8. Pressure ulcers

A pressure ulcer is an ischemic lesion located in an area of the skin and underlying tissue caused by sustained pressure / prolonged over two hard planes, causing ischemia (produced by a number of forces that will be described below) and necrosis.

The strengths responsible for the onset of ulcers are:

• Pressure: force acting perpendicular to the skin as a result of gravity, that cause a tissue flattening between two hard planes, one belonging to the patient (heel, sacrum ..) and the other belonging to the outer (bed, chair, tube ..). A pressure above 32mmHg occludes capillary blood flow in soft tissue, causing hypoxia and therefore necrosis.
• Friction: tangential force that acts parallel to the skin, causing friction by movement or pull.
• Shear: combining friction and pressure. The shear force occurs when there is adjacent sliding surfaces (bed fowler position, what causes the patient to slide below).

In addition to the forces mentioned above, are also involved:

• Maceration: produced by excessive moisture in the skin which leads to softening and reduced skin resistance.
• Poor nutritional status: hypoproteinemia, anemia, dehydration and vitamin deficiency affecting the integrity of tissues

The ulcers usually occur in partial / total bedridden patients or in patients who are sitting in one position a long period of time. However, can also appear in patients with pressure maintained in a defined area, such as the nose because of the pressure exerted by an oxygen mask or on the ears or the pressure exerted by the rubber mask.

Typically, the ulcers are over bony prominences, being more sensitive (and frequent) the shoulder blades, elbows, external malleolus, sacrum, coccyx, heels, ischial tuberosities and trochanteric prominences.

Pathophysiological risk factors of occurrence of ulcers are skin lesions (aging and related conditions), oxygen transport disorders, nutritional deficiencies, altered state of consciousness (drugs, confusion and coma), motor deficit (stroke, fractures , paralysis, paresthesia), sensory deficits (loss of thermal and pain sensitivity), abnormal elimination (urine and feces).

Situational risk factors of occurrence of ulcers are: wrinkles in bed, poor hygiene, objects of touch, pain, immobility,

The environmental risk factors of occurrence of ulcers are: misuse prevention material, lack of unified criteria in planning cures, lack of health education or malpractice of healthcare professionals.

When a patient presents with an ulcer, you have to make a comprehensive evaluation of this, taking into account:

1. Background of the wound
2. Personal history, family, and social drug.
3. Physical examination of the patient and the wound
• Size
• Edema, erythema and warmth
• Wound bed (type of tissue, tendon exposure)
• Edges of the wound
• Characteristics of the wound edges (bagged, edema, pigmentation)
• Wound location, color, and odor exudate
• Temperature
• Blood pressure
• Neurological examination
• Arterial pulses
• Response to the elevation of the limb, and pain in the same
4. Etiology of injury
5. Diagnosis of comorbidities
6. Current status of the wound
7. Treatment Plan

The classification of ulcers is done in 4 degrees / stages:

• Grade I: are those appearing cutaneous erythema (skin pink / red) that not giving up when you remove the pressure. In dark skin may appear purple. Only there is involvement of the epidermis.

• Grade II: are those in which it's produced a solution of continuity of the skin, vesicles and bullae. It affects the epidermis and the superficial dermis. Presents abrasion appearance or shallow crater.

• Grade III: are those in which there is subcutaneous tissue affectation. The tissue necrosis extending deep through the skin, reaching the deep dermis and hypodermis. Lesions appear as deep crater (if not covered by necrotic tissue).

• Grade IV: are those in which there is a total loss of skin thickness and necrosis in deep structures (muscle, bone or supporting structures). Appear cavernous and tunneling lesions.

It is very important that, before determining the degree of ulcer, removed the necrotic tissue in order to properly assess the degree of involvement of deeper tissues.

For the assessment of the ulcers we have the Norton scale, in which we make a valuation of: patient's general physical condition, mental condition, activity, mobility and incontinence.

This scale must be done continuously, as it may be modified by a variety of factors.

