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INTEGUMENTARY SYSTEM

The integumentary system is the organ system that protects the body from
various kinds of damage, such as loss of water or abrasion from outside. The largest
organ of the body, the skin. The system comprises the skin and its appendages

(including hair, scales, feathers, hooves, and nails). The integumentary system has a
variety of functions; it may serve to waterproof, cushion, and protect the deeper
tissues, excrete wastes, and regulate temperature, and is the attachment site for
sensory receptors to detect pain, sensation, pressure, and temperature. In most
terrestrial vertebrates with significant exposure to sunlight, the integumentary system
also provides for vitamin D synthesis.
CHANGES IN ELDERLY
Epidermis and dermis becomes thinner
Reduced number of elastic fibers
Circulation to the skin decreases and causes:
Coldness
Dryness
Poor healing of injured tissue
Senile Lentigines:
Dark yellow or brown colored spots
Maybe called liver spots not related to liver
Collagen becomes stiffer
When the fatty tissue layer of the skin diminishes, lines and wrinkle develop.
Nails become thick, tough, and brittle.
Increased sensitivity to cold.
Subcutaneous fat diminishes particularly in the extremities, but gradually
increases in other areas of the body (abdomen in men, thighs in women)
Decreased number of capillaries in the skin diminished blood supply
Loss of resiliency and wrinkling and sagging of the skin
genetic
Hair pigmentation decreases gradual graying
Balding- Hair looses color and hair loss occurs.
Decreased activity of sebaceous and sweat glands Skin becomes drier and
susceptible to irritations
Reduced tolerance to extremes of temperature and to exposure to the sun.

COMMON DISORDERS
AGE SPOTS
Age spots, or "liver spots" as theyre often called, have nothing to do with the
liver. Rather, these flat, brown spots are caused by years of sun exposure. They are
bigger than freckles and appear in fair-skinned people on sun-exposed areas such as
the face, hands, arms, back, and feet. The medical name for them is solar lentigo.
They may be accompanied by wrinkling, dryness, thinning of the skin, and rough
spots.
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DRY SKIN AND ITCHING

Many older people suffer from dry skin, particularly on their lower legs, elbows,
and forearms. The skin feels rough and scaly and often is accompanied by a
distressing, intense itchiness. Low humidity caused by overheating during the
winter and air conditioning during the summer contributes to dryness and itching.
The loss of sweat and oil glands as you age also may worsen dry skin. Anything that
further dries your skin such as overuse of soaps, antiperspirants, perfumes, or hot
baths will make the problem worse. Dehydration, sun exposure, smoking, and
stress also may cause dry skin


SKIN CANCER
Both basal cell carcinoma and squamous cell carcinoma are more common in
individuals over 55 years of age. Pigmented spots that bleed easily and are enlarging
characterize these carcinomas.

Skin cancers that primarily result from sun exposure are basal cell carcinoma,
squamous cell carcinoma, and malignant melanoma . The risks for skin cancer seem
to be associated with the type of sun exposure. Intense, in-termittent exposures, such
as severe sunburns, are associated with both basal cell car-cinoma and malignant
melanoma. The risk for squamous cell carcinoma is strongly associated with chronic
sun exposure but not with intermittent exposure.


ACTINIC KERATOSIS
The most common precancerous lesion is actinic keratosis, also known as solar
ker-atosis and senile keratosis. Actinic keratotic lesions are more common in men
than women. It is estimated that 1 in 1,000 will progress to skin cancer, usually
squamous cell carcinoma, in a 1-year period. Erythematous actinic keratosis is the
most common type and appears as a sore, rough, scaly, erythematous papule or
plaque. Other types of actinic keratosis include hypertophic and cutaneous horn. The
most common sites for all types of actinic keratosis are sun-exposed areas such as the
hands, face, nose, tips of the ears, and bald scalp.


