114 REVIEWER Nightingale was the first geriatric nurse.

HISTORICAL PERSPECTIVE ON THE STUDY

OF AGING
Roles of a Geriatric Nurse
 19th Century- Childhood and Adulthood
❑ Researcher
 Childhood
❑ Nurse Leaders
➢ infant
❑ Educators
➢ toddler
❑ Patient Advocates
➢ preschool
❑ Administrators
➢ school age
❑ Primary care provider
➢ adolescence

 1960- 20 yrs old to 65 years old most

economically productive  1966-ANA Established the Division of Geriatric
Nursing Practice with a goal to create standards
 Late 1960- Illness to wellness (disability and for quality nursing care for the aged.
disease were no longer considered unavoidable
parts of aging)  1969 The standards and scope of
gerontological nursing practice were developed
by ANA.

Geriatrics is the medical specialty that deals with the  1970s the term gerontological nursing replaced
physiology of aging and with the diagnosis and treatment the term Geriatric Nursing
of diseases affecting

older adults.
Aging- is a normal process of time related change,
Greek word begins with birth and continuous throughtout life

❖ “geros” means old age Aging- is a multidimensional process of physical,

psychological and social change
❖ “iatro” means medical treatment
Aging -is a complex process that can be described
chronologically, physiologically, and functionally.
Gerontology Chronologic age, the number of years a person has lived
Greek word 65 years old is the mandatory age for retirement from the
❖ “gero”, related to old age service.

❖ “ology” study of
AGE CATEGORY
55 to 64 years old Older
Gerontology-is the study of all aspects of the aging
65 to 74 years old Elderly
process, including the clinical, psychologic, economic,
and sociologic prob_x0002_lems of older adults and the 75 to 84 years old Aged
consequences of these problems for older adults and
society. 85 and older Extremely aged
Gerontology affects nursing, health care, and all areas of
our
GERONTOPHOBIA- the fear of aging and the refusal to
society—including housing, education, business, and
accept older adults into the mainstream of society (
politics. irrational fears)

Ageism-the extreme forms of gerontophobia, It is the

disliking of aging and older adults based on the belief
Gerontics, or Gerontic Nursing- nursing care and the that aging makes people unattractive, unintelligent, and
service provided to older adults encompasses a holistic unproductive.
view of aging with the goal of increasing health,
providing comfort, and caring for older adult needs
(Gunter and Estes in 1979)
A. PERSPECTIVE ON AGING

Aging is a Developmental Process

Geriatric Nursing- is a field of nursing that specializes in
Growing older, or chronological aging, is a relentless and
the care of the elderly.
unstoppable process that happens to all humans a
Florence Nightingale and Doreen Norton provided early natural developmental process for human beings
insights into the care of aged. (Meilaender, 2011).
According to Meilaender (2011), aging is a normal stage B. DEMOGRAPHY OF AGING AND IMPLICATIONS
of life in which our bodies begin to function less FOR HEALTH AND NURSING CARE
effectively, making us more vulnerable to disease.
1.Global Aging
Aging is a Developmental Process
The number and proportion of people aged 60 years and
Evolutionary biologists (Carnes & Olshansky, 1993) refer older in the population is increasing. In 2019, the number
to this process as “senescence.” “the time-dependent of people aged 60 years and older was 1 billion. This
accumulation of damage at the molecular level” number will increase to 1.4 billion by 2030 and 2.1 billion
by 2050. This increase is occurring at an unprecedented
Even if a person ages well, because of senescence that pace and will accelerate in coming decades, particularly
person will still ultimately die of some cause (Gems, in developing countries.
2011).
2. Aging Philippines
Aging is a Developmental Process
According to the Philippine Statistics Authority (PSA), the
The human body does not invest in sustaining itself number of Filipinos aged 60 years and above has
beyond the productive task and, in turn, becomes more doubled to 9.22 million in 2020 from only 4.6 million in
vulnerable to the harmful effects of deleterious genes, a 2000. The Population Commission projects that 14
weakening immune system, increasingly brittle bones, percent of the population 12 years from now will be
and deteriorating sensory systems (Kirkwood & Austad, senior citizens from the current 8.5 percent .
2000).

Indigent Seniors receiving a social pension of P1,000 a

A.Biological Perspective- all humans grow, experience month from the Department of Social Welfare and
puberty, mature, and age as the course of a normal, Development (DSWD)
healthy life.
RA 10868 or the Centenarians Act of 2016 which
entitles all Filipinos who reach 100 years old and above
B. Humanistic Perspective-human beings generally with a cash gift worth P100,000. Two in every 100,000
desire a complete life, understood in the terms of the full Filipinos are centenarians as of 2020, and majority of
life cycle, parent their children and bond with their them are women
grandchildren and want to gain wisdom through life
experiences (Meilaender, 2011).
House Bill (HB) No. 7535, which seeks to grant P1
million to Filipinos who reach 101 years old or
C. Scientific Perspective-aging as a biological centenarians, whether living here or abroad, and
condition that can be manipulated, treated, and delayed P25,000 to Filipinos who reach the age of 80 and 85
(Kelland, 2010). (octogenarians), and 90 and 95 (nonagenarians). All of
them will also receive a letter of felicitation from the
President of the Philippines.
D. Theoretical Perspective

1. Disengagement Theory (Cumming & Henry, 1961). RA 7432 Senior Citizens Act-AN ACT TO MAXIMIZE
THE CONTRIBUTION OF SENIOR CITIZENS TO
➢ Enable younger people to assume important
NATION BUILDING, GRANT BENEFITS AND SPECIAL
roles, a society must encourage its older people
PRIVILEGES AND FOR OTHER PURPOSES.
to disengage from their previous roles and to
take on roles more appropriate to their physical
and mental decline. This theory is considered a
functionalist explanation of the aging process. C. Impact of Aging Members of the Family

