NURSING GERONTOLOGY

Mrs. Sheryll Liz B. Regis, RN,RM

College of Nursing
St. Paul University Dumaguete
Alcohol and caffeine containing beverages should not
be included in the fluid total.

Cognitive impaired adults should be offered fluids

throughout the day.
► risk for dehydration
 Symptoms felt to be better indicators of dehydration
include:

1. sunken eyes
2. headache
3. lightheadedness
4. confusion
5. dry mucous membranes
6. long tongue furrows
7. dry axillae
8. Lethargy
9. darkened urine
10. ↓ed urine output
Common supplements that older persons may be
taking for reasons other than prevention of
deficiencies:

1. Folic acid, vitamin B12 and B6 for

hyperhomocysteinemia

 High levels of homocystein concentration are

associated with increased risk of cardiovascular
disease and stroke.
 Supplementation with both folic acid and B12 has
been shown to lower high homocystein plasma
concentration. ( Homocystein Lowering Trialist
Collaboration 1998).
 Sensory and Perceptual Changes

1. Vision

2. Hearing

3. Taste and Smell

4. Physical Sensation
Sensory and Perceptual Changes : Eyes / Vision
 Sensory and Perceptual Changes : Eyes / Vision

Decreased orbital fat – sunken eyes

Decreased elasticity of lids – ectropion or entropion
Decreased tears – dry eyes
Decreased corneal sensitivity – ↓ed corneal reflex
Increased lipid deposits around cornea – arcus senilis
Decreased aqueous humor –↓ed lens accommodation
Atrophy of ciliary muscles –↓ed peripheral vision
Decreased elasticity of the lens- ↓ed ability to adapt to
light and dark
 Sensory and Perceptual Changes : Eyes / Vision

9. Increased density of lens – glare intolerance

10. Decreased color of iris – impaired night vision
11. Decreased pupil size – decreased visual acuity
12. Increased vitreous debris – floaters
13. Thickening of the lens, presbyopia
14. Decreased color perception (difficulty discriminating
colors like blue, green and purple)
 Environmental modifications

1. Provide adequate lighting in high traffic areas

2. Recommend motion sensors to turn on lights when

an older person walks into a room.

3. Look for areas when lighting is inconsistent. Dark

and shadowy areas can obscure objects.

4. Use proper lampshades to prevent glare.

.
 Environmental modifications

5. Use contrast when painting so that older person can

easily discriminate between walls, floors and other
structural elements of the environment

6. Avoid reflective floors.

7. When designing signs, use bright colors such as

red, orange and yellow. Avoid soft blues, grays and
light greens because the contrast between the
colors will be poor.
 Environmental modifications

8. Use supplementary lamps near work and reading

areas.

9. Use red colored tape or paint on the edges of stairs

and on entryways to provide a warning and signal
the need to step up or down.

10. Avoid complicated rug patterns that may

overwhelm the eye and obscure steps and edges
 VISUAL PROBLEMS

1. ARMD (Age related macular degeneration)

– degenerative disorder of the macula which affects
both central vision(scotoma) and visual acuity
2 types:

Dry form – or atrophic form

occurs as a result of
atrophy, retinal
pigment degeneration
and drusen accumulation.
b. Wet form (also known as Neovascular exudate
ARMD)

– blood or serum leaks from newly formed

blood vessels beneath the retina. This
seepage of fluid ultimately leads to scar
formation and visual problems
Patient with ARMD

a. They experience blurry vision

b. central scotomas (blind spots within the visual field)

c. metamorphopsia in which images are distorted to

look smaller (micropsia) or larger ( macropsia) than
they actually are.

d. straight line appear crooked or wavy. (wet form)

e. Experience dark spot in the center of field of vision

 Risk factors for ARMD
a. Age above 50

b. Family hx of ARMD

c. Cigarette smoking

d. hypertension and cardiovascular disease

e. Drug side effects

f. Increased exposure to UV light

g. Caucasian race and light colored eyes

h. Lack of dietary intake of antioxidants

 DIAGNOSING ARMD

History

Exam procedures Used

a. Amsler’s Grid

b. Color Vision

c. Retinal Exams
Direct Opthalmoscopy

Indrect Binocular
Ophthalmoscopy
Biomicroscopy (90 3D Lens)
 Patient education

People over age 65 should be examined every 1 to

2 years.

Preventive measures such as:

- wearing protective lenses in the sun
- smoking cessation
- exercising routinely
- healthy diet consisting of fruits and vegetables
Current recommendations for those with ARMD include:

1. zinc oxide 80mg

2. cupric oxide 2mg

3. betacarotene 15 mg

4. Vitamin C 500mg

5. Vitamin E 400Iu taken in divided doses twice a day

to slow the risk of progression.
2. CATARACT - opacities or yellowing of the lenses

Signs and symptoms:

a. Cloudy, blurred or dim vision
b. Increasing difficulty with vision at night
c. Sensitivity to light and glare
d. Halos around lights
e. The need for brighter light for reading and
other activities
f. Frequent changes in eyeglass or contact lens
prescription
g. Fading or yellowing of colors
h. Double vision in a single eye
 Different Types of cataract

Age-related cataract

Congenital cataract

Secondary cataract

Traumatic cataract
Risk Factors

1. Age

2. Diabetes

3. Family history of cataracts

4. Previous eye injury or inflammation

5. Previous eye surgery

6. Prolonged use of corticosteroids

Methods of cataract removal

1. Intracapsular Cataract Extraction (ICCE) – the lens is

removed within its capsule through a small incision. A
lens implantation may be performed.

2. Extracapsular cataract extraction – the lens is lifted

out without removing the lens capsule, may be
performed with phacoemulsification in which lens is
broke up by an ultrasonic vibration and extracted.

3. Phacoemulsification (Phaco)
3. GLAUCOMA
- is associated with optic nerve damage due to an
increase in IOP which can lead to vision loss.
- When the IOP is greater than 21mmhg, the optic
nerve has the potential for atrophy and vision loss.
- Increase IOP as a result of inadequate drainage of
aqueous humor from the canal of schlemm or the
overproduction of aqueous humor  damage the
optic nerveleads to progressive loss of vision 
leads to blindness if not properly dx and treated.
2 types:
a. open angle glaucoma
b. angle closure glaucoma
2 types:
a. open angle glaucoma – most common form of
glaucoma.
- no early symptoms with the IOP slowly rising
and the cornea adapts without swelling.
- characterized by excessive production of fluid
inside the eye which does not drain properly. It does
not drain the excess fluid at a pace sufficient to
prevent the rise of IOP.
- Elevated IOP causes optic nerve damage to
slowly degenerate causing slow deteriorating loss of
vision.
b. angle closure glaucoma
- caused by an acute blockage of the fluid at the base
of the inferior angle between the iris and the cornea.
- IOP rises dramatically and very quickly.
Iris is pushed forward resulting in closure of the
angle normally found between the iris and cornea.
- medical emergency and may result in permanent
vision loss if IOP is untreated for 24 to 48 hours.
Symptoms for Glaucoma

a. Unilateral headache
b. Visual blurring
c. Nausea
d. Vomiting
e. Photophobia

Glaucoma has an insiduous onset with the first

noticeable symptom being perception of halos around
lights particularly with night vision. As the condition
progresses, loss of peripheral vision is reported.
Risk factors:

1. Increased intraocular pressure

2. older than 60 years of age

3. family history of glaucoma

4. personal history of myopia, diabetes,

hypertension, migraines

5. African American ancestry

Management of glaucoma involves:

1. lowering the IOP – normal is 10 to 21mmhg

2. therapy involves medications (oral or topical) to

decrease IOP

3. Laser surgery to increase the flow of aqueous

humor by creating a new drainage exit.

