Hs 194

HS 194

Christmas Break Assignment

Submitted to:
ERIC G. BARORO, PTRP, RN
CLINICAL INSTRUCTOR

Submitted by:
REYNEL DAN L. GALICINAO
BSN-IV, BLK. CCC

January 7, 2010

CARDIOPULMONARY CONDITIONS
Cardiac Cycle
PHASES OF CARDIAC CYCLE DESCRIPTION OF PHASE
 The first phase of the cardiac cycle
initiated by the P wave of the ECG or atrial
PHASE I - ATRIAL CONTRACTION / ATRIAL depolarization.
SYSTOLE  Atrial depolarization causes atrial muscles
to contract which in turn increases the
pressure in the atrial chambers causing the
AV valves to open. Blood flow rapidly
forces into the ventricles.
 After atrial contraction is complete, atrial
pressure falls causing AV valves to return
to its pre-position.
 At this point, ventricular volumes are
maximized, which is termed as EDV or
end-diastolic volume.
 A heart sound is sometimes noted during
atrial contraction (fourth heart sound,
AV VALVES OPEN; SEMILUNAR VALVES CLOSED S4). This sound is caused by vibration of
the ventricular wall during atrial
contraction.
PHASE II - ISOVOLUMETRIC CONTRACTION

 This phase of the cardiac cycle begins with
the appearance of the QRS complex of the
ECG, which represents ventricular
depolarization.
 The AV valves to close as intraventricular
pressure exceed atrial pressure.
 Ventricular volume does not change
because all valves are closed during this
phase. Contraction, therefore, is said to be
"isovolumic" or "isovolumetric."

ALL VALVES CLOSED
 This phase represents the initial and rapid
ejection of blood into the aorta and
pulmonary arteries from the left and right
ventricles, respectively.
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PHASE III - RAPID EJECTION  Ejection begins when the intraventricular
pressures exceed the pressures within the
aorta and pulmonary artery, which causes
the aortic and pulmonic valves to open.
 No heart sounds are ordinarily noted

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during ejection because the opening of
healthy valves is silent. The presence of
sounds during ejection (i.e., ejection
murmurs) indicates valve disease or
intracardiac shunts.

AORTIC AND PULMONIC VALVES OPEN; AV
VALVES REMAIN CLOSED
PHASE IV - REDUCED EJECTION/ VENTRICLULAR
SYSTOLE

 This phase shows ventricular repo-
larization occurs as shown by the T-wave
of the electrocardiogram.
 Repolarization leads to a decline in
ventricular active tension and therefore the
rate of ejection (ventricular emptying)
falls.
 Left atrial and right atrial pressures
gradually rise due to continued venous
return from the lungs and from the
systemic circulation, respectively.

AORTIC AND PULMONIC VALVES OPEN; AV
VALVES REMAIN CLOSED
 As the intraventricular pressures fall at the
PHASE V - ISOVOLUMETRIC RELAXATION end of phase 4, the aortic and pulmonic
valves abruptly close (aortic precedes
pulmonic) causing the second heart sound
(S2) and the beginning of isovolumetric
relaxation.
 After valve closure, the aortic and
pulmonary artery pressures rise slightly
(dicrotic wave) following by a slow decline
in pressure.
 Ventricular pressure decreases, but volume
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remains constant because of the closed
valve.
 The volume of blood that remains in a
ALL VALVES CLOSED ventricle is called the end-systolic volume
and is ~50 ml in the left ventricle. The

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difference between the end-diastolic
volume and the end-systolic volume is ~70
ml and represents the stroke volume.
PHASE VI - RAPID FILLING / DIASTOLE
 As the ventricles continue to relax at the
end of phase 5, the intraventricular
pressures will at some point fall below
their respective atrial pressures. When this
occurs, the AV valves rapidly open and
ventricular filling begins.
 Ventricular filling is normally silent. When
a third heart sound (S3) is audible, it may
represent tensing of chordae tendineae and
AV ring during ventricular relaxation and
filling. This heart sound is normal in
children; but is often pathological in adults
and caused by ventricular dilation.
A-V VALVES OPEN
PHASE VII - REDUCED FILLING

 As the ventricles continue to fill with blood
and expand, they become less compliant
and the intraventricular pressures rise.
This reduces the pressure gradient across
the AV valves so that the rate of filling
falls.
 Aortic pressure and pulmonary arterial
pressures continue to fall during this
period.

A-V VALVES OPEN
(Cardiovascular Physiology Concepts by Richard A. Klabunde)

Lung Capacities
Normal
Term Symbol Description Significance
Value*
The tidal volume may not
Tidal VT or The volume of air inhaled 500 mL or
vary, even with severe
volume TV and exhaled with each breath 5–10 mL/kg
disease.
Inspiratory The maximum volume of air
reserve IRV that can be inhaled after a 3,000 mL
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volume normal inhalation
Expiratory reserve volume is
Expiratory The maximum volume of air
decreased with restrictive
reserve ERV that can be exhaled forcibly 1,100 mL
conditions, such as obesity,
volume after a normal exhalation
ascites, pregnancy.

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The volume of air remaining Residual volume may be
Residual
RV in the lungs after a maximum 1,200 mL increased with obstructive
volume
exhalation disease.
A decrease in vital capacity
The maximum volume of air may be found in
Vital exhaled from the point of neuromuscular disease,
VC 4,600 mL
Capacity maximum inspiration generalized fatigue,
VC = TV + IRV + ERV atelectasis, pulmonary
edema, and COPD.
The maximum volume of air
A decrease in inspiratory
Inspiratory inhaled after normal
IC 3,500 mL capacity may indicate
Capacity expiration
restrictive disease.
IC = TV + IRV
The volume of air remaining
Functional Functional residual capacity
in the lungs after a normal
Residual FRC 2,300 mL may be increased with COPD
expiration
Capacity and decreased in ARDS.
FRV = ERV + RV
Total lung capacity may be
The volume of air in the
decreased with restrictive
Total Lung lungs after a maximum
TLC 5,800 mL disease (atelectasis,
Capacity inspiration
pneumonia) and increased in
TLC = TV + IRV + ERV + RV
COPD.
*Values for healthy men; women are 20-25% less.
(Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 10th Ed. By: Smeltzer, C.S., Bare,
B.G., Hinkle, J.L., Cheever, K.H., P. 468)

Graphic Representation
of Lung Volumes and
Capacities

(Fundamentals of
Nursing: Standards and
Practice 2nd Ed. By
DeLaune. P 881) HS 194 | 1/7/2010

Four Principles of Cardiac Conditioning
PRINCIPLES OF
CARDIAC DISCUSSION
CONDITIONING

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The cardiorespiratory response to exercise depends on the type of
BASIC EXERCISE exercise, the environmental conditions, and the physiologic status of the
PHYSIOLOGY patient. Changes that occur with a single bout of acute exercise are
called responses and are temporary.
 HEART RATE -The body's initial hemodynamic response to dynamic
exercise is an increase in heart rate.
 BLOOD PRESSURE - The systolic and diastolic blood-pressure
RESPONSE TO ACUTE response to exercise varies with the type and intensity of the exercise
EXERCISE and the age of the person.
 BLOOD FLOW- At rest, a large portion of the cardiac output is
directed to the spleen, liver, kidneys, brain, and heart, with only
about 20% going to the skeletal muscles. During exercise, the
skeletal muscles can receive more than 85% of the cardiac output.
Physiologic adaptations to training can be divided into morphologic,
ADAPTATIONS TO
hemodynamic, and metabolic categories. The application of an
CHRONIC EXERCISE
appropriate stimulus results in adaptation; the greater the stimulus, the
(TRAINING)
greater is the adaptation.
PHASES OF CARDIAC The typical phases in cardiac rehabilitation are coronary care unit and
REHABILITATION inpatient care (phase I), convalescence in an outpatient or home
AFTER MYOCARDIAL program (phase II), and recovery in a long-term community-based or
INFARCTION home program (phase III).
(Kelley’s Textbook of Internal Medicine 4th ED, by H. David Humes & Herbert L. Dupont, pp 96)

Cardiac Rehabilitation
Cardiac rehabilitation is a program that targets risk reduction by means of education,
individual and group support, and physical activity.
The goals of rehabilitation for the patient with an MI are to extend and improve the
quality of life. The immediate objectives are to limit the effects and progression of atherosclerosis,
return the patient to work and a pre-illness lifestyle, enhance the psychosocial and vocational
status of the patient, and prevent another cardiac event. These objectives are accomplished by
encouraging physical activity and physical conditioning, educating patient and family, and
providing counseling and behavioral interventions.
The target heart rate in phase I is an increase of less than 10% from the resting heart rate,
or 120 beats per minute. In phase II, the target heart rate is based on the results of the patient’s
stress test (usually 60% to 85% of the heart rate at which symptoms occurred), medications, and
underlying condition. Oxygen saturation may also be assessed to ensure that it remains higher
than 93%. If signs or symptoms occur, the patient is instructed to slow down or stop exercising. If
the patient is exercising in an unmonitored program, he or she is cautioned to cease activity
immediately if signs or symptoms occur and to seek appropriate medical attention.
Patients who are able to walk at 3 to 4 miles per hour are usually able to resume sexual
activities. The nurse recommends that the patient be well rested and in a familiar setting; wait at
least 1 hour after eating or drinking alcohol; and use a comfortable position. The patient is
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cautioned against anal sex. Sexual dysfunction or cardiac symptoms should be reported to the
health care provider.
PHASES OF CARDIAC REHABILITATION
Cardiac rehabilitation occurs along the continuum of the disease and is typically
categorized in three phases.

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Phase I may begin with the diagnosis of atherosclerosis, which may occur when the
patient is admitted to the hospital for ACS (unstable angina, acute MI). It consists of low-level
activities and initial education for the patient and family. Because of the brief hospital stay,
mobilization occurs earlier, and patient teaching is prioritized to the essentials of self-care, rather
than instituting behavioral changes for risk reduction. Priorities for in-hospital education include
the signs and symptoms that indicate the need to call 911 (seek emergency assistance), the
medication regimen, rest-activity balance, and follow-up appointments with the physician. The
nurse needs to reassure the patient that, although CAD is a lifelong disease and must be treated as
such, most patients can resume a normal life after an MI. This positive approach while in the
hospital helps to motivate and teach the patient to continue the education and lifestyle changes
that are usually needed after discharge. The amount of activity recommended at discharge
depends on the age of the patient, his or her condition before the cardiac event, the extent of the
disease, the course of the hospital stay, and the development of any complications.
Phase II occurs after the patient has been discharged. It usually lasts for 4 to 6 weeks but
may last up to 6 months. This outpatient program consists of supervised, often ECG-monitored,
exercise training that is individualized based on the results of an exercise stress test. Support and
guidance related to the treatment of the disease and education and counseling related to lifestyle
modification for risk factor reduction are a significant part of this phase. Short-term and long-
range goals are collaboratively determined based on the patient’s needs. At each session, the
patient is assessed for the effectiveness of and adherence to the current medical plan. To prevent
complications and another hospitalization, the cardiac rehabilitation staff alerts the referring
physician to any problems. Outpatient cardiac rehabilitation programs are designed to encourage
patients and families to support each other. Many programs offer support sessions for spouses
and significant others while the patients exercise. The programs involve group educational
sessions for both patients and families that are given by cardiologists, exercise physiologists,
dietitians, nurses, and other health care professionals. These sessions may take place outside a
traditional classroom setting. For instance, a dietitian may take a group of patients and their
families to a grocery store to examine labels and meat selections or to a restaurant to discuss
menu offerings for a “heart-healthy” diet.
Phase III focuses on maintaining cardiovascular stability and long-term conditioning. The
patient is usually self-directed during this phase and does not require a supervised program,
although it may be offered. The goals of each phase build on the accomplishments of the previous
phase.
B.G., Hinkle, J.L., Cheever, K.H., P. 728-729)

