an appropriate variety and sufficient amount of food

Factors affecting Nutrition in the elderly

Social Risk Factors

Depression

Loneliness/Social Isolation (especially death of spouse)

Lack of motivation

Food is more than a means of meeting nutritional needs

Also used as part of religious cermonies in social interactions and as a means of cultural expression

Many major religions such as Islam, Judaism, and Catholicism include some dietary restrictions

Risk for Imbalanced Nutrition

Data Collection

Appetite Changes

Nutritional Intake (food diary)

Social & cultural factors (such as fasting)

Home care/discharge planning (discharge planning begins on admission)

Imbalanced nutrition:less than body requirements

Imbalanced nutrition:more than body requirements

Risk for imbalanced nutrition:more than body requirements

Readiness for enhanced nutrition

Maintain body wt within normal limits for ht

Obtain adequate nutrients to maintain healthy tissue

Identify internal and external cutes that influence eating patterns

Adhere to a prescribed therapeutic diet (low sodium for CHF pts)

Collect date to determine cause of problem

Weekly wts (CHF daily wts)

Dietary record

Explain importance of nutrition

Determine food likes & dislikes

Monitor lab values (especially albumin-liver function & malnutrition)

Assess skin, hair, nails, mucous membranes

Consult with dietitian.

Document!

Nursing Interventions for Home 

(Imbalanced Nutrition)

Assist the individual in setting up resources (meals on wheels, food stamps, etc)

Involve family in shopping/meal planning

use any appropriate interventions that are used in institutional setting

Assessment

Deficient Fluid Volume

Occurs when an individual has an inadequate intake/excessive loss of fluids

Can easily progress into dehydration and can result in death.

Likely to manifest dry mucous membranes, thirst, decreased skin turgor, rapid wt loss ,sunken eyes, weakness, decreased volume/increased concentration of urine.

Excessive intake/inadequate output of fluids

Primary indication is edema

Pulmonary edema may result in SOB, dyspnea, cough, gurgling on respiration, and frothy sputum

Wt gain can be sudden & dramatic

Hematocrit normally decreases as plasma volume increases

May experience behavioral changes including restlness and anxiety

Deficient fluid volume

Excess Fluid volume

Risk for Deficient fluid volume

Risk for imbalanced fluid volume

Readiness for enhanced fluid balance

Nursing Interventions for Fluid Volume

Hospitals/Extended Care Facilities

Complete a thorough obj and subjective assessment

Monitor vitals

I&O, Lab values

Weigh pt daily before breakfast

Measure changes in girth of body parts such as legs and abdomen.

Maintain adequate fluid intake.

Adminster meds as ordered.

Refer to dietician. Provide skin care.

Report & document findings.

Nursing Interventions for fluid volume

Home Care

Complete a thorough sub and obj date collection

Teach individual and his/her family members how to monitor fluid intake

Promote wellness by reviewing the prescribed dietary and fluid intake with individual

Explain methods of increasing or decreasing fluid intake

use any appropriate interventions that are used in the instituitional setting.

Is there any hx of stroke/any problem that could interfere with chewing/swallowing?

Is individual alert and able to follow commands?

Any facial drooping? (have them stick out tongue)

Does the person complain of something sticking in their throat?

Does the person cough, choke, or drool when eating?

Does the perosn complain or hoarseness/dry throat?

Does the person pocket food?

Is the person's gag reflex weak/absent?

Can the person close their lips?

Neurologic problems that result in paralysis or weakness of the face, mouth, or throat

Altered level of consciousness, awareness, or sensation

Mechanical devices such as a tracheostomy tube/NG tube

a narrowing/obstruction of the pharynx/esophagus

excessive fatigue

Determine his/her unique problems and needs

Consult with speech therapist, occupational therapist and dietitician to develop a dysphagia program

Verify that dentures fit properly and maintain good oral hygiene

Position the person with his/her head upright and the chin flexed slight forward to facilitiate swallowing

Encourage rest periods before meals

Allow adequate time for meals

Start with small amounts of food and thickened fluids

Place foods into the unaffected/stronger side of mouth

Present foods in an appealing manner.

Select foods based on taste, texture, temperature, and fluid content

Ensure that the lips are closed by applying slight pressure/stroking

Stimulate swallowing by stroking the side of the neck and support the weakend side if appropriate.

Give frequent verbal cues. Reduce distractions

Keep suction equipment available.

Provide oral hygiene before & after meals.

Adminster tube feedings as ordered by the phsician to individuals who are unable to achieve adequate oral intake.

Assessment

Risk for Aspiration

Does the person have cough/gag reflexes?

Does the person have a reduced level of consciousness?

Does the person have a trach?

Is the person in the supine position during feedings?

Is the person recieving feedings/meds through a gastric tube?

Assessment

Risk for Aspiration (cont)

Does the person have signs of abd distention?

Are the person's stomach contents more than 150mL before a scheduled feeding?

Is there any noise with respiration?

Is there a productive cough? what is the consistency of sputum?

Are the pulse and respiratory rates elevated?

Neurologic problems, particularly those that affect the cough and/or gag reflexes

Reduced level of consciousness

Continous supine positioning

Trach tubes, gastric tubes

Decreased gastric motility, excessive amts of residual gastric contents or gas

Nursing Goals/Outcomes

(Risk for aspiration)

Remain free from episodes of aspiration

Maintain clear, noiseless breath sounds

Nursing Interventions

Hospital/Extended Care

Risk for Aspiration

Position the person appropriately

Date collection (abd check for distention)

Avoid feeding rapidly

Avoid liquids and pureed foods

Monitor respiratory sounds & resp rate and observe the amt and type of sputum produced.

Keep suction equipment avaliable

Nursing Interventions

Hospital/Extended Care

Risk for Aspiration (Cont)

Check placement of nasogastric tube using the approved method

Measure stomach contents before starting intermittent feeding, then reinstill stomach contents

Maintain clean technique for all feeding tubes, equipment, and formula.

Nursing Interventions

Home

Risk for Aspiration

Explain safety precatuions to the individual and the family/caregiver

Encourage enrollment in a home safety course that include the Heimlich and CPR

Use any appropriate interventions that are used in the institutional setting.