18. WELFARE LEVELS

To achieve a continuity of taken care, there is essential the detection of the problems that arise throughout the time and that are operated on them. For it it is necessary to transform the traditional assistance into geriatric specialized assistance with his different welfare levels, where the patient will be located in the most suitable place according to his condition. With these welfare specialized levels, the results of the Geriatrics are maximum.

The elders need of an equipment to interdiscipline that it supports his assistance: nurses, doctors, social workers, therapists, psychologists..

Geriatric unit of sharp is the welfare level related to the hospitalization of those major persons who present sharp processes or reagudizaciones of chronic diseases.

The Unit of Half A Stay receives those already diagnosed patients who have overcome the sharp phase of the disease and in that the risk of losing his independence, though they are clinical stable, is high, or, the treatment that applies them, due to his complexity, cannot be realized of ambulatory form.

The Day hospital attends to elders of ambulatory form by means of the application of treatments of rehabilitation and / or follow-up of medical problems or of nursing.

The Geriatric domiciliary assistance is the integral assistance to the major person in his domicile with the aim that it is kept in the community and in his environment in the best bill of health and of possible functionality, though he suffers chronic diseases and of invalidity.

It is important that every patient comes to the center that corresponds to him not to saturate the hospitals of Sharp.

17. EDUCATION FOR THE HEALTH

Though some persons think that the education only is for the children, because they are beginning, forming and learning. The elders also need education. Education to be able endure and to extend like his quality of life and well-being.

It is important that they support his independence, because this provides quality of life and health.

Also the identification of the disabilities is important, and this way to be able to put solution in time.

Promotion of health:

It is a process by means of which the persons, families and communities manage to improve his level of health on having assumed a major control on yes same. There are included the actions of education, prevention and promotion of health, where the population acts coordinated in favor of policies, systems and healthy ways of life, by means of the law,  and construction of a system of social support that allows him to live healthier.

The promotion of the health includes a series of controls that have to be carried out in the consultation of the center of health or in the hospital to anticipate diseases and risks.

These are: capture of the arterial pressure, control of lipids, electrocardiogram, densitometria bony, capillary Glycemia, Examination of the mental and mental condition, TSH, blood conceals in dregs, mamography, cytology, colonoscopia, PSA, valuation of eyes and ears, vitamin B12.

Since I have said in other income, the prevention is a work of the professional of nursing, and is an act that avoids dead many people.

16. URINARY INCONTINENCE

The urinary system consist of two kidneys, two ureters, the urinary bladder, and the urethra. The urinary system supports homeostasis by eliminating wastes and excessive fluid from the body.

The kidneys decrease in size from approximately 400 g at age 40 to only 250 g by age 80. By age 70, they lose approximately one-third of their efficiency and they lack functional reserve. Others changes are decreased number of functional nephrons, decreased blood supply, decreased muscle tone…etc.

One of common disorders seen in the aging is urinary incontinence, the involuntary loss of urine, isn`t a routine or normal occurrence with aging. The urinary incontinence is when urine is lost involuntarily and objective, and may occur as a result of psysiologic changes, or other medical problems.

The incontinent person suffers, because she is worried all day, for if her urinate on herself, urine going to smell…

The highest prevalence was found in those units where the stay is greater, particularly in residential institutions₅.

Epidemiological studies show that IUE is the most common symptom of IU referred_4.

Is produced with major frequency in woman_4. And more frequent incontinence is incontinence due to detrusor instability

Is the acute and chronic urinary incontinence. The acute incontinence is transitory and sudden onset, and  Within the chronic there are various types of urinary incontinence: stress incontinence, urge incontinence, overflow incontinence, functional incontinence, total incontinence…

Stress incontinence is most commonly observed in woman, particularly those who have weakened perineal muscles resulting from aging and childbearing.

I wanted to provide this information, because as women are most affected by this pathology, for which of the incontinence was also the most common in them.

