CARE LEVELS

For proper heath care is a need for adequate coordination of different stakeholders involved. It involves an interdisciplinary work.

• Primary care
• General Hospital
• Geriatrics unit

PRIMARY CARE

It takes care of the vast majority of older people, developing activities of health promotion and preventive, curative, or rehabilitative.

The functions of this level:

• Health Promotion
• Assessment of health status
• Preventive activities
• Detection and early care
• Tracking Task
• Palliative cares

Sanitary education with the patients and their families:

• Nursing cares.
• Identification of signs and symptoms.
• Know the necessities of health to elaborate objectives.
• Evaluate the faults in home.
• Sanitary education.
• Healing.
• Emotional support.

Health education:

• Nutrition.
• Hygiene.
• Exercise.
• Tobacco, alcohol and drugs.
• Prevention of falls.
• Mental hygiene.
• Hypertension, diabetes, obesity, dementias, arthritis…

Health education to prevent the cancer:

• Change of a mole.
• Persistent cough.
• Modification in intestinal habits.
• Blood hides in feces.
• Problems in the urination.

GENERAL HOSPITAL

It deals with the elderly patient who is not a geriatric patient, requiring input by a disease.

Nursing care:

• Making constant
• Cures
• Sampling
• Hygiene / demonstrations
• Respiratory physiotherapy
• Oxygen
• Catheterization, nasogastric
• Injectable

SPECIALIZED CARE

Geriatric services are interdisciplinary units to cater specifically to the "geriatric patients", as well as providing support to primary care and play activities of teaching. Acute Geriatric Unit is intended for geriatric patient admissions for comprehensive assessment and management of their acute or chronic diseases.

1. The Geriatric Acute Unit: is for geriatric patients to evaluate them and heal their diseases (acutes or chronics).
2. Half stay unit: to the reestablish the medical, surgical and functional process.
3. Residence for the elderly: to patients that have chronic deterioration in their functional capacity and they can’t be maintained in their home.
4. Geriatric Day Hospital: to weak patients that need physical recovery, sanitary cares and training in the daily activities.

In my opinion, I think that the health education is very important to prevent some diseases and to be a best prognostic because if a person knows how to avoid the risks it could be better for long time.

I believe that the family is very important because the must help to the elderly to identify the symptoms of the diseases to ask to the doctor early.

A disease caught in time has a better prognosis.

HEALTH PROMOTION AND HEALTH MAINTENANCE

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

The most common diseases are:

• Hypertension
• Ischemic stroke
• Cardiac failure
• Diabetes
• Dementia
• Depression

RISK FACTORS

• Organics: hypertension, malnutrition, incontinence and sensorial difficulties.
• Environmental: inactivity, barriers…
• Relationships: lonesomeness and insomnia.

OBJECTIVES OF GERIATRIC PREVENTION:

• Reduce mortality
• Increase life expectancy
• Improving the quality of life
• Dependence
• Disability

Provide attention to the old persons and their surroundings are our labor like nurses. Inside of the care processes are:

•  Reinforcement: the old person is independent and the carer only say him/her some action she/he have to do.
• Support: the carer gives to the old persons some advices and guides them to execute some actions. 
• Aid: the carer contributes in some activities because the old person has some physical and mental  problems.
• Substitution: the old person present incapacity to do all the activities, so the carer does the total action.

Dependency: functional consequences of disability with changes in activity, which causes difficulties in basic activities

Disability: partial or total decrease of the ability to perform an activity

HEALTH PROMOTION 

1. Blood pressure: once a week. Prevention: hypertension.
2. Control of lipids: screening in adults without symptoms (more than 35 years in men and more than 45 years in women). Prevention: dislipemia.
3. Electrocardiogram: once per year in older than 75 years. Prevention: arrhythmia and fibrillation with anticoagulant and other medications.
4. Glycaemia: once a year. Prevent: diabetes II. 
5. Test of mental state: once a year. Prevent: cognitive deterioration.
6. Blood hide in feces. Prevent: colon cancer. 
7. Mammography: each 1 o 2 years. Prevent: breast cancer.
8. Rectal touch: to prevent prostate cancer.
9. Study audiometric
10. Rating ophthalmological

I think that the health promotion is very important to prevent the diseases because if we observe the symptoms we can do an early prognosis and the consequences are less.

Our job as nurses is to insist on the importance of promotion and health education to reduce the possible complications of the different diseases.

