Aging: Common Problems and Care I:

Skin, Nails, Muscles, Bones and Respiration

 

4 Inservice or Class Hours

 

Objectives:

 

At the end of this class, you should be able to:

 

1. Discuss common problems of the skin, nails, muscles, bones, and respiration.
2. Detail ways that you can prevent these problems and care for the aging person with these problems.

 

Introduction

 

There are more aging people in the United States than everybefore. Many people say it is the “Graying of America”. We have learned a lot about these people and their needs in the last few years. Many old people are young in body and mind. All old people are not all the same. They are different. They all have different needs.

 

This class will teach you about some of the common problems and care that are NOT a normal part of aging. To learn about the normal changes, take our class called “Aging: What It Is and What It is NOT”.

 

You will learn about problems of the:

 

·         Skin

·         Nails

·         Bones

·         Muscles and

·         Respiratory System

 

Skin and Nails

 

The skin becomes more thin, dry, pale, fragile, rough, less elastic and with less sweat glands and fat as the person gets older. The older person may get these problems as a result of these changes.

 

·         Skin tears (thin and fragile skin)

·         Skin breakdown and pressure ulcers. The skin is thin, dry,fragile and has less cushion as the person ages.

·         Skin cancer and sun burns. The pale and fragile skin makes the person prone to sunburns and skin cancer.

·         Rashes and infections, like contact allergies with some soaps and shingles.

·         Less able to cope with heat and cold. The person may get too cold because they have less fat tissue. The person may also get too hot because they have less “cooling off” sweat glands.

 

Skin Care

 

Dry skin care.

 

Dry skin is one of the most common skin problems with old people. Dry skin can lead to burning, itches and cracked skin. Scratching the skin can lead to a bad infection. Skin lotions and mild soaps should be used. Also, the person does not always need a daily bath or shower.

 

Skin tears and other skin breakdown

 

Skin breakdown and pressure ulcers are a very serious problem. The older person must not be gripped during a transfer. This can lead to a skin tear. Pressure ulcers are very painful and costly. People on bed rest are most at risk.

 

Other risks for the older person are:

 

·         Lack of mobility. Pressure ulcers occur when people are not up and walking. They form when a person stays in the bed, a  chair or a wheelchair for a long time. Blood is cut off to areas where bones are close to the skin when a person stays in a chair or in a bed for a long time. The weight of the body pushes against a bony area and cuts off the blood and oxygen to that area. The sacrum, elbows, ears, shoulders, toes and heels are some of these bony areas that can break down when a person is kept in one position for a long period of time.

• Poor diet. Patients and residents with a poor diet are at risk for pressure ulcers. The skin and other tissue, as well as the rest of the body, does not get the food and nutrition it needs to be healthy and without injury if the diet is not good. Patients who are not to eat or drink safely do not get a good diet. A feeding tube may be used.
• Moisture. Residents and patients who are wet are at risk for pressure ulcers. Patients who are incontinent of urine or stool, those that sweat a lot. and those that have draining wounds are at risk for pressure ulcers. Moisture makes the skin soft. This softness leads to skin breaks.
• Mental problems. When a person is confused, very sleepy, or in a coma, they may not turn like other alert patients do even when they are sleeping. People that do not have a normal sense of pain and the physical ability to turn will remain in one position for a very long time unless someone else turns them. If a patient stays in one position for a long time, they will get a pressure ulcer.
• Friction . Friction occurs when a patient or resident is pulled up in bed or in the chair. These forces can make the skin irritated. They can cause the skin to break and develop a pressure ulcer.
• Wrinkled sheets or hard objects. Uneven pressure is created when sheets are wrinkled. This leads to pressure ulcers. Objects such as spoons, tissue boxes, eye glasses, food crumbs, hair pins and other hard objects that are left in the bed or sitting chair also cause pressure and pressure ulcers.

Ways that a nursing assistant can prevent pressure ulcers:

• Provide good skin care. Use mild soap and gentle strokes with a soft washcloth when giving a bath to a resident or patient. Rinse the skin well and then pat it dry with a soft towel. Use a bland lotion to help dry skin. Lotion helps to keep the skin healthy and soft. No NOT use alcohol or alcohol base lotions on skin. Alcohol dries the skin. Look at areas where skin touches skin, such as under the breasts. If these areas are moist, place a light dusting of corn starch to help keep this area dry.
• Keep the skin clean and dry. Immediately remove all wet or dirty linens, briefs and clothing. Do not let the patient remain wet or dirty with urine, feces or other fluids, including water or tea. Wash, rinse and dry all wet and dirty skin as your read above.
• Turn and position patients at least every 2 hours. Patients and residents who stay in bed, the chair or wheelchair must be moved and re-positioned at least every 2 hours. Many patients have to be turned and positioned even more often if they are at risk for pressure ulcers. Make the time to move your patients. It takes much more time to treat a pressure ulcer than it takes to turn a patient.
• Observe and report the condition of the skin. Look at and observe the patient's skin for signs of whiteness (blanching), redness, heat, tearing or breaks.
• Encourage mobility. Encourage your patients to walk about and move if it okay with their MD. Walking and moving about increases blood flow.
• Provide for toileting needs. Anticipate the patient's need to use the commode or bathroom. Follow the patient's bowel and bladder training program if it is ordered. Patients that are wet with urine or soiled with feces are at risk for getting a pressure ulcer.
• Encourage and provide nutrition and fluids. Encourage the person to eat good foods and lots of fluids. Every time you are with a patient, ask them if they would like a drink of water or juice. Make meal times happy and pleasant. Encourage the patient to eat their whole meal. If they are not eating, offer them another choice of food. Report and record all food and fluid intake.
• Use pressure reducing cushions, mattresses, beds, booties, elbow pads, etc. These items lower pressure when patients stay in the bed or chair for long periods of time.
• Do NOT elevate the head of the bed more than 30 degrees, unless ordered. If the bed is higher than this, it will cause friction, shearing and the need to pull the patient up in the bed more often than necessary.
• Do NOT allow a patient to remain on a bedpan for a long period of time. Remaining on a bedpan also creates pressure, a force that leads to pressure ulcers.
• Use a lifting device like a Hoyer Lift or a lifting sheet to move or lift a patient. Do NOT drag a person's body along bed sheets. Lifting devices and lifting sheets lower friction and shear. They also prevent patient and staff injury.

