PRESSURE ULCERS

This type of wounds is a damage in the skin and other tissue around of the skin that is caused by pressure in much time.

These njuries is produced in old man with immobility and more than 70% appear in old man with more than 70 years.

It’s important to know that 95% of PU is avoided, and the best actuation we can do is the prevention in risk factors.

The areas more damaged are bone protuberance, like sacrum and upper part of the femur.

RISK FACTORS

Pathological:

  - Skin damages.

  - Oxygen transport upset.

  - Nutritional deficits: overweight, anemia, thinness.

  - Cancer, infection.

  - Coma, confusion or drugs.

  - Fracture, brain damage.

  - Sensorial deficit.

  - Urinary and fecal upset.

Treatment:

  - Immobility.

  - Chemotherapy and radiotherapy.

Situational:

  - Hygiene absence.

  - Wrinkle in the clothes.

  - Immobility caused by pain or fatigue.

By the environmental:

  - Absence of sanitary education.

  - Absence of rules in the planning to the treatment.

  - Overloading of work.

CLINIC EVALUATION

To evaluate the pressure ulcer risk we use two scales: Braden and Norton.
Braden Scale has a specify of 64 – 77%.

Norton Scale has a specify of 61 – 94%.

Localization of the wound
In the consult, we must do a global valuation, and localize and count the ulcers. We evaluate the next notes:
  - Ulcer’s precedent.
  - Personal, family and pharmacology precedents.
  - Physical exploration.
  - Treatment plain.

Define the state of the ulcer
We use the classification of Byrne and Feld that contain 4 states (this classification doesn’t include the necrotic tissue.

Before to evaluate the state, we have to move away the necrotic tissue.
  - State 1: erythema doesn’t disappear and the epidermis is intact.
  - State 2: ulcer like an abrasion or crater less deep.
  - State 3: injury or necrosis of the subcutaneous tissue.
  - State 4: affected to the muscle and maybe the bone.

State 1

State 2

State 4

State 3

Area and volume of the ulcer
Include information about the area and the volume. This last is realized by the Wolter and Cols. Technique.

This technique consist in introduce serum in the ulcer and count how much serum there is in the wound.

TREATMENT
In this video is explained the ulcers, their states and all the treatment.

Cleanliness:
We use serum with a syringe in the wound directly. We only use antiseptic when:
  - Wound with lifeless tissue that is going to be debridement.
  - Ulcers with infection by Acinobacter

Debridement:

• Surgical: move away lifeless tissue with a surgical technique. Its needed expert professional and asepsis. Video
• Enzymatic: in dry ulcers we use “colagenasa, estreptoquinasa y fibrolisina” before the debridement. Video
• “Autolítico”: is a wet heal to promote the immune system to destroy the necrotic tissue. Video

DRESSING
“Hidrogeles”: 
  • Ulcers with necrotic tissue. 
  • It has to cover with other dressing. 
  • Promote the debridement.

“Hidrocoloides”:
  • Treatment to vascular and pressure ulcers with less exude.
  • Protect the wounds.
  • This dressing can wet it.
  • When the dressing contact with the exude, it forms a gel that alleviate the pain.
  • Not use in case of infection.
  • Move away in 3 or 4 days.

“Alginatos”:

• Highly absorbent.

• Vascular and pressure ulcers, burns and exudative and infect injury.
• It has to cover with other dressing.

Foam:
  • Highly exude.
  • Compressive therapy.

“Hidrocapilares”:
  • Levels exude highly.
  • It absorbs great exude.

Antimicrobial dressing of silver:
  • In infect ulcers.

Foam

Hidrogel

Hidrocapilar

                                                  











VASCULAR NURSE EXPLORATION
  - Color and temperature of the skin: cold, pallid, red, cyanotic.
  - Atrophy cutaneous, necrosis, gangrene, arterial ulcers…
  - Ploy exploration: Allen test (video, upper extremities) and Samuels’s arch ischemic (lower extremities).

Ankle and arm rate
  - Define the arterial ulcer and classify it. Video

With this chart you can calculate the result.

Depend of the result:

  - 0,9 – 1,3: repeat it between 2 or 3 years.

  - > 1,3: control de risk factors. Periodic revisions, care of the feet.

  - 0,5 – 0,89: exercise, drugs, care of the feet.

  - < 0,5: move on vascular surgery.