2. Activity Theory by (Choi & Kim, 2011). 1. Emotional Effect

➢ Older people benefit themselves and their ✓ guilt

society if they continue to be active. Their ✓ fear and anxiety
positive perceptions of the aging process are
crucial to their ability to remain active. This ✓ anticipatory grief
theory is considered an interactionist explanation
of the aging process. 2. Financial Effect

3. Conflict Theory by (Novak, 2012) 3. Structural Effect

➢ Older people experience age-based prejudice 4. Physical Effect

and discrimination. Inequalities among the aged 5. Positive Effect
exist along the lines of gender, race/ethnicity,
and social class. This theory falls into the more
general conflict theory of society.
THEORIES OF AGING SOMATIC MUTATION THEORY is similar but proposes
that aging results from deoxyribonucleic acid (DNA)
“For the unlearned, old age is winter; for the learned, it is damage caused by exposure to chemicals or radiation
the season of the harvest.” and that this damage causes chromosomal abnormalities
that lead to disease or loss of function later in life.

The maximal life expectancy for humans today The FREE RADICAL THEORY provides one explanation
appears to be 120 years, but why is this so? for cell damage.

Theories of aging have been considered throughout Free radicals are unstable molecules produced by the
history as mankind has sought to find ways to avoid body during the normal processes of respiration and
aging. metabolism or following exposure to radiation and
pollution.
No one has identified a single unified rationale for why
we age and why different people live lives of different These free radicals are suspected to cause damage to
lengths. Theories abound to help explain and give some the cells, DNA, and the immune system.
logical order to our observations. Observations, including Excessive free radical accumulation in the body is
physical and behavioral data, are collected and studied to purported to contribute to the physiologic changes of
scientifically prove or disprove their effects on aging. aging and a variety of diseases such as:

• arthritis
THEORY VS FACT • circulatory diseases
Fact: Observations about the world around us. • diabetes, and
Example: “It’s bright outside.” • atherosclerosis.
Theory: A well-substantiated explanation acquired One free radical, named lipofuscin, has been identified
through the scientific method and repeatedly tested and to cause a buildup of fatty pigment granules that cause
confirmed through observation and experimentation. age spots in older adults.
Example: “When the sun is out, it tends to make it bright Individuals who support this theory propose that the
outside.” number of free radicals can be reduced by the use of
ANTIOXIDANTS, such as vitamins A, C and E,
carotenoids, zinc, selenium, and phytochemicals.
BIOLOGIC THEORIES

CROSSLINK OR CONNECTIVE TISSUE THEORY,

PROGRAMMED THEORY: proposes that everyone has which proposes that cell molecules from DNA and
a “biologic clock” that starts ticking at conception. connective tissue interact with free radicals to cause
bonds that decrease the ability of tissue to replace itself.
In this theory, each individual has a genetic “program”
This results in the skin changes typically attributed to
specifying an unknown but predetermined number of cell
aging such as dryness, wrinkles, and loss of elasticity.
divisions. As the program plays out, the person
experiences predictable changes such as atrophy of the
thymus, menopause, skin changes, and graying of the
hair. WEAR-AND-TEAR THEORY presumes that the body is
similar to a machine, which loses function when its parts
wear out, damaged by internal or external stressors.
RUNOUT-OF-PROGRAM THEORY: proposes that every When enough damage occurs to the body’s parts, overall
person has a limited amount of genetic material that will functioning decreases. This theory also proposes that
run out eventually good health maintenance practices will reduce the rate of
wear and tear, resulting in longer and better body function.

RATE OF LIVING THEORY: proposes that individuals

have a finite number of breaths or heartbeats that are CLINKER THEORY, combines the somatic mutation, free
used up over time radical, and crosslink theories to suggest that chemicals
produced by metabolism accumulate in normal cells and
cause damage to body organs, such as the muscles,
GENE THEORY: proposes the existence of one or more heart, nerves, and brain.
harmful genes that activate over time, resulting in the
typical changes seen with aging and limiting the life span
of the individual. NEUROENDOCRINE THEORY focuses on the
complicated chemical interactions set off by the
hypothalamus of the brain. With age, the hypothalamus
ERROR THEORY: proposes that errors in ribonucleic appears to be less precise in regulating endocrine
acid protein synthesis cause errors to occur in cells in the function, leading to age- related changes such as
body, resulting in a progressive decline in biologic decreased muscle mass, increased body fat, and
function. changes in reproductive function.
RELIABILITY THEORY OF AGING AND LONGEVITY is
a complex mathematical model of system failures first
used to describe failure of complex electronic equipment.
It is used as a model to describe degradation (disease)
and failure (death) of human body systems.

The IMMUNOLOGIC THEORY proposes that aging is a

function of changes in the immune system.

According to this theory, the immune system— an

important defense mechanism of the body— weakens
over time, making an aging person more susceptible to
disease.

The immunologic theory also proposes that the increase

in autoimmune diseases and allergies seen with aging is
caused by changes in the immune system.

PSYCHOSOCIAL THEORIES

DISENGAGEMENT THEORY was developed to explain

why aging persons separate from the mainstream of
society.

This theory proposes that older people are systematically

separated, excluded, or disengaged from society because
they are not perceived to be of benefit to the society.

This theory further proposes that older adults desire to

withdraw from society as they age; the disengagement is
mutually beneficial.

