Week 3 DiscussionMrs. T. is a 62-year-old woman who immigrated f.docx

Week 3 Discussion
Mrs. T. is a 62-year-old woman who immigrated from Taiwan
with her husband to rejoin their son who moved to the United
States for a job eight years ago. Mrs. T. had a difficult time
adjusting to life in a new country but was very happy to be
reunited with her son and his wife, who are expecting a baby.
Mrs. T. only speaks Mandarin and she moved to a neighborhood
with a high concentration of Chinese speaking immigrants,
which was helpful in acclimating.
About six months after moving, Mr. T. unexpectedly passed
away. Her son’s job transferred him to a city two hours away
and very soon after, he and his wife had their baby. Mrs. T.
loves the new baby very much, but she feels they have no room
in their new life for her. She doesn’t want to move from the
neighborhood where she can speak her native language, and she
is feeling very sad and alone.
Mrs. T. says she doesn’t feel like doing much of anything and
says nothing brings her happiness anymore. She hasn’t been
sleeping well and says she spends most of the day in bed
watching Chinese television. She is not eating much and has
lost about 10 lbs.
Her son rearranged the furniture in her home to improve the
feng shui. He would like her to see an acupuncturist and a
Chinese herbal medicine specialist in her neighborhood to
restore balance to her body.
For your initial post, use the biopsychosocial formulation grid
system below to formulate your diagnosis and develop a
comprehensive treatment plan for the case scenario.
What is your diagnosis? Do you agree with the son’s plan as
part of her treatment plan? What is your treatment plan?
Paper should be at least 300 words. Use at least two scholarly
source to connect your response to national guidelines and
evidence-based research in support of your ideas. Use inside
citation. All sources must be referenced and cited using APA

Style, including a link to the source.
Chapter 20
Respiratory Function
Copyright © 2019, by Elsevier Inc. All rights reserved.
Respiratory system responsible for gas exchange between
environment and blood and involves two processes: ventilation
and oxygenation
Processes of respiration, including rate and depth, are
controlled by chemoreceptors in medulla oblongata, arch of the
aorta, and in carotid artery and are sensitive to oxygen levels
and pH.
Introduction
2
Ribs become less mobile and chest wall compliance decreases.
Osteoporosis and calcification of costal cartilage lead to
increased rigidity and stiffness of thoracic cage.
Progressive loss of elastic recoil of lung parenchyma and
conducting airways and reduced elastic recoil of lung and
opposing forces of chest wall
Age-Related Changes in Structure and Function (1 of 4)
3
Lung becomes less elastic as collagenic substances surrounding
alveoli and alveolar ducts stiffen and form cross-linkages that
interfere with elastic properties of lungs.
Muscle strength declines with age, and respiratory muscles

weaken.
Respiratory rates generally are faster and shallower.
4
Decrease in surface area available for gas exchange, which
contributes to the systemic reduction in partial pressure of
arterial oxygen (PaO2)
Decrease in number and effectiveness of cilia in
tracheobronchial tree
Decreased immunoglobulin A (IgA) in nasal respiratory
mucosal surface that neutralizes viruses
Oxygen-carrying capacity of blood is reduced.
5
PaO2 drops by 1 mmHg per year—PaO2 of 70 mmHg for a 70-
year-old is relatively normal (“70 at 70”).
Ventilatory responses to hypoxia and hypercapnia may be
diminished by 50%.
Vital capacity is decreased.
6
Increased oxygen demands during exercise periods may well
exceed the abilities of older patients, and for those with chronic
obstructive pulmonary disease (COPD), activity intolerance is
exacerbated.
Smoking damages lungs, respiratory infections become more
likely.

The five As of smoking cessation: asking, advising, assessing,
assisting, and arranging.
Factors Affecting Lung Function (1 of 2)
7
Obesity results in decrease in chest wall compliance and
reduction in FRC, VC, and ERV.
And is a precursor to sleep apnea
Anesthesia and surgery increased risk of aspiration and
postoperative immobility decreases ventilation and increases
risk of airway clearance problems.
Factors Affecting Lung Function (2 of 2)
8
Alterations in breathing patterns, dyspnea, and coughing
Physiologic responses to hypoxemia and hypercapnia are
blunted in older patients; compensatory changes in heart rate,
respiratory rate, and blood pressure may be delayed and
cerebral perfusion may suffer.
An early sign of respiratory problems is a change in mental
status including subtle increases in forgetfulness and
irritability.
Respiratory Symptoms Common in Older Patients (1 of 2)
9
Dyspnea at rest is most often associated with acute respiratory
or cardiac illness.
Dyspnea on exertion may be related to immobility and
respiratory muscle deconditioning.

Cough mechanism in older patients is altered because of loss of
elastic recoil and decreased respiratory muscle strength.
Respiratory Symptoms Common in Older Patients (2 of 2)
10
Older patients usually do not complain of dyspnea until it
begins to interfere with ADLs and then only if those activities
are important to them.
10
Obstructive lung diseases: characterized by changes in
expiratory airflow rates and obstruction of airway
Restrictive lung disease: characterized by decreased ability to
expand chest, impaired inhalation, and decreased lung volumes
Respiratory Disease
11
Chronic inflammatory disease affecting airways; characterized
by reversible airway obstruction, airway inflammation, and
increased airway responsiveness to a variety of stimuli
Signs and symptoms: dyspnea, audible wheezing, palpitations,
tachypnea, tachycardia, use of accessory muscles of respiration,
pulsus paradoxus, diaphoresis, and chest hyperinflation
Obstructive Pulmonary Disease: Asthma
12
12

Prognosis is relatively good.
Treatment
Control asthma by reduction of impairment and risk
Long-term control medications taken on a daily basis:
antiinflammatory agents, long-acting bronchodilators,
leukotriene modifiers, and corticosteroids
Quick relief medications treat acute symptoms and
exacerbations.
Medications administered through a stepwise approach
Asthma
13
13
Assess effect of respiratory symptoms on activities of daily
living (ADLs), quantity of breathlessness on a scale of 1—10,
presence of asthma triggers, and frequency of need for
bronchodilator therapy
Physical exam
Can you name three nursing diagnoses for asthma?
Asthma: Assessment and Diagnosis
14
Airway obstruction resulting from bronchospasm, excessive
mucus production, tenacious secretions, adventitious breath
sounds, or a combination of all of these
Decreased gas exchange resulting from alveolar–capillary
membrane changes
Need for patient teaching resulting from lack of information and

education about asthma
14
The patient will do the following:
Maintain a patent airway
Maintain arterial blood gas (ABG) values at baseline
Be able to demonstrate proper use of the PEFM
Be able to demonstrate relaxation techniques to control
breathing
Be able to list the significant and reportable signs and
symptoms
Asthma: Planning and Expected Outcomes
15
Educate on asthma self-management; basic facts about asthma;
roles of medications; environmental control measures; the use
of inhalers, spacers, and PEFMs; and a daily written action plan
for management of exacerbations
Accommodate any neurologic changes such as altered senses,
decreased fine motor movements, and memory loss.
Asthma: Intervention
16
16
Based on normal breath sounds and ability to clear secretions
and maintain airways with a normal respiratory rate
Determine frequency of rescue inhaler use, success at avoiding
triggers, and patient’s ability to monitor and address lifestyle
changes

Asthma: Evaluation
17
Characterized by excessive mucous production with a chronic or
recurrent cough on most days for a minimum of 3 months of the
year for at least 2 consecutive years in a patient in whom other
causes have been ruled out
Symptoms: persistent cough, dyspnea on exertion, purulent
sputum, cyanosis, crackles on auscultation, tachycardia, pedal
edema, unexplained weight gain, and a decreased PaO2 with a
normal or elevated PaCO2
Obstructive Pulmonary
Disease: Chronic Bronchitis
18
18
Characterized by progressive destruction of alveoli and their
supporting structures
Physical signs: classic barrel chest appearance and use of
accessory muscles of respiration
Clinical presentation: dyspnea on exertion or at rest, decreased
weight, chronic cough with little sputum production, digital
clubbing, hyperresonance of chest, elevated hemoglobin level,
crackles, and wheezes
Disease: Emphysema
19

Characterized by progressive airflow limitation that is not fully
reversible where lung tissue becomes abnormally inflamed
(chronic bronchitis and emphysema)
Progressive and ultimately fatal disease
Risk factors: age, male gender, reduced lung function, air
pollution, exposure to secondhand smoke, familial allergies,
poor nutrition, and alcohol intake
Disease: COPD
20
Characteristic symptoms are chronic and progressive dyspnea,
coughing, and sputum production.
Diagnosis is considered based on a history of exposure to
tobacco smoke or other occupational irritants and progressive
dyspnea, a chronic cough, and chronic sputum production.
Diagnosis should then be confirmed with spirometry testing.
COPD Signs and Symptoms,
Diagnostic Tests, and Procedures
21
Include smoking cessation
Bronchodilators
Beta2-agonists
Anticholinergics
Glucocorticosteroids
Vaccines
Oxygen therapy
Surgical options
COPD Treatment

22
22
Evaluation effect of respiratory symptoms on ADLs;
quantifying breathlessness on a scale of 1—10; identifying
environmental and social factors that may be contributing to
symptoms
Identify type of onset and any precipitating factors
Physical exam including percussion and auscultation
Can you name five nursing diagnoses for COPD?
COPD: Assessment and Diagnosis
23
23
203656 (BB) - Please note that in other chapters, for question
"Can you name ... nursing diagnose ...", the answer has been
listed in the notes part. Please provide the same in this slide.
Maintain a stable weight
Maintain ABG values at baseline
Maintain a balanced intake and output
Effectively clear secretions
Demonstrate diaphragmatic and pursed-lip breathing
Demonstrate relaxation techniques to control breathing
Maintain a respiratory rate 16–25 breaths per minute
List significant and reportable signs and symptoms