To learn more about pressure ulcers, take our class called “Preventing Pressure Ulcers”.

 

Skin cancer and sun burns

 

Sun burns and skin cancer are a problem among old people because their skin is pale and fragile. Also, skin cancer is more common when the person has spent a lot of time in the sun when they were young. Some of the risks that can lead to skin cancer are:

 

·         Fair skin

·         Red or blonde hair

·         Light color eyes

·         Moles, freckles and birth marks

 

The nursing assistant should:

 

·         Observe the person’s skin. Report any skin area that looks different, larger, darker or has blood.

·         Keep the patient safe in sunlight. The person should wear tight weave clothes, long sleeves and a big hat to protect the skin.

·         Stay out of the sun from 11 in the morning to 3 in the afternoon when the sun rays are strong.

·         Have the person wear sunglasses to protect the eyes.

·         Use sunscreen of 15 or more SPF. Put it on the person ½ hour before going into the sum. Put more on if the person becomes wet from swimming or sweating. Cover all skin areas with it.

 

Rashes and infections

 

Most rashes are from allergic contact with some substances, some drugs, and infections, rather than dry skin. If the person gets a rash from a certain kind of soap, another milder soap (body and laundry soap) should be used. The person’s skin should be observed carefully, especially if the person is getting a new drug. Any rash should be reported right away.

Some of the skin infections that are seen among the older group are scabies (mites) and shingles.

Shingles are very common in older people. About ½ of old people will get shingles by the time they are 80 years of age. it is most common in 60 to 80-year-old people. People who have had chickenpox get shingles. One in every 5 people who have had chickenpox gets shingles. The virus stays in the body for life, so at times, it will come out as shingles. The body’s immune system gets weaker as the person gets older. This also puts the person at risk.

The person may have a burning, itching, or tingling feeling on the back, chest,  waist, face or eye area. Some may feel weak in the early stages. A red rash may come in 48 to 72 hours. Blisters that look like chickenpox appear.

Since 2006,we have a vaccine to prevent shingles in people over 60 years old. and older, even if they have already had it. This gives the person’s immune system so the person will not get it, or they will not get it again.

The nursing assistant should, again, observe the person’s skin and report anything that is not normal. A rash is not normal. Also, you must give good hygiene, including good bathing, and keeping the person’s nails clean and short so the person does not scratch any skin areas. This can lead to a bad skin infection.

Less coping with heat and cold

 

The person may get too cold because they have less fat tissue. The person may also get too hot because they have less “cooling off” sweat glands. Other things that affect the person’s coping with heat and cold are diabetes, thyroid problems, dehydration, infection, and some drugs.

 

Heat is produced by activity, high metabolism and shivering. Heat is lost by low metabolism, a lack of activity and sweating.

Hypothermia is defined as a drop in the core body temperature below 95 degrees. It can be mild or severe. The signs are:

·         Confusion

·         Being tired

·         Hostility

·         Slow pulse

·         Slow breathing

·         Cool or cold skin

·         Pale skin

·         Stiff muscles

·         Tremors

·         Poor coordination and balance

·         Slow movements

·         Blue lips, fingers and/or toes

 

The nursing assistant can prevent this with these things:

 

·         Make sure that the person is dressed in clothes that are warm.

·         Keep the person well hydrated.

·         Observe the person and report any signs of this.

 

Hyperthermia is often called heat stroke. It happens when the core body termperature of the person gets too high (101 degrees or more when the person does not have a fever) as a result of a lot of exercise, some drugs, aging, and/or being in a hot area or room.

 

Some of the signs are:

 

·         Hot skin

·         Dry skin

·         Red skin

·         Low blood pressure

·         Dizziness

·         Confusion

·         Increased heart rate

·         Increased breathing

 

Plenty of fluids, little exercise and a limited time in the heat are the best ways to prevent this. The nursing assistant must know their patients. Some patients are more apt to get this thanothers.The person who is affected by the heat should be moved to a cooler environment as soon as they show signs and it must be reported. Cooling soaks and drinking water often help.

