Month: May 2021

The Structure of the Skin and what it is:

Epidermis: The thin, top layer of the skin surface.

Dermis: The thicker layer underneath the

Surface.

The dermis contains:

Blood Vessels: Tubes that carry blood through the body, with oxygen and food.

Nerves: Fibers that carry sensations to and from the brain.

Oil Glands: Organs that secrete an oily lubricating fluid.

Sweat Glands: Organs that separate waste products from the blood and secrete them as sweat.

Hair Follicles: Organs that create hair.

Fatty Tissue: Layer of fat under the skin.

Although it is not part of the skin, the fatty tissue provides a protective layer of padding (to prevent injury to underlying bones and muscles) and insulation (to keep heat in).

The Aging of Skin: What Happens?

⇒The skin and fatty tissue layer gets thinner.

⇒The skin becomes less elastic.

⇒Oil glands produce less oil, so skin is drier.

⇒Blood vessel walls get thinner and more delicate, so they break easily.

⇒Circulation of the blood slows down, so the skin is not getting as much oxygen and nutrition from the blood, causing the skin to become poorly nourished and fragile.

Because of these changes in the skin, older

people:

• Tend to feel cold

• Suffer from skin tears

• Heal slowly

• Become wrinkled

• Develop pressure sores

Caring for Older Skin: What to do!

• Keep skin clean.
• Pat skin – do not rub when washing or drying.
• Use powder sparingly, excess powder can cause irritation.
• Keep skin lubricated.
• Use lotions liberally.
• Frequent bathing with soap will dry the skin—use lotion cleansers.
• Keep skin creases and folds dry.
• Keep clothes and bedding dry.
• Eat nutritious food and drink lots of water.
• Change position often to improve circulation and prevent pressure sores.
• Do not disturb moles.
• Massage the skin, but avoid bony projections and irritated areas:
• Massage around but not directly on irritated or sensitive areas.
• Use chair cushions and good beds.
• Inspect skin daily for redness, tears, blisters, scrapes, or irritated areas.
• Report any problems to a nurse or doctor.

Skin Problems

Decubitus Ulcers (Bed Sores or Pressure Sores)

Causes:

• Sustained pressure on the skin compresses the blood vessels and prevents nutrition and oxygen from getting to the skin cells. Over time, the skin tissue dies, and Decubitus Ulcers develop.
• The skin is under pressure where the bones press against the skin tissue, especially when the weight of the body or a body part is pushing down on a pressure point.
• Body fluids such as Urine and Feces contain damaging chemicals. When they remain on the skin, they cause moist areas that become irritated and develop sores.
• Friction from clothing or bedding can injure the skin and lead to skin ulcers.

What to report to the Nurse, Doctor, or Supervisor:

• A red pressure area that does not become

normal after 20 minutes without pressure

• A reddened area of the skin that does not turn white when you push on it.
• A skin area that is warm or hot to the touch.
• Any swelling
• Any opening in the skin
• Blisters, tears, craters, rashes, or holes
• Scrapes or Abrasions
• Drainage or weeping from the skin.

• Be especially alert when you are caring for residents that are frail, do not move around much, or have poor nutrition. Patients with little or no feeling in parts of the body, such as stroke victims, must be watched because they cannot feel pressure spots and need to frequently change positions.

Preventing Skin Problems

• Encourage or help patients to walk or exercise several times a day.
• Encourage or help patients to keep their skin clean, dry, and lubricated.
• Encourage or help patients to keep their bedding free of wrinkles.
• Encourage or help patients to eat well and drink plenty of liquids.

For patients who are in chairs most of the time:

• Encourage or help them to stand, walk, or shift their weight every 15 minutes.
• Teach them how to do chair push-ups with their arms.
• Teach them how to sit with their knees at the same level as their hips, with their thighs horizontal to the chair. This

will distribute their weight along their thighs and away from pressure points.

• If a patient cannot do these things, he or she should return to bed after an hour in a chair.