4. Follow up care with the ophthalmologist is essential

to monitor the adequacy of treatment and to ensure
that the IOP remains below 20mmhg.
5. Open angle glaucoma is usually managed with one
or several of the following medications:

a. Betablockers – remain the first line therapy

for glaucoma because they decrease the
rate of intraocular fluid production.
▪ Betagan, Timoptic, Ocupress

b. Miotics/cholinesterase inhibitors
▪ pilocarpine, humorsol
c. alpha adrenergic agonist
▪ Lopidine, Alphagan, Epinal

d. prostaglandin analogues
▪ Xalatan, Lumigan

e. carbonic anhydrase inhibitors

▪ trusopt, azopt
Nursing Management:
1. Provide a safe environment
2. Teach the client the need for carefully following
prescribed drug therapy.
3. Instruct the client to avoid anticholinergic medication
– precipitate severe pain.
4. Instruct client to avoid activities that raise IOP.
5. Instruct client to report eye pain, halos around lights,
changes in vision to the physician.
6. Instruct client when maximal medical therapy jas
failed to halt progression of visual field loss and optic
nerve, surgery will be recommended.
a. Prepare client for trabeculoplasty to facilitae
aqueous humor drainage.
b. Trabeculectomy – allows drainage of A H into the
conjunctival spaces by creation an opening.
4. DIABETIC RETINOPATHY

- is a microvascular disease of the eye occurring in

both type I and type 2 diabetes.

2 forms of diabetic retinopathy:

1. nonproliferative – the endothelium layers of the

blood vessels within the eye become damaged and
microaneurysms develop.

2. proliferative
- more advance stage and is a result of retinal
ischemia due to damaged blood vessels.
▪ neovascularization
4. DIABETIC RETINOPATHY

- occurs with long standing DM

- hemorrhage in small blood vessels in vitreous
humor
▪ weakened retinal capillaries which may leak
blood or fluid into the vitreous humor causing scarring
or retinal detachment.

Symptoms:
- decreased visual acuity
- decreased color perception
- glare disability
 Patient Education:

1. Proper nutrition including low carbohydrate and low

cholesterol diet is imperative

2. Exercise

3. Educate patients on how to check serum sugar

levels, when and how to administer medications
and symptoms of hypoglycemia .
Client Reflections: Misperceptions of Older Adults Who
Are Hard of Hearing

Mr. Devin, age 83, is somewhat hard of hearing but has

no cognitive impairment. In addition, he is a retired
university English professor. He is hospitalized for a
colon resection and makes the following comments: “
I am always amazed at the inept caregivers who
assume that my difficulty in hearing is (falsely)
accompanied with a lack of intelligence. Invariably,
the nurse or nursing assistant will approach me with
shouts of simplistic commands as though speaking to
a 7 yr old. I usually don’t get angry and try to be
patient with their lack of accuracy in my abilities.
Age related changes:

► The external appearance of the ear changes with

age as the auricle tends to wrinkle and sag.

► Cerumen tends to be drier and harder and tends to

accumulate in the ear canal

► Dryness of the canal can also cause pruritus and the

epithelial lining of the ear canal may be easily irritated
and injured

► involve atrophy of the organ of Corti and cochlear

neuron

► Presbycusis – loss of hearing related to aging

Moderate exposure to loud noise may initially cause
temporary hearing loss termed as : Temporary
threshold shift.
 TIPS FOR COMMUNICATING WITH OLDER
PERSONS WHO HAVE HEARING IMPAIRMENT

1. Eliminate extraneous noise in the room.

2. Stand 2 to 3 feet from the patient

3. Try to lower the pitched of your voice.

4. Pause at the end of each phrase or sentence.

5. If the patient has a hearing aid, provide assistance

with the device plus glasses if needed
 TIPS FOR COMMUNICATING WITH OLDER
PERSONS WHO HAVE HEARING IMPAIRMENT

6. Assess the illumination in the room and make sure

the patient can see you. Face the patient at all times
during the conversation.

7. The patient may read lips, so it is important not to

cover your mouth or chew gum.

8. Speak slowly and clearly in a normal tone of voice.

 TIPS FOR COMMUNICATING WITH OLDER
PERSONS WHO HAVE HEARING IMPAIRMENT

9. If your patient does not understand your message,

rephrase it rather than repeating the same words.

10. Gestures , if appropriate may help.

11. Use written communication if the patient is able to

see and read.

12. Ask the patient for an oral or written response to

determine if the communication was successful.
 Sensory and Perceptual Changes :Taste and smell

► Taste perception declines and salivation is

diminished.

Hypogeusia – diminished sense of taste

► Olfactory nerve cells decrease in number.

Hyposmia – diminished sense of smell.

 Sensory and Perceptual Changes :Taste and smell

Intervention:

1. Older adults are encourage to eat frequently

throughout the day.

2. Nurses should strive to make food visually appealing

and know client’s preferences.

3. Teach clients about healthy eating pattern.

4. Family members and other caregiver should be alert

for safety hazards
 Sensory and Perceptual Changes :Taste and smell

Intervention:

5. For xerostomia: Appetite enhancement strategies

such as:
a. adding flavors
b. checking dentures for fit and cleanliness
c. inspecting mouth for ulcers or gingivitis
d. carefully reviewing medications and identifying
possible offenders known to affect taste
e. encouraging fluids
f. maintaining bowel records
g. assessing palatability of food
 Sensory and Perceptual Changes :Taste and smell

Patient education for hyposmia involves safety

precautions such as:

1. dating and labeling all foods

2. placing natural gas detectors in the home if the

patient has gas heat or stove.

3. placing smoke detectors in strategic locations

4. establishing schedule for personal hygiene and

house cleaning.
 Physical sensation

► Tactile sensation diminishes in addition to the ability

to detect temperature extremes.

