VN057 Gerontology 10
Nursing Process for Impaired
Oral Mucous Membranes
ch 17 cont’d
2
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
3
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
4
Periodontal Disease (cont.)
• Gingivitis causes gum swelling, tenderness,
and bleeding and eventually leads to recession
of the gum tissue away from the tooth
5
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
9
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
10
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
11
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
12
Leukoplakia (cont.)
13
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.
14
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
15
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
16
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
17
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
18
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
19
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
20
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
21
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
22
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
23
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
25
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.
26
Normal Elimination Patterns
27
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
28
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
29
Elimination and Aging
30
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 privacy
32
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
33
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 feces
35
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.
38
Nursing Process for
Constipation
39
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?
40
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?
41
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?
42
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
44
Nursing Goals/Outcomes
• Exhibit regular patterns of bowel elimination
• Identify behaviors that promote normal bowel
functioning
• Modify behaviors to enhance regular bowel
elimination
45
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
46
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
47
Nursing Process for Diarrhea
48
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
50
Assessment
• Same as for constipation
52
Nursing Diagnosis
• Altered elimination pattern-Diarrhea
53
Nursing Goals/Outcomes
• Exhibit regular patterns of bowel elimination
• Identify behaviors that promote normal bowel
functioning
• Modify behaviors to enhance regular bowel
elimination
54
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
55
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
56
Which nursing diagnosis is most important for
the patient with diarrhea?
A. Disturbed body image
B. Fluid volume deficit
C. Knowledge deficit
D. Impaired gas exchange
57
Nursing Process for Bowel
Incontinence
58
Assessment
• Same as for constipation
59
Nursing Diagnosis
• Bowel incontinence
60
Nursing Goals/Outcomes
• Exhibit regular patterns of bowel elimination
• Identify behaviors that promote normal bowel
functioning
• Modify behaviors to enhance regular bowel
elimination
61
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
62
Nursing Process for Impaired
Urinary Elimination
63
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
65
Urinary Retention (cont.)
• Symptoms
– feeling of fullness, discomfort, or tenderness
– Small frequent voids
– Frequent bladder infections
– Restlessness
– diaphoresis
66
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
71
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
72
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
73
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
74
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?
75
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?
76
Nursing Diagnoses
• Altered elimination
– Functional urinary incontinence
– Reflex urinary incontinence
– Stress urinary incontinence
– Urge urinary incontinence
– Impaired urinary elimination
– Urinary retention
77
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
78
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
79
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
80
Nursing Interventions (cont.)
• Administer medications as prescribed by the
physician
• Insert catheter as prescribed by the physician
81
Disposable and Reusable Incontinence
Garments
82
Disposable Incontinence Pads
83
Catheters
85