ACTIVITY THEORY proposes that activity is necessary

HAVIGHURST’S THEORY details the process of aging
for successful aging.
and defines specific tasks for late life, including:
Active participation in physical and mental activities
(1) adjusting to decreased physical strength and
helps maintain functioning well into old age.
health;
Purposeful activities and interactions that promote self-
(2) adjusting to retirement and decreased income;
esteem improve overall satisfaction with life, even at an
older age. (3) adjusting to the loss of a spouse;
“Busy work” activities and casual interaction with others (4) establishing a relationship with one’s age group;
were not shown to improve the self-esteem of older
adults. (5) adapting to social roles in a flexible way; and

(6) establishing satisfactory living arrangements

LIFE-COURSE THEORIES are perhaps the theories

best known to nursing. These theories trace personality NEWMAN’S THEORY
and personal adjustment throughout a person’s life.
Newman’s theory identifies the tasks of aging as:
Many of these theories are specific in identifying life-
oriented tasks for the aging person. Four of the most (1) coping with the physical changes of aging;
common theories—Erikson’s, Havighurst’s, Newman’s,
and Jung’s—are worth exploring. (2) redirecting energy to new activities and roles,
including retirement, grandparenting, and
widowhood;

(3) accepting one’s own life; and

(4) developing a point of view about death.

JUNG’S THEORY proposes that development continues

throughout life by a process of searching, questioning,
and setting goals that are consistent with the individual’s
personality.
MIDLIFE CRISIS can lead to radical career or lifestyle CARE OF AGING SKIN AND MOCUOS MEMBRANES
changes or to the acceptance of the self as is.

As aging continues, Jung proposes that the individual is

likely to shift from an outward focus (with concerns about INTRODUCTION
success and social position) to a more inward focus. • The skin undergoes several changes with
Successful aging, according to Jung, includes aging that make it more susceptible to
acceptance and valuing of the self without regard to the damage. Over time, the epidermal layer
view of others. becomes thinner and the subcutaneous
padding diminishes, increasing the risk for
traumatic injuries such as skin tears or
pressure ulcers.
IMPLICATIONS FOR NURSING
Bruises are more common because capillary walls are
more fragile. Skin tears can turn into chronic wounds if not
Physical theories of aging indicate that, although treated properly. Medications used to treat various health
biology places some limitations on life and life problems can cause problems. Corticosteroids make the
expectancy, other factors are subject to behavior and life skin more fragile, and anticoagulants increase the risk for
choices. bleeding with even minor trauma. Decreased sebaceous
secretions and circulatory changes contribute to the dry
skin and scaliness of the lower extremities common with
aging.
Psychosocial theories help explain the variety of
behaviors seen in the aging population. Aging skin is more susceptible to inflammation, infection,
and rashes. Pruritus (itching), which is a common
complaint in older adults, may be caused by dryness,
Nursing can help individuals achieve the longest, irritation, or infection but can be related to diseases such
healthiest lives possible by promoting good health as diabetes mellitus, kidney disease, malignancy, or
maintenance practices and a healthy environment, anemia.

Changes in the function of dermal receptor cells result in

a decrease in the ability of the older person to perceive
Understanding all of these theories can help nurses sensations such as touch and pressure, increasing the
recognize problems and provide nursing risk for pressure-related disorders.
interventions that will help aging individuals
successfully meet the developmental tasks of aging. Although skin problems usually are not life threatening,
they are significant because they can distress the older
person and lead to decreased quality of life. Skin
problems should be prevented whenever possible; in
situations in which the problems are not preventable, they
should be recognized, treated, and resolved in a timely
manner.

• Medications used to treat various health

problems can cause problems.

• Decreased sebaceous secretions and

circulatory changes contribute to the dry
skin and scaliness of the lower extremities
common with aging

• Aging skin is more susceptible to

inflammation, infection, and rashes. Pruritus
(itching), which is a common complaint in
older adults, may be caused by dryness,
irritation, or infection but can be related to
diseases such as diabetes mellitus, kidney
disease, malignancy, or anemia.

AGE-RELATED CHANGES IN SKIN, HAIR, AND

NAILS

Changes in the skin, hair, and nails may indicate a

variety of problems related to nutritional and circulatory
adequacy. Because these structures are the ones most
easily observed, they can provide a great deal of
information about the metabolic health of the entire body
 DRY SKIN

❑ Dry skin is one of the most common

problems of aging.

❑ Physiologic changes, excessive bathing, the use

of harsh soaps, and a dry environment all
contribute to problems with dry skin.

❑ Dry skin can result in itching (pruritus), burning,

and cracking of the skin (Figure 17-2).

Studies have shown that 75% of people older than 65

years of age experience dry skin.

Healthcare workers who assist with bathing or other

care to promptly report any unusual or questionable
observations to a nurse for further investigation.
Inspection should follow a logical order so that no
pertinent observations are missed. Most nurses find
that a head-to-toe progression is the most helpful, as
is a body diagram on which observations are indicated.

❑ Older people may develop a habit of

scratching or picking at dry or cracked skin,
increasing their risk for further tissue
damage and infection.

❑ Skin irritation can be severe and can cause

intense discomfort to older adults.

❑ In fact, it may be so distracting that affected

SKIN COLOR individuals stop participating in social
activities.
Changes in skin color can indicate a variety of disorders.
When assessing skin for color, it is important to be
aware of the differences in skin pigments among ethnic
groups. RASHES AND IRRITATION

❑ skin in good ❑ Rashes and skin irritation can be caused by

factors other than dryness. Medications,
❑ preferably natural, light communicable diseases, and contact with
chemical substances are common causes of
❑ compare one side of the body with the other
skin rashes and pruritus (Figure 17-3).
❑ use touch to determine skin temperature or the
presence of rashes or irritation. Stretching the
skin slightly may help in determining the
underlying tones.

❑ Color changes = pallor, cyanosis, jaundice, or

erythema, can indicate a variety of problems.

❑ Record and report the extent and location of any

color changes promptly.
 ❑ Skin tears, abrasions, lacerations, and ulcers
most often result from pressure or pressure
Allergic response to medications can manifest as diffuse combined with shearing forces.
rashes over the body. Whenever a rash develops soon
after administration of new medication, a drug allergy ❑ Even simple incidents such as bumping a leg
should be suspected. It is appropriate to withhold that into an open dishwasher door, sliding across
particular medication and contact the primary care bed linens, or the removal of tape may result in
provider to report the symptom. significant skin trauma to the older person.

