Chapter 13Skin CareCopyright © 2020 by Elsevier, Inc. All

Chapter 13
Skin Care
Copyright © 2020 by Elsevier, Inc. All rights reserved.
1
Skin
Functions of skin
Protect underlying structures
Regulate body temperature
Sensory input
Stores fat
Metabolism of salt and water
Gas exchange
Production of vitamin D
2
Review Table 13.1 for expected changes related to aging
You need to know what is normal to know what to consider
abnormal and in
Need of intervention.
2
Often overlooked because focus is on acute problems or disease
Can affect health and compromise quality of life

Many age-related changes are visible
Due to aging, genetics, environment
Common Skin Problems
Xerosis
Extremely dry, cracked, and itchy skin
Most common skin problem associated with aging
Caused by decrease in epidermal filaggrin, which is a protein
required for binding of keratin into macrofibrils
Seen primarily on the extremities, mostly legs, but may affect
trunk and face
Best practices (Box 13-2)
3
How might the skin care be different for the older patient?
3
4
XEROSIS
Pruritis

Itchy skin (not a disease, but a symptom)
Can cause skin injury secondary to scratching
Aggravated by perfumed detergents, fabric softeners, heat,
sweating, restrictive clothing, fatigue, exercise, and medications
May result from systemic disease such as chronic renal failure,
biliary, or hepatic disease
Failure to control itching increases risk for eczema,
excoriations, cracks, infection
5
Itching can cause disruption in the skin and needs to be
addressed to reduce risk of infection
5
Scabies
Causes intense itching
Caused by tiny mite, Sarcoptes scabiei
Contagious, easily transmitted through close physical contact;
intimate or casual
Scabies with thick crust contain large number of mites and eggs
May be transmitted on clothing, linen, furniture
Diagnosed visually or via skin scraping
Treated with prescribed lotions and creams; clothes and linens
need to be washed in hot, soapy water and dried with high heat;
rooms cleaned and vacuumed
6
6

7
Consider this a possibility if your patient has a lot of itchiness
at night
Can spread easily, so you will want to identify it early and
check others
Who have been in contact with the patient
All belongings must be treated also
7
Purpura
Fragility of dermal capillaries secondary to dermal thinning
causing blood vessels to rupture
Extravasation of blood into surrounding tissue is called purpura
Commonly seen on dorsal forearm and hands
Increases with age
Persons on blood thinners are more susceptible
8
9
How might you adjust care for this person because of increased
bruising?
9

Skin Tears
Occurs because skin is thin and fragile
Painful, acute, accidental in nature
Categorized according to the Payne-Martin classification system
Management: proper assessment, control of bleeding, cleanse
with nontoxic solution, appropriate dressing, management of
exudate, and prevention of infection
10
11
Keratosis
Seborrheic Keratosis
Benign growth
Mainly see on trunk, face, scalp, and neck
Waxy, raised, stuck-on appearance
Flesh colored or pigmented, various sizes
Actinic Keratosis
Precancerous
Related to exposure to UV light
Risk: increased age, fair complexion
Rough scaly sandpaper patches
Pink to reddish brown with erythematous base
12
Actinic keratoses

Seborrheic keratosis
13
Seborrheic keratosis: Image of raised brown, scaly patch of skin
Actinic keratoses: Image of older man’s forehead with raised,
crusty red patches, some with scabs
13
Herpes zoster (Shingles)
Viral infection caused by reactivation of the varicella-zoster
(chicken pox) virus
Preceded by itching, tingling, rash along the dermatome prior to
outbreak of vesicular lesions
Lesions rupture, crust over, and heal
Infectious until it crusts over
Treatment: analgesics, calamine lotion, antiviral agents, Zoster
vaccine if greater than 60 years
Complications: postherpetic neuralgia, eye involvement
14
14
15

NEVER goes around the entire body—is limited to one side,
following the dermatome
15
Candidiasis
Caused by fungus Candida albicans found on the skin
Risk factors for infection: obesity, malnourishment, antibiotic
or steroid use, immunocompromised, chemotherapy, and
diabetes
Found in warm, moist areas of skin, like skinfolds, axilla, groin
Commonly called “thrush” when inside the mouth
Tips for best practice (Box 13-6)
16
17
Skin Cancer
Cancer of the skin is the most common cancer
Major public health problem on the rise
One in five Americans will develop skin cancer in the course of
a lifetime
Caucasian populations are at a higher risk
All skin types should minimize sun exposure
18

