Care of the Older Adults

Skin Structure and Function of NORMAL AGE-RELATED CHANGES

Desquamation - Male pattern baldness common in men

- keratinocytes produces keratins - Changes in pigmentation with
- these keratins are the barriers accumulation of discoloration, photoaging
- melanocytes which gives skin colour and protects is common
effects from the sun - Decrease in accrine, apocrine, and
sebaceous glands
Most common signs of aging - Decrease number of melanocytes lending
- wrinkling to decreased photoprotection
caused by sunlight, photo aging - Decreased elasticity with decreased tensile
intervention: use sunscreen strength
- poor skin turgor - Decrease number of blood vessels with
corresponding decreased response to injury
Dermis and thermoregulation
- decreased blood flow - Hair thin and turns gray
- skin may get drier or gets fewer nutrition - Loss of eyelid elasticity
- losing sensation - Loss of subcutaneous tissue and thinning of
- composed of collagen and elastin > collagen is dermis
responsible for making skin looks tight > elastin helps - Decrease elastin associated with wrinkling
the skin holds like a scaffolding - Vascular lesions (cherry angiomas,
- skin is sagging petechiae, and telagectasia) become
- arrector pili more common
- sebaceous glands produces sebum which - Adipose tissue redistributes to the waist line
nourishes hair and hips
- sweat glands – sweat under the sun ganyorns - Increased probability of pressure ulcers due
- seborating dermatitis to decreased blood flow and thinner skin
> easily managed - Decreased touch receptors with
- protection corresponding slow or reflexes
- temperature maintenance
- synthesis and storage of nutrients Senile Purpura
- sensory reception - normal age related change
- excretion and secretion - patches of discoloration of skin that is related to
small breakages in the small blood vessels
INTEGUMENTARY SYSTEM

Functional Relationship
Melanocytes
- for skin color SKELETAL SYSTEM
- provides structural support
Carotene - synthesizes vitamin D3. Essential for calcium
- for pigmentation absorption

MUSCULAR SYSTEM
Hemoglobin - contractions of skeletal muscle pull against skin of
- for pigmentation and for O2 capacity face, producing facial expressions

NERVOUS SYSTEM
Effects of UV Radiation - controls blood flow and sweat gland for
- activates synthesis of Vitamin D thermoregulation
- responsible for photoaging, wrinkles, sunburn, - stimulates contraction of arrector pili muscles to
premature aging elevate hairs
- may cause carcinoma and melanoma - receptors in dermis and deep epidermis provide
sensations of touch, pressure,vibration, temperature
and pain Risk factors:
Intrinsic Factor
ENDOCRINE SYSTEM - Aging
- sex hormones stimulate sebaceous gland activity, - Chronic disease
male and female sex hormones influence hair - Impaired mobility and limited activity
growth, distribution of sc fat, and apocrine sweat - Incontinence
gland activity, adrenal hormone alter dermal blood - Malnutrition
flow and help mobilize lipid from adipocytes - Sensory impairment
- synthesizes vitamin D3 Extrinsic
CARDIOVASCULAR SYSTEM - pressure
- provide oxygen and nutrients - friction
- delivers hormones and cells of immune system, - shearing > sliding of parallel forces against
carries away CO2, waste products and toxins, each other
provides heat to maintain normal skin temperature - moisture > can cause skin to wrinkle
- stimulation by mast cells produced localized
change in blood flow and capillary permeability Structure, function and comorbidities

LYMPHATIC SYSTEM Pressure injuries are a result of poor nursing care

- assists in defending the integument by providing
addtional macrohpasges and mobilizing
lymphocyte
- provides physical barriers that prevent pathogen
entry; macrophages resist infection; mast cells
trigger inflammation and initiate the immune
response
RESPIRATORY SYSTEM
- provide oxygen and eliminates CO2
- hairs guard entrance in nasal cavity
DIGESTIVE SYSTEM
- provides nutrients for all cells and lipids for storage
by adipocytes
- synthesizes vitamin D3, needed for calciumand
phosporus absorption
Healthy Skin
*subcutaneous layer contains blood vessels and
cushioning fat
*dermis is where new cells are made
*bones support the body
*sweat glands lubricate the skin
*the epidermis is the outer protective covering
Fragile Skin
*subcutaneous layer has fewer and flatter fat
cells
*dermis produces cells more slowly
*bone protrude
*fewer sweat glands make less lubrication
*the epidermis is dry and loses cell layers

URINARY SYSTEM Most common area

- excretes waste products, maintains normal body - sacral area and ankles
fluid ph and ion composition
- assists in elimination of water and solutes; Red color
keratinized epidermis limits fluid loss through skin - indication of ischemia
Purple color
REPRODUCTIVE SYSTEM
- breakage in the blood vessels
- sex hormones affect hair distribution, adipose
Black color