Exercise Tolerance Test
PROTOCOLS HOW THEY ARE DONE
The test is conducted in three minute stages; The Bruce protocol
starts at a Functional Class 2 workload (4.6 METS of work, a speed
of 1.7 mph and a grade of 10 degrees). Each 3 minutes the workload
is increased by a combination of increasing the speed and the grade
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BRUCE PROTOCOL of the treadmill. Stage 2 reaches a FC1 activity with a speed of 2.5
mph and a grade of 12 degrees. The protocol continues until one of
several endpoints is reached. These include a true positive or
negative test, hypo or hypertension, fatigue, dyspnea, certain
arrhythmias, or gait problems.
MODIFIED BRUCE The Modifies Bruce basically starts at a lower workload than the

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PROTOCOL Bruce, and is used for patients who are post MI, whose history
suggests symptoms at a low workload, and for elderly or sedentary
patients who may not be able to keep up with the faster Bruce
protocol.
 Bicyle ergometry- involves a devise equipped with a wheel operated by pedals that can be
adjusted increase the resistance to pedaling (multistage testing). It can be used for arm
cranking, foot pedaling, or both. Advantages are that this mode of exercise is relatively
inexpensive and the equipment is portable. However, frequent recalibration is required and
localized muscle group fatigue is often induced.
 In treadmill stress testing, the patient walks a treadmill or rides a stationary bicycle until
reaching a target heart rate; typically 70% to 80% of the maximum predicted heart rate.
Treadmill stress testing has 70% sensitivity and specificity among the general population.
 Indications for stress testing have been adapted from the American Heart Association (AHA)
and the American College of Cardiology (ACC)
Indications for Stress Test
CLASS I INDICATIONS (Clear indications for stress testing)
 Suspected or proven coronary artery disease (CAD)
 Male patients who present with atypical chest pain
 Evaluate functional capacity and assess prognosis of patients with CAD
 Patients with exercise-related palpitations, dizziness, or syncope
 Evaluation of recurrent exercise-induced arrhythmias
CLASS II INDICATIONS (Stress testing may be indicated)
 Evaluation of typical or atypical symptoms in women
 Evaluation of variant angina
 Evaluation of patients who are on digoxin preparations or who have a right bundle-branch
block
CLASS III INDICATIONS (Stress testing is probably not necessary)
 Young or middle-age asymptomatic patients who have no risk factors for CAD
 Young or middle-age asymptomatic patients who present with noncardiac chest pain
 Evaluation of patients for CAD who have complete left bundle-branch block
 Evaluation of patients for CAD who have pre-excitation syndrome
Complications of stress testing include supraventricular tachyarrhythmias, bradycardias, heart
failure, hypotension, ventricular ectopy (due to ventricular tachycardia), ventricular fibrillation,
stroke, MI, and death.
Absolute Contraindications: (Fischbach p.926)
 Acute febrile illness
 Pulmonary edema
 Systolic blodd pressure >250 mmHg
 Diastolic blood pressure >120 mmHg
 Uncontrolled hypertension
 Uncontrolled asthma
 Unstable angina
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Relative Contraindications: (Fischbach p.926)
 Recent MI (<4 weeks)
 Resting tachycardia (>120 bpm)
 Epilepsy
 Respiratory failure
 Resting ECG abnormalities

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(Lippincott Manual of Nursing Practice, 8th Ed. By Nettina, S.M., Mills, E.J., p 330-331)
(http://www.theberries.ca/ARchives/bruce.html)

Four Components of Exercise Prescription
The exercise prescription includes four components: mode, duration, frequency, and
intensity. Additionally, an exercise prescription will incorporate progression, resistance training
and flexibility training.
Mode is the activity selected by the patient. Ask the patient what types of exercise they
would like to do or can incorporate into their lifestyle. Walking is a popular choice as it requires
no special equipment and can be done anywhere. Patients with osteoarthritis or other mobility-
limiting conditions may benefit from pool-based activities such as swimming and water aerobics.
Duration is the length of time of each exercise session. An initial goal is 20-30 minutes of
aerobic activity per exercise session. As the patient becomes more committed to the exercise
program and makes it a habit, the patient can gradually increase the duration to a final goal of up
to 60 minutes per session.
Frequency is the number of times per week that the patient will engage in the exercise. A
reasonable goal is exercising 3-4 times per week. However, even sedentary individuals will have
overall improvement with as few as 1-2 exercise sessions per week.
Intensity refers to how hard the patient is working during the exercise session. Intensity
can be measured in several ways. In the exercise prescription presented, target heart rate is
calculated for a low intensity, moderate intensity, and vigorous intensity workout. The patient
gradually increases their heart rate goal to increase the intensity of their workout. An option is to
use the Borg scale for perceived exertion.
Completing these four components will constitute the exercise prescription. As the patient
makes exercise a regular part of their life, their cardiovascular fitness will gradually improve.
Initial follow up occurs at approximately 4-6 weeks with subsequent follow up scheduled at less
frequent intervals.
Resistance training and flexibility training should also be part of an exercise prescription
as both reduce the incidence of injury and improve overall fitness.
(Writing an Exercise Prescription by Jennifer Frank, MD, MAJ, US Army; Martin Army Community
Hospital Family Medicine Residency Program)

ECG Leads Placement

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(Lippincott
Manual of
Nursing
Practice, 8th Ed.
By Nettina,
S.M., Mills, E.J.,
P. 333)

(ECG Notes:
Interpretation and
Management Guide by
Shirley A. Jones P. 13,
16.)
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ECG Findings

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(ECG Notes: Interpretation and Management
Guide by Shirley A. Jones Pp 79-83)

 Ischemia
o Lack of oxygen to cardiac tissues,
o Represented by ST segment depression and T wave inversion or both.
 Anterolateral ischemia
o Normal QRS complexes,
o ST segment depression in leads I,II, V4-V6 and ST segment depression in lead V5.
 Anterior ischemia
o Normal QRS complexes, ST segment depression in leads V4-V6 and ST segment
depression in lead V4.
 Left ventricular hypertrophy (LVH) - QRS amplitude (voltage criteria; i.e., tall R-waves in
LV leads, deep S-waves in RV leads). Delayed intrinsicoid deflection in V6 (i.e., time from
QRS onset to peak R is >0.05 sec).Widened QRS/T angle (i.e., left ventricular strain
pattern, or ST-T oriented opposite to QRS direction).Leftward shift in frontal plane QRS
axis.
 Right Ventricular Hypertrophy- Right axis deviation (>90 degrees). Tall R-waves in RV leads;
deep S-waves in LV leads. Slight increase in QRS duration. ST-T changes directed opposite to
QRS direction (i.e., wide QRS/T angle).
 Right Atrial Enlargement (RAE) – P wave amplitude >2.5 mm in II and/or >1.5 mm in V1
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(these criteria are not very specific or sensitive). Better criteria can be derived from the
QRS complex; these QRS changes are due to both the high incidence of RVH when RAE is
present, and the RV displacement by an enlarged right atrium. QR, Qr, qR, or qRs
morphology in lead V1 (in absence of coronary heart disease) . QRS voltage in V1 is <5 mm
and V2/V1 voltage ratio is >6 (Sensitivity = 50%; Specificity = 90%)

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 Left Atrial Enlargement (LAE)- P wave duration > 0.12s in frontal plane (usually lead II) .
Notched P wave in limb leads with the inter-peak duration > 0.04s. Terminal P negativity in
lead V1 (i.e., "P-terminal force") duration >0.04s, depth >1 mm. Sensitivity = 50%; Specificity =
90%

Assessment Tools for Peripheral Vascular Disease
Doppler Ultrasound
 Doppler ultrasound can be used to evaluate arterial and peripheral venous patency as well as
valvular competence.
Plethysmography (Pulse Volume Recording)
 A noninvasive measurement of changes in calf volume corresponding to changes in blood
volume brought about by temporary venous occlusion with a high pneumatic cuff.
 Ocular pneumoplethysmography, indirectly measures carotid artery blood flow by the
application of pneumatic pressure on the eye to measure ophthalmic artery pressure.
Oscillometry
 Degree of arterial occlusion may be measured by an oscillometer, which measures pulse
volume. One extremity may be compared with the other to evaluate arterial patency.
 An inflatable cuff is wrapped around the extremity, and the oscillometric index is determined
by inflating the cuff and reading the dial.
Phlebography (Venography)
 An X-ray visualization of the vascular tree after the injection of a contrast medium
(Renografin) to detect venous occlusion
Ankle-Brachial Index (ABI)
 The ABI is the ratio of the ankle systolic blood pressure to the arm systolic blood pressure. It
is an objective indicator of arterial disease that allows the examiner to quantify the degree of
stenosis.
Continuous-wave (CW) Doppler ultrasound
 Continuous-wave (CW) Doppler ultrasound detects blood flow in peripheral vessels.
Combined with computation of ankle or arm pressures, this diagnostic technique helps health
care providers characterize the nature of peripheral vascular disease.
(Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 10th edition, Suzanne C. O’Connell
Smeltzer, RN, EDD, FAAN, Brenda G. Bare, RN, MSN; page 468)

Pulmonary Function Tests
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Obstructive and Restrictive Lung Disease
Obstructive lung diseases
Obstructive lung
diseases are diseases of the
lung where the bronchial tubes
become narrowed making it
hard to move air in and
especially out of the lung.
Patients have decreased airflow
(decreased FEV1/FVC ratio)
and usually have normal or
above-normal lung volumes.
COPD (emphysema, chronic
bronchitis, asthma, cystic
fibrosis, and bronchiectasis)
encompasses this category.
Restrictive lung diseases
Restrictive lung Patterns of respiratory disease as shown by measurement of forced
vital capacity.
diseases (also known as
interstitial lung diseases) are a category of respiratory disease characterized by a loss of lung
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compliance, causing incomplete lung expansion and increased lung stiffness. The underlying
process is usually pulmonary fibrosis (scarring of the lung). As the disease progresses, the normal
lung tissue is gradually replaced by scar tissue interspersed with pockets of air. This can lead to
parts of the lung having a honeycomb-like appearance.

