Geriatric Syndrome

INTRODUCTION
University of the Philippines
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Geriatric Syndrome
GERIATRIC SYNDROMES are common clinical conditions that don't fit into
specific disease categories but have substantial implications for:
functionality and life satisfaction in older adults
Besides leading to increased
mortality and disability,
decreased financial and
personal resources, and longer
hospitalizations, these
conditions can substantially
diminish quality of life

INTRODUCTION
COLLEGE OF NURSING
Geriatric Syndrome
Main:
Pressure ulcers,
incontinence, falls,
functional decline
delirium.
Others:
Malnutrition,
eating and feeding problems,
sleeping
problems,
dizziness and syncope and
self-neglect have

5 COMMON CONDITIONS
Main:
Pressure ulcers,
incontinence, falls,
functional decline
delirium.
Others:
Malnutrition,
eating and feeding problems,
sleeping
problems,
dizziness and syncope and
self-neglect have
(Inouye, Studenski,
Tinetti, & Kuchel, 2007).
INTRODUCTION
COLLEGE OF NURSING

NEW “EVOLVING” SYNDROMES
sarcopenia
polyprovider
polypharmacy
pain
frailty
INTRODUCTION
COLLEGE OF NURSING

Urinary Incontinence
Geriatric Syndrome
Alfie R. Espinosa, RN
Infection Control Officer
Perioperative Nurse

What is UI?
URINARY INCONTINENCE
 involuntary loss of urine that is sufficient to be a problem (Fantl et al., 1996)
 the involuntary loss of urine so severe as to have social and/or hygienic
consequences for individuals and/or their caregivers, is a major clinical
problem and a significant cause of disability and dependency.
COLLEGE OF NURSING
Continence Foundation of the Philippines, (2006)

 14.6% for urinary incontinence among
females and 6.8% among males
 UI is only half as prevalent among men
compared to women.
 Whereas mixed urinary incontinence
(58.7%) prevails among women
 most reports show the predominance of
overactive bladder or detrusor
overactivity (49%) among men.
ASIAN prevalence rate (1998):
Continence Foundation of the Philippines, (2006)
COLLEGE OF NURSING

 Cellulitis
 Pressure ulcers
 Urinary Tract Infection
 Falls with fractures
 Sleep deprivation
 Social withdrawal
 Depression
 Embarrassment (50%)
 Interference with activities
 Caregiver burden - contributes
to institutionalization
 Increase in healthcare cost
 Decrease quality of life
CONSEQUENCES of UI:
COLLEGE OF NURSING
Dementia 11-90%
Community Dwelling
8-38%
Homebound
15-33%
Hospitalized
10.5%
Post-Hip Surgery
19-32%
Admission
36%
Additional: Hospitalized 13-42%
AACN Hartford Faculty Development

COLLEGE OF NURSING
Micturation is the discharge of urine from the
bladder via the urethra.
Lower Urinary Tract
1. Bladder
2. Urethra
Phases
1. Storage Phase
2. Expulsion Phase

COLLEGE OF NURSING
Physiology of Micturition

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AGE-RELATED CHANGES AFFECTING BLADDER FUNCTION
Clinical Gerontological Nursing
(Stone, Wyman, Salisbury, 1999)
CHANGE EFFECTS
Decreased bladder capacity
Frequency
Increased residual urine volume
Risk for urinary tract infection
Uninhibited bladder contractions Urgency, frequency, incontinence
Increased nocturnal urine production Nocturia, enuresis
Decreased estrogen
Atropic vaginitis, urgency, frequency, UTI, risk
for pelvic organ prolapse
Lower urethral pressure (women) Stress incontinence
Benign prostatic hyperplasia
Urgency, frequency, straining, urinary retention,
overflow incontinence

COLLEGE OF NURSING
ACUTE or TRANSIENT INCONTINENCE
 Sudden onset and is related to an
illness, treatment, or medication.
 When an illness resolves or the
identified cause was managed,
this condition usually resolves.
D - elirium
I – nfection
A - trophic vaginitis or urethritis
P - harmaceuticals
P – sychological causes
E – xcess fluids
R – estricted mobility
S – tool impaction
Urinary Incontinence Guideline Panel
(Resnick, 1992)

COLLEGE OF NURSING
PHARMACOLOGIC CAUSES
Opiods
Depress detrusor activity &
produce urinary retention
and overflow incontinence
Calcium Channel Blockers
Anti-Parkinsons Drugs
Anticholinergic Drugs
Prostaglandin Inhibitors

COLLEGE OF NURSING
PHARMACOLOGIC CAUSES
Sedatives  awareness, detrusor activity Func & O UI
Loop diuretics Diuresis overwhelms bladder capacity Urge & O UI
Alcohol Polyuria,  awareness  Urge & Functional UI
Caffeine Polyuria,  detrusor activity  Urge

COLLEGE OF NURSING
ESTABLIHED INCONTINENCE or PERSISTENT URINARY INCONTINENCE
 Stress Incontinence
 Urge Incontinence
 Mixed Incontinence
 Overflow Incontinence
 Functional Incontinence

COLLEGE OF NURSING
STRESS URINARY INCONTINENCE (SUI)
Characterized by loss of small amount of urine in the absence of detrusor
contraction usually during sudden increase in intraabdominal pressure such as
with:
 Coughing
 Sneezing
 Laughing
 Lifting
 Bending
The underlying cause is the inability of the urethra to
sustain pressure that exceeds that of the bladder,
particularly under EXERTIONAL EVENTS
(Diokno et al., 1986; Fantl et al., 1991; Makinen et al., 1992)
*more frequent in WOMEN than in MEN