Older adults, especially individuals who suffer from

chronic illness, dementia, or a depressed immune
system, are particularly vulnerable to scabies infections. PRESSURE ULCERS
Signs of scabies include intense itching and fine, dark, ❑ Pressure ulcers are a particular risk to older
wavy lines at the flexor surface of the wrist or elbow, the adults who suffer from compromised circulation,
webbed area of the fingers, the axilla, and the genitals. restricted mobility, altered level of
Recognition of scabies may be difficult in older adults consciousness, fecal or urinary incontinence, or
because it has an asymptomatic incubation period of 4 to nutritional problems (Table 17-2).
6 weeks and because atypical presentations are
common. When infestation is suspected, skin scrapings ❑ Pressure ulcers have negative effects on the
should be examined to determine the presence of ova or overall health of an older adult. They can lead to
mites. infection, pain, loss of function, and even death.

To reduce outbreaks of scabies infection within an ❑ It is important to carefully assess and document
institution, all new residents in extended-care settings any pressure ulcers that are present upon
should be assessed carefully on admission. All cases admission.
must be identified and treated promptly to prevent spread
Studies estimating the occurrence of pressure ulcers vary
or reinfestation with the parasite.
widely, but one consistent point is that they occur in all
settings. Although most studies show that the incidence
of pressure ulcers has declined, there is still much work to
❑ One communicable source of skin irritation and do regarding prevention. Furthermore, incidence of
severe pruritus is scabies. Scabies is a pressure ulcers can leave care facilities and nurses
superficial infection caused by a parasitic mite vulnerable to lawsuits for negligence. A single pressure
(Sarcoptes scabieivar. hominis) that burrows ulcer can cost up to $40,000 to treat, and that does not
under the skin (Figure 17-4). include the human cost of pain and suffering. New
❑ Scabies is spread from person to person by Medicare rules specify that a hospital will not be
direct contact. Because recognition is difficult, reimbursed for the care of a patient who develops a
treatment maybe delayed, allowing the parasite “reasonably preventable” pressure ulcer after being
to infect other people. admitted to a hospital. In some states, it is mandatory to
report the development of a stage III or IV pressure ulcer
to the Department of Health.

PIGMENTATION

❑ Changes in skin pigmentation are common with

aging.

❑ Many of the changes are cosmetic and do not

cause problems unless they are located on the
face or arms, where they may be distressing to
the affected person.

❑ Common conditions such as acne rosacea can

be treated with topical medications, which help Excessive pressure on tissues, particularly over bony
heal the skin and reduce redness prominences, can quickly lead to skin breakdown (Figure
17-5).
Whereas others can be concealed by appropriate use of
cosmetics. Changes in the size or pigmentation of moles
are of greater significance and must be reported because
these changes may indicate the presence of a
precancerous or cancerous condition that needs
immediate medical attention.

TISSUE INTEGRITY

❑ Breaks in tissue integrity increase the older

person’s risk for infection and often result in the
need for costly, time-consuming treatments.

❑ These breaks can cause disfigurement and are

frightening to older adults.
Ulcer development depends on the amount of pressure, minimizes risk factors and promotes skin
the length of time pressure is exerted, and the underlying integrity.
status of the tissues involved. Tissue that is subjected to
excessive pressure does not receive adequate oxygen or
nutrients. This can result in ischemia and increased
susceptibility to breakdown. When tissue is deprived of
necessary nutrients for a longer period, necrosis and
tissue destruction is the result. Tissue that is fragile
because of poor nutrition or circulation is most susceptible
to breakdown.

Early danger signs indicating a risk for breakdown

include pale or reddened tissue. Pressure ulcers are
categorized or staged based on their appearance and
the depth of tissue penetration (Figure 17-6).

Individuals who have had one pressure ulcer are at

greater risk for future development of additional ulcers.
Additional factors that contribute to development of
pressure ulcers include the following:

❑ Obesity

❑ Malnutrition

❑ History of alcohol and tobacco use

❑ Edema

❑ Moisture: bladder and/or bowel incontinence,

use of incontinence briefs

❑ Immobility

❑ Shearing forces

❑ Cognitive impairment
AMOUNT, DISTRIBUTION, APPEARANCE, AND
CONSISTENCY OF HAIR
❑ It is recommended to perform a formal risk
assessment at the time of admission, upon ❑ The amount, distribution, appearance, and
discharge, upon any change in patient condition, consistency of the hair change with aging. Hair
and then at regular intervals. typically becomes thinner and has a finer
consistency with advanced age.
❑ Guidelines recommend that this assessment
include a complete history and physical ❑ Heredity and gender play a role in hair loss
examination, skin inspection, and use of a patterns.
pressure ulcer risk assessment tool (Ayello &
❑ The amount and distribution of body hair also
Sibbald, 2012).
change with aging. Diminished or absent hair on
❑ The most common tools used for this the lower legs or feet, particularly when
assessment are the Braden and Norton Scales combined with excessively dry, scaly, or flaky
(Tables 17-3 and 17-4). skin and weak or absent pedal pulses, indicates
decreased blood supply to the lower extremities.
❑ Nurses use the information from this
assessment to develop a plan of care that Men tend to lose more hair than do women, although
some men retain a full head of hair throughout life. Male
pattern baldness typically results in progressive loss of the top of the toe and grows into the flesh on the bottom,
hair at the temples and back of the head. Sudden and causing pain. When the discomfort becomes severe, the
excessive hair loss (alopecia) or breakage is likely to older person may stop wearing shoes and decrease
indicate a systemic problem. Abnormal hair loss can be ambulation in an attempt to reduce the discomfort. In such
related to high fevers, medications, nutrition problems, severe cases, care from a podiatrist is needed. Nail
fungal or bacterial infections, endocrine disorders, or fungus is increasingly common with aging. Fungi cause
stress. Sudden or unusual hair loss should be reported so the nails to become thick, brittle, misshapen, and
that the primary care provider can determine the cause. discolored. Fungal infections are more likely to affect the
feet because the environment in shoes (dark, moist, and
warm) supports growth of these microorganisms. Fungal
TISSUE OF THE FEET infections are more common in older adults with diabetes
or other conditions of diminished peripheral circulation.
❑ Inspection of the tissue on the feet warrants These infections need to be recognized and treated so
special attention in older adults. Because many that they do not cause more widespread problems.
aging individuals are unable to bend adequately
to view the feet, a family member or friend can
perform this inspection for independent older OTHER COMMON FOOT PROBLEMS
adults (Figure 17-7).
❑ Other common foot problems include corns,
❑ In an institutional setting, nursing staff should calluses, blisters, and bunions, which usually
perform foot inspection. Many older adults result from years of wearing poorly fitted
neglect their feet simply because they cannot footwear, including high heels.
see or reach them. Unless foot inspection is
done on a regular schedule, severe problems ❑ This practice is dangerous and significantly
can occur before anyone is aware of them. increases the risk for serious foot infections,
which may necessitate amputation of a toe, toes,
or the entire foot. Older people with diabetes or
impaired peripheral circulation are particularly
prone to develop foot ulcers or infections and
are at greatest risk for amputation.