COPD: Planning and Expected outcomes
24
Suggest pulmonary rehabilitation program.
Assist with smoking cessation.
Instruct on appropriate nutrition.
Teach diaphragmatic breathing and pursed-lip breathing,
expectations of chest physiotherapy, pulmonary hygiene,
medications, and proper use of inhalers.
Advise on home management of oxygen therapy.
Teach signs and symptoms of lung infection and exacerbation.
COPD: Interventions
25
25
Focuses on airflow as measured by spirometry, ability to
accomplish ADLs, and minimization of exacerbations
COPD: Evaluation
26
The physical assessment on an older adult patients reveals the
following: barrel chest, dyspnea on exertion, clubbing of the
digits, and chronic cough and crackles in lower lung fields.
These findings are consistent with which lung disorder?
Asthma
Emphysema
Pneumonia

Chronic bronchitis
Quick Quiz!
27
ANS: B
Answer to Quick Quiz
28
Leading cause of cancer deaths
Risk factors: tobacco, marijuana use, recurring inflammation,
exposure to asbestos, talcum powder, or minerals; radon
exposure, heredity, vitamin A deficiency, and exposure to air
pollution
Small-cell lung carcinoma (SCLC)—most lethal
Non–small-cell lung carcinoma (NSCLC)—slow growing less
aggressive
Restrictive Pulmonary
Disease: Lung Carcinoma (CA)
29
29
Initial workup: CBC, CEA level, CXR, CT scan, ABGs, PFTs,
and ECG
Sputum cytology used to determine cell type
If metastasis is suspected additional tests are performed.
Fiberoptic bronchoscope obtains tissue confirmation of
diagnosis.

Surgical diagnosis includes cervical mediastinoscopy,
mediastinotomy, and thoracotomy.
Lung CA Diagnostic Tests and Procedures
30
Treatment is based on histologic analysis and staging.
Options include surgery, radiation therapy, and chemotherapy
based on staging.
Management of pain, nausea, vomiting, and chemotherapy-
related side effects
Lung CA Treatment
31
Identification of risk factors for lung cancer
Common early signs: coughing, chest pain, and hemoptysis
Assessment of anxiety level
Can you name five nursing diagnoses for lung CA?
Lung CA: Assessment and Diagnosis
32
Maintain ABG values at baseline
Sustain spontaneous respiration
Verbalize their feelings about the diagnosis of lung cancer
Have good pain control
Report a decrease in the number of episodes of breathlessness

Lungs will be clear on auscultation
Maintain a stable weight
Report feeling a decrease in fatigue
Maintain a realistic level of activity
Lung CA: Planning and Expected Outcomes
33
Provide relief of pain, emotional support, counseling, and
discussion of options.
Provide factual information concerning diagnosis, treatment,
and prognosis.
Encourage attitude of realistic hope.
Acknowledging patient’s spiritual and cultural background
Encouraging verbalization of feelings, perceptions, and fears
Lung CA: Intervention
34
Assess how often symptoms occur, how patient has been able to
incorporate changes into lifestyle, and how symptoms alter
patient’s ADLs.
Determine success of pain management and level of patient
comfort.
Assess signs of depression.
Lung CA: Evaluation
35
Caused by mycobacterium tuberculosis organism
Seen in populations living in close quarters and in those with
little or no health care or preventive care

Number one fatal and communicable disease in the United
States
Transmitted by inhalation of infected droplets aerosolized in air
from cough or sneeze
Changes in immune system increase the risk for reactivation of
TB.
Restrictive Pulmonary Disease: Tuberculosis (TB)
36
36
Skin testing is an unreliable indicator of TB because older
adults are more likely to have false-negative results due to
reduced immune system activity.
Chest x-ray
Additional testing for positive PPD, symptoms, and a positive
CXR: CBC, erythrocyte sedimentation rate, chemistry panel,
sputum test for AFB performed three times, and a bone marrow
biopsy
TB Diagnostic Tests and Procedures
37
37
Standard four-drug anti-TB therapeutic regimen will cause a
rapid reduction in the number of viable mycobacteria within 2

weeks.
Most common drugs: isoniazid, rifampin, ethambutol,
streptomycin, and pyrazinamide
Monitoring of liver function on a monthly basis is
recommended.
Multidrug resistant TB is on the rise.
Prognosis is good if the patient follows the medical regimen and
maintains good nutrition.
TB Treatment and Prognosis
38
Signs and symptoms: fatigue, weight loss, weakness, night
sweats, low-grade fever, purulent sputum, and sputum positive
for AFB
With disease progression: hemoptysis, lung consolidation,
crackles and wheezes on auscultation, upper-lobe patchy
infiltrates, and cavitation on chest radiography
Can you name four nursing diagnoses for TB?
TB: Assessment and Diagnosis
39
Inadequate breathing pattern, resulting from decreased lung
capacity
Need for health teaching, resulting from lack of knowledge
about the disease process and therapeutic regimen
Noncompliance, resulting from lack of knowledge of disease
process, lack of motivation, and long-term nature of treatment
Inadequate nutrition, resulting from chronic poor appetite,
fatigue, and productive cough
39

Demonstrate safe coughing techniques
Verbalize the medication regimen
Verbalize the side effects of the anti-TB medications
Verbalize the need for continued medication
State how TB is transmitted
Verbalize feelings related to social isolation
TB: Planning and Expected Outcomes
40
Educate about measures necessary to prevent further TB
transmission.
Teach the importance of continued medication administration
and good nutrition.
Inform patient on the drug side effects to report to the health
care practitioner.
Provide psychological interaction and support.
TB: Intervention
41
41
Assessment of medication compliance
Evaluate compliance with public health measures
Monitoring of hepatic and renal function and repeated sputum
cultures for AFB
Evaluate for depression
TB: Evaluation

42
Inflammation of lung parenchyma, usually associated with
filling of the alveoli with fluid
Can be viral, bacterial, or caused by aspiration
Extremely serious illness that often results in death
Increased risk of mortality related to the normal age-related
deterioration of the immune system, increased likelihood of
chronic illnesses, weakened cough reflex, and decreased
mobility
Atypical symptoms such as altered mental status, dehydration,
and a failure to thrive may also be seen.
Pneumonia
43
Lower respiratory tract infection that has an onset in community
or within first 2 days of hospitalization
Classic symptoms: fever, coughing, sputum production, general
feelings of fatigue and malaise, and shortness of breath
Do not always exhibit a fever and coughing but often have:
dehydration, confusion, and a respiratory rate greater than 26
breaths/min
Streptococcus pneumoniae is the leading cause.
Community-Acquired Pneumonia (CAP)
44
44
New-onset pneumonia seen in patients who: Was hospitalized in

an acute care facility after 2 days or longer within 90 days of
the infection; resided in a long-term care facility; received
recent intravenous antibiotic therapy, chemotherapy, or wound
care within a month of the current infection; or was seen in a
hemodialysis facility
Ventilator-associated pneumonia (VAP) occurs more than 48
hours after endotracheal intubation.
Health Care–Associated
Pneumonia (HCAP)
45
Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas
aeruginosa, and Escherichia coli most often cause nosocomial
pneumonia.
Older adults more likely to be in high-risk areas: residential
centers, hospitals, and extended care facilities
Nosocomial Pneumonia
46
Viral pneumonia most often associated with a history of the
influenza A virus
Aspiration pneumonia is associated with: stupor, coma,
cardiopulmonary resuscitation, alcohol or drug intoxication,
neurologic illness, nasogastric feeding, and general anesthesia
Other Pneumonias
47
47

Diagnosis based on history and signs and symptoms
Laboratory sampling includes total white WBC, blood cultures,
Gram stain, and sputum culture.
CXR—anterior, posterior, and lateral
Pneumonia Diagnostic Tests and Procedures
48
Administration of appropriate antibiotics, hydration, good
nutrition, and rest
Length of treatment with antibiotics can range from 10 to 14
days, depending on the causative organism.
Severity of the illness, site of acquisition, age, and presence of
comorbid illnesses are all considerations in determining initial
antibiotic therapy.
Pneumonia Treatment
49
Clinical improvement usually occurs between 3 and 5 days.
Most common cause of death in older adults because of altered
immune response related to aging, underlying chronic disease,
and diminished cough reflex
Pneumonia Prognosis
50
History of fatigue, malaise, decreased appetite and fluids, and a
viral infection
Fever, chills, shortness of breath, sputum production, and an
abnormal chest examination
Complete respiratory assessment
Assess for dehydration and confusion

Be alert to signs and symptoms of an increasing severity of
illness and potential need for intensive care
Can you name five nursing diagnoses?
Pneumonia: Assessment and Diagnosis
51
51
Maintain a PaO2 of 80 mmHg by ABG analysis or an SaO2
greater than 90% by pulse oximetry
Have decreased complaints of fatigue
Have clear lungs on auscultation
Be able to clear secretions effectively
Be able to sleep through the night without episodes of
breathlessness or coughing
Maintain baseline vital signs and weight
Pneumonia: Planning and Expected Outcomes
52
52
Maintenance of hydration, promotion of effective airway
clearance, and proper positioning
Monitoring fluid status, vital signs, and oxygenation parameters

Maintaining a clean environment, and assisting patient with
airway clearance by encouraging coughing or by suctioning
Provide early vaccination.
Assess for potential for aspiration.
Pneumonia: Intervention
53
53
Achievement of expected outcomes, return of sputum to
preinfection color and consistency, and return to baseline
respiratory status
Monitor patient for adequate hydration by assessing vital signs,
body weight, and tissue turgor.
Monitor patient’s lungs for adventitious lung sounds and use of
accessory muscles of respiration.
Pneumonia: Evaluation
54
History of foreign travel is imperative to determine if he or she
had exposure or close contact within 10 days of symptoms with
a person known to have or suspected of having SARS.
Signs and symptoms: temperature over 100.4°F, coughing,
shortness of breath, dyspnea, or hypoxemia
Treatment is usually supportive.
Severe Acute Respiratory
Syndrome (SARS)
55

Most common form of PE caused by the increased capillary
hydrostatic pressure that results from myocardial infarction,
mitral stenosis, decreased myocardial contractility, left
ventricular failure, or a fluid overload
Acute cardiogenic PE presentation: acute shortness of breath,
orthopnea, frothy, blood-tinged sputum, cyanosis, diaphoresis,
and tachycardia
Cardiogenic Pulmonary Edema (PE)
56
56
Diagnosis is based on clinical presentation and diagnostic
testing ABG measurements.
Biomarker, B-type natriuretic peptide (pro-BNP) may be drawn
to help provide additional data for cardiogenic vs.
noncardiogenic pulmonary edema.
Hemodynamic measurements reveal decreased cardiac output,
increased pulmonary artery pressure, and right-sided heart
pressure in biventricular failure.
Cardiogenic PE Diagnostic Tests and Procedures
57
Reduce preloading and after loading and correct the underlying
process if possible.
Supplemental oxygen administration
Diuresis and pulmonary/cardiac dilation
Morphine reduces anxiety which reduces oxygen demand.