What is primary and secondary prevention for skin cancer?
While much damage might have already been done
We can still teach them ways to reduce risk
18
Basal cell
Most common malignant skin cancer
Mainly in older persons
Slow growing and metastasis rare
Triggered by extensive sun exposure, burns, chronic irritation,
or ulceration
Early detection and treatment minimizes damage
Squamous cell
Second most common
Aggressive and high incidence of metastasis
Major risk factors are sun exposure, fair skin,
immunosuppression
Slightly different clinical presentations and may be overlooked
Treatment depends on size, histology, and patient preference
Skin Cancer
19
Basal cell
Squamous cell
Skin Cancer
20
Basal cell: Image of raised mole with irregular borders and

visible vasculature on man’s nose
Squamous cell: Raised mole with irregular borders and dry,
crusty ulceration
20
Skin Cancer
Melanoma
Neoplasm of the melanocytes
Accounts for less than 2% of all skin cancers
Highest incidence in Caucasians
Multicolored, raised, asymmetrical, irregular borders
More common in men than women
Risk factors: more than 50 moles, sun sensitivity, history
excessive sun exposure, severe sunburns, tanning beds
21
21
22
Skin Cancer
23
23

Indoor tanning
Melanoma is most common cancer in people less than 30 years
Indoor tanning increases risk of melanoma by 75% when started
before age 35
2.5 times more likely to develop squamous cell
1.5 times more likely to develop basal cell
Goal of Healthy People 2020 is to reduce the use of indoor
tanning devices
Promoting Health Skin
24
Box 13-7 in text
24
Pressure Ulcers
70% of pressure ulcers (PU) occur in older adults
A PU is a “localized injury” to the skin and/or underlying
tissue, usually over a bony prominence, as a result of pressure,
or pressure in combination with shear

Affects health and quality of life
Considered a geriatric syndrome
Major cause of morbidity and mortality worldwide
National Pressure Ulcer Advisory Panel has developed a PU
registry to track the problem
25
25
Pressure Ulcers
Characteristics
Most frequently occur on the posterior aspects of the body,
especially sacrum, heels, and greater trochanter
May also be seen on lateral knees and ankles, pinna of the ears,
occiput, elbows, and scapulae
25%-35% of PU are on the heels
Persons with peripheral vascular disease at greatest risk for
development of heel ulcers
26
26
Pressure Ulcers
27
Suspected deep tissue injury

First image: Cross-section of the layers of the skin
Second image: Stage 1 pressure ulcer on heel of African
American client
27
Pressure Ulcers
28
Stage I
First image: Cross-section of skin showing stage 1 pressure
ulcer
Second image: Red, purple discoloration of intact skin on
client’s left hip
28
Pressure Ulcers
29
Stage II
First Image: Cross-section of skin showing stage II pressure
ulcer
Second Image: Red discolored skin with open areas; client
photo of stage II pressure ulcer

29
Pressure Ulcers
30
Stage III
First Image: Cross-section of skin, stage III pressure ulcer
Second Image: Large stage III pressure ulcer spreading across
both buttocks; excoriated, red, sanguineous tissue
30
Pressure Ulcers
31
Stage IV
First Image: Cross-section of skin showing stage IV pressure
ulcer
Second Image: Stage IV pressure ulcer showing muscle
31
Pressure Ulcers
32
Unstageable

First Image: Cross-section of skin showing unstageable pressure
ulcer with black necrosis in center of image
Second Image: Unstageable pressure ulcer with black, necrotic
center
32
Pressure Ulcers
Classification
EPUAP and NPUAP (Box 13-10)
Medical Device-Related Pressure Injury
Mucosal Membrane Pressure Injury
Pressure injuries are always classified by the highest stage
“achieved”
Reverse staging is never used
33
33
Risk Factors
Changes in skin
Comorbid illnesses
Nutrition status
Frailty
Surgical procedure (orthopedic/cardiac)
Cognitive deficits
Incontinence
Reduced mobility
Risks (Box 13-11)
Consider intensity and duration of pressure and tissue tolerance

Redness or blanching may NOT be the first sign of PU in darker
pigmented persons, but may look purplish in color or look like a
bruise
Pressure Ulcers
34
34
Pressure Ulcers
Prevention of PU
Prevention is key
A comprehensive PU program with multiple interventions
appears to improve outcomes
Significant interventions include addressing limited mobility,
compromised skin integrity, and nutritional support
A team approach is best when addressing this complex problem
35
35
Pressure Ulcers
Key nursing sensitive quality indicator
Can significantly impair recovery and rehabilitation and impact
quality of life
Increased risk of mortality

