Nursing Interventions for SpecificProblems in Older Person
Integumentary System-primary functions are protection fromenvironmental stresses, regulation oftemperature, maintenance of fluid andelectrolyte balance, excretion of metabolicwaste and sensory reception.
Skin Management: Changes in the Integumentary SystemDecreased skin elasticity (sagging of skin) with decreased tensil strengthMen experience hair loss (balding) and both sexes develop gray hair and wrinklesChanges in pigmentation with accumulation of discoloration, photoaging is commonNormal oral temperatures are lower later in the life than in younger yearsSkin fold thickness is significantly reduced in the forearm and the back of the handsSensitivity to cold temperatureDry skinLoss of subcutaneous tissueThinning of dermisDecrease elastin associated with wrinklingVascular lesionDecreased proliferative potential delays wound healing delays wound healing and vitamin D production
2 Categories of Aging ChangesIntrinsic factors –related to decrease inproliferative capacity that leads to cellularsenescence resulting in altered biosyntheticactivity of skin derived cells. (Genetics play rolein this factor)Extrinsic factor –are environmental withsunlight being the primary culprit Cumulativechanges related to environmental factors arereferred to as photoaging, which is dependenton the degree of exposure and skin pigment.
PruritusNursing Intervention•Restricting amount/frequency of bathing & soap use and by applying topical ointments.• Application of oily emollients & those containingalpha-hydroxy acids relieve symptoms by improving thebarrier function of the skin.•Topical lotion that contain menthol and camphorrelieves itching• Traditional systemic antihistamines may providesome relief from itching (adverse effect: urinaryretention, impaired psychomotor function anddrowsiness.
XerosisNursing Intervention•Avoid using rough textured bed linens•Encourage or assist patient to wear loose fitting clothing•Apply lubricant to moisten lips and oral mucosa as needed•Loosely apply incontinent garments (if used)•Refrain from using alkaline soap in the skin•Keep bed linens clean, dry and free from wrinkles
RashesNursing Interventions•Proper hygiene by gently cleansing to remove the exudates and gentle drying.•When rash is related to dry skin, moisturizing agent is immediately applied.•Massage or cool compress•Antihistaminic drugs•Topical corticosteroids
Eczema/ DermatitisNursing Interventions•Avoidance of drying agents such as soap and water•Application of moisturizers and topical immunosuppressant•Tropical corticosteroids•Tacrolimus ointment and Pimecrolimus cream
Seborrhic DermatitisNursing Intervention•Cream or shampoo containing ketoconazole for initial treatment• Ciclopirox olamine cream (Tarmed)•Topical glucocorticosteroids• In the scalp: Shampoo than contains yeast suppressants such as ketoconazole, pyrithione zinc, selenium sulfide, salicylic acid or tar.
IntertrigoNursing Intervention•Keeping affected areas clean and dry and separating adjacent tissues.•Folds should be washed with tepid water and dried thoroughly.•Soft gauze may be used to separate adjacent surfaces.•For breast candidiasis, a well fitting cotton brassiere will help absorb moisture and reduce chafing.•In perineal candidiasis, an adductor block pillow may improve circulation to the affected area, reducing air accumulation.
•Appropriate treatment of the rash with antifungal agents and good hygiene often reduce the discomfort and anxiety associated with rashes.•Superficial fungal infections usually are treated first with topical antifungal.Topical antifungal agents include:Polyene antibiotics (nystatin)Azoles (ketoconazole)ClotrimazoleCiclopiroxOlamineAllylamines
Lichen Simplex ChronicusNursing Intervention•Steroid creams and antihistamines•Bedtime oral antihistamines•Patients are encouraged to keep their fingernails short•Application of a dressing such as DuoDerm may protect the plaque from scratching.•Mittens may be needed for confused older adults.
•For localized lesions, a tape that is impregnated with topical steroid can be applied for a maximum of 24 hours.•Caution patients not to apply occlusive dressings over corticosteroids because they greatly increase absorption of the medication.•Provide cold pack.•Oatmeal baths, moisturizers, menthol and ultraviolet B light•Excoriated areas may require topical antiseptics
Lichen SclerosisNursing Intervention•Topical anti inflammatory steroids such as betamethasone valerate 0.1%•Skin examination at least twice each year
Pruritus AniNursing Intervention•Avoidance of irritating medications•Use of warm compresses or baths•Application of mild steroid creams•Administration of anti pruritic medications
Drug EruptionsNursing Intervention•Withdrawal of the drug is the primary treatment.•Topical corticosteroids•Anti pruritic lotions•Antihistamines
Seborrheic KeratosesNursing Intervention•Can be removed for microscopic study or forcosmetic reasons.•Biopsy, shave or excision may be used to remove completely the lesions or specimen for examination.
Actinic KeratosesNursing Intervention•Decreased exposure to sunlight•Topical agents such as fluorouracil, diclofenacsodium and aminolevilinic acid with blue lightphotoactivation after 14 to 18 hours.•During treatment, patients should avoid directsun exposure.Nonmelanoma Skin CancerNursing Intervention•Avoid or minimize use of tanning bed.
