ASSISTANCE LEVELS

For a correct attention it is needed a good coordination with the different level of assistance.

-          primary care

-          general hospital

-          geriatric unit

Primary health care

From my point of view the primary health care is one of the most important levels in geriatric. The primary health care will take care first to perform a primary prevention.

This will get help seniors to improve their daily lives by guidelines, exercises, advice and vaccines.

Also takes care of healthy or sick patient and has an important part to teach prevent cancer or know when to see your doctor to explain the symptoms of new appearance.

The frail elderly or high risk, should be of primary importance in the different programs or systemic action.

General Hospital

Responsible for the elderly patient who is not a geriatric patient and requires input for a disease.

Specialized attention

In my opinion is the other most important level of care in geriatrics.

This is destined for the entry of geriatric patients for valuation and management of their pathologies.

1. Acute geriatric unit: geriatric patients with acute disease to become independent in daily living activities

2. Medium unit stay: to restore the functioning of medical procedures, surgical or traumatic

3. Residence

4. Day hospital: patients who need physical recovery and health care and training in daily living activities

PALLIATIVE CARE NURSING

Palliative cares are those who are going to make a terminally ill patient or his prognosis is not good.

In my opinion the care of these patients begins in knowing how to communicate their status, to know when they do not want to receive more information and know how to treat the family.

I think the most difficult cases are those in which your family will not tell the truth or when patients do not want to see their reality.

To achieve proper communication professional must overcome:

anxiety to give bad news

fear of the reaction the patient

fear of overidentifying

fear of ignorance to questions

To communicate the bad news, there Buckman communication strategy:

• Stage 0: explain that the results may not be good
• Stage 1: the diagnosis must be certain and not suspicion
• Stage 2: before reporting must know who knows the patient
• Stage 3: what want the patient to know?
• Stage 4: The finely share with the patient. We know how to give depending on the patient information
• Stage 5: responding to the patient's feelings
• Stage 6: Plan of care

I think the most important stages 3 and 4, they must identify when the patient does not wish to receive information but does not say so directly. We will also have to know how to give the information, their desire and ability of acceptance.

INCONTINENCE URINARY

Urinary incontinence (UI) is the involuntary loss and objective at a time and unsuitable place and toilet is a problem, social and psychic

There are several types of incontinence, form my point of view the most important and interesting in elderly are:

-          IU acute, transient or reversible is of sudden onset and is associated with acute conditions

o       It may be for urinary tract infections or alterations in motility, this type of incontinence is solved when these disorders are referred.

-          IU chronic:

o       IU of effort or stress is produced with Valsalva manoeuvre (coughing, sneezing, and laughing). It is the most common in women.

In this case of incontinence will be advisable to make kegel exercises to strengthen pelvic muscles.

o       IU urgency: irreversible urge to urinate. It is the most common in the elderly. Can be of different types:

-          IU detrusor unsteadiness

-          IU sensitive instability of detrusor

Treatment

-          Residue <100 ml. à Kegel exercises.

o       Two or three daily sessions of about 20 to 25 repetitions (rounds 3-4 were held in each session)

-          Residue >100 ml

o       There will be a probing or reconstructive surgery

o       If incontinence is acontractile, we use behaviour modification techniques (probes or diapers)

I believe that nurses have an important role in the education of the patient who suffers from incontinence. We must teach the exercises to be performed and explain the correct way. Also we have the family because in the event that the patient was independent family should know what to do and as is the case for example of diapers and toilet of the patient.

http://www.observatoriodelaincontinencia.es/

PATHOLOGIES OF THE DIGESTIVE SYSTEM

The pathologies of the digestive system are a serious problem from the standpoint of psychosocial. The prevalence of these pathology increases from sixty years, and so one of the great problems of geriatrics. Some of the most common are:

- Constipation

- Ostomy

- Faecal incontinence

- Dysphasia

All of them are really old issues affecting both physically, socially and mentally.

From my point of view the problems that can affect and what more we can help nursing are constipation and faecal incontinence.

