ATTENDANCE LEVELS

 INTRODUCTION.

The care of the adults that before was a familiar obligation, at present, has happened to be competition of very different social estates. This happened cause the changes that has produced in the family unity and the changes in our profesional lyfe style that is more and more exhausting.

By the other hand, the aged that live more years, represents a great group in our population that has his own and specifics needs that the modern society have to attend.

From the sanitary point of view, the residences of majors and the geriatrical hospitals among others, are those that already comprise significant of our social surroundings and, in this evolution, they are become jumbled so much average physicists as sanitary personal. In my opinión, in all these nevels in the aged care the nurse has an inportant function.

NURSERY ACTIVITIES IN HOSPITABLE ATTENTION.

The objective is to carry out a progressive care of the old patient from the acute phase of the disease to securing the greater degree of independence.

1.- General hospital and Geriatrical Hospital.

At present in Spain, the hospitals specialized in geriatrical attention are few, in the majority of the times the services of geriatrics or the geriatrical units are integrated in the general hospitals. As much in a case as in the other, the nursing activities are the following:

            -To receive and to accompany to old and the familiar ones. To teach to them to the norms and the operation of the different services.

            -Initial valuation of the old patient processing the history of infirmary based on the model of Virginia Henderson and applying the scales of geriatrical valuation.

            -To apply well-taken care of of infirmary during the entrance of the patient.

            -To fulfill the facultative prescriptions and to supervise the activities of the auxiliary personnel of its unit.

            -To take responsibility of the organization of the rooms and plants and the other general services for a suitable operation of the center.

            -To try that it is provided to them to the old ones entered a comfortable atmosphere, clean and safe.

            -To guard the medical histories at any moment taking care of the update and exactitude of the data written down in these documents.

2.- Day Geriatrical Hospital.

The day Geriatrical Hospitals are diurnal centers of operation, whose purpose is to guarantee the clinical stability of the old ones and to apply rehabilitating processing directed to the recovery of the activities of the daily life.

There are assistan services between the Hospital and the aged home.

The type of subsidiary patient of this modality of hospitalization is old with neurological pathologies (Parkinson, Alzheimer), cerebrovascular accidents, bony fractures, rheumatisms, …

Activities of nursing in the day Geriatrical Hospital:

            -Integral Valuation of the patient.

            -Taken care of of the corporal hygiene and feeding.

            -Drug control and you rule therapeutic

-Control and taken care of of the surgical wounds and ulcerations.

            - Sanitary education to patients and relatives.

3.- Hospitalization at home.

This modality of hospitalization must like objective guarantee the continuity of the attendance by means of Primary the Hospital-Attention coordination.

Activities of nursing in the Domiciliary Hospitable Attention:

            -Sanitary education that enables to the old one and/or to the family to assume the precocious possible self medication and to obtain a greater autonomy and a smaller dependency of the sanitary personal.

            -To identify signs and symptoms of risk.

            -To value the conditions of the address: accessibility, security and general cleaning, etc. Sometimes will be necessary to adapt the surroundings to the sanitary needs.

            -To support psychological to the old one and the family.

            - Communication with other services: social assistants, services of aid at home.

PAE.

PAE. Characteristics:

1.- VALORATION.

2.- DIAGNOSIS.

3.- PLANIFICATION.

4.- EJECUTION.

5.- EVALUATION.

It is necessary to consider that a geriatrical patient has different pathologies and characteristics that the other patients. Diverse pathologies, chronic enfermerdades, different needs that the patients from other ages.

The nurse must have all this in account, at the time of realising of PAE destined to geriatrical patients. The interview, observation and physical examination will have to go related to the geriatrical syndromes.

It is fundamental that the nurse, realises one complete valuation, exploration and anamnesis of the patient, as well as of his surroundings.

URINARY INCONTINENCE.

Urinary incontinence is any involuntary loss of urine that originates a hygienic and/or psycho-social problem and that can be demonstrated objectively.

The nurse will have to know and to know how to explain the exercises of kegel as one first form of processing in incontinence. The processing will have to be individualized.

It is important that the nurse verifies that they have understood since they become, he realises a demonstration and he asks the patient who repeats it.

Exercises of involution of the pelvic ground of Kegel, they constitute the processing of forward edge in the boarding of the effort incontinence slight-you moderate, but also they can be useful in the processing of the hyperactive bladder and in the processing of the IU after a dical prostatectomía ra- or a trasuretral prostate resection (RPTU).

