Transcript VN057_gerontology_10x

VN057 Gerontology 10
Nursing Process for Impaired
Oral Mucous Membranes
ch 17 cont’d
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Dental Caries
• Tooth decay, loose teeth, and lost teeth are
ongoing problems in the population
• Poor nutrition and decreased appetite can
often be attributed to dental problems
• Decay, or caries-caused by bacteria that
penetrate through the enamel shield of the
tooth and cause destruction
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Periodontal Disease
• A less obvious but potentially more serious
complication of poor oral care
• Food debris & plaque build up in the mouth
and on the teeth when oral hygiene is
inadequate
• Activity of bacteria on debris cause bad
breath, or halitosis.
– often disturbing to the older person and to
anyone in close contact
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Periodontal Disease (cont.)
• Gingivitis causes gum swelling, tenderness,
and bleeding and eventually leads to recession
of the gum tissue away from the tooth
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Pain
• Dental caries and periodontal disease
– most common reasons for oral pain
– oral lesions such as stomatitis or altered
sensations in the mouth are also reported
• Pain may be limited to the oral cavity or may
affect the face and jaw
• Oral pain can cause loss of appetite,
decreased food intake, a negative effect on
the overall quality of an older person’s life
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Dentures
• Partial plates tend to catch particles of food
and may weaken healthy teeth
• Complete dentures-difficult to fit
• Dentures may not fit properly if a significant
amount of weight is gained or lost
• Dentures can cause irritation, inflammation,
and ulceration of gums and oral mucous
membranes
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Dry Mouth
• Xerostomia, or dry mouth is common
– may result from normal age-related reduction in saliva
secretion, medication side effects inadequate hydration,
or diseases such as diabetes
• Makes chewing and swallowing more difficult,
promotes tooth decay, and alters the sense of taste
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Leukoplakia
• White patches in the mouth
• Often are precancerous and require prompt
medical attention
• Can also be med s/e or thrush
• Lesions on the posterior third or sides of the
tongue often are abnormal and should be
brought to the attention of the physician
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Leukoplakia (cont.)
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A disease that is suspected to play a role in
thromboembolic disorders, bacterial
endocarditis, and myocardial infarction is:
A. dental caries.
B. halitosis.
C. gingivitis.
D. periodontal disease.
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Cancer
• Oral or pharyngeal cancer have poor prognosis
• Early recognition and treatment before mets
to other tissues offer the best hope
• Symptoms- include leukoplakia or
erythroleukoplakia, sores in the mouth that do
not heal, oral bleeding, pain or difficulty
swallowing, difficulty wearing dentures,
swollen lymph nodes in the neck, earache
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Disorders Caused by Vitamin
Deficiencies
• Certain deficiencies of riboflavin, niacin, and
vitamin C can affect oral mucous membranes
• A smooth purplish sore tongue may be related
to riboflavin deficiency
• Complaint of a burning sensation or soreness
of the mouth may indicate niacin deficiency
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Superinfections
• Superinfections of the mouth are relatively
common in older individuals who receive
broad-spectrum antibiotic therapy for some
other infection
• Antibiotics destroy the normal mouth flora
and allow opportunist bacteria or yeast
colonies to become established and grow
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Superinfections (cont.)
• A hairy tongue is the result of enlargement of
the papillae on the tongue; this often follows
antibiotic therapy
• Black or brown discoloration on the tongue
may be caused by tobacco use or by a
chromogenic (color-producing) bacterium
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Alcohol- and Tobacco-Related
Problems
• Alcohol and tobacco, even in small amounts,
can harm the mucous membranes
• Alcohol- chemically irritating and drying to the
mucous membranes
• Tobacco, whether smoked, chewed, or taken
as snuff, increases the risk for oral cancer
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Problems Caused by Neurologic
Conditions
• Neuro conditions such as stroke, multiple
sclerosis, or Parkinson’s disease decrease
coordination and strength
– difficult for the person to manipulate the
equipment needed for oral hygiene
– Can be difficult to open mouth
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Problems Caused by Neurologic
Conditions (cont.)
• severe arthritis may find equipment difficult
to manipulate
– May be difficult to open the mouth adequately for
good, thorough cleaning
• medication for seizure or other neuro
disorders need to use special precautions
– medications often cause gum problems
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Nursing Interventions for Impaired Oral Mucous
Membranes
• Complete a thorough assessment of the oral
mucous membranes
• Initiate referral to a dentist or dental hygienist
• Provide oral hygiene
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Nursing Interventions for Impaired Oral Mucous
Membranes (cont.)
• Promote adequate intake of nutrients and
fluids
• Provide lozenges or topical analgesics as
prescribed
• Communicate suspected oral side effects of
medication therapy to the physician and
dentist
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Dental care
• Access to dental care is often an issue for
people with impaired mobility
– Getting to the office
– Ability to tolerate time in wheel chair/use walker
– Getting on to the chair
– Ability to cooperate with personnel
– Ability to open their mouth
Chapter 18
Elimination
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Objectives
• Describe the normal elimination processes.