COLLEGE OF NURSING
URGE INCONTINENCE
 Involuntary loss of urine in association with a strong sensation of urinary
urgency. This type of incontinence is characterized by strong urge to void
immediately prior to the loss of the urine. (Stone, Wyman, Salisbury, 1999)
Results from:
 detrusor (bladder) instability
 Hyperreflexia
 uninhabited bladder contractions
“KEY-IN-LOCK” SYNDROME
 they loss urine in arriving home and
unlocking their door.
 It may include urine loss on the way
to the bathroom or the "key in the
lock“ or "hand on the doorknob"
syndrome (no urge to urinate until
the key is in the doorlock or the
hand is on the knob and then it is
impossible to wait).
womensbladderhealth.com
OVERACTIVE
BLADDER

COLLEGE OF NURSING
MIXED INCONTINENCE
 Combination of STRESS and
URGE INCONTINENCE

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FUNCTIONAL INCONTINENCE
This pattern of urine loss is precipitated by factors outside the lower urinary tract,
rather than abnormal bladder or urethral function
(Stone, Wyman, Salisbury, 1999)
(Malone, Fletcher, Plank, 2004)
Characterized by inability to get into the
toilet on time as a result of the following:
1. physical impairments
2. chronic cognitive impairments
3. environmental or physical barriers
4. or the lack of caregiving assistance

COLLEGE OF NURSING
OVERFLOW INCONTINENCE
Characterized by involuntary loss of frequent or constant
dribbling and a failure to empty the bladder completely,
resulting in over distention.
• Outlet obstruction
• Hypoactive detrusor
MEN
Prostatic Hyperplasia
Prostatic Cancer
Urethral Stricture
Women
Severe Pelvic Organ
Prolapse
Antiincontinence
Surgery
(Stone, Wyman, Salisbury, 1999
(Malone, Fletcher, Plank, 2004)

COLLEGE OF NURSING
The Urinary Distress
Inventory-6 (UDI-6) is a self-
report symptom inventory for
UI that is reliable and valid
for identifying the type of
established UI in community
dwelling females
Female Patient
The Male Urinary Distress
Inventory (MUDI) is a valid
and reliable measure of
urinary symptoms in the
male population
Male Patient
INITIAL HISTORY FOR UI
Ask screening questions such as:
“Have you ever leaked urine? If yes, how much does it bother you?”

COLLEGE OF NURSING
UROGENITAL DISTRESS INVENTORY SHORT FORM (UDI-6)
Questions to ask on history taking and review of systems about UI
Do you experience, and, if so, how much are you bothered by:
Frequent urination This may indicate: Irritative/Overactive Bladder
Leakage related to feeling of urgency This may indicate: UI/Irritative
Leakage related to activity, coughing, or sneezing This may indicate:UI/Stress
Small amount of leakage (drops) This may indicate: UI/Stress
Difficulty emptying bladder
This may indicate Obstructive/Discomfort:
Obstructive Micturation
Pain or discomfort in lower abdominal or genital area This may indicate: Obstructive/Discomfort

COLLEGE OF NURSING
INITIAL HISTORY FOR UI
• Differentiate between transient and established UI because transient
UI may convert to persistent UI
• The seven-day bladder diary or record is the most evaluated and
recommended tool to quantify UI and identify activities associated
with unwanted urine loss
• A three-day bladder diary may be more feasible in the clinical setting

COLLEGE OF NURSING
kidney.niddk.nih.gov/kudiseases/pubs/diary/
THE BLADDER DIARY
TRIXIE ROSARIO
Juice 500 Lifting
Water 300 Dancing

The bladder diary
can help identify
potential bladder
irritants (e.g.,
acidic foods or
fluids, aka acid-
ash) that contribute
to UI

COLLEGE OF NURSING
THE BLADDER DIARY
• If the initial scheduled toileting time is set for 7 A.M., yet at 6:30 A.M. the
patient consistently attempts to independently void or is noted to be
incontinent, then the toileting time should be adjusted to 6 A.M.
• Prompted voiding requires the caregiver to ask if the patient needs to void,
offer assistance, and then offer praise for successful voiding
Example
• To assess UI
• Develop an individualized scheduled toileting program
which mimics the patient’s normal voiding patterns
Continual assessment and evaluation improves success

COLLEGE OF NURSING
PHYSICAL EXAM FOR UI
Observe the patient during urination to determine ability to
remove undergarments, sit on toilet etc.
Abdominal exam:
• Determine the presence of bladder distention
• Determine presence of stool impaction in left
quadrant

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Inspect male and female genitalia
*Note perineal irritation or long-standing
pigmentation change, often indicative
urinary leakage

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Valsalva maneuver (if not medically contraindicated) to detect pelvic
prolapse (e.g., cystocele, rectocele, uterine prolapse) or urine leakage
(suggestive of stress UI), as a result of increased intra-abdominal pressure
with bearing down
• Ask the patient to cough while observing for urinary leakage, especially
important when performing a “Valsalva” maneuver is contraindicated
• During the genitalia examination, instruct the patient to cough while
assessing for urine leakage that may be attributed to Stress UI
Female Patient

COLLEGE OF NURSING
Look for signs of atrophic vaginitis post-
menopausal women
1. Perineal inflammation
2. Tenderness and, on occasion, trauma as a
result of touch)
3. Thin, pale genitalia tissues that are often
friable and prone to bleeding
Perform digital rectal exam to identify
constipation or fecal impaction
Women

COLLEGE OF NURSING
Assess for “anal wink” (contraction of
the external anal sphincter) by lightly
stroking the circumanal skin.
• Indicative of intact sacral nerve routes
• Absence of the “anal wink” may
suggest sphincter denervation

COLLEGE OF NURSING
Men
In men, palpate the prostate gland.
• Typically an enlarged prostate is readily detected and
correlates with symptoms of:
1. urinary urgency
2. incomplete bladder emptying
3. decreased urinary stream
4. nocturia