High prevalence of health care litigation
Centers for Medicare and Medicaid consider PU a preventable
adverse event and do not reimburse treatment for PU acquired
during admission
36
36
Promoting Healthy Aging Implications for Gerontological
Nursing
37
Assessment of PU
Thorough assessment of skin
Braden Scale
Nutritional evaluation
Laboratory studies
Positioning
Incontinence care
Wound specialist nursing consult when indicated
37
38

Question 1
Which is the most common malignant skin cancer?
Melanoma
Squamous cell carcinoma
Basal cell carcinoma
Actinic keratosis
39
ANS: C
39
Question 2
What is the #1 treatment of PU?
Prevention
Early identification
Thorough patient history
Risk assessment
40
ANS: A
40

Chapter 12
Hearing
1
2
3

4
5
Hearing Impairment
6
Third most prevalent chronic condition and the foremost
communicative disorder
Under recognized public health issue
Men are more likely than women to be hearing impaired
65% of persons over the age of 70 are affected
Factors affecting hearing impairment are complex and include
age-related changes, genetics, lifestyle, and environmental
factors

Consequences of Hearing Impairment
Loss of self-esteem
Safety risks
Cognitive decline
Increases feelings of isolation
May be diagnosed with dementia inappropriately
7
Diminishes quality of life
Decline in function
Increased hospitalizations
Miscommunication
Depression
Falls
Types of Hearing Loss

Sensorineural
Damage to inner ear or neural pathways
Presbycusis (age related):
Most common form of hearing loss, worsens with age
First sign is difficulty hearing in noisy environments
Affects high frequency
Noise induced:
Second most common cause
Mechanical injury to the sensory hair cells of cochlea
Continuous noise exposure, expected to rise
Consider better ear protection devices
8
9
Types of Hearing Loss
Conductive
Abnormalities of external and middle ear that reduce
transmission of sound
Causes include
Cerumen impaction occurs in 33% of nursing home residents

Otosclerosis
Infection
Perforated eardrum
Fluid in middle ear
Tumor
Cerumen accumulation
10
First image is of a healthy inner ear. Second image is of
impacted cerumen in the ear canal.
10
Interventions to Enhance
Hearing
11
Hearing aids
Personal amplifying system

Numerous types: digital, analog, vary in size, appearance,
effectiveness
Type of device depends on type of hearing impairment and what
the person can afford
Not usually covered by insurance or Medicare
Hearing aid care and use
Hearing
12
Cochlear implants
Increased use for sensorineural hearing loss where hearing aids
aren’t effective
Bypasses damaged portions of the ear and directly stimulates
auditory nerve

Two parts: one piece surgically implanted under the skin and
external portion that sits behind the ear
Surgery destroys residual hearing
Avoid magnetic resonance imaging
13
Image of cochlear implant with transmitter behind the ear,
microphone over the ear, and the processor.
13
Hearing
14
Assistive listening and adaptive devices

Personal listening systems
Adjunct to hearing aids or used in place of
Enhance face-to-face communication
Text messaging devices
Closed-caption
Special service dogs
Use of computers and email
Pocket-sized amplifiers
Promoting Healthy Aging: Hearing
15
Screening for hearing impairment is essential primary care for
older adults

Assessment includes focused history and physical examination
and screening assessment
Self-assessment instruments may be helpful (Box 12-3)
May require referral to an audiologist
Removal of cerumen impaction (Box 12-2)
Follow best practices for communicating with older adults (Box
12-5)
Question 1
Which are best practices for communicating with older adults?
Never assume hearing loss is from age until other causes are
ruled out
Lower your tone of voice, articulate clearly, use a moderate rate
of speech
Inappropriate responses, inattentiveness, and apathy may be
signs of hearing loss
All of the above
16

ANS: D
16
Question 2
What is the most common type of hearing loss in the older adult
?
Conductive
Noise induced
Otosclerosis
Presbycusis
17
ANS: D
17
CHAPTER 11
VISION
1
Changes in Vision With Age
Changes in eye structure begin early, are progressive, and affect
both function and structure

Presbyopia (decreased near vision) is a common change of
aging
Nearly 95% of those over 65 years of age wear glasses
2
Extraocular changes
Eyelids lose elasticity contributing to drooping
Entropion: inward turning of the lower lid
Ectropion: outward turning of the lower lid (Figure 11-1)
Xerophthalmia: excessively dry eyes
3
Ocular changes
Cornea becomes flatter, less smooth, thicker, and loses luster
Increased astigmatism
Chambers that control the movement of aqueous fluid decrease
in size and volume capacity, leading to development of
glaucoma
Iris is slower to respond to changes from light to dark
Glare is a major problem
Decreased ability of the lens to accommodate
Development of cataracts from ultraviolet exposure
4

