Geriatric Syndrome - Urinary Incontinence, Pressure Ulcers, Feeding Problems

INTRODUCTION

University of the Philippines

COLLEGE OF NURSINGWHO Collaborating Center for Leadership in Nursing Development

Geriatric SyndromeGERIATRIC SYNDROMES are common clinical conditions that don't fit into

specific disease categories but have substantial implications for:

functionality and life satisfaction in older adults

Besides leading to increased

mortality and disability,

decreased financial and

personal resources, and longer

hospitalizations, these

conditions can substantially

diminish quality of life

INTRODUCTION



Geriatric SyndromeMain:

Pressure ulcers,

incontinence, falls,

functional decline

delirium.

Others:

Malnutrition,

eating and feeding problems,

sleeping

problems,

dizziness and syncope and

self-neglect have

5 COMMON CONDITIONS

Main:

Pressure ulcers,

incontinence, falls,

functional decline

delirium.

Others:

Malnutrition,

eating and feeding problems,

sleeping

problems,

dizziness and syncope and

self-neglect have

(Inouye, Studenski,

Tinetti, & Kuchel, 2007).

INTRODUCTION



NEW “EVOLVING” SYNDROMES

sarcopenia

polyprovider

polypharmacy

pain

frailty

INTRODUCTION



Urinary IncontinenceGeriatric Syndrome

Alfie R. Espinosa, RNInfection Control Officer

Perioperative Nurse

What is UI?

URINARY INCONTINENCE

involuntary loss of urine that is sufficient to be a problem (Fantl et al., 1996)

the involuntary loss of urine so severe as to have social and/or hygienicconsequences for individuals and/or their caregivers, is a major clinicalproblem and a significant cause of disability and dependency.



Continence Foundation of the Philippines, (2006)

14.6% for urinary incontinence amongfemales and 6.8% among males

UI is only half as prevalent among mencompared to women.

Whereas mixed urinary incontinence(58.7%) prevails among women

most reports show the predominance ofoveractive bladder or detrusoroveractivity (49%) among men.

ASIAN prevalence rate (1998):


Continence Foundation of the Philippines, (2006)




Cellulitis Pressure ulcers Urinary Tract Infection Falls with fractures Sleep deprivation Social withdrawal Depression Embarrassment (50%) Interference with activities Caregiver burden - contributes

to institutionalization Increase in healthcare cost Decrease quality of life

CONSEQUENCES of UI:



Dementia 11-90%

Community Dwelling 8-38%

Homebound 15-33%

Hospitalized

10.5%

Post-Hip Surgery19-32%

Admission

36%

Additional: Hospitalized 13-42%

AACN Hartford Faculty Development




Micturation is the discharge of urine from the bladder via the urethra.

Lower Urinary Tract

1. Bladder2. Urethra

Phases

1. Storage Phase2. Expulsion Phase




Physiology of Micturition




AGE-RELATED CHANGES AFFECTING BLADDER FUNCTIONClinical Gerontological Nursing

(Stone, Wyman, Salisbury, 1999)

CHANGE EFFECTS

Decreased bladder capacityFrequency

Increased residual urine volumeRisk for urinary tract infection

Uninhibited bladder contractions Urgency, frequency, incontinence

Increased nocturnal urine production Nocturia, enuresis

Decreased estrogenAtropic vaginitis, urgency, frequency, UTI, risk

for pelvic organ prolapse

Lower urethral pressure (women) Stress incontinence

Benign prostatic hyperplasiaUrgency, frequency, straining, urinary retention,

overflow incontinence




ACUTE or TRANSIENT INCONTINENCE

Sudden onset and is related to an

illness, treatment, or medication.

When an illness resolves or the identified cause was managed, this condition usually resolves.

D - elirium

I – nfection

A - trophic vaginitis or urethritis

P - harmaceuticals

P – sychological causes

E – xcess fluids

R – estricted mobility

S – tool impaction

Urinary Incontinence Guideline Panel(Resnick, 1992)





PHARMACOLOGIC CAUSES

Opiods

Depress detrusor activity &

produce urinary retention

and overflow incontinence

Calcium Channel Blockers

Anti-Parkinsons Drugs

Anticholinergic Drugs

Prostaglandin Inhibitors





PHARMACOLOGIC CAUSES

Sedatives awareness, detrusor activity Func & O UI

Loop diuretics Diuresis overwhelms bladder capacity Urge & O UI

Alcohol Polyuria, awareness Urge & Functional UI

Caffeine Polyuria, detrusor activity Urge




ESTABLIHED INCONTINENCE or PERSISTENT URINARY INCONTINENCE

Stress Incontinence

Urge Incontinence

Mixed Incontinence

Overflow Incontinence

Functional Incontinence




STRESS URINARY INCONTINENCE (SUI)

Characterized by loss of small amount of urine in the absence of detrusorcontraction usually during sudden increase in intraabdominal pressure such aswith:

Coughing Sneezing Laughing Lifting Bending

The underlying cause is the inability of the urethra to sustain pressure that exceeds that of the bladder,

particularly under EXERTIONAL EVENTS

(Diokno et al., 1986; Fantl et al., 1991; Makinen et al., 1992)

*more frequent in WOMEN than in MEN




URGE INCONTINENCE

Involuntary loss of urine in association with a strong sensation of urinaryurgency. This type of incontinence is characterized by strong urge to voidimmediately prior to the loss of the urine. (Stone, Wyman, Salisbury, 1999)

Results from:

detrusor (bladder) instability Hyperreflexia uninhabited bladder contractions

“KEY-IN-LOCK” SYNDROME

they loss urine in arriving home andunlocking their door.

