Care of the Older Adults

Skin Structure and Function of - Decreased elasticity with decreased tensile

strength
Desquamation
- Decrease number of blood vessels with
- keratinocytes produces keratins
corresponding decreased response to injury and
- these keratins are the barriers
thermoregulation
- melanocytes which gives skin color and protects effects
- Hair thin and turns gray
from the sun
- Loss of eyelid elasticity
Most common signs of aging - Loss of subcutaneous tissue and thinning o8f
- wrinkling dermis
caused by sunlight, photo aging - Decrease elastin associated with wrinkling
intervention: use sunscreen - Vascular lesions (cherry angiomas, petechiae,
- poor skin turgor and telangiectasia) become more common
Dermis - Adipose tissue redistributes to the waist line and
- decreased blood flow hips
- skin may get drier or gets fewer nutrition - Increased probability of pressure ulcers due to
- losing sensation decreased blood flow and thinner skin
- composed of collagen and elastin > collagen is - Decreased touch receptors with corresponding
responsible for making skin looks tight > elastin helps slow or reflexes
the skin holds like a scaffolding
- skin is sagging Senile Purpura
- arrector pili - normal age-related change
- sebaceous glands produces sebum which nourishes - patches of discoloration of skin that is related to small
hair breakages in the small blood vessels
- sweat glands – sweat under the sun ganyorns Functional Relationship
- seborating dermatitis
> easily managed SKELETAL SYSTEM
- protection - provides structural support
- temperature maintenance - synthesizes vitamin D3. Essential for calcium
- synthesis and storage of nutrients absorption
- sensory reception
- excretion and secretion MUSCULAR SYSTEM
- contractions of skeletal muscle pull against skin of face,
INTEGUMENTARY SYSTEM producing facial expressions

Melanocytes NERVOUS SYSTEM

- for skin color
Carotene
- for pigmentation
Hemoglobin
- for pigmentation and for O2 capacity
Effects of UV Radiation
- activates synthesis of Vitamin D
- responsible for photoaging, wrinkles, sunburn,
premature aging
- may cause carcinoma and melanoma
NORMAL AGE-RELATED CHANGES
- Male pattern baldness common in men
- Changes in pigmentation with accumulation of
discoloration, photoaging is common
- Decrease in eccrine, apocrine, and sebaceous
glands
- Decrease number of melanocytes lending to
decreased photoprotection
- controls blood flow and sweat gland for
thermoregulation
- stimulates contraction of arrector pili muscles to elevate
hairs
- receptors in dermis and deep epidermis provide
sensations of touch, pressure, vibration, temperature
and pain
ENDOCRINE SYSTEM
- sex hormones stimulate sebaceous gland activity, male
and female sex hormones influence hair growth,
distribution of sac fat, and apocrine sweat gland activity,
adrenal hormone alter dermal blood flow and help
mobilize lipid from adipocytes
- synthesizes vitamin D3
CARDIOVASCULAR SYSTEM
- provide oxygen and nutrients
- delivers hormones and cells of immune system, carries
away CO2, waste products and toxins, provides heat to
maintain normal skin temperature
- stimulation by mast cells produced localized change in - Healthy Skin
blood flow and capillary permeability *subcutaneous layer contains blood vessels and
cushioning fat
LYMPHATIC SYSTEM *dermis is where new cells are made
- assists in defending the integument by providing *bones support the body
additionaladdtional macrophagesmacrohpasges and *sweat glands lubricate the skin
mobilizing lymphocyte *the epidermis is the outer protective covering
- provides physical barriers that prevent pathogen entry;
macrophages resist infection; mast cells trigger Fragile Skin
inflammation and initiate the immune response *subcutaneous layer has fewer and flatter fat cells
RESPIRATORY SYSTEM *dermis produces cells more slowly
- provide oxygen and eliminates CO2 *bone protrude
- hairs guard entrance in nasal cavity *fewer sweat glands make less lubrication
*the epidermis is dry and loses cell layers
DIGESTIVE SYSTEM
- provides nutrients for all cells and lipids for storage by Most common area
adipocytes - sacral area and ankles
- synthesizes vitamin D3, needed for calcium Red color
andcalciumand phosphorusphosporus absorption - indication of ischemia
Purple color
URINARY SYSTEM - breakage in the blood vessels
- excretes waste products, maintains normal body fluid Black color
ph and ion composition - necrosis
- assists in elimination of water and solutes; keratinized
epidermis limits fluid loss through skin Pressure ulcers in the elderly