Peripheral vasodilation
Inotropic support
Cardiogenic PE Treatment
58
Good when symptoms are easily reversed and cardiac
complications are controlled
Cardiac or lung disease increases risk for complications.
Extensive rehabilitation and physical therapy may assist older
adults to return to independent living and baseline ADLs.
Cardiogenic PE Prognosis
59
Pulmonary edema results from a variety of noncardiac causes.
Includes: Adult respiratory distress syndrome (ARDS),
reexpansion pulmonary edema, and neurogenic pulmonary
edema
Other causes include: Posttraumatic head injury, salicylate
toxicity, pulmonary embolus, and opioid overdose
Noncardiogenic PE
60
Diagnosis is based on clinical presentation and diagnostic
testing.
ABG
Biomarker, B-type natriuretic peptide (pro-BNP) helps provide
additional data for cardiogenic vs. noncardiogenic pulmonary
edema.
Hemodynamic measurements

ARDS Diagnostic Tests and Procedures
61
Supplemental oxygen therapy, ventilation support, and
maintenance of hemodynamics
Neuromuscular blocking agents, sedatives, and narcotics
Positive end-expiratory pressure added to mechanical
ventilation to improve oxygenation
Pulmonary artery catheter used to monitor fluid volume status
Fluids and vasopressors may be indicated for maintenance of
adequate blood pressure.
ARDS Treatment
62
Fair to poor with a mortality rate is approximately 30%–60%.
If mechanical ventilation is not required, the prognosis is good
to fair.
ARDS Prognosis
63
Evaluate respiratory and cardiac status
Identify predisposing factors
Assess for signs and symptoms
Can you name at least six nursing diagnoses for PE?
PE: Assessment and Diagnosis
64

64
Maintain ABG values and oxygenation within normal limits
Have a cardiac output within normal values
Verbalize feelings related to the illness
Maintain a patent airway and balanced intake and output
Communicate effectively if receiving mechanical ventilation
Maintain skin integrity
Sustain spontaneous ventilation without mechanical ventilation
Have stable hemodynamics
PE: Planning and Expected Outcomes
65
Daily weights, energy-conserving ADLs, elevation of the feet
and legs, reduction in or elimination of sodium intake, and use
of diuretics
Assess respiratory status
Position patient to facilitate ventilation/perfusion efforts
Discussion about patient’s wishes in regard to high-technology
medical care and advanced directives
Supplemental oxygen, mechanical ventilation, and nursing
measures to promote oxygen balance
PE: Intervention
66

66
Based on improvement in clinical picture, resolution of
symptoms, and prevention of further complications
Monitor vital signs, cardiac function, and oxygenation status for
stability and improvement.
Monitor older adult’s reaction to frightening therapies and
invasive interventions.
Evaluate daily weight and intake and output.
Monitor the patient’s subjective measure of dyspnea.
PE: Evaluation
67
Blockage of pulmonary arteries by a thrombus, fat, or air
embolus from a deep vein thrombosis
Occlusion of lung with a large embolus causes pulmonary
infarction, necrosis of lung tissue.
Clinical presentation: coughing, dyspnea at rest, hypotension,
hypoxia, hemoptysis, tachycardia, anginal or pleuritic chest
pain, decreased PaO2, and S3 or S4 gallop
Pulmonary Emboli
68
Diagnosis based on ventilation/perfusion lung scan (VQ scan) or
pulmonary angiography
ABG measurements
ECG
Chest x-ray
D-dimer

Pulmonary Emboli Diagnostic
Tests and Procedures
69
Heparin is drug of choice.
Thrombolytic therapy in patients with extensive pulmonary
emboli and hemodynamicaly unstable
Long-term with warfarin
Recurrent pulmonary emboli are candidates for Greenfield vena
cava filters.
Prognosis is variable.
Pulmonary Emboli Treatment and Prognosis
70
Identify risk factors.
Clinical signs and symptoms: sudden dyspnea, chest pain,
restlessness, a weak, rapid pulse, tachypnea, and tachycardia
Can you name three nursing diagnoses for pulmonary emboli?
Pulmonary Emboli: Assessment and Diagnosis
71
71

Maintain ABG values within normal limits
Maintain adequate respiratory muscle function
Be able to sustain spontaneous ventilation without mechanical
ventilation
Maintain adequate oxygenation
Have adequate pain control
Maintain adequate cardiac output
Maintain adequate vital signs
Pulmonary Emboli: Planning and Expected Outcomes
72
Monitor tissue oxygen delivery, signs and symptoms of
respiratory failure, laboratory values, hemodynamic parameters,
and respiratory pattern.
Initiate heparin therapy.
Reassure patient and monitor vital signs.
Intravenous fluids and vasopressors if necessary
Monitor for bleeding complications.
Promote mobility as soon as medically possible.
Antiembolic stockings, passive and active ROM
Educate on anticoagulant therapy.
Pulmonary Emboli: Intervention
73
73
Based on successful achievement of expected outcomes
Monitor patient’s response to oxygen therapy, respiratory
support, and effective pain management and relief by using a
pain scale.

Monitor patient for follow-up care with INR blood draws,
dietary restrictions, and medication compliance.
Pulmonary Emboli: Evaluation
74
Disorder of breathing during sleep due to periodic reduction
(hypopnea) or cessation (apnea) of breathing due to an
obstruction of the upper airway
Results in partial awakening with a startle response of snorts
and gasps, which move tongue and soft palate and relieve
obstruction
Can have chronic affects on the cardiovascular system
Cycle of apnea and arousal may occur as many as 200–400
times in 8 hours of sleep.
Obstructive Sleep Apnea
Syndrome (OSAS)
75
Obesity is a dominant risk factor.
Other risk factors include family history, genetic syndrome,
smoking, alcohol use, employment requiring shift rotation or
sleep restrictions, medications, and ethnicity.
OSAS Risk Factors
76
Diagnosis of OSAS is made based on the history and the
objective measurement in tandem with polysomnography (PSG)
in the sleep laboratory.
Sleep study criteria include more than five episodes of
obstructive apnea longer than 10 seconds in duration per hour of

sleep and one or more of the following: frequent arousal from
sleep, bradycardia, tachycardia, and arterial oxygen desaturation
associated with apneic episodes.
OSAS Diagnostic Tests and Procedures
77
Teaching patient to avoid alcohol or sedatives at bedtime,
humidify air, and wear dental device to keep jaw forward;
weight loss should also be encouraged.
Nasal continuous positive airway pressure (CPAP)
Surgical interventions include tracheotomy or
uvulopalatopharyngoplasty.
Weight loss and daily use of nasal CPAP are essential for a
good prognosis.
OSAS Treatment and Prognosis
78
78
Assess for the presence of chronic loud snoring, gasping or
choking episodes during sleep, excessive daytime sleepiness,
automobile or work-related accidents attributed to fatigue, and
personality changes or cognitive difficulties
Clinical signs: obesity, systemic hypertension, nasopharyngeal
narrowing, and, in rare cases, pulmonary hypertension and cor
pulmonale
Can you name three nursing diagnoses for OSAS?
OSAS: Assessment and Diagnosis

79
79
Verbalize a feeling of rest and well-being
Verbalize an improvement in quality of life
Report an absence of sleepy episodes during the day
Have increased ability to concentrate and endurance
Maintain adequate vital sign
Maintain adequate oxygenation and ventilation during sleep
Achieve or maintain appropriate body weight
OSAS: Planning and Expected Outcomes
80
Monitoring patient’s sleep pattern, noting physiologic and
psychologic circumstances that interrupt sleep
Implementing sleep-promoting therapies such as massage,
lifestyle changes, bedtime routines, and use of CPAP
Assist patient with nutrition counseling, weight reduction, and
exercise plans
OSAS: Intervention
81

Based on achievement of expected outcomes and improvement
in patient’s perception of sleep
Evaluate patient’s daytime somnolence and ability to complete
ADLs, note frequency of naps, and monitor for lower extremity
edema, fluid retention, and weight gain.
OSAS: Evaluation
82
The nurse is teaching the patient and his spouse about OSA.
What needs to be included in the teaching? (Select all that
apply.)
Take a mild sedative to help you stay asleep.
Avoid alcohol prior to bedtime.
Use the CPAP machine every night.
Try to lose excess weight.
Try to take a nap every day.
Quick Quiz!
83
ANS: B, C, D
84
Chapter 19
Cardiovascular Function

Cardiovascular disease is the leading cause of death in the
United States and is a major cause of disability.
Risk factors: high cholesterol levels, hypertension, diabetes
mellitus, tobacco use, physical inactivity, obesity, alcohol use,
age, and heredity
Older adults who stay physically fit have twice the work
capacity and a lower amount of body fat than older adults who
are sedentary.
Introduction
2
Heart rate decreases, left ventricular wall thickens, increased
collagen and decreased elastin in heart muscle and vessel walls,
size of left atrium increases, and aortic distensibility and
vascular tone decrease.
Decrease in cardiac output and reserve
S4 heart sound and grade 1 or 2 systolic murmur are common.
3
3
Conduction system
SA node, AV node, and the bundle of His become fibrotic with
age; number of pacemaker cells decreases.
Vessels
Calcification of vessels occurs; elastin in vessel wall decreases;
less sensitive to the baroreceptor regulation of blood pressure.