PRESSURE ULCER
Pressure ulcer is defined as a lesion caused by unrelieved pressure that results
in dam-age to underlying tissue. Pressure ulcer formation often occurs on the soft
tissue over a bony prominence, although it can occur on any tissue that is exposed to
external pres-sure for a length of time that is greater than capillary closing pressure.




CELLULITIS
Cellulitis is an acute bacterial infection of the skin and subcutaneous tissue
that may cause an older person a great deal of pain and distress. Cellulitis, which
occurs most frequently on the lower legs and face, is characterized by symptoms of
inflammation, which include intense pain, heat, redness, and swelling. It may appear
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in a localized area as a complication of a wound infection, or it may involve an entire
limb. In severe infections, fever may be present, as well as an increase in white blood
cells and tender lymph nodes (lymphadenopathy). An elevated temperature, although
a common sign of infection, may not be present in the older person.

Onychomycosis
fungal infection (i.e., Trichophyton rubrum, T. mentragro-phytes) of the toenail,
most commonly occurs on the big toe. The toenail appears thick, discolored, and
protruding from the nail bed . Older persons may complain of severe pain when their
shoe presses on the deformed toe, often causing them to reduce their activity or wear
open shoes and sandals. The older person should see a doctor for treatment to prevent
the condition from spreading to the other parts of the foot.


MANAGEMENT
AGE SPOT TREATMENT:
A number of treatments are available, including skin-lightening, or "fade" creams;
cryotherapy (freezing); and laser therapy. Tretinoin cream is approved for reducing the
appearance of darkened spots. A sunscreen or sun block should be used to prevent
further damage.
TREATMENT FOR DRY SKIN AND ITCHING:
The most common treatment for dry skin is the use of moisturizers to reduce water
loss and soothe the skin. Moisturizers come in several forms ointments, creams,
and lotions. Ointments are mixtures of water in oil, usually either lanolin or
petrolatum. Creams are preparations of oil in water, which is the main ingredient.
Creams must be applied more often than ointments to be most effective. Lotions
contain powder crystals dissolved in water, again the main ingredient. Because of their
high water content, they feel cool on the skin and dont leave the skin feeling greasy.
Although they are easy to apply and may be more pleasing than ointments and
creams, lotions dont have the same protective qualities. You may need to apply them
frequently to relieve the signs and symptoms of dryness. Moisturizers should be used
indefinitely to prevent recurrence of dry skin.
A humidifier can add moisture to the air. Bathing less often and using milder soaps
also can help relieve dry skin. Warm water is less irritating to dry skin than hot water.

Skin Cancer Treatments
Four types of standard treatment are used:
Surgery
Surgery to remove the tumor is the primary treatment of all stages of melanoma. The
doctor may remove the tumor using the following operations:
Local excision: Taking out the melanoma and some of the normal tissue around it.
Wide local excision with or without removal of lymph nodes.
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Lymphadenectomy: A surgical procedure in which the lymph nodes are removed and
examined to see whether they contain cancer.
Sentinel lymph node biopsy: The removal of the sentinel lymph node (the first lymph
node the cancer is likely to spread to from the tumor) during surgery. A radioactive
substance and/or blue dye is injected near the tumor. The substance or dye flows
through the lymph ducts to the lymph nodes. The first lymph node to receive the
substance or dye is removed for biopsy. A pathologist views the tissue under a
microscope to look for cancer cells. If cancer cells are not found, it may not be
necessary to remove more lymph nodes.
Skin grafting (taking skin from another part of the body to replace the skin that is
removed) may be done to cover the wound caused by surgery. Even if the doctor
removes all the melanoma that can be seen at the time of the operation, some patients
may be offered chemotherapy after surgery to kill any cancer cells that are left.
Chemotherapy given after surgery, to increase the chances of a cure, is called
adjuvant therapy.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer
cells, either by killing the cells or by stopping them from dividing. When chemotherapy
is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream
and can reach cancer cells throughout the body (systemic chemotherapy).
When chemotherapy is placed directly into the spinal column, an organ, or a body
cavity such as the abdomen, the drugs mainly affect cancer cells in those areas
(regional chemotherapy). In treating melanoma, anticancer drugs may be given as a
hyperthermic isolated limb perfusion.
This technique sends anticancer drugs directly to the arm or leg in which the cancer is
located. The flow of blood to and from the limb is temporarily stopped with a
tourniquet, and a warm solution containing anticancer drugs is put directly into the
blood of the limb. This allows the patient to receive a high dose of drugs in the area
where the cancer occurred. The way the chemotherapy is given depends on the type
and stage of the cancer being treated.
Radiation
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of
radiation to kill cancer cells or keep them from growing. There are two types of
radiation therapy. External radiation therapy uses a machine outside the body to send
radiation toward the cancer. Internal radiation therapy uses a radioactive substance
sealed in needles, seeds, wires, or catheters that are placed directly into or near the
cancer. The way the radiation therapy is given depends on the type and stage of the
cancer being treated.
Biologic therapy
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Biologic therapy is a treatment that uses the patient's immune system to fight cancer.
Substances made by the body or made in a laboratory are used to boost, direct, or
restore the body's natural defenses against cancer. This type of cancer treatment is
also called biotherapy or immunotherapy.