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Patients have decreased lung volumes or TLC (total lung capacity) with normal airflow
(normal FEV1/FVC ratio but with reduced values for both FVC and FEV1 individually). There are
five primary types:
 Pleural--diseases of the pleura that restrict lung expansion and decrease lung volumes (eg,
pleural effusions or pleural thickening).
 Alveolar--diseases of alveolar spaces that prevent air from filling those same spaces (eg,
pneumonia, cancer, and pulmonary edema).
 Interstitial--various diseases contracting the space in the lung parenchyma between the
alveoli (interstitium), reducing lung volumes (eg, sarcoidosis, pulmonary fibrosis, silicosis,
and pneumoconiosis).
 Neuromuscular--Normal lung parenchyma with an inability to take a deep breath (eg,
diaphragmatic paralysis, Guillain-BarrŽ syndrome, myasthenia gravis, and amyotrophic lateral
sclerosis).
 Thoracic cage--Skeletal abnormalities with normal lungs (eg, kyphoscoliosis, obesity).
Obstructive lung diseases Restrictive lung diseases
Affect the patency or elasticity of the airways, Interfere in or change chest wall or lung
leading to an increase in airway resistance parenchyma
Expiration is primarily affected Inspiration is primarily affected
Vital capacity is decreased Vital capacity is normal or decreased
Total lung capacity is increased Total lung capacity is decreased
Residual volume is increased Residual volume is decreased

Indications and Contraindications of Oxygen Therapy
Indications
A change in the patient’s respiratory rate or pattern may be one of the earliest indicators
of the need for oxygen therapy. The change in respiratory rate or pattern may result from
hypoxemia or hypoxia. The signs and symptoms signaling the need for oxygen may depend on
how suddenly this need develops. With rapidly developing hypoxia, changes occur in the central
nervous system because the higher neurologic centers are very sensitive to oxygen deprivation.
The clinical picture may resemble that of alcohol intoxication, with the patient exhibiting lack of
coordination and impaired judgment. Longstanding hypoxia (as seen in chronic obstructive
pulmonary disease [COPD] and chronic heart failure) may produce fatigue, drowsiness, apathy,
inattentiveness, and delayed reaction time. The need for oxygen is assessed by arterial blood gas
analysis and pulse oximetry as well as by clinical evaluation.
Contraindications
Oxygen should never be used in explosive environments, and its use is cautioned against
when there is a risk of sparks or materials combusting as oxygen accelerates combustion.
Smoking during oxygen therapy is a fire hazard and a danger to life and limb, especially with
home oxygen if compliance is poor. Oxygen may worsen the effects of paraquat poisoning and is
therefore contraindicated in such cases. Oxygen therapy is not recommended for patients who
have suffered pulmonary fibrosis or other lung damage resulting from Bleomycin treatment.
OXYGEN TOXICITY
Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is
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administered for an extended period (longer than 48 hours). It is caused by overproduction of
oxygen free radicals, which are byproducts of cell metabolism. If oxygen toxicity is untreated,
these radicals can severely damage or kill cells.
Antioxidants such as vitamin E, vitamin C, and beta-carotene may help defend against
oxygen free radicals (Scanlan, Wilkins & Stoller, 1999). The dietitian can adjust the patient’s diet

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so that it is rich in antioxidants; supplements are also available for patients who have a decreased
appetite or who are unable to eat.
Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias,
dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, and alveolar infiltrates
evident on chest x-rays. Prevention of oxygen toxicity is achieved by using oxygen only as
prescribed. If high concentrations of oxygen are necessary, it is important to minimize the
duration of administration and reduce its concentration as soon as possible. Often, positive
endexpiratory pressure (PEEP) or continuous positive airway pressure (CPAP) is used with
oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen
to be used. The level of PEEP that allows the best oxygenation without hemodynamic
compromise is known as “best PEEP.”
SUPPRESSION OF VENTILATION
In patients with COPD, the stimulus for respiration is a decrease in blood oxygen rather
than an elevation in carbon dioxide levels. Thus, administration of a high concentration of oxygen
removes the respiratory drive that has been created largely by the patient’s chronic low oxygen
tension. The resulting decrease in alveolar
ventilation can cause a progressive increase in arterial carbon dioxide pressure (PaCO2),
ultimately leading to the patient’s death from carbon dioxide narcosis and acidosis. Oxygen-
induced hypoventilation is prevented by administering oxygen at low flow rates (1 to 2 L/min).
OTHER CONTRAINDICATIONS:
Because oxygen supports combustion, there is always a danger of fire when it is used. It is
important to post “no smoking” signs when oxygen is in use. Oxygen therapy equipment is also a
potential source of bacterial cross-infection; thus, the nurse changes the tubing according to
infection control policy and the type of oxygen delivery equipment.

Mechanical Ventilators
Negative Pressure Ventilators
 Applies negative pressure around the chest wall. This causes intra-airway pressure to become
negative, thus drawing air into the lungs through the patient's nose and mouth.
 No artificial airway is necessary; patient must be able to control and protect own airway.
 Indicated for selected patients with respiratory neuromuscular problems, or as adjunct to
weaning from positive pressure ventilation.
 Examples are the iron lung and cuirass ventilator.
IRON LUNG (DRINKER RESPIRATOR TANK)
The iron lung is a negative-pressure chamber used for ventilation. It was used extensively
during polio epidemics in the past and currently is used by polio survivors and patients with
other neuromuscular disorders.
BODY WRAP (PNEUMOWRAP) AND CHEST CUIRASS (TORTOISE SHELL)
Both of these portable devices require a rigid cage or shell to create a negative-pressure
chamber around the thorax and abdomen. Because of problems with proper fit and system leaks,
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these types of ventilators are used only with carefully selected patients.
Positive Pressure Ventilators
During mechanical inspiration, air is actively delivered to the patient's lungs under positive
pressure. Exhalation is passive. Requires use of a cuffed artificial airway
 Pressure limited
o Terminates the inspiratory phase when a preselected airway pressure is achieved.

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o Volume delivered depends on lung compliance.
o Use of volume-based alarms is recommended because any obstruction between the
machine and lungs that allows a buildup of pressure in the ventilator circuitry will
cause the ventilator to cycle, but the patient will receive no volume.
 Volume limited
o Terminates the inspiratory phase when a designated volume of gas is delivered into
the ventilator circuit (5 to 7 mL/kg body weight usual starting volume).
o Delivers the predetermined volume regardless of changing lung compliance (although
airway pressures will increase as compliance decreases). Airway pressures vary from
patient to patient and from breath to breath.
o Pressure-limiting valves, which prevent excessive pressure buildup within the patient-
ventilator system, are used. Without this valve, pressure could increase indefinitely
and pulmonary barotrauma could result. Usually equipped with a system that alarms
when selected pressure limit is exceeded. Pressure-limited settings terminate
inspiration when reached.
 Time-cycled
o Time-cycled ventilators terminate or control inspiration after a preset time.
o The volume of air the patient receives is regulated by the length of inspiration and the
flow rate of the air.
o Most ventilators have a rate control that determines the respiratory rate, but pure
time-cycling is rarely used for adults. These ventilators are used in newborns and
infants.
 Non-invasive Positive-Pressure Ventilation
o Positive-pressure ventilation can be given via facemasks that cover the nose and
mouth, nasal masks, or other nasal devices. This eliminates the need for endotracheal
intubation or tracheostomy and decreases the risk for nosocomial infections such as
pneumonia.
o The most comfortable mode for the patient is pressure controlled ventilation with
pressure support. This eases the work of breathing and enhances gas exchange. The
ventilator can be set with a minimum backup rate for patients with periods of apnea.
o Patients are considered candidates for noninvasive ventilation if they have acute or
chronic respiratory failure, acute pulmonary edema, COPD, or chronic heart failure
with a sleep-related breathing disorder. The device also may be used at home to
improve tissue oxygenation and to rest the respiratory muscles while the patient
sleeps at night.
o It is contraindicated for those who have experienced respiratory arrest, serious
dysrhythmias, cognitive impairment, or head or facial trauma.
o Noninvasive ventilation may also be used for patients at the end of life and those who
do not want endotracheal intubation but may need short- or long-term ventilatory
support (Scanlan, Wilkins & Stoller, 1999).
o Bilevel positive airway pressure (bi-PAP) ventilation offers independent control of
inspiratory and expiratory pressures while providing pressure support ventilation. It
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delivers two levels of positive airway pressure provided via a nasal or oral mask,
nasal pillow, or mouthpiece with a tight seal and a portable ventilator. Each
inspiration can be initiated either by the patient or by the machine if it is programmed
with a backup rate. The backup rate ensures that the patient will receive a set number
of breaths per minute (Perkins & Shortall, 2000).

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o Bi-PAP is most often used for patients who require ventilatory assistance at night,
such as those with severe COPD or sleep apnea. Tolerance is variable; bi-PAP is
usually most successful with highly motivated patients.
(Lippincott Manual of Nursing Practice, 8th Ed. By Nettina, S.M., Mills, E.J. P. 259)
B.G., Hinkle, J.L., Cheever, K.H.)
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17

GERIATRIC AND NEOPLASTIC CONDITIONS
Demographics of Aging Population
The world’s elderly
population (65 years of age and
over) is currently growing at a
rate of 2.4 per cent per year,
considerably faster than the
global total population. In
developed countries as a whole,
the present elderly population
numbers 165 million, and is
projected to expand to 257
million by the year 2025.
Sweden, with 17.5 per cent of its
population aged 65 and over in
1997, has the highest
proportion of elderly people of
the major countries of the
world. Other notably high
proportions (in excess of 16 per
cent) are found in Italy,
Belgium, Greece, and the United Kingdom.
The exceptional growth in the percentage of the elderly worldwide is related to the
following factors: the substantial decrease in birth rates during the past 20 years in many
countries, the migration of younger persons out of certain areas because of economic reasons, and
the decrease in overall mortality, including that due to infectious diseases in developing countries
and that due to coronary artery disease and stroke in European and other developed countries. In
the USA, Canada, and Australia, mortality due to coronary artery disease has decreased by an
average of 50% over the past 25 years.
(Oxford Textbook of Geriatric Medicine by JG Evans, et al p.8)

Theories of Aging
Aging is a complex process of biologic, psychosocial, cultural, and experiential changes.
No one theory on aging completely embraces and explains all the many facets of change.
Following is a discussion of several biologic and psychosocial theories on aging that provide a
frame of reference for providing nursing care to elderly clients.
Biological Theories
The stress theory suggests that irreversible structural and chemical changes occur in the
body as a result of stress throughout the life span and that individuals must learn to adapt to
these changes.
The cross-linkage theory describes the deterioration of tissues and organs as the cause of
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loss of flexibility and functional mobility that occurs with aging.
The somatic mutation theory takes a similar cellular level approach in stating that changes
in DNA that are not repaired lead to replication of mutated cells, which brings about decreased
cellular functioning and loss of organ efficiency.

