VN057 Gerontology 10

Nursing Process for Impaired Oral Mucous Membranes

ch 17 cont’d

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Dental Caries

• Tooth decay, loose teeth, and lost teeth are ongoing problems in the population

• Poor nutrition and decreased appetite can often be attributed to dental problems

• Decay, or caries-caused by bacteria that penetrate through the enamel shield of the tooth and cause destruction

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Periodontal Disease

• A less obvious but potentially more serious complication of poor oral care

• Food debris & plaque build up in the mouth and on the teeth when oral hygiene is inadequate

• Activity of bacteria on debris cause bad breath, or halitosis.– often disturbing to the older person and to anyone

in close contact

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Periodontal Disease (cont.)

• Gingivitis causes gum swelling, tenderness, and bleeding and eventually leads to recession of the gum tissue away from the tooth

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Pain

• Dental caries and periodontal disease– most common reasons for oral pain– oral lesions such as stomatitis or altered sensations

in the mouth are also reported• Pain may be limited to the oral cavity or may

affect the face and jaw• Oral pain can cause loss of appetite, decreased

food intake, a negative effect on the overall quality of an older person’s life

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Dentures

• Partial plates tend to catch particles of food and may weaken healthy teeth

• Complete dentures-difficult to fit• Dentures may not fit properly if a significant

amount of weight is gained or lost• Dentures can cause irritation, inflammation,

and ulceration of gums and oral mucous membranes

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Dry Mouth

• Xerostomia, or dry mouth is common– may result from normal age-related reduction in saliva

secretion, medication side effects inadequate hydration, or diseases such as diabetes

• Makes chewing and swallowing more difficult, promotes tooth decay, and alters the sense of taste

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Leukoplakia

• White patches in the mouth• Often are precancerous and require prompt

medical attention• Can also be med s/e or thrush• Lesions on the posterior third or sides of the

tongue often are abnormal and should be brought to the attention of the physician

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Leukoplakia (cont.)

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A disease that is suspected to play a role in thromboembolic disorders, bacterial endocarditis, and myocardial infarction is:A. dental caries.B. halitosis.C. gingivitis.D. periodontal disease.

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Cancer

• Oral or pharyngeal cancer have poor prognosis• Early recognition and treatment before mets

to other tissues offer the best hope• Symptoms- include leukoplakia or

erythroleukoplakia, sores in the mouth that do not heal, oral bleeding, pain or difficulty swallowing, difficulty wearing dentures, swollen lymph nodes in the neck, earache

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Disorders Caused by Vitamin Deficiencies

• Certain deficiencies of riboflavin, niacin, and vitamin C can affect oral mucous membranes

• A smooth purplish sore tongue may be related to riboflavin deficiency

• Complaint of a burning sensation or soreness of the mouth may indicate niacin deficiency

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Superinfections

• Superinfections of the mouth are relatively common in older individuals who receive broad-spectrum antibiotic therapy for some other infection

• Antibiotics destroy the normal mouth flora and allow opportunist bacteria or yeast colonies to become established and grow

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Superinfections (cont.)

• 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

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Alcohol- and Tobacco-Related Problems

• Alcohol and tobacco, even in small amounts, can harm the mucous membranes

• Alcohol- chemically irritating and drying to the mucous membranes

• Tobacco, whether smoked, chewed, or taken as snuff, increases the risk for oral cancer

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Problems Caused by Neurologic Conditions

• Neuro conditions such as stroke, multiple sclerosis, or Parkinson’s disease decrease coordination and strength– difficult for the person to manipulate the

equipment needed for oral hygiene– Can be difficult to open mouth

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Problems Caused by Neurologic Conditions (cont.)

• severe arthritis may find equipment difficult to manipulate– May be difficult to open the mouth adequately for

good, thorough cleaning• medication for seizure or other neuro

disorders need to use special precautions– medications often cause gum problems

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Nursing Interventions for Impaired Oral Mucous Membranes

• Complete a thorough assessment of the oral mucous membranes

• Initiate referral to a dentist or dental hygienist• Provide oral hygiene

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Nursing Interventions for Impaired Oral Mucous Membranes (cont.)

• Promote adequate intake of nutrients and fluids

• Provide lozenges or topical analgesics as prescribed

• Communicate suspected oral side effects of medication therapy to the physician and dentist

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Dental care

• Access to dental care is often an issue for people with impaired mobility– Getting to the office– Ability to tolerate time in wheel chair/use walker– Getting on to the chair– Ability to cooperate with personnel– Ability to open their mouth

Chapter 18

Elimination

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Objectives

• Describe the normal elimination processes.• Identify the older adults who are most at risk

for problems with elimination.• Describe age-related changes in bladder and

bowel elimination.