• Identify the older adults who are most at risk
for problems with elimination.
• Describe age-related changes in bladder and
bowel elimination.
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Normal Elimination Patterns
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Bowel Elimination
• typical adult: moderate amount formed
brown stool passed without difficulty
• Usual adult: bowel movements every 1- 2 days
• urge usually occurs 30 to 45 minutes p meal
– gastrocolic and defecation reflexes stimulate
peristalsis
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Urinary Elimination
• Usual adult: urge when bladder contains
approximately 300 mL of urine
– This varies greatly
• Voluntary control of external sphincter allows
healthy adults to hold larger amounts until it’s
convenient
• Most adults void between 6 and 10 times per
day
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Elimination and Aging
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Constipation
• Hard, dry stools- difficult to pass
• Increased risk associated with aging
– decreased abdominal muscle tone
– Inactivity &/or immobility
– inadequate fluid intake
• Especially combined with bulk forming agents [metamucil]
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inadequate dietary bulk
disease conditions [parkinsons, gastroparisis + more]
Medications
dependence on laxatives or enemas
various environmental conditions
• Inability to get to toilet-holding too long, lack of privacy
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Constipation (cont.)
• Dietary fiber-important role in promoting
normal elimination
– indigestible substance traps moisture & provids bulk
• Repeatedly ignoring the urge to defecate can
lead to suppression or even extinction of the
defecation reflex
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Fecal Impaction
• mass of hardened feces trapped in the rectum
& can’t be passed
– result of unrelieved constipation
• Symptoms
– longer-than-usual delay in defecation
– Passage of small amounts of liquid stool without
any formed fecal material
• Digital examination of the rectum may reveal
presence of a hardened mass of feces
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Objectives
• Discuss methods for assessing elimination
practices.
• Identify selected nursing diagnoses related to
elimination problems.
• Describe interventions used to prevent or
reduce problems related to elimination.
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Nursing Process for
Constipation
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Assessment
• How often do bowel movements occur? Is
there any pattern?
• Is the person continent or incontinent?
• consistency?
• amount ?
• color ?
• Are blood, mucus, undigested food, or other
unusual substances evident in the stool?
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Assessment (cont.)
• Has it been checked for occult blood?
• Do they have to strain?
• Is the stool expelled with excessive force, or
does it ooze from the body?
• Does the person report or has the nurse
observed any particular foods that affect
bowel movements?
– Do these foods cause diarrhea or constipation?
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Assessment (cont.)
• Does the person rely on aids for elimination
(suppositories, laxatives, enemas)?
– How long has the person been using this aid?
• Is the abdomen distended?
• If the person cannot speak, does he or she rub
the abdomen?
• Has the person’s appetite decreased?
• Are they nausiated?
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Assessment (cont.)
• If they don’t feel like they have to have a b.m.what do you feel with digital examination?
• Does the diet have adequate bulk?
• Does the person take any bulk enhancers?
– Do they take adequate fluid with them
• What does the person say about his or her
bowel habits?
• Has the bowel pattern changed recently?
• Does the person report any concerns related
to bowel elimination?
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Nursing Diagnosis
• Altered elimination pattern-Constipation
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Nursing Goals/Outcomes
• Exhibit regular patterns of bowel elimination
• Identify behaviors that promote normal bowel
functioning
• Modify behaviors to enhance regular bowel
elimination
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Nursing Interventions for Constipation
• Assess bowel elimination patterns and
contributing factors
• Increase physical activity
• Increase intake of dietary fiber and fluids
• Schedule or encourage toileting at times when
the person’s defecation urge is strongest
• Position to facilitate ease of elimination
• Provide privacy for elimination
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Nursing Interventions for Constipation
(cont.)
• Administer stool softeners or bulk-forming
laxatives as prescribed by the physician
• Administer prescribed suppositories or
enemas if other methods have not been
effective
• Perform digital rectal examination and
impaction removal as ordered or according to
agency policy
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Nursing Process for Diarrhea
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Diarrhea
• Frequent passage of liquid, unformed stools
– Stools are liquid because they pass through the
large intestine too rapidly and are expelled before
sufficient water can be absorbed in the large
intestine
• Symptom of another problem
– many causes
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malabsorption syndromes
Obstruction- tumors of the GI tract or stool
lactose intolerance
Diverticulosis
pathogenic organisms
medications
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Assessment
• Same as for constipation
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Nursing Diagnosis
• Altered elimination pattern-Diarrhea
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Nursing Goals/Outcomes
• Exhibit regular patterns of bowel elimination
• Identify behaviors that promote normal bowel
functioning
• Modify behaviors to enhance regular bowel
elimination
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Nursing Interventions for Diarrhea
• Assess the elimination pattern and suspected
causative factors
• Maintain adequate fluid intake
• Institute measures to maintain skin integrity
• Promptly report observations to the physician,
and follow up on physician’s orders regarding
medications that decrease intestinal motility
• Stool testing as ordered
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Bowel Incontinence
• common for those who are unable to recognize
&/or respond to normal sensation
– mental impairment
– Mobility
– Delayed assistance
• Less frequently disorders of color or rectum
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Cancer
inflammatory bowel disease
Diverticulitis
weak rectal muscles
diarrhea
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Which nursing diagnosis is most important for
the patient with diarrhea?