When I was in my first practice, in surgery floor and in medical center, the ulcers were treated correctly, because they use the dressing according to the exude, infection, state… But I never saw if the nurses measured the ulcers.

DIABETIC FOOT
Include the diseases causes by ischemic, neuropathy or infection. These can cause the apparition of ulcers because of a traumatism.

Wagner classification:

Risk factors
  - Neuropathy.
  - Infection.
  - Tobacco and alcohol.
  - Feet alterations.

Education to the patient

• Inspect the feet, their colors, wounds, blister or some graze.
• Prevent the injuries: always wearing some type of shoes, never barefoot; avoid burns, use adequate utensils to the hygiene of skin and nails.
• Wash with tepid water, soap with neutral pH, meticulous drying and moisturize the skin.
• To cut the nails: after de shower, straight.
• Wounds:  wash the wound, dry it and use antiseptic.

NUTRITION
According to some articles, like Revisión sistemática del soporte nutricional en las úlceras por presión or Valoración del riesgo de úlceras por presión en una Unidad de geriatría, the nutrition is very important such as in prevention as in treatment of ulcers.

The patients who are more nourished, the healing of their ulcers are faster than the patients who are undernourished.

I think this point is very important because when the patients are hospitalized is our labor to give their correct nutrition and evaluate their nutritional state.

Finally this subject is too important because in Spain the population is very old and there are a lot of old people who require special cares comparing with young people.

GERIATRIC SYNDROMES

In geriatric pathologic process, there are many symptoms that don’t appear like in young people. There are some symptoms as depression, pain, disorientation, dehydration… that repeat in many diseases.

Stomachache and thoracic pain are important to look after, because it can mean important diseases. 

The fever in old people is symptom of infections and other generalized upsets.

In the article Geriatric Syndromes: Clinical, Research and Policy Implications for a Core Geriatric Concept. In this, it is explained the Geriatric Syndromes, their risk factors, and the rule to this syndromes.

I think it's important to know the factors risk to prevent these diseases and provide to the patients the best cares.

Effects of pain:

  - Depression.

  - Decreased of socialization.

  - Changes in dreams.

  - Increased of costs and used of health services.

To measure the pain we must use the EVA scale. 

My view about the pain is imprecise yet, because the pain is very subjective for each person. Every person had had differents pains in differents ages, and differents capacity of resistance to the pain.

But, on the other hand, I think we must treat all types of pain, because we don't feel the pain and we don't know if the grade of pain is more or less that the patient say.

Urinary and digestive problems

The urinary problems most common in the ageing are polyuria, “nicturia” and “polaquiuria”.

If these are served with dysuria, it will be urinary infections.

Regarding digestive problems, the most common diseases are: heartburn, aerophagia and burps, intestinal obstruction and colecistitis.

Fatigue and debility

It could be a sign for anemia, infection, depression, dehydration or second effect for a drug. The edema in limbs it cause by the immobility too.

RISK FACTORS

• Organic origin: hypertension, malnutrition, incontinence and difficulty sensorial.
• Environmental origin: immobility, alcoholism and polimedication.
• Relational risk: solitude, insomnia and disorientation.

GERIATRIC SYNDROM

Group of diseases are expressed by pathologic symptoms that not are included in usual diseases.

  - Infections.

  - Instability.

  - Urinary and fecal incontinence.

  - Intellectual impairment.

  - Inanition.

  - Impairment of vision and hearing.

  - Irritable colon.

  - Isolation.

  - Iatrogenesis.

  - Immune deficiency.

GERIATRIC SYNDROME CHARACTERISTICS

  - Most pathologies.

  - Lot of factors.

  - Diseases fast progress.

  - Sensible to infections, dehydrations, anemia, malnutrition and accidents.

  - Immobility syndrome.

  - Apathy, depression and mental confusion.

  - The prognosis is not much favorable.

Diseases geriatrics

  - Psychic dependence.

  - Iatrogenic.

  - Immobility syndrome: ulcers, incontinences, constipation.

I have found a Guide to Geriatric Syndromes where are defined the most common of this syndromes and their cares. This guide is from New York, so we can compare our cares with their.

NURSING PROCESS ATTENTION

Aims:

  -  Identify the health state of the patient.

  -  Establish care plane.

  -  Provide specific interventions to solve these necessities.