These conditions often cause discomfort for older adults

and lead to some degree of activity restriction. Many
independent older adults use commercially available foot
remedies or attempt to remove corns or calluses with a
knife or scissors.

NURSING PROCESS FOR IMPAIRED SKIN

INTEGRITY

NAILS ASSESSMENT / DATA COLLECTION

• Aging results in hyperkeratosis of the nails, ❑ What is the general appearance of the person’s
particularly the toenails. Thick, hard nails are skin?
difficult to cut using normal foot care equipment.
The strength and effort required to cut these ❑ Are any lesions evident on the scalp?
nails may exceed the older person’s abilities,
❑ What is the skin color? Are there any signs of
resulting in overgrowth.
pallor, jaundice, cyanosis, or erythema? If so,
where?

Soaking the feet in warm water before attempting to cut ❑ Are there any areas of dry skin? If so, where?
them may soften the nails and make them easier to cut.
Assistance from a family member or health care provider
is appropriate when there is no history of circulatory
problems or diabetes. When diabetes or circulatory
problems are present, care should be provided by a foot
care specialist, since nails can be thick and the underlying
tissue is easily injured, which can lead to infection. Special
heavy-duty equipment may be needed to accomplish
proper nail care. Use of safety glasses is recommended
during nail care to prevent eye injuries resulting from flying
nail particles.

If proper care is neglected, uncut nails confined in shoes

often begin to curl under the toes, resulting in a condition
called ram’s horn nails. In this condition, the nail curls over
 ❑ Does the person complain of itching? depth of the affected area or areas; and identify
any conditions or changes that may have
❑ Is there any evidence of scratching? caused the problem.
❑ Are there any signs of scabies (fine, wavy, dark Changes in skin condition can occur rapidly in older
lines, or spots at the webs of the fingers or folds adults. Measure and document all areas of concern
of the skin)? so that improvement or further breakdown can be
❑ Are there any rashes? If so, where are they evaluated. Explore any possible causes for the
located? problem and institute nursing measures to prevent or
reduce further tissue damage.
❑ What is their appearance (e.g., macular,
papular, or vesicular)?

❑ Is there any sign of pallor or erythema over bony 2. Institute measures to reduce the risk for
prominences? skin and tissue breakdown.

❑ Are there any breaks in the skin integrity? If so, ◦ Reduce the frequency of complete
where? What do they look like? bathing. The type and frequency of
baths or showers depend greatly on the
❑ Are any abrasions or skin tears evident? individual.
❑ Is there any change in the amount, distribution, The condition of the skin and the presence of perspiration
or appearance of the hair? or other body wastes must be considered. Some
individuals require a complete bath or shower daily;
❑ What is the appearance of the toenails? Are they
others benefit more from a complete bath on a biweekly
thickened? Difficult to cut? Discolored?
or weekly basis. On days when total baths are not taken,
❑ Are any lesions evident on the feet or ankles? partial or sponge baths of the face, axilla, and perineum
provide adequate cleanliness and prevent body odors.
❑ What is the person’s nutritional status? Is the
person overweight or underweight? ◦ Keep skin free from wastes and exudate
by using mild nondetergent soaps.
❑ Is the person alert and able to move freely? If Reducing the frequency of bathing is
not, what is the level of immobility? suggested if dryness is a problem.
❑ Is the person incontinent of bladder or bowel? Use of mild, nondetergent, nonperfumed, superfatted
soaps (e.g., Basis Sensitive Skin, Neutrogena
❑ Are there pedal pulses? Are they easy or difficult
Transparent [fragrance free]) for cleansing decreases
to palpate?
excessive skin dryness.

◦ Use emollients, lotions, creams, and oils

NURSING DIAGNOSIS to maintain skin moisture. Emollients
help keep moisture in the skin and
❑ Risk for impaired skin integrity reduce dryness. This can reduce the risk
❑ Impaired skin integrity of skin tears.

❑ Risk for impaired tissue integrity Since most preparations are effective for only a short
period of time, apply them frequently. A variety of
❑ Impaired tissue integrity preparations are available at a wide range of costs.
Ointments, particularly those containing petrolatum, are
occlusive and tend to be more long-lasting than lotions or
NURSING GOALS/OUTCOMES IDENTIFICATION creams. Avoid lotions containing alcohol because they
can contribute to drying. It may be necessary to try various
The nursing goals for older individuals with or at risk for emollients and lotions to find the one (or the combination)
impaired skin or tissue integrity are to that provides the most relief to the older individual (Box
17-2).
(1) remain free from excessive skin dryness or skin
breakdown; ❑ Rinse skin carefully.