It consists of contracting vigorous mind the pubococcígeos muscles without using muscles of the abdomen or glutei. It is important to teach to the patient how to do or during a digital inspection.

It is considered that most effective is to realise of 40 to 80 contractions per day with 5 rest s after each contraction to allow the reoxigenación of the muscle.

Also one is due to teach to the patient how to tighten its pelvic ground before coughing or raising weights. The minimum duration required to secure benefits is of 15-20 weeks.

FALLS.

A fall is a precipitation to the ground, sudden, involuntary and nonawaited, with or without secondary injury, confirmed by the patient or a witness.

By their frequency, consequences and complications, constitute in case single a geriatrical syndrome of great importance.

           

The nurse will have to value the different advice and changes to realise in the home and the routines of the aged one.

I think that this has an important paper in the falls, since she is the one that can influence in the prevention of these. It must be very observant to detect all the possible causes and to know how to explain it so that old or the their caretakers understand the changes that are due to do.

She will have to recommend in:

-Postural recommendation: To rise in two times.

-Medication: To reduce hipotensivos doses, drugs and review interaction between medicaments.

-Sedatives: to diminish dose. Not to mix with alcohol. To advise nonpharmacological

measures.

-If there are muscular problems: training in transferences and march, exercises, learning of the correct use of technical assistance for the march

-Modifications of the surroundings: illumination. To avoid obstacles, to eliminate carpets, to avoid slippery grounds, to avoid electrical cables in zones of transit, telephone surround or tele-help, positioning of objects to medium altitude, to place railings, use of footwear and suitable clothes…

AGING THEORIES.

All of we, have an idea about what is became an ancient. However, define what is the aging is not easy.

In general, the majority of specialists define the aging like all the physics, metabolic, mental and functional processings that take place along the time that supose the reduction of adaptation capacity and more dificulty for our mean internal maintenance. This process is continous and inevitable so that, in the end the death arrives.

This chages are named "physiological aging", which there are to add the chages that cause the different styles from life, the environment and the suffered diseases, that is to say the "patological aging". This last one is different for each individual and each device and system. It gives the "biological os functional age us", in contrast with the "chronological age". All we know people who represent an age different from hers, sometimes less, sometimes more young people.

To age is not a disease, but an inseparable change of the life.

There are several aging theories but we have wanted to speak about the free radicals theory.

The definition of this theory is: "Accumulated cellular damage produced by the exhibition to free radicals, highly toxic substances that are generated like products collaterals of the aerobic life".

It was postulated for the first time by Harman in 1950.

The free radicals suppose a cellular and consequently tissue damage, affecting to the yield of the devices. Damage at DNA level will taje place, with the consequent worsening concerning production of proteins and injures in membrane lipids altering the fluidity and in this way making difficult to a good comunication intra and cellular inter. We will as much have therefore a damage at structutal levels as functional of the cells (signals of molecule growth, apoptosis, neurotransmition,...)

It implies a worsening of the organism to respond to stress and to maintain the homeostasis (to respond before oxidating stress, thermal shock, radiations,etc)

GLOBAL AGING VALUE.

An important part of the global geriatrical valuation is the valuation of the functional sphere. In this two concepts are valued: Activities of Daily Living and Instrumental Activities of Daily Living.

ACTIVITIES OF DAILY LIVING. (ADL).

Routine activities that people tend to do everyday without needing assistance. There are six basic
ADLs : eating, bathing, dressing, toileting, walking and continence. An single ´s ability to perform ADLs is important for determining what type of long-term care and coverage the individual needs.

Theres several scales for value the ADL, most used: Katz and Barthel Index.

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL).

Instrumental Activities of Daily Living refer to a series of life functions necessary for maintaning a person´s inmediate environment. They include managing money, shopping, telephone use, travel in community, housekeeping, preparing meals and taking medications correctly. It measures and elderly or mentally handicapped or terminally ill person´s ability to live independently. Increasing inability to perform IADLs may result in need for care facility placement.

The scale more used for instruments of daily living is Lawton and Brody index.

In primary attention, the nurse has an important paper in the valuation of the aged one. She will have to know the different scales and the different sections from these, to be able to realise in an adress if it is precise.