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The programmed aging theory states that life span is determined by heredity and that an
internal genetic clock is responsible for the rate at which an individual develops, ages, and
eventually dies.
Psychosocial Theories
Psychosocial theories on aging present the position that many factors in addition to
genetics contribute to the aging process.
The disengagement theory posits that as individuals age, they inevitably withdraw from
society and society withdraws from them in a mutually agreed on dance of separation.
The continuity theory suggests that an individual’s values and personality develop over a
lifetime and that goals and individual characteristics will remain constant throughout life; an
individual thus learns to adapt to changes and will tend to repeat those reactions and behaviors
that brought success in the past.
The activity theory proposes that an individual’s satisfaction with life depends on
involvement in new interests, hobbies, roles, and relationships. Volunteering is one way that
many retirees stay connected to the community. In addition to providing social connection,
volunteer activities provide a daily routine, a way to make a contribution, and a sense of being
needed.
Developmental Theories of Aging
Erikson (1963) theorized that a person’s life consists of eight stages, each stage
representing a crucial turning point in the life span stretching from birth to death with its own
developmental conflict to be resolved. According to Erikson, the major developmental task of old
age is to either achieve ego integrity or suffer despair. Achieving ego integrity requires accepting
one’s lifestyle, believing that one’s choices were the best that could be made at a particular time,
and being in control of one’s life. Despair results when an older person feels dissatisfied and
disappointed with his or her life, and would live differently if given another chance.
Havighurst (1972) also suggested a list of developmental tasks that occur during a lifetime.
The tasks of the older person include adjusting to retirement after a lifetime of employment with
a possible reduction of income, decreases in physical strength and health, the death of a spouse,
establishing affiliation with one’s age group, adapting to new social roles in a flexible way, and
establishing satisfactory physical living arrangements.
Combining the concepts of both Erikson and Havighurst suggests the following
developmental tasks for the older adult: (1) maintenance of self-worth, (2) conflict resolution, (3)
adjustment to the loss of dominant roles, (4) adjustment to the deaths of significant others, (5)
environmental adaptation, and (6) maintenance of optimal levels of wellness.
Nursing Theory
Miller (2004) has developed the functional consequences theory, which challenges nurses
to consider while planning care the effects of normal age-related changes as well as the damage
incurred through disease or environmental and behavioral risk factors. Miller suggests that nurses
can alter the outcome for patients through nursing interventions that address the consequences
of these changes.
(Fundamentals of Nursing: Standards and Practice 2nd Ed. By DeLaune. Pp 352-353)
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Normal Changes Associated With Aging
SYSTEM OR STRUCTURE/CAUSES CHANGES
Integumentary
Skin
■ Decreased collagen and subcutaneous fat ■ Increased wrinkling
■ Decreased elasticity
■ Atrophy of sweat glands and decreased ■ Increased dryness
function ■ Pruritus
■ Thinning
■ Decline in fibroblast proliferation, cell ■ Increased healing time
production, and epidermal turnover ■ Bruising
■ Capillary fragility and decreased vascularity ■ Decreased sensory perception
■ Decreased sensory receptors and increased ■ Decreased vitamin D production
thresholds ■ Increased skin lesions

Hair
■ Decreased melanocytes ■ Graying of body hair
■ Decreased hair follicle density ■ Uneven skin color
■ Loss and thinning of hair
Nails
■ Hypo/hyperplasia of nail matrix ■ Increased longitudinal ridges
■ Nails thick and brittle
■ Decreased blood supply to nails ■ Growth slow

HEENT
Eyes
■ Decreased orbital fat ■ Sunken eyes
■ Decreased elasticity of lids ■ Ectropion or entropion
■ Decreased tears ■ Dry eyes
■ Decreased corneal sensitivity ■ Decreased corneal reflex
■ Increased lipid deposits around cornea ■ Arcus senilis
■ Decreased aqueous humor ■ Decreased lens accommodation
■ Atrophy of ciliary muscles ■ Decreased peripheral vision
■ Decreased elasticity of lens ■ Decreased ability to adapt to light and dark
■ Increased density of lens ■ Glare intolerance
■ Decreased color of iris ■ Impaired night vision
■ Decreased pupil size ■ Decreased visual acuity
■ Increased vitreous debris ■ Floaters

Ears
■ Increased external canal hair in men ■ Conductive hearing loss
■ Decreased cerumen
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■ Degeneration of middle ear bones
■ Thickened tympanic membrane
■ Decreased hair in inner ear ■ Decreased speech discrimination
■ Atrophy of cochlea and organ of Corti ■ Difficulty hearing higher-frequency sound

Nose

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■ Atrophic changes ■ Vasomotor rhinitis
■ Decrease in sense of smell and ability to
distinguish odors
Respiratory
■ Rigid ribs and thoracic wall ■ Increased anterior-posterior diameter
■ Senile kyphosis
■ Decreased muscle strength ■ Decreased vital capacity
■ Increased residual lung capacity
■ Atrophy of cilia ■ Reduced cough and clearing
■ Decreased elastic recoil ■ Decreased lung compliance
■ Decreased pulmonary bed ■ Decreased ventilation and perfusion
■ Thickening and decrease in number of alveoli ■ Decreased PaO2 and O2 saturation
■ Decreased response to hypoxia/hypercarbia ■ More difficulty in maintaining acid-base
balance
Cardiovascular
Heart
■ Decreased cardiac output and cardiac index ■ Decreased stroke volume and output
■ Decreased response to beta-adrenergic
stimulation
■ Decreased heart muscle with increase in fat ■ Increased myocardial oxygen demands
and collagen
■ Thickening of ventricular walls ■ Ventricular hypertrophy
■ Decreased compliance ■ S4
■ Increased dependence on atrial contraction
■ Calcification of valves ■ Murmurs
■ Decreased sinoatrial node pacer cells and ■ Arrhythmias
bundle of His fibers ■ Slower rates in response to stress

Arteries
■ Decreased elastin and smooth muscle ■ Increased BP
■ Decreased compliance and stiffness of vessels
■ Increased peripheral vascular resistance
■ Aortic dilatation
■ Decreased baroreceptor response ■ Orthostatic hypotension
■ Rigidity of arteries leading to decreased ■ Decreased pulses
peripheral circulation ■ Cool temperature

Veins
■ Increased tortuosity ■ Varicosities

Gastrointestinal
Mouth and Teeth
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■ Decreased dentine ■ Potential loss of teeth
■ Gingival recession
■ Decreased papillae on tongue ■ Decreased sense of taste
■ Increased threshold for tasting salt and sugar
■ Decreased saliva ■ Dry oral mucous membranes

21

Esophagus
■ Decreased sphincter pressure ■ Heartburn
■ Decreased motility ■ Dysphagia
■ Increased risk for hiatal hernia,
gastroesophageal reflux disease (GERD), and
aspiration
Stomach
■ Decreased gastric acid and hydrochloric acid ■ Decreased absorption of iron, B12, and
calcium
■ Atrophy of mucosa ■ Food intolerance
■ Decreased blood flow
■ Delayed emptying ■ Decreased hunger
■ Weight changes
Small Intestine
■ Decreased villae, enzymes, and motility ■ Decreased absorption of nutrients and fat-
soluble vitamins
Large Intestine
■ Decreased blood flow and motility ■ Constipation
■ Decreased sensation of need to defecate ■ Increased risk for diverticular disease

Liver
■ Decrease in number and size of cells ■ Decreased drug metabolism and ability to
■ Decreased protein synthesis detoxify
■ Decreased regeneration

Pancreas
■ Decreased lipase and reserve ■ Impaired fat absorption
■ Possible glucose intolerance
Kidneys
■ Decreased renal mass, nephrons, glomerular ■ Decreased ability to concentrate urine,
filtration rate, blood flow resulting in loss of free water and increased
sensitivity to salt
■ Decreased creatinine clearance
■ Increased blood urea nitrogen
■ Decreased toxins and drug clearance
Bladder
■ Decreased smooth muscle and elastic tissue ■ Decreased control and possible incontinence
■ Decreased capacity
■ Decreased sphincter control ■ Increased frequency, urgency, and nocturia

Female Reproductive
■ Decreased hormones ■ Thin, pale vaginal mucosa
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■ Decreased size of ovaries and uterus ■ Decreased vaginal secretions
■ Decreased pelvic elasticity ■ Decreased intensity of sexual response
■ Atrophy and fibrosis of cervical and uterine
walls
■ Decreased elasticity of vagina ■ Potential for prolapses and infections
■ Vaginal secretions pH alkaline

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■ Involution of mammary gland tissue ■ Sagging of breasts
■ Decreased elasticity and subcutaneous tissue ■ Possible stringy feeling of mammary ducts
■ Increased adipose tissue

Male Reproductive
■ Enlarged prostate ■ Prostatic hypertrophy
■ Decreased sperm count and seminal fluid ■ Decreased intensity of sexual response
volume
■ Seminal vesicles atrophy ■ Increased time to achieve erection
■ Increased estrogen levels ■ Decreased force of ejaculation
■ Decreased testosterone ■ Tendency of testes to hang lower
■ Reduced elevation and decreased size of ■ Gynecomastia
testes

Musculoskeletal
Bones
■ Narrow intervertebral discs ■ Loss of height (1–4 inches)
■ Increased cartilage in nose and ears ■ Kyphosis
■ Wider pelvis
■ Increased length of nose and ears
■ Decreased bone mass, bone growth, and ■ Increased risk for osteoporotic fractures
osteoblastic activity

Muscles
■ Decreased number of muscle fibers ■ Decreased strength
■ Muscle atrophy
■ Increased fat in muscles
■ Slow muscle regeneration
■ Stiffening of ligaments and tendons ■ Decreased agility
■ Increased contraction and latency time

Joints
■ Decreased cartilage ■ Decreased ROM and mobility
■ Increased erosion and calcium deposits ■ Osteoarthritis

Neurological
Brain
■ Decreased brain size, weight, and volume ■ Decreased processing and reflexes
■ Decreased neurons, glial cells, and ■ Delayed reaction time
conduction of nerve fibers
■ Neurofibrillary tangles ■ Decreased psychomotor performance
■ Hypoperfusion
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■ Atrophy ■ Depression
■ Decreased neurotransmitters, dopamine, ■ Altered pain response
norepinephrine, serotonin, and acetylcholine ■ Decreased proprioception
■ Elevated cortisol, sodium, and monoamine ■ Increased balance problems
oxidase levels ■ Decreased sensory input
■ Decreased deep sleep and rapid eye ■ Increased periods of being awake and

23

movement (REM) sleep difficulty falling asleep
■ Decreased dreaming
Endocrine
■ Decreased BMR ■ Increased weight
■ Decreased sensitivity to hormones ■ Decreased insulin response, glucose response,
glucose tolerance and sensitivity of the renal
tubules to antidiuretic hormone (ADH)
■ Decreased febrile response ■ Decreased shivering and sweating
■ Decrease in hormones (e. g., growth, thyroid) ■ Effects of hormonal change
Immunologic/Hematologic
■ Decreased immunoglobulin IgA ■ Decreased ability to reject foreign substances
■ Involuted thymus ■ Increased autoimmune disorders
■ Decreased thymopoietin, lymphoid, ■ Delayed hypersensitivity reactions
antibodies, T lymphocytes
■ Increased autoantibodies ■ Decreased response to acute infection
■ Decreased memory of previous antigenic ■ Increased incidence of malignancy
stimuli
■ Decreased responsiveness to immunizations ■ Recurrent latent herpes zoster or tuberculosis
■ Increased anergy
Source: Lewis, S., Heitkemper, M., and Dirksen, S. (2000). Medical Surgical Nursing Assessment
and Management of Clinical Problems, ed. 5. Philadelphia: C. V. Mosby, pp. 225–260.

Pathologic Manifestations of Aging
Eyes and Ears About the age of 40, eyesight weakens, and at around 60, cataracts and macular
degeneration may develop. Hearing also declines with age.
Sight:
a. Presbyopia is a slow loss of ability to see close objects or small print. It is a normal
process that happens as you get older. Holding the newspaper at arm's length is a sign of
presbyopia. Reading glasses usually fix the problem. This occurs because of a decrease in blood
supply to theeyes.
b. Cataracts are cloudy areas in the eye's lens causing loss of eyesight. Cataracts often form
slowly without any symptoms. Some stay small and don't change eyesight very much. Others may
become large or dense and harm vision. Cataract surgery can help. Cataract surgery is safe and is
one of the most common surgeries done in the United States.
c. Glaucoma comes from too much pressure from fluid inside the eye. Over time, the
pressure can hurt the optic nerve. This leads to vision loss and blindness. Most people with
glaucoma have no early symptoms or pain from the extra pressure. You can protect yourself by
having annual eye exams that include dilation of the pupils
Hearing: About one-third of Americans between the ages of 65 and 74 have hearing problems.
About half the people who are 85 and older have hearing loss.
a. Presbycusis (prez-bee-KYOO-sis) is age-related hearing loss. It becomes more common
in people as they get older. The decline is slow.
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b. Tinnitus (tih-NIE-tuhs) accompanies many forms of hearing loss, including those that
sometimes come with aging. People with tinnitus may hear a ringing, roaring, or some other noise
inside their ears. Tinnitus may be caused by loud noise, hearing loss, certain medicines, and other
health problems, such as allergies and problems in the heart and blood vessels.
Cardiovascular
a. High Blood pressure -Increased peripheral resistance/ increased BP esp. systolic.