When a patient comes to the emergency department with this pathology or consultation, the valuation is very important to find out by asking questions type of incontinence you have, and also write down all your data. Emphasize the importance of writing the pharmacological history.

Treatment depends on the type of problem you have and what best fits your lifestyle. It may include simple exercises, medicines, special devices or procedures prescribed by your doctor or surgery_1.

Some general measures found in books and studies advise:

Measures to reduce constipation, change in the type of clothes to use (comfortable and easy openings) or modification of those medications that affect continence may also be beneficial measures.₆

There is a proven association between smoking and IU₇, perhaps due to increased abdominal pressure in chronic smokers.

 Facilitate access to the bathroom avoiding physical barriers and have domestic substitutes (urinals, sanitary wedges, etc.) or some adaptation. This is especially important in patients with IUU or IUM fundamentally if they have limited mobility (elderly).

An acceptable treatment in overweight women is weight reduction. Today it is considered as an effective preventive measure to avoid the overhead of maintaining pelvic floor adecuado₇ weight.

An abundant fluid intake, especially in the hours before the night's rest, is related to a greater number of episodes of UTI. Narrow this intake from snack and reduce exciting substance use (alcohol, coffee, tea) can have effects

Search other items, has helped me learn about other measures, and data very curious, but I also have noticed that there is data that match.

Finally, I would like to say, the UI is obviously not a life-threatening process, but significantly impairs the quality of life of patients, limiting their autonomy and self-esteem reduces_3.

Bibliography:

1. Medline. Incontinencia Urinaria. Medline Plus. [Revisado el 20 de abril del 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/urinaryincontinence.html

2. Incontinencia urinaria. Clinica Universidad de Navarra. [Revisado el 15 de abril del 2013]. Disponible en: http://www.cun.es/area-salud/enfermedades/sistema-nefro-urinario/incontinencia-urinaria

3. Espuña Pons M. Incontinencia de orina en la mujer. Med Clin (Barc) 2003; 120: 464-472

4. Robles, J.E. Urinary Incontinence. Anales. [Revisado el 16 de mayo del 2013]. Disponible en: http://www.cfnavarra.es/salud/anales/textos/vol29/n2/revis2a.html

5. Rexach Cano L, Verdejo Bravo C. Incontinencia urinaria. Inf Ter Sist Nac Salud 1999; 23: 149-159.

6. Sampselle CM, Palmer MH, Boyington AR, O´Dell KK, Wooldridge L. Prevention of Urinary Incontinence in Adults: Population-Based Strategies. Nursing Research 2004; 53 (Supl. 6): S61-S67. 

7. Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG 2003; 110: 247-254.

15. TAKEN CARE PALLIATIVE

When I hear the word palliative, I come me to the head many things.  I believe that palliative it is not to recover, it is to relieve. It is a term that much is in use in the field of the oncology, for taken care to terminal patients. When these patients are in his terminal phase, receive taken care palliative to relieve the suffering and to improve in possible the quality of life the time that they still have.

There are taken cares that are used in oncology patients, but also in other pathologies in terminal phase. Any patient that this dying and need to relieve the pain that this provoking his disease, it can request taken care palliative.

I believe that there would have to be in every hospital a unit of taken care palliative, to be able to help all the persons to have pain. Worse unfortunately this is not like that.

More than the half of the persons who die a year in Spain needs taken care palliative at the end of his life, but not they all receive the specialized attention that they need. According to the last information of the Spanish Company of Elegant Palliative (SECPAL), nowadays there are approximately 400 specialized equipments but 700 would need.

The palliative care would have to carry out, not only in the terminal stage, but very much before, to avoid all the possible suffering.

In these units there are people specialist in the treatment of these persons in his last days. In the agony that they suffer last days. In the support family. Very important point. For many persons, his family is his great support. And they need that they are with them until the end.

The family situation is characterized by a great emotional impact. The patient's family is sad by the end of your loved one. But at the same time, they want to appear strong in front of him, to help.