The nurse will have to be able of:

-To value the importance of the functionally and autonomy for the greater adult.

-To identify the scales for the functional evaluation of the adults.

-To evaluate the functionally of the adults majors using appropiate sclaes to measure the activities of the daily life, the instrumental activities of the daily life and, to evaluate the march and the balance.

-To design strategies to improve or to maintain the functional state of the elderly people.

HEALTH EDUCATION IN GERIATRIC PATIENTS

The preservation of health and functional independence are the most important aspects of health promotion in older adults.

There are some risk factors that may go associated with other problems or be the trigger of the disease that we have to bear in mind at home as well as in the health center. These factors may be organic (because of the disease), environmental (architectural barriers, inactivity) or relational (loneliness).

The objectives we must follow in the prevention of geriatric patients are mainly to keep their functional independence, to improve their quality of life, To reduce mortality and to increase life expectancy, providing individual attention to the old man and his environment.

To achieve these objectives, we are going to incide on a series of parametres to promote health.

•   Blood pressure control at least once a year both supine and in standing.

•    Lipid control every five years in asymptomatic patients to prevent dyslipidemia.

•   Annual EGC over 75 years to prevent arrhythmias to decrease the risk of stroke.

•   prolonged.

•   Annual fasting glucose to prevent diabetes melitus especially in patients with a family history of obesity, hypertension or glucose intolerance.

•   Annual review of the mental state by Pfeiffer or MEC tests to prevent cognitive decline and to apply preventive measures as soon as possible if necessary.

•   Mood annual review to prevent depressions and to initiate early treatment.

•   TSH control every five years to prevent hypothyroidism, especially in women.

•   Control of vitamin B12 every five years to prevent pernicious anemia, responsible of many irreversible neurological lesions.

•   Annual monitoring of fecal occult blood to prevent colon cancer, making screening in patients from  75 to 80 years ( patients with good health).

•   Mammography every 1-2 years to prevent breast cancer untill 70 years if life expectancy is from five to ten years.

•   Pap smear every three years to prevent cervical cancer, interrupting the controls at age of 65 in explored women without having been ever positive, and in no explored women after two exams without alterations within one year.

•   DRE and PSA testing for prostate cancer prevention.

•   Annual audiometric study to prevent hearing loss and fitting a hearing aid as soon as possible.

•   Study to prevent presvicia yearly eye, cataracts, glaucoma, diabetic retinopathy and macular degeneration, and to perform necessary preventive treatments.

AUXILIARY ELEMENTS FOR THE MOBILIZATION.

The nurse will have to teach to the old patient the correct form of use of the auxiliary organizational elements for the mobilization: cane, walker and crutch.

A correct use, would improve the quality of life of anciano.y its capacity of mobilization. Also the power consumption would improve doing an suitable use of these elements.

With the cane:

-To be placed the cane in the hand opposed to the affected extremity, to extend the support base and to reduce the voltage on the extremity.

-To advance with the cane at the same time as it forwards moves the affected leg.

-To be placed the cane sufficiently near the body to avoid the inclination.

-To lean on the cane when the affected extremity does not initiate the phase of balance.

With the walker:

-To lean in the bed or a chair to rise, never to lean in the walker to put itself still on.

-To take the walker by the handles to obtain major stability.

-To raise the walker placing it against if while it pushes its body slightly forwards.

-To walk with the walker, being supported the weight of the body in the hands when advancing with the weak leg but.

-To balance by itself on the feet.

-To raise the walker and to return it to place to the front.

-To watch at the front while it walks.

  

          

With the crutches:

- It should have the size and length adapted for its weight and charts. It to place the crutches stuck to the body from the feet, when taking them with the hands the shoulders do not have to rise nor to lower, is , it is called anatomical position.

-Advice:

-To use a footwear with nonskid, comfortable and closed sole.

 -To use comfortable clothes that allow freedom him of movements.

 -To watch at the front and to stay raised.

 -To forwards place the crutches next to each foot and a little.

  If he can support feet both:

  -Being standing up it must have three supports of     the four possible ones.

           -Left crutch>>>>Right foot.

           -Right crutch>>>Left foot.

  -In order to walk it must advance both crutches to the same height.

  -To advance to a foot and the other soon.

   If he only can support one:

  -Being stopped it must have three supports of the four possible ones, and drop the weight of the body on the healthy extremity.