(2) display timely healing of wounds, lesions, and Soaps tend to dry the skin and should be rinsed off
ulcerations; and completely before drying. If a basin is being used,
complete rinsing may require frequent water changes.
(3) maintain optimal nutritional status to promote tissue
integrity and healing. ❑ Dry skin tissue gently and thoroughly. To
decrease skin irritation, dry the skin by patting
rather than rubbing
NURSING INTERVENTIONS/IMPLEMENTATION If the skin is severely irritated, use soft towels that have
The following nursing interventions should take been rinsed carefully to remove all detergents.
place in hospitals, in extended-care facilities, and at ❑ Turn and position the person frequently and
home: reduce sources of pressure by keeping bed linen
1. Assess the level of impairment and the tight and clear of foreign objects.
contributing factors. Perform a daily skin
inspection; measure the location, size, and
Pressure over bony prominences restricts blood flow to the aging body. Therefore, older adults may require
the tissues that are being compressed (Figure 17-8). additional rest periods during the day.
These areas are most likely to become ischemic or
necrotic. Redistributing pressure is an important
component of pressure ulcer prevention. Frequent ❑ Check wounds daily for signs of inflammation or
position changes allow reestablishment of blood flow and infection, and obtain cultures of wound drainage
reduce the risk for skin breakdown. The maximum time a if appropriate
person should be in one position must not exceed 2 hours.
More frequent turning is necessary for individuals at high The typical signs of inflammation or infection may be
risk for skin problems. Base the frequency of position absent or diminished in older adults; therefore, pay
changes on your assessment of pressure points special attention to any open areas. Wound cultures are
indicated if any purulent or foul-smelling drainage is
❑ Wash the skin and supply clean, dry linens after observed. Infection delays healing and places additional
episodes of incontinence stress on older adults.
Urine and stool contain waste products that are highly ❑ Avoid using adhesive strips for skin tears.
irritating
If possible, hold the dressing in place with a stocking-like
❑ Keep the skin dry after episodes of diaphoresis; or tubular bandage, but be careful it is not excessively
check skin surfaces where moisture caused by tight.
normal perspiration can become trapped.
❑ Follow aseptic technique when cleansing
Moisture on the skin surface can cause maceration wounds, changing dressings, or applying
(whitening and softening) and tissue breakdown. Moisture medications
caused by perspiration usually evaporates and causes
few problems unless perspiration is excessive or is
trapped between skin surfaces (e.g., under pendulous
4. Provide good foot care. The feet of older
breasts). Frequent sponging with clear water and
adults are particularly susceptible to problems.
thorough drying, exposure to air, or use of a drying
Poor circulation, increased incidence of problems
substance such as cornstarch helps reduce the amount of
such as bunions, excessively thick toenails, and
moisture and friction between skin surfaces.
the result of years of wearing poorly fitted shoes
❑ Move and transfer the person carefully. The skin all contribute to foot problems in older adults
of older individuals is thinner, less elastic, and
The feet should be soaked regularly to remove old, dry
has less subcutaneous padding than that of
skin. After a good soaking, dry the feet by patting rather
younger people. This makes it particularly
than rough rubbing. Thoroughly dry the feet, paying
vulnerable to shearing forces during movement.
careful attention to the areas between the toes. If
When the head of the bed is elevated, it is recommended permitted, cut the toenails straight across and file the
that the elevation be kept at or below 30 degrees to sharp edges off. The toenails of people with diabetes and
reduce the shearing force that may occur when a person other older adults with circulatory problems should be
slides down in bed. To reduce the shearing forces that cared for by a foot specialist. Use emollients if the skin on
occur when tissue is dragged overbed linens, use transfer the feet is very dry. When emollients are used on the feet,
sheets or other assistive devices when turning, teach older adults to be aware of the importance of
repositioning, or transferring a frail older person. wearing socks to prevent slipping. Encourage a daily
change into clean socks or stockings, because clean foot-
❑ Provide appropriate pads, cushions, mattresses, wear reduces the risk for infection. Encourage older
or beds that are designed to reduce pressure. persons with diabetes or circulatory impairment of the
Many types of beds and mattresses that are designed to lower extremities to wear clean white cotton socks to
distribute weight over a larger area and reduce pressure promote cleanliness and provide early recognition of
on body tissues are available. injury or drainage. Use caution to ensure that the socks fit
properly and do not cause excessive constriction around
❑ Encourage older adults at high risk for skin tears the ankles or calves. Document and report promptly signs
to wear long sleeves, long trousers, or knee-high of foot irritation, color change, skin breakdown, or
socks changes in the appearance of the nails.

Shin guards and leg protectors have also been found to

help those who experience repeat tears on their shins.
NURSING INTERVENTIONS/IMPLEMENTATION

