15. Levels of care

Daycare centers for the elderly

One of the social resources for the care of the elderly are daycare centers.

These centers are a geriatric service and family support that offered during the day attention to basic needs therapeutic and socio-cultural from older people affected by certain degrees of dependency, promoting their independence.

Typically, users who request these centers are elderly people with loss of functional capacity (physical or mental).

This service provides individualized comprehensive care, attend to their personal hygiene needs, nutrition, rehabilitation, social integration, counseling, retraining in lost skills..

The objectives of this resource is aimed at the prevention of institutionalization, rehabilitation, maintenance of autonomy and support to families. Although, the main objective is to promote decent living conditions always encouraging their level of independence. Likewise, it also has more specific objectives:

• Prevent increased dependence (rehabilitative and therapeutic activities)
• Provide a framework where you can develop relationships and activities
• Avoid unnecessary and unwanted institutionalization
• Facilitate the conduct of AVD, offering the necessary help.
• Provide social support and care 

Besides all this, these centers offer programs and services that formulate objectives and activities for individualized care and interdisciplinary:

• Prevention programs and health promotion
• Programs psychological area: assessment of affective state and cognitive stimulation activities

In my opinion, all seniors, when lose a spouse or are at risk of loneliness, should belong to a day center, as they have the opportunity to be accompanied all day, interacting with the other elders, doing recreational activities, etc.. Besides all this, the family is certain that his father / mother is feeding well (since they feed there too).

Bibliography

• Rodríguez Martín, M. La soledad en el anciano. Gerokomos v.20 (n.4). Madrid: 2009. Disponible en: http://scielo.isciii.es/scielo.php?pid=S1134-928X2009000400003&script=sci_arttext
• Soldevila Benet, A. Los centros de día para personas mayores. Lleida: Ediciones de la Universitat de Lleida; 2003.

14. Urinary incontinence

One of the major geriatric symptoms is the urinary incontinence. Patients who suffer this, lose urine unintentionally, in a time and place inadequate. Likewise, occurs with frequently enough to be a hygiene problem, social and psychic to the patient. Typically, this syndrome affects more women than men.

One type of incontinence that exists is stress incontinence (grouped into chronic urinary incontinence).

This type of incontinence is an involuntary loss of urine that occurs during physical activity / Valsalva maneuver (coughing, estornudad, laughing, walking or lifting).

One of the causes related to incontinence are weak pelvic sphincter muscles that support the bladder and urethra (the sphincter can not stop the flow of urine when pressure is exerted on the abdomen). This weakness can be caused by childbirth, injury to the urethral area, medication or surgery of the prostate or pelvic area.

Risk factors for stress incontinence include female gender, labor, prolonged coughing (bronchitis, asthma), older age, obesity and smoking.

Complementary testing that can be carried out on physical examination are:

• Electromyography (EMG) to study muscle activity in the urethra or pelvic floor.
• Exam of the towel health: the patient is asked to perform physical activity while wearing a towel and, after exercise, weigh the towel to find out the amount of urine lost.
• Abdominal or pelvic ultrasound.
• Test to view the inside of the bladder (cystoscopy).
• Urinalysis (urine culture) to rule out urinary infection.
• Urinary stress test (the patient is asked to stand with a full bladder, and then cough)
• Radiography with contrast kidney and bladder

There are four types of treatment for urinary stress incontinence:

• Changes in behavior:
• Drink less liquid
• Urinating more often
• Avoid jumping and running
• Take fiber to be regular bowel movements.
• Quitting smoking (reduces coughing)
• Avoid alcohol and caffeine (stimulate the bladder).
• Medications:
• Anticholinergics (overactive bladder control)
• Alpha-adrenergic agonists (increase sphincter strength)
• Estrogens (improve symptoms of urinary frequency and urgency)
• Training the muscles of the pelvic floor:
• Kegel Exercises
• Surgery:
• Anterior vaginal repair (if the bladder protrudes inwardly of the vagina)
• Artificial urinary sphincter (mainly in men)
• Collagen injections (become thicker urethra à helps control urine leakage or seepage)
• Tension-free vaginal tape

I understand that urinary incontinence is a major problem in the elderly, but I think it is not as severe as other geriatric syndromes. Fortunately, today we have many resources and methods of prevention.

