Skin-7

Cancer-

Wounds
The three types of pressure ulcers are:

 A necrosis of the epidermis or dermis, which may or may not progress to a

deep lesion.
 A deep or malignant pressure ulcer where necrosis is observed initially in the
subcutaneous tissue and tracks outward.
 Full-thickness wounds of dry black eschar.

 Prevention: Avoid sitting unless for meals, use pillows, reposition q2hrs,
encourage independent position changes
  Stage 1- clean with tepid water without soap. They heal faster if reinjured.

Assessment-
-Skin changes leave the older person increasingly susceptible to skin injuries such as
pressure ulcers and skin tears with a steadily decreasing ability to effect skin repair
-Common skin conditions of the older adult include skin cancer, skin tears, pressure
ulcers, delayed skin healing, cellulitis, and fingernail and toenail problems.

Cardiovascular -5

Changes-
-Increased stiffness of the heart and blood vessels
-Diastolic dysfunction due to impaired diastolic filling
-Systolic dysfunction due to increased left ventricular afterload
-Decreased cardiac output with rest and with exercise
-A decrease in cardiovascular reserve or a decrease in cardiac output may be the
result of deconditioning and/or disease or the result of natural aging processes

CAD management-
Women- Symptoms include: sleep disturbance, chest discomfort, squeezing, fullness,
or pressure that can come and go; discomfort in the back, neck, jaw, or stomach;
shortness of breath; and feelings of nausea and light-headedness, or breaking out in
a cold sweat.

Risk Factors
 HTN- Check for postural HTN! (orthostatic)

Immune system-2

Responses
Nosocomial infection
Reduce risk= Begin aspiration precautions for dysphagia.

Changes-
-Decrease in the nature and quantity of antibodies produced
-progressive decrease in immune functioning, or immunosenescence.
-Decrease in effectiveness of the cilia of the respiratory tract
-Decreased production of antibodies after immunization
-Suppressed immune system from the use of medications
-Decrease in lymphocyte production
-A decreased ability to respond to antigenic stimulation by B lymphocytes is a
common characteristic of the aging humerol immune system.
-The number of B cells in the circulation decreases in some individuals. As a result,
tissues are slower to repair and are more vulnerable to disease, especially
infections.

• Remind pt to get pneumonia vaccine at age 65 because there is a decrease in

antibody response in the body
 • RA= antibodies form against pt’s own IgG and the inflammatory process is
stimulated by T cells and they destroy articular cartilidge
• Shrimp and asthma = Type 1 hypersensitivity
• A decline in responsiveness of immune system-pt with pneumonia and temp
of 99.5F (baseline body temp in old people is lower)
• Memory is a reason for the immune system to develop long lasting protection
against specific antigens

GI -6

Swallowing- Dysphagia – is defined as difficulty in any part of the process involved

with swallowing solid foods or liquids.
1. Monitor during meals for a change in respirations.
2. Maintain an upright position for 1 hour after eating.
3. Raise the head of the bed to a 90 degree angle during meals.
5. Ensure that one bite has been swallowed before providing another.

1. Slurred speech
2. Extreme lethargy
3. Weak voice and cough
4. Drooling

Changes- Biological changes in GI function include:

Changes in the mouth
Decreased esophageal motility
Diminished gastric motility with increased stomach-emptying time
Diminished capacity of the gastric mucosa to resist damage
 Decrease in  esophageal sphincter pressures, sphincter relaxation, decreased
peristaltic. While a normal change, when combined with disease or med SE can lead
to development of dysphagia or aspiration.

gastric motility and stomach emptying elevates the risk for GERD (Hall, 2009) this
also contributes to decreased hunger can contribute to diminished food intake and
malnutrition (Visvanathan & Chapman)

How does damage to the gastric mucosa occur? Mucin Diminished capacity of the
gastric mucosa to resist damage can be secondary to NSAID’s use and helicobacter
pylori. Taking an NSAID with food only slightly protects the stomach from local
irritation. NSAIDS can also activate IBD. Damage to the stomach lining is more likely
the result of decreased prostaglandin production. H.pylori incidence increases with
age and is implicated in 90% of duodenal and gastric ulcers not associated with
NSAIDS.

Fluid and Electrolytes

GU/sexuality- 11

 CRF/ARF
 o Chronic renal failure is caused by irreversible damage to the kidneys.

Risk factors

Lab values

Changes

 CBI
o Irrigation solution continuously infused and drained from bladder
o Discontinue when bleeding stops
o Urine should be light pink without clots
o Inflow and outflow of irrigant must be monitored and documented
o Document drainage
o Terms: bright red, brick red, tea colored, amber, yellow or clear
o Number and size of clots
o Aseptic technique with catheter care and CBI
 o Tape catheter to leg
o Maintain closed drainage system
o Don’t allow irrigant to go dry (Can cause bleeding)
o Refrain driving or intercourse until see MD
o Catheter care (if discharged with catheter)
o Maintain oral fluids 2-3 L per day
o Observe S/S UTI and wound infection
o Signs of bladder infection
 Bladder spasm
 Change in mental status (confusion) vs. fever
 Hematuria
o Managing UI
o Retrograde ejaculation
o Anxiety
o Sexual counseling
o ED
o 2 months for bladder capacity return to normal
o Urinate q 2-3 hr
o Avoid bladder irritants (aged cheeses, chocolate, onions, rye and sourdough
breads, sour cream, citrus juices….)
o Hospice care if late stage
o Pain control
o

