NCMB312 LECTURE

WEEK 4: HEALTH PROMOTION, HEALTH MAINTENANCE AND HOME HEALTH

CONSIDERATIONS
PROFESSOR: MR. EDWIN MALIC 3RD YEAR 1ST SEM 2023
WEEK 4: PHYSICAL CARE OF THE OLDER ADULT
consult the dietitian for nutritional
Care of Aging Skin and Mucous Membranes evaluation
- The skin undergoes several changes with aging that
make it more susceptible to damage. Over time, the Diminished Assess the patient’s and family’s ability
epidermal layer becomes thinner and subcutaneous sensation to provide care; educate caregivers
padding diminishes, increasing the risk for traumatic decreased mental status regarding
injuries such as skin tears or pressure ulcers pressure ulcer prevention

Impaired skin Avoid pressure; do not use

Dry Skin
integrity donut-shaped cushions or sheepskin;
- Dry skin can result in itching (pruritus), burning, and lubricate skin; apply barrier ointments to
cracking of the skin protect skin from moisture; do not
massage red areas; Do not use heat
Rashes and Irritation lamps, heating pads, or hot water.
- Rashes and skin irritation can be caused by factors
other than dryness. Medications, communicable Pressure Points
diseases, and contact with chemical substances are
common causes of skin rashes and pruritus

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. Skin tears, abrasions,
lacerations, and ulcers most often result from friction,
shearing force, moisture, and pressure.
- Even simple incidents such as contact with furniture,
sliding across bed linens, a grip during a transfer, or
the removal of tape may result in significant skin
trauma to the older person.

Pressure Ulcers
- Pressure ulcers are a particular risk to older adults
who suffer from compromised circulation, restricted
mobility, altered level of consciousness, fecal or
urinary incontinence, or nutritional problems

Risk Factor Nursing Interventions

Immobility Establish individualized turning

schedule; reduce shear and friction by
using trapeze and/or turning sheet;
elevate HOB <30 degrees; provide
pressure-relief surface