COLLEGE OF NURSING
LAB TESTS FOR UI
Urinalysis and/ urine culture and sensitivity
Post void residual urine or simple bedside urodynamics
The International Continence Society (ICS) does
not recommend urodynamic testing in the initial
assessment and management of UI

COLLEGE OF NURSING
TREATMENT VS REFERRAL
Initiate referral if any of the following apply:
Need for additional testing
Abnormal U/A or culture
Palpable abdominal or pelvic mass
Elevated PVR
Abnormal prostate exam
Vaginal bleeding; obstruction; new underlying disorder; surgical candidate

COLLEGE OF NURSING
BEHAVIORAL MANAGEMENT
Scheduling Regimen
Scheduling regimens include:
• timed voiding
• habit training
• prompted voiding
• bladder training
Success of this regimens when used in institutionalized patients relies on staff member’s training,
compliance, and incentives for active participation. Thus, it is important to develop management
procedures to monitor the staff implementation of toileting interventions and to provide
feedback about the performance (Schnelle, 1990).

COLLEGE OF NURSING
TIME VOIDING
The fixed voiding schedule usually every 2 hours is used for:
• Stress UI
• Overflow UI
• Functional UI
• Reflex UI

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HABIT TRAINING
This is carried out through individualized and prescribed toileting schedule
which involves toileting intervals adjusted to the patient’s voiding pattern.
• Stress UI
• Urge UI
• Functional UI
• Reflex UI

COLLEGE OF NURSING
PROMTED VOIDING
It consists 3 elements used by caregivers:
1. Monitoring the patient on regular basis
2. Prompting the patient to try to use the toilet
3. Praising the patient for maintaining continence and using the toilet
Prompted voiding is recommended for patients who can:
1. Ask assistance
2. Respond when prompted to toilet
3. Learn to recognize some degree of bladder fullness or need to void
(Fantl et al., 1996)

COLLEGE OF NURSING
(Fantl et al., 1996)
BLADDER TRAINING
This technique consists of a:
• patient education in combination
• progressive voiding schedule
• positive reinforcement technique
It is usually used to treat outpatients who are cognitively intact and have Sx of:
• Urge UI
• Stress UI
• Mixed UI

COLLEGE OF NURSING
Kegel’s exercises
RATIONALE: PFMEs facilitate continence by increasing strength,
endurance, and contractibility of the pelvic muscles, which
support the bladder neck, contribute to optimal anatomical
positioning of the urethra, and facilitate neuromuscular control
necessary for continence
Men
During the rectal
examination, male patients
are instructed to squeeze
the rectal muscles
Women
Teach PFMEs during the pelvic
examination
Instruct the patient to squeeze
(contract) her vaginal muscles
around the examiner’s gloved
hand
MANAGEMENT OF UI: PELVIC FLOOR MUSCLE EXERCISES
(PFMES) FOR STRESS URINARY INCONTINENCE

COLLEGE OF NURSING
Ideally, each PFME should
consist of a contraction
lasting for 10 seconds,
followed by a relaxation
period of 10 seconds
MANAGEMENT OF UI: PELVIC FLOOR MUSCLE
EXERCIZES (PFMES) FOR STRESS UI
Patient should be instructed to avoid
contracting abdominal, buttocks, or
thigh muscles so as to not increase intra-
abdominal pressure.
While there are variations on the number of
PFME per day required, it is usual
practice to recommend 15 PFMEs three
times per day

COLLEGE OF NURSING
PFMEs may cause neuromuscular changes that promote
a decrease in the autocontractility of the bladder,
thereby inhibiting the urge to urinate
There is evidence that PFMEs decrease incontinent
episodes related to urge UI
(Bradway & Castronovo, 2015)
Available at: http://consultgerirn.org/uploads/File/aprncenter/slidelibrary/APRN-SlideLib_UI.ppt

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Urine stream interruption test (UST)
• is a simple measure of pelvic floor muscle
strength and provides a numerical value to
supplement data collection

COLLEGE OF NURSING
 Patients may need several weeks to note improvement in
bladder control
 Once patients are confident with performing PFMEs they may
benefit from “The Knack”
Women
UST should be under two
seconds in women reporting
significantly fewer UI
episodes
Men
UST is currently being tested
in a male sample
Urine stream interruption test (UST)

COLLEGE OF NURSING
 Occlusive and Pelvic support devices
 Surgical procedures
OTHER MANAGEMENT OF STRESS UI

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Occlusive and Pelvic Support Devices

COLLEGE OF NURSING
Surgery
Surgery is indicated in the
treatment of stress
incontinence, overflow
incontinence secondary to
Anatomical obstruction, and
urge incontinence
secondary to lower urinary
tract pathology. (e.g.
bladder stone, tumor, or
diverticulum).
Augmentation Cystoplasty
• the surgery most often performed for
severe urge incontinence.
• a part of the bowel is added to the bladder
Sacral Nerve Stimulation
• is a newer type of surgery. A small unit is
implanted under your skin
• This sends small electrical pulses to the
sacral nerve (one of the nerves that comes
out at the base of your spine)

COLLEGE OF NURSING
• oxybutynin (Ditropan®)
• tolterodine (Detrol®)
• darifenacin (Enablex®)
• trospium chloride (Sanctura ®),
• solifenacin succinate (Vesicare ®)
Long-acting formulations,
transdermal patch preparations, and
lower dose preparations are available.
MANAGEMENT FOR UI: MEDICATIONS
Available Medications
Anticholinergic
(antimuscarinic)/antispasmodic
• This medications are commonly
prescribed for urge UI and OAB
because they reduce detrusor
overactivity and spasm, and in turn,
decrease urinary urgency, frequency,
and urge UI If prescribed, the nurse
should assess the patient for common
side effects

COLLEGE OF NURSING
ENVIRONMENTAL MANAGEMENT
Environment plays a vital role in managing functional UI
Incontinence
• Individuals are often dependent on adaptive devices
(e.g., walker) or caregivers for assistance with voiding
• Facilitate access to toilets or toileting substitute may
prevent or reduce functional incontinence (urinal,
commode, bedpan)
• Wearing loosely fitting cloths with elastic waistbands
or snap or Velcro fasteners facilitates disrobing for
those patients with manual dexterity problems.