Nursing Assessment of the older person with tactile

impairment

1. A wisp of cotton.
2. A cotton swab can also be used with wooden end
3. Small test tubes can also be filled with warm (not hot)
and cold water
 Physical sensation

Nursing interventions for impaired sense of touch could

focus on:

1. continuous monitoring of skin intactness

2. assessment of safety risk

[Link] of a safety plan with instructions to

minimize injury.

a. Water heaters should be turned down to 110F to

prevent scalding.
 Physical sensation

b. protective padding of upper and lower

extremities can prevent bruising and protect
skin integrity

c. Older patients with diabetes should place a

mirror on the wall close to the floor, remove
their shoes and examine the bottom of their
feet daily for blisters, redness, ulcerations.
Integumentary
Integumentary
Epidermis
Major cells in the skin:
►Keratinocytes – produces keratin which provides
the tough outer barrier of the skin.
►Langerhan’s cells which reside in the keratinocytes,
provide immune protective function.
► Melanocytes located at the junction of the
epidermis and dermis, produces melanin which gives
the skin its color and shields the body of the harmful
effects of the sun.
Persons with dark skin have larger melanosomes
and more active melanin production than those with
lighter skin.
Epidermis
►contains less moisture - contributes to dry skin,
rough skin appearance.
► epidermal mitosis slows by 30% after age 50 –
longer healing time
Epidermis
► rete ridges flatten resulting in fewer contact areas
between the 2 layers – increases the risk for skin
tears.
▪ rete ridges which connects the epidermis and dermis flatten.
►melanocyte decreases in # – contributes to paler
complexion & ↑ risk for damage from UV radiation
► age spots or liver spots and increase in the # and
size of freckles (lentigo senilis)
Dermis
►is made up of connective tissue and is rich of blood
supply, lymph and neurosensory receptors.
►contains fibroblast, mast cells and lymphocytes.
● the white elastin fibers and yellow fibrous
collagen produced by the fibroblast provide
strength to the skin and give it the ability to
stretch during movement.
● Sensory nerve endings provide responses to
temperature, touch, pressure and pain.
Dermis
► decreased elastin and collagen – drying, wrinkling
and sagging of the skin leading to development of
elongated ears, jowls, and double chin.

► collagen become less organized & causes a loss

of turgor
Dermis
► decreased vascularity of the dermis contributes to
paler complexion.
► increased capillary fragility
Hypodermis
► is the subcutaneous layer, specialized connective
tissue that lies beneath the dermis and attaches to
the muscles below.

► contains blood vessels, lymphatic channels, hair

follicles and sweat glands that extends from the
dermis as well as adipose or fat tissue.

► subcutaneous fat is more abundant in the lower

back and buttocks and absent in eyelids and tibia.
► this layer also contains blood vessels, lymphatic
channels, hair follicles and sweat glands that extend
from the dermis.
Hypodermis
► decreased subcutaneous fat
 Dermal Accessory Structures

Hair
► Hair is located in all skin surfaces except the soles of
the feet and palms of the hand.
► Each hair strand grows independently and can differ
in its rate of growth depending on the location in the
body.

► Gray and eventually white hair – hair loses its original

color as the production of melanin decreases.
►Hair tends to thin both on the head and elsewhere on
the body.
Nails
► Nails becomes dull and yellow or gray in color.
► Nails thicken and become more brittle.

► Longer striations also appear due to damage to

the nail matrix.
Glands
► sebaceous glands are found on most skin areas
with exception of the palms of the hand and soles of
the feet.
▪ most abundant on the face, head and chest.
▪ sebaceous gland secretes sebum, an oily
substance that keeps hair supple and lubricates
the skin. Sebum protects skin from water loss.
► apocrine sweat glands are large glands that
produce milk substance that causes odor when
bacteria that is present on the skin acts upon it.

► Eccrine glands produce sweat.

Glands
► sebaceous glands increases in size but
decreases in functioning.
▪ the sebum produced is decreased  hastens
the evaporation of water which results in cracked ,
dry skin.
► eccrine and apocrine glands decreases in size, #
and function – result in heat exhaustion.
 CLIENT EDUCATION
1. Instruct client to avoid excessive use of soap, hot water
and brisk rubbing when bathing.
▪ Bath once a day.
▪ Limit soap, use superfatted soap without hexachloraphene (Dove)
▪ Dry with a soft towel
▪ Apply emollient to the skin immediately after bathing (white petroleum)

2. Teach the client to pat skin dry instead of brisk rubbing.

3. Use lotion for itching and dryness.
▪ For dryness (xerosis- decrease sebum production) - mineral oil after
bathing

▪ For itchiness – cool compresses of saline solution, oatmeal compresses,

epsom salt bath, nutraderm lotion
4. Use of humidifier. – increase room humidity
5. Avoid prolonged pressure on bony prominences.
6. Protect the skin from temperature extremes.
▪ ↓ in eccrine which plays a role in regulating heat and
cooling of body. So the older people has decrease
ability to regulate heat.
7. Protect skin from sun exposure (wear protective
clothing, hats, sunglasses, sunblock with high SPF=
solar protection factor of at least 15 and avoidance of
peak sun hours.)
8. Soak nails in water before trimming. Cut nails straight
across.
9. Dress appropriately for weather and climate.
 Common Problems of Older Person
SKIN CANCER
Types:
1. Basal cell carcinoma (non melanoma skin cancer)
► most common form of skin cancer of caucasians
which accounts 80% of non melanoma skin cancer
► can extend below the skin to the bone and
metastasis is rare.
► originates in the lowest layer of the epidermis and
appears as small fleshy bumps.
► can occur on any exposed skin but is frequently
found on head, neck, nose and ears.
 SKIN CANCER
2. Squamous cell carcinoma
► 2nd most common form of skin cancer in caucasian
and represents the remaining 20% of non melanoma
skin cancer.
► it may appear as flesh colored to erythematous,
indurated scaly plaques, papules or nodules and may
have ulceration or erosion in the center.
► they metastasize more frequently. Even then, the
metastasis is quite low.
► can be found on the rim of the ear, face, lips and
mouth, however it can spread to other parts of the
body.
 SKIN CANCER
Types:
3. Melanoma
► most serious of skin cancers.
► originates in the melanocytes and may grow from an
existing mole or a new lesion.
► it is the rarest but most virulent form of skin cancer
► more serious type of cancer.
► melanomas can form in any parts of the body not
covered by skin such as eyes, mouth, vagina, large
intestine and other internal organs
 Distinguishing benign moles from melanoma:

To prevent melanoma, it is important to examine your skin

on a regular basis, and become familiar with moles, and
other skin conditions, in order to better identify
changes. According to recent research, certain moles
are at a higher risk for changing into malignant
melanoma. Moles that are present at birth, and atypical
moles, have a greater chance of becoming malignant.
Recognizing changes in your moles, by following this
ABCD Chart, is crucial in detecting malignant
melanoma at its earliest stage. The warning signs are:
Normal Melanoma Sign Characteristics
Asymmetry when half of the mole
does not match the other
half

Border when the border (edges)

of the mole are ragged or
irregular

Color when the color of the

mole varies throughout

Diameter if the mole’s diameter is

larger than a pencil’s
eraser
Skin Tears

► It is a traumatic separation of the epidermis from the

dermis occurring primarily on the extremities of older
person.

► Skin tears may be caused by friction alone or in

combination of shearing force and friction.
▪ shearing – occurs when your skin moves to one direction and the
underlying bone moves in another direction. Ex. Sliding down on
bed/raising head of bed >30 degrees.
shearing is the sliding of parallel surface against each other.