Basal Cell CarcinomaNursing intervention•Removal of the lesion by electrodessication and curettage, cryosurgery, excision , micrographic surgery, radiotherapy•Imiquimod 5% cream for superficial BCCsSquamous Cell CarcinomaNursing Intervention•Removal by cautery, curettage, deep cryotherapy,excision, or radiotherapy.•For regional metastasis, surgery with adjuvantradiotherapy is needed.
Malignant MelanomaNursing Intervention•Modified ultraviolet exposure•Avoid sun exposure in prolonged time•Use sun screens with a sun protections factor (SPF) of 15 or higher
Herpes ZosterNursing Intervention•Antiviral therapy such as acyclovir (Zovirax), famciclovir and Valacyclovir (Valtrex)•Controlled opioid analgesics•Compresses of hypertonic solutions such as Burow’s and gentle washing with antibacterial soaps•Topical antibiotic such as mupirocin ointment (2-3 times daily)•Systemic corticosteroids/ oral corticosteroids•Topical treatments/ creams such as capsaicin cream and topical anesthetics•Acupuncture, nerve blocks, transcutaneous electrical nerve stimulation, and deep brain stimulation
PsoriasisNursing Intervention•Topical medications such as corticosteroids, tazarotene, anthralin, tars, dithranol, vitamin D derivatives (calcipotriene)•Keratolytic agents such salicylic acid with topical steroids•Ultraviolet B light exposure enhances absorption of topical therapy with tar and anthralin•Photochemotherapy with UVA and systemic agents or oral methoxsalen for moderate to severe psoriasis•Systemic drugs include oral retinoids (acitretin), biological agents (alefacept) and cytotoxic drugs (methotrexate)
Leg Ulcers and Stasis DermatitisNursing Intervention•Determine the cause of the ulcer•Peripheral pulses and sensation should be assessed to rule out arterial disease and neuropathy•Application of compression to a limb with arterial insufficiency•Compression bandages or hosiery when venous disease is confirmed•Four layer compression dressing or compression pump•Superficial occlusive dressings, topical ointments, corticosteroids therapy and antibiotics
Pressure Ulcers (Decubitus Ulcers)Nursing Intervention•Assessment•Debridement to remove necrotic tissues•Gentle cleansing with tepid normal saline, povidone iodine and hypochlorite•Dressing>Occlusive dressing>Semi permeable transparent films sucha as Opsite>Absorptive gels such as karaya powder>Noncontact normothermic wound therapy thatinvolved warming the dressing
Over all Nursing Managements for Skin Conditions:Goal: Preservation or restoration of skin integrity without complications, relief of discomfort and implementation of measures to reduce the risk of ulcers.• Stress good personal grooming and cleanliness• Avoid friction, irritation or mechanical injury when bathing, dressing, moving or turning an older patient.• Baths are not necessary everyday for elder people. The bath water temperature should not exceed 105F. Avoid soap and rubbing alcohol because they tend to dry the skin.• Do not put oily lubricants in the bathtub because they make the tub surface slippery; instead put lubricants directly into the skin.• Include hair and nail care in personal hygiene. Soak the feet to loosen debris under the nails and makes it easier to cut
• Encourage diet high in vitamins and nutrients to help maintain healthy skin in older adult. Vitamins A and C and protein• Teach patient about foods high in nutrients and help ensure that they are included in the diet.• Environmental modification also can be made to promote healthy skin.• Advise older adult to stay out of the sun and avoid exposure to wind and cold.• Provide soft, unwrinkled clothing next to the skin to minimize skin irritation and pruritus.• Encourage ambulatory patients to wear supportive shoes that protects feet from trauma
Nursing Care of Patients withMusculoskeletal Alterations
Changes in Musculoskeletal of elderpatients• Decrease bone mass• Bone shrinkage due to a loss of cartilage and thinning of vertebrae, causing long bones to appear disproportionately long• Decrease tough receptors with corresponding slowing ofreflexes, and pain sensation• Decreased proliferative potential delays wound healing and vitamin D production• Diminished muscle mass• Decreased height• Muscle mass is lost• Muscle mass can decline rapidly without exercise• Slight hip/knee flexion• Kyphosis and backward head tilt
Nursing Intervention*When a patient is bedridden, instruct to:1. Turn from side to side in bed2. Flex the knees bilaterally and raise the hips (bridging)3. Move from supine to a sitting position, with legs dangling over the side of the bed4. Assume prone position in bed
* To assess mobility, nurse should:1. Have the patients walk with shoes on. For older patients with shuffling gait, sway, hold the arms out for balance, keep the feet wider apart and watch his or her feet.2. If safe, ask the patient to walk down stairs3. Ask the patient to pick up an object from the floor. The older person may bend the waist rather than the knees and hold onto furniture for support. Have the patient rise from a sitting position to a standing position.4. If appropriate, ask the patient to rise from a reclining position to a sitting position.
Nursing Goals: Preservation, restoration or improvement of joint mobility, muscle strength and skeletal health; maintenance, restoration or improvement in mobility and self-care; relief of discomfort related to musculoskeletal disorders or injuries; prevention of complications associated with immobility or musculoskeletal disorders.
Other interventions:•Exercise (active and passive), proper nutrition and patient education.•Proper sitting of patients in the wheelchair•Prevent fallsTypes of exercises:*ROM exercises*Resistive exercise*Isometric exercise*Isotonic exercise*Isokinetic exercise*Balance exercise*Aerobic exercise