4
Decreased cardiac output and cardiac reserve decrease older
adult’s response to stress.
During stress or stimulation, heart rate increases more slowly;
once elevated, takes longer to return to the resting rate
Response to Stress and Exercise
5
50% of hospitalizations attributed to coronary heart disease;
conditions such as strokes, hypertension, heart failure,
arrhythmias, valvular conditions, and peripheral vascular
disease account for other cardiovascular diseases.
Common Cardiovascular Problems
6
6
Nonmodifiable:
Age, gender, family history
Modifiable:
Smoking, high blood pressure, high-fat diet, obesity, physical
inactivity, stress
Risk Factors
7

7
Reducing fat content will reduce cholesterol.
Stop smoking
Walking is the best activity for older adults.
Maintain healthy body weight—BMI 18.5–25 kg/m2.
If diabetic monitor for symptoms of CAD
Effectively manage stress
Be aware menopause increases rate of heart disease for women
Lifestyle Changes to Reduce
Risk Factors
8
More than 50% of the population older than age 65 has high
blood pressure.
Normal blood pressure is a SBP less than 120 mmHg and/or
DBP less than 80 mmHg.
Prevention and proper management is necessary to reduce the
risk of cardiovascular, renal, and cerebrovascular diseases.
Primary—family history, age, race, diet, smoking, stress,
alcohol and drug consumption, lack of physical activity, and
hormonal intake
Secondary—caused by underlying disease
Hypertension (HTN)
9
Blood pressure should be lowered gradually, beginning with low
doses of a single agent.
Goal of treatment is a blood pressure less than 120/80 mmHg.

Diuretics
Beta-blockers
Angiotensin-converting enzyme inhibitors
Calcium channel blockers
HTN: Pharmacologic Treatment
10
Unrecognized and untreated: significantly increases the risk of
coronary disease, heart and renal failure, and stroke
Individual pharmacologic and nonpharmacologic treatment
program based on assessment of total cardiovascular risk; the
risk of cardiovascular-related death from stroke and heart attack
can be reduced
HTN Prognosis
11
Symptoms early in disease: vague discomfort, fatigue,
headache, epistaxis, and dizziness
Symptoms in severe disease: throbbing occipital headache,
confusion, vision loss, focal deficits, and coma
Check for heart and kidney involvement
Objective data: blood pressure taken on three separate
occasions, with patient both sitting and standing
Can you name four nursing diagnoses for HTN?
HTN: Assessment and Diagnosis
12
Potential for injury
Need for patient teaching, resulting from new diagnosis of

hypertension, self-care management, and interventions
Poor coping mechanisms, resulting from perceived limitations
of diagnosis
Inadequate nutrition resulting from high fat, caloric, and sodium
intake, and altered taste
12
The patient will demonstrate the following:
Identify personal risk factors
Explain the disease process and its effects on health and well-
being
Incorporate nonpharmacologic treatment measures into daily
living
Verbalize purpose, dose, action, and significant and reportable
side effects
Increase social interaction
Eat a low-fat, low-cholesterol, and reduced-calorie diet
HTN: Planning and Expected Outcomes
13
Teach disease process and therapeutic interventions.
Provide information about disease process, signs and symptoms
of hypertension, treatment regimen, medications, and
monitoring.
Explain importance of low-sodium, high-potassium, low-fat,
reduced-calorie diet
Encourage alcohol restriction, smoking cessation exercise, and
weight loss
HTN: Intervention

14
Determine the patient’s achievement of the expected outcomes.
Patient’s blood pressure should decrease and return to optimum
levels.
Patient should be able to maintain treatment plan without side
effects or complications.
Determine patient’s perception of any change in quality of life.
Accurate documentation of blood pressure, exercise, and dietary
intake
HTN: Evaluation
15
The nurse caring for an older adult notices his blood pressure
reading have been running high. Last check was 188/95. The
nurse questions the patient, and he states he was on a water pill
but didn't like having to go to the bathroom so much so he
stopped taking it. The nurse realized that patient has a
knowledge deficit and needs to begin a teaching session. Which
areas are a priority to include in the nurse’s teaching at this
time?
Quick Quiz!
16
16
Answers will vary but should include disease process, diet,
exercise, and pharmacologic and nonpharmacologic treatments.

17
Atherosclerosis is usual cause; angina, myocardial infarction
(MI), and sudden death may be final outcomes.
Normal process of aging; severity can be accelerated with
smoking, physical inactivity, and obesity, elevated serum
cholesterol levels, hypertension, and diabetes
Symptoms of angina or MI may be vague and atypical due to
neuropathies and changes in pain recognition.
They may seek not medical attention as soon as they should
Unrecognized MI may cause cardiac damage and precipitate
complications of heart failure and pulmonary edema.
Coronary Artery Disease (CAD)
18
12 lead electrocardiogram (ECG)
Cardiac biomarkers/enzymes
Complete blood count (CBC)
Comprehensive metabolic panel
Serum lactate dehydrogenase (LDH)
Chest radiography
Color-flow Doppler transthoracic echocardiography and
coronary angiography
Exercise stress test
CAD: Diagnostic Tests and Procedures
19
Directed toward restoring balance between myocardial oxygen
demand and oxygen supply

Nitrates
Beta-blockers
Calcium channel blockers
Fibrinolytics, anticoagulants, and antiplatelets
Lipid lowering drugs
CAD: Pharmacologic Treatment
20
Percutaneous transluminal coronary angioplasty (PTCA)
Coronary artery bypass graft (CABG) surgery
Age-related physiologic changes, longstanding unhealthy
lifestyles, and chronic conditions in older adults may
complicate the progress and treatment of CAD, but adopting
healthy lifestyle can influence outcomes.
CAD: Nonpharmacologic
Treatment and Prognosis
21
CAD is leading cause of death in women.
Smaller coronary arteries that occlude easier
They experience atypical symptoms: epigastric pain and
shortness of breath
Do not receive the same standard of emergency coronary care as
men
Have poorer outcomes
CAD in Women
22

Complete health history and physical examination
Complaints of dyspnea, fatigue, syncope, vertigo, and confusion
warrant further investigation
Can you name five nursing diagnoses for CAD?
CAD: Assessment and Diagnosis
23
Chest discomfort, resulting from an imbalance between oxygen
need and supply
Ineffective cardiac output, resulting from decreased pumping
ability of the heart
Decreased activity level, resulting from decreased cardiac
output
Potential for nonadherence
Anxiety, resulting from fear of death
23
Verbalize pain relief
Maintain adequate circulation
Tolerate activity
Explain the disease process and therapeutic plan
Describe actions to take in the event of chest pain
Express fears and have reduced anxiety
CAD: Planning and Expected Outcomes
24
24

Focus on relieving pain, improving myocardial blood flow,
decreasing myocardial workload, and educating the patient.
System assessments should be conducted on a regular basis to
detect progress and prevent complications.
Encourage participation in cardiac rehabilitation programs.
Discuss resumption of sexual activity.
CAD: Intervention
25
25
Evaluation and documentation of progress of an older patient
with CAD focus on the achievement of goals outlined in the
planning process
CAD: Evaluation
26
Atrial fibrillation, sick sinus syndrome, and heart block occur
more often in the older population.
Atrial fibrillation is the most common contributing factor for
ischemic stroke.
Sick sinus syndrome is alternating episodes of bradycardia (<60
beats/min), normal sinus rhythm (60–100 beats/min),
tachycardia (>100 beats/min), and periods of long sinus pauses.
Heart block is delayed or blocked impulses between the atria
and ventricles and is classified as first-, second-, or third-
degree heart block.

Arrhythmia
27
27
Diagnosed by ECG
Holter monitor
Patient-activated event recorder
Test to determine cause after arrhythmia is diagnosed
Arrhythmia: Diagnostic Tests and Procedures
28
Control the underlying cause, slow the heart rate and/or
converting the rhythm to a normal sinus rhythm, and preventing
stroke
Drugs for rate control: beta-blockers and calcium channel
blockers
Oral anticoagulants are prescribed to reduce risk of
thromboembolic events.
Elective cardioversion is appropriate for acute atrial fibrillation.
Atrial Fibrillation Treatment
29
Treatment of sick sinus syndrome is permanent Pacemaker.
Treatment for first-degree heart block includes correction of the
causative factor (e.g., electrolyte imbalance or drug toxicity).
Permanent cardiac pacemaker for symptomatic second- and
third-degree blocks

When corrected arrhythmias have an excellent prognosis
A-Fib has an increased risk for ischemic stroke.
Sick Sinus Syndrome and Heart Block Treatment and
Arrhythmia Prognosis
30
History of CAD, heart failure, hypertension, cardiac valve
disease, and current medications
Symptoms: confusion, palpitations, and dizziness, SOB, chest
pain and syncope
Objective data: LOC, orientation, HR and rhythm, BP,
peripheral pulses, and urine output
Laboratory values: electrolytes, hemoglobin, and hematocrit
Can you name four nursing diagnoses?
Arrhythmia: Assessment and Diagnosis
31
Reduced cardiac perfusion, resulting from altered heart rate and
rhythm
Reduced physical stamina, resulting from altered heart rate and
cardiac output
Potential for injury, resulting from potential thrombus and
emboli formation
Potential for nonadherence, resulting from lack of information
about disease process, drugs, and treatment plan
31
Maintain an adequate cardiac output.
Tolerate activity.
Remain free from injury.