Inactivity Provide assistive devices to increase

activity

Incontinence Assess the need for incontinence

management; clean and dry skin after

Malnutrition Provide adequate nutritional and fluid

intake; assist with snacks and meals,
monitor intake and output (I & O);
 Elimination - Constipation R/T decrease motility of
gastrointestinal tract
Subjective Data
- Unable to pass stool
- Complain of abdominal pain
- Complain of pain with defecation
Objective Data
- Hard, formed stool
- Straining with Defecation
- distended
Goal/planning/outcome
- Will establish or regain normal pattern of bowel
functioning.
Intervention
- Instruct and Encourage a diet of balanced fiber and
fiber supplement. To improve consistency of stool and
facilitate passage through the colon.
- Promote adequate fluid intake including high fiber fruit
juices, fruit/vegetable smoothies, suggest drinking
warm, stimulating fluid. promote passage of stool
- Encourage activity and regular exercise within limits
of individual activity. Stimulate contraction of the
intestine
- Provide privacy and routinely scheduled time for
defecation. The client can respond to urge
- Administer stool softener as ordered
- Administer enema as order.
Urge Urinary Incontinence r/t Impaired bladder
Contractility
Subjective Data
- Report involuntary loss of urine
Objective Data
- Observer inability to reach toilet
Goal/planning/outcome
- Will demonstrate behavior or techniques to control or
avoid situation
Intervention
- Provide help or assistance or device as indicate for
the client ( place bedside commode or bedpan)
- Offer help or assistance prompt client to bathroom on
regularly time schedule
- Encourage use of incontinence pad
- Emphasize importance of regular perineal care
Activity exercise - Activity Intolerance r/t bedrest or
immobility
Subjective Data
- verbalize of feeling weak
TRANSCRIBED BY: MICHAEL GABRIEL JIMENEZ
Objective Data
- Abnormal heart rate or blood pressure response to
activity
Goal/planning/outcome
- Will report measurable increase in activity tolerance
Intervention
- Monitor v/s and cognitive signs (present of confusion)
- Give supplemental oxygen as ordered
- Increase exercise/activity gradually
- Plan activity to balance rest period
- Involve client in planning of activity
- Assist with activity, possible use of assistive device
Ineffective Airway Clearance r/t retained secretions
Subjective Data
- Complain of dyspnea
Objective Data
- Diminished breath sounds (crackles)
- Changes in respiratory rate/rhythm
- Excessive sputum
Goal/planning/outcome
- Will demonstrate reduction of congestion with breath
sounding clear.
Intervention
- Maintain client on high fowler’s position
- Suctioned secretion
- Perform airway clearance technique
- Encourage breathing exercises
- Administer medications as order
- Give oxygen support if needed and as order
- Assist with sputum collection if needed
- Encourage to increase oral fluid intake if not
contraindicated
- Monitor for signs of respiratory distress
Ineffective Airway Clearance r/t retained secretions
Subjective Data
- Complain of dyspnea
Objective Data
- Diminished breath sounds (crackles)
- Changes in respiratory rate/rhythm
- Excessive sputum
Goal/planning/outcome
- Will demonstrate reduction of congestion with breath
sounding clear.
Intervention
- Maintain client on high fowler’s position
- Suctioned secretion
- Perform airway clearance technique
 - Encourage breathing exercises
- Administer medications as order
- Give oxygen support if needed and as order
- Assist with sputum collection if needed
- Encourage to increase oral fluid intake if not
contraindicated
- Monitor for signs of respiratory distress
Ineffective Breathing Pattern r/t Hyperventilation
Subjective Data
- Complain of Difficulty in breathing
Objective Data
- Dyspnea
- Bradypnea
- Pursed lip breathing
- Use of accessory muscle
Goal/planning/outcome
- Will establish normal breathing pattern
Intervention
- Put the client on High fowler's position
- Provide oxygen support as order
- Encouraged deep breathing exercise
- Encourage slower/ deeper respiration
Impaired Physical Mobility R/T Impaired Mobility
Subjective Data
- Report Unwillingness to move
Objective Data
- Limited ability to perform motor skills
- Difficulty in turning
- Postural instability
- Slowed movement
Goal/planning/outcome
- Will maintain or increase muscle strength
Intervention
- Encourage to participate in ROM
- Change position every 2 hours if the client is unable
to move
- Put side rail at all times for safety
- Provide regular skin care
- Schedule activities with adequate rest of time
- Encourage adequate fluid intake and eat nutritious
food
Sleep/Rest
- Sleep deprivation r/t aging related sleep stage shift
Subjective Data
- Verbalize decreased ability to function
TRANSCRIBED BY: MICHAEL GABRIEL JIMENEZ
Objective Data
- Restlessness
- Acute confusion
- agitation
Goal/planning/outcome
- Will report improvement in sleep pattern
Interventions
- Encourage to restrict late afternoon or evening intake
of caffeine, large amount of fluid
- Avoid eating large volume of food during evening or
late-night meal
- Promote adequate physical exercise activity during
day
- Suggest abstaining from daytime naps
- Recommend quiet activities such as reading or
listening to soothing music
- Instruct relation technique
- Provide calm quiet environment
- Review medication that may affect sleep deprivation
PSYCHOSOCIAL CARE OF THE OLDER ADULT
Self-Perception and Self-Concept
- Anxiety r/t change in health status
Subjective Data
- Report concerns due to changes in life events
Objective Data
- Poor eye contact
- Impaired attention
- Restlessness
Goal/planning/outcome
- Will appear relaxed and report anxiety is reduced to a
manageable level
Intervention
- Establish therapeutic relationship
- Clarify meaning of feelings and actions by providing
feedback and checking meaning with client
- Acknowledge anxiety or fear do not deny or reassure
client everything will be alright
- Provide physical comfort
- Modify procedures as much as possible (IM injections
to oral or combine blood draw)
- Manage environmental factors, such as harsh
lightning and high traffic flow
- Allow the behavior to the client do not respond
personally
- Accept client as is
Cognition and Perception
- Impaired Memory r/r neurological disturbances

Subjective Data
- Report experiences of forgetting
Objective Data
- Inability to recall if behavior was performed
- Inability to learn/retain new skills or information
Goal/planning/outcome
Goal/planning/outcome
- Will establish methods to help in remembering
essentials things when possible
Interventions
Interventions
- Orient or re orient client as much as possible
- Implement appropriate memory-training techniques
- Encourage ventilation of feelings of frustration and
helplessness refocus attention to areas of control and
progress
- Structure teaching methods and intervention to
client’s level of functioning
- Determine client’s response to and effects of
medication prescribe to improve memory process
- Encourage to identify individuals who can provide
support
- Discuss desire to continue or reconnect with previous
belief
- Explore alternatives or modifications of ritual based
on setting and individual needs and limitations
Sexual Dysfunction R/T Effects Of Aging
- Will verbalize understanding of sexual anatomy and
function and alterations that may affect function
- Establish therapeutic nurse-client relationship
- Provide factual-information about individual condition
involve
- Provide information about availability of corrective
measures such as medications
- Refer to appropriate resources as needed

Coping and Stress

- Ineffective coping r/t inadequate social support

Subjective Data
- reports inability to cope
- Sleep pattern disturbances

Objective Data
- Lack of goal-directed behavior
- Poor concentration
- Decreased use of social support

Goal/planning/outcome
- Will verbalize awareness of own coping abilities

Intervention
- Promote therapeutic communication
- Treat client with respect and courtesy
- Help the client to learn how substitute positive
thoughts for negative one
- Encourage verbalization of thoughts and anxiety

Values and Beliefs

- Impaired religiosity r/t aging

Goal/outcome/planning
- Will express ability to once again participate in beliefs
and rituals

Interventions
- Use therapeutic communication skills
- Encourage expression of feelings about condition

TRANSCRIBED BY: MICHAEL GABRIEL JIMENEZ