1. Curcio Borrero Carmen Lucía. SOPORTE SOCIAL INFORMAL, SALUD Y FUNCIONALIDAD EN EL ANCIANO. Hacia promoc. Salud  [serial on the Internet]. 2008  Dec [cited  2013  May  04] ;  13(1): 42-58. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0121-75772008000100004&lng=en.
2. Rangel Rivera Julio César, Lauzardo García del Prado Gema, Quintana Castillo Maritzabel, Gutiérrez Hernández María Elena, Gutiérrez Hernández Norlistaymi. Necesidad de crear programas de promoción y prevención en el adulto mayor. Rev Cubana Estomatol  [revista en la Internet]. 2009  Mar [citado  2013  Mayo  04] ;  46(1): . Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75072009000100004&lng=es.

PALLIATIVE CARE

 

According to the World Health Organization, palliative care focuses on reducing the symptoms of a disease without attempting to provide a cure; it neither hastens nor postpones death. Palliative care affirms life while accepting death as its normal conclusion. interventions are designed to optimize the patient’s ability to live as active and complete a life as possible until death comes. Medical treatment and nursing care focus on actions that enable the dying person to have the highest quality of life for whatever time remains in his or her life.

Communication is an informative process that starts from a point of origin and arrives at a destination, irrespective of the channel or medium used.

Main fears:

• Death and a dying healthcare professionals and caregivers in psychological reactions that lead to the patient avoid communication terminal.
• Overcome à the anxiety generated disclose bad news, the fear of provoking and overreaction in sick, the fear of over identifying, fear of lack of response to questions from the patient.

Basic principles

• Velocity of communication according to the assimilation of each person.
• The diagnostic, treatment and prognosis must be in different sessions, never in the same because the patient has to assimilate the information.
• If the patient won’t know the information we have to respect his posture and say her/his that if he/she change the opinion they can talk with us.
• Never take off the hope but neither generates it.

Professional communication models:

• Technical: focus on à Health and disease  à Ignore the psychosocial area
• Paternalistic: Intermediate between health and illness and psychosocial area 
• Complacent: can not make therapeutic distance
• Deliberative: focus on à same level in health and disease in the psychosocial area.

Bad notices

It’s information that alters the vision of the patient about her/his future. Here are some directives to follow when you are going to say bad notices:

Analgesia scale by WHO

 

NURSING CARES

Anorexia

• Less food in big plates.
• Adequate preparation of the food.
• Delicious food for the patient.

Vomits and nauseas

• Adequate diet and drugs.

Constipation

• Increase the intake of liquids.
• Restriction of diets rich in fibber.
• Drugs.

Mouth

• Clean lips and oral mucous.
• Eliminate place and rests.
• Prevent oral infection.
• Eliminate pain in oral intake.

Nursing is very important in palliative cares. We must know how to communicate with the patient because is necessary to transmit to the patient our knowledge, explain carefully all they want to know... We must know how to ask their questions and help to them. We stay with the patient and with the family for along time and we must to be professionals but we must to have empathy with them too.

1.     Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

URINARY INCONTINENCE IN THE ELDERLY

Urinary incontinence is the involuntary loss of urine in sufficient amount or frequency to be a social or hygiene problem. Urinary incontinence is not a normal part of aging but is a major problem in the aging population. Women are twice as likely tu experience urinary incontinence as men.

Incontinence has medical, emotional, social and economic consequences for older adults. It can result in skin irritation or breakdown and can contribute to pressure ulcers.

Reversible causes of incontinence:

• Delirium
• Infections
• Atrophic vaginitis
• Psychological causes (depression)
• Pharmaceutical agents
• Endocrine conditions (DM)
• Restricted mobility
• Stool impaction

Incontinence can be reduces if there is a commitment to success rather than a defeatist attitude. Stressing the benefits to the patient and identifying the benefits to caregivers can help motivate the process. All member of the health care team are essential to reduce incontinence.

Treatment:

General:

• The nurse should assess and apply analytical and urine culture.
• Correct precipitating factors favoring and incontinence
• One should look for proper voiding habit
• Constipation should be corrected 

Residual urine <100 ml:

• Pelvic floor exercises (Kegel)

Residual urine> 100ml:

• Overflow: probe or reconstructive surgery
• Acontractile: modification techniques such as catheterization or incontinence pads.

The nurse must assess elimination pattern, assess fluid intake patterns, explain measures that help improve tone of the sphincter muscles, modify clothing to make toileting easier, answer call signals promptly, initiate actions to maintain skin integrity, insert catheter as prescribed by physician, discuss methods for coping with incontinence…

In short, I think that a nurse is very important to help the patient with urinary incontinence. We must inform and explain to the patient the problems and how to prevent it.

The incontinence could produce pressure ulcers and we should clean the skin carefully to prevent it.

A good nurse must provide all necessary care to the patient for a better life.