                   -Left crutch.

                   -Right foot.

                   -Right crutch.

                   -Left foot.

  -In order to walk it must advance the first crutches and the affected extremity.

  -Next, letting fall the weight of the body on the crutches, advance with the healthy extremity

THE INTEGUMENTARY SYSTEM.

The deep effects of the aging on the skin are not demonstrated until the end of the fifth decade of the life.

The majority of these changes takes place in the dermis.

Pictures. Thinner and fragile skin. The thickness of the dermis falls in a 20%. The skin becomes almost translucent and provides less protection against the invasive organisms.

Another changes that take place are that the skin heals worse and are more susceptible to the development of diseases like cancer most leather, itching and ulcers.

*The nurse have to watch and to control the skin of the old patient. Realising the necessary valuations.

The sebaceous glands diminish their size: greater incidence of insolations in old.

*To get a suitable hydration. To maintain a suitable temperature.

The reduction of collagen production. It produces that the skin is less flexible implying greater susceptibility to the tear injuries.

*Valuation of the skin.

The reduction of the function of the gland sudorípara, contributes to the dryness of a skin, that is broken.

*To hydrate skin. These injuries can become vestibules of entrance of bacteria and cause to cutaneous injuries majors.

GERIATRICAL SYNDROME.

Syndrome: defined like “a group of signs and symptoms that appear together and characterize in particular to an anomaly”.

The geriatrical syndromes talk about to multi-factor, own conditions of health of the old patient, that happen when the effects of the accumulation of deteriorations, in multiple systems, return to a vulnerable person against physiological or physiopathological demands.

                       

Geriatrical syndromes of greater prevalence exist, are the great calls geriatrical syndromes, these are urinary Incontinence, falls, Immobility and the mental deterioration. Others exist like; sensorial deprivation, constipation, pressure ulcers, insomnia, depression, social isolation, malnutrition, hypothermia and fainting.

So that, a cause can derive in several geriatrical syndromes, and the other way around, several causes can cause one or more syndromes.

The nurse will have an important paper as far as the prevention and precocious detection of the possible syndromes.

Also of the pursuit of these syndromes to manage a greater rehabilitation and one to improve its quality of life.

ALZHEIMER.

The Alzheimer is a demential disease that takes a loss of intellectual capacity.

The symptoms, that appear generally in adults of 65 years, can include losses in the abilities of the language, like difficulty in the spoken expression, problems in the abstract thought, capacity of judgment, disorientation in the time and space, upheavals of conduct and personality.

The general result is a reduction of the personal activities and in the performance of the work. The fact that the people who suffer Alzheimer face daily to this disease have an important effect on the quality of life of the people who suffer it and in the life of their familiar since, although some patients with Alzheimer live in geriatrical, the majority are taken care of by their familiar.

As the patients are become less independent, she falls a greater responsibility on the figure of the caretaker/assistant that it is exposed as well to a high risk of physical and psychological diseases being able to accelerate the internment of the patients in geriatrical institutions.

By all these reasons, fodder that is a fundamental necessity, to enable to the personnel of infirmary in this area to be able to do against this terrible situation which every day old ones face our and logically all.

                           

PALLIATIVE CARE

In my last practice rotation I was fortunate to work in a team that I didn’t know: the ESAD (Equipment Homecare Support). It is an important element to provide palliative home care.

The WHO defines palliative care as the active, total care of patients whose disease is not responsive to curative treatment.

The way to deal with family and patients is very different from the Primary Care. The psychological aspects, the  necessary empathy and the way in which we transmit knowledge have a degree of complexity that I hadn’t faced before.

In this team I learned:

·      To make independent valuation of immobilized patients. They use many scales for the complete evaluation of patients:

o   For functional status: Barthel, Karnofsky and ECOG.

o   For cognitive status: Pfeiffer.

They value sociodemographic, clinical variables, ethical –clinical dilemas, assessment of the symptoms severity...

·      To provide advice and information to the caregiver. To give psychological, social and spiritual support.

·      Subcutaneous way handling. Knowing hoy to explain to the family their proper use.

·      The treatment of cancer pain and other symptoms.

·      Nutritional assessment and monitoring in immobilized patients.

·      Dressings uses and cures of skin lesions.

It's a team that plays a very important role: to get a good quality of life to the patient during the terminal phase and very a very important support to the family at this critical moment.

