Nursing Interventions for Specific Problems in Older Person

Integumentary System -primary functions are protection from environmental stresses, regulation of temperature, maintenance of fluid and electrolyte balance, excretion of metabolic waste and sensory reception.

Skin Management: Changes in the Integumentary System

Decreased skin elasticity (sagging of skin) with decreased tensil strengthMen experience hair loss (balding) and both sexes develop gray hair and

wrinklesChanges in pigmentation with accumulation of discoloration, photoaging is

commonNormal oral temperatures are lower later in the life than in younger yearsSkin fold thickness is significantly reduced in the forearm and the back of

the hands Sensitivity to cold temperatureDry skinLoss of subcutaneous tissueThinning of dermisDecrease elastin associated with wrinklingVascular lesionDecreased proliferative potential delays wound healing delays wound

healing and vitamin D production

2 Categories of Aging Changes Intrinsic factors –related to decrease in proliferative capacity that leads to cellular senescence resulting in altered biosynthetic activity of skin derived cells. (Genetics play role in this factor)Extrinsic factor –are environmental with sunlight being the primary culprit Cumulative changes related to environmental factors are referred to as photoaging, which is dependent on the degree of exposure and skin pigment.

Common Skin Disorders

PruritusNursing Intervention •Restricting amount/frequency of bathing & soap use

and by applying topical ointments.• Application of oily emollients & those containing alpha-hydroxy acids relieve symptoms by improving the barrier function of the skin.•Topical lotion that contain menthol and camphor relieves itching • Traditional systemic antihistamines may provide some relief from itching (adverse effect: urinary retention, impaired psychomotor function and drowsiness.

XerosisNursing Intervention •Avoid using rough textured bed linens•Encourage or assist patient to wear loose fitting clothing•Apply lubricant to moisten lips and oral mucosa as needed•Loosely apply incontinent garments (if used)•Refrain from using alkaline soap

in the skin•Keep bed linens clean, dry and free

from wrinkles

RashesNursing Interventions•Proper hygiene by gently cleansing to

remove the exudates and gentle drying.

•When rash is related to dry skin, moisturizing agent is immediately applied.•Massage or cool compress •Antihistaminic drugs •Topical corticosteroids

Inflammatory

Conditions

Eczema/ DermatitisNursing Interventions•Avoidance of drying agents such as soap and water •Application of moisturizers and topical immunosuppressant •Tropical corticosteroids•Tacrolimus ointment and

Pimecrolimus cream

Seborrhic DermatitisNursing Intervention•Cream or shampoo containing ketoconazole

for initial treatment• Ciclopirox olamine cream (Tarmed)•Topical glucocorticosteroids • In the scalp: Shampoo than contains yeast suppressants such as ketoconazole, pyrithione zinc, selenium sulfide, salicylic acid or tar.

IntertrigoNursing Intervention•Keeping affected areas clean and dry and separating

adjacent tissues.•Folds should be washed with tepid water and dried

thoroughly.•Soft gauze may be used to separate adjacent surfaces.•For breast candidiasis, a well fitting cotton brassiere

will help absorb moisture and reduce chafing.•In perineal candidiasis, an adductor block pillow may

improve circulation to the affected area, reducing air accumulation.

•Appropriate treatment of the rash with antifungal agents and good hygiene often reduce the

discomfort and anxiety associated with rashes.•Superficial fungal infections usually are treated first

with topical antifungal.Topical antifungal agents include:Polyene antibiotics (nystatin)Azoles (ketoconazole)ClotrimazoleCiclopirox OlamineAllylamines

Lichen Simplex ChronicusNursing Intervention•Steroid creams and antihistamines•Bedtime oral antihistamines•Patients are encouraged to keep their fingernails short•Application of a dressing such as DuoDerm may protect the plaque from scratching.•Mittens may be needed for confused older adults.

•For localized lesions, a tape that is impregnated with topical steroid can be applied for a maximum of 24 hours.