 

Nail Care and Foot Care

 

The nails become thick and more brittle as the person gets older. The skin around the nails gets thin and more fragile. This could cause problems. The person can get a foot infection.

Some of the things that the nursing assistant can do for the older patient are below.

The feet and toes should be washed and dried during every bath and kept clean. Leaving the area between the toes wet can lead to soft skin that could break down. It is also important use a good skin lotion on the feet but NOT between the toes. This will soften the area and make it more prone to sores.

Special foot care is also done.

• Sit the person in a chair if it is possible. If the person is on bed rest, foot care can be done by flexing the person's leg and then doing this special care
• Fill a wash basin with water at about 110 degrees
• Put a towel under the basin
• Place the person's feet in the basin to soak them for about 10 minutes
• Clean under the nails with a nail care stick

Our clients also need their nails looked at every day. Nails should be clean, short and smooth. Dirty fingernails spread infection. Jagged fingernails can cause injury. Nail care is done best when the person is sitting in a chair. If the person is not able to sit in a chair, it can be done in the bed.

Some hospitals, home care agencies, nursing homes and assisted living facilities do not let nursing assistants cut the toenails, so check your policy. Do NOT, however, cut the toenails of anyone that has diabetes or bad circulation to the feet.

Again, before you do any procedures, including nail care, you must wash your hands, put on gloves, introduce yourself to the client, explain what you are about to do, identify the patient and maintain privacy, standard precautions, caring, respect, comfort and safety throughout the task.

The steps for cutting finger and toe nails is below:

• Fill a wash basin with water at about 110 degrees
• Put a towel under the basin
• Put the person's hands or feet in the basin to soak them for about 10 minutes
• Trim the nails using a clipper
• File the edges with a nail file so that they are smooth
• Dry the hands or feet
• Apply lotion to the hands and feet but NOT the areas between the toes.

The nursing assistant must closely observe the hands, feet and nails during this care. Any thing that is NOT normal must be reported.

You must report and document any of these signs because they are not normal:

• Blue or pale nail beds
• Broken nails
• Cut skin
• Bleeding
• Corns or bunions
• Excess dryness
• Any sores

Bones

 

As the body ages, the bones:

 

·         lose calcium.

·         get weak, thin, brittle and weak. .

·         of the spine get smaller so some will have a curve in the spine and lose a couple of inches in their height.

·         joints become less flexible and less mobile.

 

Many people get broken bones and fractures because of these changes. Joint movement may become less because the ends of the bones and joints may break down. People can lose about 2 inches of their height when the discs of the spine become smaller. The can also lead to a curve in the spine.

 

The most common problems of the bones are:

 

·        Osteoporosis

·        Osteoarthritis

·        Rheumatoid arthritis

·        Gout

·        Bursitis

Osteoporosis is a disease that thins and weakens the bones to the point that they become fragile and break easily. During our life, the body breaks down old bone and replaces it with new bone. More bone is broken down and less replaced as the person gets older. The person may not know they have it until they break a bone with a small bump or fall.

In addition to age, these things place a person at risk:

·         Gender. Women have it more than men because they tend to have smaller bones and they have hormone changes with their “change of life”.

·         Ethnicity. Caucasian and Asian people are at greatest risk followed by African-American and Hispanic people.

·         Family. It tends to run in families.

·         History of Previous Fracture. People who have had a fracture after the age of 50 are at high risk of having another.

You CANNOT change the above risks.

Some of the risk factors that you CAN change are:

·         Diet. Getting too little calcium and vitamin D increases the risk. 

·         Some diseases like uncontrolled diabetes.

·         Lack of exercise.

·         Long periods of immobility.

·         Too much sugar and/or red meat in the diet.

·         Cigarette smoking.

·         Coffee and alcohol use.

The nursing assistant should do these things to prevent and slow down this problem:

·         Provide the person with a good healthy diet.

·         Make sure the person gets enough calcium and vitamin D.

·         Provide the person with regular, daily, exercise.

·         Encourage the person to walk and get out of bed, if they can.

·         Prevent falls because a fall can lead to serious breaks and injuries.

Preventing Falls

Patients can fall for a number of reasons. Falls can lead to great injury and even death. Some of the things that make people fall are:

• Age. Older people fall more than young people.
• Poor vision. People who cannot see well can trip over things they cannot see.
• Confusion. People who are confused may not see dangers. They may try to stand up when their muscle are too weak to hold their body up; they may fall down stairs thinking that someone is calling them and they may try to walk to the bathroom in a dark room that has a lot of clutter without calling the nurse or nursing assistant for help.
• Some drugs. Many patients and residents fall because they are taking a drug that makes them sleepy or dizzy. Other patients may fall from drugs that lower blood pressure when they stand.
• Poor balance, coordination, gait and range of motion (ROM). A person will fall when they can't keep their balance. Many older patients and those that have had a stroke have poor balance. They may walk in a way that is not natural, that is, they have poor gait and coordination. They will also fall when their muscles are not able to flex and extend in a normal way.
• Weak muscles. People that have weak muscles or damaged nerves will fall if help, safety and good patient care are not given. Weak muscles are a very big problem when the legs are weak.
• Jerky muscles. Patients and residents with shaky or jerky muscles are at risk for falls.
• Some diseases. A person can be weak and dizzy if they have a heart problem or a head or nervous system problem, like a seizure. Also, arthritis, a disease of the bones, can make the bone joints stiff and not able to hold the body in a safe and correct position when a person walks. A person with a stroke or another disease, like Parkinson's disease, is at risk for falls.
• Slow reaction time. Older people do not react or respond to dangers as fast as young people. For example, an old person may fall when they can not stop fast enough to avoid a puddle on the floor or an old person may not be able to stop their car when the light turns red and they are driving a car.
• Poor control of the body and its functions. Patients that can not hold their urine or feces until they get to the bathroom may slip on their own urine or stool.
• An unsafe area. Patient rooms that have clutter, poor light or have no nurse call bell are not safe. They can make a person fall or trip. Glare also adds to falls.
• Patient foot wear. Shoes and slippers that are NOT skid proof are a danger. All patients must have sturdy, skid proof shoes or slippers that fit well.
• No answers to calls for help. Calls for help must be answered right away. A nursing assistant or nurse must go to the patient room right away when a patient calls for help and/or turns on their nurse call bell. This is VERY important if the person is at risk for falls. If that call bell is not answered and a patient falls while going to the bathroom,who is wrong? The patient or the nursing staff member?
• Broken equipment. If a cane, walker, wheelchair or wheelchair brake is broken it can make a person fall. Do NOT use anything that is broken. Report ALL broken equipment to the nurse.
• Past falls. Patients and residents that have had a fall in the past are at risk for future falls. Patients and residents with more than one fall in the past are at very great risk for future falls
• Fear of falling. Patients and residents will tense and tighten their muscles and be stiff if they have a fear of falling. This fear of falling can lead to a fall and injury.
  
  

Nursing assistants and other people that work in homes, hospitals and nursing homes can prevent falls. That is good news. Preventing falls is a team effort. All people that take care of patients and residents must make sure that their patients and residents are safe. They must make sure that no patient or resident falls. EVERY patient and resident must be safe.

 

Nurses and other people that work in homes, hospitals and nursing homes, like the doctor and the physical therapist, must assess a resident or patient for falls. They have to find out if the patient or resident is at risk for falls. They must find out if a new patient or resident that comes to the hospital or nursing home is at risk for falls. They ask, "Can this person fall? What things can lead to a fall? What can we do to make sure that this patient or resident does not fall? What special things can we do to make sure that this person does NOT fall?" The things that we can do to make sure that a person does not fall should be written in the person's plan of care. Nursing assistants will do many of these special care things that are in the plan of care. Nursing assistants have a very important role with falls.

 

Nurses and other people that work in homes, hospitals and nursing homes, like the doctor and the physical therapist, must again assess a patient or resident when they or their medications have changed. For example, a person has changed when they are alert on Monday morning and they are confused on Tuesday. This patient's condition has changed. This change must be reported to the nurse so that the patient or resident can be assessed again for risk for falls. They may now be at risk for falls when they were not at risk for falls on Monday. Special care must also be done to prevent falls if the patient or resident has a condition change.

 

Patients and residents must also be assessed at least every three months even if their condition has not changed. This extra check is to make sure that very little patient changes do NOT add up to a risk for falls. Little changes can often add up to big danger. A person that you have taken care of for 4 years may change slowly to the point where they, too, are now in danger of falling.

 

Special things must start as soon as any patient or resident is assessed as fall risk. Many hospitals and nursing homes have a Falls Risk Program. These special things must be done to save patients and residents from a fall. Nursing assistants MUST know and follow this program.

 

Other hospitals may make nurses and nursing assistants move the patient's bed and/or room closer to the nursing station or they make sure that all of these patients have a bed and/or chair alarm.

 

Other special fall risk care items that should be in the care plan for fall risk patients and residents, as needed, are:

 

·         Low beds

·         More frequent patient monitoring and observation

·         Using protective, gym type, mats on the floor next to the bed to lower the risk and extent of injury if a patient falls in spite of all efforts

·         Balance, gait, muscle and/or range of motion exercises and training

·         Assistive devices, such as canes, walkers and Merry Walkers

·         High toilet seats

·         Non skid socks and foot wear

 

All patients and residents, even if they are not identified as high risk for falls, need very close attention to their safety needs.

All patients must have a safe room and patient care area that is:

• Well lit and with no glare
• Kept clean, dry and uncluttered
• Skid proof and dry
• Equipped with handrails and grab bars, especially in the bathrooms and in areas where patients walk, like the hallways
• Filled with stable and sturdy chairs at a good height and with armrests to assist the patient or resident with standing
• Free of wires, cords and other tripping hazards
• Free of side rails and restraints

All patients must also have:

• Their need for independence and freedom balanced with their safety needs
• Frequent monitoring and observation to prevent falls
• Sturdy, non skid shoes and footwear
• A workable nurse call bell that is always within reach and that is promptly answered
• Instruction about changing position slowly and being alert to safety risks
• Their bed at the lowest possible level
• Toileting, fluid and food needs anticipated for and promptly met

Many elderly patients and residents also need:

• A bedside commode nearby so they can safely use it
• Adequate and easy to reach assistive devices, such as walkers or canes. If the patient needs assistance with these devices, nurses and nursing assistants must give them the help they need.
• Ramps to safely enter and leave a building without using stairs. In the home, wheelchair lifts are sometimes used if the person lives in a two-story house.
• Properly fitting eyeglasses that are easily reached or provided to them by the nursing assistant or nurse

Most falls can be predicted and prevented. Nursing assistants play a very important role in the prevention of falls. If a patient is at risk for falls, all preventive measures must be done and documented, as required by your facility.