• BPH
Irritative
• Urinary frequency
• Urgency
• Dysuria
• Bladder pain
• Nocturia
• Incontinence
• Complications
• Acute urinary retention
• UTI
• Obstructive
• Decrease in caliber and force of urinary stream
• Difficulty initiating voiding
 • Intermittency
• Dribbling
• Early signs of urinary retention
• Treatment
• Avoid decongestants and anticholinergics
• 5-alpha-reductase inhibitors
• Finasteride (Proscar) & Dutasteride (Avodart)
• SE: decreased libido, decreased volume of ejaculate and ED
• Alpha-Adrenergic receptor blockers
• Tamsulosin (Flomax)
• SE: orthostatic hypotension, dizziness, retrograde ejaculation, nasal
congestion
• Herbals: Saw palmetto -Can improve urinary symptoms and urinary flow
measures. INCREASE risk of bleeding: contraindicated if concurrent GI
disorders, GI side effects, discontinue prior to surgery, may increase BP

Incontinence

• Treatments for UI fall into five categories:

• Lifestyle modification
• Scheduled voiding regimens
• Pelvic floor muscle strengthening
• Anti-incontinence devices
• Supportive interventions

Sexuality-9
 Womens changes- the cessation of menses. These include decreased vaginal
lubrication, atrophic vaginitis, more frequent UTIs, UI, cognitive changes,
vasomotor instability, and sleep disturbances.

Men’s changes- Impotence, or erectile dysfunction (ED), affects nearly 70% of

men over the age of 70. It is defined as the inability to achieve or maintain an
erection sufficient for sexual satisfaction.

Intimacy- safe sex

Respiratory-6

• Changes-
-Stiffening of elastin and the collagen connective tissue supporting the lungs.
-Altered alveolar shape resulting in increased alveolar diameter
-Decreased alveolar surface area available for gas exchange

-Increased chest wall stiffness

-Stiffening of the diaphragm

Pneumonia-

TB-

• Mycobacterium tuberculosis – is spread through the air and usually infects

the lungs and sometimes other organs are involved.
• Tuberculosis (TB) infects one third of the world’s population, approximately 9
billion people.
• The highest burden of TB continues to be among older adults.
• In 2010, adults ages 65 years and older had a case rate of 5.5 cases per
100,ooo.
o Transmission: Airborne
o Diagnosis: skin test and chest x-ray
o Treatment: Antibiotics

Endocrine-9

• Changes
Decreased secretion of insulin
• Potential for thyroid function problems with systemic symptoms that may be
attributed to aging.
• Decreased sensitivity to insulin resulting in variation blood glucose levels.
 • Peripheral tissues may become insulin resistant, especially with obesity.
• Andropause is a condition that is associated with the decrease in the male
hormone testosterone.
• Menopause is the time that marks the end of menstrual cycles. It's
diagnosed after 12 months without a menstrual period. 40s or 50s, but the
average age is 51 in the United States.
• Adrenopause a gradual and progressive decrease in the secretion of
hormones by the adrenal glands that occurs normally with increasing age
during adult life
• Somatopause a gradual and progressive decrease in growth hormone
secretion that occurs normally with increasing age during adult life and is
associated with an increase in adipose tissue and LDL levels and a decrease
in lean body mass.

Diabetes

Risk factors
Increased waist circumference
BP > 129/84 or on antihypertensive meds
Plasma triglycerides > 149 or on meds
HDL< 40 for men or 50 for women or on meds
FBS > 99
Race, family history, HTN, low HDL, gestational diabetes, obesity,
glucose intolerance, screen q3 yrs

 Treatment-
 Foot Care
 Insulin
 Complications
 Heart disease
 Stroke
 Kidney failure
 Nerve damage
 Vision problems
 Diet
 Exercise
 Emergency medications
 Monitoring
 Life style Changes
 Sick day management
 Skin alterations
 Wound infections
 Thyroid

• Hasimoto’s Tyroiditis
• Prevalence age>74
• 21% women
• 16% men
• Causes
• Hashimoto’s disease or autoimmune thyroiditis most common cause
• Drug induced: lithium carbonate, amiodarone, iodine
• Diagnosis
• History and Physical exam
• TSH, serum free T4
• Subclinical hypothyroidism in the older adult
• TSH elevated
• T4 levels normal
• May progress to overt hypothyroidism
• Older adults
• Insidious onset, subclinical presentation with atypical symptoms
• Most common complaint in older adult
• Fatigue, cold intolerance, weight gain, muscle cramps,
paresthesias and confusion
• Treatment
• Thyroid hormone replacement L-thyroxine
• Follow up 3,6, and 12 months
• Graves disease
• Autoimmune disorder associated with sustained thyroid over activity
• Treatment-

Hypothyroidism – Levothyroxine sodium

• The average dose for persons over 65 years of age is 25 to 30 mcg/day by

mouth.

Hyperthyroidism – radioactive sodium iodide (131I).