Virginia Henderson’s cares.

Help the person in the realization of these activities that contribute to their health, recovery or calm death.

Maslow's pyramid

To plan in geriatrics

Use the dates of the evaluation to elaborate a plan care. Stages:

  •  Assignment of priorities.

  •  Establish the aims.

  •  Plan the strategies.

  •  Redact the orders.

  •  Redact the care plan.

Execution

This stage is done by the nurse, patient, family, community or other professional. The purpose is catching the objectives.

Stages:

         1.      Reassessment of the patient.

         2.      Validation of the care plan.

         3.      Determining the necessity of attendance.

         4.      Execution of strategies.

         5.      Communicate of the actions.

    

Evaluation

In this stage we know the effect that we have done in the patient and the efficiency of our care plan. According to Virginia Henderson, the necessities of geriatric patients are:

         1.  Breathing normally.

         2.  Drinking and eating adequate.

         3.  Eliminate for all our corporal tracts.

         4.  Maintain a good corporal alignment.

         5.  Sleep and rest.

         6.  Use adequate clothe, dress and undress.

         7.  Normal corporal temperature.

         8.  Maintaining good hygiene.

         9.  Avoid environmental risks.

        10. Communicate.

        11. Having beliefs and principles.

        12. Be busy.

        13. Participate in recreational activities.

        14. Learning, finding and satisfy the curiosity.

Breathing normally

     Care nursing:

         - Avoid fatigue.

         - Promote the exercise.

         - Control de weight and the liquids.

         - Teach to cough.

         - Avoid the tobacco.

Drinking and eating suitably

Care nursing:

  - Control de nutrition.

  - Help in the hygiene of the food.

  - Teach a diet.

Elimination

Care nursing:

  - Intestinal training.

  - Bladder training.

  - Cares in the intestinal incontinence.

  - Help with the hygiene.

  - Establish a timetable for ingest of liquids.

  - Avoid irritant drink.

  - Diet rich in fiber but poor in grease.

Maintain a good corporal alienation

Care nursing:

  - Improve corporal mechanism.

  - Control the energy.

  - Promote the exercise.

  - Teach activities and exercises.

  - Relax the musculature.

  - Valuate the home’s condition.

  - Valuate the emotional state. 

  - Observe the positions.

 Sleep

 Care nursing:

      - Control ingest of liquids.

      - Increase physical activity.

      - Promote comfortable clothe to sleep.

      - If there are big changes in this situation, derive to a specialist.

Dress and undress

Care nursing:

  - Valuate the capacity to dress, hygiene.

  - Adjust recommendations to the clothes and footwear achcording to the patient’s economy.

  - Inform about using natural cloth and to wear clothe and footwear adequate to the temperature.

Temperature

Care nursing:

  - Control de temperature.

  - Application hot or cold.

  - Treatment the fever or hypothermia.

  - Do exercise.

  - Avoid exposition to sunlight.

  - Control ingest of liquids. Avoid the alcohol.

  - Use adequate cloth.

  - Protect zones exposed to the sunlight.

   Maintaining good hygiene

   Care nursing:

     - Promote mouth hygiene.

     - Special attention to the feet: nails, use pumice stone..

     - Prevention the ulcers or other wounds.

Avoid environmental risks

Care nursing:

  - Exercise therapy.

  - Use of drugs.

  - Control of the medicines.

  - Information about helps like: canes, hearing aid...

Communicate

Care nursing:

• Promote the comunication.
• Promote the socialization.
• Give them information about places where they can interact whit other people.

Having beliefs and principles

Care nursing:

  - Inform about the importance to have balance espiritual.

    Be busy

    Care nursing:

       - Look for activities.

       - Group therapy.

       - Family suport.

    Learning, finding and satisfy the curiosity

    Care nursing:

      - Sanitary education.

      - Teach about the disease.

      - Valuate cognitive function.

I think Virginia Henderson’s cares are very important, but we, in many cases don’t use it because we have much patients and not much time.

    

    When I was in the medical center in Zaragoza I only use these evaluation for my PAE, so in my opinion, it would must necessary to reduce the patients that go to the consult in the same day. With this we expend more time in each patient and the attention will be better.

GLOBAL GERIATRIC EVALUATION

It’s a diagnosis process that detects de problems, needs and the capacity of the old age, such us mental, functional, clinical and social aspects.