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b. Orthostatic hypotension- Baroreceptors less sensitive due to a decreased sensitivity to
change in positions
c. Increased dependent edema- as a result of Decreased venous valve competency.
d. Dysrhythmias- possibly as a result of decreased pacemaker cells.
Bones and Joints- The weight-bearing bones and the movable joints take much wear and tear as
the body ages. The most common age-related conditions are:
a. Osteoporosis: OSTEOPOROSIS is a disease that weakens bones to the point where they
break easily—most often bones in the hip, backbone (spine), and wrist—and most often in
women. As people enter their 40s and 50s, bones begin to weaken. The outer shell of the bones
also gets thinner. Bone density decreases as a result of weak bones.
b. Arthritis: There are different kinds of ARTHRITIS, each with different symptoms and
treatments. Arthritis can attack joints in almost any part of the body. Millions of adults and half of
all people age 65 and older are troubled by this disease. Osteoarthritis (OA) is the most common
type of arthritis in older people. OA starts when cartilage begins to become ragged and wears
away. At OA's worst, all of the cartilage in a joint wears away, leaving bones that rub against each
other. Rheumatoid Arthritis (RA) is an AUTOIMMUNE disease. In RA, that means your body
attacks the lining of a joint just as it would if it were trying to protect you from injury or disease.
RA leads to inflammation in your joints. This inflammation causes pain, swelling, and stiffness
that can last for hours.
Digestive and Metabolic
As we grow older, the prevalence of gastrointestinal problems increases. Gastroesophageal reflux
disease, or GERD, occurs when the lower esophageal sphincter (LES) does not close properly. This
is due to a weak muscle that prevents the reflux of gastric contents.
Urogenital
a. Incontinence: Loss of bladder control is called urinary INCONTINENCE. It can happen
to anyone, but is very common in older people. At least 1 in 10 people age 65 or older has this
problem. Symptoms can range from mild leaking to uncontrollable wetting. Women are more
likely than men to have incontinence. Aging alone does not cause incontinence. It can occur for
many reasons: Urinary tract infections, vaginal infection or irritation, constipation, and certain
medicines can cause bladder control problems that last a short time. In most cases urinary
incontinence can be treated and controlled, if not cured. If you are having bladder control
problems, don't suffer in silence. Talk to your doctor.
b. Benign Prostatic Hypertrophy (BPH): The PROSTATE GLAND surrounds the tube
(URETHRA) that passes urine. This can be a source of problems as a man ages because the
prostate tends to grow bigger with age and may squeeze the urethra. A tumor can also make the
prostate bigger. These changes, or an infection, can cause problems passing urine. Sometimes
men in their 30s and 40s may begin to have these urinary symptoms and need medical attention.
For others, symptoms aren't noticed until much later in life.
c. Prostate Cancer: Prostate cancer is the second most common type of cancer among men
in this country. Only skin cancer is more common. Out of every three men who are diagnosed
with cancer each year, one is diagnosed with prostate cancer.
Dental
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a. Gum diseases (sometimes called PERIODONTAL or GINGIVAL DISEASES) are infections
that harm the gum and bone that hold teeth in place. When plaque stays on your teeth too long,
it forms a hard, harmful covering, called TARTAR, that brushing doesn't clean. The longer the
plaque and tartar stay on your teeth, the more damage they cause. This is called GINGIVITIS. If
gingivitis is not treated, over time it can make your gums pull away from your teeth and form
pockets that can get infected. This is called PERIODONTITIS. If not treated, this infection can

25

ruin the bones, gums, and tissue that support your teeth. In time, it can cause loose teeth that
your dentist may have to remove.
Skin
The simplest and cheapest way to keep your skin healthy and young looking is to stay out of the
sun. Sunlight is a major cause of the skin changes we think of as aging — changes such as
wrinkles, dryness, and age spots. Your skin does change with age. For example, you sweat less,
leading to increased dryness. As your skin ages, it becomes thinner and loses fat, so it looks less
plump and smooth.
a. Dry Skin affects many older people, particularly on their lower legs, elbows, and forearms.
The skin feels rough and scaly and often is accompanied by a distressing, intense itchiness. Low
humidity — caused by overheating during the winter and air conditioning during the summer —
contributes to dryness and itching. The loss of sweat and oil glands as you age also may worsen
dry skin. Anything that further dries your skin — such as overuse of soaps, antiperspirants,
perfumes, or hot baths — will make the problem worse. Dehydration, sun exposure, smoking, and
stress also may cause dry skin.
b. Decrease in thermoregulation – the inability of the body to regulate body heat due to a
diminish in sweat glands.
c. Wrinkles, poor skin turgor – the skin becomes wrinkled due to collagen and
subcutaneous fat decreases. This also makes the subcu medicines to absorb more slowly.
d. Gray hair – hair follicles decreased / produce less melanin as the reason of baldness and
gray hair.
e. Skin cancer is the most common type of cancer in the United States. According to
current estimates, 40 to 50 percent of Americans who live to age 65 will have skin cancer at least
once. There are three common types of skin cancers. Basal cell carcinomas are the most common,
accounting for more than 90 percent of all skin cancers in the United States. They are slow-
growing cancers that seldom spread to other parts of the body. Squamous cell carcinomas also
rarely spread, but they do so more often than basal cell carcinomas. The most dangerous of all
cancers that occur in the skin is melanoma. Melanoma can spread to other organs, and when it
does, it often is fatal.
f. Shingles is a disease that affects nerves and causes pain and blisters in adults. It is caused
by the same varicella-zoster virus that causes chickenpox. After you recover from chickenpox, the
virus does not leave your body, but continues to live in some nerve cells. For reasons that aren't
totally understood, the virus can become active instead of remaining inactive. When it's activated,
it produces shingles.
Memory loss - As adults age, many worry that they are becoming more forgetful. They think
forgetfulness is the first sign of Alzheimer's Disease (AD). In the past, memory loss and confusion
were accepted as just part of growing older. However, scientists now know that people can remain
both alert and able as they age, although it may take them longer to remember things. This is due
to a decline in the function of the neurons and its numbers.
Functional Abilities
Falls become an increasingly common reason for injuries. Just ask any of the thousands of older
men and women who fall each year and break a bone. Falls can come as a result of other changes
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in the body: Sight, hearing, muscle strength, coordination, and reflexes aren't what they once
were as we age. Balance can be affected by diabetes and heart disease, or by problems with your
circulation or nervous system. Some medicines can cause dizziness. Any of these things can make
a fall more likely.
(http://www.nlm.nih.gov/medlineplus/magazine/issues/winter07/articles/winter07pg10-13.html)

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Assessment Instruments for Geriatric Population
PSYCHOSOCIAL ASSESSMENT
Altered Mental Status
 Assessment of cognitive function to detect altered mental status involves examination of
memory, perception, communication, orientation, calculation, comprehension, problem
solving, thought processes, language, construction abilities, abstraction, attention, aphasia,
and apraxia.
 Assessment can be facilitated by use of the Folstein Mini-Mental State Examination.
Assessment items include:
o Orientation to time (year, season, date, day, month); 5 points.
o Orientation to place (state, county, town, hospital, floor); 5 points.
o Registration of 3 items; 1 point for repeating each item correctly.
o Calculation by subtracting serial 7’s, starting with 100; 1 point for each correct up to 5
trials. Alternately spell “world” backwards; 1 point for each letter correct.
o Recall of the three items registered earlier; 1 point for each correct.
o Naming 2 items shown such as pencil and pen; 1 point each.
o Repeating “No ifs, ands, or buts”•; 1 point.
o Following a 3-stage command: “Take this paper in your right hand, fold it in half, and
put it on the floor”•; 3 points.
o Obeying the written command “Close your eyes”•; 1 point.
o Writing a sentence; 1 point.
o Copying a complex polygon; 1 point.
 Total possible score is 30. Score of 24 to 30 indicates intact cognitive function; 20 to 23, mild
cognitive impairment; 16 to 19, moderate cognitive impairment; 15 or less, severe cognitive
impairment. This scale can help to follow the elderly person's mental status over time and
assess for acute and or chronic changes.
 Although success on scales such as this has been associated with education and
socioeconomic status, this scale continues to be used as an appropriate screening tool for
abnormal cognitive function.
 Assessment of altered mental status or behavior may elicit criteria that lead to a diagnosis of
dementia. It is essential to differentiate dementia from delirium (which is treatable and
reversible).
FUNCTIONAL ASSESSMENT
Functional assessment is the measurement of a patient's ability to complete functional tasks and
fulfill social roles, specifically addressing a person's ability to complete tasks ranging from simple
self-care to higher-level activities.
Purpose
 Functional assessment is essential in the care of the elderly patient because it:
o Offers a systematic approach to assessing elderly people for deficits that commonly go
undetected.
o Helps the nurse to identify problems and utilize appropriate resources.
o Provides a way to assess progress and decline over time.
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o Helps the nurse evaluate the safety of the person's ability to live alone
 Functional status includes the evaluation of sensory changes, ability to complete ADL,
instrumental ADL, gait and balance problems, and elimination.
Instruments to Measure Functional Ability
 Functional status may be assessed by several methods: self-report, direct observation, or
family report. Direct observation is the method of choice, when possible.

27

 The instrument chosen should be based on the specific goal or purpose for the evaluation. For
example, if the focus is on basic self-care and mobility, the Barthel index should be used.
 Performance measures, such as the Tinetti Gait and Balance measure or the Chair Rise test,
can be used to evaluate higher-level function.
(Lippincott Manual of Nursing Practice, 8th Ed. By Nettina, S.M., Mills, E.J., p172-174)

Katz Index for Activities of Daily Living and Instrumental Activities of Daily Living
ACTIVITIES OF DAILY LIVING INSTRUMENTAL ACTIVITIES OF DAILY LIVING
1. Bathing - Sponge bath, tub bath, or 1. Can you use the telephone?
shower 0 = without help, including looking up numbers
0 = no assistance (gets in and out of tub by and dialing
self) 2 = with some help (can answer phone or dial 911
1 = uses a device to get in or out of tub but in emergency, but need special help in getting the
able to bathe self number or dialing)
2 = requires partial assistance with bathing Why?__________________________________
3 = full bath required (unable to bathe) 3 = completely unable to use the telephone
2. Dressing - includes getting clothes from 2. Can you get to places out of walking distance?
closet and drawers (under and outer 0 = without help (travels alone on buses, taxis,
garments and able to use fasteners) drives own car)
0 = no assistance with getting clothes and 1 = with some help in transferring on and off
dressing self (device and/or person)
1 = able to get clothes and get dressed, 2 = with help of someone while travelling
except for assistance with shoes 3 = totally dependent on specialized arrangements
2 = receives assistance with getting clothes for travel (ie, ambulance) or doesn't travel at all
or getting dressed 3. Can you go shopping for groceries or clothing?
3 = requires complete assistance or stays 0 = without help taking care of all shopping needs
partly or completely undressed (assuming had own transportation)
3. Toileting - going to bathroom for bowel 1 = able to take care of all shopping needs but
and urine elimination, self-cleaning and requires companion to help
arranging clothes 2 = requires assistance in preparation of shopping
0 = requires no assistance list as well as a companion to help with shopping
1 = requires no assistance but uses device 3 = totally dependent on another person for all
(cane, walker, wheelchair, bedpan at night, shopping needs
but able to empty in morning) 4. Can you prepare your own meals?
2 = receives partial assistance with going to 0 = without assistance (plan and cook full meals
the bathroom or in cleansing or arranging for yourself)
clothing 2 = with some assistance (can prepare some things
3 = receives full assistance or does not go but unable to cook a full meal)
to the bathroom Why?__________________________________
4. Transfer 3 = totally unable to prepare meals
0 = moves well in and out of bed and/or 5. Can you do your housework?
chair without assistance 0 = without assistance (scrub floor, etc.)
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1 = moves well in and out of bed and/or 2 = able to do light housekeeping but needs help
chair with device with heavy work
2 = moves in and out of bed and/or chair ie ___________________________________
with assistance 3 = unable to do any housework
3 = requires full assistance 6. Can you take your own medicine?