For the treatment of ulcers, it is necessary to perform:

• Debridement: it's the remission of foreign material and devitalized (contaminated tissue) adjacent to a traumatic injury or contaminated until healthy tissue disappears. There are several types of debridement: surgical, autolytic, enzymatic, mechanical and others.

• Hydrocolloid dressings: these dressings decreased the oxygen tension and also reduce the pH in the ulcer (reduce the presence of bacteria). These dressings have the advantage that: they reduce infection rates, accelerate the healing process, causing less damage to the removal, autolytic, reduce odor and have better cost-effectiveness, provide comfort to the user.

• Alginates: derived from seaweed. Of these sodium alginate is extracted, which mecienta an exchange process with a solution containing calcium ions, produces precipitation of calcium alginate fibers, which are highly absorbent hemostatic products and biodegradable, which possess antibacterial activity.

• Hydrogels: contain lots of water. They are indicated in ulcers with minimal or moderate exudate. Have the feature that in addition to being occlusive, hydrate, relieve pain and they are debriding autolytic effective in surfaces with slough, bedsores and fibrin.

• Silver Antimicrobial Dressings: Silver prevents respiration and feeding bacterial, which inhibits bacterial enzymes and interferes with cellular respiration (the dressing is very useful, as the pus, necrotic tissue and slough are bacterial breeding grounds).

The prevention of pressure ulcers is far more important than anything I mentioned above. It is essential to follow a series of preventive measures such as:

• Mitigate or eliminate the pressure
• Frequent changes in position to avoid blocking blood flow
• Do not drag the patient to avoid friction
• Observe skin daily to see if there is redness or whitish areas
• Use decubitus, air or water mattresses
• Do not raise the head of the bed more than 30 degrees to prevent sliding pressure
• Make assets and liabilities exercise
• Dry thoroughly after bathing
• Bedding clean, dry and wrinkle
• Diet rich in proteins and vitamins (especially vitamin C)

In my opinion, it is vital to prevent pressure ulcers, especially in patients immobilized because, once an ulcer appears, has a long time to disappear.

Bibliography

• Álvarez C, Lorenzo M. Cuidados de enfermería en una población geriátrica con riesgos de úlcera por presión. Enfermería Global 2011; 23: 172-182. Disponible en: http://scielo.isciii.es/pdf/eg/v10n23/administracion3.pdf
• Martínez López, J. F. Prevención y tratamiento de úlceras y escaras. Málaga: Editorial vértice; 2008.
• Morales Martínez, F. Temas prácticos en geriatría y gerontología (Tomo 1). Costa Rica: Editorial Universidad Estatal a Distancia; 2007.

7. Immobility

The immobility is defined as a decreased ability to perform activities of daily living by impairment of motor functions.

There are two types of immobility:

• Relative immobility: the old man leads a sedentary life but is able to move independently.
• Risk: bedridden
• Absolute immobility: implies bedridden and has very limited postural variability.
• Risk: institutionalization, morbidity and appearance of caregiver syndrome.

The causes of immobility in elderly patients are varied, among which are: physiological changes of aging, common diseases and environmental causes.

The problem that arises after prolonged immobilization is that changes occur in different organ systems (cardiovascular, musculoskeletal and dermal mainly) that tend to perpetuate the syndrome.

Orthostatic hypotension

One of the changes that occur in the cardiovascular system is orthostatic hypotension, which can be defined as change in normal blood pressure regulation that decreases sharply after a sudden change in body position, usually when shifting from lying down to sat. It usually lasts only a few seconds or minutes.

Causes of orthostatic hypotension include:

• Hypovolemia:
• Excessive use of diuretics
• Vasodilator medications
•  Dehydration
• Prolonged bed rest
• Nervous system damaged  by diseases such as:
• Diabetes
• Anemia
• Decreased cardiac muscle contractility or vascular responsiveness.
• Drugs:
• Antidepressants
•  Antipsychotics
• Barbiturates
• Alcohol

In relation to the symptoms that come with orthostatic hypotension appear: confusion, weakness, blurred vision, dizziness and eventually fainting (brief loss of consciousness).