It may include urine loss on the wayto the bathroom or the "key in thelock“ or "hand on the doorknob"syndrome (no urge to urinate untilthe key is in the doorlock or thehand is on the knob and then it isimpossible to wait).

womensbladderhealth.com

OVERACTIVEBLADDER




MIXED INCONTINENCE

Combination of STRESS andURGE INCONTINENCE




FUNCTIONAL INCONTINENCE

This pattern of urine loss is precipitated by factors outside the lower urinary tract, rather than abnormal bladder or urethral function

(Stone, Wyman, Salisbury, 1999)

(Malone, Fletcher, Plank, 2004)

Characterized by inability to get into the toilet on time as a result of the following:

1. physical impairments2. chronic cognitive impairments3. environmental or physical barriers4. or the lack of caregiving assistance




OVERFLOW INCONTINENCE

Characterized by involuntary loss of frequent or constant dribbling and a failure to empty the bladder completely,

resulting in over distention.

• Outlet obstruction

• Hypoactive detrusor

MEN

Prostatic Hyperplasia

Prostatic Cancer

Urethral Stricture

Women

Severe Pelvic Organ Prolapse

AntiincontinenceSurgery

(Stone, Wyman, Salisbury, 1999

(Malone, Fletcher, Plank, 2004)




The Urinary Distress Inventory-6 (UDI-6) is a self-report symptom inventory for UI that is reliable and valid for identifying the type of established UI in community

dwelling females

Female Patient

The Male Urinary Distress Inventory (MUDI) is a valid and reliable measure of urinary symptoms in the

male population

Male Patient

INITIAL HISTORY FOR UI

Ask screening questions such as:

“Have you ever leaked urine? If yes, how much does it bother you?”




UROGENITAL DISTRESS INVENTORY SHORT FORM (UDI -6)

Questions to ask on history taking and review of systems about UI

Do you experience, and, if so, how much are you bothered by:

Frequent urination This may indicate: Irritative/Overactive Bladder

Leakage related to feeling of urgency This may indicate: UI/Irritative

Leakage related to activity, coughing, or sneezing This may indicate:UI/Stress

Small amount of leakage (drops) This may indicate: UI/Stress

Difficulty emptying bladderThis may indicate Obstructive/Discomfort:

Obstructive Micturation

Pain or discomfort in lower abdominal or genital area This may indicate: Obstructive/Discomfort




INITIAL HISTORY FOR UI

• Differentiate between transient and established UI because transientUI may convert to persistent UI

• The seven-day bladder diary or record is the most evaluated andrecommended tool to quantify UI and identify activities associatedwith unwanted urine loss

• A three-day bladder diary may be more feasible in the clinical setting




kidney.niddk.nih.gov/kudiseases/pubs/diary/

THE BLADDER DIARYTRIXIE ROSARIO

Juice 500 LiftingWater 300 Dancing

The bladder diary

can help identify

potential bladder

irritants (e.g.,

acidic foods or

fluids, aka acid-

ash) that contribute

to UI




THE BLADDER DIARY

• If the initial scheduled toileting time is set for 7 A.M., yet at 6:30 A.M. the patient consistently attempts to independently void or is noted to be incontinent, then the toileting time should be adjusted to 6 A.M.

• Prompted voiding requires the caregiver to ask if the patient needs to void, offer assistance, and then offer praise for successful voiding

Example

• To assess UI

• Develop an individualized scheduled toileting program

which mimics the patient’s normal voiding patterns

Continual assessment and evaluation improves success




PHYSICAL EXAM FOR UIObserve the patient during urination to determine ability to

remove undergarments, sit on toilet etc.

Abdominal exam:

• Determine the presence of bladder distention• Determine presence of stool impaction in left

quadrant




Inspect male and female genitalia

*Note perineal irritation or long-standing pigmentation change, often indicative

urinary leakage

PHYSICAL EXAM FOR UI




Valsalva maneuver (if not medically contraindicated) to detect pelvicprolapse (e.g., cystocele, rectocele, uterine prolapse) or urine leakage(suggestive of stress UI), as a result of increased intra-abdominal pressurewith bearing down

• Ask the patient to cough while observing for urinary leakage, especially important when performing a “Valsalva” maneuver is contraindicated

• During the genitalia examination, instruct the patient to cough while assessing for urine leakage that may be attributed to Stress UI

Female Patient





Look for signs of atrophic vaginitis post-menopausal women

1. Perineal inflammation

2. Tenderness and, on occasion, trauma as a result of touch)

3. Thin, pale genitalia tissues that are often friable and prone to bleeding

Perform digital rectal exam to identify constipation or fecal impaction


Women





Assess for “anal wink” (contraction of the external anal sphincter) by lightly stroking the circumanal skin.

• Indicative of intact sacral nerve routes• Absence of the “anal wink” may

suggest sphincter denervation





Men

In men, palpate the prostate gland.