Bibliography

• Medline. [Monografía de internet]. [Fecha de consulta 30 de abril de 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/000891.htm
• Vicente Solá, D; Jack Pardo, S; Paolo Ricci, A; Enrique Guiloff, F; Humberto Chiang, M. cirugía mínimamente invasiva en el tratamiento de la incontinencia urinaria femenina de esfuerzo: TVT-O. Chil. obstet. ginecol. V.71 (n.1). Satiago: 2006. Disponible en: http://www.scielo.cl/scielo.php?pid=S0717-75262006000100002&script=sci_arttext

13. Health education in the geriatric patient

The geriatric prevention goals are to reduce mortality caused by diseases (acute and chronic), maintain the functional independence of the person, increase active life expectancy and improve quality of life.

One of the major issues in which nurses must emphasize, is the prevention of hypertension.

Hypertension is the sustained increase in blood pressure in relation to age-appropriate considerations, for patients older than 60 years, the normal BP is <160/90mmHg and hypertension is> 170/100mmHg.

Can be considered three degrees of severity of hypertension, depending on their organic impact:

• Grade 1: no visceral impact
• Grade 2, appearance of:
• Left ventricular hypertrophy
• Mild hypertensive retinopathy
• Proteinuria
• Increased plasma creatinine
• Grade 3: signs/symptoms as a result of damage to various organs:
• Heart failure
• Hypertensive encephalopathy
• Cranial hemorrhage
• Hypertensive retinopathy
• Renal insufficiency

Hypertension is an asymptomatic process, but there is sometimes mild headache, fatigue, confusion, and vision and hearing problems.

In connection with the treatment, there are two measures:

• Pharmacological:
• Diuretics
• Beta-blockers
• ACE inhibitors
• Calcium channel blockers
• Angiotensin II antagonists
• Alpha blockers
• No drug:
• Changing habits and risk behaviors
• Balanced and organized life
• Removing the tobacco consumption
• Practice physical activity
• Feeding
• Decrease alcohol, salt and coffee
• Avoiding overweight and obesity

Nursing plays an important role in the prevention of this disease, from the nursing consultation we can influence the process stages (uptake of hypertension, diagnosis and control and monitoring).

Measurement of blood pressure must be annual in:

• Patients older than 50 years.
• Patients with first-degree hypertension.
• In diabetic and hypercholesterolemic.
• Smokers and alcohol consumers.
• Patients exposed to psychosocial stress.
• Patients on antihypertensive drug treatments, hormonal contraceptives or corticosteroids.

I believe that nurses have an important role in preventing tipically diseases in the elderly. The health education is imperative.

Bibliography

• Dieter Faulhaber, H. Como prevenir y sanar la hipertensión. Medidas efectivas para su control y tratamiento. Barcelona: Ediciones Robinbook; 2007.
• Fisterra. [Monografía de internet]. [Fecha de consulta 29 de abril de 2013]. Disponible en: http://www.fisterra.com/salud/1infoConse/hipertension_arterial.asp
• Hergueta, G. Guía de hipertensión arterial (2ª edición). Madrid: ediciones Norma-Capitel; 2002. 

12. Nursing in palliative cares

"You have to give life to the hours, not hours to life."

A patient at-terminalidad is one patient who suffers from an irreversible disease without the possibility of active treatment with prognosis no more than 6 months. This situation has a great impact on the patient and family and the multidisciplinary team.