28

5. Continence 0 = without assistance (correct doses, correct
0 = controls urination and bowel time)
movements completely by self 1 = able if someone prepares it for you
1 = has occasional “accidents”• 2 = able to if someone prepares it for you and
2 = supervision helps keep bowel or urine reminds you to take it
control or is incontinent 3 = require someone to prepare and give you your
3 = catheter is used medication
6. Feeding 7. Can you handle your own money?
0 = able to prepare foods, serve and feed 0 = without assistance (able to pay bills, write
self without assistance checks)
1 = requires help in preparation of food but 2 = able to manage day-to-day buying but need
is able to feed self help with managing check book and paying bills
2 = requires help in preparation of food, Why?________________________________
cutting of meat, buttering How long has this been going on?________
3 = receives full assistance or is fed partly 3 = requires full assistance with money
or completely by tubes management
_____________ Score _____________ Score
Best score is 0, most independent; worst score is 18, most dependent.
Katz, S., et al. (1963.) Studies of illness in the aged, in the aged the index of ADL: A standardized measure of biologic and
psychosocial function. Journal of the American Medical Association, 185,914-919.

Geriatric Rehabilitation and Restorative Care
Characteristics
 The primary goal is restoring the older adult to maximum functional level.
 Multidisciplinary service involving input from the primary care provider; nursing personnel;
physical, occupational, speech, and recreational therapists; social worker; psychologist; and
dietitian.
 Rehabilitation and restorative nursing involves developing a rehabilitation philosophy of care.
o Patients are encouraged, and allowed sufficient time, to perform as much of their
personal care as possible.
o Goals are set with the patient rather than for the patient.
o Prevention of further impairment is imperative.
o Focus on skin and wound care, regaining or maintaining bowel and bladder function,
independent medication use, good nutritional status, psychosocial support, an
appropriate activity/rest balance, and patient and family education.
1. Encourage independence.
2. Use a positive, reassuring approach.
3. Be alert to limitations and client-expressed need for help.
4. Encourage client decision-making.
5. Communicate with words easily understood by the client. Ask client to repeat directions in
order to assess their comprehension.
6. Provide positive reinforcement often.
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7. Use repetition through words and actions (i.e., demonstration).
8. Provide rest periods as needed.
9. Ensure client safety by safeguarding against injury at all times.
(Lippincott Manual of Nursing Practice, 8th Ed. By Nettina, S.M., Mills, E.J., p178)

29

Environmental Modifications for Geriatric Population
A safe environment allows the patient to move about as freely as possible and relieves the
family of constant worry about safety. To prevent falls and other injuries, all obvious hazards are
removed. Nightlights are helpful. The patient’s intake of medications and food is monitored.
Smoking is allowed only with supervision. A hazard-free environment allows the patient
maximum independence and a sense of autonomy. Because of a short attention span and
forgetfulness, wandering behavior can often be reduced by gently persuading or distracting the
patient. Restraints are avoided because they may increase agitation. Doors leading from the house
must be secured. Outside the home, all activities must be supervised to protect the patient, and
the patient should wear an identification bracelet or neck chain in case he or she becomes
separated from the caregiver.
 Remove furniture if patient cannot sit on it and have his feet reach the floor.
 Remove clutter.
 Make sure furniture and any assistive devices used are in good condition.
 Make sure lighting is adequate.
 Make sure safety bars are available in bathroom.
 Minimize specific hazards in the home (e.g., remove stove knobs, store cleaning products and
medications in a locked area, clear floor and hallway of obstacles). To make the home
environment safer.
 Keep nightlights on at night. Decreases the potential for falls.
 Instruct family to install an alarm system on all exit doors. To minimize the possibility of
wandering.

Nomenclature of Neoplasm
Malignant tumors are classified by histologic origin: tumors derived from epithelial tissues
are called carcinomas; from epithelial and glandular tissues, adenocarcinomas; from connective,
muscle, and bone tissues, sarcomas; from glial cells, gliomas; from pigmented cells, melanomas;
and from plasma cells, myelomas. When tumors are derived from erythrocytes, they are called
erythroleukemia; from lymphocytes, leukemia; and from lymphatic tissue, lymphoma.
Benign (-oma)
 Adenoma
o Benign epithelial neoplasm that forms a glandular pattern.
o A neoplasm derived from glands but does not necessarily form glandular patterns.
o example: thyroid follicular adenoma, cystadenoma of ovary, adrenocortical adenoma
 Papilloma – Benign epithelial neoplasm producing macroscopically or microscopically visible
fingerlike or warty projects from epithelial surfaces.
 Teratoma – Neoplasms made up of cellular elements representing more than or (usually all
three) of the embryonic germ layers.
o example: Ovarian teratoma
 Hamartoma – A disorganized mass of mature, specialized tissues or cells indigenous to a
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particular site.
o example: Lung hamartoma – mixture of mature respiratory and cartilage cells in the
lung.
 Choristoma – Nests of "normal" tissues in ectopic locations.
Benign or Malignant

30

 Polyp – Benign or malignant neoplasm that produces a macroscopically visible projection
above a mucsal surface.
o example: colonic polyp (nomeoplastic/hyperplastic or neoplastic/adenoma), polypoid
cancers.
Malignant
 Carcinoma – malignant epithelial neoplasm (two types)
o example: Adenocarcinoma, squamous cell carcinoma, or can specify site (renal cell
adenocarcinoma), or can specify differentiation (large cell undifferentiated carcinoma
of lung).
 Sarcoma – Malignant mesenchymal neoplasm (mesenchymal means anything that is not
epithelial)
o example: liposarcoma, osteosarcoma, chondrosarcoma
 Benign and Malignant
o Tumors with "Mixed" Differentiation – adenofibronoma/fibroadenoma,
carcinosarcoma/malignant mixed tumor.
 Inappropriate Nomenclature – You’d think they are benign but they are malignant
o Hepatoma – hepatocelluar carcinoma
o Melanoma – melanocarcinoma
o Lymphoma
o Astrocytoma/glioma
o Seminoma
(Diseases: A Nursing Process Approach to Excellent Care 4th Ed. 312)

Models of Care for Cancer Patients
SURGICAL MANAGEMENT
A surgical intervention usually provides the initial diagnosis; subsequent procedures may be
needed for treatment.
 Primary treatment - involves the removal of a malignant tumor and a margin of adjacent
normal tissue.
o Local excision - is the simple excision of a tumor and a small margin of normal tissue.
o Wide excision - includes the removal of the primary tumor, regional lymph nodes, and
neighboring structures.
 Adjuvant treatment involves the removal of tissues to decrease the risk of cancer recurrence.
It includes debulking procedures.
o Debulking surgery is the removal of the bulk of the tumor; should be performed before
the start of chemotherapy whenever possible.
 Salvage treatment - involves the use of an extensive surgical approach to treat a local
recurrence after implementing a less extensive primary approach.
 Palliative treatment - is surgery that attempts to relieve the complications of cancer (eg,
obstruction of the GI tract, pain produced by tumor extension into surrounding nerves).
 Reconstructive/rehabilitative surgery - is the repair of defects from previous radical surgical
resection; can be performed early (breast reconstruction) or delayed (head and neck surgery).
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 Preventive/prophylactic surgery - is the removal of lesions that, if left in the body, are at risk
of developing into cancer. An example is polyps in the rectum or mastectomy in women who
are at high risk.

31

CHEMOTHERAPY FOR CANCER
Chemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by
interfering with cellular function and reproduction. It includes the use of various
chemotherapeutic agents and hormones.
RADIATION THERAPY
Radiation therapy is the use of high-energy ionizing rays to destroy a cancer cell's ability to
grow and multiply. The goal of radiation therapy is to deliver a precisely measured dose of
irradiation to a defined tumor volume with minimal damage to surrounding healthy tissue. This
results in eradication of tumor, high quality of life, prolongation of survival, and allows for
effective palliation or prevention of symptoms of cancer, with minimal morbidity.
IMMUNOTHERAPY
Biologic therapy is cancer treatment that produces antitumor effects primarily through the
action of natural host defense mechanisms. It is capable of altering the immune system with
either stimulatory or suppressive effects. Biologic therapy has emerged as an important fourth
modality for the treatment of cancer.

Phases of Cancer Rehabilitation
Prevention
The preventive phase of cardiac rehabilitation is designed to reduce the impact and
severity of the expected disabilities and to assist the individual to learn how to cope with and
manage any disability (for example, rehabilitation required after a major surgical procedure such
as mastectomy or colostomy formation) to prevent long-term effects such as problems with body
image.
Restoration
The restorative phase of cancer rehabilitation is designed to return the patient to a pre-
illness level of functioning without residual disabilities from or related to the treatment of disease;
for example, after intensive treatment for malignancies with a good prognosis such as leukemia or
lymphoma, where remissions or cure is achieved but the patient may find it hard to ‘return to
normal’.
Support
The supportive phase is characterized by persistence of the disease, a continuing need for
treatment and progressive changes in functional ability. The rehabilitation goal is to limit
functional changes and to provide support to reduce any disabilities or loss of function; for
example, inoperable lung cancer, where the patient may need rehabilitation support to adopt to
long-term symptoms such as breathlessness.
Palliation
The palliative phase of rehabilitation is appropriate where there is an increasing loss of
function. The goal is to reduce the complications of the disease process and to provide comfort
and emotional support for the patient and family; for example, when a patient is dealing with
recurrence of advanced disease.
(Cancer Nursing: Care in Context by Corner, J., Bailey, C. P443)
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INTEGUMENTARY SYSTEM
Anatomy of the Skin

(Human Anatomy and Physiology 7th Ed. By Marieb, EN, Hoehn, K.)