► Skin tears may be accompanied by ecchymosis and

edema because of subcutaneous tissue atrophy
 Prevention of Skin Tears

1. Do not use any pulling or sliding movement when

assisting older persons with a change in their position.

2. Padding any surfaces that come in contact with leg and

arm movement such as side rails, wheelchair arm and
leg supports.

3. Keep the environment free of obstacles and well lit.

4. Keep skin moist with adequate fluids and skin

moisturizing creams

5. Encourage long sleeves and long pants to add a layer

of protection over the skin.
 Management of Skin Tears

▪ The recommended clinical care of a skin tear would

include the following (Baranoski, 2001):

1. Clean with normal saline or other nontoxic cleaner.

2. Pat or air dry.
3. Gently place the torn skin in its approximate normal
position.
4. Apply dressing (saline ) and change per protocol or
product requirements.
5. Document the assessment and intervention.
Photograph if permitted.
 Pressure Ulcer in Older Person

 Pressure ulcer is a lesion caused by unrelieved

pressure that results in damaged to underlying tissue

3 types of pressure ulcer: (from a review of the research

literature by Nixon 2001)

1. A necrosis of the epidermis or dermis which may or

may not progress to deep lesion
▪ may be caused by friction against the skin. Ex. If sheet is pulled
from under the patient causing damage to the epidermis.
2. A deep or malignant pressure ulcer where necrosis
is observed initially in the subcutaneous tissue and
tracks outward.
▪ occurs from an unrelieved pressure over a long period of time.
▪ this type of ulcer begins deep in the subcutaneous tissue and
tracks outward toward the dermis.

3. full thickness wounds of dry black eschar

▪ appears in areas that were previously normal, and occur due to
chronic arterial narrowing and inadequate tissue perfusion.
 Etiology of Pressure Ulcers

▪ General etiology is the intensity and duration of pressure as well as

tolerance of the skin and its supporting structures to pressure.

1. Tissue tolerance: Extrinsic factors

Extrinsic factors that affect skin tolerance includes:
- shearing forces, friction, moisture and skin irritants
Pressure is the primary force that occludes blood flow and
causes tissue
damage but shearing forces are also important factor in the
development of pressure ulcers.
Friction may remove the stratum corneum which could disrupt
the
epidermis and lead to pressure ulcer.
Skin irritants –soaps, detergents affect tissue tolerance by
removing
sebum which normally protects the skin.
 Etiology of Pressure Ulcers

▪ General etiology is the intensity and duration of pressure as well as

tolerance of the skin and its supporting structures to pressure.

2. Tissue tolerance: Intrinsic factors

Intrinsic factors that affect tissue tolerance and lead to skin
breakdown include 2 major areas:
a. structure and function of the skin and surrounding structures
b. ability of the vascular system to provide circulation to the skin.

Intrinsic factors that affect skin integrity:

- changes in collagen – collagen falls gradually after
age 30 and with dramatic loss at age 60
- advancing age
- poor nutrition
- steroid administration
Laboratory Values to determine risk for Pressure ulcer:

1. Serum albumin below 3.5g/dl is considered low

and below 2.5g/dl is considered a serious
depletion of protein.
2. Serum transferrin is considered a more accurate
indicator of protein stores
Serum transferrin below 200mg/dl is considered low
and below 100mg/dl is a serious depletion in
protein.
3. A total lymphocyte below 1500/mm3 indicates loss of
energy to skin.
A moderate decrease is 800 to 1200/mm3.
 Nonpharmacologic Treatment of Pressure Ulcers

▪ The AHCPR Clinical Practice Guideline: Treating

Pressure Ulcer Ulcers (1994) provides the clinical
community with synthesis of research and expert
opinions of treatment options for pressure ulcer and
wound healing.
It is a great resource for both nurses and physicians.

Areas of nursing responsibility include:

1. Assessment of the risk for pressure ulcer
2. Prevention and Modification of Risk Factors
3. Treatment of pressure ulcers
1. Assessment of the risk for pressure ulcer
 use of Braden Scale for predicting pressure sore
risk
▪ is a widely used tool that assesses mobility, activity,
sensory perception, skin moisture, friction, shear
and nutritional status.
▪ each dimension is rated from 1 to 4 on a likert type
scale and the total score range from 6 to 23.
▪ a score of 16 or less indicates a pressure risk and a
need for prevention plan.
▪ A lower Braden Scale Score indicates a lower level
of functioning and, therefore, a higher level of risk
for pressure ulcer development. A score of 19 or
higher, for instance, would indicate that the patient
is at low risk, with no need for treatment at
this time.
2. Prevention and Modification of Risk Factors
a. Reposition every 2 hours. Use a pull sheet to
prevent shear and friction. If redness occurs,
consider a 1 1/2 hour turning schedule
b. Ensure proper positioning
 Use pillows or wedges to prevent the skin from
touching the bed on trochanter, heels and
ankles.
c. The sitting position either in bed or chair should
be limited to 2 hours.
Time in the chair should be scheduled around
meal times .
The person in bed should not be left in the 90
degree position except during meals.
d. Increase activity by encouraging older person to
change position by making small body shifts.
ROM exercises should be done every 8 hours

e. Skin Care Considerations to prevent pressure ulcer

▪ Keep the skin clean and dry
▪ Lubricate the skin with moisturizer. Massage the
area around the reddened area. Then apply a thin
layer of a petroleum based product followed by a
baby powder cornstarch product to reduce friction
and moisture
▪ Evaluate and manage incontinence.
▪ Monitor nutrition. Determine factors that cause
inadequate nutrition. Obtain laboratory data
Provide additional canned supplements, vitamin C
and zinc to promote skin healing.
3. Treatment of Pressure Ulcer:
The ff are the components of the nursing care of a
pressure ulcer:

a. Assessing and staging the wound

b. Debriding necrotic tissue
Debridement is the removal of devitalized necrotic
(black) tissue or yellow slough tissue.
c. Cleaning the wound - isotonic solution (0.9%)
d. Dressings to provide a moist wound bed.
Stage Wound cleaning Debridement Change Frequenc
dressing y
choices
Nonblanchable Transparent Q 3 to 7
I. erythema of intact film; adherent days prn
skin. hydrocolloid

Partial thickness Normal saline Transparent Q 3 to 7

II skin loss involving or approved film; hydrogel days prn
epidermis, dermis cleaner hydrocolloid 3x a
or both week
Q 3 to 7
days prn
Stage Wound cleaning Debridement Change dressing Frequ
choices ency
Full thickness skin Normal saline 1. Wet to dry
III loss involving or approved saline dressing,
damage or necrosis cleaner. If moistened gauze
of subcutaneous necrotic tissue 2. Cover with
tissue that may present gauze
extend down. debridement 3. Use least
must be done. irritating taping
method

Full thickness skin Same as stage Same as stage III

IV. loss with extensive III
destruction, tissue
necrosis or damage
to muscle, bone or
supporting
structures.
b. Debriding necrotic tissue
Debridement is the removal of devitalized necrotic
(black) tissue or yellow slough tissue.