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Normal Elimination Patterns

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Bowel Elimination

• typical adult: moderate amount formed brown stool passed without difficulty

• Usual adult: bowel movements every 1- 2 days• urge usually occurs 30 to 45 minutes p meal– gastrocolic and defecation reflexes stimulate

peristalsis

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Urinary Elimination

• Usual adult: urge when bladder contains approximately 300 mL of urine– This varies greatly

• Voluntary control of external sphincter allows healthy adults to hold larger amounts until it’s convenient

• Most adults void between 6 and 10 times per day

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Elimination and Aging

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Constipation• Hard, dry stools- difficult to pass• Increased risk associated with aging– decreased abdominal muscle tone– Inactivity &/or immobility– inadequate fluid intake

• Especially combined with bulk forming agents [metamucil]– inadequate dietary bulk– disease conditions [parkinsons, gastroparisis + more]– Medications– dependence on laxatives or enemas– various environmental conditions

• Inability to get to toilet-holding too long, lack of privacy32

Constipation (cont.)

• Dietary fiber-important role in promoting normal elimination– indigestible substance traps moisture & provids bulk

• Repeatedly ignoring the urge to defecate can lead to suppression or even extinction of the defecation reflex

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Fecal Impaction

• mass of hardened feces trapped in the rectum & can’t be passed– result of unrelieved constipation

• Symptoms– longer-than-usual delay in defecation– Passage of small amounts of liquid stool without

any formed fecal material• Digital examination of the rectum may reveal

presence of a hardened mass of feces35

Objectives

• Discuss methods for assessing elimination practices.

• Identify selected nursing diagnoses related to elimination problems.

• Describe interventions used to prevent or reduce problems related to elimination.

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Nursing Process for Constipation

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Assessment

• How often do bowel movements occur? Is there any pattern?

• Is the person continent or incontinent?• consistency?• amount ?• color ?• Are blood, mucus, undigested food, or other

unusual substances evident in the stool?

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Assessment (cont.)

• Has it been checked for occult blood?• Do they have to strain?• Is the stool expelled with excessive force, or

does it ooze from the body?• Does the person report or has the nurse

observed any particular foods that affect bowel movements?– Do these foods cause diarrhea or constipation?

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Assessment (cont.)

• Does the person rely on aids for elimination (suppositories, laxatives, enemas)?– How long has the person been using this aid?

• Is the abdomen distended?• If the person cannot speak, does he or she rub

the abdomen?• Has the person’s appetite decreased?• Are they nausiated?

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Assessment (cont.)• If they don’t feel like they have to have a b.m.-

what do you feel with digital examination?• Does the diet have adequate bulk?• Does the person take any bulk enhancers?– Do they take adequate fluid with them

• What does the person say about his or her bowel habits?

• Has the bowel pattern changed recently?• Does the person report any concerns related to

bowel elimination?43

Nursing Diagnosis

• Altered elimination pattern-Constipation

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Nursing Goals/Outcomes

• Exhibit regular patterns of bowel elimination• Identify behaviors that promote normal bowel

functioning• Modify behaviors to enhance regular bowel

elimination

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Nursing Interventions for Constipation

• Assess bowel elimination patterns and contributing factors

• Increase physical activity• Increase intake of dietary fiber and fluids• Schedule or encourage toileting at times when

the person’s defecation urge is strongest• Position to facilitate ease of elimination• Provide privacy for elimination

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Nursing Interventions for Constipation (cont.)

• Administer stool softeners or bulk-forming laxatives as prescribed by the physician

• Administer prescribed suppositories or enemas if other methods have not been effective

• Perform digital rectal examination and impaction removal as ordered or according to agency policy

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Nursing Process for Diarrhea

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Diarrhea• Frequent passage of liquid, unformed stools– Stools are liquid because they pass through the large

intestine too rapidly and are expelled before sufficient water can be absorbed in the large intestine

• Symptom of another problem– many causes

• malabsorption syndromes• Obstruction- tumors of the GI tract or stool• lactose intolerance• Diverticulosis• pathogenic organisms• medications

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Assessment

• Same as for constipation

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Nursing Diagnosis

• Altered elimination pattern-Diarrhea

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Nursing Goals/Outcomes

• Exhibit regular patterns of bowel elimination• Identify behaviors that promote normal bowel

functioning• Modify behaviors to enhance regular bowel

elimination

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Nursing Interventions for Diarrhea

• Assess the elimination pattern and suspected causative factors

• Maintain adequate fluid intake• Institute measures to maintain skin integrity• Promptly report observations to the physician,

and follow up on physician’s orders regarding medications that decrease intestinal motility