Epidermis
The epidermis, the outermost skin layer, varies in thickness from less than 0.1 mm on the
eyelids to more than 1 mm on the palms and soles. It's composed of avascular, stratified squamous
(scaly or platelike) epithelial tissue that contains multiple layers: a superficial, keratinized, horny
layer of cells (stratum corneum) composed of several layers of cells in various stages of change as
they migrate upward and a deeper, germinal (basal cell) layer.
Stratum corneum
After mitosis occurs in the basal cell layer, epithelial cells undergo a series of changes as
they migrate to the outermost part of the stratum corneum, made up of tightly arranged layers of
cellular membranes and keratin. Interspersed among the keratinized cells below the stratum
corneum are the specialized Langerhans' cells. These cells have a function in the immune
response and assist in the initial processing of antigens that enter the epidermis. Epidermal cells
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usually are shed from the surface as epidermal dust. Differentiation of cells from the basal cell
layer to the stratum corneum takes up to 28 days.
Basal cell layer
The basal cell layer produces new cells to replace the superficial keratinized cells that are
continuously shed or worn away. The layer's deepest part contains melanocytes, which produce
the brown pigment melanin and disperse it to the surrounding epithelial cells. Melanin primarily

33

serves to filter ultraviolet radiation (light). Exposure to ultraviolet light can stimulate melanin
production.
Dermis
The second layer of skin, the dermis or corium, is an elastic system that contains and
supports blood vessels, lymphatic vessels, nerves, and epidermal appendages (hair, nails, and
eccrine and apocrine glands). The dermis consists of two layers: the superficial papillary dermis
and the reticular dermis.
The papillary dermis is studded with fingerlike projections (papillae) that nourish the
epidermal cells. The epidermis lies over these papillae and bulges downward to fill the spaces. A
collagenous membrane known as the basement membrane lies between the epidermis and
dermis, holding them together.
The reticular dermis covers a layer of subcutaneous tissue (adipose layer, or panniculus
adiposus), a specialized layer primarily composed of fat cells. It insulates the body to conserve
heat, acts as a mechanical shock absorber, and provides energy.
Intercellular material called matrix makes up most of the dermis. Matrix contains
connective tissue fibers called collagen, elastin, and reticular fibers. Collagen, a protein, gives
strength to the dermis; elastin makes the skin pliable; and reticular fibers bind the collagen and
elastin together.
The matrix and connective tissue fibers are produced by spindle-shaped connective tissue
cells (dermal fibroblasts), which become part of the matrix as it forms. Fibers are loosely arranged
in the papillary dermis but more tightly packed in the deeper reticular dermis.
Epidermal appendages
The epidermal appendages include hair, nails, sebaceous glands, eccrine glands, and
apocrine glands.
Hair
Hairs are long, slender shafts composed of keratin. Each hair has an expanded lower end
(bulb or root) indented on its undersurface by a cluster of connective tissue and blood vessels
called a hair pilus. Each lies within an epithelium-lined sheath called a hair follicle. A bundle of
smooth-muscle fibers (arrector pili) extends through the dermis to attach to the base of the hair
follicle. Contraction of these muscle fibers causes the hair to stand on end. Hair follicles also have
a rich blood and nerve supply.
Nails
Like hair, nails are composed mainly of keratin. They're situated over the distal surface of
the end of each digit. The nail plate, surrounded on three sides by the nail folds (cuticles), lies on
the nail bed; the germinative nail matrix, which extends proximally for about 5 mm beneath the
nail fold, forms the plate. The distal portion of the matrix shows through the nail as a pale,
semilunar area (the lunula). The translucent nail plate distal to the lunula exposes the nail bed.
The vascular bed imparts the characteristic pink appearance under the nails.
Sebaceous glands
The sebaceous glands are found on all skin parts except for the palms and the soles. They
occur predominantly on the scalp, face, upper torso, and anogenital region. Sebum, a lipid
substance, is produced by the sebaceous glands and secreted in the hair follicle by way of the
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excretory duct and then exits through the hair follicle opening to reach the skin surface. Sebum
may help waterproof the hair and skin and promote the absorption of fat-soluble substances into
the dermis. It may also be involved in the production of vitamin D3 and have some antibacterial
function.

34

Eccrine glands
Eccrine glands are widely distributed, coiled glands that produce an odorless, watery fluid
with a sodium concentration equal to that of plasma. A duct from the secretory coils passes
through the dermis and epidermis and opens into the skin surface. Eccrine glands in the palms
and soles secrete fluid primarily in response to emotional stress. The remaining 3 million eccrine
glands respond primarily to thermal stress and effectively regulate temperature.
Apocrine glands
Apocrine glands, located primarily in the axillary and anogenital areas, have a coiled
secretory portion that lies deeper in the dermis than the eccrine glands do. A duct connects the
apocrine glands to the upper portion of the hair follicle. Apocrine glands, which begin to function
at puberty, have no known biological function. Bacterial decomposition of the fluid produced by
these glands causes body odor.
(Diseases: A Nursing Process Approach to Excellent Care 4th Ed. P 1242-1244)

Wound Healing
First Intention Healing (Primary Closure)
Wounds are made
sterile by minor
debridement and
irrigation, with a
minimum of tissue
damage and tissue
reaction; wound edges
are properly
approximated with
sutures.
Granulation tissue is
not visible, and scar formation is typically minimal (keloid may still form in susceptible people).
Secondary Intention Healing (Granulation)
Wounds are left
open to heal
spontaneously or
surgically closed at a
later date; they need
not be infected.
Examples in which
wounds may heal by
secondary intention
include burns,
traumatic injuries,
ulcers, and suppurative
infected wounds.
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The cavity of the wound fills with a red, soft, sensitive tissue (granulation tissue), which
bleeds easily. A scar (cicatrix) eventually forms. In infected wounds, drainage may be
accomplished by use of special dressings and drains. Healing is thus improved. In wounds that are
later sutured, the two opposing granulation surfaces are brought together.
Secondary intention healing produces a deeper, wider scar.
Third- intention Healing (secondary suture)

35

Is used for
deep wounds that have
either not been
sutured early or that
break down and
resutured later, thus
bringing together 2
apposing granulation
surfaces. This results
in a deeper wider scar.
These wounds are also
packed postoperatively with moist gauze and covered with a dry sterile dressing.

(Lippincott Manual of Nursing Practice, 8th Ed. By Nettina, S.M., Mills, E.J., p 126)

Complications of Wound Healing
EARLY COMPLICATIONS
COMPLICATION CAUSE PREVENTION MANAGEMENT
 dislodged clot, a. Check status of wound  Assess the bleeding
a slipped meticulously. site. Apply icepacks
stitch, or b. Monitor vital signs. for vasoconstriction.
erosion of a c. Apply pressure dressings  Monitor vital signs
HEMORRHAGE blood vessel to the wound. and observe for signs
d. Avoid touching the suture of hypovolemic shock.
line.  Notify physician.
 Fluid replacements.
 contaminatio a. Observe strict sterile  Antibiotic therapy
n of a wound technique.  Assess progress/
with b. Provide frequent dressing decline of infection.
microorganis change and wound care.  Maintain sterility to
ms c. Monitor for signs of prevent worsening of
infection such as infection especially
INFECTION
inflammation, odor, and during wound care.
pain.
d. Observe any elevation of
WBC counts and fever
which are indicators of
infection.
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 sudden a. Avoid doing excessive  Support the wound
DEHISCENCE straining, Valsalva maneuver. with large sterile
AND POSSIBLE dehydration, b. Avoid lifting heavy objects. dressing soaked in
EVISCERATION excessive c. Eat food that promotes sterile normal saline
coughing, faster wound healing. solution.

36

vomiting, d. Avoid unnecessary  Place client in bed
obesity, coughing or sneezing. with knees bent to
multiple e. Apply occlusive dressing decrease pull on the
trauma, poor as necessary. incision.
nutrition  Notify surgeon
because immediate
surgical repair of the
area may be
necessary.
 due to a. Prevent the cause such as  Provide skin
infection or infection and poor wound protection.
FISTULA poor wound healing.  Perform frequent
healing b. Adequate nutrition and dressing change.
exercise  Notify physician.
 Local a. Eat a diet rich in protein,  sitz bath
infection, zinc, vitamin A and C, and  Use devices such as
hypoxia, trau calories. pressure reduction
ma, foreign b. Prevent causes such as cushions and
bodies, or infections, cell hypoxia, mattresses
DELAYED
systemic etc.  at food that promote
problems c. Avoid prolonged pressure faster wound healing.
WOUND
such to the wound. Rotate from
HEALING
as diabetes side to side when lying
mellitus, maln down.
utrition,
immunodefici
ency, or
medications
LATE COMPLICATIONS
COMPLICATION CAUSE PREVENTION MANAGEMENT
 due to a. Avoid using the same  Herniorrhaphy
stretching of incision site.
scar tissue b. Observe proper weight
that forms management since obesity
after surgery is a risk factor.
INCISIONAL and occurs c. Promote muscle tone in
HERNIA due to the area.
constant d. Eat nutritious food that
pressure of promotes muscle growth.
abdominal
contents on
the scar
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 increased a. Promote healing and  Fusiform excision
collagen prevent infection.  Millard Flap
HYPERTROPHIC
synthesis b. Apply gentle pressure on procedure
SCARS
resulting to wound.
excessive c. Cover area and keep moist.

37

accumulation d. Massage lightly.
of collagen or
decreased
collagen
degradation
occurs
 excessive a. Treat bruises and cuts  Fusiform excision
collagen right away.  Millard Flap
accumulation b. Consume a lot of collagen- procedure
KELOIDS
/ decreased rich food and drinks such
collagen as soymilk, cheese, red
breakdown peppers or tomatoes.
 tension a. Promote healing and  Fusiform excision
perpendicular prevent infection.  Millard Flap
WIDENED to the wound b. Apply gentle pressure on procedure
SCARS edges during wound.
the healing c. Cover area and keep moist.
process d. Massage lightly
 Prolonged a. Prevent factors that delays  Removal of dead
delayed wound healing such as tissue
TISSUE
wound healing Local infection,
NECROSIS
hypoxia, trauma, foreign
bodies.
(Kozier, et al. Fundamentals of Nursing, 7th ed.)
(Fitzpatrick's Dermatology In General Medicine (Two Vol. Set) 6th edition by Irwin M. Freedberg)

Wound Assessment and Monitoring Tools
a. Pressure Ulcer Scale for Healing- clinical tool to assist clinicians with routine evaluation of
healing Stage II to
Stage IV pressure
ulcers. The PUSH tool
evaluates three
parameters consisting
of two wound
measurements (surface
area — length x width
— and depth) and
tissue type. A score of 0
out of 16 is an
indication of a
completely healed
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wound. It provides
consistent monitoring and observing reverse staging for pressure ulcers.
b. Wound Assessment Tool (T.I.M.E) - used to coordinate the data collection into more useful
elements which assist in planning cost-effective care. Clustering the information under the key
headings of TIME encourages the practitioner to relate what they are seeing to what is
happening at a cellular level and manage wounds in a proactive rather than reactive manner,

38

setting clear management/care objectives to facilitate the wound to heal where this is
appropriate.
c. Sessing Scale - based on a seven-point series of interview parameters including descriptions of
granulation tissue, infection, drainage, necrosis, and eschar developed by clinical wound
specialists. Each parameter is assigned a value of 0 to 6, with 0 indicating normal skin at risk
for a wound and 6 indicating breaks in skin with the presence of infection, drainage, necrosis,
and possible sepsis. Scores are determined by calculating the change in numerical value of
assessments over time.
d. Sussman Wound Healing Tool – diagnostic instrument to predict and track the impact of
physical therapy on pressure wound healing over time. The SWHT is based on an acute wound
healing model consisting of 10 categories describing the presence or absence of tissue
attributes (eg, necrosis, maceration, hemorrhage) and 11 wound measurement characteristics
(eg, depth, location, wound healing phase).
e. Bates-Jensen Wound Assessment Tool – evaluates 13 wound characteristic with numeral
rating scale and rate them from best to worst possible. BWAT is recommended for use as a
method of assessment and monitoring pressure ulcers and other chronic wound. Its reliability
was demonstrated on adult patients.
(Kozier, et al. Fundamentals of Nursing, 7th ed.)