CONSTIPATION

Constipation is excessively dry stool evacuation, rare or uncommon

Complications such as fecal impaction may occur, which normally MUST be extracted so the patient does not feel violent and maintain their privacy.

I believe that with constipation what we do first will change the habits of life:

- Correct the diet, increasing fiber, water consumption, and maintain a diet rich in vegetables and fruits

- Regular exercise is important

- Establish a few hours to go to the toilet

In my opinion will be secondary pharmacological treatment because many elderly take many drugs

FAECAL INCONTINENCE

Faecal incontinence is one of the most geriatric syndromes affects the quality of life of elderly and caregiver.

This condition is a physical and economic impact.

There are different types of incontinence, nursing is very important to improve the quality of life of these patients.

It will be important:

- Increase the intake of fluids to prevent dehydration

- Avoid using toilet paper or towels

- Realised gentle washing with warm water

- Daily physical exercise

- Habitat modification

INSTABILITY AND FALL

The falls are a common phenomenon among the elderly, they are a major cause of injury, disability or even death.

The elderly generally have more problems with balance, this is manifested by the march senile

- Rigid stance and flexion

- Short and slow steps

- Rotating block

- Imbalance

- Wide base stall

- Less oscillation of the arms

In my opinion is important, that when a falls, in addition to the physical, psychological may also appear (post fall syndrome) and even social by isolation or dependence

The alarm indicators that indicate risk of falls are:

- Ocular

- Hearing impairment

- Nervous system disorders

- Emotional disorders

- Depression

- Denial of physical limitations

I think that one of the most important can be the ocular, because vision problems are important for the functions of daily life, and sometimes the elderly do not give importance to their vision loss. Also are very important hearing problems because notified of what may be going around so we will have to be revised in order to detect problems.

Some of the most common triggers from my point of view are:

- Age over 75 years

- Patients with 4 or more medications

- Previous falls

- Muscle devilidad

There are 3 types of prevention that we perform nursing

- Primary prevention: is to improve the circumstances of patients to prevent falls

          - Maintain functional capacity and exercise programs

          - Safety at home

* Risk Score Dowton

What nursing should consider is, avoid dangerous floors, good lighting, safety clamps elderly

            - Secondary prevention: will be held once produced the fall

      - We ask questions about how and where he was and what he was doing at the time

      - Assess the state of the elderly and possible injury

           - Third prevention: the finaliadd is to reduce the consequences of caira

      - Teach the elderly to rise

      - Restore stability

      - Retrain gait

 

Care Plan

- pain

- Impaired physical mobility

I believe that the three caveats are important, and we put the same interest in all. It is so important to get a security atmosphere in the elderly, in their daily lives as teaching the old man to get up when they suffer a fall.

COGNITIVE IMPAIRMENT

Dementia is one of the cognitive problems that affect the elderly.

The elderly often complain of memory loss, we as nurses we perform a rating to these patients. The most important that are affected are memory, difficulty performing complex tasks and language ability.

I think it is very important to identify few before dementia cases to act as soon as possible. Should not be detected it is more difficult to recover the functions that have been lost.

Nursing has rating scales:

- Mini mental state examination of Folsteina (MMSE)

- Memory impairment screen (MIS)

- Review of 7 minutes

In my opinion the most complete scale to detect dementia is the MMSE as it includes all fields that are affected in patients with dementia such as:

- Orientation

- Memory

- Language

- Calculation

ALZHEIMER

Alzheimer's is a type of dementia.

I think it might be hard to detect at first because in each patient symptoms vary.

It begins with the loss of short term memory. The middle stage the patient is having trouble recognizing objects and things or to communicate. And the final stage is the absence of memory and intellectual capacity.

Alzheimer's is a type of dementia.

I think it might be hard to detect at first because in each patient symptoms vary.

It begins with the loss of short term memory. The middle stage the patient is having trouble recognizing objects and things or to communicate. And the final stage is the absence of memory and intellectual capacity.

I believe that nurses have a very important function and beautiful. We must improve as much as possible the quality of life of patients with outbuildings and teach your family also guidelines to assist in the care.