Actinic keratosis treatment options may include:

Freezing (cryotherapy). An extremely cold substance, such as liquid nitrogen, is
applied to skin lesions. The substance freezes the skin surface, causing blistering or
peeling. As your skin heals, the lesions slough off, allowing new skin to appear. This is
the most common treatment, takes only a few minutes and can be performed in your
doctor's office. Side effects may include blisters, scarring, changes to skin texture,
infection and darkening of the skin at the site of treatment.
Scraping (curettage). In this procedure, your surgeon uses a device called a curet to
scrape off damaged cells. Scraping may be followed by electrosurgery, in which a
pencil-shaped instrument is used to cut and destroy the affected tissue with an
electric current. This procedure requires a local anesthetic. Side effects may include
infection, scarring and changes in skin coloration at the site of treatment.
Creams or ointments. Some topical medications contain fluorouracil (Carac,
Fluoroplex, Efudex), a chemotherapy drug. The medication destroys actinic keratosis
cells by blocking essential cellular functions within them. Another treatment option is
imiquimod (Aldara), a topical cream that modifies the skin's immune system to
stimulate your body's own rejection of precancerous cells. Diclofenac gel (Voltaren,
Solaraze), a nonsteroidal anti-inflammatory topical drug, may help, too. Side effects
may include skin irritation such as pain, itching, stinging or burning sensation,
crusting, and sensitivity to sun exposure at the site of treatment.
Chemical peeling. This involves applying one or more chemical solutions
trichloroacetic acid (Tri-Chlor), for example to the lesions. The chemicals cause your
skin to blister and eventually peel, allowing new skin to form. Skin peeling usually
lasts for five to seven days. Other side effects may include stinging or burning
sensation, redness, crusting, changes in skin coloration, infections and, rarely,
scarring. This procedure may not be covered by insurance, as it's often considered
cosmetic.
Photodynamic therapy. With this procedure, an agent that makes your damaged
skin cells sensitive to light (photosensitizing agent) is either injected or applied
topically. Your skin is then exposed to intense laser light to destroy the damaged skin
cells. Side effects may include redness, swelling and a burning sensation during
therapy.
Laser therapy. A special laser is used to precisely remove the actinic keratoses and
the affected skin underneath. Local anesthesia is often used to make the procedure
more comfortable. Some pigment loss and scarring may result from laser therapy.
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Dermabrasion. In this procedure, the affected skin is removed using a rapidly moving
brush. Local anesthetic is used to make the procedure more tolerable. The procedure
leaves skin red and raw-looking. It takes several months for the skin to heal, but the
new skin generally appears smoother.
FOR PRESSURE ULCER:
Stage I and stage II pressure sores usually heal within several weeks to months with
conservative care of the wound and with ongoing, appropriate general care that
manages risk factors for pressure sores. Stage III and IV pressure sores are more
difficult to treat. In a person who has a terminal illness or multiple chronic medical
conditions, pressure sore treatment may focus primarily on managing pain rather
than complete healing of a wound.