1.     Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

DIGESTIVE-ENDOCRINE PATHOLOGY

CONSTIPATION

It is not a disease but rather a symptom of some other problem. Constipation is defined as hard, dry stools that are difficult to pass.

Causes of the constipation:

• Obstructive, cancer, hernias…
• Diet poor in fibre, anal fissure, haemorrhoids, irritable colon.
• Laxative, antidepressant, antacid, opiate.
• Diabetes, uraemia, hypothyroidism.
• Trauma, Parkinson, dementia, depression. 

Complications of constipation

• Faecal impaction:
• Anal fissure:
• Circulatory disorders:
• Faecal incontinence:
• Urinary retention.

Treatment and nursing intervention:

Dietary treatment should be the first therapeutic step in the management of constipated patients. A diet rich in fibre is associated with an increased frequency and weight of stools.

Fibre works by increasing faecal bulk and decreasing intestinal transit time by stimulating bowel motility.

To achieve normal bowel function is advised to eat a moderate amount of fibre and plenty of fluids and physical exercise regularly.

Insoluble fibre is more advisable since it captures more water, which results in a greater increase in faecal mass and acceleration of intestinal transit.

It is also important to educate the patient to gain or regain the habit of defecating regularly, preferably every day.

Regular physical exercise and particularly those exercises that strengthen the abdominal pressure and pelvic floor are particularly beneficial for the treatment of constipation and faecal incontinence

OSTOMY

Stoma: surgical creation of a temporary or permanent opening which brought about the digestive tract to the exterior through the abdominal wall.

The objective of dietary recommendations in the elderly ostomised is to regulate intestinal transit and prevent diarrhea and constipation, as well as reset a good nutritional status

Types of stoma

FECAL INCONTINENCE

Is one of the principal geriatrics syndromes that affects in quality of life and overloading to the principal career.  The impact isn’t only physical, also economic and psychosocial.

Types of faecal incontinence:

Minor:

• Soiling (get dirty the underwear): haemorrhoids, diarrhea, immobility, dementia and depression.
• Gas incontinence: avoid flatulent food and carbonic drinks.
• Urgency to defecate: they feel the dregs in the rectum but they aren’t able to maintain the incontinence until go to the toilet.

Greater:

• Lesion in the pelvic floor.
• Drugs: laxatives and antibiotics.
• Rectum cancer.
• Neurologic alterations: central, spinal cord, and peripheral.

Risk factors:

• Urinary incontinence.
• Immobility.
• Previous neurologic diseases.
• Cognitive alteration.
• More than 70 years.

Nursing care:

• Lifestyle modifications.
• Treatment of perianal discomfort: avoid soap, toilet pape. Wash with warm water and cotton.
• Treatment of faecal impaction
• Modification of architectural barriers
• Uses of absorbent

DYSPHAGIA

Difficulty to swallow the liquids or solids elements because one or more phases of swallowing are affected.

Treatment

• Present the food in little quantity.    
• Not mix solids with liquids consistency.
• Avoid the contact the spoon with the spoon
• Relax ambient, not force.
• Flavour the food with nutrients, proteins…
• Respect taste and experience new flavours

1.     Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

INSTABILITY AND FALLS.

Falls are the most common safety problems in older adults.

As people age they lose the normal protective responses or reflex against falls as the extension of hands and arms.

Fall prevention is everyone’s responsibility. Outreach sessions about fall prevention designed to meet the needs of elderly adults, their families, and anyone who has contact with elderly adults could be offered at senior centers, libraries, businesses, and community colleges.

When an elder falls may appear physical consequences (hip fracture), psychological (post-fall syndrome) and social (isolation and dependence for AVD)

ALARM INDICATOR

• Eye disorders: decreased of visual acuity, accommodation capacity, near vision, night vision and Peripherals vision, decreased tolerance to bright Light.
• Auditory disorders: disorder in the discrimination of language, increasing the threshold of pure tone, tendency to excessive accumulation of earwax
• Nervous system disorders: slowing of reaction time, decreased of sensory recognition.

PREVENTION.