The following interventions should take place in the

3. Institute measures to promote tissue home:
healing.

❑ Promote adequate nutritional intake

❑ Encourage adequate fluid intake and good
Tissue regeneration occurs more slowly in older adults nutrition.
than in younger individuals. Increased intake of calories
with emphasis on protein and vitamin C is particularly Nutritious foods and adequate fluid intake are needed to
important because these nutrients are necessary for maintain healthy tissue. Inadequate intake of nutrients
tissue repair. Encourage adequate rest. Tissue healing such as protein, vitamin A, and vitamin C can result in
uses energy and places additional physiologic stress on fragile tissue that is more susceptible to bruising, shearing
force injuries, and breakdown. When inadequate intake is
suspected, a more complete assessment (including a
food and fluid diary) is appropriate. This helps nurses (1) failure of older adults to see dental care as a priority;
determine the cause or causes (e.g., depression and (2) the cost of dental care;
illness) and plan suitable interventions.
(3) restricted access caused by transportation problems
or inadequate availability of dental services, which is
particularly a problem in rural areas; and
❑ Maintain adequate humidity in the environment.
(4) physical or cognitive limitations. Many older adults are
Exposure to hot, dry air, whether in the desert or in overly unable or unwilling to maintain good oral hygiene
warm living quarters, results in excessively dry skin. An practices. Unfortunately, nursing staff members too often
excessively dry environment intensifies the tendency place oral hygiene at a lower priority than other more
toward dryness, which is already a problem in older visible aspects of care.
adults. The result is skin that is rough, dry, cracked,
irritated, and more susceptible to breakdown and In recent years, oral hygiene has been proven to be a high
infection. Dry mucous membranes usually accompany dry priority; however, cases of pneumonia have been linked
skin, increasing the risk for epistaxis (nosebleeds). Living to inadequate oral care in intensive care unit (ICU)
spaces should be maintained at a temperature of patients (Parsons, 2013). Some nursing experts tell
approximately others that if you are able to perform only one assessment
to determine a person’s overall quality of care, inspect the
❑ Avoid excessive exposure to the sun. person’s oral cavity. When oral care is good, then there is
Older adults have fewer melanocytes, which are unevenly a high probability that all of the care is good. Nurses need
distributed over exposed body areas. Excessive exposure to recognize the importance of this aspect of care and give
to sunlight can cause irregular, blotchy, and cosmetically it the attention it deserves.
unacceptable tanning. Use of a safe sunblock is
recommended when sun exposure is expected.
Encourage older adults to wear loose, lightweight, light- DENTAL CARIES
colored clothing and wide brimmed hats to prevent
exposure to the ultraviolet rays in sunlight that increase • Tooth decay, loose teeth, and lost teeth are
the risk for skin cancer. ongoing problems in the older adult population.
Poor nutrition and decreased appetite in older
❑ Obtain regular professional foot care. adults can often be attributed to dental
problems. Decay, or caries, is caused by the
Older people, particularly those living alone, often find that action of bacteria that penetrate through the
foot care is difficult because of the loss of flexibility. enamel shield of the tooth and cause destruction
Regular appointments with a foot-care specialist reduce If caries is not recognized early, a significant
the risk for trauma or infection. Professional foot care is amount of the tooth structure may be destroyed.
essential for individuals with diabetes or impaired
peripheral circulation. If the caries extends deep into the tooth, a nerve may be
exposed, and painful neuritis (tooth-ache) may result.
Replacement of the lost tooth material with amalgam
❑ Use any appropriate interventions that are used restorations (fillings) can help rebuild the tooth, but this
in the institutional setting leaves a weakened structure that remains susceptible to
problems. Lost restorations leave rough edges that cause
irritation of the oral mucous membranes, particularly the
cheek and tongue.
AGE-RELATED CHANGES IN ORAL MUCOUS
MEMBRANES

• Problems in the oral cavity may render an older PERIODONTAL DISEASE

adult unable to chew certain foods. Inspection of
the oral cavity is an important part of the head- • Food debris and plaque accumulate in the
to-toe assessment and is needed to determine mouth and on the teeth when oral hygiene is
the status of the individual’s teeth, tongue, and inadequate. Activity of bacteria on this debris,
oral mucous membranes. especially the tongue, causes halitosis, or bad
breath, which is often disturbing to the older
Changes in the condition of the gums and oral mucous person and to anyone who has close contact
membranes may be related to several factors. Dental care
was not readily available to many of today’s older adults Periodontal disease is a less obvious but potentially more
during their youth because of the cost and the associated serious complication of poor oral care. One form of
discomfort. Therefore, older individuals who neglected periodontal disease is gingivitis, or inflammation of the
their teeth now suffer tooth loss. Even those who gums. Gingivitis causes gum swelling, tenderness, and
maintained good dental practices are likely to experience bleeding and eventually leads to recession of the gum
tooth decay and loss because preventive dental tissue away from the tooth. As the gums recede, the teeth
techniques were not as advanced as today. lose support, become loose in the sockets, and eventually
fall out. When a tooth is lost, a gap is created. Healthy
Water fluoridation, which started in the 1940s, has helped teeth shift position or move into the space, resulting in an
prevent some dental problems, resulting in a larger uneven bite. Chewing becomes increasingly difficult when
percentage of today’s older adult population who have significant numbers of teeth, particularly the molars
retained at least some of their teeth. Studies show, needed for chewing and grinding food, become loose or
however, that poor oral hygiene is a major problem for the lost. Periodontal disease is suspected to play a role in
older population. Reasons for this include thrombo-embolitic disorders, bacterial endocarditis, and
myocardial infarction. Individuals with a cardiac history
are typically given prophylactic antibiotics before or
following any dental work.

PAIN
Inspection of the mouth can reveal a number of
• Dental caries and periodontal disease are the abnormalities. White patches in the mouth, called
most common reasons for oral pain, but oral leukoplakia, often are precancerous and require prompt
lesions such as stomatitis or altered sensations medical attention (Figure 17-11). Lesions on the posterior
in the mouth are frequently reported. Pain may third or the sides of the tongue often are abnormal and
be limited to the oral cavity or may affect the should be brought to the attention of the primary care
face and jaw. provider.

In one study, 7% of older adults reported oral pain within

the previous 6 months. Oral pain can cause loss of
appetite and decreased food intake and can have a CANCER
negative effect on the overall quality of an older person’s • The incidence of this cancer increases with age.
life. These forms of cancer have a poor prognosis,
primarily because they are often discovered late

DENTURES

• Dentures can cause irritation, inflammation, and

ulceration of the gums and oral mucous
membranes. Older adults should inspect their
mouths regularly and promptly report any
problems to the dentist. Sometimes, a minor
adjustment of the denture or use of a fixative
agent or cushion is all that is required to prevent
painful problems.