▪ For a pressure ulcer to heal, the wound must be

free from infection and necrotic tissue. Most devitalized
tissue supports the growth of the bacteria, delaying the
healing process. Necrotic tissue is avascular, tx with
systemic antibiotic is not effective.

4 Methods of debridement:

▪ Sharp debridement – use of scalpel and other

sharp instrument. It is the quickest form of debridement.
Large extensive ulcers such as stage 4 with thick
adherent eschar needs sharp debridement.
 ▪ Mechanical debridement – removal of exudate
by the use of wet to dry dressing, wound irrigation and
hydrotherapy.
It is effective for wounds with small to
moderate exudate and are usually changed every 4 to 6
hours.
For wet to dry dressing, gauze pads are
moistened with saline and placed in the open wound,
covering the necrotic tissue only. The wet dressing
adheres to the dead tissue and is allowed to dry. When
the dry dressing is removed, When the dry dressing is
removed, the dead, devitalized tissue is removed with
it. The dry dressing should not be moistened before
removal or the purpose of wet to dry dressing is
defeated.
 ▪ Chemical debridement- use of topical enzymatic
agent to break down devitalized tissue. It can be used
alone, after sharp debridement or with mechanical
debridement.
▪ Autolytic debridement – involves the use of
moisture retentive dressing to cover the wound and
allow enzymes in the wound bed to liquify selective
dead tissue. Moist dressing are used to promote tissue
healing.
c. Cleansing the wound – to remove bacteria, debris
and small amounts of devitalized tissue to allow optimal
healing
▪ topical antiseptic: povidone iodine, acetic acid,
hydrogen peroxide, dakin’s solution should not be used
on the wound because these products have been found
to be toxic to wound fibroblast and macrophages
(Ovington, 2001)
▪ isotonic saline (0.9%) is the safest, cost effective
and most common cleaning agent for wounds.
▪ wound cleansing can be done by:
1. pouring a saline solution over the wound.
2. applying saline soaked gauzes to clean debris.
3. squeezing a saline filled bulb syringe over the
wound.
d. Dressings to Provide a Moist Wound Bed
▪ to heal a pressure ulcer, a clean moist
environment must be maintained.
▪ 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.
▪ A dry wound environment has been found to
result in further tissue death or dry necrosis beyond the
cause of the wound
e. Preventing and treating Infection
▪ Infection is the proliferation of bacteria in healthy
cells that produces symptoms of local redness, pain,
fever and swelling. Serious infection that can be
complications of pressure ulcer are bacteremia, sepsis,
osteomyelitis, and advancing cellulitis.
 ▪ Use of topical and systemic antibiotic
Urgent care is required for older persons with
systemic infections. This care includes obtaining wound
cultures and blood cultures and providing tx with
appropriate systemic antibiotics that will cover the
offending organism.
A blood culture will allow the causative organisms
to be identified, and antibiotic can be directed at the
offending microorganisms.
They are very serious complication of pressure
ulcers and immediate medical attention is advised.
 Fingernail and toenail conditions

a. Onychomycosis – a fungal infection of the toenail

most commonly occur in the big toe.
The toenail appears thick, discolored and protruding
from the nail [Link] person may complain of severe
pain, often causing them to reduce their activity.
 Fingernail and toenail conditions

Treatment:
Relief of pain – reduce pressure on toe by cutting a
hole in their slipper or shoe.
Patient education – frequent tx to prevent condition
from spreading to other parts of toes.
Oral antifungal agents – may provide a cure.
Itraconazole (topical is applied to the
affected area)
(toenails) Itraconazole 200mg po daily for 12 weeks
 Fingernail and toenail conditions

b. onychia is inflammation of the nail matrix

Paronychia is the inflammation of the matrix plus the
surrounding and deeper tissue.
Older persons who have been exposed to wet work
such as dishwashing, fishing are at high risk.
Characterized by separation of the cuticle from the nail
which allows organish to ener. The organism may
cause swelling, redness and tenderness of the nail fold
accompanied by purulent drainage.
 Fingernail and toenail conditions

Cont.. Onychia & Paronychia

Characterized by separation of the cuticle from the

nail which allows organism to enter. The organism
may cause swelling, redness and tenderness of the
nail fold accompanied by purulent drainage.

Treatment is keeping affected nails dry and antibiotic.

Drainage is sometimes needed.
 Fingernail and toenail conditions

c. onychogryphosis chronic hypertrophy of the nail

plate characterized by hooked or curved nail.
Any pressure on the nail may cause pain. The
deformed nail may cause pressure on the adjacent
toe, leading to a dangerous pressure.

Tx: Podiatry consultation and surgical intervention. The

podiatrist should trim thickened nails. Nails should be
kept short. Proper foot care
and hygiene are essential.
 Normal Changes of the GIT

Mouth
1. The taste buds of the tongue decrease in number.
Taste buds - are sensory organ that allow you to
experience taste that are sweet salty sour
and bitter.
Papillae contains taste buds.
 Normal Changes of the GIT

2. Salivary function decreases over time

Saliva – provides a fluid medium to dissolve food and
to provide a lubricant to aid in chewing and
swallowing.
- to irrigate the mouth – to keep it moist and to
prevent growth of infectious agents in the
mouth (saliva contains lysozyme)
Moist buccal cavity is essential for clear speech.
Secretes digestive enzymes.
It allow taste
 Normal Changes of the GIT

3. The gums may recede leaving teeth vulnerable to

cavities below the gum line.

4. The enamel on the surface of the teeth may worn

away leaving teeth open to staining, damage and
cavities.
5. Delayed swallowing time.
▪ Alteration in the swallowing reflex causes delayed
swallowing time.

[Link] emptying of the esophagus.

▪ Decreases esophageal motility.
▪ Peristaltic action decreases with relaxation of the
esophageal sphincter and this causes a decreased in
emptying of the esophagus.

7. Shrinkage of gastric mucosa leads to changes in the

levels of HCL acid, the reason for many adults
complaints of heartburn.
Decreased gastric acid and HCL acid
Decrease in digestive enzymes and reduction in gastric
pH (increase tendency for indigestion).
8. Decreased intestinal absorption, motility and blood flow.
▪ Absorption of nutrient decreases.
▪ Decreased muscle tone of the intestines; decreased
peristalsis; decrease free body fluid (increased
tendency for constipation.
 Common Older Persons Problem

1. Xerostomia

▪ Dry mouth can result from mouth breathing,

dehydration due to diuretic use, oxygen therapy, oral
and systemic diseases.
▪ drug induced- the most [Link] of xerostomia:
sedatives, antidepressants, tranquilizers
antihypertensive (alpha& betablockers)
antihistamine, calcium channel blockers,
ACE inhibitors, antiseizure and antiparkinsonian
agents
 ▪ Oral symptoms associated with xerostomia:
a. altered taste
b. difficulty eating, chewing and swallowing
c. halitosis
d. chronic burning sensation in the mouth
e. intolerance to spicy foods.