Verbalize knowledge about his or her diagnosis, treatment plan,
and health maintenance behaviors.
Arrhythmia: Planning and Expected Outcomes
32
32
Monitor vital signs, heart rate, and rhythm.
Encourage patient to promptly report symptoms.
Assess cardiovascular, respiratory, and neurologic systems, as
well as intake and output.
Assist patients to identify of factors that increase or decrease
activity tolerance.
Prevent injury.
Consult home health agency.
Encourage patient to wear medical-alert bracelet.
Arrhythmia: Intervention
33
33
Patient should maintain a cardiac rhythm that supports adequate
cardiac output.
Older adult’s readiness for independence is defined by their
ability to resume ADLs, knowledge of the therapeutic plan, and
achievement of expected outcomes.
Documentation: patient’s response to treatment plan and how
well symptoms are controlled
Arrhythmia: Evaluation

34
34
A 78-year-old is admitted to the telemetry unit with congestive
heart failure (CHF). Hx: HTN, chronic mitral valve
regurgitation. Meds: Lasix 80 mg QID, Dioxin 0.125 mg daily,
Cardizem 60 mg TID. Initial assessment: pulse rate rapid and
very irregular, patient is restless, skin is pale and cool, she is
dizzy when she stands up and is slightly SOB. Blood pressure
(BP) 106/88, cardiac monitor shows atrial fibrillation rate
ranging from 150 to 170 bpm; Pox is 90%.
1. What should you do first?
2. What other assessments would you perform?
3. What possible treatment will be ordered for this patient?
Quick Quiz!
35
35
1. What should you do first?
Oxygen, obtain VS call rapid response or HC provided give
medications if due
2. What other assessments would you perform?
LOC, neurocheck, cardiovasc, resp, and I&O
3. What possible treatment will be ordered for this patient?
Beta-blockers, calcium channel blockers, elective cardioversion,
and anticoagulant therapy

36
Later that evening, the patient calls the nurse and states that she
feels something terrible is going to happen. The patient c/o SOB
and has coughed up bloody sputum.
1. What do you suspect is happening?
2. What is the first action you need to take?
3. What other assessments should you perform at this time?
Quick Quiz!
37
37
1. What do you suspect is happening?
P.E.
2. What is the first action you need to take?
Call rapid response provide oxygen, obtain VS elevate HOB.
3. What other assessments should you perform at this time?
Neuro, respiratory
38
Major risk factor for syncope and falls
Dizziness with position changes, results from decreased
sensitivity of baroreceptors
Defined: decrease of 20 mmHg or greater in systolic blood
pressure, or a decrease of 10 mmHg or greater in diastolic blood
pressure, on standing

Risk factors: autonomic dysfunction, low cardiac output, and
hypovolemia; use of sedatives, antihypertensives, vasodilators,
and antidepressants; increase in sedentary activity
Orthostatic Hypotension
39
Complete health history and physical examination
Investigate reports of syncope, falls, and near falls in relation to
medications, meals, and environmental factors.
Evaluate hydration status along with a CBC and serum glucose
level.
Check orthostatic blood pressure.
Review all prescribed and OTC medication for those known to
cause hypotension.
Orthostatic Hypotension: Assessment
40
Remain free of injury
Verbalize and correctly demonstrate measures to prevent
symptoms of orthostatic hypotension
Verbalize fears and identify coping measures
Can you name three nursing diagnoses?
Orthostatic Hypotension: Diagnosis, Planning, and Expected
Outcomes
41
Potential for reduced cardiac perfusion

Need for health teaching, resulting from positional
hemodynamic changes and risk for falls
41
Teach how to change positions slowly.
Exercise lower legs and ankles.
Work with patient and physician to eliminate unnecessary
medications.
Encourage patient to limit alcohol intake, avoid large meals,
and monitor and control diabetes.
Provide education on environmental safety.
Safe performance of ADLs and document trends in BP.
Orthostatic Hypotension: Intervention and Evaluation
42
42
Syncope is a transient loss of consciousness, usually related to
decreased cerebral perfusion, with spontaneous recovery.
Most frequent cardiovascular causes of syncope—cardiac
arrhythmias, sick sinus syndrome, atrioventricular block, aortic
stenosis, cardiomyopathy, acute myocardial cell death, and
orthostatic hypotension.
Syncope With Cardiac Causes
43
43

Complete history and physical examination
Obtain information from witnesses to syncopal episode.
12-lead ECG
Auscultate carotid arteries for bruits
CBC, complete chemistry panel, and glucose levels
Can you name three nursing diagnoses for syncope?
Syncope: Assessment and Diagnosis
44
Reduced cardiac output, resulting from inadequate left
ventricular filling, arrhythmia, or orthostasis
Anxiety, resulting from near or full loss of consciousness
44
Regain a normal range of cardiac output as demonstrated by
stable vital signs and alert and oriented sensorium.
Verbalize understanding of the cause of syncope and the
therapeutic treatment plan.
Syncope: Planning and Expected Outcomes
45
45
Emergency measures to correct life-threatening arrhythmias
when needed
Administer oxygen and monitor O2 saturation.

Assist in the identification of causes of syncope.
Implement measures to avoid constipation.
Instruct to lie down if dizzy or symptomatic.
Positive change in the clinical picture with identification of
causes and prevention methods
Syncope: Intervention and Evaluation
46
46
Cardiac valves do not completely open or close.
Most common in mitral and aortic valves
Stenosis of mitral valve impedes blood flow from left atrium to
ventricle during diastole.
Mitral regurgitation allows ejected blood to flow back into left
atrium from ventricle during systole
Stenosis of aortic valve obstructs blood flow from left ventricle
to aortic arch during systole.
Aortic regurgitation allows ejected blood to flow back into left
ventricle from the aorta during diastole.
Valvular Disease
47
47
CXR and ECG
ECG with doppler and ultrasonography
Cardiac catheterization
Exercise tests

Valvular Disease Diagnostic
Tests and Procedures
48
Manage presenting symptoms and correct the cause.
Treat heart failure and A-fib if present.
Prophylactic antibiotics before invasive procedures
Surgical repair or replacement may be necessary.
Mortality and morbidity rates higher for those requiring valve
surgery but surgery has increased quality of life
Valvular Disease
Treatment and Prognosis
49
49
History of prior infections, family history of cardiac disease,
current medications
Symptoms
Cardiac and respiratory system
Auscultation
Can you name four nursing diagnoses for valvular disease?
Valvular Disease: Assessment and Diagnosis
50
Reduced cardiac output, secondary to altered blood flow
through the heart

Reduced activity level, secondary to decreased cardiac output
Anxiety, secondary to new diagnosis, treatment plan, and
uncertain outcome
Inadequate knowledge, secondary to lack of previous exposure
to information about the disease process, drugs, and treatment
plan
50
Maintain adequate cardiac output
Tolerate a usual level of daily activity
Experience reduced anxiety
Correctly explain the disease process, therapeutic plan, and
preventive precautions
Valvular Disease: Planning and Expected Outcomes
51
51
Cardiovascular and respiratory assessments
Monitor patients for therapeutic and adverse reactions to
medications prescribed.
Monitor VS, heart and breath sounds, and cardiac rhythm.
Ensure patient maintains bed rest when ordered and performs
range-of-motion exercises.
Elevate head of bed.
Administer oxygen as prescribed.
Valvular Disease: Intervention (1 of 3)

52
Assess a patient’s activity level and balance activity with rest
periods.
Teach patient to rise slowly and stay in a sitting position for a
few minutes before standing.
Encourage use of secure footwear and handrails for support.
Review disease process and treatment plan.
Review low-sodium diet and bleeding precautions.
Antibiotics for invasive procedures
53
53
If scheduled for valvular surgery, pre- and postoperative
education provided to patient and family
After surgery, monitor closely for complications
Exercise and ADLs should be gradually resumed during the first
6 weeks of recovery.
Signs, symptoms, and complications of valvular disease should
be reviewed with patient.
54
Should demonstrate adequate cardiac output, ability to perform
ADLs within limitations, and control of symptoms
Documentation should accurately reflect care delivered in
preoperative and postoperative periods.