For patients who are in bed most of the time:

• Teach them how to use the side rails and the trapeze to change position frequently, at least every two hours. Be available to assist them if necessary. Even small shifts in body weight are helpful.
• When you are helping a patient to change position, move him or her carefully so you do not create friction and shearing between the skin and the bedding or clothes.
• The head of the bed should be raised as little as possible, no more than 30 degrees, to prevent sliding and pressure on the bony areas. If it must be raised higher for eating, it should be lowered an hour later.
• Massage the skin when possible but avoid massaging pressure points or irritated areas.

For patients who use special chair cushions or mattress overlay pads:

• Check to be sure that the pads are thick enough to do the job. Place your hand under the pad while the resident is on top of it—if you can feel the patient’s body through the cushion, the pad is too thin.

For patients with pressure sores:

• Keep weight and pressure off any reddened areas and wounds.
• Use pillows to elevate or separate body parts and keep pressure off an area, such as a pillow under the calf to raise the heel off the bed, or a pillow between the legs to keep the knees from touching each other.

Emalee Walton 5/26/21

Sources:

Caring for Aging Skin : AJN The American Journal of Nursing (lww.com)

Aging Adults and Skin Care | Caring for Our Skin as We Age (parentgiving.com)

Elderly Skin Care: Tips for Taking Care of Aging Skin and Avoiding Disease – Caring People (caringpeopleinc.com)

What causes urinary incontinence?

People who cannot control when or where they urinate suffer from urinary incontinence, or U.I. There are things that can be done to improve this condition, but it is important to know what the cause is so the right care and treatment can be given.

This condition is not the person’s fault, and it is not a necessary or normal part of growing older. It is not caused by laziness or meanness. U.I. is a health problem with several possible causes. Some of the most common causes include the following:

• Urinary tract infections (U.T.I.)
• Confusion and forgetfulness
• Muscle weakness
• Vaginal problems (in women)
• Prostate problems (in men)
• Medication reactions
• Problems with clothing
• Trouble getting to the bathroom.
• Constipation

What are the symptoms of urinary incontinence?

Any patient who wets the bed or him- or herself, leaks urine on the way to the bathroom, or must use protective pads or padded briefs is suffering from U.I. If you notice a resident, a bed, or a room that has urine stains or a urine odor, then you know the resident needs help with this condition.

However, you probably do not know what kind of U.I. the resident might have. You can often determine this by watching the resident closely and keeping track of his or her urinating habits on a bladder tracker.

There are three different types of U.I.:

• Urge incontinence. With this type, people may leak urine on their way to the bathroom, after they drink just a little bit of liquid, or as soon as they feel the urge to go.

• Stress incontinence may cause urine to leak when they sneeze, cough, or laugh, or when they exercise or move a certain way (getting out of bed nor up from a chair, walking, lifting). This is common in women.

• Overflow incontinence causes people to feel they need to urinate again right after going, or to feel as though they never totally empty the bladder, or to pass small amounts of urine without feeling any need to go. It may be a sign of prostate problems in men.  

What can YOU do to help a patient with urinary incontinence?

Your first responsibility is to report U.I. to your supervisor or the patient’s doctor. A doctor or nurse should check a resident with U.I., and your observations about the resident, such as a bladder record, will help them determine the cause and type of U.I.

The three treatments for U.I. are:

1. Medicine.
2. Surgery.
3. Behavioral treatments, which help people control their urine and use the toilet at the right time. They work well for patients who have problems getting to the bathroom or are not able to tell you when they need to urinate.

Behavioral Treatments for Urinary Incontinence

Scheduled Toileting

Use scheduled toileting for patients who cannot get out of bed or cannot get to the bathroom alone. To do this treatment, assist the patient to the bathroom every two to four hours on a regular schedule.