tissue
- necrosis
- skin covers genitalia

Pressure ulcers in the elderly

COMMON ILLNESS IN THE ELDERLY IN THE SKIN
I. Stage 1
- PRESSURE ULCER
- is called pressure injury II. Stage 2
- an injury to the skin integrity where there are
stages III. Stage 3
- caused by unrelieved pressure
- occurs in soft tissue over bony prominences
- can be assessed through aging
 IV. Stage 4 obscure the depth of tissue loss; may include
undermining and tunneling
Deep Tissue Injury - red to dark red colored tissue where
epidermal area is lost 1-2 cm deep
Unstageable V. Stage 4
Full-thickness tissue loss with exposed bone,
Areas: tendon or muscle; slough or eschar may e present
Scapular, Occipital, Elbows, Sacral Area, Thighs, or some parts of the wound bed; often includes
Heel undermining and tunneling

most common is in sacral area and the second Unstageable

most common is in the heel Full-thickness tissue loss with the base of the ulcer
covered by slough (yellow, tan, gray, green or
- Already called a pressure injury brown) or eschar (tan, brown, black) in the wound
- A combination with shear pressure and bed
friction
- As we age the muscle, adipose tissues - According to the National pressure ulcer
(especially on bony prominences), and the advisory panel there is a new staging system
skin (thins) decreases for pressure ulcers
- Aging is the greatest risk for pressure ulcers - Always carefully assess pressure points and
- Bed-bound, immobile, and those who are bony prominences
healthy adults o Because if there is presence of this, it
is considered poor nursing care
- Blanching- a paling of a part of the skin
Assessment of pressure ulcers depending on stages because there is an obstruction in the blood
flow
NPUAP STAGING SYSTEM FOR PRESSURE ULCERS - Slough- a hanging tissue
o Usually the area that you need to
I. Suspected deep-tissue injury
remove because it can cause
- Purple or maroon localized area of discolored,
contamination
intact skin or blood filled blister caused by
o Flush off that slough
damage to underlying soft tissue from pressure or
o Before you do it, you should be a
shear; the discoloration may be preceded by
certified wound-care nurse
tissue that is painful, firm, mushy, boggy or warmer
o Three different types of microbiotic
or cooler compared with adjacent tissue
growth
II. Stage 1
o Contamination- presence of a
Intact skin with nonblanchable rednes of a
microorganism in an area
localized area, usually over a bony prominence,
o Colonization- proliferation of a
dark pigmented skin may not have visible
certain microorganism without
blanching, and the affected area may differ from
causing an infection (no
the surrounding area; the affected tissue may be
inflammatory response)
painful, firm, soft, or warmer or coolercompared
o Infection- the clients experience
with adjacent tissue
signs of inflammation
III. Stage 2
- Unstageable- deep, already has an eschar
Partial-thickness loss of dermis appearing as a
o Looks like charred tissue
shallow, open ulcer with a red-pink wound bed,
o Necrotic tissues are present
without slough; may also appear as an intact or
- They may present foul-smelling
open/ruptured serum-filled blister; this stage hould
manifestation over the injury
not be used to describe skin tears; tape burns,
o It may be infected- the most
perineal dermatitis, macerations, or excoriations
common opportunistic
- the epidermal area is already open,
microorganism that creates the foul
dermal area is exposed
odor is the pseudomonas aeruginosa
IV. Stage 3
▪ Wound will look beefy and
Full-thicknes tissue loss; subcutaneous fat may be
smell is foul
visible, but bone, tendon or muscle is not
o The wound is already necrotic
exposed; slough may be present, but does not
Nursing diagnosis
- Impaired skin integrity r/t skin lesions and
inflammatory response
o Defined as the state an individual
experiences damage of the
epidermal or dermal tissue
o Tissue integrity is used when the
damage already reaches the
deeper tissues
▪ Disruption on the tissue
▪ Incision
▪ Ulcers
- Risk for infection and pain may also be a
diagnosis
- Impaired skin integrity r/t skin lesions and
inflammatory response
- Risk for impaired skin integrity r/t physical
immobility
- Risk for impaired skin integrity r/t decreased
skin turgor
- Maturation Phase
Stages of wound healing
- Three phases of wound healing
- On the third phase it is divided into 2
o Maturation and contraction
- Inflammatory Phase
Bleeding occurs at the site of injury
immediately after the injury, and mas cellts in
the region trigger an inflammatory response
- Inflammatory responses activate during this
phase
o Macrophages has the growth factor
beta
o Initiates the control of the
inflammatory response and the
wound healing to focus on the
injured area
o Last for 5 days only
- Proliferation Phase
After several hours, a scab has formed and
cells of the stratum germinativum are
migrating along the edges of the wound.