• Typically an enlarged prostate is readily detected andcorrelates with symptoms of:

1. urinary urgency2. incomplete bladder emptying3. decreased urinary stream4. nocturia




LAB TESTS FOR UI

Urinalysis and/ urine culture and sensitivity

Post void residual urine or simple bedside urodynamics

The International Continence Society (ICS) does not recommend urodynamic testing in the initial assessment and management of UI




TREATMENT VS REFERRAL

Initiate referral if any of the following apply:

Need for additional testing

Abnormal U/A or culture

Palpable abdominal or pelvic mass

Elevated PVR

Abnormal prostate exam

Vaginal bleeding; obstruction; new underlying disorder; surgical candidate




BEHAVIORAL MANAGEMENT

Scheduling Regimen

Scheduling regimens include:

• timed voiding• habit training• prompted voiding• bladder training

Success of this regimens when used in institutionalized patients relies on staff member’s training, compliance, and incentives for active participation. Thus, it is important to develop management

procedures to monitor the staff implementation of toileting interventions and to provide feedback about the performance (Schnelle, 1990).





TIME VOIDING

The fixed voiding schedule usually every 2 hours is used for:

• Stress UI• Overflow UI• Functional UI• Reflex UI





HABIT TRAINING

This is carried out through individualized and prescribed toileting schedule which involves toileting intervals adjusted to the patient’s voiding pattern.

• Stress UI• Urge UI• Functional UI• Reflex UI





PROMTED VOIDING

It consists 3 elements used by caregivers:

1. Monitoring the patient on regular basis2. Prompting the patient to try to use the toilet3. Praising the patient for maintaining continence and using the toilet

Prompted voiding is recommended for patients who can:

1. Ask assistance2. Respond when prompted to toilet3. Learn to recognize some degree of bladder fullness or need to void

(Fantl et al., 1996)





(Fantl et al., 1996)

BLADDER TRAINING

This technique consists of a:

• patient education in combination• progressive voiding schedule• positive reinforcement technique

It is usually used to treat outpatients who are cognitively intact and have Sx of:

• Urge UI• Stress UI• Mixed UI




Kegel’s exercises

RATIONALE: PFMEs facilitate continence by increasing strength, endurance, and contractibility of the pelvic muscles, which

support the bladder neck, contribute to optimal anatomical positioning of the urethra, and facilitate neuromuscular control

necessary for continence

MenDuring the rectal

examination, male patients are instructed to squeeze

the rectal muscles

WomenTeach PFMEs during the pelvic

examination

Instruct the patient to squeeze (contract) her vaginal muscles around the examiner’s gloved

hand

MANAGEMENT OF UI: PELVIC FLOOR MUSCLE EXERCISES (PFMES) FOR STRESS URINARY INCONTINENCE




Ideally, each PFME should consist of a contraction lasting for 10 seconds,

followed by a relaxation period of 10 seconds

MANAGEMENT OF UI: PELVIC FLOOR MUSCLE EXERCIZES (PFMES) FOR STRESS UI

Patient should be instructed to avoidcontracting abdominal, buttocks, or

thigh muscles so as to not increase intra-abdominal pressure.

While there are variations on the number of PFME per day required, it is usual

practice to recommend 15 PFMEs three times per day




PFMEs may cause neuromuscular changes that promote a decrease in the autocontractility of the bladder,

thereby inhibiting the urge to urinate

There is evidence that PFMEs decrease incontinent episodes related to urge UI

(Bradway & Castronovo, 2015)

Available at: http://consultgerirn.org/uploads/File/aprncenter/slidelibrary/APRN-SlideLib_UI.ppt




Urine stream interruption test (UST)

• is a simple measure of pelvic floor muscle

strength and provides a numerical value to

supplement data collection




Patients may need several weeks to note improvement in bladder control

Once patients are confident with performing PFMEs they may benefit from “The Knack”

WomenUST should be under two

seconds in women reporting significantly fewer UI

episodes

MenUST is currently being tested

in a male sample

Urine stream interruption test (UST)




Occlusive and Pelvic support devices

Surgical procedures

OTHER MANAGEMENT OF STRESS UI




Occlusive and Pelvic Support Devices





Surgery


Surgery is indicated in the treatment of stress

incontinence, overflow incontinence secondary to

Anatomical obstruction, and urge incontinence

secondary to lower urinary tract pathology. (e.g.

bladder stone, tumor, or diverticulum).

Augmentation Cystoplasty

• the surgery most often performed for severe urge incontinence.

• a part of the bowel is added to the bladder

Sacral Nerve Stimulation

• is a newer type of surgery. A small unit is implanted under your skin

• This sends small electrical pulses to the sacral nerve (one of the nerves that comes out at the base of your spine)




• oxybutynin (Ditropan®)

• tolterodine (Detrol®)

• darifenacin (Enablex®)

• trospium chloride (Sanctura ®),

• solifenacin succinate (Vesicare ®)

Long-acting formulations, transdermal patch preparations, and lower dose preparations are available.

MANAGEMENT FOR UI: MEDICATIONSAvailable Medications

Anticholinergic

(antimuscarinic)/antispasmodic

• This medications are commonly

prescribed for urge UI and OAB

because they reduce detrusor

overactivity and spasm, and in turn,

decrease urinary urgency, frequency,

and urge UI If prescribed, the nurse

should assess the patient for common

side effects




ENVIRONMENTAL MANAGEMENT

Environment plays a vital role in managing functional UI

Incontinence

• Individuals are often dependent on adaptive devices

(e.g., walker) or caregivers for assistance with voiding

• Facilitate access to toilets or toileting substitute may

prevent or reduce functional incontinence (urinal,

commode, bedpan)

• Wearing loosely fitting cloths with elastic waistbands

or snap or Velcro fasteners facilitates disrobing for

those patients with manual dexterity problems.