These patients have symptoms highly variable among which are:

• Pain
• Insomnia
• Nausea and vomiting
• Anorexia
• Change in bowel habits, constipation
• Dyspnoea
• Alterations in the oral mucosa

A patient at-terminalidad passes through 5 stages that were described by Dra. Kubler-Ross:

1. Denial (rejection of truth): denial is a unconscious defense mechanism that has the patient to attempt to reduce the sources of anxiety.
2. Anger and rage (recognition of truth): initial denial gives way to feelings of anger and rage: the patient becomes intolerant, irascible, and unjustly accused at the others of the situation you have.
3. Denial (commitment to truth): the patient tries to extend its life or eliminate discomfort or pain that the disease generates. Follow strictly the prescribed treatment and demands radical solutions.
4. Depression (depression): the patient is aware that the disease continues to progress and progressive weakness. Feel a sense of loss, is a depressive reaction associated with events that are going to be developing in the near future. Physical deterioration is usually the main cause of depression.
5. Acceptance (reconciliation with the truth): if the patient has been able to live and express their feelings properly supported, can enter the final stage of acceptance and resignation; assumes that its end is mint and there is no solution. It's important to respect the patient's wishes.

The overall goals of palliative care are:

• Perform proper care of the physical, psychological, social and spiritual.
• Helping the family by providing resources necessary for the patient's environment and family is appropriate to the situation.
• Respect the daily routine of the patient and family, providing adequate guidelines and commensurate with their way of life.
• Detect the information and support needs (both patient and family).
• Identify the primary caregiver and provide information on the process evaluation.
• Educate family on therapeutic aspects, nutritional information and communication with the patient and emotional care.

At this stage of life, there are patients who choose to die at home (instead of dying in the hospital). There, as in all decisions, there are advantages and disadvantages, which are:

• Dying at home:
• Advantages:
• The patient is surrounded by family, friends and personal items.
• It's in a familiar environment in which there are no rules.
• Disadvantages:
• Family claudication (tiredness, exhaustion)
• The patient receives basic care
• You cannot administer certain treatments
• Create family conflicts
• Dying in hospital:
• Advantages:
• Professional rotation
• Professional experts care
• Required very specific treatment
• Very specific necessary treatments
• Disadvantages:
• Surrounded by other patients and health professionals
• Unknown Environment
• Inflexible rules

In my opinion, when a patient reaches this stage, the nurse should prioritize their care, as it is a fatal situation in the patient and also he feels that he is dying, so confused his feelings. You should try to make reality all his wishes.

Bibliography

• AECC. Asociación española contra el cáncer. [Monografía de internet]. [Fecha de consulta 29 de abril de 2013]. Disponible en: https://www.aecc.es/SOBREELCANCER/CUIDADOSPALIATIVOS/Paginas/Objetivosdeloscuidadospaliativos.aspx
• Bermejo J. C; Díaz-Albo, E. Sánchez, E. manual básico para la atención integral en cuidados paliativos.  Madrid: Cáritas España; 2011.
• Lefrançois, G. R. El ciclo de la vida (6ª edición). Madrid: Thomson; 2005.

11. Digestive - endocrine pathology

The ostomies

A stoma is a temporary or permanent abouchement viscera to the skin surface in order to permit the release of gut contents, is an artificial communication organ surgically created abdominal wall to supply the natural route of excretion.

The ostomies are classified according to the organ that is affected:

• Digestive: it loses voluntary control of elimination, since the stoma has no sphincter
• Ileostomy: externalization of the ileum through the abdominal wall to permit the release of intestinal contents (liquid stool very irritating to the skin). It is located in the abdomen.
• Colostomy: externalization of the colon through the abdominal wall may be ascending (feces liquid / semi-liquid irritant), transverse (semisolid stool little irritating) and downstream (solid feces non-irritating), depending on the position of the exteriorized colon.
• Urinary: not change the function of the kidneys; deflect the normal course of urine. There are three types: nephrostomy, ureterostomy skin and Bricker

Hygiene and Care of the stoma:

Also on proper care of the stoma, must also maintain a correct hygienic the peristomal area; must be kept clean, dry and well hydrated.