COLLEGE OF NURSING
Strategies specific to manage overflow UI include PFMEs if it is determined
that bladder outlet obstruction is due to persistent contraction of the pelvic
floor muscles
Interventions to manage overflow UI:
1. Crede’s maneuver
2. Timed voiding
3. Double voiding
4. Intermittent urinary catheterization
MANAGEMENT: OVERFLOW UI

COLLEGE OF NURSING
MANAGEMENT: OVERFLOW UI
Crede’s maneuver: Cautiously used and requires manual
compression over the suprapubic area during bladder
emptying
Avoid: If vesicoureteral reflux or overactive sphincter
mechanisms are suspected as the Crede’s maneuver would
dangerously elevate pressure within the bladder
Double Void: Repositioning to void again directly after
the initial void.
For a patient with overflow UI the APRN should evaluate if medications
may be causing urinary retention

COLLEGE OF NURSING
PATIENT EDUCATION: AHRQ UI CLINICAL PRACTICE GUIDELINES
 Majority of patients delay seeking health care for UI because of
inadequate knowledge, embarrassment, feelings that symptoms were
“normal” or advice-seeking from non-health care providers
Continence policies and research
add an important contribution in
understanding what is known about
translating continence guidelines into
practice
United Kingdom
general
practitioners
hospital
services
nurse
Learned UI
from
40.0
28.0
8.0

COLLEGE OF NURSING
Work closely with older adults who fear that unwanted
urine loss results from increased fluid intake
1. Focus education on the adverse consequence of
inadequate fluid intake such as volume depletion, or
potential for dehydration.
2. Emphasize that too little fluid intake causes urine to
become concentrated which in turn, leads to increased
bladder contractions and feelings of urinary urgency
3. To manage and limit nocturia, advise to limit fluid intake
a few hours before bedtime
PATIENT EDUCATION: FLUID INTAKE

COLLEGE OF NURSING
1. Examine and discuss medications contributing to UI
with the prescribing health care provider
2. Determine the necessity of the medication or ideal
scheduling to promote continence
PATIENT EDUCATION: MEDICATIONS

COLLEGE OF NURSING
NURSING IMPLICATIONS/CONSIDERATIONS
1. Teach pelvic floor muscle exercises (DuBeau et al, 2010;
Hodgkinson et al., 2008).
2. Provide toileting assistance and bladder training PRN
(whenever necessary) (DuBois et al., 2010).
3. 3. Consider referral to other team members if
pharmacological or surgical therapies are warranted.

COLLEGE OF NURSING
Overflow UI:
1. Allow sufficient time for voiding.
2. Discuss with interdisciplinary team the need for determining a post-void
residual (PVR) (Newman & Wein, 2009).
3. Instruct patients in double voiding and Crede’s maneuver.
4. If catheterization is necessary, sterile intermittent is preferred over
indwelling catheterization PRN.
5. Initiate referrals to other team members for those patients requiring
pharmacological or surgical intervention.

COLLEGE OF NURSING
Urge UI and OAB:
1. Implement bladder training (retraining) (DuBeau et al., 2010).
2. If patient is cognitively intact and is motivated, provide information on urge
inhibition.
3. Teach PFMEs to be used in conjunction with bladder training, and instruct in urge
inhibition strategies (Rathnayake, 2009)
4. Collaborate with prescribing team members if pharmacologic therapy is
warranted.
5. Initiate referrals for those patients who do not respond to the previous steps.

COLLEGE OF NURSING
Functional UI:
1. Provide individualized, scheduled toileting, timed voiding, or
prompted voiding (Lee et al., 2009).
2. Provide adequate fluid intake.
3. Refer for physical and occupational therapy PRN.
4. Modify environment to maximize independence with
continence (Jirovec et al., 1988).

Pressure Ulcers
Geriatric Syndrome
Perioperative Nurse

PRESSURE ULCERS
COLLEGE OF NURSING
National Pressure Ulcer Advisory Panel (NPUAP) and
European Pressure Ulcer Advisory Panel (EPUAP):
"A pressure ulcer is localized injury to the skin and/or
underlying tissue, usually over a bony prominence, as a result
of pressure, or pressure in combination with shear. A number
of contributing or confounding factors are also associated with
pressure ulcers; the significance of these factors is yet to be
elucidated.“
Also known as DECUBITUS ULCERS
WHAT IS PRESSURE ULCER?

PRESSURE ULCERS
COLLEGE OF NURSING
ETIOLOGY
It is generally accepted that pressure ulcers are causally related
to the effects of 3 tissue forces: pressure, shear, and friction.
 Pressure is a perpendicular force that compresses tissues,
typically between a bony prominence and an external
surface, and can result in decreased tissue perfusion and
ischemia. Tissue necrosis can result when there is unrelieved
pressure or ischemia that is potentiated by compromised
host (eg, chronic medical conditions, protein-energy
malnutrition, or sepsis).