Phagocytic cels are removing debris, and
more of these cells are arriving with the
enhanced circulation in the area. Clotting
around the edges of the affected area
partially isolates the region.
o Begins after the injury
o Up to 3 weeks of the injury
- A wound that does not heal in 6 weeks is
o Rebuilds the damage tissues
o With the use of the three tissue repair
processes
▪ Epithelization- covers the
denuded epithelial surface
▪ Cover the top area and
closes the skin In order for
repair to happen beneath
the epithelial covering
▪ Granulation- dermal area is
replaced
▪ Blood vessels are replaced
▪ Connective tissues are
developed and forms a
blood vessel- angiogenesis
▪ Collagen synthesis- collagen
strands are built in order to
form tissue and blood vessels
as well
o Exposing of wound
o Good circulation of oxygenated
blood
o Vitamins C and E
o Dietary amino acids
One week after the injury, the scab has been
undermined by epidermal cells migrating
over the meshwork produced by fibroblast
activity. Phagocytic activity around the site
has almost ended, and the fibrin clot is
disintegrating
o 1-3 weeks after the injury
o Process starts when collagen is being
synthesized and continues to create
thicker and more compact layers
between the epithelial layer
o Filling of the spaces of the wound
o Contraction
After several weeks, the scab has
been shed, and the epidermis is
complete. A shallow depression
marks the injury site, but fibroblasts in
the dermis continue to create scar
tissue that will gradually elevate the
overlying epidermis
A part off maturation
o A healed scar is present
o Scabs are present
o Initiated by the myofibroblasts- an
important healing mechanism
o Dark red and becomes whitish in
color (3-5 days) > covering will
slough off and there will be new
tissue in the area
already called chronic wound
o May be due to diabetes
o Peripheral vascular diseases
 o Adequate blood volume and
cardiac output in order for blood to
perfuse the area
Nursing management
- Use a lift sheet to prevent shearing injury
- Do not use any pulling or sliding movements
when assisting older radults with change in
their position
o You log roll the client
- Protect the older adult by padding any
surfaces that come in contact with leg and
arm movements such as side rails, wheelchair
arm and leg supports, and table corners
o Side rails, rails of the wheelchair
- Keep the environment free of obstacles and
well lit
- Avoid harsh soaps
o Harsh soaps will damage epithelial
layer
- Keep skin moist with adequate fluids
- Keep fingernails and toenails cut short and
filled to remove rough edges and prevent
self-inflicted skin tears
o Be careful not to injure the finger and
the toe nails of the client
o A podiatrist may do this is available
- Apply skin-moisturizing creams to arms and
legs twice daily
- Wear long sleeves and long pants to add a
layer of protection over the skin
- Use a lift sheet
- Do not use pulling
- Protect the older adult
- Keep the environments
o Should remove all rugs and carpets
o Because it may make the client at
risk for falling
Nursing care
- Assessing and staging the wound
o history of wound, pressure ulcer size and
depth, any evidence or signs of
tunneling, undermining, exudate and
infection
- Debriding necrotic tissues
- Sharp
o Use a scalpel
- Mechanical
o Wet to dry dressing
o Wound irrigation
- Chemical
o A topical agent that removes the slough
- Autolytic
o A moisturized retentive dressing
o Placed inside the wound
o A small mesh of cloth then a topical
material and collagen forming gel
o Increases healing capacity
o Mesh is absorbable
o To remove the dead tissues from the
wound and allow healing to progress
o Stop debridement if there is already no
necrotic tissue
- Cleansing the wound
o isotonic saline (0.9%)
o no povidone, iodine, acetic acid,
hydrogen peroxide, Dakin’s solution –
toxic to the wound fibroblasts and
macrophages as they are responsible
for the rate of wound healing
o debridement – to remove the dead
tissue from the wound and to allow
healing to progress
o stop debridement – if there is no longer
a necrotic tissue
Applying dressings to provide a moist wound bed
- a moist wound environment promotes cellular
activity in all phases of wound healing, provides
- insulation, increases the rate of epithelial cell
growth and reduces pain
- Preventing and treating infection
- contamination
- colonization
- infection
- Cleansing of wound
o Do not use povidone iodine,
hydrogen peroxide, dakin’s solution
and acetic acid this will destroy the
fibroblasts and macrophages
o They are responsible in controlling
the healing rate
o Use an isotonic saline solution (0.9%)
o Get a syringe, remove the needle
get saline, then gently spray it in the
wound
▪ This is much better because it
can remove slough
o Another way is to get a gauze then
squeeze
o Pain depends on the area of injury
o If dermal area is destroyed > no pain