• Removing the remains of effluents that are left in the skin, can be done with a tissue.
• Clean the entire area, including the stoma with soap and water in a circular motion from the outside towards the inside.
• Dry the area well with a towel
• Once clean and dry, replace the device.
• Open bag (which is closed by a clamp, which are collected liquid stool)
• Urostomy (which closes with a drain valve in which urine is collected)
• Closed bag (for solid stool).

Placing/removing to the ostomy bag:

• Placing the ostomy bag:
• Measure the diameter of the stroma to cut the adhesive to proper length to prevent the effluent into contact with the skin.
• If the device having two parts, after the above process, disk placed over the stoma  and then closing the pouch to adapt the lock subsequently
• Removing to the ostomy bag:
• Withdraw slowly, without jerks, just as in the placement, from bottom to top holding with the other hand always the peristomal area.
• Change to the device:
• Opened bags are emptied several times a day and changed every 24 hours.
• At night, there are bags of more capacity
• Colostomy bags are removed when the patient believes are filled; 2-3 times a day

Ostomy complications:

During the first 30 days after surgery, may appear:

• Abscess and infection: onset of inflammation and suppuration of the area.
• Nursing cares: watch the progression of symptoms and administration of prescribed treatment. Change the dressing every 24 hours
• Dehiscence: Separation between the mucosa and the peristomal skin.
• Nursing cares: care for healing every 24 hours
• Allergic dermatitis: skin injury by sensitization of device components.
• Nursing cares: Avoid positioning the device that caused the allergic reaction and try perilesional area with relevant drugs (barrier creams or dressings for healing).
• Edema: thickening of the intestinal mucosa
• Nursing cares: apply compresses with water or cold saline and check the measurement of edema to verify the improvement
• Stenosis: widening to stomal orifice below the extent necessary to ensure adequate evacuation.
• Nursing cares: measure the stoma regularly to watch their reduction, stoma dilation using a lubricant to ensure attachment to the skin and fascia
• Fistula: contamination from the intestinal light and peristomal skin which gives rise to effluent outlet
• Nursing cares: Care of the stoma and peristomal skin using a device to prevent leakage
• Bleeding: blood loss through the stoma from the peristomal area or from the own viscera
• Nursing cares: implementation of local hemostasis; compresses with cold saline and, if necessary, suture the subcutaneous vessels.
• Hernia / eventration: abdominal wall failure that causes the output of the stoma and peristomal skin, resulting in a bulge that appears when the patient stands up.
• Nursing cares: provide fiber diet to avoid constipation. Recommend the abandonment of physical effort and show massages on the abdomen.
• Necrosis: insufficient blood supply to the mucosa of the stoma; becomes black.
• Nursing cares: resect the necrotic area and, if necessary, intervene again
• Ulcers: lesions of the skin or mucosa of the stoma by improper care, skin infections, etc..
• Nursing cares: care to the wound applying cares for the healing by second intention, debridement, silver nitrate, healing dressings and exudate control, etc.. the cure is to be done every 24 hours, watching its evolution well

It is my opinion, it is very important that the patients who carrying a ostomy made the properly carried hygiene to prevent the large number of complications that may develop.

Bibliography

• Contel Segura, J. C; Gené Badía, J; Peya Gascons, M. Atención domiciliaria: organización y práctica. Barcelona: Springer; 1999.
• Fisterra. [Monografía de internet]. [Fecha de consulta 29 de abril de 2013]. Disponible en: http://www.fisterra.com/ayuda-en-consulta/tecnicas-atencion-primaria/manejo-cuidado-estomas-digestivos-urinarios-colostomia-ileostomia-ureterostomia/
• Medline. [Monografía de internet]. [Fecha de consulta 29 de abril de 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/ency/patientinstructions/000204.htm

10. Injuries and falls

Falls are very common in the elderly. They are a major cause of injury, disability and even death.