Strategies specific to manage overflow UI include PFMEs if it is determined that bladder outlet obstruction is due to persistent contraction of the pelvic floor muscles

Interventions to manage overflow UI:

1. Crede’s maneuver

2. Timed voiding

3. Double voiding

4. Intermittent urinary catheterization

MANAGEMENT: OVERFLOW UI




MANAGEMENT: OVERFLOW UI

Crede’s maneuver: Cautiously used and requires manual

compression over the suprapubic area during bladder

emptying

Avoid: If vesicoureteral reflux or overactive sphincter

mechanisms are suspected as the Crede’s maneuver would

dangerously elevate pressure within the bladder

Double Void: Repositioning to void again directly after

the initial void.

For a patient with overflow UI the APRN should evaluate if medications

may be causing urinary retention




PATIENT EDUCATION: AHRQ UI CLINICAL PRACTICE GUIDELINES

Majority of patients delay seeking health care for UI because of

inadequate knowledge, embarrassment, feelings that symptoms were

“normal” or advice-seeking from non-health care providers

Continence policies and research add an important contribution in

understanding what is known about translating continence guidelines into

practice

United Kingdom

general practitioners

hospital services

nurse

Learned UI

from

40.0

28.0

8.0




Work closely with older adults who fear that unwanted urine loss results from increased fluid intake

1. Focus education on the adverse consequence of inadequate fluid intake such as volume depletion, or potential for dehydration.

2. Emphasize that too little fluid intake causes urine to become concentrated which in turn, leads to increased bladder contractions and feelings of urinary urgency

3. To manage and limit nocturia, advise to limit fluid intake a few hours before bedtime

PATIENT EDUCATION: FLUID INTAKE




1. Examine and discuss medications contributing to UI with the prescribing health care provider

2. Determine the necessity of the medication or ideal scheduling to promote continence

PATIENT EDUCATION: MEDICATIONS




NURSING IMPLICATIONS/CONSIDERATIONS

1. Teach pelvic floor muscle exercises (DuBeau et al, 2010; Hodgkinson et al., 2008).

2. Provide toileting assistance and bladder training PRN (whenever necessary) (DuBois et al., 2010).

3. 3. Consider referral to other team members if pharmacological or surgical therapies are warranted.





Overflow UI:

1. Allow sufficient time for voiding.

2. Discuss with interdisciplinary team the need for determining a post-void

residual (PVR) (Newman & Wein, 2009).

3. Instruct patients in double voiding and Crede’s maneuver.

4. If catheterization is necessary, sterile intermittent is preferred over

indwelling catheterization PRN.

5. Initiate referrals to other team members for those patients requiring

pharmacological or surgical intervention.





Urge UI and OAB:

1. Implement bladder training (retraining) (DuBeau et al., 2010).

2. If patient is cognitively intact and is motivated, provide information on urge

inhibition.

3. Teach PFMEs to be used in conjunction with bladder training, and instruct in urge

inhibition strategies (Rathnayake, 2009)

4. Collaborate with prescribing team members if pharmacologic therapy is

warranted.

5. Initiate referrals for those patients who do not respond to the previous steps.





Functional UI:

1. Provide individualized, scheduled toileting, timed voiding, or

prompted voiding (Lee et al., 2009).

2. Provide adequate fluid intake.

3. Refer for physical and occupational therapy PRN.

4. Modify environment to maximize independence with

continence (Jirovec et al., 1988).

Pressure UlcersGeriatric Syndrome


Perioperative Nurse

PRESSURE ULCERS



National Pressure Ulcer Advisory Panel (NPUAP) and

European Pressure Ulcer Advisory Panel (EPUAP):

"A pressure ulcer is localized injury to the skin and/or

underlying tissue, usually over a bony prominence, as a result

of pressure, or pressure in combination with shear. A number

of contributing or confounding factors are also associated with

pressure ulcers; the significance of these factors is yet to be

elucidated.“

Also known as DECUBITUS ULCERS

WHAT IS PRESSURE ULCER?

PRESSURE ULCERS



ETIOLOGY

It is generally accepted that pressure ulcers are causally related to the effects of 3 tissue forces: pressure, shear, and friction.

Pressure is a perpendicular force that compresses tissues,typically between a bony prominence and an externalsurface, and can result in decreased tissue perfusion andischemia. Tissue necrosis can result when there is unrelievedpressure or ischemia that is potentiated by compromisedhost (eg, chronic medical conditions, protein-energymalnutrition, or sepsis).

PRESSURE ULCERS



Shear is a force parallel to the skin surface. When thehead of the bed is raised or a patient slides downwardin a chair, the body is angulated above the supportsurface, causing skeletal muscle and deep fascia toslide downward with gravity while the skin andsuperficial tissues adhere to the chair surface or bedlinens.

This shear force can cause a change in the angle of the vessels, and thus, compromise blood supply, resulting in

ischemia, cellular death, and tissue necrosis.

ETIOLOGY

PRESSURE ULCERS



Friction is the adherent force resisting shearingmovement of the skin, which may result in denudedareas of the dermis through repeated epidermalshedding or avulsion of sheets of epidermis.