The main treatment of orthostatic hypotension is tracking a number of recommendations:

• Getting up slowly after lying down and stay a few minutes sitting on the edge of the bed.
• Avoid alcohol
•     Perform Isometric exercises (squeezing a ball for a few minutes) before you stand; raise blood pressure and prevent a sharp decrease when you get up.

I think it's very important to explain to patients the prevention of falls that occur as a result of orthostatic hypotension, because many seniors get up quickly from the bed when the phone rings, when they hear a bump or when they remember that they have forgotten something. It is very important to emphasize that you should be sitting on the edge of the bed a few seconds before getting up.

Bibliography

• Medline. [Monografía de internet]. [Fecha de consulta 18 de abril de 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/007278.htm
• Micheli, F; Nogués, M. A; Asconapé, J. J; Fernández Pardal, M. M; Biller, J. Tratado de neurología clínica. Argentina: Editorial Médica Panamericana; 2002.
• Voyatzis Norwood, D. Hipotensión ortostática. NYU Langone Medical Center [en línea] 2012 [fecha de acceso 18 de abril del 2013]. URL disponible en: http://www.med.nyu.edu/content?ChunkIID=104084
• Cleveland Clinic. [Monografía de internet]. [Fecha de consulta 18 de abril de 2013]. Disponible en http://my.clevelandclinic.org/es_/disorders/orthostatic_hypotension/hic_orthostatic_hypotension.aspx

6. Geriatric syndromes

Geriatric syndromes are a set of symptoms originated from the combination of a number of diseases that have their expression through pathologies non-framed in common diseases.

The 13 geriatric syndromes were defined by Kane and include:

• Immobility
• Instability
• Incontinence
• Intellectual impairment
• Infection
• Inanition
• Impairment of vision and hearing
• Irritable colon
• Isolation (depression)/insomnia
• Iatrogenesis
• Immune deficiency
• Impotence

They follow a series of features such as: multiple disorders, multifactorial cause, onset and rapid progress, minimal clinical manifestations, sensitive to infection / dehydration / accidents, more severe in intensity of tissue damage, irreversible immobility syndrome, tendency to chronicity processes, mental confusion, acceptance of disability by the patient and family, iatrogenic responses, denial of symptoms and unfavorable prognosis.

The malnutrition 

Then I will focus on a major geriatric syndromes mentioned above, such as is the malnutrition (hunger).

Malnutrition is pathological disorder of nutrition resulting from inadequate intake of one or more essential nutrients resulting in a caloric deficit and protein. 

The causes of malnutrition in the elderly are numerous and can be grouped into: 

• Physiological causes:
• Deterioration of the senses: taste, smell and sight.
• Alterations in the oral cavity: mouth, teeth and gums are damaged, and even wear poorly fitting dentures and they cause mouth sores. Besides this, painful mouth can be caused by stomatitis, glossitis or esophageal candidiasis.
• Digestive disorders: decreased ability to chew and swallow or decreased salivary secretion.
• Psychosocial causes:
• Loneliness, boredom, depression, widowhood..
• Limitation of financial resources.
• Pathological causes:
• Polypharmacy: causes problems such as: changes in appetite, taste, constipation, weakness, drowsiness, diarrhea and nausea (among others).
• Disabilities
• Pluripathology 

Malnutrition worsens the prognosis of life and increases the risk of complications if the patient has a disease.

The Mini Nutritional Assessment (MNA) is a test that nurses make to the assessment of nutritional status in elderly patients. With this test, it is possible to identify people at risk of malnutrition.

The recommendations to develop a diet for the elderly are:

• Diets simple and easy to prepare
• Foods colorful presentation and pleasant
• Diet split into 4-5 meals a day
• The last meal (dinner) must be light
• Liquids and juices between meals were supplied (not during them).
• Moderate consumption of coffee and exciting drinks
• Do not abuse liquor and beverages sweetened
• Keep personal tastes and habits
• The timing of the intake should be an act of coexistence and social relations (where possible).