Document of progress toward self-care and degree of functional
ability
Valvular Disease: Evaluation
55
Leading cause of hospitalization in the older adult population
Classification: The ACCF/AHA stages of heart failure
determine the presence of and severity of failure, the New York
Heart Association (NYHA) functional classification focuses on
symptomatology and exercise capability
Common risk factors include coronary heart disease,
hypertension, diabetes mellitus, obesity, and smoking.
Heart Failure
56
56
12-lead ECG
B-type natriuretic peptide, CBC, urinalysis, serum electrolytes,
kidney function, thyroid panel, and lipid panel
Chest x-ray
Echocardiogram
Heart Failure Diagnostic Tests and Procedures
57
Control of precipitating factors
Pharmacologic therapy
Low-sodium diet

Restriction of fluids
Appropriate rest and exercise
Pharmacological therapy
Nonpharmacological therapy
Heart Failure Treatment
58
Systolic heart failure:
Diuretics, ACEIs, beta-blockers, aldosterone antagonists,
digoxin, anticoagulants, sympathomimetics
Diastolic heart failure:
Calcium channel blockers, ACEIs, ARBs, beta-blockers or dig
for rate control, diuretics
Poor prognosis with higher mortality for systolic heart failure,
80 years and older: mortality at 5 years is roughly 50%
Heart Failure Specific Treatment and Prognosis
59
59
History of CAD, rheumatic heart disease, hypertension, cardiac
valve disease, infection, and current medications
BP, pitting edema, jugular venous distension, heart and lung
sounds
Orthopnea, fatigue at rest, paroxysmal nocturnal dyspnea, and
nocturnal urination
Determine how symptoms have affected ADLs
Can you name eight nursing diagnoses for heart failure?
Heart Failure: Assessment and Diagnosis

60
Reduced cardiac output resulting from decreased cardiac
contractility
Altered gas exchange resulting from pulmonary venous
congestion
Increased fluid volume resulting from increased sodium and
water reabsorption
Anxiety resulting from perceived threat to self
Reduced stamina resulting from decreased cardiac output
Decreased ability to cope resulting from knowledge deficit and
fear of uncertain outcome
Altered sleep pattern resulting from nocturnal dyspnea and
nocturnal urination
Need for health teaching resulting from lack of previous
exposure to disease process, drugs, and treatment plan
60
Maximize cardiac output
Improved gas exchange
Reduced dependent edema and abdominal girth
Experience less anxiety
Restoration of activity level
Adequate sleeping pattern
Adequate knowledge
Heart Failure: Planning and Expected Outcomes
61
61

Assess BP, apical pulse, heart rate, heart and lung sounds, and
peripheral edema
Monitor intake and output, daily weights, and electrolytes
Increase the patient’s activity according to tolerance position
Instruct on diet, fluids, and diuretics
Instruct to report a weight gain of 3 lb in 48 hours
Referral to home health agency
Heart Failure: Intervention
62
62
Improved ventricular function
Increased activity levels without experiencing dyspnea and
return to usual ADLs
Document trends
Heart Failure: Evaluation
63
The nurse is preparing an older adult for discharge after
treatment for congestive heart failure. The nurse is sure to
include which of the following instructions? (Select all that
apply.)
Resume all usual activity as before admission.
Take diuretic with dinner every night.
Take blood pressure and heart rate daily.
Notify health care provider of a weight gain of 3 lbs in 48
hours.
Take digoxin in the morning with breakfast.

Maintain a low sodium diet.
Quick Quiz!
64
64
ANS: C, D, F
65
Associated with significant morbidity and mortality; if left
untreated, can be life-threatening
Symptoms appear when the artery is unable to supply the tissues
with adequate oxygenated blood flow.
Intermittent claudication (muscle ischemia) is one of the initial
symptoms of atherosclerosis obliterans.
Foot appears pale when elevated and dusky red in dependent
positions.
Can result in dry skin, thickened toenails, loss of pedal hair,
cool skin, and painful arterial ulcers
Advanced stages of ischemia lead to necrosis, ulceration, and
gangrene of the toes.
Peripheral Artery Disease (PAD)
66
66

Tests and procedures
Doppler ultrasound (Duplex), angiography
Treatment
Lifestyle modifications, pharmacotherapy, percutaneous
transluminal angioplasty, thromboendarterectomy,
revascularization, amputation
Lifestyle changes can prevent or halt the progression of PAD
but if ineffective, pharmacological therapy or surgical
intervention may be necessary.
PAD Diagnostic Procedures, Treatment, and Prognosis
67
Subjective and objective data
Can you name four nursing diagnoses for PAD?
PAD: Assessment and Diagnosis
68
Decreased peripheral tissue perfusion, resulting from decreased
arterial blood flow
Decreased activities of daily living, resulting from an imbalance
between tissue need and blood supply
Potential for skin integrity issues
Inadequate knowledge, resulting from lack of previous exposure
to disease process, drug, and treatment plan
68
Manifest reduced signs and symptoms of arterial insufficiency
Successfully participate in activities within limits imposed by
the disease
Demonstrate protective behavior and self-care measures to

prevent injury to the skin
Correctly describe the disease process and treatment plan
The patient will identify personal risk factors and methods to
reduce these factors.
PAD: Planning and Expected Outcomes
69
Initiate a graduated, regular exercise program
Encourage patients to balance activities with rest
Educate patient to prevent injuries
Focuses on achievement of expected outcomes
PAD: Intervention and Evaluation
70
Common disorders: varicose veins, venous ulceration, and deep
vein thrombosis
Primary varicose veins can lead to venous ulcers.
Secondary varicose veins result from deep vein thrombosis.
Chronic Venous Insufficiency (CVI)
71
Tests and procedures:
Doppler ultrasound, plethysmography, venous duplex
ultrasonography, contrast venography
Laboratory work: platelet count, prothrombin time, PTTs, aPT,
INR, D-dimer, and chemistry
Treatment:
Palliative measures to ease symptoms, pharmacologic therapy,

surgical strategies
CVI: Diagnostic Tests and Treatment
72
Subjective data: pain in extremity, precipitating factors,
relieving factors, modifiable risk factors, and personal and
family history
Objective data: skin color, hair distribution, atrophy, edema,
varicosities, petechiae, lesions, and ulcerations
Can you name three nursing diagnoses for CVI?
CVI: Assessment and Diagnosis
73
Potential for skin integrity issues resulting from venous stasis
Decreased peripheral tissue perfusion resulting from
interruption of venous flow
Pain resulting from inflammatory processes
73
Skin integrity will be maintained or improved.
The patient will exhibit no ulceration or signs of the
inflammatory process.
Tissue perfusion will be improved, as evidenced by decreased
edema and fewer complaints of discomfort.
CVI: Planning and Expected Outcomes
74

Assessment of skin integrity
Doppler sensor if pulses seem absent
Elevate affected extremity
Demonstrate application and removal of elastic compression
stockings
Prevent hazards of immobility
Instruction on foot care
Progress in maintaining skin integrity, improving venous
circulation, and reducing pain and discomfort
CVI: Intervention and Evaluation
75
75
Over 20% of older adults over the age of 85 have anemia.
Usually insidious in nature and an incidental finding on
hematological studies
Common causes: iron deficiency anemia, anemia of chronic
disease, and anemia related to CKD
Anemia
76
History and physical
CBC with differential and peripheral smear
Reticulocyte count
Lactate dehydrogenase level
Serum ferritin
Serum iron
Total iron-binding capacity

Anemia Diagnostic Tests and Procedures (1 of 2)
77
Anemia Diagnostic Tests and Procedures (2 of 2)
Vitamin B12
Folate
TSH
Serum chemistry with eGFR
78
Iron deficiency anemia
Stool for occult blood
Treatment includes dietary sources of iron and supplemental
intake of iron, if no response to oral replacement, IV iron
should be tried.
Anemia of chronic disease
C-reactive protein, fibrinogen, erythrocyte sedimentation rate,
IL6, and hepcidin levels
Treatment focuses on the underlying disease.
Administration of an erythropoiesis stimulating agent
Additional Diagnostic Tests, Procedures, and Treatment (1 of 2)
79
Folate deficiency
Homocysteine levels
Treatment: increased dietary intake (e.g., citrus fruits and dark
green vegetables) of folic acid; older adults with alcoholism
usually require exogenous folic acid

Pernicious anemia
Serum B12 level, methylmalonic acid level
Treatment: vitamin B12 given oral, nasal, or injection
Additional Diagnostic Tests, Procedures, and Treatment (2 of 2)
80
Depends on cause
With medications and dietary changes, prognosis usually good
Anemia Prognosis
81
Focuses on underlying cause and its effects on functional ability
Can you name three nursing diagnoses for anemia?
Anemia: Assessment and Diagnosis
82
Decreased activity resulting from an imbalance between oxygen
supply and demand
Inadequate nutrition resulting from malabsorption or decreased
intake of vitamins, minerals, and nutritious foods
Need for patient teaching resulting from lack of exposure to
information about condition and treatment plan
82
Experience increases in activity without dyspnea.
Consume a well-balanced diet with foods high in minerals and

vitamins.
Verbalize an understanding of the cause of anemia and the
treatment plan.
Anemia: Planning and
Expected Outcomes
83
83
Instruct on diet and food selection.
Monitor for side effects of medications.
Assess income for food purchases.
Instruct on maintaining activity and rest balance.
Patient should have fewer complaints of dyspnea, fatigue, and
dizziness, and weight should be within the established norm.
Normal values of hemoglobin, hematocrit, and RBC count
indicate success of interventions.
Anemia: Intervention and Evaluation
84
Chapter 17
Integumentary Function
Is to serve as barrier against harmful bacteria and other
threatening agents; skin is the first line of defense for the
immune system

Prevents fluid loss or dehydration
Protects the body from ultraviolet (UV) rays and other external
environmental hazards
Protects underlying organs from injury
Provides thermal regulation of body temperature
Primary Function of Skin
2
Replacement rate of first layer of epidermis declines by 50% as
person ages.
Area of contact between epidermis and dermis decreases with
age.
Is thinner
Number of melanocytes decreases with age.
Age spots
Age-Related Changes in Epidermis
3
Decreases in thickness by approximately 20%
Number of sweat glands, blood vessels, and nerve endings
decreases.
Collagen stiffens and becomes less soluble.
Decreased amount of subcutaneous tissue and a redistribution of
fat to abdomen and thighs
Breast tissue becomes more granular and atrophic.
Age-Related Changes in the Dermis and Subcutaneous Fat
4
Fewer eccrine glands and apocrine sweat glands exist.
Sebaceous glands and pores become larger.