A. Disturbed body image
B. Fluid volume deficit
C. Knowledge deficit
D. Impaired gas exchange
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Nursing Process for Bowel
Incontinence
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Assessment
• Same as for constipation
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Nursing Diagnosis
• Bowel incontinence
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Nursing Goals/Outcomes
• Exhibit regular patterns of bowel elimination
• Identify behaviors that promote normal bowel
functioning
• Modify behaviors to enhance regular bowel
elimination
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Nursing Interventions
• Assess patterns of elimination and causative
factors
• Establish a toileting schedule
• Take measures to prevent or reduce episodes
of constipation
• Use appropriate aids or garments
• Clean the person promptly after each episode
of incontinence
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Nursing Process for Impaired
Urinary Elimination
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Urinary Retention
• Abnormal accumulation of urine in the bladder; bladder
unable to empty completely
– Normally, no more than 50 mL of urine remains in the bladder
after voiding
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decreased muscle tone in the bladder wall
medications
prostate gland enlargement/uterine prolapse
trauma to the muscles of the perineum
neurologic problems
anxiety
Decreased fluid intake
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Urinary Retention (cont.)
• Symptoms
– feeling of fullness, discomfort, or tenderness
– Small frequent voids
– Frequent bladder infections
– Restlessness
– diaphoresis
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Urinary Retention Treatment
• If caused by perineal trauma or anxiety
– noninvasive tx such as medications, peppermint
oil [inhaled scent] or a sitz bath may be enough to
stimulate effective voiding
• If severe retention is caused by an obstruction
such as an enlarged prostate, catheterization
or surgery may be necessary
– prevent serious bladder damage that could result
from persistent or excessive bladder distention
• Pessarys were once commonly used with
uterine prolapse, now usual tx is surgery
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Urinary Incontinence
• The involuntary loss of urine
– social or hygiene problem
• In some cases, incontinence is curable using
surgery ,medications, or other treatments
• In others- better managed, thus allowing the
older person a more normal lifestyle
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Types of Urinary Incontinence
• Stress incontinence
– Leakage of urine
• conditions that increase intra-abdominal pressure
• exercise, lifting heavy objects, laughing, coughing, or sneezing
• Urge incontinence
– Caused by involuntary contraction of the detrusor muscle
of the bladder
• Overflow incontinence
– Leakage of small amounts of urine from an overly full
bladder
– Common with retention problems
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Types of Urinary Incontinence (cont.)
• Functional incontinence
– normal urethral and bladder function
– cognitive or physical in nature
• Total incontinence
– A condition in which older adults experience
continuous and unpredictable loss of urine
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Assessment
• Is the person continent or incontinent?
• any specific time of day or under any special
conditions?
• history of any medical conditions that would
interfere with urine elimination (neurogenic
bladder)?
• history of any medical condition that would
decrease awareness of the need to void?
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Assessment (cont.)
• difficulty in starting to urinate?
• any involuntary loss of urine when he or she
coughs, laughs, or sneezes?
• pain or burning with urination?
• What is the person’s pattern of fluid intake?
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Nursing Diagnoses
• Altered elimination
– Functional urinary incontinence
– Reflex urinary incontinence
– Stress urinary incontinence
– Urge urinary incontinence
– Impaired urinary elimination
– Urinary retention
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Nursing Goals/Outcomes
• Exhibit a reduction in episodes of urinary
incontinence or retention
• Urinate at acceptable times in acceptable
places
• Identify measures that reduce episodes of
urinary incontinence or retention
– Ie-toilet every 2 hours
• Establish a routine to reduce or prevent the
occurrence of bladder elimination problems
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Nursing Interventions
• Assess elimination and fluid intake patterns
• Explain measures that help improve tone of
the sphincter muscles
– Kegel exercises
• Modify clothing to make toileting easier
• Reduce environmental barriers
– grab bars in the bathroom, installing toilet risers,
keeping the urinal or bedpan readily available, and
providing a call signal for assistance
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Nursing Interventions (cont.)
• Answer call signals promptly
• Develop a toileting schedule
• Familiarize older adults with the locations of
bathrooms throughout the facility
• Provide support and encouragement
• Initiate actions to maintain skin integrity
• Provide incontinence pads or garments when
appropriate
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Nursing Interventions (cont.)
• Administer medications as prescribed by the
physician
• Insert catheter as prescribed by the physician
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Disposable and Reusable Incontinence
Garments
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Disposable Incontinence Pads
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Catheters
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