Prolonged exposure of this tissue injury to moisture from perspiration, urinary or fecalincontinence, or wound exudate will further

weaken the intercellular bonds in the epidermal layers, causing maceration and

epidermal ulceration$

ETIOLOGY

PRESSURE ULCERS



COMMON PRESSURE ULCERS SITES

Supine:

23% sacro-coccygeal

8% heels

1% occiput; spine

Sitting:

24% ischium

3% elbows

Lateral:

15% trochanter

7% malleolus

6% knee

3% heels

PRESSURE ULCERS



According to the NPUAP and EPUAP, there are 6 categories of pressure ulcers.

NPUAP refers to these categories as stages and EPUAP refers to them as grades.

Only the numbered categories (I through IV) represent increasing degrees of skin

and tissue damage. Two other categories are qualitative descriptors that do not

necessarily reflect the severity of the ulcer.

The classification system:

• Category I – Nonblanchable erythema

• Category II – Partial-thickness skin loss

• Category III – Full-thickness skin loss

• Category IV – Full-thickness tissue loss

• Suspected Deep Tissue Injury – Depth unknown

• Unstageable – Depth unknown

CLASSIFICATION OF PRESSURE ULCERS

PRESSURE ULCERS



STAGE I PRESSURE ULCER: NONBLANCHABLE ERYTHEMA

Intact skin with non-blanchable redness of a localized area usually

over a bony prominence. Darkly pigmented skin may not have visible

blanching; its color may differ from the surrounding area.

PRESSURE ULCERS



STAGE II PRESSURE ULCER: PARTIAL-THICKNESS SKIN LOSS

Partial thickness loss of dermis presenting as a shallow open ulcer

with a red pink wound bed, without slough. May also present as

an intact or open/ruptured serum-filled blister.

PRESSURE ULCERS



STAGE III PRESSURE ULCER: FULL-THICKNESS SKIN LOSS

Full thickness tissue loss. Subcutaneous fat may be visible but bone,

tendon or muscles are not exposed. Slough may be present but does

not obscure the depth of tissue loss. May include undermining and

tunneling

PRESSURE ULCERS



STAGE IV PRESSURE ULCER: FULL-THICKNESS TISSUE LOSS

Full thickness tissue loss with exposed bone, tendon or muscle.

Slough or eschar may be present on some parts of the wound bed.

Often include undermining and tunneling.

PRESSURE ULCERS



SUSPECTED DEEP TISSUE INJURY (SDTI)

Purple or maroon localized area of discolored intact skin or blood-

filled blister due to damage of underlying soft tissue from pressure

and/or shear. The area may be preceded by tissue that is painful, firm,

mushy, boggy, warmer or cooler as compared to adjacent tissue.

PRESSURE ULCERS



UN-STAGEABLE PRESSURE ULCER:FULL-THICKNESS SKIN OR TISSUE LOSS – DEPTH UNKNOWN

Full thickness tissue loss in which the base of the ulcer is covered byslough (yellow, tan, gray, green or brown) and/or eschar (tan,brown or black) in the wound bed. Base of the wound cannot bevisualized.

PRESSURE ULCERS



CAUSATIVE FACTORS FOR THE DEVELOPMENT OF PRESSURE ULCERS

Immobility or limited mobility

Bowel & Bladder Incontinence

Shearing and friction injuries

Advanced age

Malnutrition or debility

Obesity

History of pressure ulcers

Dehydration

Contractures

Use of orthotic devises or restraints

Lack of compliance

Use of diapers / excess skin moisture

Intrinsic Factor

Nutrition

Aging

Low arteriolar pressure

Low oxygen tension

Extrinsic Factor

Moisture

Friction and Shear

PRESSURE ULCERS



PRESSURE ULCER PREVENTION / NURSING INTERVENTIONS

Turn every 2 hours (q2h) Schedule: e.g. alternating positions Right/Back/Left

q2h. May place pillow under one hip at a time if patient cannot tolerate full

turning.

Maximal Remobilization: Passive range of motion, physical therapist (PT)

consult to plan appropriate measures for patient. Spinal Cord Injury and Disorder

(SCI&D) patients (or any patient with custom chairs) are to sit in their own

wheelchairs and cushions only.

Protect Heels: Support entire leg with pillows to allow heels to suspend above

the mattress or use heel protectors. Assess heels everyday for signs of pressure.

Consider pressure relieving / distribution bed surface.

PRESSURE ULCERS



Manage Moisture: Correct cause, (e.g., diarrhea), reduce or eliminate

incontinent episodes (e.g., bladder training); Use mild soap, rinse, and dry skin

well and apply moisture barrier cream. No diapers while patient in bed.

Manage Nutrition: Increase protein intake more than 100% RDA, if not

renal or liver impaired. Dietary consult to determine dietary needs and/or

effectiveness of tube feedings.

Reduce Friction and Shear: Use bed trapeze or pull sheet for lifting and

moving patient up in bed. Apply transparent film or hydrocolloid dressing

(Duoderm) over friction areas (e.g., elbows) Keep the head of the bed less

than 30 degrees as often as possible.

PRESSURE ULCER PREVENTION / NURSING INTERVENTIONS

PRESSURE ULCERS



MANAGEMENT OF STAGE- I

Stage I on Trunk of the Body

Manage incontinence, keeping area clean and dry.

Use moisture barrier cream PRN.

Off load area of pressure ulcer with pressure reducing / distribution

surface and turning and repositioning schedule.