Intraocular changes
Deterioration of vitreous humor may lead to development of
“floaters” (lines, webs, spots, dots)
Retinal changes affect color, with red, orange, and yellow seen
more easily
Color clarity diminishes by 59% in the eighth decade, secondary
to yellowing of the lens
Drusen spots may appear on the macula
5
6
Vision loss is not an inevitable part of aging, but age-related
changes contribute to decreased vision (Table 11-1)
Even older persons with good visual acuity need
accommodations to enhance vision and safety
Visual Impairment
7

7
Blindness and visual impairment are major causes of disability
in older adults
As the population ages, rates of blindness and visual
impairment in disadvantaged and minority populations will
increase in prevalence
World Health Organization’s Universal Eye Health: A Global
Action Plan 2014-2019
8
Consequences of Visual Impairment
Associated with cognitive and functional decline, decreased
quality of life, and depression
Associated with increased risk for injury and falls

“Snowball” effect, impacting families, caregivers, and society
at large
9
Prevention of Visual Impairment
Have yearly dilated eye examination
Get routine eye examinations
NEHEP/NEI
10
10
Diseases and Disorders of the
Eye
Cataracts
Opacity of the lens causing the lens to lose transparency and
scatter light
Often caused by oxidative damage
Cardinal sign is appearance of halos around objects as light is
diffused
11

12
13
Very blurry image of two small children hugging and holding
soccer balls.
13
Eye
Treatment of cataracts
Requires surgery under local anesthesia
95% return to excellent vision
Education regarding vision and adaptation to light changes
Post-surgery avoid heavy lifting, straining, bending at the waist
Fall prevention
14
Eye
Glaucoma
Affects over 2.3 million persons over the age of 40 and almost
half don’t know they have it

African Americans at greater risk for developing glaucoma at an
early age
Primary open angle glaucoma is most common and is the second
leading cause of legal blindness in the United States
Other types include congenital, low and normal tension,
secondary, and acute angle closure
15
16
17
Eye
Primary open angle
Progressive, asymptomatic with visual field loss
May complain of headache, poor vision in dim lighting, tired
eyes
Increased intraocular pressure damages optic nerve
Vision loss can be prevented if detected early
Acute angle closure
Emergency

Angle of iris obstructs flow of aqueous humor
May be related to infection or trauma
Intraocular pressure rises rapidly
Eye is red and painful, severe H/A, N/V
Avoid anticholinergics
18
19
First image of two boys hugging and holding soccer balls; the
image is clear. Second image of same boys but the edges of the
image are dark with a bright circle around the boys’ heads to
signify the vision changes associated with glaucoma.
19
Eye
Screening and treatment of glaucoma
Adults over the age of 65 or those at risk should have an annual
eye examination with dilation
Treated with oral or topical eye drops to decrease intraorifice
pressure (IOP) (beta-blockers first line of therapy),
trabeculoplasty, and filtration surgery

20
Eye
Diabetic retinopathy
Occurs in both type 1 and type 2 diabetes
Chronically high blood sugar from diabetes is associated with
damage to the tiny blood vessels in the retina, leading to
diabetic retinopathy.
Blood and lipid leakage leads to macular edema and hard
exudates (composed of lipids).
In advanced disease, new fragile blood vessels form and
hemorrhage easily.
21
21
22
22

23
Same image of the boys, but the image is indecipherable due to
black spots signifying diabetic retinopathy.
23
Diseases and Disorders of the Eye
24
24
Screening and treatment of retinopathy
Early detection is essential
Annual fundoscopic dilated eye examination
Fundoscopic evaluation includes microaneurysms, flame-shaped
hemorrhages, cotton wool spots, hard exudates, and dilated
capillaries

Maintain strict control of blood sugar, cholesterol, and blood
pressure
Diabetic macular edema (DME)
Thickening of the center of the retina
Most common cause of visual loss due to diabetes and leading
cause of legal blindness
Treat with cortisone drugs, growth factors, and laser therapy
Retinal vessels become leaky and fluid accumulates within the
macula
Annual dilated retinal examination
25
25
26
Eye
Detached retina
Emergency medical treatment required to save vision
Actual areas of the retina are torn that lead to retinal

detachment
May have gradual increase in floaters and/or light flashes in the
eye
Repair requires surgery
Early intervention improves vision results
27
Age-related macular degeneration
Most common cause of new visual impairment among persons
greater than 50 years and increases with age
Progressive loss of central vision
Caused by systemic changes in circulation, accumulation of
cellular waste, tissue atrophy, and growth of abnormal vessels
in choroid layer beneath the retina
Fibrous scarring affects nourishment of photoreceptor cells
28
29
30