Some nursing goals and interventions that will make are:

- Increase independence in basic activities

- Increase safety and prevent accidents

- Replace gas cooker by hob

- Replace bathtub by shower

- Protection of doors and windows

- Indicate what each medication and point when this taken

INMOBILITY

I believe that mobility is one of the most important indicators of health status at any age and that determines independence. In the elderly depend on specific factors:

- Motor Skills

- Degree of health and self-confidence

- Personal and environmental resources

Two types of immobility

- Relative: sedentary life but able to move

- Absolute: chronic bedridden, in which there may be problems for the patient as pressure ulcers and for caregivers and burnout syndrome

Some of the most important causes of immobility are the changes that the elderly suffer in their bones, muscles, heart and lungs and nervous system, either by physiological changes or diseases of age that may affect mobility.

From my point of view I think that the most important may be the decrease in muscle mass, osteoporosis and diseases like Parkinson's.

In patients with mobility problems we realize a rating, first try to get the maximum possible information possible with the help of family and caregivers to know the type of activities conducted scales we can help like Brathel and Lawton.

Also we will inform us about the drugs because some drugs can alter motility.

In my opinion is very important to conduct a home visit to determine the presence of architectural barriers as well as the family and social environments. Then I would conduct a physical exam comprehensive malaria, with special emphasis on the respiratory system, mucular, cardiac and neurological.

For the valuation are recommended two scales:

- Time up and go test

- Tinetti scale

Once the valuation will be proposed and relaistas individual goals, the main objective is to recover the baseline situation

The priority that we have in terms of the objectives of bedridden patients will be the prevention of skin problems by postural changes, hydration, hygiene and massage

Aids in immobility

PRESSURE ULCERS

Pressure ulcers occur when the pressure on the skin reduces the blood flow to the area.

Some risk factors include:

-          Malnutrition

-          incontinence

-          Disease That Affects blood flow, vascular disease or diabetes Including

-          Stay in bed for a long time

-          Fragile skin

Valuation

The patient must be evaluated through the scales valuation of risk for identify the elderly patient with risk of developed a pressure ulcer.

The Braden and Norton's scales are the most used.

When already has developed a pressure ulcer need a comprehensive evaluation that includes the location and number of lesions. The most common sites of pressure ulcers are the trochanters, sacrum, buttocks and heels.

Pressure sores are grouped by their severity.

-          Stage I: A reddened area on the skin that, when pressed, does not turn white.

-          Stage II: ulcer-like abrasion bleb or shallow crater

-          Stage III: There is damage to the tissue below the skin.

-          Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

The worst complication in this hurt is the infection, bacteria multiply, the healing is disrupted and damaged tissues.

The symptoms typical are inflammation, pain, hot and blush.

The cleaning must be realised with physiological saline.

Debridements are the removal of necrotic tissue by a surgical technique. This technique is not performed if there are circulation disorders, infection...

The dressings used in pressure ulcers depends wound exudate and the presence or absence of infection.

-          Hydrogels are used in necrotic tissue must be covered with a secondary dressing.

-          Hydrocolloids are used in the treatment of vascular and pressure ulcers. These dressings form a gel to absorb the wound exudate.

-          Alginates not be used on dry wounds, are very absorbent so used to heavily exuding wounds.

-          Foam may be adhesives or not. Retain large amounts of exudate.

-          Hidrocapilares serve low and high level of exudate, are very adaptable. They have a pad covered with a water resistant material, their most important characteristic is that they are capable of absorbing large amounts of exudate

In my opinion is very important know all the different characterist dressing to can choose the better in which tipe of ulcer. Also it is important change the dressing when it is necesary.
I think that will be important stabilish a norms of the ulcers´s traments for all the healh peronal could be trated the same form.

As we have seen most importantly in pressure ulcers is from my point of view, the prevention of the same. Preventing ulcers is much easier to treat, for it can be proposed guidelines:

-          Change position At least every 2 hours to relief pressure

-          Use items That Can help reduce pressure: pillows, sheepskin, foam padding, and powders from medical supply stores

-          After urinating or having a bowel movement, clean the area and dry it well

-          Keep skin clean and dry

When the ulcer is already the most important thing will be treated as early as possible and so we will have to assess the ulcer, cleaning and studying the best way to act.