Treatment team
Addressing the many aspects of wound care usually requires a multidisciplinary
approach. Members of a care team may include:

A primary care physician who oversees the treatment plan
A physician specializing in wound care
Nurses or medical assistants who provide both care and education for managing
wounds
A social worker who helps a person or family access appropriate resources and
addresses emotional concerns related to long-term recovery
A physical therapist who helps with improving mobility
A dietitian who assesses nutritional needs and recommends an appropriate diet
A neurosurgeon, orthopedic surgeon or plastic surgeon, depending on whether surgery
is required and what type of surgery is needed
Relieving pressure
The first step in treating a sore at any stage is relieving the pressure that caused it.
Strategies to reduce pressure include the following:

Repositioning. A person with pressure sores needs to be repositioned regularly and
placed in correct positions. People using a wheelchair should change position as much
as possible on their own every 15 minutes and should have assistance with changes in
position every hour. People confined to a bed should change positions every two hours.
Lifting devices are often used to avoid friction during repositioning.
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Support surfaces. Special cushions, pads, mattresses and beds can help a person lie
in an appropriate position, relieve pressure on an existing sore and protect vulnerable
skin from damage. A variety of foam, air-filled or water-filled devices provide cushion
for those sitting in wheelchairs. The type of devices used will depend on a person's
condition, body type and mobility.
Removing damaged tissue
To heal properly, wounds need to be free of damaged, dead or infected tissue.
Removing these tissues (debridement) is accomplished with a number of methods,
depending on the severity of the wound, your overall condition and the treatment
goals. Options include:

Surgical debridement involves cutting away dead tissues.
Mechanical debridement uses one of a number of methods to loosen and remove
wound debris, such as a pressurized irrigation device, a whirlpool water bath or
specialized dressings.
Autolytic debridement, the body's natural process of recruiting enzymes to break
down dead tissue, can be enhanced with an appropriate dressing that keeps the
wound moist and clean.
Enzymatic debridement is the use of chemical enzymes and appropriate dressings to
break down dead tissues.
Cleaning and dressing wounds
Care that promotes healing of the wound includes the following:

Cleaning. It's essential to keep wounds clean to prevent infection. A stage I wound can
be gently washed with water and mild soap, but open sores are cleaned with a
saltwater (saline) solution each time the dressing is changed.
Dressings. A dressing promotes healing by keeping a wound moist, creating a barrier
against infection and keeping the surrounding skin dry. A variety of dressings are
available, including films, gauzes, gels, foams and various treated coverings. A
combination of dressings may be used. Your doctor selects an appropriate dressing
based on a number of factors, such as the size and severity of the wound, the amount
of discharge, and the ease of application and removal.
Other interventions
Other interventions that may be used are:

Pain management. Interventions that may reduce pain include the use of
nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin, Advil, others) and
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naproxen (Aleve, others) particularly before and after repositioning, debridement
procedures and dressing changes. Topical pain medications, such as a combination of
lidocaine and prilocaine, also may be used during debridement and dressing changes.
Antibiotics. Pressure sores that are infected and don't respond to other interventions
may be treated with topical or oral antibiotics.
Healthy diet. Appropriate nutrition and hydration promote wound healing. Your
doctor may recommend an increase in calories and fluids, a high protein diet, and an
increase in foods rich in vitamins and minerals. Your doctor may also prescribe
dietary supplements, such as vitamin C and zinc.
Muscle spasm relief. Muscle relaxants such as diazepam (Valium), tizanidine
(Zanaflex), dantrolene (Dantrium) and baclofen may inhibit muscle spasms and
enable the healing of sores that may have been caused or worsened by spasm-related
friction or shearing.
Surgical repair
Pressure sores that fail to heal may require surgical intervention. The goals of surgery
include improving the hygiene and appearance of the sore, preventing or treating
infection, reducing fluid loss through the wound, and lowering the risk of cancer.