Hair thins, and its growth declines with progressive loss of
melanin.
Changes in the patterns of hair growth and distribution
Nails grow more slowly and become thicker, brittle, dull and
develop longitudinal striation with ridges.
Age-Related Changes in Dermal Appendages
5
Common, bright red, 1–5-mm superficial vascular lesions that
increase in number with age
Cause of lesions unknown
Most commonly found on trunk, but can be located anywhere on
body and vary in number
Benign growths
Cherry Angiomas
6
Benign, scaly growths with “stuck-on,” crumbly appearance;
varies in color from tan to brown to black; elevated and range in
diameter from 2 to 3 mm
Characterized by slow growth
Borders may be round and smooth or irregular and notched.
Have greasy feeling and often occur in sun-exposed areas but
can appear anywhere on body
Seborrheic Keratoses
7
Common stalklike, benign tumors often found on neck, axilla,

eyelids, and groin, although can be located anywhere on body.
Tiny, flesh-colored or brown excrescences that develop into a
long, narrow stalk (up to 1 cm)
As they mature, can be easily removed with scissors,
electrocautery, or liquid nitrogen
Skin Tags (Acrochordons)
8
Chronic inflammation of skin
Common sites: scalp, ear canals, eyebrows, eyelashes,
nasolabial folds, axilla, breasts, chest, and groin area
Appears as a white or yellow scale with a plaquelike appearance
Usual pattern of distribution begins with the scalp and moves
down toward the eyebrows, progressing to the chest with a
bilateral, symmetric presentation
Inflammatory Dermatoses:
Seborrheic Dermatitis
9
Results from friction of opposing skin surfaces and the
irritation this causes
Usually found in armpits, inner aspects of thighs, skin folds of
breasts, and abdominal folds
Area is erythematous and may itch.
Antimicrobial agent (antifungal or antibacterial), low potency
topical steroid and keeping the skin clean and dry
Intertrigo
10

Autoimmune condition
Associated with cardiovascular disease, metabolic syndrome,
hypertension, dyslipidemia, and Crohn’s disease
Genetic component
Periods of remission and relapse with varying degrees of
intensity
Well-circumscribed, pink plaques covered with silver-white,
loosely adherent scales
Affects skin of elbows, knees, scalp, lumbosacral areas,
intergluteal cleft, and glans penis
Psoriasis
11
11
Recognizing inflammatory dermatitis and noting location,
degree of erythema, itching, and scaling
Can you name four nursing diagnoses for inflammatory
dermatoses?
Inflammatory Dermatoses Nursing Management: Assessment
and Diagnosis
12
Reduced skin integrity, resulting from immunologic deficit
(psoriasis)
Reduced skin integrity, resulting from bedbound state

(seborrheic dermatitis)
Reduced skin integrity, resulting from the physiologic disease
process (intertrigo)
Distorted body image, resulting from the psoriatic lesions
12
Have skin lesions free from infection
Experience resolution of the inflammatory process
Verbalizing the rationale for regular and consistent skin care
Verbalizing knowledge of maintenance therapy
Verbalizing triggers to inflammatory dermatitis
Correctly demonstrating application of topical medications
Inflammatory Dermatoses Nursing Management: Planning and
Expected Outcomes
13
Ensure proper use of medications to treat inflammatory
dermatoses
Teach patient and family the correct way to apply the prescribed
treatments
Explain that treatment measures and importance of follow-
through will increase compliance and involvement in care
Symptom management is an area where nurses can have positive
effect on older adult’s quality of life.
Inflammatory Dermatoses Nursing Management: Intervention
14
Accurate, comprehensive charting describing physical

assessment and maintenance interventions
Response to teaching as measured by patient and family
compliance with treatment
Inflammatory Dermatoses Nursing Management: Evaluation
15
The nurse caring for an older adult patient notices a scaly well-
prescribed pink plaque covered with silver white area on the
patient’s elbow. What does the nurse tell the patient?
“This area needs to be checked for basal cell carcinoma.”
“Daily application of an antiseborrheic shampoo will help.”
“Continue the treatment plan provided by your physician.”
“This skin lesion is caused by the chickenpox virus.”
Quick Quiz!
16
ANS: C
17
Term for itching so intense it causes the patient to scratch
Most common cause is dry skin.
Can be precipitated by heat, sudden temperature changes,
sweating, clothing, cleaning products such as soap, fatigue, and
emotional stress; can be more severe in winter
Can be related either skin disorder or systemic disease
Pruritus

18
Full skin assessment warranted when patient complains of
pruritus
Inquire about patterns of behavior that precipitate itching and
obtain information about bathing practices and kinds of soaps,
detergents, and skin products used
Assess for rashes, vesicles, scaling, and erythema
Can you name four nursing diagnoses for pruritus?
Pruritus Nursing Management: Assessment and Diagnosis
19
Potential for reduced skin integrity, resulting from scratching
Pain, resulting from persistent burning and itching
Anxiety, resulting from role strain, family crisis, or other
sources of patient’s anxiety
Potential for infection, resulting from impaired skin integrity
19
Have intact skin
Experience adequate periods of rest without symptoms of
scratching
Obtain adequate pain relief, as evidenced by verbalization of
comfort and pain relief
Pruritus Nursing Management: Planning and Expected
Outcomes
20

Influenced by cause of pruritus
Teach management of pruritus and need to prevent skin trauma
from scratching
Explain treatment measures to increase compliance and
involvement in care
Pruritus Nursing Management: Intervention
21
Focuses on symptom relief, prevention of secondary
complications, and, when possible, identification of source of
pruritus
Documentation of physical presentation, response to treatment
measures, patient comprehension of teaching, and other nursing
interventions
Pruritus Nursing Management: Evaluation
22
Inflammatory process of epidermis caused by yeastlike fungus
Candida albicans
Normally occurring flora in mouth, vagina, and gut
Antibiotics, diabetes, topical and inhalant steroids, skin
maceration, and immunocompromised conditions create
environment that fosters development of yeast infections.
Erythematous, denuded, or raw skin usually surrounded by
satellite papules or pustules
Candidiasis
23

Inspect skin particularly under any fat folds, where moisture
will accumulate.
Conduct medication assessment to identify medications that
may have precipitated fungal infection.
Conduct diet assessment if patient is diabetic to evaluate
compliance and check blood sugar level.
Can you name three nursing diagnoses for candidiasis?
Candidiasis Nursing Management:
Assessment and Diagnosis
24
Reduced skin integrity, resulting from poor control of moisture
Inadequate toileting self-care
Inadequate urinary elimination
24
Have skin lesions that are healing without evidence of infection
Perform self-care practices (within limitations) for keeping the
skin dry and clean
Have skin that has regained its usual appearance without
evidence of candidiasis
Planning and Expected Outcomes
25
Keep skin dry.
Cleanse and dry skin well, and apply a zinc-based cream to
buttocks and perineal area.
Promptly delivery of care after incontinent events.

Evaluate for positive outcomes, adherence with preventive
actions, and verbalized comprehension.
Document how infection responds to medical treatment and
maintenance therapy of keeping skin dry and applying moisture
barrier.
Intervention and Evaluation
26
Caused by reactivation of latent varicella zoster virus
Main reason for recurrence is immune system deficiency caused
by advanced age, stress or emotional upset, fatigue, or
radiotherapy, immunocompromised state caused by disease or
drugs
May spread through direct contact with open sores
Often has prodromal symptoms of tingling, hyperesthesia,
tenderness, and burning or itching pain along affected
dermatome
Herpes Zoster (Shingles)
27
Prodromal symptoms followed by vesicles with erythematous
base occurring within 3–5 days
Unilateral, bandlike, erythematous, maculopapular rash first
occurs along involved dermatome and rarely crosses midline of
body.
Rash develops into clustered vesicles that become purulent,
rupture, and crust.
Affects thoracic region 50%, cranial dermatomes 15%, and
cervical and lumbar regions 10%

Major complication: postherpetic neuralgia
Shingles Clinical Manifestation
28
28
Interview patient to identify prodromal symptoms
Obtain pertinent health history
Identify at risk persons whom the patient has had close physical
contact who have not had chickenpox or the chickenpox vaccine
On basis of lesions and prescribed treatments, must determine
effect on patient’s mobility and capacity for activities of daily
living (ADLs)
Can you name five nursing diagnoses for shingles?
Shingles Nursing Management: Assessment and Diagnosis
29
Reduced skin integrity, resulting from immunologic deficit
Potential for infection, resulting from impaired skin integrity
Disrupted sleep pattern, resulting from impaired skin integrity
or pain
Pain, resulting from inadequate pain relief from analgesia
Need for health teaching, resulting from lack of previous
exposure to disease process and treatment
29
Have skin lesions will remain free from necrotic tissue and
infection