because nerves are there
▪ Stage 1 and 2 there is still
pain
o Always drain the water, do not wipe
because it may cause further injury
- Applying dressings
o Should be soaked in a saline solution
 o Remember: dressings should be
changed 2-3 times a day
o If the dressing sticks to the wound,
wet it again with the same solution
then remove it gently
o Not too soaked because moisture is
also another factor for pressure injury
- Preventing and treating infection
o MRS. Aureus is a normal flora of the
skin but I it enters a wound it can
infect it
▪ Most common infective
agent
o A. Baumanii
▪ A usual colonizer
- Reposition client every 2 hours to reduce
extrinsic factors
- If client is sitting upright use pillows to cover
the edges
- Rolled towels (trochanter rolls) for heels and
ankles
- Do not use donut pillows because it causes
unrelieved pressure
- Avoid sitting for a long time
- Ask the client to ambulate
- Ask the client to exercise while seated
Nursing management of skin tears
- Use a lift sheet to prevent shearing injury
- Do not use any pulling or sliding movements
when assisting older radults with change in
their position
- Protect the older adult by padding any
surfaces that come in contact with leg and
arm movements such as side rails, wheelchair
arm and leg supports, and table corners
- Keep the environment free of obstacles and
well lit
- Avoid harsh soaps
- Keep skin moist with adequate fluids
- Keep fingernails and toenails cut short and
filled to remove rough edges and prevent
self-inflicted skin tears
- Apply skin-moisturizing creams to arms and
legs twice daily
- Wear long sleeves and long pants to add a
layer of protection over the skin
Nursing Management of Pressure Injury
● Reposition q2h. Use a pull sheet to prevent
shear and friction. If redness occurs,
consider a 12-hour turning schedule. The
older adult should be turned in a 30 angle
position to the mattress when on his or her
side.
o 4-6 hours ulcerations can progress
o Always take note of the depth,
length and width, signs of infection,
and tunneling 
o Macrophages and fibrinogens
secrete growth factor beta
o pressure injuries are also associated
with quality of care
o create a schedule for the positioning
for every 2 hours
o use a draw sheet to turn the patient
to prevent shear and friction
o turning client needs two nurses
o put a pillow on the back of the
patient when turning so he will not
fall back flat
o always make sure that linens and
diapers are not soaked
o follow the schedule for turning
● Ensure proper positioning. Use pillows or
wedges to prevent the skin from touching
the bed on a trochanter, heels, and ankles.
Do not use rings or donuts.
o use trochanter pillows between the
legs to prevent friction
o do not use donuts because it does
not decrease the risk of
development of pressure injuries
● Avoid sitting. The sitting position, either in
bed or in the chair, should be limited to 2
hours. Time in the chair should be scheduled
around mealtimes. The person in bed should
not be left in the 90-degree position except
during meals.
o encourage the client to walk
o if the movement is limited use a
walker
o if client is not able to move assist
from bed to chair vice versa
● Increase activity. Encourage older adults to
change positions by making small body
shifts. This will redistribute weight and
increase perfusion. Range-of motion
exercises should be done every 8 hours, and
the techniques should be taught to family
and patients.
o move the legs and arms sideways or
up and down to exercise it
● Keep the skin clean and dry.
o provide bath at least once a day 
● Lubricate the skin with a moisturizer.
Massage the area around the reddened
area or bony prominence. (Do not massage
any reddened area.) Then apply a thin layer
of a petroleum-based product, followed by
a baby powder-cornstarch product, to
reduce friction and moisture
o apply emollient creams to provide
protection and to prevent pressure
injuries
 o massage around the area to aid in
circulation and prevent venous
pooling
● Evaluate and manage incontinence. A
bowel and blad-der management program
should be in place. If soiling occurs, skin
should be cleansed per routine. Underpads
that absorb moisture and present a
quick<drying surface to the skin should be
used. Plastic-lined bed pads should not
contact the person's skin. Use minimal pads
and cover them with a sheet or pillowcase.
o if patient has diarrhea replaced and
check the diaper routinely
o assess the patient if he or she has
urinary incontinence because this is
a common problem for the older
adults
o if patient is not bed bound,
bedbound keep commode or
bedpan near the bed
o use underpads and diapers in order
to decrease soiling of linens
● Monitor nutrition. Determine factors that
might cause inadequate nutrition. Obtain
laboratory data. Provide additional canned
supplements, vitamin C, and zinc to
promote skin healing.