 

Some of the other things that you can do to prevent falls and patient injury are listed below.

• Keep nurse call bells within the reach of the patient at all times
• Look for call bell lights and answer them promptly even if the patient is not assigned to you
• As you walk down a hall turn your head back and forth viewing all patients and their rooms so you identify safety hazards and patient behaviors
• Listen for calls of help, banging, falling objects, etc.
• Listen for bed and chair alarms
• Know your patients
• Closely observe and monitor your patients
• Know which patients on your unit are at risk for falls
• Know about the ways that falls have been successfully prevented for each of your patients
• Anticipate and meet your patients' needs
• Document and report your observations and your interventions
• Clean up small non-hazardous spills immediately or block off the area immediately if you are waiting for someone to clean up a large spill
• Keep all bed gatches in the retracted position
• Remove all clutter from patient rooms and care areas
• Tell the patient and family members about safety measures to prevent falls in your facility
• Keep minimal distance between frequent points of contact. For example, keep the distance from the bed to the commode or bathroom or the chair to the bed to the least possible.
• Provide frequent toileting, according to the patient's bowel and bladder pattern, if identified
• Report patient falls immediately
• Report any changes in the patient or resident condition
• Get help from another member of the team to transfer and lift patients, whenever necessary in order to prevent patient injury and injury to yourself.
• Make patient safety and falls prevention your priority
• Encourage others to make safety and falls prevention their priority
• Be a team member. Preventing falls is everyone's job.

 

Take our class called “Preventing Falls” to learn more about falls risk and preventing falls.

Osteoarthritis 

Osteoporosis is the most commonly seen form of arthritis among the old people. The lining of the joints wears out and get rough.

Some have no signs of it. Others may have:

 

·         pain in the bones, particularly the back and chest;

·         joint pain that can get worse with exercise or as the day moves on;

·         stiffness after a period of immobility, such as sleep; and

·         pain with range of motion.

Some of the things that can happen as a result of this disorder are:

• fractures;
• deformities;
• trouble walking and moving; and
• spinal damage.

This problem can be prevented and slowed down with the same kinds of things that are done for osteoporosis, as described above.

Rheumatoid Arthritis

Rheumatoid arthritis leads to the painful swelling of the small joints of the body. It begins later in life from about 30 to 50 years of age. More women than men get it.

Some of the signs are:

• a low grade fever,
• fatigue,
• weight loss, 
• loss of appetite,
• joint pain,
• loss of joint function, and
• deformed joints.

There is no cure for this problem because its cause is not known, but there are things that you can do for your patient to lower the pain and keep good joint function. 

These things are:

• Rest. Regular rest and sleep are needed.
• Nutrition. A good diet is needed.
• Exercise. Active exercise and range of motion should be done when the person is not in pain. Passive range of motion, to the point of pain, should be done when the person’s is having an episode of great pain.

Gout

People get gout in earlier years, but it, like rheumatoid arthritis, continues to come and go through life into older years. The cause of gout is not known. The person with it has high uric acid in their body. More men than women get it. The big toe is the joint that most often has it.

Some of the signs are:

• acute pain;
• redness;
• swelling;
• tenderness;
• warm, shiny skin over the joint;
• tense purple or red skin; 
• fast pulse;
• chills;
• fever; and
• less joint movement.

The person can get chronic arthritis and permanent loss of joint movement if bouts are not prevented and treated.

 The nursing assistant should provide the person with these things:

• Good diet. The person should eat a good diet and lots of water.
• NO purine foods (gland food like liver and kidney).
• NO alcohol.

Muscles

 

As a person gets old, the muscles:

 

·         Have less tone.

·         Have less mass as fat builds up in the body.

·         Are less strong.

 

The most common problems of the muscles are:

 

·         Muscle weakness and loss of tone as well as mass; and

·         Increased fat as muscle mass gets lower.

 

Regular exercise is very important in order to maintain and improve muscle function. It also helps other body functions, like digestion, mood, getting around, balance and over all well being. It is also fun and it helps people to stay independent. Some people with chronic problems, like diabetes, heart problems, high blood pressure and arthritis, can improve with exercise. When a person does a stretch, it helps them stay flexible. Exercise to the top of the body helps people do things like carry things and open jars. Lower body exercise helps the person walk well, help balance and climb stairs. All people including the old person should do regular, daily exercise if the MD says that it is okay.

Range of Motion

The nursing assistant should help the person to do range of motion exercise so the person can move their muscles and joints completely. This is very important after a long period of bed rest, or immobility, and after the person has a disorder, like a stroke, that affects range of motion. Pain and the lack of movement happen when a joint does not have normal range of motion.