I believe that malnutrition is one of the most common geriatric problems, because the elderly when they are alone, become depressed and were "away the desire of all" and, I also believe that when a person is alone at home, the first thing that they neglected is the schedule and type of meals.

Bibliography

• Rodríguez, Ávila, N. manual de sociología gerontológica. Barcelona: Publicacions 1 edicions de la Universitat de Barcelona; 2006.
• Pubmed. [Monografía de internet]. [Fecha de consulta 18 de abril de 2013]. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/9990575
• Leturia Arrazola, F. J; Yanguas Lezaun, J. J; Arriola Manchola, E; Uriarte Méndez, A. La valoración de las personas mayores: evaluar para conocer, conocer para intervenir. Manual práctico. Cáritas; 2001.

5. Theories of aging

Aging is a series of changes that occur as we get older and that cause loss of bodily functions eventually causing death. Currently, there is no single universally accepted theory to explain this process.

One of the biological theories on aging is the free radical theory, which began developing Gerschman and Harman (though they weren't the only).

To begin to explain the theory, the first thing we need to know is that free radicals are unstable molecules produced by normal cellular metabolism or after exposure to radiation and contamination.

These molecules, in addition to be the causative of several of cellular oxidative processes (by reaction of oxygen with organic substances) react with various enzymes and proteins causing a disorder of the capacity of the cell to function normally, so that tissues are damaged body and the outer cell membranes. All this leads to a cumulative effect of free radicals and a decrease in physical availability of antioxidants.

Besides all this, it's known that free radicals also have an effect on DNA, since we don't have all the DNA in the chromosomes, if not that much of it is located inside the mitochondria. This mitochondrial DNA is particularly vulnerable to damage by free radicals because it is closely related to oxidative reactions. Therefore, any damage to the DNA will have a serious effect on the proper functioning of cells (reaching even cause mutations).

Another theory we know today, is the theory developed by Bürger, in that he established that there is a relationship of free radicals in the formation of inter-and intramolecular junctions (cross-links) to the DNA and collagen, resulting the formation less permeable membranes, thus hindering nutritional level exchanges of organs and tissues.

Other authors related the autoimmune reactions with the formation of these crosslinks because  deteriorate the immune system.

Finally, we know that lipofuscin is a pigment derivative of lipid peroxidation, and is also a sign of cell aging caused by the action of free radicals. Normally, lipofuscin accumulates in differentiated cells and exerts its action on unprotected parts of the epidermis and produced colored spots. Furthermore, atrophy sweat and sebaceous glands causing an obstacle to perspiration and, moreover, produces dry skin. However, lipofuscin not only has an effect on the skin, but also acts on tissues, particularly in the central nervous system.

Moreover, the accumulation of free radicals and also damage cellular function, is related to diseases associated with age such as atherosclerosis, arthritis, muscular dystrophy, cataract, pulmonary dysfunction neurological disorders, immune system decline even cancer.

Today, we have several studies that suggest that the use of antioxidants (such as vitamins A, C, E and carotenoids) reduces the formation and hence the action of these free radicals.

In my opinion, this theory itself does not meet the whys of aging. I think to associate with others to explain the aging process in its entirety.

Bibliography

• García Hernández, M; Torres Egea, Mª P; Ballesteros Pérez, E. Enfermería geriátrica (2ª edición). Barcelona: Elsevier Masson; 2006.
• Guillén Llera, F; Ruipérez Cantera, I. Manual de geriatría. Barcelona: Masson; 2003.
• Lefrançois, G. R. El ciclo de la vida (6ª edición). México: Thomson; 2005. 
• Medline. [Monografía de internet]. [Fecha de consulta 13 de abril de 2013]. Disponible en: http://espanol.ninds.nih.gov/trastornos/esclerosis_lateral_amiotrofica.htm
• Mishara, B. L; Riedel R. G. El proceso de envejecimiento (3ª edición). Madrid: Ediciones Morata; 2000.
• Pubmed. [Monografía de internet]. [Fecha de consulta 13 de abril de 2013]. Disponible en:  http://www.ncbi.nlm.nih.gov/pubmed/23434764
• Céspedes Miranda, E; Rodríguez Capote, K; Llópiz Janer, N; Cruz Martí, N. Un acercamiento a la teoría de los radicales libres y el estrés oxidativo en el envejecimiento. Rev cubana invest bioméd Vol.19 (n.3). Cuidad de la Habana: 2000.
• Youngson, R. Antioxidantes y radicales libres. Madrid.