Stage I on Heels

Ensure that heel(s) are floated at all times with frequent monitoring.



MANAGEMENT OF STAGE- II

Dry Wound Bed

Cleanse with normal saline, apply small amount of hydrogel

and cover with non adherent dressing, change every day.

Off load area of pressure ulcer with pressure reducing /

distribution surfaces and turning and repositioning schedule.

Minimal Drainage

Cleanse with normal saline, apply hydrocolloid dressing

every three days and PRN soiling or dislodging. Monitor

placement every day.

PRESSURE ULCERS



MANAGEMENT OF STAGE- III

Minimal Drainage and Clean Wound Bed

Cleanse with normal saline, apply small amount of hydrogel

and cover with non adherent dressing change every day.

Off load area of pressure ulcer with pressure relieving /

distribution surface and turning and repositioning schedule.

Presence of Slough with drainage

Sharp debridement / Enzymatic debridement

Use Foam or Calcium Alginate dressing for moderate to copious

drainage management.

Slough 30% or less in the wound, negative pressure wound

therapy is preferred treatment.

PRESSURE ULCERS



MANAGEMENT OF STAGE- IVMinimal Drainage and Clean Wound Bed

Cleanse with normal saline, apply hydrogel and cover with

non adherent dressing change every day.

Off load area of pressure ulcer with pressure relieving

surface and turning and repositioning schedule.

Presence of Slough with drainage

Sharp debridement / Enzymatic debridement

Use Foam or Calcium Alginate dressing for moderate to

copious drainage management.

Slough 30% or less in the wound, negative pressure wound

therapy is preferred treatment.

Tunneling and undermining shall be filled appropriately.

PRESSURE ULCERS



MANAGEMENT OF SUSPECTED DEEP TISSUE INJURY

Cleanse with normal saline, apply foam dressing

change every day.

Off load area of pressure ulcer with pressure

relieving / distribution surface and turning and

repositioning schedule.

Use Foam dressing for drainage management.

Castor oil / Balsam / Peru / Trypsin spray is the

preferred treatment.

PRESSURE ULCERS



MANAGEMENT OF UN-STAGEABLE PRESSURE ULCERS

Cleanse with normal saline, apply hydrogel and cover with

non adherent dressing change every day.

Off load area of pressure ulcer with pressure relieving /

distribution surface and turning and repositioning schedule.

Use Foam dressing for drainage management.

Castor oil / Balsam / Peru / Trypsin spray is the preferred

treatment for wounds with Intact eschar.

Sharp or enzymatic debridement for the management of

slough.

PRESSURE ULCERS



NEGATIVE PRESSURE WOUND THERAPY (V.A.C.(R) THERAPY

This negative pressure wound therapy consists of a specialized open cellfoam dressing, evacuation tubing, a fluid-collection canister, and a vacuumtherapy pump with adjustable settings and continuous feedbacktechnology. The foam dressing is cut to conform to the specific size andshape of the wound and is then placed into the wound cavity. Theevacuation tube is either inserted into or attached to the foam dressing sothat it exits parallel to the skin and the wound site. The foam dressing isthen covered with a thin adhesive film to create an airtight seal. Thisconverts the previously open wound to a controlled closed system. Afterthe wound is sealed, the proximal end of the evacuation tube is attached toan effluent collecting canister, and the canister is connected to theadjustable vacuum pump. Depending on the nature of the wound, thepump can deliver either continuous or intermittent subatmosphericpressures ranging from -50 to -200 mm Hg. This negative pressure istransmitted uniformly through the open cell foam dressing to all woundsurfaces.

PRESSURE ULCERS



NEGATIVE PRESSURE WOUND THERAPY (V.A.C.(R) THERAPY

1. removing tissue fluids and chronic wound exudate

2. reducing infectious materials

3. assisting in the formation of granulation tissue.

Application of topical negative pressure has been shown to help

promote wound healing by

PRESSURE ULCERS



Patient and wound assessment

Assessing risk factors and establishing that a patient is at risk should be part of the initial assessment for any patient who is

entering the health care system. Incorporating this assessment into a comprehensive examination ensures that systemic factors compromising wound healing are promptly

identified. Following global evaluation of the patient, attention is then focused on the pressure ulcer itself, and a detailed

wound evaluation is accomplished. Once the patient and the wound have been completely assessed, the practitioner must

initiate a plan of care to address the factors placing the patient at risk, the systemic factors compromising host

healing, and the advanced wound care efforts to be initiated.

Nursing Implications

PRESSURE ULCERS



Risk Assessment

Preventing pressure ulcers or inhibiting progression of an existing ulcer is greatly facilitated by the use of a practical,

validated risk assessment instrument that enables the practitioner to objectively evaluate a patient's level of risk.


The guideline on pressure ulcer prevention from the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality

PRESSURE ULCERS




PRESSURE ULCERS

Wounds are very painful, thus causing patients a great deal of suffering.

The anatomical location of the ulcer may result in a loss of dignity.

Quality of life is affected, as the patient must alter activities to help heal the wound and may face long-term hospitalization.

A nonhealing ulcer is at high risk for infection, which can be life threatening.

Ulcer treatments may require surgical procedures such as debridement, colostomies, and amputations, which the patient would otherwise not have to face.

An ulcer that heals forms scar tissue, which lacks the strength of the original tissue and is more easily ulcerated again and again.