OBJECTIVES

  -  Progress the diagnosis.

  -  Found problems that before we didn’t found.

  -  Progress the functional and cognitive state.

  -  Progress life quality.

  -  Know the family surrounding.

  -  Reduce the mortality.

Physical clinical evaluation

  1. Interview.

  2. Questions about de geriatric symptoms.

  3. Pharmacological story.

  4. Nutritional story.

  5. Physical exploration.

  6. Exploration complement.

  7. Do a list with problems and care nursing.

Geriatrics symptoms

  -  Immobility.

  -  Skin integrity.

  -  Altered intelligence.

  -  Instability.

  -  Incontinence.

  -  Immunodeficiency.

  -  Sensorial insufficiency.

  -  Poverty.

  -  Fateful.

ANAMNESIS

The nurse must be attentive to the next limitations:

1. Communication: do short interviews, speak to their high, give their time to answer us, talk with the family or principal career to get more information.
2. Symptoms description: the signs and symptoms are diffused, so we must ask their easy questions. With these questions we are going to do the Henderson's valuation.
3. Numerous grumbles: they mix the symptoms so we listen all of theme, we ask many times, and classified the pathologies according to the priority and gravity.

The next sections must be included in the anamnesis:

• Personal history: diagnosis, hospital admits, surgeries, nursing actuations in the past. 
• Henderson’s valuation: cardiovascular, respiratory, nervous, tegumentary, digestive, endocrine and genitourinary system.
• Pharmacological history: treatment and dose in the last year and in the moment of the evaluation. With this we want detect symptoms of the secondary effects of the medicines.
• Nutritional history: diet, number of lunches per day, prescript diet. In this case we can use the Mini Nutritional Assessment (MNA). If the patient has more than 17 points in this test, there is a malnutrition risk.

Sometimes, do the anamneses is so difficult because the patients have some incapacities, like deafness, expression difficulty, physic problems…

For that, we have to take the time they need to complete de anamneses. If it’s necessary, talk to them with signals, opening the mouth to a better understanding and looking directly face to face.

I think we don’t waste time on this interview because in medical center the nurse and the doctor have much patients and not much time. 

But in my view, we should expend more time in this because we can extract much information that is as important as we extract with de physical exploration. 

PHYSICAL EXPLORATION

The first we do is: evaluate the physic aspect, personal care, cleanliness and hygiene. After that, we take his the vital sign.

• Blood pressure, weight, height, temperature.
• Skin: look for skin injury, ulcers or carcinomas.
• Head and neck: palpate arteries, visual acumen, cataracts, visual hearing and palpate the thyroid.
• Thorax: breathing pattern, capacity to cough, cardiac auscultation, analyze women’s breasts.
• Abdomen: look for masses, hernias, rectal touch and gynecologic exploration.
• Nervous system: motor role, balance, march, sensitivity, motor coordination and trembling.
• Vascular periphery system: pulse and varicose veins.
• Musculoskeletal exploration: deformities, mobility’s limitations, crunches, atrophies and swelling.

LABORATORY

  -  Complete hemogram.

  -  Biochemistry.

  -  Blood in faeces.

  -  ECG.

  -  Mantoux and X – ray.

  -  Mammogram.

With this valuation we collect information about de capacity of the elderly person to do their common activities, like have a shower, eat, cook, get dressed…

To do this evaluation we use scales. The most important are: Lawton and Brody scale, Katz scale and Barthel scale.

It’s important know that when the functional rank reduces there are many things that increases:

  -  Mortality risk.

  -  Hospital admits.

  -  Medical visits.

  -  Drugs consumption.

  -  Necessity of social ways.

MENTAL AND SOCIAL VALUATION

• 25% elderly person suffers some psychic diseases.
• Anxiety and depression are the most common diseases in this age.
• Biologic factors: family precedent, changes in the neurotransmission associated to the age, sex and race.
• Medical factors: diseases, chronic diseases associated to de pain and terminal diseases.
• Functional factors: if they interact with the depression, the prognostic will be negative.
• Psychic factors: alcoholism, anxiety and dementia.
• Social factors: widowhood, hospitalization, loneliness, death of a close person.

In some occasions, depression, anxiety… is hidden by other physical diseases and is such as important like the other and we have to treated it too.

Clinical interview

We star the interview when the patient enters in the office. We’ll talk with the family too.