PRESSURE ULCERS
COLLEGE OF NURSING
 Shear is a force parallel to the skin surface. When the
head of the bed is raised or a patient slides downward
in a chair, the body is angulated above the support
surface, causing skeletal muscle and deep fascia to
slide downward with gravity while the skin and
superficial tissues adhere to the chair surface or bed
linens.
This shear force can cause a change in the angle of the
vessels, and thus, compromise blood supply, resulting in
ischemia, cellular death, and tissue necrosis.
ETIOLOGY

PRESSURE ULCERS
COLLEGE OF NURSING
 Friction is the adherent force resisting shearing
movement of the skin, which may result in denuded
areas of the dermis through repeated epidermal
shedding or avulsion of sheets of epidermis.
Prolonged exposure of this tissue injury to
moisture from perspiration, urinary or fecal
incontinence, or wound exudate will further
weaken the intercellular bonds in the
epidermal layers, causing maceration and
epidermal ulceration$
ETIOLOGY

PRESSURE ULCERS
COLLEGE OF NURSING
COMMON PRESSURE ULCERS SITES
Supine:
23% sacro-coccygeal
8% heels
1% occiput; spine
Sitting:
24% ischium
3% elbows
Lateral:
15% trochanter
7% malleolus
6% knee
3% heels

PRESSURE ULCERS
COLLEGE OF NURSING
According to the NPUAP and EPUAP, there are 6 categories of pressure ulcers.
NPUAP refers to these categories as stages and EPUAP refers to them as grades.
Only the numbered categories (I through IV) represent increasing degrees of skin
and tissue damage. Two other categories are qualitative descriptors that do not
necessarily reflect the severity of the ulcer.
The classification system:
• Category I – Nonblanchable erythema
• Category II – Partial-thickness skin loss
• Category III – Full-thickness skin loss
• Category IV – Full-thickness tissue loss
• Suspected Deep Tissue Injury – Depth unknown
• Unstageable – Depth unknown
CLASSIFICATION OF PRESSURE ULCERS

PRESSURE ULCERS
COLLEGE OF NURSING
STAGE I PRESSURE ULCER: NONBLANCHABLE ERYTHEMA
Intact skin with non-blanchable redness of a localized area usually
over a bony prominence. Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding area.

PRESSURE ULCERS
COLLEGE OF NURSING
STAGE II PRESSURE ULCER: PARTIAL-THICKNESS SKIN LOSS
Partial thickness loss of dermis presenting as a shallow open ulcer
with a red pink wound bed, without slough. May also present as
an intact or open/ruptured serum-filled blister.

PRESSURE ULCERS
COLLEGE OF NURSING
STAGE III PRESSURE ULCER: FULL-THICKNESS SKIN LOSS
Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscles are not exposed. Slough may be present but does
not obscure the depth of tissue loss. May include undermining and
tunneling

PRESSURE ULCERS
COLLEGE OF NURSING
STAGE IV PRESSURE ULCER: FULL-THICKNESS TISSUE LOSS
Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound bed.
Often include undermining and tunneling.

PRESSURE ULCERS
COLLEGE OF NURSING
SUSPECTED DEEP TISSUE INJURY (SDTI)
Purple or maroon localized area of discolored intact skin or blood-
filled blister due to damage of underlying soft tissue from pressure
and/or shear. The area may be preceded by tissue that is painful, firm,
mushy, boggy, warmer or cooler as compared to adjacent tissue.

PRESSURE ULCERS
COLLEGE OF NURSING
UN-STAGEABLE PRESSURE ULCER:
FULL-THICKNESS SKIN OR TISSUE LOSS – DEPTH UNKNOWN
Full thickness tissue loss in which the base of the ulcer is covered by
slough (yellow, tan, gray, green or brown) and/or eschar (tan,
brown or black) in the wound bed. Base of the wound cannot be
visualized.

PRESSURE ULCERS
COLLEGE OF NURSING
CAUSATIVE FACTORS FOR THE DEVELOPMENT
OF PRESSURE ULCERS
 Immobility or limited mobility
 Bowel & Bladder Incontinence
 Shearing and friction injuries
 Advanced age
 Malnutrition or debility
 Obesity
 History of pressure ulcers
 Dehydration
 Contractures
 Use of orthotic devises or restraints
 Lack of compliance
 Use of diapers / excess skin moisture
Intrinsic Factor
Nutrition
Aging
Low arteriolar pressure
Low oxygen tension
Extrinsic Factor
Moisture
Friction and Shear

PRESSURE ULCERS
COLLEGE OF NURSING
PRESSURE ULCER PREVENTION / NURSING INTERVENTIONS
 Turn every 2 hours (q2h) Schedule: e.g. alternating positions Right/Back/Left
q2h. May place pillow under one hip at a time if patient cannot tolerate full
turning.
 Maximal Remobilization: Passive range of motion, physical therapist (PT)
consult to plan appropriate measures for patient. Spinal Cord Injury and Disorder
(SCI&D) patients (or any patient with custom chairs) are to sit in their own
wheelchairs and cushions only.
 Protect Heels: Support entire leg with pillows to allow heels to suspend above
the mattress or use heel protectors. Assess heels everyday for signs of pressure.
Consider pressure relieving / distribution bed surface.

PRESSURE ULCERS
COLLEGE OF NURSING
 Manage Moisture: Correct cause, (e.g., diarrhea), reduce or eliminate
incontinent episodes (e.g., bladder training); Use mild soap, rinse, and dry skin
well and apply moisture barrier cream. No diapers while patient in bed.
 Manage Nutrition: Increase protein intake more than 100% RDA, if not
renal or liver impaired. Dietary consult to determine dietary needs and/or
effectiveness of tube feedings.
Reduce Friction and Shear: Use bed trapeze or pull sheet for lifting and
moving patient up in bed. Apply transparent film or hydrocolloid dressing
(Duoderm) over friction areas (e.g., elbows) Keep the head of the bed less
than 30 degrees as often as possible.
PRESSURE ULCER PREVENTION / NURSING INTERVENTIONS

PRESSURE ULCERS
COLLEGE OF NURSING
MANAGEMENT OF STAGE- I
Stage I on Trunk of the Body
 Manage incontinence, keeping area clean and dry.
 Use moisture barrier cream PRN.
 Off load area of pressure ulcer with pressure reducing / distribution
surface and turning and repositioning schedule.
Stage I on Heels
 Ensure that heel(s) are floated at all times with frequent monitoring.