•Caution patients not to apply occlusive dressings over corticosteroids because they greatly increase absorption of the medication.•Provide cold pack.•Oatmeal baths, moisturizers, menthol and ultraviolet B light•Excoriated areas may require topical antiseptics

Lichen SclerosisNursing Intervention•Topical anti inflammatory steroids such as betamethasone valerate 0.1%•Skin examination at least twice each year

Pruritus AniNursing Intervention•Avoidance of irritating medications •Use of warm compresses or baths •Application of mild steroid creams •Administration of anti pruritic medications

Drug EruptionsNursing Intervention•Withdrawal of the drug is the primary

treatment.•Topical corticosteroids•Anti pruritic lotions•Antihistamines

Cosmetic Skin Change TreatmentWrinkles Photoprotection, Tretinoin (Retin A), Dermal

Peel, Face-lift, Botox (Botulinum toxin), Laser

Hair loss Minoxidil (Rogaine), Antiandrogens, Hair transplantation

Gray Hair Hair coloring

Unwanted facial hair Facial bleaches, Shaving, waxing, electrolysis

Skin tags Scissor incision, electrodesiccation and curettage

Cherry angiomas Electrodesiccation and curettage, cryosurgery, shave excision

Seborrheic keratoses Cryosurgery, glycolic acid, alpha-hydroxy acid

Sebaceous hyperplasia Photoprotection, cryosurgery, E and C

Solar lentigines Photoprotection, 3% hydroquinone, cryosurgery

Telangiectasia Photoprotection, Electrodesiccation/ intense pulsed light

Neoplastic Disorders

Seborrheic KeratosesNursing Intervention•Can be removed for microscopic study or for cosmetic reasons.•Biopsy, shave or excision may be used to remove completely the lesions or specimen for examination.

Actinic Keratoses Nursing Intervention•Decreased exposure to sunlight•Topical agents such as fluorouracil, diclofenac sodium and aminolevilinic acid with blue light photoactivation after 14 to 18 hours.•During treatment, patients should avoid direct sun exposure.

Nonmelanoma Skin CancerNursing Intervention•Avoid or minimize use of tanning bed.

Basal Cell Carcinoma Nursing intervention •Removal of the lesion by electrodessication and curettage, cryosurgery, excision , micrographic surgery, radiotherapy •Imiquimod 5% cream for superficial BCCs

Squamous Cell CarcinomaNursing Intervention•Removal by cautery, curettage, deep cryotherapy, excision, or radiotherapy.•For regional metastasis, surgery with adjuvant radiotherapy is needed.

Malignant MelanomaNursing Intervention•Modified ultraviolet exposure•Avoid sun exposure in prolonged time•Use sun screens with a sun protections factor (SPF)

of 15 or higher

Infectious Disorders

Herpes ZosterNursing Intervention•Antiviral therapy such as acyclovir (Zovirax), famciclovir and Valacyclovir (Valtrex)•Controlled opioid analgesics•Compresses of hypertonic solutions such as Burow’s and gentle washing with antibacterial soaps•Topical antibiotic such as mupirocin ointment (2-3 times

daily)•Systemic corticosteroids/ oral corticosteroids•Topical treatments/ creams such as capsaicin cream and

topical anesthetics•Acupuncture, nerve blocks, transcutaneous electrical nerve stimulation, and deep brain stimulation

Psoriasis Nursing Intervention•Topical medications such as corticosteroids, tazarotene,

anthralin, tars, dithranol, vitamin D derivatives (calcipotriene)

•Keratolytic agents such salicylic acid with topical steroids•Ultraviolet B light exposure enhances absorption of

topical therapy with tar and anthralin •Photochemotherapy with UVA and systemic agents or

oral methoxsalen for moderate to severe psoriasis•Systemic drugs include oral retinoids (acitretin), biological agents (alefacept) and cytotoxic drugs (methotrexate)