Experience adequate periods of restful sleep
Obtain adequate pain relief
Demonstrate increased knowledge of his or her condition
Shingles Nursing Management: Planning and Expected
Outcomes
30
Follow through with medical and nursing management
Monitor closely for development of secondary bacterial
infections
Teach cause of shingles so anxiety and misconceptions can be
alleviated, and explain treatment measures to increase
compliance and involvement in care
Promptly administer pain medications
Use antidepressants as adjuncts to analgesics if postherpetic
neuralgia occurs
Shingles Nursing Management: Intervention
31
Focuses on pain control, with documented results of analgesics
and adjunct therapies, and on prevention of secondary infection
by frequent monitoring of site
Documentation of assessment, response to treatment measures,
patient comprehension of teaching, and other nursing
interventions demonstrate nursing accountability.
Shingles Nursing Management: Evaluation
32
Premalignant lesion of epidermis caused by long-term exposure

to UV rays
Most common on dorsum of hands, scalp, outer ears, face, and
lower arms
Begins as reddish macule or papule that has rough, yellowish
brown scale that may itch or cause discomfort
Induration, inflammation, or oozing may indicate malignancy
and merit prompt referral.
Actinic Keratosis
33
Interview to determine risk factors
Inspect skin for any rough lesions or erythematous macule or
papule
Explain value of treating skin cancer early
Can you name three nursing diagnoses for actinic keratosis?
Actinic Keratosis Nursing Management: Assessment and
Diagnosis
34
Reduced skin integrity, resulting from removal of a lesion
Potential for infection, resulting from a break in skin integrity
Distorted body image, resulting from disfigurement and scarring
resulting from removal of lesion
34
Have healing on the site of lesion removal without evidence of
secondary infection
Demonstrate no changes in body image perception
Demonstrate behavior change through adoption of preventive

skin care practices
Actinic Keratosis Nursing Management: Planning and Expected
Outcomes
35
Reinforce treatment regimen with patient and family
Monitor treated site to prevent secondary infection, providing
support, and teaching preventive strategies
Lower patient’s anxiety and assist with body image changes by
explaining treatment
Encourage sunscreen with a sun protection factor (SPF) of at
least 15
Actinic Keratosis Nursing Management: Intervention
36
Documentation addressing treatment progress, including
physical description, patient comprehension of educational
information, and identification of and coping with body image
disturbances
Actinic Keratosis Nursing Management: Evaluation
37
Most common skin cancer more prevalent in fair-skinned,
blond, or red-headed individuals with extensive previous sun
exposure
Most commonly found on face and scalp
Usually does not metastasize, but if left untreated, may
metastasize to bone, lungs, and brain
Pearly papule with depression in center, giving lesion a

doughnut-shaped appearance with telangiectasia on or around
lesion
Basal Cell Carcinoma
38
38
Cancer arising from epidermis and found most often on scalp,
outer ears, lower lip, and dorsum of hands
Can also develop in chronic leg ulcers or open fractures and has
20% incidence of metastasis
Etiologic factors can be UV rays, chemical carcinogens, and x-
rays.
Squamous Cell Carcinoma
39
Usually presents as a firm, elevated lump
It may have a thick, adherent scale with a center that is often
ulcerated or crusted
May even look like a wart
The base may be inflamed and red and usually bleeds easily.
Squamous Cell Carcinoma
Clinical Manifestations
40
Malignant neoplasm of pigment-forming cells capable of
metastasizing to any organ of body, even before lesion is noted
If detected and treated before spreading to the lymph nodes,
there is a 99% five-year survival rate.

Ninety-five percent of melanomas can be attributed to UV
exposure.
Genetic predisposition—10% of patients have parent or sibling
with history of melanoma
Fair skinned, red or blond hair, have multiple nevi, and have a
tendency to freckle.
Melanoma
41
Clinical hallmark: irregularly shaped nevus, papule, or plaque
that has undergone a change, particularly in color
Characteristic signs of majority of malignant melanomas
referred to as the ABCDs:
Asymmetry, border irregularity, color variation (red, white,
blue), diameter greater than 6 mm
Some clinicians now include E: evolution, elevation
Melanoma Clinical Manifestations
42
Lentigo maligna occurs most often in the elderly, is a brown-tan
macular lesion with varied pigmentation and highly irregular
borders
Acral lentiginous melanoma usually occurs on the palms of
hands and soles of feet, as well as under finger/toe, most
common melanoma found in blacks and Asians.
Melanoma
43
Determine how long lesion has been present
Identify risk factors such as chronic sun exposure and family

history
Inspect and palpate suspicious lesion, surrounding tissue, and
lymph nodes
Explain that early treatment lessens the extent of scarring and
possibly metastasis
Discuss patient’s feelings and fears about cancer
Can you name four nursing diagnoses for skin cancer?
Melanoma Nursing Management: Assessment and Diagnosis
44
Reduced skin integrity, resulting from removal of a cancerous
lesion
Fear of cancer, pain, or death, resulting from having a
cancerous skin lesion
Potential for infection, resulting from a break in skin integrity
and a surgical wound
Distorted body image, resulting from disfigurement and scarring
resulting from removal of a cancerous lesion
44
Experience healing at site of excision will heal without
evidence of infection
Verbalize fears related to the diagnosis and actively seek
information and clarification
Identify community resources for support and additional
information
Verbalize understanding of the treatment plan
Demonstrate increased knowledge of condition, as evidenced by
adoption of preventive strategies
Melanoma Nursing Management: Planning and Expected
Outcomes

45
Reinforce treatment regimen by monitoring wound for
secondary infection
Reinforcement caring component by discussing patient’s and
family’s feelings related to cancer
Teach patient or family dressing care and signs of infection
Focus on comfort, education, and emotional support
Melanoma Nursing Management: Intervention
46
Focuses on monitoring for infection, effectiveness of pain
control measures, comprehension of patient education, and
discussions related to body image changes and fears about
cancer
Documentation of assessment, response to treatment measures,
patient comprehension of teaching, and other nursing
interventions demonstrate nursing accountability.
Melanoma Nursing Management: Evaluation
47
Common problem in older adults - from three causes: arterial
insufficiency, venous hypertension, and diabetic neuropathy
Arterial or ischemic ulcers result from arterial insufficiency.
Referred to as peripheral vascular disease (PVD)
Risk factors, including obesity, diabetes, hyperlipoproteinemia,
and hypertension
Arterial Ulcers

48
Pain with exercise, at night, or while resting
Cramping, burning, or aching
As disease advances, extremity develops cyanotic hue and
becomes cool.
Skin becomes thin, shiny, and dry with loss of hair and
thickened nails.
Arterial ulcers are usually located on the outer ankle, feet, and
toes.
Treatment is usually surgical intervention with
revascularization, amputation if advanced disease
Arterial Ulcer
49
Also known as stasis ulcers, thought to arise secondary to
chronic venous insufficiency
Venous hypertension is primary cause of venous ulcers.
Valvular incompetence of the deep or perforating veins of the
lower leg is present.
The accumulation of erythrocytes in the tissue produces a
brownish skin discoloration caused by the release of
hemoglobin.
Discoloration and thickening of the skin (lipodermatosclerosis)
is the first indication of venous hypertension.
Venous Ulcers
50
Usually on medial aspect of lower leg, with flat or shallow
craters and irregular borders, accompanied by varicosities,

liposclerosis, and itching
Generate large amount of exudate and usually surrounded by
erythema and edema
Venous ulcers heal with prolonged elevation of affected
extremity; however, compliance is difficult.
Venous Ulcer
51
Risk factors for developing a diabetic foot lesions are peripheral
neuropathy, foot deformity, peripheral arterial disease, and
history of previous foot lesions.
Risk factor for lower extremity amputation is neuropathy,
implicated in approximately 90% of diabetic foot ulcers.
Pain and temperature usually first sensations affected by
neuropathy
Diabetic Foot Lesions
52
Lesions tend to be bilateral, symmetric, and located on the
plantar surface of the foot.
Complain of pain and paresthesias, they also have diminished or
absent vibratory and temperature sensation of the affected
extremities.
Pain relieved by walking is one diagnostic sign of neuropathy.
Patient education to minimize the risk of chemical, thermal, and
mechanical trauma is the first line of defense against diabetic
foot lesions.
Diabetic Foot Lesions
53

Determine wound dimensions, depth, and amount of exudate
Palpate popliteal pulses
Pain assessment
Nutritional assessment
Can you name two nursing diagnoses for lower leg ulcers and
lesions?
Lower Leg Lesions Nursing Management: Assessment and
Diagnosis
54
Reduced skin integrity, resulting from altered circulation
Potential for infection, resulting from open, chronic wounds
54
Have skin lesions free from necrotic tissue and infection
Have edema in lower extremities that is controlled
Have skin lesions that will heal with minimum scarring
Be able to maintain a healed state for at least 6 months
Lower Leg Lesions Nursing Management: Planning and
Expected Outcomes
55
Keep the legs elevated.
Implement compression therapy.
Administer wound care.
Educate the patient about the causes of a lower extremity ulcers

and lesions; the strategy of compression therapy, and specific
wound care.
Stress the need to maintain compression therapy to facilitate
healing of venous ulcers and avoid further breakdown.
Lower Leg Lesions Nursing Management: Intervention
56
Focuses on prevention of further wound deterioration and
infection, as well as the effectiveness of patient education
A return demonstration of compression therapy application and
wound care is a concrete evaluation and ensures patient
comprehension.
Lower Leg Lesions Nursing Management: Evaluation
57
Pressure injury is a more appropriate term than pressure ulcer or
decubitus.
Pressure on soft tissue over bony prominences or other hard
surfaces is primary causative factor.
Common bony prominences susceptible are sacrum, ischial
tuberosity, lateral malleolus, trochanter, and heels.
Intensity of pressure leading to capillary closure, compounded
by duration of pressure and tissue tolerance, results in tissue
anoxia, ischemia, edema, and eventually tissue necrosis.
Pressure Injuries
58
Is major contributing factor in the development of a pressure
injury

Defined as the ability of the skin and supporting structures to
endure the effects of pressure
Extrinsic factors: moisture, friction, and shearing
Intrinsic factors: poor nutrition, advanced age, hypotension,
emotional stress, smoking, and skin temperature
Pressure Injuries Tissue Tolerance
59
Shearing forces can decrease blood supply, leading to tissue
ischemia and necrosis.
Friction primarily affects epidermal and dermal layers, causing
a superficial abrasion.
Moisture from incontinence or profuse sweating can decrease
tensile strength, alter skin resiliency to external forces, and
exacerbate friction and shearing forces.
Protein deficiency weakens tissue tolerance, making soft tissue
more susceptible to breakdown when pressure intensity is
prolonged.
Factors Influencing Tissue Tolerance
60
A risk assessment should be conducted on all individuals who
are bed bound, chair bound, incontinent, frail, disabled, or
nutritionally compromised or who have demonstrated altered
mental status.
Norton risk assessment tools
Simple to use, with five assessment categories
Those with a score of 16 or lower considered to be at risk
The Braden Scale
Assesses sensory perception
Scoring below 18 considered to be at high risk

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