o increase protein intake
o bed bound patients are mostly fed
through the nasogastric tube or
percutaneous endoscopic
gastrostomy tube
o PEG  tubes are placed on the
abdomen directly inserted to the
colon and is a permanent tube
o nasogastric tube should be changed
after 72 hours because it is only
temporary
● <16 score indicates at risk for pressure injury
● assessment of risk of development of
pressure ulcers
● determines if patient is high risk or not
● if there is a risk create a prevention plan
including the turning schedule
●  friction or shear force
o when  patient uses an air mattress
there is decreased risk of friction or
sheer
o air mattresses are connected to a
machine which continuously pumps
air and detects where pressure is
● the braden scale is one part of the
comprehensive geriatric assessment
Braden Scale for Predicting Pressure Sore Risk
The Hartford Institute for Geriatric Nursing
recommends this scale be used for risk
assessment in the following categories of older
patients:
● All bed- or chair-bound patients, or those
whose ability to reposition is impaired
● All at-risk patients on admission to
healthcare facilities and regularly thereafter
● All older patients with decreased mental
status, incontinence, and nutritional deficits
● First important thing to do is assess and
stage the wound
● For monitoring healing of pressure ulcers 
● First component is the length and the width
of the wound
● also include the depth of the wound-  this
will determine the grade and the stage of
the ulcer
● Tissue types
o 1 Common are abrasions
o 2  lacerations or cuts 
● Results will help in managing and preparing
the treatment and medications needed
● a score lower than six you only need to
apply topical medications and dressing
● a score greater than eight provide more
extensive treatment
● this tool also helps in the referral of the client
to the wound care nurse
● Clean pressures with no presence of healing
warrants topical medications
● if pressure orders have discharge but no
presence of infections topical antibiotics are
needed
● Cellulitis- is an infection of the hypodermis
o Nonnecrotizing infection
o Manifested by redness, swelling, pain
in the affected leg
o most common causes of cellulitis is
staphylococcus and streptococcus
bacteria
o most often a clean ulcer does not
have cellulitis
● No presence of cellulitis but is in stage 1
o Only apply protective dressing
● Stage 2 (damage of the epidermis and
dermis) without the damage of the
hypodermis
o Wound dressing if clean wound
o Use moist dressing
o There is blood vessels in that area,
therefore it may be invaded by
microbes
● Stage 3 and stage 4 without tissue necrosis
o Surgery doctors will prescribe
medications and determine if
patient is a candidate for
debridement and the type of
debridement
o All wounds should be referred to
surgery
o Stage 3 and 4 should be referred to
the senior resident on duty (SROD)
● If wound does not improve in 14 days five
topical antibiotics already, then clean the
wound and dress it
Four Elements of Negligence
● Duty of care
● Breach of duty
● Causation of injury to the victim
● Damages to the victim
● All of these should be present to be
considered negligence
Changes in vision and hearing of older adults
- Visual impairment is defined as visual acuity
of 20/40 or worse while wearing corrective
lenses, and legal blindness or severe visual
impairment is 20/200 or more as measured by
a Snellen wall chart at 20 feet
- Visual impairment and blindness in the older
person is the result of our main causes:
cataracts, age-related macular
degeneration, glaucoma, and diabetic
retinopathy
- Assessment of the vision we check the
appearance of the ears first
- Check the clothing, discolorations/
inappropriate makeups, check the behavior,
bruises
o The client may be exhibiting visual
impairments
- The nurse should also assess the eyes for
abnormalities
o Assess discharges, movements of
eyelids, excessive tearing, absence of
a pupillary response, and abnormal
color of sclera
o Acuity test- performed in a low-light
room
o May appear without no visual deficits
in this condition
o Because they may have a problem
with glares
- Ask them if they experience, eye discharges,
headaches, eye strains when reading or
doing tasks, feel any foreign body sense,
flashing lights,
- Visual impairment can lead to a loss of
independence, social isolation, depression,
and a decreased quality of life
o Because the client can no longer see
or do what he/she usually does
- Visual impairment increases the risk of falls
and fractures, making it more likely that an
older person will be admitted to a hospital or
nursing home, be disabled, or die
prematurely (Ham, Sloane, Warshaw et al.,
2007)
o Arcus senilis- is a grayish or yellowish
ring around the cornea
▪ These are lipid deposits but is
not related to
hypercholesterolemia or any
lipid abnormalities
 ▪ No negative effect
o Lens thickens and hardens- a
yellowish or opaque color will be
observed
▪ Lens help light focus with this,
light will scatter and interfere
with color discrimination
▪ Increase the risk the risk of
injury or accident
o Pupils slow in reacting to light
▪ Client will read from a far or
near because pupils have a
delay in focusing
▪ Making older adults harder to
adapt to light
- The healthy older adult should schedule a
complete eye examination every other year.
