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.

CHANGES

PHYSIOLOGIC CHANGES

The WHO defines de health as a physical mental and social well-being and not merely the absence of disease

The ageing process represents the biological changes without influence of environmental, diseases or other factors. This process is natural and not all this changes are bad.

The process of ageing is influenced by the environmental, lifestyle and deseases.

The old age, depend of the country, culture and genetic. In most countries, the old age becomes when they finish the job.

I think, in many countries the old men are very valued and respected in Africa, China, Japan… than in other countries (like Spain, or some countries of Europe). In this book La vejez desconocida. Una mirada desde la biología a la cultura (page 18 and further on) are explained different cultures of ageing in different countries. We can see, when someone of this cultures achieve the old age, are more important that the youngers.

In my view, in Spain, the old men see them like a burden to the society because they loss their work, loss capacities with the ages… so we must extol more the figure of old men. They are such as important like young people.

BIOLOGIC CHANGES

Integumentary system: the epidermis becomes more fragile so it can cause skin damages (tears, maceration and infection).

• Liver spots are seen in the areas that are more exposed to the sunlight.
• Hair color: it tends to become gray and be thinner, as pubis and axilla hair. The change of hair color is hereditary.
• Decrease subcutaneous fat, that it increases the probability of traumas.
• Increased androgen/estrogen ratio that it causes the increased of facial hair in women.

Care strategies:

1. Provide adequate fluid to prevent dehydration.
2. Institute measures to reduce pressure over bony prominences; possible dermatology referral
3. Keep skin dry. Pad surfaces to reduce friction. Report abnormal observations for treatment.
4. Modify skin care reduce drying. Refer to podiatrist.

Liver spots

Liver spots

Graying

The musculosketal system

• Decrease bone calcium, increased osteoporosis.
• Decreased fluid in intervertebral disks.
• Decreased blood supply to muscles, decreased muscle strength.
• Decreased muscle mass.
• Osteoporosis: porus, brittle and fragile bones that are susceptible to breakage.
• Osteoarthritis: the cartilage on the bone’s articulating surfaces this and begins to wear out.
• Rheumatoid arthritis: is an autoimmune process and a collagen disease. This process causesinflammation of the synovial damage to the cartilage and bone.
• Bursitis: inflammation of bursa and the surrounding fibrous tissue can result from excessive stress on a joint or from a localized infection. This problem can occur at any age.
• Gouty arthritis: is caused by an elevated level of uric acid in the body. Crystals of these acid cause episodes of severe painful joint swelling.

Osteoporosis

Rheumatoid arthritis

Rheumatoid arthritis

Bursitis

Bursitis

Gouty arthritis

Gouty arthritis

The respiratory system:

• Decreased body fluid.
• Decreased number of cilia.
• Decreased muscle strength and endurance.
• Decrease number of capillaries.
• COPD (chronic obstructive pulmonary disease): it’s a group of 3 respiratory disorders: asthma, emphysema and chronic bronchitis. Symptoms: productive caught, wheezing, cyanosis and dyspnea on exertion.
• Influenza: is a contagious respiratory infection caused by a variety of influenza viruses.
• Pneumonia: acute inflammation of the lungs caused by bacterial, viral, fungal, chemical or mechanical agents. 

  Viral pneumonia: headache, fever, aching muscles and cough with mucopurulent sputum.

  Bacterial pneumonia: abrupt and dramatic in onset, tachycardia, and tachypnea.

In this image you can see the Pneumonia physiology. In this page ( Pneumonia) you can find the causes, symptons or treatments about this disease.

Care strategies:

1. Position to facilitate ease of respiration. Encourage incentive spirometry.
2. Encourage adequate fluid intake and smoking cessation and avoidance of environmental  pollutants.
3. Teach careful hand washing and disposal of contaminated secretions.

The cardiovascular system:

• Decreased cardiac muscle tone.
• Increased heart size left ventricular enlargement.
• Decreased cardiac output.
• Decreased pacemaker cells.
• Increased incidence of vascular sclerosis.