The type of reconstruction that's best in any particular case depends mainly on the
location of the wound and whether there's scar tissue from a previous operation. In
general, though, most pressure wounds are repaired using a pad of the person's own
muscle, skin or other tissue to cover the wound and cushion the affected bone (flap
reconstruction).
FOR CELLULITIS:
Usually, doctors prescribe a drug that's effective against both streptococci and
staphylococci. The doctor will choose an antibiotic based on your circumstances.
The doctor also might recommend elevating the affected area, which may speed
recovery.
FOR ONYCHOMYCOSIS:
Oral medications
Antifungal such as terbinafine (Lamisil) and itraconazole (Sporanox).

Are experiencing pain or discomfort from your nail infection
These medications help a new nail grow free of infection, slowly replacing the infected
portion of the nail. You typically take these medications for six to 12 weeks. It may
take four months or longer to eliminate an infection. Recurrent infections are possible,
especially if continue to expose nails to warm, moist conditions.
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Antifungal drugs may cause side effects ranging from skin rashes to liver damage.
Doctors may not recommend them for people with liver disease or congestive heart
failure or for those taking certain medications.

NURSING CONSIDERATIONS
Good skin, nail, and hair care are essential:
1. Use mild soaps. Bathe once a day, using superfatted soaps such as Dove or
Caress. Avoid any drying agents such as alcohol.
2. Dry with a soft towel, including between the toes.
3. Lanolin lotions used. Apply emollients liberally to the skin immediately after
bathing, while skin is moist. Reapply frequently.
4. Use white petroleum for an effective emollient for dry skin treatment. It is
inexpensive and does not contain irritating additives such as perfumes.
5. Keep humidity as high as possible, especially during the winter months.
6. Wear soft, nonirritating clothing next to the skin.
7. Prescription creams may also be useful
8. Shampooing done less frequently.
9. Use the appropriate sunscreen protection, at least 15 SPF. It is never too late to
protect yourself against further damage. Do a total body check, using a mirror if
needed, and record any spots so that change can be noted.
a. Be aware that many drugs can cause increased photosensitivity and
accelerate damage to the skin.
b. Reapply sunscreen when needed. Be aware of ears and bald scalp areas
when applying sunscreen. These areas are often the sites of skin cancer.
10. Any sores on skin should be cared for immediately.
11. Advised the client to take antibiotics or antifungal medication in full course.
12. Do wound care every day especially for sores and wounds.
13. Promote nutritious diet with optimal protein, vitamins and iron rich fruits and
vegetables.
14. Encourage ambulation and exercises.
15. Use normal saline for cleaning and disinfecting wounds.
16. Apply wet to dry dressings or enzyme ointments for debridement as directed.
17. Apply topical antibiotics to locally infected pressure ulcer as prescribed.
18. Cover the wound with protective dressings.
19. Advise the client to use ambrella for protection from sunlight.