Feeding ProblemsGeriatric Syndrome


Perioperative Nurse

FEEDING PROBLEMS



DEFINITIONS

•Feeding: The concept of feeding is defined as, "the process of getting the food from the plate to the mouth. It is a primitive sense without concern for social niceties"( Katz, Downs, Cash, & Grotz, 1970, p. 22).

•Eating: Feeding is differentiated from eating, which is defined as "the ability to transfer food from plate to stomach through the mouth"(Siebens et al., 1986, p. 193).

•Feeding behavior: an environmental and contextual approach to examining the interaction between the person being fed and the caregiver, as well their separate actions (Amella & DiMaria, 2001).

FEEDING PROBLEMS



FEEDING PROBLEMS



FEEDING PROBLEMS



Nutritional Screening Initiative (NSI)

FEEDING PROBLEMS



FACTORS LEADING TO DECREASED NUTRITION IN THE ELDERLY

Physical Obstacles to Eating

• difficulty in holding and using utensils or in conveying food from plate to mouth• decreased ability to chew and swallow• decreased appetite• decreased awareness of hunger and thirst

Arthritis

When arthritis occurs in the hands, an

inability to manipulate utensils—due to

swelling and decreased joint function

as well as pain and inflammation—can

affect the ability to pick up or cut food

or use a cup.

Stroke

Stroke can lead to paralysis; weakness

and changes in muscle tone, usually on

one side of the body; and difficulty

chewing, manipulating food in the

mouth, and swallowing.

FEEDING PROBLEMS




Physical Obstacles to Eating

DENTITION PROBLEMS

Missing or painful teeth and ill-fitting

or uncomfortable dentures may make

chewing difficult or impossible.

SMELL AND TASTE PROBLEMS

Diminishes as a natural consequence of

aging, which can decrease interest in

and appreciation of food

FEEDING PROBLEMS




Apraxia is the inability to perform

physical actions despite having

intact physical ability.

APRAXIA

Amnesia can lead people to forget to

eat altogether; to forget that they have

just eaten, leading them to eat again;

or to think they have eaten when they

haven’t, causing them to skip the nextmeal.

AMNESIA

Cognitive/Perceptual Obstacles to Eating

FEEDING PROBLEMS




Executive functioning is necessary for

self-regulation and awareness. A

deficit in this area can lead people to

exhibit unsafe behavior or behavior

that is socially inappropriate, such as

taking food from other people’s

plates or not regulating the amount

of food they are eating.

EXECUTIVE FUNCTIONING

Agnosia is the inability to interpret sensory

information despite having intact senses.

Those with agnosia may not react to smells

and taste with an increased appetite,

decreasing the likelihood that they

experience hunger. In addition, they might

eat dangerous, non-food items. They may

not recognize the feeling of thirst and may

become dehydrated.

AGNOSIA

Cognitive/Perceptual Obstacles to Eating

FEEDING PROBLEMS



FEEDING PROBLEMS



POTENTIAL UNDERLYING CAUSE OR RISK INTERVENTIONS

FEEDING PROBLEMS




FEEDING PROBLEMS




FEEDING PROBLEMS




FEEDING PROBLEMS



ADAPTIVE EQUIPMENT

Some of the equipment includes:

• Non-slip materials; the use of foam handles or large, molded handles

that slip over regular utensils; or a universal cuff to increase the

client’s ability to grip and/or for joint protection

• Rubber-coated spoons for people who have a tendency to bite down

on utensils

• Plates with a built-up edge for scooping against and plate guards to

prevent food from being pushed off the edge

• Rocker knives or roller knives, similar to pizza cutters, which require

less strength and coordination to cut with than standard knives

FEEDING PROBLEMS



ADAPTIVE EQUIPMENT

Some of the equipment includes:

• Divided plates to keep food separate on plates and prevent it from moving

around too much

• Two-handled mugs

• Cups with a cut-out near the top or an integral straw so that the client can

drink without tilting the head back (to prevent aspiration), for those with

tremors who have a difficult time sipping, or for those who have only a

sucking reflex

• Suction cups or non-slip mats to keep cups, bowls, and plates in place

FEEDING PROBLEMS



Nursing Implications to Caring

A. Environment

1. Dining or patient room: encourage older adult to eat in dining room to increaseintake, personalize dining room, no treatments or other activities occurring duringmeals, no distractions.

2. Tableware: use of standard dinnerware (e.g., china, glasses, cup and saucer,flatware, tablecloth, napkin) versus disposable tableware and bibs

3. Furniture: older adult seated in stable arm chair; table-appropriate height versuseating in wheelchair or in bed.

4. Noise level: environmental noise from music, caregivers, and television is minimal;personal conversation between patient and caregiver is encouraged.

FEEDING PROBLEMS




A. Environment

5. Music: pleasant, preferred by patient.

6. Light: adequate and nonglare-producing versus dark, shadowy, or glaring.

7. Contrasting background/foreground: use contrasting background and foregroundcolors with minimal design to aid persons with decreased vision.

8. Odor: food prepared in area adjacent to or in dining area to stimulate appetite.

9. Adaptive equipment: available, appropriate, and clean; caregivers and/or older adultknowledgeable in use; occupational therapist assists in evaluation.