Eye
Dry AMD
90% of cases
Rarely causes severe impairment
Can lead to wet
Three stages
Common early sign: Drusen bodies seen on fundoscopic
examination
Wet AMD
Also called neovascular
Abnormal blood vessels grow under the macula, causing its
displacement
Affects central vision
Progression can be rapid with resultant blindness within 2 years
31
AMD screening and treatment
Early diagnosis is key
Amsler grid to determine clarity of vision helps identify central
vision problems
Treatment: photodynamic therapy, laser photocoagulation, and
anti-vascular endothelial growth factor (VEGF) therapy
32

33
Dry eye (keratoconjunctivitis sicca)
A common complaint rather than a disease
Tear production diminishes with age
More common in postmenopausal women
Can be related to medications, Sjogren’s syndrome
Use artificial tears, consider Vitamin A deficiency
Promoting Healthy Aging
Warm incandescent lighting
Increase light intensity
Control glare
Use sunglasses
Select colors with good contrast
Reading material with large, dark, evenly spaced print
Red and orange colors can be seen the best
34

34
Special Considerations in Long-Term Care (LTC)
35
Cognitive impairment interferes with ability to communicate
visual disturbances
If a person has glasses, he or she should wear them
Routine eye care is a gap in care and can lead to functional
decline, decreased quality of life, and depression
One-third of vision problems in LTC setting are reversible
Low-Vision Optical Devices
An array of low-vision assistive devices are available
Persons with severe visual impairment may qualify for
disability, financial, and social service assistance through
government and private programs
36

Question 1
One of the most common visual changes associated with aging
is:
macular degeneration.
presbyopia.
glaucoma.
cataract.
37
ANS: B
37
Question 2
Which is considered an eye emergency?
Cataract
Acute angle closure glaucoma
Age-related macular degeneration (wet)
DME
38
ANS: B
38
Instructions: PLEASE READ CAREFULLY!!! Complete the
following case study and critical thinking questions. Provide
rationales for each item that you write in APA style citation.
Provide a full reference list with all citations. Only use credible
resources: refer to Stratford Library for the use of credible APA
resources. All answers must include a rationale and APA
citation for full credit. This is a 2 part assignment.

Touhy: Ebersole & Hess’ Toward Healthy Aging, 10th Edition
Chapter 13: Skin Care
Part 1: Case Study:
Patrick is an 82-year-old black male admitted to the hospital for
surgical repair of a fractured right hip. He lives alone and his
neighbors found him lying on his bathroom floor around 7 pm.
James told them he had been lying there since the afternoon but
could not reach the phone to call for help and was unable to
move. James has a history of hypertension and diabetes.
As the nurse is performing an assessment on the second
postoperative day, he documents an area on James’s right heel
that is purplish in color and appears to be a bruise. The area is
cooler to touch than the surrounding skin. There is no redness
and there are no open areas; James denies any pain in the heel.
On the basis of the nursing study, develop a nursing care plan
using the following procedure: (Identify a NANDA approved
nursing diagnosis in the text or 4gcM0.pdf (israa.edu.ps) and
identify possible and potential problems for this client. See this
resource Nursing Diagnosis Guide for 2022: Complete List &
Tutorial - Nurseslabs.
1) List the subjective data from the client’s case?
2) List information from the case study that provides objective
data.
3) From these data, identify and state, using an accepted format,
two priority nursing diagnoses you determine are most
significant at this time with rationales on why you selected
these diagnosis for this client.
4) Determine and state outcome criteria for each diagnosis.
These must reflect some alleviation of the problem identified in
the nursing diagnosis and must be stated in concrete and
measurable terms. Example: The clients wound will not develop

infection during the hospital stay. The goal must be measurable.
You can not use the example.
5) Plan and state one or more interventions for each diagnosed
problem. Provide specific documentation of the source used to
determine the appropriate intervention (see Chapter 13; Boxes
13-3, 13-8, 13-10, 13-12, 13-14, 13-15; and NPUAP Pressure
Ulcer Guidelines).
Part 2: Critical thinking Questions and Activities
1. What risk factors for pressure ulcers are present in this
situation? (see Box 13-11 for list of risk factors).
2. How does skin color affect the presentation of deep tissue
injury?
3. What areas of the body are susceptible to pressure ulcer
development and why?
4. What education needs to be provided to the patient, staff, and
family?
a. Discuss risk factors for pressure ulcers and appropriate
assessment of risk factors and skin (see Boxes 13-9, 13-10, 13-
11, 13-12; Box 13-4 presents resources for education on
prevention).
5. When James returns home, what interventions to enhance his
safety would be appropriate?
(Chapter 20).