CONSTIPATION IN THE ELDERLY AND LAXATIVES.

Constipation is considered one of the most common health problems in the elderly.

As a measure to solve the problem, they tend to abuse of laxatives because they are the fastest way.

As future nurses, we must leave laxatives as the last option, trying to change the elder’s  life habits:

• ·      Diet, including a higher intake of fiber substances.
• ·      Increasing water intake to 1.5 l per day.
• ·      Increasing exercise and mobility.
• ·      Checking the drugs they take and can cause constipation: opiates, anticholinergics, antiacids, NSAIDs, antihistamines, calcium, iron salts, calcium supplements...
• ·      Encouraging bowel habit as routin.

Laxatives must  be used for a limited time as they may cause patient’s tolerance or colon irritation.

The nurse plays a key role in patient education and in monitoring their evolution.

PRESSURE ULCERS

Pressure ulcers are avoidable in 95% of cases. A nurse has an important function in preventing them and in their correct treatment.

Many years ago I was at a nursing home in a small town and I saw for the first time a pressure ulcer in a patient. What I was surprised of, apart from the size of it, covering the entire back, was how the nurse was spreading honey all over the ulcer to heal it.

In our practice as future nurses we see the use of techniques that are not correct because they are not based on scientific evidence.

I’m going to make a reflection on the mistakes we that tend to make when we don’t follow the scientific evidence.

The most usual mistakes in prevention:

• Not using the Norton scale à You must use the Norton scale for assessing the risk of pressure ulcers.
• Applying alcohol on the skin àYou must not apply it, because it produces dryness.
• Massaging red areas and bony prominences à Don’t do it.  AGHO should be applied in areas exposed to friction, pressure or shear.
• Not to do postural changes à postural changes must be scheduled, programmed and individualized and wehave to teach the patient or caregiver to do them.
•   Raise the bed 30 ° à It must not be done.
•  Use floats as a seating surfaces à Don’t do it, because pressure is concentrated on the body area in contact with the float and produces a compressive effect.
• Bandages on the heels à foam heels are more effective than padded bandages.
• Carelessness on the sterility of productsàWe must maintain sterilit.

Most common mistakes in treatment:

• Changes on treatment before 8-10 days à We must keep it a minimum of 8-10 days to make sure it is useful.
• Dry cure à Moist wound healing provides the level of temperature and humidity suitable for biological remediation and a semipermeable barrier that prevents the evaporation of excess moisture and acts as a wall to bacteria.
• Cleaning  wound bed with antiseptic products à It must not be done. These are inactivated by contact with organic matter. They can irritate the granulation tissue. They need a minimum operation time. And the residual effect is short-lived.
• Touching wound bed when we dry  the ulcer à Do not touch, dry surrounding skin only.

·      Debridement:

o   Mixing collagenase + silver à silver is inactivated. Correct choice: collagenase + hydrogel.

o   Debridement on the heel à It’s not necessary, there is risk of osteomyelitis.

·      In Infection:

o   Using antibiotic ointments à Antibiotic treatment must be oral. Use silver dressings.

o   Improper dressing Size à it must be put on the wound and about 2-3 cm of healthy skin.

o   Placing gauze under dressings à it difficults the exudate management and can it adhere.

o   Placing adhesive dressings after applying hyper-oxygenated fatty acids à  they don’t adhere properly.

o   Putting silicone net dressing  with healing dressings for moist evironment so that the injury doesn’t stick à It only increases costs.

o   Setting cures regardless of wounds evolution à We should Schedule them depending on the state of the wound.

o   Not recording properlythe size of the lesions à We don’t have objective data of the lesion evolution.

o  Not thinking about an extra protein intakeà It should be administrated if there is no contraindication to have a protein diet with supplements of vitamin C.

GERIATRIC PATIENT.

A common misconception regarding geriatrics is to classify to all elderly people as geriatric patients.

It’s possible to be a geriatric patient being under 75 years old, and it’s also possible not to be a geriatric patient being over 75 years old, although the second case is more usual.

The geriatric patient definition is determined by several criteria, from which three or more must be present:

• ·      Older than 75 years old.
• ·      Relevant comorbidity.
• ·      Disabling main disease.
• ·      There is mental illness.
• ·      There are social problems related to their health.

It is very important to know these criteria so that we can classify geriatric patients correctly.