▪ Nursing Interventions:
a. Sugar free chewing gum
b. Low sugar diet
c. Urging regular dental evaluation
d. Mouth rinses
e. Bedside humidifiers
f. Dietary modifications: avoidance of food difficult
to chew or swallow.
 Common Older Person’s Problem

2. Oral Candidiasis
▪ Is a condition in which the fungus Candida albicans
accumulates on the lining of your mouth.
Symptoms: Appears as thick white or cream colored
deposits on mucosal membrane.
Infected mucosa of the mouth may appear
inflamed (red and possibly raised)
Treatment:
a. Topical antifungal drugs – nystatin, miconazole or
amphotericin B. ( 2 minutes swish around the mouth)
Amphotericin B may be used when other
medications aren't effectiv
Some antifungal medications may cause liver damage.
For this reason, your doctor will likely perform blood
tests to monitor your liver function, especially if you
require prolonged treatment or have a history of
liver disease

b. Small soft toothbrush – considered the most

effective mechanical method to control dental
plaque.
Teeth should be brushed daily for 3 to 4 minutes,
.
 c. Mouth rinses – for cleaning, moisturizing or killing
germs.
Hydrogen peroxide harms the oral mucosa and
causes negative subjective reaction in
patients.
Sodium bicarbonate dissolves mucous and oral
debris but has unpleasant taste and can
burn oral mucosa.
Chlorhexidine (peridex) is used widely to treat
gingival and periodontal disease and other
oral infections.
.
 Common Older Persons Problem

3. Gingivitis and Periodontitis

Gingivitis is the inflammation of the gum with redness,

swelling and the tendency to bleed.
Gingivitis is a precursor to chronic periodontitis.

Periodontitis is a serious gum infection that destroys

the soft tissue and bone that supports your teeth.
Periodontitis can cause tooth loss.
Signs and symptoms of periodontitis:
a. swollen gums
b. bright red or purplish gums
c. gums that feel tender
when touched
d. gums that pull away
from your teeth making
your teeth appear longer
than normal
e. new spaces developing
between your teeth
f. pus between your teeth &gums
g. bad breath
h. bad taste in your mouth
I. a change in the way your teeth
fit together when you bite
Plaque formation (Plaque forms on your teeth when
starches and sugars in food interact with bacteria
normally found in your mouth) - - - brushing teeth

Plaque that stays on your teeth longer than 2 to 3 days

can harden under your gum line into tartar
(calculus). Tartar makes plaque more difficult to
remove and acts as a reservoir for bacteria- - -
Professional dental cleaning
 self care activities:
a. Daily flossing
b. twice daily brushing
c. twice yearly cleaning and evaluation
d. eating well balanced diet
e. avoiding tobacco products
 Common Older Persons Problem

4. Mouth Cancer

Mouth cancer refers to cancer that develops in any of

the parts that make up the mouth. Mouth cancer
can occur on the lips, gums, tongue, inside lining of
the cheeks, and the roof and floor of the mouth.
Oral cancer is cancer that occurs on the inside of the
mouth.
Signs and symptoms of Mouth Cancer:
1. A sore that does not heal
2. A lump or thickening of the skin or lining of your mouth
3. A white or reddish patch on the inside of your mouth
4. Loose teeth
5. Poorly fitting dentures
6. Tongue pain
7. Jaw pain or stiffness
8. Difficult or painful chewing
9. Difficult or painful swallowing
10. Sore throat
11. Feeling that something is caught in your throat
LEUKOPLAKIA appears
as thick, white patches
on your gums or on the
insides of your cheeks.
Erythroplakia – red patch
on the soft tissues of the
mouth
Test: A tongue biopsy and gum biopsy, and
microscopic examination of the lesion
confirm the diagnosis of oral cancer.

Treatment
1. Surgical Removal of Tumor
Smaller cancers may be removed through minor
surgery.
Larger tumors may require more extensive procedures.
For instance, removing a larger tumor may involve
removing a section of your jawbone or a portion of
your tongue.
2. Radiation therapy and chemotherapy
Radiation therapy uses high-energy beams, such as X-
rays, to kill cancer cells

Radiation therapy can also be used before or after

surgery.

Side effects of radiation therapy to your mouth may

include dry mouth, tooth decay, mouth sores,
bleeding gums, jaw stiffness, fatigue and red, burn-
like skin reactions.
Chemotherapy is a treatment that uses chemicals to kill
cancer cells.
Chemotherapy drugs can be given alone, in combination
with other chemotherapy drugs or in combination
with other cancer treatments.
Chemotherapy may increase the effectiveness of radiation
therapy, so the two are often combined.
Side effects of chemotherapy depend on which drugs you
receive. Common side effects include nausea,
vomiting and hair loss.
4. Rehabilitation may include speech therapy or other
therapy to improve movement, chewing, swallowing,
and speech.
 Common Older Person’s Problems

5. Dysphagia
► is the most common esophageal disorder in older
people.
Defined as difficulty in any part of the process involved
with swallowing solid foods and liquids.
3 stages: oral stage (food from mouth to
oropharynx)
pharyngeal stage ( bolus propelled to the
esophagus)
esophageal stage (bolus propelled
toward the stomach)
▪ any phases of the normal swallowing may be
disrupted in patients with difficulty in swallowing.
 Dysphagia

Signs and symptoms observable in older patients at risk

for dysphagia:
1. Reports that the older person or his or her family that
swallowing food or medication is difficult.
2. Difficulty in controlling food or saliva in the mouth
(drooling and dribbling)
3. Facial droop, open mouth
4. Dementia, frailty, confusion, extreme lethargy,
decreased level of consciousness
5. Inability to sit in an upright position and maintain trunk
position for a reasonable length of time.
6. Choking or coughing while eating or drinking
7. Increased nasal or oral congestion or secretion after a
meal.
 Dysphagia
8. Weak voice, cough and tongue movements.
9. Slurred speech
10. Slurred speech
11. Change in voice during meal
12. Recurrent upper respiratory infections or pneumonia
13. Retention or pocketing of food in mouth
14. Oral thrush
15. Refusal to open mouth or accept a large bite of food
16. Unexplained weight loss.

Early detection is vital because complication is life

threatening  aspiration of fluid or food into the respi
tract can cause: choking, airway obx, aspiration
pneumonia.
 Dysphagia
Risk Factors:

1. Residents not positioned properly.

2. Residents fed inappropriate food and liquid.

3. Residents fed quickly with large bites of food.

4. Residents labelled as difficult or uncooperative.

.
 Guidelines to Follow in Caring For patients at risk for
aspiration – to facilitate safe eating and drinking

1. Try to minimize distractions during eating.

2. Try to use consistent feeding techniques with notations
as to the older person’s likes, dislikes, eating and
drinking habits and consumption patterns.
3. Make sure the older person is properly positioned and
supported during meal time.
4. Try to maintain the upright position for at least 1 hour
after feeding.
5. Ensure that patient has swallowed one bite before
giving another. Do not try to rush. The patient may
become resistive.
6. Monitor the patient’s respirations.
7. Provide oral hygiene before and after meal.
8. Plan meal at times when the patient is rested..
9. Offer food and liquid consistencies according to the
speech pathologists and dieticians recommendation. Do
not overly thicken liquids. The older person will resist
chewing, juice or liquids.
10. Keep conversation to a minimum and focus attention
on the task at hand.