The personal health has to face the fears of the family.

In my opinion, many times, the family needs more psychological support, that the patient, because of all the care required by the patient.

To conclude I want to say, that the patients are afraid of dying alone, and the major tranquillity that you can give them, is to say to him that in his last minutes that I and his family are going to be with him. Also it is important to expire all his final wills.

Finally, I would put a video. When I have seen, I have felt sadness, but also show the coping of families and patients. URL: http://www.youtube.com/watch?v=cqyM8UeS2hY

Bibliography:

1. Gandara, A. Cuidados Paliativos. Sociedad Escañola de Cuidados Paliativos. [Revisado el 11 de mayo de 2013]. Disponible en: http://www.secpal.com/presentacion/index.php

14. CONSTIPATION

Constipation means that a person has three or fewer bowel movements in a week. The stool can be hard and dry. Sometimes it is painful to pass. At one time or another, almost everyone gets constipated. In most cases, it lasts a short time and is not serious.₁

Constipation is a condition that happens a lot in the elderly for many reasons. Reasons mechanical, metabolic, endocrine, neurological, functional or pharmacological.

Constipation occurs more in women, like other geriatric syndromes such as falls

Is an adverse effect of many drugs, and the consequence of many diseases. Also it is sometimes a symptom of something in our body is wrong

The main complication of constipation are the fecal impaction.

I think the best way to prevent constipation is healthy living, eating fruits and vegetables, take fiber, white bread, etc..

In addition to drink 1-2 liters of water a day, and doing exercise. Don`t be sedentary.

But according to this study: Recommendations on treatment of costipation included an increase in dietary fiber of up to 25-30 g/day (grade C). No evidence was found to recommend measures such as exercise, increased water intake, or frequent visits to the toilet.₂

I disagree with this study, because the lead active, improves intestinal transit.

Instead, this study discusses the benefits of fiber and that if it is good for constipation.

URL:  http://scielo.isciii.es/scielo.php?pid=S0212-16112006000500007&script=sci_arttext

Bibliography:

1. Medline. Constipation. Medline Plus. http://www.nlm.nih.gov/medlineplus/constipation.html

2. Max Schmulson Wasserman, Carlos Francisconi, Kevin Olden, Luis Aguilar Paíz, Luis Bustos-Fernández, Henry Cohen, Maria do Carmo Passos, Marina Alejandra González-Martínez, Beatriz Iade, Guido Iantorno. Consenso Latinoamericano de Estreñimiento Crónico Gastroenterología y Hepatología, Volume 31, Issue 2, Pages 59-74

13. FALLS

A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Fall-related injuries may be fatal or non-fatal¹ though most are non-fatal₃

The falls are very related with the loss of mobility in the elderly.

Also influences the changes in the musculoskeletal system.

The main physical and psychological consequence of the falls is the post fall syndrome.

The post-fall syndrome leads to isolation

According to a study, the falls are a frequent occurrence among the elderly (13-25% over 65 years, 31-35% over 85 years). The falls are more common in institutionalized elderly (up to 50%), and especially in the women until 75 years. With 75 years, the frequency is the same for both sexes₁.

As OMS₃

·         Falls are the second leading cause of accidental or unintentional injury deaths worldwide.

·         Each year an estimated 424 000 individuals die from falls globally of which over 80% are in low- and middle-income countries.

·         Adults older than 65 suffer the greatest number of fatal falls.

I think that is more common in women because osteoporosis has higher incidence in women and begin with menopause.

The institutionalized elderly have more falls because they don’t know the psysical environment, and their admission is produced by physical problems that entail taking drug.

The elderly has more fear to the falls, so they feel insecurity. This situation has that they are cautious. Consequently they walk slowly, and avoid stairs and bath. As I have named before, the elderly are isolated due to fear

The most important is that the elderly know their limitations and they act accordingly.