During this examination, visual acuity should
be evaluated, pupils should be dilated with
examination of the retina, and intraocular
pressure should be tested. Older adults with
diabetes should have this complete visual
evaluation yearly (Reuben et al., 2011)
o Brightness contrast, darkness
adaptation, and recovery to glare
o IOP should be measured, because
this may result to glaucoma
o Diabetic retinopathy
Vision: nursing care
- Safety is a major concern with vision changes
in the older adult
- Because pupillary reaction slows with age, an
old adult requires more time to become
acclimated with changes in light intensity.
Nurses should instruct patients on the
importance of walking slowly when entering
a room with brighter or dimmer light
- Provide adequate lighting in high-traffic
areas
- Recommend motion sensors to turn on lights
when an older adult walks into a room
- Look for areas where lighting is inconsistent.
Dark or shadowy areas can obscure objects
- Use proper lampshades to prevent glares
o Lampshades with bulbs that are not
exposed
o Because when there is glare it causes
temporary blindness in the older adult
d/t the slowness of the reaction of
pupils
- Use contrast when choosing paint colors so
that the older person can easily discriminate
between walls, floor, and other structural
elements of the environment
o Use striking colors on the floors but
light colors on the floor
- Avoid reflective floors
- When designing signs, use bright colors such
as red, orange, and yellow. Avoid soft blues,
grays, and light greens because the contrast
between colors will be poor
o Use anti-slip
- Use supplementary lamps near work and
reading areas
- Use red-colored tape or paint on the edges
of stairs and in entryways to provide warning
and signal the need to step up or down
- Avoid complicated rug patterns, that may
overwhelm the eye and obscure steps and
ledges
Age-related macular degeneration
- Age-related macular degeneration (ARMD)
is the leading cause of blindness in adults
over the age of 65
- ARMD is a degenerative disorder of the
macula that affects both central vision
(scotoma) and visual acuity
- Patterns with ARMD often require more light
for reading. They often experience blurry
vision, central scotomas (blind spots within
the visual field), and metamorphosia, in
which images are distorted to look smaller
(micropsia) or larger (macropsia) than they
actually are
- Central vision is mainly affected by this
disorder, and peripheral vision remains intact
(NEI, 2009). A person with macular
degeneration will experience a dark spot in
the center of the field of vision and must
learn to rely on and interpret peripheral vision
in order to function
- Risk factors
o Age
o Smoking
o Family related
o Increased exposure to UV light
o Hypertension and cardiovascular
disease
- How to prevent
o Consume high doses of antioxidants
- 25% reduction in the development of
age-related macular degeneration by
consuming high doses of antioxidants
(vitamin C and E, beta-carotene) and zinc
- Lutein and zeaxanthin are antioxidant
beta-carotenoid pigments that concentrate
in the eyem is associated with a lower risk of
ARMD
o Enhance betacarotinoid treatments
concentrated in the eyes preventing
loss if vision and lowering the risk of
ARMD
- These nutrients are found in eggs, spinach,
romaine lettuce, broccoli, corn, and Brussel
sprouts
Cataracts
 - Cataracts cloud the lens, decrease the
amount of light to reach the retina, and
inhibit vision
- Nurses should encourage the elderly or other
people to prevent looking at the sun or wear
UV protective lenses when under the sun,
avoid smoking routinely
- Leading cause of blindness in the world
- Development is slow and painless, and may
be unilateral and bilateral
- Cataracts are the leading cause of blindness
in the world
o Types of cataracts
o Nuclear (central), cortical (cortex),
sub capsular (at the back), mix
o Nuclear cataract are most common
- Patients with cataracts may experience
blurry vision, glare, halos around the objects,
double vision, difficulty sensing contrasting
colors because colors appear faded or
discolored, and poor night vision
- Squinting primary sign of all
- Age, smoking, obesity, comorbidities, trauma
in the eyes, exposure to lights, use of
corticosteroids
- Treatment of choice is surgery
o Done in an out-patient basis
o Topical or local anesthesia is used
- Can develop unilateral or bilateral
- When removed it can come back
Cataracts: nursing care
- Post-surgical education includes
reinforcement not to lift any heavy objects,
strain at stool, or bend at the waist
o Preventing intraocular pressure,
because there is increase the injury to
the area may worsen
o How does bending affect? Bending,
straining, lifting heavy things you
increase your intrathoracic pressure
then increase IOP