Prompted Voiding

Use prompted voiding for patients who know when they have a full bladder but do not ask to go to the bathroom. To do this treatment:

1. Check the Patient for Wetness
2. Ask “Do you want to use the Toilet?”
3. Help the Patient to the Toilet
4. Praise the Patient for being dry.
5. Tell the Patient when you will be back to take them to the toilet again.

Habit Training

Use habit training at the same time every day.

To do this:

1. Watch the patient to find what times he or she urinates. A bladder record can help you do this.
2. Take the patient to the bathroom at those times every day.

3. Praise the patient for being dry and using the toilet.

For all behavioral treatments, remember these things.

1.    Be patient. These treatments take time.

2.    Treat the patient as an adult.

3.    Do not rush the patient.

4.    Give the patient plenty of time to completely empty his or her bladder.

5.    Give privacy by closing the door, even if you must stay in the bathroom.

6.    NEVER yell or be angry with the patient if he or she is wet. Say, “You can try again next time.”

7.    Respect dignity and confidentiality.

Other ways to help patients with Urinary Incontinence.

1. Pelvic exercises can make muscles around the bladder stronger and help with U.I. These are called Kegel exercises, and to do them, the person tightens the pelvic muscles that stop and start the flow of urine. The muscles should be squeezed tightly for a few seconds and then released, up to ten times at

one sitting, four times every day. Then, whenever the person feels that urine might leak, he or she tightens those same muscles and prevents urine from leaking.

• People who cannot get out of bed or cannot get to the bathroom for some reason may need to use a

bedpan, urinal, or bedside commode. These articles, if needed, should be kept by the bed.

• If a patient uses a wheelchair, walker, or cane to get to the bathroom, you can help by keeping the item near the bed and keeping the path to the bathroom clear and well lit.

• Encourage the patient to wear clothes that are easy to remove and that have simple fasteners.

• If a patient needs to wear special pads or clothing to help keep the skin dry, they should be changed often. Use soft pads and clothing, keep them wrinkle-free, keep the skin clean and dry, and use protective skin creams if allowed. Remember that wet skin can develop sores and rashes.

• If the patient wets the bed at night, it might be helpful to restrict evening liquids, but you should only do this if a doctor or nurse orders it. This is usually done in the three hours before bedtime. The patient should use the bathroom just before going to bed.

• Some patients need to use a urinary catheter, which is a tube inserted into the bladder by a doctor or nurse. It drains urine into a bag. Sometimes men use a condom catheter that fits over the penis. Catheters can cause infections, and condom catheters that are too tight can be harmful. Catheters should be checked often. They are not recommended for most incontinence problems.

What causes bowel incontinence?

People who cannot control when or where they pass gas or stool suffer from bowel incontinence. There are things that can be done to improve this condition, but it is important to know what the cause is so the right care and treatment can be given. This condition is not the person’s fault, and it is not a necessary part of growing older. It is a health problem that is not caused by laziness or bad behavior.

Some of the most common causes include:

• Incorrect diet or fluid intake

• Confusion and forgetfulness

• Muscle injury or weakness (the anal muscles)

• Nerve injury

• Medication reactions or laxative abuse

• Trouble getting to the bathroom

• Constipation or impaction

• Diarrhea

What can YOU do to help a patient with bowel incontinence?

Your first responsibility is to report episodes of bowel incontinence to your supervisor or the patient’s doctor. A doctor or nurse should check the resident, and your observations may help them determine the cause of the problem. Treatments for bowel incontinence include:

1. Medicine
2. Surgery
3. Dietary management
4.  Bowel management and retraining, with establishment of a habit regimen.
5. Biofeedback

Two of these treatments involve the care you provide: Diet Management and Bowel Retraining. These treatments are the same as those used to help people with constipation.

What causes constipation?

People usually say they are constipated when they are having infrequent bowel movements, but constipation is also used to refer to a sense of bloating or intestinal fullness, a decrease in the amount of stool, the need to strain to have a bowel movement, or the need to use laxatives, suppositories, or enemas to maintain regular bowel movements. It is normal for most people to have bowel movements anywhere from three times a day to three times a week, but some people may go a week or longer without discomfort or harmful effects.