   

In this picture there are some hearts problems with hearts murmurs. In National Heart, Lung and Blood Institute are explained the symptons and signs of these diseases.
In the same page you cand find the treament too.

Hemorrhoids

Varicosities

  In this article: Morbilidad cardiovascular enel adulto mayor, we can see that the cardiovascular diseases are the first cause of death in old people because of the aging. The most common disease is the hypertension.

Care strategies:

1. Determine presence and strength of peripheral pulses.
2. Hypotension is likely to occur while changing position.
3. Instruct patient to rest if short breath or fatigued.

 The hematopoietic and lymphatic systems:

• Increased plasma viscosity.
• Decreased red blood cell production.
• Increased immature T cells repose.

Care strategies:

1. Report abnormal findings, promptly to physician.
2. Administer nutritional supplements as ordered.

 The gastrointestinal system:

• Decreased thirst perception.
• Decreased muscle tone ay sphincters.
• Decreased saliva and gastric secretions.
• Decreased live size and enzyme production.

Care strategies:

1. Educate regarding importance of good oral hygiene. Dental referral as necessary.
2. Encourage posture that facilitates swallowing.
3. Educate regarding recommended dietary intake.
4. Administer laxatives stool softeners suppositories or enemas as needed to prevent   constipation.

 The urinary system:

• Decreased number of functional nephrons.
• Decreased blood supply.
• Decreased tissue elasticity.
• Increased nocturnal urine production.
• Increased size prostate.

Enlarged prostate

Care strategies:

1. Promptly notify physician of relevant observations.
2. Establish a toileting schedule based on an assessment data.
3. Palpate bladder after voiding or user Doppler.

The nervous system:

Many cellular changes have been observed in the aging brain including a reduction in its size and weight. Brain Shrinkage has been linked to a decrease in the numeral of functional cortical neurons.

Care strategies:

1. Slowed thought processes decreased ability to respond to multiple stimuli and tasks.
2. Decreased perception of stimuli.
3. Report abnormal findings to physician. Refer for neurologic evaluation.
4. Educate regarding safety precautions and use of assistive devices.

I think the changes and problems as consequence of the aging are inevitable, but we, like nurses, can do a lot of techniques, cares, evaluations, assessments, scales… that can reduce the consequences of ageing.

In the best place we can act is in the medical center, considering that we have more time with the patients, and there is a computer program that contains all of nurse’s diagnostics, interventions and objectives nurses. So, with this is easier to help de old people.

PSYCHIC CHANGES

Changes in intellectual capacity: the capacity to resolve problems becomes slower and there is a lack of spontaneity in one’s thought processes. There are alterations in memory which leads to amnesia over time

Character and personality: the ability to adapt becomes harder due to the fear of unknown situations.

SOCIAL CHANGES

Change of role and personality:

Three different dimensions:

• The old person as an individual: there are some old person who accept the death is near and live their life without stress, and there are other people who don’t accept the death, so their last days are so stressing or live with fear.
• The old person as a member of the family: first, the old person can help in the house and the relationship is good, but, when the old person begins to have physical or mental diseases, the relationship change.
• The old person as a person capable of facing up to his losses: the feeling of loneliness stars when the old person lost his abilities, her wife or her husband… This situation is difficult to recover from.

Change of role in the community:

When the old person finishes to work, they must look for many activities that they can do to not be boring or feel they are useful.

Change of role at work: the old person must brace about to leave the work and the consequences about this, like relationships and economic are reduced.

In my opinion, I prefer to have a physical problem that a mental problem (like dementia senile or Alzheimer) because you leave to be yourself. So I think we can do an important work whit physic changes. 

One advertence we would do is to the family: if they notice about some change in the memory, behavior or personality, they would say us quickly to catch the problem on time and treat it.

On the other hand the change of role in the society its important because if the feel that they don’t be used for, it can finish in depression.

So, our labor is informing them about associations where the can play with other people, learn…