1. Best Nursing Practices in Care for Older Adults
ELDER Project
Fairfield University School of Nursing
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2. Session 6 Topics: Pressure Ulcers in Older Adults and
Nutrition/Eating for Older Adults
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3. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858
Healthy People 2010
One target is to reduce the proportion of nursing home residents with a diagnosis of pressure ulcers to 8 diagnoses per 1,000 residents.
(current number varies greatly from institution to institution)
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Pressure Ulcer
What is it?
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5. Definition of Pressure Ulcer:
Any lesion caused by unrelieved pressure and resulting in damage of underlying tissue
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Prevention is the Key!
Difficulty in healing pressure ulcers due to
Decreased ambulation/mobility
Decreased nutritional status
Incontinence
Underlying medical issues
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7. Tools to Assess Risk for Pressure Ulcers
Braden Scale : for elderly population, score should be < 18
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8. Staging Pressure Ulcers
There are 4 stages of Pressure Ulcers
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Stage I Pressure Ulcer
Observable pressure-related alteration of intact skin
Changes include one or more of the following:
Skin temperature (warm, or cool)
Tissue Consistency (firm, or boggy)
Sensation (pain, or itch)
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Stage 1 continued
In lighter skin: It is a defined area of persistent redness
In darker skin: May appear with persistent red, blue or purple tones
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Stage I Pressure Ulcer
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12. Stage II Pressure Ulcers
Partial thickness skin loss
Involves epidermis and/or dermis
Superficial
Presents as:
an abrasion
blister
shallow crater
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13. Stage II Pressure Ulcer
Blister
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14. Stage III Pressure Ulcer
Full thickness skin loss
Damage or necrosis to subcutaneous tissue
Presents as
Deep crater
With or without undermining to adjacent tissue
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Stage III
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16. Stage IV Pressure Ulcer
Full thickness skin loss
Extensive destruction
Tissue necrosis
Damage to muscle, bone or supporting structures (tendons, joints)
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17. Stage IV Pressure Ulcer
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Eschar
If eschar is present, the ulcer cannot be staged
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Risk Assessment
Patients are at risk if:
Bedbound or chairbound
Impaired ability to reposition self
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Other Risk Factors
Decreased mental status
Moisture
Incontinence
Nutritional deficit (low albumin)
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21. When to Assess for Risk:
Upon admission
At regular intervals after admission depending on the setting
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Acute Care
Assess every 48 hours or whenever the condition changes
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Long Term Care
Weekly for the first four weeks
Then quarterly at a minimum
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Home Care
At every visit
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25. Skin Care & Early Treatment
Inspect skin daily and document
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26. Skin Care & Early Treatment
Individualize bathing frequency
Mild cleansing agents (or no soap)
Avoid hot water
Avoid excessive friction
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27. Skin Care & Early Treatment
Assess and treat incontinence
Cleanse at time of soiling
Topical moisture barrier
Absorbent briefs or pads
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28. Skin Care & Early Treatment
Use moisturizers for dry skin
Avoid massage over bony prominences
Use dry lubricants (cornstarch), or protective coverings to avoid shearing
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29. Skin Care & Early Treatment
Use proper positioning, transferring, turning to decrease friction
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30. Skin Care & Early Treatment
Identify and correct nutritional problems
Consider nutritional supplements
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31. Skin Care & Early Treatment
Institute a rehabilitation program
Monitor and document interventions
Monitor and document outcomes
Modify night regimen as needed
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32. Positioning and Alignment
Reposition bed-bound patients at least every 2 hours
Reposition chair-bound patients at least every hour
Use a written repositioning schedule
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33. Positioning and Alignment
Place at risk persons on a pressure reducing mattress/chair/cushion
Do not use donut type devices
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34. Positioning and Alignment
Teach chair bound patients to shift their weight every 15 minutes
Use lifting devices to move, rather than drag patients
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35. Positioning and Alignment
Use devices that totally relieve pressure on heels (ie: pillow under calf)
Use pillows or foam wedges to keep boney prominences from direct contact with each other
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36. Positioning and Alignment
Avoid positioning directly on trochanter when side-lying (use 30 degree angle)
Elevate the head of bed as little as possible for short times only
(max 30 degrees)
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Plan of Care