COLLEGE OF NURSING
MANAGEMENT OF STAGE- II
Dry Wound Bed
 Cleanse with normal saline, apply small amount of hydrogel
and cover with non adherent dressing, change every day.
 Off load area of pressure ulcer with pressure reducing /
distribution surfaces and turning and repositioning schedule.
Minimal Drainage
 Cleanse with normal saline, apply hydrocolloid dressing
every three days and PRN soiling or dislodging. Monitor
placement every day.
PRESSURE ULCERS

COLLEGE OF NURSING
MANAGEMENT OF STAGE- III
Minimal Drainage and Clean Wound Bed
 Cleanse with normal saline, apply small amount of hydrogel
and cover with non adherent dressing change every day.
 Off load area of pressure ulcer with pressure relieving /
distribution surface and turning and repositioning schedule.
Presence of Slough with drainage
 Sharp debridement / Enzymatic debridement
 Use Foam or Calcium Alginate dressing for moderate to copious
drainage management.
 Slough 30% or less in the wound, negative pressure wound
therapy is preferred treatment.
PRESSURE ULCERS

COLLEGE OF NURSING
MANAGEMENT OF STAGE- IV
Minimal Drainage and Clean Wound Bed
 Cleanse with normal saline, apply hydrogel and cover with
non adherent dressing change every day.
 Off load area of pressure ulcer with pressure relieving
surface and turning and repositioning schedule.
Presence of Slough with drainage
 Sharp debridement / Enzymatic debridement
 Use Foam or Calcium Alginate dressing for moderate to
copious drainage management.
 Slough 30% or less in the wound, negative pressure wound
therapy is preferred treatment.
 Tunneling and undermining shall be filled appropriately.
PRESSURE ULCERS

COLLEGE OF NURSING
MANAGEMENT OF SUSPECTED DEEP TISSUE INJURY
 Cleanse with normal saline, apply foam dressing
change every day.
 Off load area of pressure ulcer with pressure
relieving / distribution surface and turning and
repositioning schedule.
 Use Foam dressing for drainage management.
 Castor oil / Balsam / Peru / Trypsin spray is the
preferred treatment.
PRESSURE ULCERS

COLLEGE OF NURSING
MANAGEMENT OF UN-STAGEABLE PRESSURE ULCERS
 Cleanse with normal saline, apply hydrogel and cover with
non adherent dressing change every day.
 Off load area of pressure ulcer with pressure relieving /
distribution surface and turning and repositioning schedule.
 Use Foam dressing for drainage management.
 Castor oil / Balsam / Peru / Trypsin spray is the preferred
treatment for wounds with Intact eschar.
 Sharp or enzymatic debridement for the management of
slough.
PRESSURE ULCERS

COLLEGE OF NURSING
NEGATIVE PRESSURE WOUND THERAPY (V.A.C.(R) THERAPY
This negative pressure wound therapy consists of a specialized open cell
foam dressing, evacuation tubing, a fluid-collection canister, and a vacuum
therapy pump with adjustable settings and continuous feedback
technology. The foam dressing is cut to conform to the specific size and
shape of the wound and is then placed into the wound cavity. The
evacuation tube is either inserted into or attached to the foam dressing so
that it exits parallel to the skin and the wound site. The foam dressing is
then covered with a thin adhesive film to create an airtight seal. This
converts the previously open wound to a controlled closed system. After
the wound is sealed, the proximal end of the evacuation tube is attached to
an effluent collecting canister, and the canister is connected to the
adjustable vacuum pump. Depending on the nature of the wound, the
pump can deliver either continuous or intermittent subatmospheric
pressures ranging from -50 to -200 mm Hg. This negative pressure is
transmitted uniformly through the open cell foam dressing to all wound
surfaces.
PRESSURE ULCERS

COLLEGE OF NURSING
NEGATIVE PRESSURE WOUND THERAPY (V.A.C.(R) THERAPY
1. removing tissue fluids and
chronic wound exudate
2. reducing infectious materials
3. assisting in the formation of
granulation tissue.
Application of topical negative
pressure has been shown to help
promote wound healing by
PRESSURE ULCERS

COLLEGE OF NURSING
Patient and wound assessment
Assessing risk factors and establishing that a patient is at risk
should be part of the initial assessment for any patient who is
entering the health care system. Incorporating this
assessment into a comprehensive examination ensures that
systemic factors compromising wound healing are promptly
identified. Following global evaluation of the patient, attention
is then focused on the pressure ulcer itself, and a detailed
wound evaluation is accomplished. Once the patient and the
wound have been completely assessed, the practitioner must
initiate a plan of care to address the factors placing the
patient at risk, the systemic factors compromising host
healing, and the advanced wound care efforts to be initiated.
Nursing Implications
PRESSURE ULCERS

COLLEGE OF NURSING
Risk Assessment
Preventing pressure ulcers or inhibiting progression of an
existing ulcer is greatly facilitated by the use of a practical,
validated risk assessment instrument that enables the
practitioner to objectively evaluate a patient's level of risk.
The guideline on pressure ulcer
prevention from the Agency for
Health Care Policy and Research
(AHCPR; now the Agency for
Healthcare Research and Quality
PRESSURE ULCERS

COLLEGE OF NURSING
PRESSURE ULCERS
 Wounds are very painful, thus causing patients a great deal of suffering.
 The anatomical location of the ulcer may result in a loss of dignity.
 Quality of life is affected, as the patient must alter activities to help heal the wound
and may face long-term hospitalization.
 A nonhealing ulcer is at high risk for infection, which can be life threatening.
 Ulcer treatments may require surgical procedures such as debridement, colostomies,
and amputations, which the patient would otherwise not have to face.
 An ulcer that heals forms scar tissue, which lacks the strength of the original tissue
and is more easily ulcerated again and again.