Chapter 15
Hydration and Oral Care
1
Hydration Management
2
2
Water is important for thermoregulation and dilution of water-
soluble medications, facilitates bowel and renal function, and
maintains metabolic processes
A significant number of older adults drink less than 1 L of
fluid/day, less than the recommended amount of 1500 mL/day

Adequate fluid consumption and maintenance of fluid balance is
essential to health
Hydration Management
Age-related changes affecting hydration
Thirst sensation diminishes
Creatinine clearance declines
Total body water decreases
Loss of muscle mass and increase in fat cells
See Box 15-1 for more changes
Other contributing factors include medications, functional
impairment, and other comorbid conditions like diabetes
3
3
Dehydration
4

Complex problem that results in reduction of total body water
Often related to changes of aging in older adults
Considered a geriatric syndrome
Significant issues associated with dehydration:
thromboembolic complications
kidney stones
constipation
falls
medication toxicity
renal failure
Seizure
electrolyte imbalance

hyperthermia
delayed wound healing
Dehydration
5
Majority of older people develop dehydration from increase
fluid losses combined with decreased fluid intake, related to
decreased thirst
Risk factors for dehydration include emotional illness, surgery,
trauma, higher physiological demands (see Box 15-4)
Dehydration
Signs and symptoms
Often atypical in the older adult
Skin turgor is not a reliable indicator in older adults
Look for
dry mucous membranes in mouth and nose

furrows on the tongue
Orthostasis
speech incoherence
rapid pulse
decreased urine output
extremity weakness
dry axilla
sunken eyes.
6
6
Dehydration
Laboratory tests and urine
Labs: serum sodium, serum and urine osmolarity, and specific
gravity (less fluid/more sodium and solute in relation to fluid in
bloodstream)
Most cases of dehydration have an elevated blood urea nitrogen
(BUN); however, there are many other causes for elevation of
BUN/creatinine ratio
Observe urine patterns for changes
7

7
Dehydration
8
8
Interventions
Based on comprehensive assessment, risk identification, and
hydration management
Monitor closely and implementation of intake and output is
essential
Oral hydration is the first treatment approach
Water is the best fluid to offer
See Box 15-5
Dehydration

9
9
Rehydration
Depends on severity and type of dehydration
Intravenous
Replace 50% of loss within first 12 hours or sufficient quantity
to relieve tachycardia and hypotension
Hypodermoclysis
Infusion of isotonic fluids into the subcutaneous space
Not for severe dehydration
Oral Health
10

10
Dental health increasingly neglected with advanced age,
debilitation, and limited mobility
Poor oral health associated with dehydration, malnutrition, and
other systemic diseases
Tips for best practice: Promoting Oral Health (Box 15-6)
Healthy People 2020 (Box Healthy People 2020)
Common Oral problems
11
Xerostomia (mouth dryness) and hyposalivation
30% of older adults affected
Affects eating, swallowing, speaking
More than 400 medications cause hyposalivation

Treatment:
review medications,
good oral hygiene,
adequate water,
avoid alcohol and caffeine,
over-the-counter oral saliva substitutes
Oral Cancers
Occur more frequently later in life
Occur more frequently in men than women
Early detection essential as 60% of cases aren’t diagnosed until
Stage 4
Risk factors (Box 15-7)
Tobacco use
Alcohol use
HPV (human papillomavirus) infection
Genetic susceptibility
12
12

Promoting Healthy Aging: Implications for Gerontological
Nursing
Assessment of oral health
Physical examination of oral cavity and oral health
Federal regulations mandate annual examination for LTC
residents
Oral health instrument: The Kayser-Jones Brief Oral Health
Status Examination (BOHSE)
13
13
Interventions for oral health
Promote oral health through teaching persons and caregivers
recommended interventions, screening for oral disease, making
dental referrals
Provide supervision and evaluation of oral care in hospitals and
LTC facilities
Box 15-10
Nursing

14
14
Nursing
Dentures
Patient and/or caregiver education of proper cleaning techniques
Tips for best practices: Denture Care (Box 15-12)
Damaged and ill-fitting dentures are a common problem
Only 13% of persons with dentures get an annual dental
examination
Box 15-11
15
15
Nursing
Oral hygiene in hospitals and LTC

Lack of attention to oral hygiene contributes to poor nutrition
and negative outcomes
Cleaning teeth with a toothbrush after meals lowers risk of
aspiration pneumonia
Crucial in prevention ventilator-associated pneumonia
LTC residents vulnerable secondary to cognitive impairment
and dependency on staff to provide good oral care
16
16
Nursing
Tube feedings and oral hygiene
Tube feedings are associated with significant pathological
colonization in the mouth
Provide oral care twice a day for persons with gastrostomy
tubes and brush teeth after each feeding
Only toothbrushes assist in the removal of plaque; use foam
swabs to clean mouth of endentulous
17
17
Which is NOT an age-related change that affects hydration?