I see important to the prevention of falls, because most are preventable, leave here the link to this video₂: http://www.youtube.com/watch?feature=player_embedded&v=w9qHZdCj8IE#

Also, I would like to say that in the prevention of falls has a very important role nurses because we can give advice and help to prevent falls.

The comorbidity of falls prevention leads to environmental factors or the environment, and those specific to the elderly. So I think it's very important to carry out a primary prevention, secondary and terciary.

It is good that the elderly have a little fear, before of daring to do things and to fall.

There are places where there is more danger of falling, the most dangerous place in the house is the bathroom. And in the street, the stairs, the field... etc

Based on scares the elderly see their chances

Finally, The fall risk assessment should be performed in the framework of GERIATRIC ASSESSMENT GLOBAL, focusing specifically on the assessment of gait and balance. By the following scales: TINETI and TIME-UP AND GO.

And other scale for valuate to fall risk is the DOWNTON scale.

Bibliography:

1. Marnet. Las caidas en los ancianos. Kioskea Salud. [Revisado el: 10 de mayo del 2013]. Disponible en: http://salud.kioskea.net/faq/3434-las-caidas-en-los-ancianos
2. OMS. Falls. World health organization. [Revisado el: 1 de mayo de 2013]. Disponible en: http://www.who.int/mediacentre/factsheets/fs344/en/index.html

12. NEUROLOGICS DISEASES

Dementia is defined as an acquired syndrome of impaired intellectual, emotional, volitional and persistent behavior that compromises the function of multiple spheres of mental activity such as memory, language, visuo spatial skills, warmth, personality or cognition. It implies a decline over the patient's premorbid functional level. It leads to a progressive global deterioration, personal and social_1.

As the doctor Castro, Alberdi, and Marey, Dementia Alzheimer's type (DAT) is the most common type of dementia (70% of dementias) and has a prevalence of approximately 6% in people over 70 years in our country (GPC Dementia NHS, 2010). In Spain there should be about half a million people who suffer from this process₁.

I would like talk about Alzheimer, because is the most common type of dementia.

Alzheimer's is a form of dementia that gradually gets worse over time and affects memory, thinking and behavior₂.

I enclose a link to a video about Alzheimer:  http://www.youtube.com/watch?v=7On9Dja5HfM

Alzheimer is one disease asociated to process of aging, affects people younger than age 65₃. I found on another page of evidence that Alzheimer's cases having less than 60 years. These are linked to alterations in the genes APP, PS1 and PS2_1.

Nearly 4 percent of the more than 5 million Americans with Alzheimer’s have younger-onset₃. 

By contrast, according to data CEAFA, the Spanish Confederation of Alzheimer, in Spain 60% of people with Alzheimer's are still undiagnosed, often due to lack of information from families who think memory leaks are a normal part of aging.

In my opinion, Alzheimer' disease isn’t only a medical problem, also is a familiar and social problem. Because disease affects to patient, but your family also is affected.

The nurses have that explain the symptoms to the family, so that if they detect the symptoms, come to the doctor, and may have an early diagnosis.

I would also like to say that among the symptoms of Alzheimer's disease, apathy is the most prevalent according to study Alzheimer Foundation TRACA Spain (FAE), realiced in 1200 caregivers, which showed that apathy affects 99 percent of patiens.

I think it's because as patients do not remember things, they don`t know what they like, sometimes people do not know their environment, then they feel sad and apathetic. This situation produced them frustration and they are lost.

Finally, I will provide link entity in which you can see how the brain works and how Alzheimer's affects it. There are 16 interactive slides. As you view each slide, roll your mouse over any colored text to highlight special features of each image. Then, click on the arrow to move to the next slide.