Feeding Problems
Geriatric Syndrome
Perioperative Nurse

FEEDING PROBLEMS
COLLEGE OF NURSING
DEFINITIONS
•Feeding: The concept of feeding is defined as, "the process of
getting the food from the plate to the mouth. It is a primitive
sense without concern for social niceties"( Katz, Downs, Cash, &
Grotz, 1970, p. 22).
•Eating: Feeding is differentiated from eating, which is defined
as "the ability to transfer food from plate to stomach through the
mouth"(Siebens et al., 1986, p. 193).
•Feeding behavior: an environmental and contextual approach
to examining the interaction between the person being fed and
the caregiver, as well their separate actions (Amella & DiMaria,
2001).

FEEDING PROBLEMS
COLLEGE OF NURSING

FEEDING PROBLEMS
COLLEGE OF NURSING
Nutritional Screening Initiative (NSI)

FEEDING PROBLEMS
COLLEGE OF NURSING
FACTORS LEADING TO DECREASED NUTRITION IN THE ELDERLY
Physical Obstacles to Eating
• difficulty in holding and using utensils or in conveying food from plate to mouth
• decreased ability to chew and swallow
• decreased appetite
• decreased awareness of hunger and thirst
Arthritis
When arthritis occurs in the hands, an
inability to manipulate utensils—due to
swelling and decreased joint function
as well as pain and inflammation—can
affect the ability to pick up or cut food
or use a cup.
Stroke
Stroke can lead to paralysis; weakness
and changes in muscle tone, usually on
one side of the body; and difficulty
chewing, manipulating food in the
mouth, and swallowing.

FEEDING PROBLEMS
COLLEGE OF NURSING
Physical Obstacles to Eating
DENTITION PROBLEMS
Missing or painful teeth and ill-fitting
or uncomfortable dentures may make
chewing difficult or impossible.
SMELL AND TASTE PROBLEMS
Diminishes as a natural consequence of
aging, which can decrease interest in
and appreciation of food

FEEDING PROBLEMS
COLLEGE OF NURSING
Apraxia is the inability to perform
physical actions despite having
intact physical ability.
APRAXIA
Amnesia can lead people to forget to
eat altogether; to forget that they have
just eaten, leading them to eat again;
or to think they have eaten when they
haven’t, causing them to skip the next
meal.
AMNESIA
Cognitive/Perceptual Obstacles to Eating

FEEDING PROBLEMS
COLLEGE OF NURSING
Executive functioning is necessary for
self-regulation and awareness. A
deficit in this area can lead people to
exhibit unsafe behavior or behavior
that is socially inappropriate, such as
taking food from other people’s
plates or not regulating the amount
of food they are eating.
EXECUTIVE FUNCTIONING
Agnosia is the inability to interpret sensory
information despite having intact senses.
Those with agnosia may not react to smells
and taste with an increased appetite,
decreasing the likelihood that they
experience hunger. In addition, they might
eat dangerous, non-food items. They may
not recognize the feeling of thirst and may
become dehydrated.
AGNOSIA
Cognitive/Perceptual Obstacles to Eating

FEEDING PROBLEMS
COLLEGE OF NURSING
POTENTIAL UNDERLYING CAUSE OR RISK INTERVENTIONS

FEEDING PROBLEMS
COLLEGE OF NURSING
ADAPTIVE EQUIPMENT
Some of the equipment includes:
• Non-slip materials; the use of foam handles or large, molded handles
that slip over regular utensils; or a universal cuff to increase the
client’s ability to grip and/or for joint protection
• Rubber-coated spoons for people who have a tendency to bite down
on utensils
• Plates with a built-up edge for scooping against and plate guards to
prevent food from being pushed off the edge
• Rocker knives or roller knives, similar to pizza cutters, which require
less strength and coordination to cut with than standard knives

FEEDING PROBLEMS
COLLEGE OF NURSING
ADAPTIVE EQUIPMENT
Some of the equipment includes:
• Divided plates to keep food separate on plates and prevent it from moving
around too much
• Two-handled mugs
• Cups with a cut-out near the top or an integral straw so that the client can
drink without tilting the head back (to prevent aspiration), for those with
tremors who have a difficult time sipping, or for those who have only a
sucking reflex
• Suction cups or non-slip mats to keep cups, bowls, and plates in place

FEEDING PROBLEMS
COLLEGE OF NURSING
Nursing Implications to Caring
A. Environment
1. Dining or patient room: encourage older adult to eat in dining room to increase
intake, personalize dining room, no treatments or other activities occurring during
meals, no distractions.
2. Tableware: use of standard dinnerware (e.g., china, glasses, cup and saucer,
flatware, tablecloth, napkin) versus disposable tableware and bibs
3. Furniture: older adult seated in stable arm chair; table-appropriate height versus
eating in wheelchair or in bed.
4. Noise level: environmental noise from music, caregivers, and television is minimal;
personal conversation between patient and caregiver is encouraged.

FEEDING PROBLEMS
COLLEGE OF NURSING
A. Environment
5. Music: pleasant, preferred by patient.
6. Light: adequate and nonglare-producing versus dark, shadowy, or glaring.
7. Contrasting background/foreground: use contrasting background and foreground
colors with minimal design to aid persons with decreased vision.
8. Odor: food prepared in area adjacent to or in dining area to stimulate appetite.
9. Adaptive equipment: available, appropriate, and clean; caregivers and/or older adult
knowledgeable in use; occupational therapist assists in evaluation.