Thirst sensation diminishes
Creatinine clearance declines
Total body water decreases
Loss of fat cells and increase in muscle mass
Question 1
18
ANS: D
18
Signs and symptoms of dehydration in an older adult include all
of the following except:
dry mucous membranes in mouth and nose.
decreased skin turgor.
dry axilla.
speech incoherence.
Question 2
19
ANS: B
19
Chapter 14
Nutrition
1

Nutrition
2
2
The quality and quantity of diet are important factors in
preventing, delaying onset, and managing chronic illnesses
associated with aging
Diet can affect longevity, and when combined with lifestyle
changes, reduces disease risk
About half of all American adults have one or more preventable
diet-related chronic diseases, including cardiovascular disease,
type 2 diabetes, and overweight and obesity
Nutrition
Age-related changes affect the gastrointestinal (GI) system (Box
14-1), but are not the primary cause of inadequate nutrition in
older persons
Factors impacting nutritional needs are most likely related to
Chronic disease
Lifelong eating habits
Ethnicity
Socialization

Income
Transportation
Housing
Mood
Food knowledge
Functional impairments
Health
Dentition
3
The nurse will want to assess for each of these factors. Think
about how you eat—how has that impacted what diet you follow
today
This is the same issue for your older adult who is also faced
with special diets, loneliness, etc
To help them get adequate nutrition, we must identify what is
affecting it!
3
Nutrition
Age-related requirements
Based on 2015-2020 Dietary Guidelines for Americans
Choose My Plate is a guide that provides a visual depiction of
daily food intake
Older adults generally need less calories because activity
decreases and metabolic rates slow down
Still require the same or higher amounts of nutrients
4

5
Image of MyPlate for older adults that shows various food
choices for each of the food groups
5
Nutrition
Dietary recommendations
Fats: less than 10% of total calories, limit saturated fat and
trans fatty acids
Protein: increase for older adult who tends to experience protein
deficiency when ill; minimizes frailty
Fiber: 25 g fiber recommended daily (Box 14-4)
Vitamins and minerals: consumption of five servings of
fruits/vegetables provides adequate A,C,E, and potassium;
changes of aging contribute to decreased absorption of B12
6
6
Obesity (Overnutrition)
7

7
Obesity is a global epidemic and major public health concern
It is associated with increased costs, functional impairments,
disability, chronic disease, and admission to nursing home
More than a third of persons over 60 years are obese
Obesity paradox: some research found that persons who
survived to 70 years had lower mortality rate if they were
overweight
Malnutrition (Undernutrition)
Rising incidence in acute care, long-term care (LTC), and in the
community
Institutionalized older adults at high risk for malnutrition due to
chronic disease and functional impairments
Increased risk of infection, pressure ulcers (PUs), anemia, hip
fractures, hypotension, impaired cognition, and increased
morbidity and mortality
Can be related to inadequate consumption of micro and macro
nutrients, or consequence of inflammation
Comprehensive screening and assessment is critical to identify
older adults at risk
8

8
Factors Affecting Fulfillment
of Nutritional Needs
Lifelong eating habits
Socialization
Socioeconomic deprivation
Transportation
Chronic diseases and conditions
Polypharmacy
Inactivity
High-fat, high-volume meals
Comorbid conditions
9
Chronic Conditions That Affect Nutrition
10
GERD
Diverticular disease

Dysphagia
11
12
13
Nursing
Nutrition screening and assessment (Box 14-14)
Several screening tools available
Minimum Data Set—includes risk factors and triggers for
further evaluation
Interview and physical examination
Anthropometrical measurements
Weight/height considerations
Biochemical analysis/measures of visceral protein

14
14
Nursing
Interventions
Formulated around specific problems
Nurses hold a pivotal role in ensuring adequate nutrition to
promote healthy aging
Collaboration with interprofessional team
Considerations: modification of environment, supervision,
feeding techniques that enhance intake and preserve dignity and
independence
Evaluate the outcome
15
15
Nutritional Problems in Institutional Setting
Feeding assistance
Estimated that 50% of all residents unable to eat independently
Inadequate staffing is associated with poor nutrition and
hydration
The Centers for Medicare and Medicaid Services implemented a
rule that allows feeding assistance, with 8 hours of approved
training
See Box 14-15