There are three (3) kinds of range of motion exercise. They are:

• Active Range of Motion. Active range of motion is used when the patient or resident is able to do full range of motion to one or more parts of their body without the physical help of another. Nursing assistants and other members of the healthcare team may simply have to remind the person to do these exercises and to watch the person to make sure that they are doing these exercises in the right way.
• Active Assistive Range of Motion. This range of motion is used when a patient or resident needs some help doing full range of motion to one or more parts of the body because their muscles are too weak or stiff to do these exercises on their own. For example, a person that is physically weak or cannot move a weak limb after a stroke needs active assistive range of motion. The nursing assistant and other members of the team will have to help this person with their range of motion.
• Passive Range of Motion. This range of motion is used for patients and residents who cannot move one or more parts of their body need it to all joints without any help from the patient or resident.

Active assistive and passive range of motion exercises are done in a gentle, slow way so you do not hurt or harm the joints and bones. If the person gets pain, stop. These exercises are NOT done to the point of pain. They should also NOT be done to an area that has an untreated fracture.

 

Muscle Strengthening

 

These exercises are used for patients and residents of all ages. For the older person, the goal of these exercises may be to get the person strong enough to perform some basic activities of daily living, such as combing one’s hair.

For the younger person, the goal of these exercises may be to restore weak muscles to their full strength. For example, a baseball pitcher may need muscle strengthening exercises after they have had an injury to their arm so that they can return to the game. Muscle strengthening exercises are sometimes done with weights.

 

General Conditioning

 

These are most often used after a long period of bed rest and immobility in order to:

• increase the function of the heart and lungs,
• to maintain range of motion and
• to increase muscle strength.

Nursing assistants and other members of the team often help and/or remind the patient or resident to perform these exercises.

 

Coordination and Balance

 

 

 

Theses exercises are mostly used for patients and residents that need help

to use their hands properly or to walk with good balance and gait. For example, a person that has had a stroke may need these exercises in order for them to be able to pick up a spoon and place it in their mouth. Or, they may need them to be able to walk in a balanced and safe manner after a stroke.

 

Transfers

 

Many people get physical therapy in order for them to be able to transfer safely from the bed to the chair, from the bed or chair to the commode or from a sitting to a standing position. When a person is not able to do these transfers they must depend on others for help.

 

 

The goal of this exercise to help the person move about in a safe way without the help of others. Many people who have had a stroke or a bone fracture need it.

 

Ambulation

 

Some people can bear weight on both legs. Others can not. When a person is not able to bear full and strong weight on both legs, they may need a cane, a walker, a chair with a high seat and/or a self lifting chair for some transfers.

 

This exercise is a form of therapy for many patients and residents. A young person may need it after they have had surgery. An older person may need it  after a long illness and bed rest.

 

The purpose is to help the patient or resident to walk safely without the help of another person. Some use some sort of device, such as a cane, crutches or a walker. The goal for the older person may be to take short and safe steps to the bathroom or around their own home. The goal for a younger person may be to walk the same way they did before they had their illness, accident or surgery.

 

It is often necessary for the patient or resident to have range of motion, balance, and muscle strengthening and/or coordination exercises before ambulation exercises can be started. At times a splint or brace may also be needed. Many people also practice with parallel bars, like the ones above, and/or a gait or ambulation belt.

 

 

Once the person is able to walk safely on a flat and level surface, they may then practice how to walk up and down stairs using a handrail. When a person walks up the stairs they should put their good leg up on the stair and then bring up the weak one.

 

Respiratory System

 

Some of the common problems are:

 

·         COPD

·         Lung cancer

·         Flu

·         Pneumonia

·         TB

COPD

COPD stands for chronic obstructive pulmonary disease. This disease affects the air flow into and out of the lungs. It gets worse as time goes on. About 14 to 16 million people in the United States have COPD.

COPD is very serious and a major cause of death. People with COPD may have:

• a constant cough,
• shortness of breath,
• trouble breathing which is sometimes very severe,
• wheezing,
• weight loss,
• blood in sputum,
• cyanosis,
• swelling of the feet and ankles, and
• abnormal breath sounds.

People that smoke are at great risk for COPD. Other risk factors include:

• second hand smoke,
• air pollution,
• poor indoor ventilation, and
• old age.

COPD is treated with a number of medicines, including those that dilate the lungs and keep the respiratory secretions thin so that they can be coughed up.

Other treatments that the nursing assistant will help with are:

• a good diet,
• plenty of fluids,
• oxygen, and
• deep breathing exercises.

Oxygen

Compressed oxygen is stored under pressure in a large cylinder that has a regulator to control the flow rate. The gas comes out only when a person inhales. The flow is cut off when the person exhales.

The liquid form of oxygen is used mostly with people who are in their home and active. It is made by cooling the oxygen gas until it turns into a liquid. This form is held in smaller tanks than compressed oxygen. A large amount of oxygen in a small container allows the person to carry it around when they leave their home.

The concentrated form of oxygen is made from room air with an electrical device. This form of oxygen is NOT portable. It costs less than other forms. In the event of a power failure, the person must use another form since electricity is necessary to make this form of oxygen.