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CARDIOVASCULAR SYSTEM
Cardiovascular system delivers oxygenated blood to tissues and removes waste
products. The heart controlled by the autonomic nervous system, pumps blood to all
organs and tissues of the body. Arteries and veins carry blood throughout the body,
keep filled with the blood and maintain blood pressures.
CHANGES
NORMAL AGE-RELATED CHANGES IN CARDIO-VASCULAR SYSTEM
With ageing there is a loss of myocardial myocytes, with a progressive increase in
myocyte cell volume. In other words the heart gets flabbier and less efficient. The
amount of interstitial fibrous tissue and fat surrounding the hear increases. If
there is no cause for hypertrophy, there is a decrease in the weight of the heart.
Autopsy findings indicate fibrotic patches within the myocardium.
Amyloid changes are noted in almost 80% of autopsy studies.
The heart valves become thicker and less elastic.
There may be decline in the sinoatrial (SA) node discharges and disruption of the
atrioventricular (AV) conduction system.
Brown atrophy- accumulation of lipofuscin in myocardial cells.
Blood vessels become rigid and narrowed with atherosclerosis.
Cardiac contractility is normal but the duration of contraction and relaxation is
prolonged.
There is little change in mean resting heart rate. Maximal heart rate response to
exercise declines but cardiac output is maintained by an increase in stroke volume.
Left ventricular end diastolic volume and resting preload is normal but after load
increases with age.
Cardiovascular reflexes are blunted; especially the heart rate response to
orthostatic and hypotension is impaired. In other words, heart rate does not
increase enough to compensate for the reduction in cardiac output due to
hypotension.

Small pathological insults on the background of decrease in reserve may
precipitate failure. Therefore steps taken so salvage small amounts of myocardium
following an MI in elderly are beneficial.
Fitness training at any age brings about an increase in maximal oxygen
consumption and improvement in cardiac reserve. Therefore regular physical
exercise should be strongly recommended.
Alterations in cardiac function with age are the manifestations of a decreased -
adrenergic responsiveness.







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COMMON DISORDERS

HYPERTENSION
Blood pressure usually rises till 65 years of age and following that there is
no increase in BP.
Hypertension is the commonest health problem in old age. More than half of
the elderly population in all developed and most of the developing societies
has hypertension. However, a majority of this hypertensive are either
undiagnosed or uncontrolled. Almost 5% of females at 65 years of age have a
BP > 200/100 mm Hg but feel well and dont complain of any symptoms,
but are predisposed to common complications.
Systolic blood pressure (SBP) has greater predictability for vascular events
(stroke, IHD, CHF, renal failure and mortality) than diastolic blood pressure
in older individuals.
A large number of the elderly hypertensives have isolated elevation of SBP,
which greatly enhances cardiovascular risk.
Primary or idiopathic hypertension is the commonest cause of high blood
pressure in old age, though a significant number of patients may have
atherosclerotic renovascular hypertension.


ISCHAEMIC HEART DISEASE

IHD is a very common cause of disability and death in old age.
The manifestations of IHD in older patients are similar to those in young
patients. However, silent ischaemia and cardiac failure are more frequent in
older subjects. Similarly, diagnostic tests are no different in old age though the
interpretation of the exercise-induced ischaemia may be difficult.

ACUTE MYOCARDIAL INFARCTION
AMI in old age may be missed due to the absence of pain. Dyspnoea is seen in
one of five patients presenting with MI and is the most common symptom. A
classical onset is described in only 19% patients. Mental confusion, sudden
death, syncope and stroke are other presentations.
Survival after acute myocardial infarction in old age is much less than in
younger patients. Older patients have a high prevalence of congestive cardiac
failure.



CHRONIC CARDIAC FAILURE
Precise prevalence figures for cardiac failure in older individuals are lacking due
to the liberal use of diuretics for any form of dependent oedema.
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Hypertension, diabetes mellitus, coronary artery disease and valvular heart
disease are the will-recognized causes of cardiac failure in old age.
Breathlessness on exertion and fluid overload are classical features of cardiac
failure. In older patients, due to lack of much physical effort, especially in a
bed-ridden patient, dyspnoea may be absent; and fatigue, weakness and
tiredness may be the only symptoms. On the other hand, fluid overload may be
present in the absence of cardiac failure due to prolonged immobility,
hypoproteinaemia and venous insufficiency.

ORTHOSTATIC HYPOTENSION
The patients present with feeling of faintness on standing, frequent falls
accompanied by an aura of faintness, syncope, or weakness in limbs while
standing. The symptoms worsen after a meal, hot bath or in hot environment.
The symptoms disappear on lying down.
The patients might present with micturition syncopes.