URL: http://www.alz.org/braintour/3_main_parts.asp

Bibliography:

1. Castro, C. Alberdi, J. Marey, J. Demencia tipo Alzheimer. Fisterra. [Revisado el 3 de mayo del 2013]. Disponible en: http://www.fisterra.com/guias-clinicas/demencia-tipo-alzheimer/

2. Medline. Mal de Alzheimer. Medline Plus. [Revisado el 14 de mayo del 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/000760.htm

3.Alzheimer`s Association. Younger/Early Onset Alzheimer's & Dementia. Alz.org. [Revisado el 25 de abril del 2013. Disponible en: http://www.alz.org/alzheimers_disease_early_onset.asp

11. INMOBILITY

The elderly in his process of aging suffers changes. One of the most important is the lost of mobility. The elderly isn`t a independent person yet. For the elderly is a important change. He can`t have the same.

In the elderly, there are decrease in mobility because they have musculoskeletal, cardiovascular, and respiratory illness.

As Montse queralt, after 65 years, 18% of individuals have problems with mobility without assistance, 50% of those over 75 have problems have trouble leaving home and 20% of them is confined at home.

This decreased mobility or "immobility syndrome" causes decreased muscle and bone mass, disturbed the balance, altered skin integrity by facilitating the development of pressure ulcers and may even favor the loss of cognitive status for lack of stimuli.

The other day, I asked with my grandfather, and he said me that doesn`t have fear of die, and he doesn`t feel sad about losting the mobility because he know his years and he consider that is the normal. I surprised me.

Improved systems are needed to address patient concerns after discharge from the hospital, specifically for patients with mobility impairments_1.

I think that after being in the hospital, mobility is affected. This is a consequence of prolonged bed rest. So many people to go home, have to do rehabilitation, and get used to the routine.

I relate the immobility with the changes in the elderly and with the falls.

If you fall, your body will suffer damage, and damage will affect  the mobility. And with the physical changes occur the same. The physical changes weaken the bones, the muscles, etc, producing fatigue and and less skill in movement.

Bibliography:

1. Dossa A, Bokhour B, Hoenig H. Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences. Pubmed [Revisado el 27 de abril del 2013]. Disponible en:  http://www.ncbi.nlm.nih.gov/pubmed/23212952

10. PRESSURE ULCER

In this blog post, I will talk about pressure ulcers, because I have seen many ulcers in my stays clinics. And it seems a very common problem in hospitals.

The ulcers for pression are areas of damaged skin caused by staying in one position for too long.₁

Pressure ulcer staging:   http://woundconsultant.com/sitebuilder/staging.pdf

Stage I: epidermis without damage and erythema of skin that it doesn`t dissapear to eliminate the pressure

Stage II: Partial-thickness skin loss including epidermis.

Stage III: Full-thickness skin loss involving subcutaneous tissue. The lession doesn`t affect the fascia.

Stage IV: Full thickness sin loss involving subcatenous tissue, muscle and bone. The lession affects the fascia.

To avoid the risk of pressure ulcers using the Norton scale and braden

http://www.nutrition411.com/wrc/pdf/w0513_norton_presure_sore_risk_assessment_scale_scoring_system.pdf

Another rating system getting more and more popularity is the Braden Scale, created in the USA, more recent  and precise than the Norton scale, which evaluates factors such as sensory perception, skin wetness, nutrition and such.

Pressure ulcers are a variety of treatments.

Depending on the stage of the ulcer, the ulcer tissue, and if there is infection or not, I use some dressings and others.

In my view, the key will not occur this in preventing ulcers.

• Change position at least every 2 hours to relieve pressure.
• Use items that can help reduce pressure -- pillows, sheepskin, foam padding, and powders from medical supply stores.
• In the zones with more risk.

• Eat well-balanced meals that contain enough calories to keep you healthy.
• Drink plenty of water (8 to 10 cups) every day.
• Exercise daily, including range-of-motion exercises.
• Keep the skin clean and dry.
• After urinating or having a bowel movement, clean the area and dry it well. A doctor can recommend creams to help protect the skin

This is the best treatment for pressure ulcers

Bibliography:

1 Medline. Ulceras por presión. Medline plus.[Revisado el 25 de mayo del 2013] Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/pressuresores.html

2. Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management. Am Fam Physician. 2008

9. GERIATRICS SINDROMS

The concept of geriatric syndrome is relatively recent, as this terminology was first used in the late 60s. At first, under the name of geriatric syndromes referred to features that had more frequently the elderly hospitalized in Geriatrics, compared to other services₁.