FEEDING PROBLEMS




B. Caregiver/Staffing

1. Provide an adequate number of well-trained staff.

2. Deliver an individualized approach to meals including choice of food,tempo of assistance.

3. Position of caregiver relative to elder: eye contact; seating so caregiverfaces elder patient in same plane.

4. Cueing: caregiver cues elder whenever possible with words or gestures.

5. Self-feeding: encouragement to self-feed with multiple methods versusassisted feeding to minimize time.

6. Mealtime rounds: interdisciplinary team to examine multifaceted processof meal service, environment, and individual preferences.

REFERENCES



Amella EJ, DiMaria RA (2001). Feeding behavior. In GL Maddox, RC Atchley, JG Evans,

RB Hudson, RA Kane, EJ Masoro, MD Mezey, LW Poon, IC Siegler (eds.).The

Encyclopedia of Aging (3rd ed.) (pp. 389 - 391). New York: Springer

American College of Obstetricians and Gynecologists. Urinary incontinence in

women. Obstet Gynecol. Jun 2005;105(6):1533-45

Bernstein M & Luggen AS. (2010). Nutrition for the older adult. Sudbury, MA: Jones

and Bartlett.

Berrut, G., Favreau, A. M., Dizo, E., Tharreau, B., Poupin, C., & Gueringuili, M.

(2002). Estimation of calorie and protein intake in aged patients: Validation of a

method based on meal portions consumed. Journals of Gerontology: Medical

Science, 57(1), M52–M56. Evidence Level III: Quasi-experimental Study.

Bottomley J. (2010). Geriatric rehabilitation: a textbook for the physical therapy

assistant. Thorofare, NJ: SLACK.

DeVere R & Calvert M. (2011). Navigating smell and taste disorders. St. Paul, MN:

AAN Enterprises.

REFERENCES



Groher, M. E. (1997). Dysphagia: Diagnosis and Management (3rd ed.). Boston:

Butterworth-Heinemann.

JF Schnelle, PA Cruise, A. Rahman. Developing rehabilitative behavioral interventions

for long-term care: technology transfer, acceptance, and maintenance issues. J Am

Geriatr Soc, 46 (1998), pp. 771–778

Katz S, Downs TD, Cash HR, Grotz RC. (1970). Progress in the development of the

Index of ADL. The Gerontologist, 10, 22.

Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in the development

of the Index of ADL. The Gerontologist, 10(1), 20–30. Evidence Level IV: Quasi-

experimental Study.

Myers, B.A. (2004). Wound Management: Principles and Practice. Prentice Hall:

Upper Saddle River, New Jersey, 37-45, 369-391

Nakasato Y. (2011). Geriatric rheumatology. New York: Springer.

National Pressure Ulcer Advisory Panel (NPUAP)

REFERENCES



Nazir T, Khan Z, Barber HR. Urinary incontinence. Clin Obstet Gynecol. Dec

1996;39(4):906-11

Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J Med. Mar

6 2008;358(10):1029-36

Siebens H, Trupe E, Siebens A, Cook F, Anshen S, Hanauer R, Oster G. (1986).

Correlates and consequences of eating dependency in institutionalized

elderly.Journal of the American Geriatric Society, 34,193.

Watson, R. (1996). The Mokken Scaling Procedure (MSP) applied to the measurement

of feeding difficulty in elderly people with dementia. International Journal of

Nursing Studies, 33, 385–393. Evidence Level III: Quasi-experimental Study.

Wilson, M.M. (2007). Assessment of appetite and weight loss syndromes in nursing

home residents. Missouri Medicine, 104(1), 46-51. Evidence Level VI.

www.npuap.org.

http://www.npuap.org/

FEEDING PROBLEMS



Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in the development of the Index of ADL. The Gerontologist, 10(1), 20–30. Evidence Level IV: Quasi-experimental Study.

Wilson, M.M. (2007). Assessment of appetite and weight loss syndromes in nursing home residents. Missouri Medicine, 104(1), 46-51. Evidence Level VI.

Groher, M. E. (1997). Dysphagia: Diagnosis and Management (3rd ed.). Boston: Butterworth-Heinemann.

Watson, R. (1996). The Mokken Scaling Procedure (MSP) applied to the measurement of feeding difficulty in elderly people with dementia. International Journal of Nursing Studies, 33, 385–393. Evidence Level III: Quasi-experimental Study.

Berrut, G., Favreau, A. M., Dizo, E., Tharreau, B., Poupin, C., & Gueringuili, M. (2002). Estimation of calorie and protein intake in aged patients: Validation of a method based on meal portions consumed. Journals of Gerontology: Medical Science, 57(1), M52–M56. Evidence Level III: Quasi-experimental Study.

References

FEEDING PROBLEMS



Amella EJ, DiMaria RA (2001). Feeding behavior. In GL Maddox, RC Atchley, JG Evans, RB Hudson, RA Kane, EJ Masoro, MD Mezey, LW Poon, IC Siegler (eds.).The Encyclopedia of Aging (3rd ed.) (pp. 389 - 391). New York: Springer

Katz S, Downs TD, Cash HR, Grotz RC. (1970). Progress in the development of the Index of ADL. The Gerontologist, 10, 22.

Siebens H, Trupe E, Siebens A, Cook F, Anshen S, Hanauer R, Oster G. (1986). Correlates and consequences of eating dependency in institutionalized elderly.Journal of the American Geriatric Society, 34,193.

References



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Health & Medicine

Geriatric Syndrome - Urinary Incontinence, Pressure Ulcers, Feeding Problems