MANAGEMENT
FOR HYPERTENSION:
Lifestyle modification
Salt restriction
Weight loss
Pharmacological interventions:
- -blocker (atenolol, metoprolol).
- Calcium channel blockers (amlodipine) alone or in combination.
- Thiazide diuretics.
- ACE inhibitors: enalapril, lisinoprilm ramipril.
Angiotensin receptor blockers: losartan, telmisartan.

FOR ISCHEMIC HEART DESEASE:
Medical management f the symptoms is usually carried out by short-and
long-acting nitrates, -adrenergic blockers and calcium channel antagonists
which are useful drugs, though development of tolerance to nitrates is a
frequent problem.
Coronary angioplasty is an excellent option for older subjects who continue
to have symptoms despite medical management. As it avoids anaesthesia
and thoracotomy, short-term survival is much better than with coronary
artery bypass grafting (CABG). Despite the high risk of peri-operative
mortality, CABG has better survival over medical management and similar
survival as coronary angioplasty in the long run. Thus, it is the co-morbidity
which should influence the decision regarding the choice of intervention in
IHD.
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FOR ACUTE MYOCARDIAL INFARCTION:
Thrombolytic therapy in old age is limited by the presence of several
contraindications and is associated with higher rates of mortality and
complications. However, aggressive therapy has been shown to have better
prognosis in old than in the middle aged individuals because better
collaterals exist in the elderly and salvage of a small amount of myocardium
may cause the difference between adequate cardiac output and
decompensated failure.

CHRONIC CARDIAC FAILURE:
The management of chronic cardiac failure in old age aims at improving the
consequences of heart failure rather than the primary heart disease.
The cornerstone of the management of chronic cardiac failure is diuretic
therapy. Choosing a diuretic among many (thiazide, furosemide, and
spironolactone) is often difficult. As a rule of thumb it is ideal to start with
a low dose of furosemide (20mg), to be increased slowly up to 160 mg in the
absence of response. It is important that renal function and electrolyte
status should be regularly monitored.
Diuretics may cause several serious problems for the older patients and
may not be tolerated. The physician should be very vigilant towards these
issues to ensure compliance.
Digoxin is a very useful drug in chronic cardiac failure in older patients.
Features of digoxin toxicity in old age include fatigue, depression,
confusion, anorexia, nausea, vomiting, diarrhea, headache and a variety of
arrhythmias.
ACE inhibitors (captopril, enalapril, and lisinopril) have got multiple
benefits in cardiac failure, including survival benefit. However, most trials
have not included very old patients while evaluating this drug. As a result
its role in old age remains largely circumstantial. First dose hypotension
and worsening of the renal function are the most important adverse effect.

ORTHOSTATIC HYPOTENTION:
Treatment of orthostatic hypotension is effective if the cause is removed. Other
modalities include:
Postural retraining for individuals has been found to be very
helpful.
The aim should be for sufficient improvement in symptoms rather
than to give vain therapy to normalize blood pressure.
If no improvement in severe symptoms is seen then wheelchair
existence may become necessary and necessary lifestyle
adjustment should be discussed with the patient.

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NURSING CONSIDERATIONS
1. Advise the client to minimize the use or intake of fatty, salty food.
2. Advise the client to increase fluid intake.
3. Avoid stress.
4. Teach the client to continue the maintenance medications and tell the bad
effect of discontinuing of it.
5. Encourage the client to eat vegetables and fruits.
6. Encourage to drink non-fat milk.
7. Encourage the client to exercise gradually, and according to appropriate to his
or her condition.
8. May avoid coffee and other drinks with caffeine.
9. Take Medications routinely every 6 am for maintenance.
10.Provide support to the patien and his family to help them cope with the recovery
and lifestyle changes.
11. Instruct to Take medications as prescribed. And report adverse effects to the
doctor.
12. Instruct to comply with the regular follow-up visits.
13. Provide psychological support.