4. Basic needs from the elderly

The assessment from the elderly needs, as I explained in the entry 3.1 (clinical and functional), we make it through the 14 basic needs described
by Virginia Henderson.

1. Need of Respiration and circulation
2. Need for nutrition and hydration
3. Need of elimination
4. Need of Movement
5. Need to rest and sleep
6. Need to dress and undress
7. Need for Maintenance of body temperature
8. Need for hygiene and maintenance of skin integrity
9. Need for security / avoid the risk
10. Need of communication
11. Need of beliefs and values
12. Need for self-realization
13. Need to recreate
14. Need to learn

Regarding the need for security/avoid the risk, it is highly recommended to follow a set of instructions (which I will mention below), to prevent any accidents in the home.

• Kitchen: is highly recommended that patients have near the tools that will required, the cabinets to a height that they won't need to use chairs to get what they need. Likewise, it is also important that, while they been cooking, let the pans with handles inside (to avoid burning) and always had tagged all cleaning products (not to lead to mistakes).
• Bathroom: It is very important to have an anti-slip (or shower mats) in the shower and in the bathtub, in addition to having railings and even a seat for more comfort in the cleanliness (and to prevent slips / falls). It is also important to have railings at the sides of the toilet . Moreover, in patients with cognitive impairment, it is advisable to avoid the mirrors (as they can be reflected and frightened because they don't recognize themselves).

• Corridors: it is very important that are well lit, with no objects that may obstruct the passage (furniture, cables, etc.) and remove carpets (or if you want to be this, you must have it stuck firmly to the ground to prevent falls). Furthermore, it is recommended that the electric outlet are at a suitable height, that corners are protected and to have a non-slip floor. Finally, as I mentioned in the bathroom, if the elderly suffer cognitive impairment, have to remove the mirrors and pictures. Do not forget that it is highly recommended to have handrails on both sides of the aisle and to had night lights (that the elderly can switch on when they need to go to the bathroom during the night).
• Rooms: As I mentioned above, you must remove the carpets (or stuck them firmly to the floor) and remove also the obstacles that hinder the passage. Is also strongly recommended to have the bed / armchair / sofa without quilt hanging on the sides. Likewise, it is also important to have the bedside table in a place where the elderly can't hit during the sleep or when they wake and to have a lamp that they can turned off easily from the bed (because if the plug is far from the bed , it is possible that the elderly when they return to the bed in the dark can be hit / fall).
• Medications: Medication must be well organized and in their boxes. We
  strongly recommend that the elderly use pillbox daily / weekly (depending on the amount of medication that they take), in addition to a list of the medications that they take daily (and dosages). It is also vitally important that seniors know the medications that they take (they must know the name, since no use saying: "I take a pill blue and white", or.. "another tiny orange" ...) if ever they have to tell all his medication to the medical staff (because we don't know all the shapes and colors of all medications).
  

In addition to these tips, it is advisable to give a number of indications to the elderly:

• Become an annual medical examination which will check the view.
• Make exercise regularly to strengthen muscles and improve balance and coordination.
• Do not get out of bed abruptly, be sitting a few seconds.
• Use non-skid soles and shoes are that fit your foot well (avoid thongs or open house slippers).
• Having pointed and near the phone the numbers of emergency service.
• Avoid smoking at home and especially in bed.
• In the event that the patient begins to suffer from a cognitive impairment, is advisable to use appropriate pictograms indicating the rooms and equipment

In my opinion, it's very important to eliminate all hazards in the homes of patients. It seems very important that from the nursing, recommendations are given about all the changes that must be made at home to avoid any accidents.