Currently, this term is used to refer to a set of tables, caused by the combination of a number of diseases that reach a large prevalence in the elderly, and are common origin or social functional disability₁.

The major geriatric syndromes, also known as the 4 giants of Geriatrics, include immobility, instability, falls, urinary incontinence and cognitive impairment_1.

The common characteristics are: high frequency, after his appearance all have an impaired quality of life, treatment is adequate, and all are preventable, and finally His diagnostic and therapeutic approach requires comprehensive assessment, interdisciplinary approach and correct use of the levels of care.

In geriatric disease processes, symptoms does not appear clearly as we have seen. However there are a number of recurring symptoms in various diseases, although not known for being itself and / or specifies the population.

In my opinion the pain is a manifestation and a symptom associated with many pathologies, and one of the most typical. Nursing plays a fundamental role. We should know to value and identify.

The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience with actual or potential tissue damage or described in terms of such damage"₂.

The best scale for study to pain is EVA.

There are many types of pain, but they all have one thing in common when you are in pain your body is affected, it is a symptom, not something you can see. qeu I think you lose your appetite, being tired, or not urinating, but the pain affects everything. They take the win, and just feel like you bust. Therefore, we need to know value it, and pay attention. It is the only way to detect and cure.

Bibliography:

1. Gómez. A, Adela. Emilia. Grandes síndromes geriátricos. Elsevier [Revisado en: 7 de mayo del 2013]. Disponible en: http://www.elsevierciencia.com/es/revista/farmacia-profesional-3/articulo/grandes-sindromes-geriatricos-13076255

2. IASP. Pain. Internacional Association for the study of pain. [Revisado el 12 de mayo del 2013]. Disponible en: http://www.iasp.ws/

8. PAE

Since freshman year, we've been doing PAES. We have explained how useful  are and their importance. I think actually, in practice not used, because when you get a patient, follow the steps of the SAP, but you can not write down all the points, because you lose a lot of time.

Have learned it is good to know what to look or have a mindset. But today, everything is computerized.

I also realized that all I've done PAES far have been elderly. Elderly people are more diseases and health problems have, so it is normal that they are going to the doctor more than young people.

I see important having to know all the changes that occur as we age. And also know how to obtain and classify the data we collect in one scan.

When we will finish the race and work in a hospital, 60-70% of people who come, will be greater than 65 years. We have to learn to accommodate them, and be able to find out what happens to help.

      

4-7. GERIATRIC GLOBAL VALUATION

It is a diagnostic dynamic and structures process that it allows to detect and to quantify the problems, needs, and capacities of the elder in the clinical spheres, functional, mental and social, to elaborate stocks on they a strategy to interdiscipline of intervention, treatment and long-term follow-up in order to optimize the resources and of achieving the major degree of independence and quality of life.

This quadruple valuation serves to discover not opposing problems, to improve the functional condition, to improve the quality of life, to establish a treatment also quadruple… etc.

The best means for a correct valuation  is: the anamnesis and the physical exploration

In every sphere a few different scales are used.

I am not going to name all, only that under my point of view I see more important.

In the functional area: Barthel scale and Lawton and Brody. 

URL:  http://fissioterapia.blogspot.com.es/2012/06/el-indice-o-escala-de-barthel.html

Cognitive sphere: Short portable mental status questionaire of pfeiffer, MMSE Folstein, Clock test, and miniexam cognoscitive os Lobo that is the spanish versión of Folstein.

Social Spere: ORS scale and Zarit Scale. And Finally Geriatric depression scale of Yesavage.

It seems very important to the realization of a good review in order to detect problems in the elderly, and put measures to solve them