- Patients with cognitive impairments such as
Alzheimer’s disease must be carefully
supervised for at least 24 hours after surgery
to ensure that they do not remove the
protective eye patch and do not rub their
eye
o If there is bilateral cataract, surgery
should be done on one eye first then
the other
o Make sure all the eye drops
prescribed will be religiously
administered
o Three eye drops that will bbe given
after surgery: decreasing IOP,
antibacterial, protective gel for the
eyes
- When surgery is needed in both eyes, one
eye is done first and the second procedure is
scheduled a month or so later to allow
healing and recovery
Glaucoma
- Is associated with optic nerve damage d/t
an increase in IOP, which can ultimately lead
to vision loss
- Presenting manifestation: peripheral vision
problem
- Increase in IOP affects canal of schlemm
and trabecular meshwork where fluids are
drained, thus
o Blockage of fluids
o Aqueous humor- nourishes the tissues
of the eyes
o Normal 10-20 mmHg, average is 15
mmHg
o Fluids will accumulate in canals and
meshwork
o Optic nerve will atrophy d/t high IOP
> vision loss
- Risk factors is increase IOP, age, family
history, myopia, diabetes, and HPN
Glaucoma: Nursing care
- When administering eye drops, it is important
for the nurse to wash his or her hands, ask the
patient to tip the head backward and look
upward, then pull the lower lid down slightly
to make a small pouch
- The nurse should try not to drop the
medication directly into the eye but rather
into the eyelid pouch to prevent a violent
blink reflex and excessive tearing
o This will cause the medication go out
- Screening schedule is at the age of 65 at
least every 1 or 2 years
o Acuity with or without corrective
lenses
o Visual field test
o Measurement of IOP
▪ Ask the client to tell what time
of the day does the IOP
increases
o Two types of glaucoma
▪ Acute angle glaucoma-
painful
▪ Closed-angle glaucoma
o Check also the optic nerve through
the use of an otoscope
- Management is lowering the IOP
o Use of eye drops
o E.g. myotics, alpha-adrenergic
blockers, and carbonic anhydrase
inhibitors
o First line therapy to decrease IOP
beta blockers
- Educate the clients on the adverse and side
effects
 o Some may cause vascular and
cardiovascular effects like occupress
(beta blocker)
o When used for a long time may cause
bradycardia, syncope
o Adrenergics- may cause other
problems e.g. alphagan (palpitations)
o Myotics- pilocarpine (cholinesterase
inhibitors/ anticholinergics, dryness of
the mucus membranes) > always
check for dryness of the mucosa
o May manifest bronchospasm,
salivation, N and V
o Carbonic anhydrase inhibitors- Azopt
(may cause hypokalemia)
- If medications is unable to decrease IOP (eye
pain and peripheral vision loss) suggest
surgery, especially for clients with acute
angle glaucoma
o Iridotomy is done
o There will be small opening in the
base of the iris where aqueous humor
will drain prevents the increase of IOP
o Done through laser
o There will be temporary blurring of
vision to the patient
o Done in an outpatient basis
Diabetic retinopathy
- 4th reason that causes blindness in the elderly
- Microvascular disease of the eye
- No insulin > glucose cannot enter > blood will
become viscous > slower blood flow>
clotting > clogging of blood vessels > tissue
necrosis may occur d/t decreased blood
flow > or increase pressure after the clog >
ruptures may occur > necrosis > blindness
● Prevention of diabetic retinopathy is
dependent on the tight glycemic control in
addition to managing hypertension and
hyperlipidemia
o If client is at risk of diabetes tell the
patient to cut off sugar or glycemic
control
o Low carbs and low cholesterol and
exercise
o Teach the client how to self-check
their glucose
● Goals of treatment for patients with
diabetes include maintaining an average
preprandial blood glucose of 80 to 120
mg/dL, an average bedtime capillary blood
glucose of 100 to 140 mg/dL, and
hemoglobin (HbA1c) of less than 7
● Nurses educate patients about diabetes
mellitus and the importance of glycemic
control to prevent retinopathy
● Proper nutrition, including a
low-carbohydrate and low cholesterol diet,
is imperative to keep blood glucose levels
down and decrease the risk not only of
cardiovascular disease and hypertension
but also to decrease the risk of
microvascular damage to the eyes
● Exercise helps to lower glucose levels, burn
extra calories for weight management, and
reduces insulin resistance in people with
type 2 diabetes
● The nurse should educate patients on how
to check serum glucose levels, when and
how to administer medications (insulin or
oral hypoglycemic medications), and signs
and symptoms of hypoglycemia and
hyperglycemia
o Preprandial blood glucose- before
eating
o At least 30 minutes before eating