Bibliography

• Stevens J. A; Olson, S. E. Lista de comprobación para evitar caídas. Manual para ancianos.
• Lista de seguridad para personas de la tercera edad sobre la prevención de caídas en el hogar. [Artículo de internet]. 2005. Revisado de: http://www.cdc.gov/ncipc/pub-res/toolkit/Falls_ToolKit/DesktopPDF/Spanish/booklet_Spa_desktop.pdf
• FCA. Family Caregiver Alliance. [Monografía de internet]. [Fecha de consulta 13 de abril de 2013]. Disponible en:  http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1408
• Medline. [Monografía de internet]. [Fecha de consulta 13 de abril de 2013]. Disponible en:  http://www.nlm.nih.gov/medlineplus/spanish/ency/article/007428.htm
• Díaz Orquendo, D; Barrera García, A. C; Pacheco Infante, A. Incidencia de las caídas en el adulto mayor institucionalizado. Rev cubana enfer Vol. 15 (n.1). Cuidad de la Habana: 1999.

3.4 Global assessment of aging: Affective assessment

When assessing the affective sphere, it's very important to establish a patient's mood, signs of anxiety and sleep and appetite disorders.

Depression is a very common disorder in the elderly because is often associated with the loss of a spouse, family or close friends, chronic pain, loss of independence or household removals. 

Normally, it's difficult to detect in the elderly, although symptoms such as anorexia or insomnia may give us a clue. However, there are a number of scales that can help us in the assessment of depression, the Corell scale for depression in dementia, the Goldberg scale of anxiety and depression, the Hamilton Depression Inventory, and finally, the scale that I go to highlight below; the Yesavage scale of geriatric Depression.

The Yesavage scale of Geriatric Depression is specifically for the elderly. There are two versions, a 15-item, and another 5 items, both with two dichotomous responses.

I think that depression in the elderly, as well as being very common, it is easy to fix. Many seniors become depressed when they feel lonely, so, I think, that if they make frequent visits and daily call (or every other day) become interested in them, they feel more "clothed" and have a happier life.

Bibliography

• Medline. [Monografía de internet]. [Fecha de consulta 7 de abril de 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/001521.htm
• Jervis, G. La depresión dos enfoques complementarios. Madrid; Editorial fundamentos: 2005.

3.3 Global assessment of aging: Mental and social assessment

When the nurses begin with the realization of the assessment of mental state, it's very important that we focus both on the field and in the affective cognitive, based on analysis of the biological, medical, functional, psychological and social factors.

Over the years, develops a cognitive impairment that, sometimes, not detected by the family until it reaches a stage where it starts to be considered dementia (also known as Alzheimer's disease).

Dementia can be defined as a loss of brain function that occurs with age and which is associated with certain diseases; is affected the memory, language and behavior judgment, therefore, the first symptoms that gives this disease is a change in one (or more) of the above issues but generally, the first manifestation is often the forgotten. However, as the disease worsens, symptoms include changes in sleep patterns and impairment in performing instrumental activities of daily living. Once dementia is very advanced, patients cannot perform alone basic activities of daily living, to the point of not knowing his family members.

In my opinion, Alzheimer's disease is one of the worst diseases that a person can suffer, because, at first, they are realizing slowly that they having forgotten and are no longer as useful as they once were . Furthermore, in advanced stages of the disease, suppose a charge for people around they.

Bibliography

• Medline. [Monografía de internet]. [Fecha de consulta 7 de abril de 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/000739.htm
• Fundación Alzheimer España. [Monografía de internet]. [Fecha de consulta 7 de abril de 2013]. Disponible en:  http://www.alzfae.org/index.php/vivir-alzheimer/cuidador-familiar/diez-reglas-oro/61-actividades-b%C3%A1sicas-de-la-vida-diaria
• Fisterra. [Monografía de internet]. [Fecha de consulta 7 de abril de 2013]. Disponible en:  http://www.fisterra.com/guias-clinicas/demencia-tipo-alzheimer/