Include strategies for
Nutrition
Pain management
Psycho-social issues
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Plan of Care
May need to include:
Debridement
Cleansing
Dressing
Pressure relief
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39. Care for Pressure Ulcers: Tips
Assess the whole person
Measure wound healing
Use solutions to cleanse that do not kill good cells
Normal saline
SOME commercial wound cleansers
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40. Avoid Cytotoxic Solutions
Dakin’s Solution
Acetic Acid
Providone Iodine
Hydrogen Peroxide
Some Commercial Skin Cleansers
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41. Selecting Dressing Materials
Maintain a moist environment (not soaking)
Avoid desiccating (drying out) wound bed
Eliminate dead space (loosely fill)
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Topic # 2: Nutrition
Nearly 50% of adults aged 65 and over are clinically malnourished upon admission to the hospital
This number increases upon discharge
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Food Diary
A 3 day food diary is the best method of obtaining a diet history
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Weight
It is important to track weight and changes in weight
Don’t rely on self report
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45. Physical Assessment for Nutrition
Focus on
Skin turgor
Skin lesions
Changes in skin color
Brittle hair
Muscle wasting
Oral status
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46. Physical Assessment Continued
Focus on
Hydration
Oral lesions, fissures around lips
Hyperplasia of gums
Enlarged, smooth, or beefy red tongue
Poor hygiene
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Hypoalbuminemia
Low albumin levels, below 3.5 g/dl
Key to assessing for malnutrition
Indicates low-protein malnutrition
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Serologic Parameters
Albumin ** (less than 3.5 g/dl)
This is KEY
Total protein (falsely elevated if dehydrated)
BUN/Creatinine Ratio (for hydration and renal function)
Complete Blood Count (CBC) (for anemia)
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49. More Serologic Parameters
Blood glucose (for hypo/hyperglycemia)
Transferrin, iron, ferritin, Vitamin B12 (for anemias)
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50. Consider Religion and Culture
Some people may observe rituals about
Preparing
Blessing
Serving
the food
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51. Anorexia in Older Adults
Principle cause: disinterest in food related to medications
Related Side Effects May Include:
Dehydration, decreased saliva
Early satiety, disinterest in eating
Altered taste
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52. Common Medications that Cause Symptoms:
Most diuretics
Digoxin
Some SSRIs (selective serotonin reuptake inhibitors)
Benzodiazepines
Opiates
Thyroxine
Antihistamines
Chemotherapeutic agents
Some antibiotics
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Depression
Depression can cause a lack of interest in eating
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Optimal Dining
Certain factors will contribute to an optimal dining experience
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55. Factors that Contribute to Optimal Dining:
Eating in a dining room
Decrease traffic & interruptions during dining
Remove noxious smells
Put food on table, rather than tray
Use of tablecloth or placemats
Use of real flatware instead of disposable
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56. Factors that Contribute to Optimal Dining:
Making sure that hot food is served hot and cold food is served cold
Ensure good lighting
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Dietary Restrictions
If an older adult is not eating enough, it may be futile to place a dietary restriction on them
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58. Plan Care to Maximize Self-Feeding
Seat the patient in an arm chair rather than on a bed
Both feet on the floor
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59. Plan Care to Maximize Self-Feeding
Note condition of the patient’s mouth
Oral hygiene
Loose or poorly fitting dentures
Cavities or broken teeth
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60. Plan Care to Maximize Self-Feeding
Cue the individual when needed
Obtain adaptive devices when needed
Sports bottles
Eyeglasses
Hearing aid
Dentures
Straws, cups with lids
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61. Plan Care to Maximize Self-Feeding
Allow enough time to self-feed
Use finger foods as needed
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62. Mealtime for Cognitively Impaired People
Remember…failure to eat is not normal behavior
Assess for possible unrecognized diseases
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63. Mealtime Tips for the Cognitively Impaired Person
Smaller,frequent meals
Deliver smaller portions if preferred
Use finger foods
Use reliable informant to learn preferences
Use pain medication if arthritis limits ability to feed self
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64. Mealtime Tips for the Cognitively Impaired Person
If the patient needs to be fed, caregiver should sit facing him/her
Never use a syringe to feed a person (could lead to aspiration)
Ensure the patient that feeding them is not a burden
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65. Reference The content covered in this presentation is provided by the
John A. Hartford Foundation Institute for Geriatric Nursing
(2001)
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66. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858
Reference:
Some of the material in this presentation obtained from graciously shared by:
Mather’s LifeWays, 2003
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67. Power Point Presentation Created by:
Diana R. Mager, CRN, MSN
Fairfield University School of Nursing
ELDER Project Director
2006
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