o If diabetic it’s okay if 100-140 mg/dL
o HbA1c and CBG are determinants of
diabetes
▪ Monitoring every meal for
CBG and every month HbA1c
to determine if diabetes is
progressing
- Mircoaneurysms > outpouching > poor blood
flow > retinal ischemia > blindness
- Eyes can adapt > retina create new blood
vessels > neovascularization > prevents
retinopathy but will cause glaucoma
- May occur around iris block drainage >
neovascular glaucoma
- If this occurs laser therapy may be suggested
- Manifestation: gradual vision loss with
generalized blurring and areas of focal vision
loss
o Retinopathy- vision loss is scattered
o Glaucoma- peripheral vision loss
- If left untreated retinopathy may lead to
blindness
- If it occurs both the first disease to appear will
be the manifestation
Age-relate changes in hearing
● Hearing loss can interfere with
communication, enjoyment of certain forms
of entertainment such as music and
television, safety and ultimately
independence
- Hearing impairments make communication
● In the older adult, cerumen tends to be drier
and harder, and tends to accumulate in the
ear canal due to decreased activity of the
apocrine glands. hearing may become
impaired if cerumen accumulates
impacting in the canal
● Cerumen impaction is one of the most
common and reversible causes of
conductive hearing loss in older adults
o Other factors that leads to hearing
loss
o Long term exposure to loud noises
 o Ototoxic medications
o Tumor in ear
o Middle ear infection
o Smoking
o Short exposures to extreme loud
noises like explosions, gun shots, may
cause hearing loss
▪ May affect the organ of corti
in the cochlea
Hearing: Nursing care
● Recommend aural hygiene involves gentle
cleansing of the auricles (outside of the
ears) while bathing or showering. the use of
cotton-tipped applicators to cleanse the
ear canal is not recommended, because
the applicator may push the cerumen
deeper into the canal and thus increase the
risk of impaction, as well as traumatize the
canal wall and tympanic membrane
(McPhee and Papadakis, 2011)
o Do not use eartips because it may
damage the tympanic membrane
o Curette- low risk of infection
▪ Disadvantage you need to be
very careful because high risk
injury
▪ A small instrument with a
scoop on the end is inserted
into the ear canal while the
helix is lifted posteriorly and
laterally
o Lavage or irrigation
▪ Irrigation is the simpler and
more straightforward
approach to cerumen
removal
▪ Place ear drops or mineral oils
to moisten the ear wax to be
easily irrigated
▪ Risk for water and infectious
agents in increased
▪ Tympanic membrane may be
perfoarated
▪ Do not do this if tympanic
membrane is perforated, tuor
▪ Done in caution if client is
diabetic
● Examination of the ear may reveal an
external infection or impaction that can be
treated appropriately to resolve the hearing
loss. if the problem is not that obvious, a few
basic screening tests can be performed: the
whisper, weber, and rinne tests
o Should be done on a regular basis, do
it simultaneously with optacheck
- Impacted cerumen checked every after
bath
● The working condition of the hearing aid is
then assessed. assessment parameters
include
o Integrity of the ear mold
▪ Check for cracks and rough
areas
o Battery
▪ Check if batteries are clean,
remove always after use
o Dials
▪ Check is dials are easily
rotated
o Switches
▪ If it can easily turn the device
on and off
o Tubing for behind the ears
▪ Are there cracks?
▪ Good connection between
the tubing and ear mold?
o Do not wet the hearing aids
o Do not soak or use alcohol just wipe
o Battery should be stored in a cold
place
o Should be placed by audiologist
every year
● Eliminate extraneous noise in the room. for
example, with the patient's permission turn
the radio or television down or off
● Stand two to three feet from the patient
● Gain the patient's attention before
speaking. touch lightly on the arm or
shoulder if needed
● Try to lower the pitch of your voice
● Pause at the end of each phrase or
sentence
● If the patient has a hearing aid, provide
assistance with the device, plus glasses if
needed
● Assess the illumination in the room and
make sure that the patient can see you.
seize the patient at all times during the
conversation
● The patient may read lips, so it is important
not to cover your mouth or chew gum. do
not speak into the chart or converse with
someone over your shoulder. the patient to
misinterpret your message
● Speak slowly and clearly in a normal tone of
voice-- do not shout
● If the patient does not understand your
message, rephrase it rather than repeating
the same words
● Gestures, if appropriate, may help
● Use written communication if the patient is
able to see and read
● Ask the patient for an oral or written dress to
determine if the communication was
successful