11. Instruct all persons who assist the patient with feeding
in the appropriate techniques.

12. Never engage in forceful feeding techniques..

 Evaluating Swallowing Reflex

1. Ask client to place his or her tongue against the

palate

2. Stroke the tonsillar arch and soft palate with moist

cotton swab and ask whether this can be felt.

3. Test normal pharyngeal contraction by stimulating

tonsillar arch with cotton swab moistened with
ice cold lemon water
 Common Older Persons Problems

6. Constipation
► is a common problem in older people .
► constipation means different to things to different
people, and many older adults feel that a daily
bowel movement is necessary for good health.
► However, constipation is not defined by presence of
daily stool passage but rather as:
- 2 or fewer stools per week
- straining at stool
- difficult passage of hard feces often with
fecal impaction
- feeling of incomplete evacuation
Normal Bowel Movement – characterized by regular, easy
and complete passage of formed stool approx 3 times
per week.

Factors Contributing to Constipation

1. Dehydration
2. Side effects of Medication
3. Insufficient fiber intake
4. Cognitive impairment
5. Immobility
► Nursing Assessment of Constipation
The older person should be questioned as to the
basis of the complaints of constipation such
as:
a. Frequency of bowel movement (fewer than 3x
per week)
b. consistency of stool (hard or difficult to pass)
c. presence of excessive straining or feeling of
fullness in the rectum after completing a
bowel movement
d. The presence of bright red blood on the stool or
toilet tissue may indicate bleeding from
internal or external hemorrhoids
Nursing Management of constipation:
1. Education on the importance of:
- fluid and fiber intake
- exercise
- avoidance of medications that can cause constipation
2. Relief of constipation:
- adequate hydration
- increased mobility
- fiber supplementation (20 to 35 g/day)
- use of laxatives

Nursing study was reported that laxative can be

discontinued for an older person with bran intake that
reached 25 g daily.
Bran mixture that significantly reduces laxative use for
older person includes:
3 cups unsweetened applesauce
2 cups coarse wheat bran
1 ½ cups unsweetened prune juice

Administering 4tbsp per day ( 2 before breakfast and 2

before supper) will stimulate natural bowel movement
and decrease dependence on laxatives
Use of laxatives is when lifestyle modification has failed,
the primary care provider may prescribed a laxative.
1. Bulk laxatives.
▪ Contraindicated in presence of intestinal obstruction or
when peristaltic activity is compromised (paralytic ileus)
▪ Examples: metamucil, citrucel, fiberCon
2. Stool softeners should be limited to patients who
complain of straining at stool, painful defecation with
presence of hemorrhoids or anal fissures.
Stool softeners are sometimes used to facilitate bowel
movement and prevent constipation in high risk patients
(post op abdominal surgery)
▪ surfactant wetting agent ( Colace, surfak)
3. Osmotic laxative
(Sorbitol and Lactulose)

4. Stimulants – increase colonic peristalsis (Dulcolax, Ex-

Lax, senna, senokot)
These agents tend to be more harsh than other agents
and can sometimes cause unpleasant cramping.

5. Suppositories & Enemas are usually reserved for for

those patients who have not responded to the other
laxatives,
(Fleet enemas & glycerine suppositories)
Enemas are treatment of choice if colonic fecal
impaction is suspected
Plain tap water or sodium phosphate are
recommended.
Soapsud enemas produce mucosal damage and
cramping and should be avoided.

Enema should be administered slowly to prevent

cramping and should generally contain 150 to 300ml or
5 to 10 fluid ounce solution.

After the initial blockage has been passed or removed

manually, a 2nd enema may be needed to remove
additional stool that has moved into the proximal colon.
3. Fecal Impaction
- A mass of hardened feces trapped in the rectum
that cannot be expelled.

Clinical manifestations:
a. Frequent oozing of thin or liquid discharge of
feces from the rectum without evidence of
passing solid stool.
b. Abdominal cramping or rectal pain
c. Abdominal distention
d. Anorexia
NURSING MANAGEMENT (Fecal Impaction)

1. Assess for bowel sounds

2. Perform digital examination of the rectal vault for
hardened mass
3. Determine the appropriateness of performing
manual evacuation of stool.
4. Review all medication that may contribute to
reduced peristalsis and consult with primary care
provider as needed.
5. Initiate a nursing care plan that will prevent further
impaction.
4. Diarrhea – defined as abnormally loose stool
accompanied by a change in frequency or volume.

The incidence of diarrhea in the older person is unknown,

but older people may be more susceptible to diarrhea
because of hypochlorhydria or achlorhydria when taking
gastric acid suppressing drugs, increased used of
antibiotics and decreased mucosal immune function.

Acute Diarrhea – diarrhea of less than 2 weeks duration

Chronic Diarrhea – diarrhea occuring longer than 4 weeks

Most diarrhea in older person is acute and self limited.

Causes: a. Infection (bacterial, viral, parasitic)
b. Medication and drug changes
c. Food intolerance
Nursing assessment of Diarrhea:
1. Careful examination of the abdomen
- cisual examination of abdomen for bloating or
excessive peristaltic movements
- auscultation of bowel sounds
- palpation to identify masses or rebound tenderness
- digital rectal examination to determine presence of
impacted stool.
2. Stool culture and analysis for:
- older patients with recent antibiotic use
- those who have experienced recent foreign travel
- those who have been exposed to food poisoning
3. Plain abdominal xray may indicate presence if an
intestinal obstruction or fecal impaction.
If toxin producing and infectious diarrhea are not
suspected, antidiarrheal agent can be administered.
However, administration of these drugs in the presence of
toxins and infectious agents can lead to colon damage
and systemic adverse effects by allowing the toxic
substance to remain in the bowel for longer periods of
time thus to be absorbed into the general circulation.
Soluble fiber (metamucil) adds bulk to the stool and is
sometimes helpful to slow bowel movement in person
requiring bulk.

Kaopectate, Peptobismol, Imodium A-D

* they can be administered after each loose
stool in divided doses.

Lomotil should be avoided of significant atropine like

side effects.
5. Colorectal cancer
Increases at age 40 and peaks in older adults between
the ages of 60 and 75.

Malignant tumor that involves the colon or rectum

Many colon cancers start at colon polyps, a growth on the

inside of the colon.
Familial or hereditary factors present
People who have a family history of colorectal cancer
are more likely to develop the cancer themselves,
particularly if you have certain gene mutations.