Wound Dressing
Types of Dressings
 Dry-to-dry dressings
o Used primarily for wounds closing by primary intention
o Offers good wound protection, absorption of drainage, and esthetics for the patient
and provides pressure (if needed) for hemostasis
o Disadvantage: they adhere to the wound surface when drainage dries (Removal can
cause pain and disruption of granulation tissue.)
 Wet-to-dry dressings
o These are particularly useful for untidy or infected wounds that must be debrided and
closed by secondary intention.
o Gauze saturated with sterile saline (preferred) or an antimicrobial solution is packed
into the wound, eliminating dead space.
o The wet dressings are then covered by dry dressings (gauze sponges or absorbent
pads).
o As drying occurs, wound debris and necrotic tissue are absorbed into the gauze
dressing by capillary action.
o The dressing is changed when it becomes dry (or just before). If there is excessive
necrotic debris on the dressing, more frequent dressing changes are required.
 Wet-to-wet dressings
o Used on clean open wounds or on granulating surfaces. Sterile saline or an
antimicrobial agent may be used to saturate the dressings.
o Provide a more physiologic environment (warmth, moisture), which can enhance the
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local healing processes as well as ensure greater patient comfort. Thick exudate is
more easily removed.
o Disadvantage: surrounding tissues can become macerated, the risk of infection may
rise, and bed linens become damp.

39

Debridement
Débridement is the removal of nonviable tissue from wounds. Removing the dead tissue is
important, particularly in instances of infection. Débridement can be accomplished by several
different methods:
Sharp surgical débridement is the fastest method and can be performed by a physician,
skilled advanced practice nurse, or certified wound care nurse in collaboration with the physician.
Nonselective débridement can be accomplished by applying isotonic saline dressings of
fine-mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris
adhering to the gauze. Pain management is usually necessary.
Enzymatic débridement with the application of enzyme ointments may be prescribed to
treat the ulcer. The ointment is applied to the lesion but not to normal surrounding skin.
Most enzymatic ointments are covered with saline-soaked gauze that has been thoroughly wrung
out. A dry gauze dressing and a loose bandage are then applied. The enzymatic ointment is
discontinued when the necrotic tissue has been débrided and an appropriate wound dressing is
applied.
Débriding agents can be used. Dextranomer (Debrisan) beads are small, highly porous,
spherical beads (0.1 to 0.3 mm in diameter) that can absorb wound secretions. Bacteria and the
products of tissue necrosis and protein degradation are absorbed into the bead layer. When the
beads are saturated, they take on a grayish yellow color, at which point their cleansing action
stops. They are then flushed from the wound with normal saline, and a fresh layer is applied.
Calcium alginate dressings can also be used for debridement when absorption of exudate
is needed. These dressings are changed when the exudate seeps through the cover dressing
or at least every 7 days. The dressing can also be used on areas that are bleeding, because the
material helps stop the bleeding. As the dry fibers absorb exudate, they become a gel that is
painlessly removed from the ulcer bed. Calcium alginate dressings should not be used on dry or
nonexudative wounds.
Skin Grafting
 Autografts - grafts done with tissue transplanted from the patient's own skin.
 Allografts - involve the transplant of tissue from one individual of the same species; these
grafts are also called allogenic or homografts.
 Xenograft or heterograft - involve the transfer of tissue from another species.
Classification by thickness.
 Split thickness (thin, intermediate, or thick) graft that is cut at varying thicknesses and is used
to cover large wounds because its total potential donor area is virtually unlimited.
 Full thickness graft consists of epidermis and all of the dermis without the underlying fat;
used to cover wounds that are too large to close primarily. They are used frequently to cover
facial defects because they provide a better contour match and less postoperative contracture.
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40

Venous, Arterial, Lymphatic Ulcers
Characteristics of Different Wound Types

Clinical Wound Assessment: A Pocket Guide by: Gottrup, F, et al. P.9

Arterial ulcer Venous ulcer Lymphatic ulcer
Valve incompetence in
inadequate blood supply perforating veins, a hx of
due to peripheral vascular DVT, a failed calf pump, Resulted form
Cause
disease, diabetes mellitus, obesity, age, or pregnancy in lymhoedema
trauma, or advanced age women with a family hx of
venous ulcers.
Present almost anywhere
on the leg; usually distal
to impaired arterial supply, Occur anywhere between
between toes or tips of the knee and the ankle,
Most common in
Location toes, over phalangeal with medial and lateral
ankles
heads, around lateral malleolus
malleolus,or at sites the most common sites.
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subjected to trauma or
rubbing of footwear.

41

Wound beds vary in
Wound beds may be pale, appearance, frequently
gray or yellow with no ruddy, beefy red, granular Ulcers are shallow,
evidence of new tissue tissue; calcification in oozing and moist &
growth; necrosis or wound base is common; a blistered.
Appearance
cellulitis may be present; superficial fibrinous Surrounding skin
commonly accompanied gelatinous necrosis may are firm, fibrotic &
by dry necrotic eschar and occur suddenly with healthy thickened
exposed tendons. appearing granulation tissue
underneath.
Usually very painful; pain
May be painless; however,
is often relieved by
pain varies unpredictably
Pain dependent leg position and
and often is relieved with leg
aggravated
elevation.
by elevation.
Ulcers are shallow,
Exudate
minimum Moderate to heavy. oozing and moist &
Production
blistered.
(http://findarticles.com/p/articles/mi_qa3977/is_200105/ai_n8937489/pg_1/)
(Wound Care: Made Incredibly Easy 2nd Ed. P122-123)

Stages of Pressure Ulcers and Management

To permit healing of stage I pressure ulcers, the pressure is removed to allow increased
tissue perfusion, nutritional and fluid and electrolyte balance are maintained, friction and shear
are reduced, and moisture to the skin is avoided.
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Stage II pressure ulcers have broken skin. In addition to measures listed for stage I
pressure ulcers, a moist environment, in which migration of epidermal cells over the ulcer surface

42

occurs more rapidly, should be provided to aid wound healing. The ulcer is gently cleansed with
sterile saline solution. Use of a heat lamp to dry the open wound is avoided, as is use of antiseptic
solutions that damage healthy tissues and delay wound healing. Semipermeable occlusive
dressing, hydrocolloid wafers, or wet saline dressings are
helpful in providing a moist environment for healing and in minimizing the loss of fluids and
proteins from the body.

Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition
to measures listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned
(débrided) to create an area that will heal. Necrotic, devitalized tissue favors bacterial growth,
delays granulation, and inhibits healing. Wound cleaning and dressing are uncomfortable;
therefore, the nurse must prepare the patient for the procedure by explaining what will occur and
administering prescribed analgesia.
Débridement may be accomplished by wet-to-damp dressing changes, mechanical
flushing of necrotic and infective exudate, application of prescribed enzyme preparations that
dissolve necrotic tissue, or surgical dissection. If an eschar covers the ulcer, it is removed
surgically to ensure a clean, vitalized wound. Exudate may be absorbed by dressings or special
hydrophilic powders, beads, or gels. Cultures of infected pressure ulcers are obtained to guide
selection of antibiotic therapy.
After the pressure ulcer is clean, a topical treatment is prescribed to promote granulation.
New granulation tissue must be protected from reinfection, drying, and damage, and care should
be taken to prevent pressure and further trauma to the area. Dressings, solutions, and ointments
applied to the ulcer should not disrupt the healing process. Multiple agents and protocols are
used to treat pressure ulcers, but consistency is an important key to success. Objective evaluation
of the pressure ulcer (eg, measurement of the pressure ulcer, inspection for granulation tissue) for
response to the treatment protocol must be made every 4 to 6 days. Taking photographs at weekly
HS 194 | 1/7/2010

intervals is a reliable strategy for monitoring the healing process, which may take weeks to
months to complete.
Surgical intervention is necessary when the ulcer is extensive, when potential
complications (eg, fistula) exist, and when the ulcer does not respond to treatment. Surgical
procedures include débridement, incision and drainage, bone resection, and skin grafting.

43

(Diseases: A Nursing Process Approach to Excellent Care 4th Ed. P 1277)

Stages of Diabetic Foot Ulcer and Management
Wagner Ulcer Classification System

Treatment of diabetic foot ulcers
Vascular
 Consider angioplasty, bypass or amputation
Infection
 Bacterial swabs help to identify organisms and sensitivity, but do not diagnose infection in
isolation from clinical features
 Superficial/local – consider topical antimicrobial treatment (e.g. sustained silver releasing
HS 194 | 1/7/2010

dressings). However, it may need systemic antibiotic therapy.
 The general treatment may also include debridement of devitalized tissue, pressure relief,
optimizing metabolic control and vascular intervention
 Deep – requires systemic antibiotic therapy to initially cover Gram-positive, Gram-negative
and anaerobic organisms. Subsequently, systemic antibiotic therapy can be modified

44

according to the results of the culture. In addition, it is essential to consider the need for
surgical debridement, drainage of infection alongside pressure relief and optimizing metabolic
control
o Topical antimicrobial (e.g. sustained silver-releasing dressings) may give added benefit
together with systemic coverage for deep infection
Pressure
 Appropriate offloading must be provided
o Total contact cast or pneumatic walker
o Deep toed or special shoes and orthotics
Local Wound Treatment
Tissue debridement
o Sharp surgery preferred
o Hydrogels, alginates
o Biosurgery
Infection
 Dependent on the outcomes of the wound assessment:
o Topical antimicrobials (e.g. sustained silver releasing dressings)
o Systemic antibiotic therapy
Exudate management
o Foams, alginates
Edge effect
 The treatment of the edge depends on the outcomes of the assessment of the edge of the
wound. In general, healthy wounds have a pink woundbed and an advancing wound
margin while un-healthy wounds have a dark and undermined wound margin
Neuropathic pain
 Occasionally, neuropathy can be associated with pain. If pain is present, consider the
following treatment:
 Tricyclic antidepressants (TCAs):
o Second generation TCA agents eg. Nortriptyline or desipramine (high in nor-adrenalin
action and fewer side effects)
o First generation TCA agent: amitriptyline
 Anticonvulsants: Gabapentin
(Wagner FW Jr. The diabetic foot. Orthopedics 1987; 10:163–72.)

Depth
Definition Treatment
Classification
0 At-risk foot, no ulceration Patient education, accommodative footwear,
regular clinical examination
1 Superficial ulceration, not Offloading with total contact cast (TCC),
infected walking brace, or special footwear
2 Deep ulceration exposing Surgical debridement, wound care, offloading,
HS 194 | 1/7/2010

tendons or joints culture-specific antibiotics
3 Extensive ulceration or Debridement or partial amputation, offloading,
abscess culture-specific antibiotics

45

Ischemia
Definition Treatment
Classification
A Not ischemic
B Ischemia without gangrene Noninvasive vascular testing, vascular
consultation if symptomatic
C Partial (forefoot) gangrene Vascular consultation
D Complete foot gangrene Major extremity amputation, vascular
consultation
(http://emedicine.medscape.com/article/1234396-overview)

HS 194 | 1/7/2010

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