FEEDING PROBLEMS
COLLEGE OF NURSING
B. Caregiver/Staffing
1. Provide an adequate number of well-trained staff.
2. Deliver an individualized approach to meals including choice of food,
tempo of assistance.
3. Position of caregiver relative to elder: eye contact; seating so caregiver
faces elder patient in same plane.
4. Cueing: caregiver cues elder whenever possible with words or gestures.
5. Self-feeding: encouragement to self-feed with multiple methods versus
assisted feeding to minimize time.
6. Mealtime rounds: interdisciplinary team to examine multifaceted process
of meal service, environment, and individual preferences.

REFERENCES
COLLEGE OF NURSING
Amella EJ, DiMaria RA (2001). Feeding behavior. In GL Maddox, RC Atchley, JG Evans,
RB Hudson, RA Kane, EJ Masoro, MD Mezey, LW Poon, IC Siegler (eds.).The
Encyclopedia of Aging (3rd ed.) (pp. 389 - 391). New York: Springer
American College of Obstetricians and Gynecologists. Urinary incontinence in
women. Obstet Gynecol. Jun 2005;105(6):1533-45
Bernstein M & Luggen AS. (2010). Nutrition for the older adult. Sudbury, MA: Jones
and Bartlett.
Berrut, G., Favreau, A. M., Dizo, E., Tharreau, B., Poupin, C., & Gueringuili, M.
(2002). Estimation of calorie and protein intake in aged patients: Validation of a
method based on meal portions consumed. Journals of Gerontology: Medical
Science, 57(1), M52–M56. Evidence Level III: Quasi-experimental Study.
Bottomley J. (2010). Geriatric rehabilitation: a textbook for the physical therapy
assistant. Thorofare, NJ: SLACK.
DeVere R & Calvert M. (2011). Navigating smell and taste disorders. St. Paul, MN:
AAN Enterprises.

REFERENCES
COLLEGE OF NURSING
Groher, M. E. (1997). Dysphagia: Diagnosis and Management (3rd ed.). Boston:
Butterworth-Heinemann.
JF Schnelle, PA Cruise, A. Rahman. Developing rehabilitative behavioral interventions
for long-term care: technology transfer, acceptance, and maintenance issues. J Am
Geriatr Soc, 46 (1998), pp. 771–778
Katz S, Downs TD, Cash HR, Grotz RC. (1970). Progress in the development of the
Index of ADL. The Gerontologist, 10, 22.
Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in the development
of the Index of ADL. The Gerontologist, 10(1), 20–30. Evidence Level IV: Quasi-
experimental Study.
Myers, B.A. (2004). Wound Management: Principles and Practice. Prentice Hall:
Upper Saddle River, New Jersey, 37-45, 369-391
Nakasato Y. (2011). Geriatric rheumatology. New York: Springer.
National Pressure Ulcer Advisory Panel (NPUAP)

REFERENCES
COLLEGE OF NURSING
Nazir T, Khan Z, Barber HR. Urinary incontinence. Clin Obstet Gynecol. Dec
1996;39(4):906-11
Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J Med. Mar
6 2008;358(10):1029-36
Siebens H, Trupe E, Siebens A, Cook F, Anshen S, Hanauer R, Oster G. (1986).
Correlates and consequences of eating dependency in institutionalized
elderly.Journal of the American Geriatric Society, 34,193.
Watson, R. (1996). The Mokken Scaling Procedure (MSP) applied to the measurement
of feeding difficulty in elderly people with dementia. International Journal of
Nursing Studies, 33, 385–393. Evidence Level III: Quasi-experimental Study.
Wilson, M.M. (2007). Assessment of appetite and weight loss syndromes in nursing
home residents. Missouri Medicine, 104(1), 46-51. Evidence Level VI.
www.npuap.org.

FEEDING PROBLEMS
COLLEGE OF NURSING
Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in the development
of the Index of ADL. The Gerontologist, 10(1), 20–30. Evidence Level IV: Quasi-
experimental Study.
Wilson, M.M. (2007). Assessment of appetite and weight loss syndromes in nursing
home residents. Missouri Medicine, 104(1), 46-51. Evidence Level VI.
Groher, M. E. (1997). Dysphagia: Diagnosis and Management (3rd ed.). Boston:
Butterworth-Heinemann.
Watson, R. (1996). The Mokken Scaling Procedure (MSP) applied to the measurement
of feeding difficulty in elderly people with dementia. International Journal of Nursing
Studies, 33, 385–393. Evidence Level III: Quasi-experimental Study.
Berrut, G., Favreau, A. M., Dizo, E., Tharreau, B., Poupin, C., & Gueringuili, M. (2002).
Estimation of calorie and protein intake in aged patients: Validation of a method based
on meal portions consumed. Journals of Gerontology: Medical Science, 57(1), M52–
M56. Evidence Level III: Quasi-experimental Study.
References

FEEDING PROBLEMS
COLLEGE OF NURSING
Amella EJ, DiMaria RA (2001). Feeding behavior. In GL Maddox,
RC Atchley, JG Evans, RB Hudson, RA Kane, EJ Masoro, MD Mezey,
LW Poon, IC Siegler (eds.).The Encyclopedia of Aging (3rd ed.)
(pp. 389 - 391). New York: Springer
Katz S, Downs TD, Cash HR, Grotz RC. (1970). Progress in the
development of the Index of ADL. The Gerontologist, 10, 22.
Siebens H, Trupe E, Siebens A, Cook F, Anshen S, Hanauer R,
Oster G. (1986). Correlates and consequences of eating
dependency in institutionalized elderly.Journal of the American
Geriatric Society, 34,193.
References

COLLEGE OF NURSING
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Geriatric Syndrome

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