Some of the oxygen supplies that are used are:

• a flow meter
• tubing
• masks
• a nasal cannula and
• a humidifier.

The flow meter is used to make sure that the person gets the right amount of oxygen. For example, it may be set at 2 liters per minute. The tubing  is used to move the oxygen from the tank to the person's nose or trach. Masks are used to move the oxygen from the tubing to the person’s nose. They are most often used when the person needs a large amount of oxygen. Nasalcannulas have 2 small prongs that deliver the oxygen into the nose without the need for a mask to cover the person's entire face. Tuck some gauze under the nasal cannula tubing to prevent the cheeks or the skin behind the ears from becoming sore.

 

Masks and nasal cannulas should be changed at least every 2 to 4 weeks. The tubing should be changed at least every month. If the patient has a cold or flu, change the tubing and mask often.

Oxygen must be used safely. Some of the safety rules that you must follow are:

1. Keep all electrical things at least three to four feet from any water (sink, tub, shower). 
2. Do NOT use if the wire is broken.
3. Do NOT use an extension cord.
4. Use a three prong grounded outlet.
5. Never smoke when oxygen is being used.
6. Tell visitors not to smoke.
7. Put up no-smoking signs in the home.
8. Keep oxygen at least five feet away from candles, gas stoves, fireplaces, and other heat.
9. Do NOT use things like cleaning fluids, paint thinners, or aerosol spray cans near the oxygen.
10. Make sure that all oxygen cylinders are stored in a safe way so that they will NOT tip over or fall.
11. Keep liquid oxygen upright so that it does not pour out and cause skin damage.
12. Keep a fire extinguisher close by and let the local fire department know that oxygen is being used in a home.

Lung Cancer

Lung cancer is one of the most deadly forms of cancer in the United States. It is more common in men than in women. It is found most often among people from 55 to 65, the older person.

 

The risk factors are:

 

• Smoking;
• Second hand smoke;
• Poor air;
• Asbestos and
• Other things used in industry, like radon.

 

The signs of it are:

 

• Coughing
• Chest pain
• Blood in the sputum
• Short of breath
• Having pneumonia or bronchitis many times
• Loss of appetite
• Weight loss
• Being tired
• No signs at all

 

Nursing assistants, and others in health care, can help prevent it by:

 

• encouraging the person to stop smoking;
• keeping the person away from pollution, second hand smoke, asbestos and other substances.

 

Lung cancer is treated with surgery, radiation and drugs. Pain, a poor appetite, nausea and vomiting may be issues with this people. 

 

The nursing assistant should:

 

• provide the person with a good diet and fluids;
• make the person as comfortable as possible; and
• observe the person’s coughing, chest pain and blood in the sputum. Report anything that is NOT normal.

 

Flu

 

The flu is a virus that is spread from one person to another thru the air, especially when they live with other people in places like group homes, assisted living, nursing homes, prisons and hospitals. It is a big problem among older people and those with other lung problems because it can lead to severe problems and death.

 

The signs of it are:

 

• Coughing
• Chills
• Fever
• Sore throat

 

Nursing assistants, and others in health care, can help prevent it by:

 

• encouraging the person to get a flu shot every year, and
• keeping patients away from those with the flu.

 

When the person has the flu, the nursing assistant should:

 

• provide the person with a good diet and fluids;
• observe the person’s coughing, chest pain and blood in the sputum. Report anything that is NOT normal;  and
• give the person as much comfort as they can.

 

 

Pneumonia

Pneumonia is a very serious infection of the lungs. The lungs give the body oxygen. The lungs take in air from outside of the body and then they fill our blood with oxygen so that it can then be carried to every part of our body. This oxygen is needed to keep all our body parts and us alive.

Pneumonia takes the needed oxygen from our body. The amount of oxygen that our body needs to live cannot be carried when the lungs fill with a liquid, pus and an infection like pneumonia. The human body and all of the body’s cells do not work in the correct way when enough oxygen is not being sent to all the body parts. When this disease is serious enough, it may very greatly lower the amount of oxygen in the body, thus leading to death.

In the past, pneumonia used to be the number one cause of death in the United States. This changed when antibiotics were developed. These new drugs controlled the disease when they first came on the market. They continue to control the disease and save many lives but it still has not gone away completely. Some people are now getting pneumonia that will not be attacked by medicines. Some pneumonia strains resist medicine.

Pneumonia and the flu are still very serious. They are the 7th leading cause of death in the United States, according to the American Lung Association.

A person of any age can get pneumonia, but it is seen most often in older adults. It is a very serious problem for this age group. The elderly are the most seriously harmed age group when pneumonia strikes. It is the number one leading infection among the elderly and it is the 4th leading cause of death in this age group.

It is very often the cause of death for older adults and people who are younger after they have had a serious illness or something like a broken hip that keeps them in bed for a long period of time. This disease often happens when a person is not mobile and out of bed. Nursing assistants can help prevent pneumonia by encouraging a person to get out of bed and to stay as mobile as possible, in addition to other things, like having the person take deep breaths and cough, by providing fluids, a good diet and using proper infection control procedures.