Dermal Ulcers

Leg Ulcers and Stasis DermatitisNursing Intervention•Determine the cause of the ulcer•Peripheral pulses and sensation should be assessed to

rule out arterial disease and neuropathy •Application of compression to a limb with arterial insufficiency •Compression bandages or hosiery when venous disease is confirmed •Four layer compression dressing or compression pump•Superficial occlusive dressings, topical ointments, corticosteroids therapy and antibiotics

Pressure Ulcers (Decubitus Ulcers)Nursing Intervention•Assessment•Debridement to remove necrotic tissues•Gentle cleansing with tepid normal saline, povidone

iodine and hypochlorite•Dressing>Occlusive dressing>Semi permeable transparent films sucha as Opsite>Absorptive gels such as karaya powder>Noncontact normothermic wound therapy that involved warming the dressing

Over all Nursing Managements for Skin Conditions:Goal: Preservation or restoration of skin integrity without complications, relief of discomfort and implementation of measures to reduce the risk of ulcers.• Stress good personal grooming and cleanliness• Avoid friction, irritation or mechanical injury when bathing,

dressing, moving or turning an older patient.• Baths are not necessary everyday for elder people. The bath

water temperature should not exceed 105F. Avoid soap and rubbing alcohol because they tend to dry the skin.

• Do not put oily lubricants in the bathtub because they make the tub surface slippery; instead put lubricants directly into the skin.

• Include hair and nail care in personal hygiene. Soak the feet to loosen debris under the nails and makes it easier to cut

• Encourage diet high in vitamins and nutrients to help maintain healthy skin in older adult. Vitamins A and C and protein

• Teach patient about foods high in nutrients and help ensure that they are included in the diet.

• Environmental modification also can be made to promote healthy skin.• Advise older adult to stay out of the sun and avoid

exposure to wind and cold. • Provide soft, unwrinkled clothing next to the skin to

minimize skin irritation and pruritus.• Encourage ambulatory patients to wear supportive

shoes that protects feet from trauma

Nursing Care of Patients with

Musculoskeletal Alterations

Changes in Musculoskeletal of elder patients• Decrease bone mass• Bone shrinkage due to a loss of cartilage and thinning of vertebrae, causing long bones to appear disproportionately long• Decrease tough receptors with corresponding slowing of reflexes, and pain sensation• Decreased proliferative potential delays wound healing and

vitamin D production• Diminished muscle mass • Decreased height• Muscle mass is lost • Muscle mass can decline rapidly without exercise• Slight hip/knee flexion• Kyphosis and backward head tilt

Nursing Intervention*When a patient is bedridden, instruct to:1. Turn from side to side in bed2. Flex the knees bilaterally and raise the hips (bridging) 3. Move from supine to a sitting position, with legs

dangling over the side of the bed4. Assume prone position in bed

* To assess mobility, nurse should:1. Have the patients walk with shoes on. For older patients with shuffling gait, sway, hold the arms out for balance, keep the feet wider apart and watch his or her feet.2. If safe, ask the patient to walk down stairs3. Ask the patient to pick up an object from the floor.

The older person may bend the waist rather than the knees and hold onto furniture for support. Have the patient rise from a sitting position to a standing position.4. If appropriate, ask the patient to rise from a reclining position to a sitting position.

Nursing Goals: Preservation, restoration or improvement of joint mobility, muscle strength and skeletal health; maintenance, restoration or improvement in mobility and self-care; relief of discomfort related to musculoskeletal disorders or injuries; prevention of complications associated with

immobility or musculoskeletal disorders.

Other interventions:•Exercise (active and passive), proper nutrition and

patient education.•Proper sitting of patients in the wheelchair•Prevent fallsTypes of exercises:*ROM exercises*Resistive exercise*Isometric exercise*Isotonic exercise*Isokinetic exercise*Balance exercise*Aerobic exercise