16
16
Approaches to Enhancing Intake in LTC
Interventions
Restorative dining rooms
Consideration of ethnic food choices
Easy access to refreshment stations with juices, water, healthy
snacks, and finger foods
Family involvement when possible
See other best practices (Box 14-16)
Other considerations: restrictive diets and caloric supplements,
pharmacological therapy, and patient education
17
17
Question 1
What is the estimated number of institutionalized older adults
who are unable to eat independently?
40%
50%
60%
70%
18

ANS: B
18
Question 2
Which condition affects nutrition in the older adult?
Diabetes
Heart disease
Dysphagia
Gout
19
ANS: C
19
Explaining how the psychoanalysis perspective fits as the
founding movement in the history and systems of psychology
helps the doctoral learner prepare for research into describing
human behavior. Further, understanding the basic components
of the ego and the philosophic influences of ego development
allow for enhanced understanding of the learner's self and those
with whom the learner comes in contact including the human
subjects of empirical research. In this assignment, you will
explore the history of Freudian theory and create a partial
outline of the larger paper you will write for submission in
Topic 4.
General Requirements:
Use the following information to ensure successful completion
of the assignment:
· Review Chapters 1 and 2 of the Ellman text.
· This assignment uses a rubric. Please review the rubric prior
to beginning the assignment to become familiar with the
expectations for successful completion.
· Doctoral learners are required to use APA 7th style for their

writing assignments.
· This assignment requires that at least two additional scholarly
research sources related to this topic, and at least one in-text
citation from each source be included.
· Refer to the Publication Manual of the American
Psychological Association for specific guidelines related to
doctoral level writing. The Manual contains essential
information on manuscript structure and content, clear and
concise writing, and academic grammar and usage.
· You are required to submit this assignment to LopesWrite. A
link to the LopesWrite technical support articles is located in
Class Resources if you need assistance.
Directions:
Using the information from Chapters 1 and 2 of the Ellman text
as well as at least two additional scholarly sources, draft a
sentence outline (an outline where subtopics and details are
expressed as complete sentences) for the first part of the paper
you will write later in the course.
Use the following major headings in your outline:
1. Freud: The First 10 Years
2. Freud: Psycho-Sexual Development
Add at least two subtopics to each of the major headings and at
least two details for each subtopic.
Include a reference list as a separate section at the end of the
outline.
Readings:
Freud’s Anxiety Neurosis Read: Donley, J. E. (1911). Freud’s
anxiety neurosis. The Journal of Abnormal Psychology, 6(2),
126-134.
https://eds-s-ebscohost-
com.lopes.idm.oclc.org/eds/detail/detail?vid=0&sid=9aa1eebb-
a58a-4069-8ae5-
e2473d09fffb%40redis&bdata=JnNpdGU9ZWRzLWxpdmUmc2
NvcGU9c2l0ZQ%3d%3d#AN=1926-00862-001&db=pdh
When Theories Touch: A Historical and Theoretical Integration
of Psychoanalytic Thought Read Chapter 1.

https://bibliu.com/app/#/view/books/9780429923937/epub/OEB
PS/xhtml/content.html#page_v
Death, Neurosis, and Normalcy: On the Ubiquity of Personal
and Social Delusions Read: Piven, J. S. (2003). Death, neurosis,
and normalcy: On the ubiquity of personal and social
delusions. Journal of the American Academy of Religion, 71(1),
135-156.
com.lopes.idm.oclc.org/eds/detail/detail?vid=0&sid=a4ca65d1-
7f96-4abb-9164-
629a2bf9f878%40redis&bdata=JnNpdGU9ZWRzLWxpdmUmc2
NvcGU9c2l0ZQ%3d%3d#AN=ATLA0001412519&db=rfh
Freud’s Three Theories of Neurosis: Towards a Contemporary
Theory of Trauma and Defense Read: Sletvold, J. (2016).
Freud’s three theories of neurosis: Towards a contemporary
theory of trauma and defense. Psychoanalytic Dialogues, 26(4),
460-475.
com.lopes.idm.oclc.org/eds/detail/detail?vid=0&sid=f6e01f22-
6b48-4418-9afb-
1e44ab8657eb%40redis&bdata=JnNpdGU9ZWRzLWxpdmUmc2
NvcGU9c2l0ZQ%3d%3d#AN=118252088&db=a9h

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