• Interrogate about family history, profession, drugs, the reason why the he comes, problems in recognize of friends and the family.
• Language.
• Deliriums, excitements, hallucinations and roam.

Here, there are the most common scales: 

  •  Pfeiffer questionnaire. 

  •  Mini – mental State Examination of Folstein (MMSE). 

  •  MEC.

  •  Clock Test.

SOCIAL EVALUATION

The most common scale is: ORS scale. This scale provides information about: family structure and social resources, economic resources, mental health, physic health and capacity to do AVD.

EMOTIONAL CAPACITY VALUATION

The nurse must ask about:

  -  Emotional state.

  -  Appetite upset.

  -  Dream upset.

  -  Signs of anxiety.

  -  Concept of death.

The scales we use are:

  -  Yesavage depression scale. 

  -  Hamilton depression scale. 

  -  Goldberg depression and anxiety scale. 

THEORIES OF AGING

BIOLOGIC THEORIES

Biologic theories treat to explain the physical changes of aging.

1. The programmed theory: every person has a "biologic clock" that starts ticking when we born.
2. The rut - out - program theory: we have a limit of genetic material.
3. The living theory: we have a finite numbers of breaths or hearts beats.
4. The gen theory: we have on or more harmful genes that limiting the life span.
5. The molecular theories: the aging is controlled by genetic materials that are encoded to predetermine growth and decline.
6. The error theory: an error in ribonucleic acid and protein synthesis, cause errors in cells in the body. the result is a progressive decline in biologic function.
7. The somatic mutations theory: the chemical or radiation can cuases damages in the deoxyribonucleic. This damage causes chromosomal abnormalities.
8. The free radical theory: free radicals are unstable molecules produces by the boy during the normal metabolism or following exposure to radiation and pollution. These free radicals are suspected to cause damage to the cells, DNA, and the immune system. Excessive accumulation of free radicals are suspected to cause free damage to the cells, DNA, and de the immune system.
9.       The cross line (connecitve tissue theory): molecules from AND and connective tissue interact with free radicals to cause bonds that decrease that ability if tissue to replace itself. These results in the skin changes typically attributed to aging such as dryness, wrinkles and loss of elasticity.
10.      The clinker theory: chemicals produced by metabolism accumulate in normal cells and cause damage to body organs such as the muscles, heart, nerves and brain.
11. The neuroendocrine theory: with age the hypothalamus appears to be less precise in regulating endocrine function leading to age related changes such as decreased muscle mass, increased body fat and changes in reproductive function.
12.     The immunologic theory: the immune system weakens over the time making an aging person more susceptible to disease.

    Other theories are published in the article Moder Biologic Theories of Aging by Kunlin Jin (click here to see it) explain that are two theories:

•    Programmed theory: aging follows a biologic timetable (a continuation of the one that regulates childhood growth and development). This regulation would depend on changes in gene expression that affect the systems responsible for maintenance, repair and defense responses.
•      Damage or error theories: emphasize environmental assaults to living organisms that induce cumulative damage at various levels as the cause of aging.

      PSYCHOSOCIAL THEORIES

1.     The disengagement theory: explain why old persons separate from the mainstream of society. Older people are separated, excluded or disengage from society because that aren't perceived to be benefint to the society.
2.     The activity theory: active participation in physical and mental activities helps maintain functioning well into old age.
3.     Life course theories: these trace personality and personal adjustment throughout a person’s life. Many of these theories are specific in identifying life oriented tasks for the aging person. There are 3 theories:

        Erikson's theory: identifies six stages of developmental tasks than an individual must confront throughout the life span: trust vs mistrusts, autonomy vs shame and doubt, initiative vs guilt, industry vs inferiority, identify vs identify confusion, intimacy vs isolation, generativity vs stagnation, integrity vs despair.

    

         Havighurt's theory: details the process of aging and defines specific tasks for late life.

       Jung's theory: proposes that development continues through life by a process of searching, questioning and setting goals thar are consistent with the individuals personality.

      IMPLICATIONS FOR NURSING

    

      Nursing can help individuals achieve the longest healthiest live possible, promoting good health, maintenance practices and a healthy environment.

Psychosocial theories help explain the variety of behaviors seen in the aging population. Understating all of these theories can help nurses recognize problems and provide nursing interventions.