The main risks triggers of fall are:

• Age over 75 years
• Altering the stability and gait
• polymedication
• cognitive Impairment
• muscle weakness
• Decreased vision
• Chronic diseases (osteoporosis) or acute (hypoglycemia)

The consequences that have these falls in the elderly may be physical (fractures) and psychosocial (social isolation). Because of the fall, the elderly don't recover the functional level that they had before, plus they may have a post-fall syndrome (which causes decreased mobility). Pain is one of the consequences of falls.

The recommendations of evaluating elderly patients after suffering a fall are:

• Anamnesis
• Number of falls
• Place of the last fall
• Activity
• Symptoms
• Consequences
• Comprehensive geriatric assessment
• Biomedical Assessment
• Functional Assessment
• Mental evaluation
• Social Assessment
• Association of geriatric syndromes
• Physical Examination
• Cardiovascular
• Neurological
• Locomotor apparatus
• Exploring the sense organs
• Visual System
• Auditory System
• Exploration of balance and gait
• Complementary examinations
• Environment Assessment

I think that it's  very important the prevention of falls in the elderly, because, at his age, not so easy to find physical form they had before the fall.

Bibliography

• Macías Núñez, J. F. Geriatría desde el principio (2ª edición). Barcelona: Editorial Glosa; 2005.

9. Neurological diseases: cognitive impairment and dementia

The cognitive level changes are attributed to multiple factors associated with aging, which may be regarded as extrinsic (psychiatric disorders, cultural isolation, sensory disturbances and the aging process itself) and intrinsic (functional reserve and brain structure, genetic background and level of adaptation to changes during the life).

Delirium

The confusional acute syndrome, also called delirium, is an alteration in mental status that is characterized by acute and reversible. It is one of the most important cognitive disorders in the elderly.

These patients require more attention from professionals, because an agitated patient is difficult to manage and are at risk of falls and fractures.

It should be very careful in diagnosing impaired elderly, as it is very easy to attribute mental deterioration to a progression of underlying disease. The delay in diagnosis can be fatal.

It usually occurs a prodrome characterized by restlessness, hypersensitivity to visual and auditory stimuli and reversal of sleep rhythm / monitors, as well as nightmares and insomnia.

The predisposing factors are multifactorial:

• Aging
• Decreased vision and / or hearing
• Mental / physical illness (Parkinson's, dementia, depression ..)

There are other factors have a multiplicative effect rather than summation:

• Adverse reactions to drugs
• Benzodiazepines + alcohol
• Environmental factors (temperature change, overstimulation, lack of sleep, fatigue..)
• Trauma or recent surgery (especially hip)
• Renal or hepatic
• Infections

The main characteristics of delirium are:

• Acute onset fluctuations throughout the day
• Disorientation in space and time
• Inability to maintain attention to external stimuli; are easily distracted
• Impairment of short-term memory
• Visual hallucinations or misinterpretations
• Altered level of activity: agitation, wandering, restlessness ..
• Language disorders: vague, incoherent
• Disorganized thinking (distorted)
• Variable Humor

One of the characteristics of the treatment is the prevention, that consists in:

• Minimize or avoid the use of anticholinergic drugs, sedatives and narcotics
• Maintaining good hydration and oxygenation
• Treat early medical complications
• Have a careful nursing management and continuous
• Physical environment quiet and guidance elements (clock, calendar ..)
• Family company

I believe that delirium is one of the age-related pathologies common suffering these patients. Likewise, I also think that it's very important to recognize this early, as many time can be confused with dementia.

Bibliography

• Nogales Gaete, J; Donoso, A; Verdugo, R. N. tratado de neurología clínica. Santiago: Editorial universitaria; 2005.
• Guías en demencia. Conceptos, criterios y recomendaciones para el estudio del paciente con demencia. Barcelona: Editorial Masson; 2003