Primary prevention:

Falls are preventable phenomenon in the elderly. Primary prevention includes measures to:

• Living habits: maintaining functional capacity, exercise programs, no toxic habits
• Environmental security measures
• Early detection and correction of intrinsic and extrinsic factors

Among the measures to note, the nurse stands out:

• Will avoid slippery uneven or vet floors
• Good lighting in all rooms where they circulate the elderly
• Smoothly and orderly environment
• Immobilizer:
• Bed side rails, bed down to the maximum
• Place hands handles in bathrooms and handrails on stairways and hallways
• Use of support measures: walkers, canes, crutches for greater base of support.
• Promote a safe environment:
• Help the elderly to recognize the dangers adapt the environment
• Leave to reach everything the patient can use

Secondary prevention:

• Discard loss of consciousness
• Discard syncopal disease
• Assessment of the state of the elderly and possible injury.
• Inform to the doctor or emergency services if necessary
• No mobilize or incorporate the old man if you suspect may have a fracture
• If there is no referral to hospital: observation

Tertiary prevention

• Teach the elderly to rise. Avoid remaining in the soil after the fall
• Rehabilitate the stability
• Exercise program
• Retraining gait. Orthotics Help
• Supportive psychotherapy

NURSING INTERVENTIONS

• Evaluate the person for the risk for falls
• Modify the environment to reduce risks
• Recognize the presence of pain
• Gently handle the limb, supporting it with pillows
• Administer prescribed analgesia
• Help frequent position changes that relieve the pressure and discomfort
• Instruct the elderly and help in changing position and transfer activities
• Teaching isometric exercises
• Start ambulation with frequent short walks
• Instruction on the safe use of auxiliary devices and monitor progress

1.     Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

NEUROLOGIC DISEASES: COGNITIVE DETERIORATION AND DEMENTIA.

Minor cognitive alteration: intellectual decrease of clinical appearance but there isn’t functional incapacity. If would be this last, it will denominate dementia.

DETERIORATION COGNITIVE EVALUATION

  

• Memory: it loss the work memory, episodic and free memory.
• Language: it loss the denomination and decreased the verbal fluency.
• Decreased the reasoning, capacity to resolve problems and the velocity to process the information.
• It preserves the attention.
• Neurologic evaluation: level of attention, orientation, collaboration, senses, muscle tone, trembling or other moves.
•  Delirium: significant fluctuations in mental status, and changes in the level of attention and level of consciousness.
• Risk factors:

•  Serious disease, depression, alcohol, dehydration, malnutrition.
•  Iatrogenic, physical restriction, use of urinary catheter.

• Depression: adversely affects cognitive functions, and can be confused with dementia. Patients with depression tend to have more subjective complaints of memory loss, often have psychomotor retardation and poor motivation in conducting the test.
• Dementia: is a syndrome that has to be understood as a decline of cognitive function

RATING SACLES:

1. Mini Mental State Examination of Folstein (MMSE)
2. Memory Impairment Screen (MIS)
3. Test seven minutes

ALZHEIMER

It is a progressive brain disorder characterized by degenerative changes of cortical nerve cells and brain nerve endings. This process produces an irreversible impairment of memory and intellectual functions destruction.

The background cause is unknown.

It is characterized by loss of memory, deterioration of intellectual and personality change.

It is classified into three stages:

First state:

• Memory: loss of memory, difficulty to remember nouns or words, loss in family ways…
• Language: decrease of communication, reduction in vocabulary, without facial expression, to say impertinences…
• Behaviour and mood: change of mood, depression, facility to distraction, necessity to look for people or places families…
• Coordination: slowing – down of reaction time, incapacity to drive.

Second state:

• Memory: unknowing about all the recent events.
• Language: repeat the same words and phrases, to speak slowly, decrease demonstration of affection, shaking, hallucination, dream alteration.
• Coordination: loss of coordination and equilibrium, difficulty to walk and write.
• Own care: necessity of help to wash, choose the cloth, fecal and urinary incontinence.

Final state:

• Memory and language: incapacity to learn new concepts, loss of memory of recent and past events, reduction of vocabulary, incapacity to read and comprehension and repeat words or phrases.
• Behaviour and mood: frequently shaking, incapacity to remember the career, difficulty to walk, write, sit down, smile or swallow.
• Own care: necessity to most help to realize the daily activities life.

It is essential that nurses remain clam when confused individuals act out. It is not easy for nurses to deal with repeated irritating or hostile behaviours, but they must remember that anger, arguments, and explanations only confuse the person and make the situation worse. Even if nurses do not say anything negative to the person, body language may communicate a lack of acceptance.

1. Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

IMMOBILITY

The immobility can be defined as the decreased of the  ability to perform activities of daily living by deterioration of motor functions.

It is a geriatric problem characterized by a reduction in exercise tolerance, progressive muscle weakness and, in extreme cases, loss of automatisms and postural reflexes which prevent wandering.

• A relative immobility, in which the old man leads a sedentary life but is able to move with more or less independence
• A total immobility involving chronic bed rest, being very limited postural variability.