As many as ¼ of our residents in long term care facilities (nursing homes) get pneumonia. That means that about 25 out of 100 get this very serious disease. It is also very common for patients and residents who have had serious surgery, like chest or abdominal surgery, those on a ventilator, or breathing machine, and those who are getting a tube feeding.

Pneumonia can affect only a section of one lung or it can affect areas of both lungs. It is caused by over 30 different causes. Most cases, however, result from a bacteria, a virus, chemicals and other things like a fungus.

People with serious diseases and with many diseases are more prone to pneumonia. Older adults over 65 years of age and those that live in a close living arrangement, like a nursing home, hospital or prison, are also at risk.

This disease is also found most often among people who have:

• taken many antibiotics,
• a tube in their throat to help them to breathe,
• smoked cigarettes,
• heart disease,
• lung disease,
• diabetes,
• kidney disorders,
• anemia (sickle cell),
• not been getting a good diet, and/or
• had major surgery.

The signs of pneumonia are:

• cough,
• fever,
• lots of mucous and sputum
  
• a fast respiratory rate,
• a fast pulse,
• confusion and delirium, especially with the elderly.

The patient’s doctor will order a chest x-ray to look at the lungs and to find out if and how much they are affected by this disorder.

 

 

The person will also have blood work done and a laboratory sputum culture.

 

When you obtain a sputum culture, you must:

• Have the person breathe deeply and cough up mucus. A sputum culture should not have saliva from the mouth. It should contain mucus from the lungs.
• Keep the sputum specimen sterile.
• Label the specimen and make sure that it gets to the lab right away and without delay.

 

 

Most young people will get better pretty quickly in their own home without having to go to the hospital. A healthy, young person may be able to lead a normal life and go back to work or school in about a week after they begin to get treatment.

 

For older people and for some kinds of pneumonia, however, it may take weeks until the person feels strong and well enough to lead a normal life. Some of these people, especially if they are older, may need some home care services from a nurse and nursing assistant while they are sick with pneumonia. Other people, like those that have been sick for a long time and older people, may have to go to the hospital. Still others may die from it.

 

People get better very quickly when they:

• see their doctor and get treatment right away,
• have good natural defenses against infection,
• are well nourished,
• healthy, and
• have NO other diseases.

 

The treatment of pneumonia includes:

 

·         Drugs to kill the germs that are causing the disease when it is caused by a bacteria or some viruses

·         Rest

·         Fluids

 

• a good diet,
• lung care (pulmonary hygiene) to clear the lungs and mucus, and
• oxygen for some people in the hospital or nursing home.

When a person takes medicine for this disease, they must take it according to the doctor’s order. They should not stop taking it even when they are feeling better or when their temperature is normal unless their doctor has told them that it is time to stop taking it. The patient may get a second, worse case of pneumonia if the person stops the medication before the doctor tells them to.

 

It can be prevented by:

• staying healthy,
• getting enough rest,
• eating a good diet,
• going to the doctor and getting treatment for any respiratory infection or problem,
• getting the pneumonia shot when the doctor advises it and
• getting the flu shot, especially if one is elderly or has a disease of the lungs, heart, etc.

 

Getting the pneumonia shot can prevent one common type of pneumonia. Not all people get this shot. People who are at risk for getting this disease and those 65 years or over should get this shot. Some people who should get this shot are those with:

• lung disease, such as COPD,
• heart disease,
• kidney disease,
• sickle cell anemia,
• diabetes, or
• other serious illnesses.

Doctors also tell people that are living in a nursing home or another long term care place, such as an assisted living facility and group place, to get the shot. This shot may protect the healthy, older person for the rest of their life. For other people, such as those who have diabetes, kidney disease, heart or lung disease, they may have to get the shot every 6 to 10 years.

 

Pneumonia often follows a respiratory infection, including a flu. One way that people can prevent pneumonia is to stay healthy and to go to doctor as soon as they have respiratory or breathing problem. Finally, another way that people can avoid getting pneumonia is to get a flu shot every year in the fall of each year. Many people who get the flu then progress to pneumonia. For these people, this shot can help to prevent pneumonia.

 

TB

 

TB can affect people of all ages, but there are some normal changes of aging that place many old people at risk for it. Some of these things are:

 

·         Malnutrition

·         Weak immune system

·         Group living conditions

·         Poor sanitation

·         Other diseases like diabetes

 

The signs of it are:

 

·         Coughing

·         Fever

·         Night sweats

·         Chest pain

·         Loss of appetite

·         Weight loss

 

The nursing assistant can help prevent, and care for the person with TB by encouraging the patient to eat a good balanced diet, report any cough, and to maintain good hygiene and clean living conditions. People will get drugs to treat TB if the person is tested for TB and they have it. They take them for a long period of time.

 

Nursing assistants must observe all of their patients about their breathing, especially older people. They must immediately report anything that is not normal.

 

 

References

 

National Institute on Aging, U.S. National Library of Medicine
National Institutes of Health, and U.S. Department of Health & Human Services. (2011). NIH: Senior Health.http://nihseniorhealth.gov/

US Administration on Aging. (2010). A Profile of Older Americans: 2010.

http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2010/2.aspx

 

Word, Gloria Hoffmann. (2008). Basic Geriatric Nursing. Mosby, Inc.

 

Copyright © 2011 Alene Burke