Many things can cause constipation, but the most common causes include:

• Inadequate fiber and fluid intake

• Inactivity or a sedentary lifestyle

• Change in routine

• Abnormal growths or diseases

• Damaged or injured muscles (sometimes from

repeatedly ignoring the urge to go)

• Medication side effects and laxative abuse (it is

NOT necessary to have a B.M. every day)

Constipation may be diagnosed if movements occur fewer than three times weekly on an ongoing basis.

What can YOU do to help a patient with constipation?

Your first responsibility is to report a patient’s constipation problems to your supervisor or the patient’s doctor. A doctor or nurse should check the patient, and your observations may help them determine the cause of the problem.

Treatments for constipation include:

1. Medicine

2. Surgery

3. Dietary management

4. Bowel management and

retraining, with establishment of a

habit regimen.

Dietary management for Urinary Incontinence

Although there is no dietary treatment for urinary incontinence, some foods and drinks can irritate the bladder, such as sugar, chocolate, citrus fruits (oranges, grapefruits, lemons, limes), alcohol, grape juice, and caffeinated drinks like coffee, tea, and cola. Patients with U.I. could try eliminating these foods and beverages from their diet and see if the condition improves.

Dietary management for bowel incontinence and constipation

The average American diet contains 10–15 grams of fiber a day. The amount of fiber recommended for good bowel function is 25–30 grams of fiber per day, plus 60–80 ounces of fluid. Look at the table below to get an idea of the fiber we get in different foods. Most people can successfully treat their bowel irregularities, both incontinence and constipation, by adding high fiber foods to their diets, along with increasing fluid intake to desired levels. Increase dietary fiber slowly to give the bowel time to adjust.

People with diverticulosis or diverticulitis should not consume a high-fiber diet.

Type of Food	Lower Fiber Foods	Fiber grams	Higher Fiber Alternatives	Fiber grams
Breads	White bread, 1 slice	0.50	Whole wheat bread, 1 slice	2.11
Cereals	Corn flakes, 1 oz.	0.45	Oat bran cereal, 1 oz.	4.06
Rice	White rice, ½ cup	1.42	Brown rice, ½ cup	5.27
Vegetables	Lettuce, ½ cup raw	0.24	Green peas, ½ cup	3.36
Beans	Green beans, ½ cup	1.89	Pinto beans, ½ cup	5.93
Fresh Fruits	Banana, 1 medium	2.19	Blackberries, 1 cup	7.20

Food sensitivities

Some people are sensitive to, or even allergic to, certain foods that cause them constipation or diarrhea. Dairy products such as milk and cheese, wheat products such as bread, and foods containing chocolate are some of the more common problem foods. A physician should evaluate a resident who seems to have food sensitivities. Bowel retraining for bowel incontinence and constipation.

Habit training

Habit training means designating a specific time each day to have a bowel movement. Keep a record of the patient’s bowel habits, just as you do with a bladder record. If a pattern develops, that pattern can be used to set up a habit regimen that will reinforce a scheduled time each day to have a bowel movement.

If no pattern can be seen in the patient’s bowel activities, then a regimen can be established by selecting a convenient time each day, or even three times a day in the case of someone with bowel incontinence, for the patient to try to have a bowel movement. Be sure to help the patient stick with this schedule, even when he or she does not feel the need to go. Over time, the body will develop a habit that conforms to the scheduled routine.

Exercises

The Kegel exercises that are used to prevent urinary incontinence can be slightly modified to strengthen the anal muscles that control the outflow of stool. To do them, the person tightens the muscles around the rectum. The muscles should be squeezed tightly for a few seconds and then released, up to ten times at one sitting, four times every day.

Emalee Walton 5/19/2021

Want to learn more about constipation in the elderly? Management of Constipation in Older Adults – American Family Physician