REPRODUCTIVE SYSTEM I. Stage 1

- sex hormones affect hair distribution, adipose tissue
II. Stage 2
- skin covers genitals
III. Stage 3
COMMON ILLNESS IN THE ELDERLY IN THE SKIN
IV. Stage 4
- PRESSURE ULCER
- is called pressure injury
Deep Tissue Injury
- an injury to the skin integrity where there are
stages Unstageable
- caused by unrelieved pressure
- occurs in soft tissue over bony prominences Ar[ eas:
- can be assessed through aging Scapular, Occipital, Elbows, Sacral Area, Thighs, Heel

Risk factors: most common is in sacral area and the second most
Intrinsic Factor common is in the heel
- Aging
- Chronic disease - Already called a pressure injury
- Impaired mobility and limited activity - A combination with shear pressure and friction
- Incontinence - As we age the muscle, adipose tissues
- Malnutrition (especially on bony prominences), and the skin
- Sensory impairment (thins) decreases
Extrinsic - Aging is the greatest risk for pressure ulcers
- pressure - Bed-bound, immobile, and those who are
- friction healthy adults
- shearing > sliding of parallel forces against each
other Assessment of pressure ulcers depending on stages
- moisture > can cause skin to wrinkle
NPUAP STAGING SYSTEM FOR PRESSURE
ULCERS
Structure, function and comorbidities
I. Suspected deep-tissue injury
Pressure injuries are a result of poor nursing care - Purple or maroon localized area of discolored, intact
skin or blood-filled blister caused by damage to
 underlying soft tissue from pressure or shear; the
discoloration may be preceded by tissue that is painful,
firm, mushy, boggy or warmer or cooler compared with
adjacent tissue
II. Stage 1
Intact skin with non-blanchablenonblanchable
rednessrednes of a localized area, usually over a bony
prominence, dark pigmented skin may not have visible
blanching, and the affected area may differ from the
surrounding area; the affected tissue may be painful,
firm, soft, or warmer or cooler
comparedcoolercompared with adjacent tissue
III. Stage 2
Partial-thickness loss of dermis appearing as a
shallow, open ulcer with a red-pink wound bed, without
slough; may also appear as an intact or open/ruptured
serum-filled blister; this stage shouldhould not be used
to describe skin tears; tape burns, perineal dermatitis,
macerations, or excoriations
- the epidermal area is already open,
dermal area is exposed
IV. Stage 3
Full-thicknessFull-thicknes tissue loss; subcutaneous
fat may be visible, but bone, tendon or muscle is not
exposed; slough may be present, but does not
obscure the depth of tissue loss; may include
undermining and tunneling
- red to dark red colored tissue where
epidermal area is lost 1-2 cm deep
V. Stage 4
Full-thickness tissue loss with exposed bone, tendon
or muscle; slough or eschar may be present or some
parts of the wound bed; often includes undermining
and tunneling
Unstageable
Full-thickness tissue loss with the base of the ulcer
covered by slough (yellow, tan, gray, green or brown) or
eschar (tan, brown, black) in the wound bed
- According to the National pressure ulcer
advisory panel there is a new staging system for
pressure ulcers
- Always carefully assess pressure points and
bony prominences
o Because if there is presence of this, it is
considered poor nursing care
- Blanching- a paling of a part of the skin because
there is an obstruction in the blood flow
- Slough- a hanging tissue
o Usually, the area that you need to
remove because it can cause
contamination
o Flush off that slough
o Before you do it, you should be a
certified wound-care nurse
o Three different types of macrobiotic
growth
o Contamination- presence of a
microorganism in an area
o Colonization- proliferation of a certain
microorganism without causing an
infection (no inflammatory response)
o Infection- the clients experience signs of
inflammation
- Unstageable- deep, already has an eschar
o Looks like charred tissue
o Necrotic tissues are present
- They may present foul-smelling manifestation
over the injury
o It may be infected- the most common
opportunistic microorganism that creates
the foul odor is the pseudomonas
aeruginosa
▪ Wound will look beefy and smell
is foul
o The wound is already necrotic
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
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 celts 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 cells 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
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 on
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
- Maturation Phase
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
- A wound that does not heal in 6 weeks is
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 adults 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, 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 adults 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 bladder management program should be in
place. If soiling occurs, skin should be cleansed
per routine. Under pads 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 under pads 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 Non-necrotizing infection
o Manifested by redness, swelling, pain in
the affected leg
o most common causes of cellulitis are
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 are 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 lighter for
reading. They often experience blurry vision,
central scotomas (blind spots within the visual
field), and metamorphopsia, 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 eyes
is associated with a lower risk of ARMD
o Enhance beta arotinoid 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 is 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 be 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 Adrenergic- 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 pre-prandial
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
- Microaneurysms > 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 lead 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 cortex 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 ear tips 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
perforated
▪ Do not do this if tympanic
membrane is perforated
▪ 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 opt check
- 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