CAUSES OF THE INMMOBILITY

Physiological:

• Decrease of mass and strength muscular, senile march
• Decrease of sensibility and reflex
• Decrease of cardiac frequency, aerobic capacity
• Decrease of elasticity of thoracic wall

Usual diseases:

• Osteoarthritis, arthritis, fractures…
• Brain damage, Parkinson, dementias…
• Cardiac insuffiency
• Visual deficits
• Depression
• Diabetes mellitus

Environmental causes:

• Obstacles

Social factors:

• Loneliness 

Rehabilitative potential and the monitoring result can be performed by the Barthel index.

GENERAL CARE OF DISABLED PATIENTS

Prevention of skin problems:

• Postural changes
• Hygiene
• Massages
• Padded
• Supply of liquids and foods

AUXILIARY ELEMENTS FOR MOBILIZATION

• Walking stick
• Crutches
• Walker

HOME ADAPTATIONS

• Stairs: reduce height
• Doors, to open easily
• Furniture: space
• Adjust the height of the bed

The best preventive measure is to keep the degree of mobility.

The elder who wears a type of autonomous and active life with regular performance of exercise has statistically decreased risk of mortality.

Scientific evidence increasingly indicates that regular physical activity can extend years of active independent life, reduce disability, and improve the quality of life for older persons.

In my opinion we must promotion the activity in the elderly to maintain the independence. We must explain to de elder the importance of realise exercise.

Nurses should educate older person about the importance of exercise and emphasize the benefits such as weight loss, prevent obesity, prevent or reduce depression, retain mobility, maintain or improve musculoskeletal function, improve appetite, encourage sleep…

We must motivate to the patients and show them different ways to do exercise. 

1. Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

PRESURE ULCERS 

Pressure ulcers  can be defined as any damage to the area of skin and underlying tissue caused by the prolonged pressure on a hard plane, not necessarily intense, and independent of position.
Prevention is a priority mainly based on methods that quantify risk factors that help predict tissue involvement because 95% of ulcers are preventable.


RISK FACTORS

Pathophysiological

• Skin lesions
• Oxygen transport disorders
• Nutritional deficits
• Immunological disorders
• Disturbances of consciousness
• Motor deficit
• Sensory deficit
• Removal altercations

Derivatives of treatment:

• Immobility imposed by treatment
• Immunosuppressive treatment: radiotherapy, chemotherapy
• Drilling for diagnostic or treatment

Situational

• Poor hygiene
• Wrinkling
• Rubbing objects
• Immobility by pain, fatigue

Environment

• Lack or misuse prevention material
• Professional motivation due to lack of training and / or specific information
• Work overload
• Lack of uniform criteria in planning cures
• Lack of health education for caregivers and patients
• Deterioration of the image of the disease.

Neuropathic Ulcers:

• Presence of distal pulses.
• Small injuries.
• Cellulites, abscess.
• Rapid progression, painless.
• Location: digital support areas
• Joints metatarsicafalángicas 
• Plantar area

Venous Ulcers:

• Hyperpigmentation
• Appear from the distal malleolus to the distal third of calf
• Can develop rapidly
• Shallow, irregular edges and bleeding, oozing plentiful
• Pigmented dermatitis around.
• Lipodermatosclerosis
• Distal pulses +

Arterial ulcers

• Develop much in the fingers
• Shallow
• Related to diabetes
• Weak distal pulses
• They tend to hurt more
• Deep, neurotic little granulation, exuding no sharp edges.

I think that the best for the pressure ulcer is the prevention. We must to explain to the patient how prevent it. The skin must be clean and there are very important the postural changes. a good nutrition is necessary too.

The job of the nurses is very important in these patients because we must do a lot of palliative treatment.

We must explain the risk factors to the patient for prevent if it is possible.

I think that our job is necessary to prevent the infection, pain, the loss of function, and even death.

1. Martínez Cuervo F., Pareras Galofré E.. La efectividad de los ácidos grasos hiperoxigenados en el cuidado de la piel perilesional, la prevención de las úlceras por presión, vasculares y de pie diabético. Gerokomos  [revista en la Internet]. 2009  Mar [citado  2013  Abr  28] ;  20(1): 41-46. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1134-928X2009000100006&lng=es.  http://dx.doi.org/10.4321/S1134-928X2009000100006.
2. Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012
3. Medeiros Adriana Bessa Fernandes, Lopes Consuelo Helena Aires de Freitas, Jorge Maria Salete Bessa. Análise da prevenção e tratamento das úlceras por pressão propostos por enfermeiros. Rev. esc. enferm. USP  [serial on the Internet]. 2009  Mar [cited  2013  Apr  28] ;  43(1): 223-228. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342009000100029&lng=en.  http://dx.doi.org/10.1590/S0080-62342009000100029.