• Stool testing as ordered

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Bowel Incontinence• common for those who are unable to recognize

&/or respond to normal sensation– mental impairment– Mobility– Delayed assistance

• Less frequently disorders of color or rectum– Cancer– inflammatory bowel disease– Diverticulitis– weak rectal muscles– diarrhea

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Which nursing diagnosis is most important for the patient with diarrhea?A. Disturbed body imageB. Fluid volume deficitC. Knowledge deficitD. Impaired gas exchange

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Nursing Process for Bowel Incontinence

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Assessment

• Same as for constipation

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Nursing Diagnosis

• Bowel incontinence

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Nursing Goals/Outcomes

• Exhibit regular patterns of bowel elimination• Identify behaviors that promote normal bowel

functioning• Modify behaviors to enhance regular bowel

elimination

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Nursing Interventions

• Assess patterns of elimination and causative factors

• Establish a toileting schedule• Take measures to prevent or reduce episodes

of constipation• Use appropriate aids or garments• Clean the person promptly after each episode

of incontinence

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Nursing Process for Impaired Urinary Elimination

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Urinary Retention• Abnormal accumulation of urine in the bladder; bladder unable

to empty completely– Normally, no more than 50 mL of urine remains in the bladder after

voiding• decreased muscle tone in the bladder wall• medications• prostate gland enlargement/uterine prolapse• trauma to the muscles of the perineum• neurologic problems• anxiety• Decreased fluid intake

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Urinary Retention (cont.)

• Symptoms– feeling of fullness, discomfort, or tenderness– Small frequent voids– Frequent bladder infections– Restlessness– diaphoresis

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Urinary Retention Treatment• If caused by perineal trauma or anxiety– noninvasive tx such as medications, peppermint oil

[inhaled scent] or a sitz bath may be enough to stimulate effective voiding

• If severe retention is caused by an obstruction such as an enlarged prostate, catheterization or surgery may be necessary – prevent serious bladder damage that could result

from persistent or excessive bladder distention• Pessarys were once commonly used with uterine

prolapse, now usual tx is surgery

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Urinary Incontinence

• The involuntary loss of urine– social or hygiene problem

• In some cases, incontinence is curable using surgery ,medications, or other treatments

• In others- better managed, thus allowing the older person a more normal lifestyle

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Types of Urinary Incontinence

• Stress incontinence– Leakage of urine

• conditions that increase intra-abdominal pressure• exercise, lifting heavy objects, laughing, coughing, or sneezing

• Urge incontinence– Caused by involuntary contraction of the detrusor muscle of

the bladder• Overflow incontinence

– Leakage of small amounts of urine from an overly full bladder– Common with retention problems

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Types of Urinary Incontinence (cont.)

• Functional incontinence– normal urethral and bladder function– cognitive or physical in nature

• Total incontinence– A condition in which older adults experience

continuous and unpredictable loss of urine

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Assessment

• Is the person continent or incontinent?• any specific time of day or under any special

conditions?• history of any medical conditions that would

interfere with urine elimination (neurogenic bladder)?

• history of any medical condition that would decrease awareness of the need to void?

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Assessment (cont.)

• difficulty in starting to urinate?• any involuntary loss of urine when he or she

coughs, laughs, or sneezes?• pain or burning with urination?• What is the person’s pattern of fluid intake?

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Nursing Diagnoses

• Altered elimination – Functional urinary incontinence– Reflex urinary incontinence– Stress urinary incontinence– Urge urinary incontinence– Impaired urinary elimination– Urinary retention

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Nursing Goals/Outcomes

• Exhibit a reduction in episodes of urinary incontinence or retention

• Urinate at acceptable times in acceptable places• Identify measures that reduce episodes of

urinary incontinence or retention– Ie-toilet every 2 hours

• Establish a routine to reduce or prevent the occurrence of bladder elimination problems

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Nursing Interventions

• Assess elimination and fluid intake patterns• Explain measures that help improve tone of the

sphincter muscles– Kegel exercises

• Modify clothing to make toileting easier• Reduce environmental barriers– grab bars in the bathroom, installing toilet risers,

keeping the urinal or bedpan readily available, and providing a call signal for assistance

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Nursing Interventions (cont.)

• Answer call signals promptly• Develop a toileting schedule• Familiarize older adults with the locations of

bathrooms throughout the facility• Provide support and encouragement• Initiate actions to maintain skin integrity• Provide incontinence pads or garments when

appropriate

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Nursing Interventions (cont.)

• Administer medications as prescribed by the physician

• Insert catheter as prescribed by the physician

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Disposable and Reusable Incontinence Garments

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Disposable Incontinence Pads

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Catheters

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