If only a few teeth are missing, the dentist may attempt to

bridge the gaps by attaching artificial teeth to the good
teeth. If too many teeth are missing, a partial plate may
be required. When all of the upper or lower teeth are
removed, a complete set of dentures is needed. Both According to the Oral Cancer Foundation, as many as
partial plates and dentures can cause problems for the 45,750 people are diagnosed with oral or pharyngeal
wearer. Partial plates tend to catch particles of food and cancer each year (Oral Cancer Foundation, 2015b). The
may weaken the healthy teeth to which they are attached. incidence of this cancer increases with age. These forms
Complete dentures are expensive and difficult to fit. of cancer have a poor prognosis, primarily because they
are often discovered late. Early recognition and treatment
Dentures that fit properly at one time may not fit properly
before the cancer has metastasized to other tissues offer
if the older person loses or gains a significant amount of
the best hope.
weight. Fit is also a problem when dentures are left out of
the mouth for a prolonged period. Many older adults
refuse to wear their dentures because of the discomfort
caused by an improper fit. This is because the arch of the DISORDERS CAUSED BY VITAMIN DEFICIENCIES
jaw changes to compensate for the edentulous state.
❑ A smooth, purplish, sore tongue may be related
Professional dental attention is needed to repair or rebuild
to riboflavin deficiency.
the dentures in these cases.
❑ Complaints of a burning sensation or soreness
of the mouth may be related to niacin deficiency.
LEUKOPLAKIA
❑ Multiple painful ulcers of the oral mucous
❑ White patches in the mouth, called leukoplakia, membranes with enlargement of the cervical
often are precancerous and require prompt lymph glands, difficulty swallowing, and foul odor
medical attention may indicate Vincent angina.

❑ Lesions on the posterior third or the sides of the Vitamin deficiencies, particularly deficiencies of riboflavin,
tongue often are abnormal and should be niacin, and vitamin C, can affect the oral mucous
brought to the attention of the primary care membranes.
provider.
Vincent angina is a condition caused by opportunistic
microorganisms that normally live in the mouth but cause
infection only when the individual becomes malnourished

SUPRAINFECTIONS

❑ Suprainfections of the mouth are relatively

common in older individuals who receive broad-
spectrum antibiotic therapy for some other
infection.
 ❑ 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 NURSING PROCESS FOR IMPAIRED ORAL MUCOUS
be caused by tobacco use or by a chromogenic MEMBRANE
(color-producing) bacterium.

Antibiotics destroy the normal mouth flora and allow

opportunists or yeast colonies to become established and
grow. Candidiasis, a yeast infection (also known as
thrush), appears as white patches that adhere to the
tongue, lips, and gums. Attempts to remove these
patches may result in sore, bleeding tissue. 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. These conditions are more commonly
observed in malnourished older adults and those with
poor oral hygiene practices. Yeast infections are usually
treated by direct oral application or swishes of prescription
medication. Hairy tongue usually resolves without medical
treatment.

ALCOHOL AND TOBACCO-RELATED PROBLEMS

❑ Alcohol and tobacco, even in small amounts,

can harm mucous membranes.

❑ Alcohol is chemically irritating and drying to the

mucous membranes. Tobacco, whether smoked,
chewed, or taken as snuff, increases the risk for
oral cancer.

PROBLEMS CAUSED BY NEUROLOGIC

CONDITIONS

❑ Neurologic conditions such as stroke, multiple

sclerosis, or Parkinson disease decrease
coordination and strength, making it difficult for
the person to manipulate the equipment needed
for oral hygiene.

❑ Individuals with severe arthritis may not only find

the equipment difficult to manipulate, but they
may also find it difficult to open their mouth
adequately for good, thorough cleaning

Good oral hygiene practices are part of routine health

maintenance, but meeting oral hygiene needs may be
difficult for older individuals who have lost strength,
coordination, or cognitive processes. Older people who
take medication for epilepsy or other seizure disorders
need to use special precautions because these
medications often cause hyperplasia of the gingiva. Oral
hygiene with soft toothbrushes or swabs is recommended
to prevent excessive trauma and bleeding from the
tender, swollen tissues. Providing oral hygiene to persons NURSING INTERVENTIONS/IMPLEMENTATION
with Alzheimer disease can be a challenge because
The following nursing interventions should take
affected people do not understand the need for oral
place in hospitals, in extended-care facilities, and at
hygiene and are likely to resist care.
home:

❑ Complete a thorough assessment of the oral

mucous membranes.

❑ Initiate referral to a dentist or dental hygienist.

❑ Provide oral hygiene.

 ❑ Promote adequate intake of nutrients and fluids.

❑ Provide lozenges or topical analgesics as

prescribed.

❑ Communicate suspected oral side effects of

medication therapy to the primary care provider
and dentist.

❑ Stress the importance of regular dental visits.

❑ Review the person’s oral hygiene practices.

❑ Provide assistive devices as needed.

❑ Obtain the assistance of family members,

friends, or community agencies.

❑ Explain the need to avoid alcohol and tobacco

use.

❑ Promote adequate intake of nutrients and fluids.

NURSING INTERVENTIONS/IMPLEMENTATION

The following interventions should take place in the

home:

❑ Discuss the benefits of adequate moisture in the

environment.]

❑ Suggest use of hard candy, chewing gum, or

artificial saliva to increase moisture in the mouth.

❑ Discuss the relationship between medications

and oral hygiene.

❑ Use any appropriate interventions that are used

in the institutional setting.

KEY POINTS

❑ Under normal conditions, the aging skin and

mucous membranes are more susceptible to
damage than the comparable tissues of younger
individuals. When disease factors are present,
the risk for damage is even greater.

❑ Careful assessment allows nurses to recognize

normal changes and identify any abnormalities
that may indicate problems that are more
serious.

❑ Nursing interventions are designed to reduce the

risk for damage or trauma to fragile tissues.