In my view thanks to the advances that have occurred in the different types of dressings and different techniques, has helped to work more efficiently.

But we must not forget that the best treatment is prevention.

Bibliography

http://www.nlm.nih.gov/medlineplus/ency/article/007071.htm

GERIATRIC SYNDROME

There are few illness that only affect old people, a lot of of there appear before 65 years old.

There are several elements which designate the carefulness.

The most difficult in the aging illness is the presentation of them furthermore different illness could different organ or system; it is very common chronic or degenerative disorder which cause dependence.

One of the objectives in aging will be the upkeep of autonomy thought the early rehabilitation.

The pain is an important point for the nurses, they must know the stage of it. The scale EVA is used to measure the pain in aging.

Urinary and digestive problem are common in aging are important, constipation, heartburn and belching.

Respect to urinary problems appear more in people with prostatic hypertrophy and originate more infections.

In my opinion, the problems there more affect this patient are shake which increase with activity and senility. And the mental problem disorder, because they are aware about their problem and fell lest and lest rewarding.

Geriatric syndrome

The term "geriatric syndrome" is using to highlight the unique features of common health condition in the elderly.

Based on a review of the literature, four shared risk factor-older age, baseline congenitive impairment, baseline funtional inpairment, and impaired morbility - were identified across five common geriatric syndromes like a pressure ulcers, incontinence, falls, funtional decline, and delirium.

 The geriatric syndromes are defined by Kane, in 1989 in his book Essential of Clinical Geriatrics like a geriatric problems, allowing its memorization by the rule of ies:

-          immobility

-          instability and falls

-          urinary and faecal incontinence

-          intellectual impairment

-          inanition

-          impairment of vision and hearding

-          irritable colon

-          isolation

-          iatrogenesis

-          immune deficiency

-          impotence

From my point of view, Kane, explains very well in his book the principal problems that the geriatric patients suffer and which the family and sanitary personnel has to face.

Some of the complications which we can meet the nurses with the geriatric patients can be, to part of the syndromes described by Kane, the osteoporosis, sores, constipation or retention of secretions which we will have to learn to treat them

Bibliography

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409147/

NURSING PROCESS ATTENTION

Nursing Process Attention

The nursing process objetive is to identificate the patient and the problems that may habe to estabilish and achieve goals and improve the health status

Maslow's pyramid

Valuation

We will perform the valuation directly (patient, family, friends) or indirectly, through interviews and physical examination.

Diagnosis

Contains conclusions on the state of the patient, so we can see the actual and potential problems

Planning

Here we find activities goals and we want to achieve in each patient

Execution

Implementation will be done by patients, nurses and family and leads to changes in the patient's health to achieve the objectives

Evaluation

Evaluation allows us to know the patient changes

From my point of view, Virginia Henderson gives definitions nicest nursing, defined as support for the activities that the person would if I had the strength and knowledge, and also help you to be independent.

Attributed to all human beings 14 basic needs

1.      Breathe normally.

a.       we try to avoid tiring the patient, we will make efforts to reduce weight and inform them about the problems of snuff 

2.      Eat and drink adequately.

a.       we control your diet and help them in feeding

3.      liminate body wastes.

a.       treat constipation and incontinence with care and exercise

4.      Move and maintain desirable postures.

a.       we will make personal exercise routines

5.      Sleep and rest.

a.       we will establish guidelines to improve sleep and dream

6.      Select suitable clothes--dress and undress

a.       we recommend the best clothing and value their ability to dress and undress.

7.      Mintain body temperature within normal range by adjusting clothing and modifying the environment.

8.      Keep the body clean and well groomed and protect the integument.

9.      Avoid dangers in the environment and avoid injuring others.

a.       prevent accidents such as falls, burns and help them to have a suitable environment

10.  Communicate with others in expressing emotions, needs, fears or opinions.

a.       We always do an active listening and encourage their communication

11.  Worship according to one's faith.

12.  Work in such a way that there is a sense of accomplishment.

13.  Play or participate in various forms of recreation.

14.  Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.