Clinical Presentation:
1. Sense of fullness in the rectum
2. Pain: vague, dull, continuous ache and
abdominal cramps.
3. Malaise, fatigue, anorexia, weight loss
4. Change in bowel pattern
a. Diarrhea, constipation—early sign
b. Small diameter stool – late sign
c. presence of blood in stool– next after
early sign
d. Tenesmus involves constantly feeling the need to
empty the bowels, along with pain, cramping, and
straining.
e. Sense of incomplete bowel evacuation

5. Anemia and elevated liver enzymes may

be present.
What Are the Symptoms of Colorectal Cancer?
In its early stage, colorectal cancer usually produces no
symptoms. The most likely warning signs include:
Changes in bowel movements, including persistent
constipation or diarrhea, a feeling of not being able to
empty the bowel completely, an urgency to move the
bowels, rectal cramping, or rectal bleeding
Dark patches of blood in or on stool; or long, thin, "pencil
stools"
Abdominal discomfort or bloating
Unexplained fatigue, loss of appetite and/or weight loss
Pelvic pain, which occurs at later stages of the diseas
Staging Colon Cancer

Stage 0
Stage 0 cancer of the colon is very early cancer. The
cancer is found only in the innermost lining of the colon.

Stage I
Also called Dukes A colon cancer, the cancer has
spread beyond the innermost lining of the colon to the
second and third layers and involves the inside wall of
the colon. The cancer has not spread to the outer wall
of the colon or outside the colon.
Stage II
Also called Dukes B colon cancer, the tumor extends
through the muscular wall of the colon, but there is no
cancer in the lymph nodes (small structures that are
found throughout the body that produce and store cells
that fight infection).

Stage III
Also called Dukes C colon cancer, the cancer has
spread outside the colon to one or more lymph nodes
(small structures that are found throughout the body
that produce and store cells that fight infection).
Stage IV
Also called Dukes D colon cancer, the cancer has
spread outside the colon to other parts of the body,
such as the liver or the lungs. The tumor can be any
size and may or may not include affected lymph nodes
(small structures that are found throughout the body
that produce and store cells that fight infection).
How Can I Prevent Colorectal Cancer?

1. Diet and Exercise: The National Cancer Institute

recommends a low-fat, high-fiber diet that includes at
least five servings of fruits and vegetables each day

Major sources of fat are meat, eggs, dairy products, and

oils used in cooking and salad dressings. To increase
the amount of fiber in your diet, eat more vegetables,
fruits, and whole-grain breads and cereals.
Diet:
1. Antioxidants
2. Other vitamins and minerals
a. Folic Acid.
The most common sources of folic acid are citrus fruits and dark
green leafy vegetables, especially spinach.
b. Calcium and Vitamin D.
Recent studies have suggested that these two substances may not
only strengthen bones, but may also fight off colon cancer. Good
sources of calcium include: milk, cheese, yogurt, salmon, sardines,
and dark-green leafy vegetables such as kale, mustard, and
collard greens. Sources of Vitamin D include salmon, sardines,
fortified cow's milk, egg yolks and chicken livers -- and don't forget
the sun.
3. Fiber and Your Colon
Fiber is thought to be a powerful weapon against
cancer.

Good sources of fiber include: whole-grain cereals and

breads, prunes, berries, kidney beans and other
legumes, fresh fruits and vegetables, and brown rice.
How Can I Prevent Colorectal Cancer?
2. Aspirin: It has been proposed that aspirin may stop
cancer cells from multiplying.

In addition, other non-steroidal anti-inflammatory drugs

(NSAIDs, such as Aleve and Motrin) may reduce the
size of polyps in the colon, and therefore, the risk of
colon cancer.
How Can I Prevent Colorectal Cancer?
3. Screening: Most health problems respond best to
treatment when they are diagnosed and treated as
early as possible.
 
PREVENTION (Colorectal Cancer)

1. Instruct client concerning importance of a nutritious

low fat diet.
2. Instruct client to report changes in bowel habits.
3. Annual DRE for clients over 40
4. Annual stool guaiac test for clients over 50
5. Sigmoidoscopy every 5 years beginning at age 50.
6. Colonoscopy every 10 years or double contrast
barium enema every 5 to 10 years.
Treatment:

Treatments may include the following, alone, or in

combination:
1. Surgery
2. Chemotherapy
3. Radiation
4. Biological therapy/ Immunotherapy - a type of treatment
that uses the body's own immune system to fight
cancer.
Treatment by stage:

a. Stage 0 Colorectal Cancer

Stage 0 colorectal cancer is found only in the innermost
lining of the colon. Treatment usually involves one of
the following:
Polypectomy or local excision to remove the tumor and a
small amount of surrounding tissue, or
More extensive surgery (resection) to remove larger colon
cancers. This may require a procedure called an
anastomosis to remove the diseased part of the colon
and reattach the healthy tissue to maintain bowel
function
.
Stage I (Dukes A) Colorectal Cancer
Stage I tumors have spread beyond the inner lining of the
colon to the second and third layers and involves the
inside wall of the colon. The cancer has not spread to
the outer wall of the colon or outside the colon.

Standard treatment involves surgery to remove the cancer

and a small amount of tissue around the tumor.
Additional treatments are not usually needed.
Treatment by stage:

Stage II (Dukes B) Colorectal Cancer

Stage II colorectal cancers are larger and extend through
the muscular wall of the colon, but there is no cancer in
the lymph nodes (small structures that are found
throughout the body that produce and store cells that
fight infection).
Standard treatment is surgical removal of the cancer and
an area surrounding the cancer:
Treatment by stage:

Stage III (Dukes C) Colorectal Cancer

Stage III colorectal cancers have spread outside the colon
to one or more lymph nodes (small structures that are
found throughout the body that produce and store cells
that fight infection).
Treatment involves:
Surgery to remove the tumor and all involved lymph nodes
if possible.
After surgery, the patient will receive chemotherapy with
5-FU and leucovorin.
Radiation may be needed if the tumor is large and
invading the tissue surrounding the colon
The five-year survival rate for Dukes C colon cancer is
about 64%. Patients with one to four positive lymph
nodes have a higher survival rate than people with
more than five positive lymph nodes.
Stage IV (Dukes D) Colorectal Cancer
Stage IV colorectal cancers have spread outside the colon to other
parts of the body, such as the liver or the lungs. The tumor can be
any size and may or may not include affected lymph nodes (small
structures that are found throughout the body that produce and
store cells that fight infection).
Tx includes:
Removal the cancer surgically or another surgical procedure to
bypass the colon cancer and hook up healthy colon (an
anastomosis).
Surgery to remove parts of other organs such as the liver, lungs, and
ovaries, where the cancer may have spread.
Chemotherapy to relieve symptoms
Erbitux, Avastin, or Vectibix in combination with standard
chemotherapy
Radiation to relieve symptoms.
6. Fecal Incontinence

Fecal Incontinence is defined as involuntary passage of

gas, mucus or stool

Types:
Transient – anytime there is a new episode of
incontinence with liquid stool without a recent solid stool

Persistent – if incontinence doesn’t resolve or has been

present for 1 month or more
Interventions:

1. Regular toileting program

2. Administration of high fiber diet
3. Elimination of med associate with diarrhea
4. Use of medicines such as loperamide to control
diarrhea
5. Care should be taken to maintain skin integrity with
thorough cleansing and drying after incontinent
episodes
Instruct patient that it may help to avoid caffeine and
lactose.