HEALTH PROMOTION AND HEALTH MAINTENANCE

Health assessment of older adults can be done on several levels, ranging from simple screening to complex, in depth-evaluations, To perform assessment accurately, nurses and other health care providers who gather information regarding older aults must possess the necesary knowledge and skill to perform the assessment correctly.
Health screening are done to identify older individuals who are in need of further, more in-depth assessment. For example, screening for hypertension, hearing problems...
Health assessments includes the collection of all of the important health-related data using a variety of techniques. Data are all the information a nurse gathers about a person. Objetive data include information that can be gathered using the senses of vision, hearing, touch, and smell.

The prevention is a part of health education and it is our work. The health education is essential to prevent some diseases like hypertension, dislipemia.... For this reason we have to explain our patient the importance of following our advices.

 

In elederly, prevention is too much important to avoid geriatric syndromes. Other point that I want highlight is the atypical presentation of illnes, for this reason , health assessments and health sreening have more importance  . I want to describe some atypical presentation of illness like:

• infectious disease: presentation like absence of fever, confusion, decreased appetite or fluid intake...
• "silent" acute abdomen: presentation like mild abdominal disconfort, constipation...
• "silent"cardiac problems: presentation like no complain of chest pain, decreased functional status...

I woul speak about an article that I found to describe the importance of heath screening.The article deal with about a study that has made in Mexico to highlight the importance of health screening to prevent aging depression. The conclusion of the study shows the role of the actions to prevent the diagnostic of depressionin elderly.

I attach one article that I found very interesting because it shows how through mental exercise, establishing a suitable diet, encourage the practice of moderate activity...we could improve the quality of life of aging population.

Bibliography:

Aguilar. S.G; Fuentes-Cantú.A; Ávila-Funes.J.A;García-Mayo. E.J.Validity and reliability of the screening questionnarie of geriatric depression used in the Mexican Health and age study.  Agosto 2007. Salud pública Méx vol.49 n.4. Cuernavaca

Zhang SC, Tao FB, Ueda A, Wei CN, Fang J. The influence of health-promoting lifestyles on the quality of life of retired workers in a medium-sized city of Northeastern China. Environ Health Prev Med. 2013 May 23.Pubmed PMID: 23700274.

URINARY INCONTINENCE

Urinary incontinence is the involuntary loss of urine in sufficient amount or frequency to be a social or hygiene problem. Urinary is not a normal part of aging. Incontinence has medical, emotional, social, and economic consequences for older adults. It can result in skin irritation or breakdown and can contribute to pressure ulcers; it can lead to guilt and frustation; it can lead social isolation; and it can be costly because of the need to purchase expensive undergarments and replace or launder clothing more frequently.

I share this video to explain the kegel exercises. Kegel exexercise are helpful in improving the tone of the sphincter muscles. Improved muscle tone can help the person hold the urine until he or she can reach a toilet or obtain assistance. 

 Other important advice to reduce the episodes of urinary incontinence is modify clothing to make toileting easier. Use velcros closures and elastic waists with loops may speed undressing and reduce functional problems related to toileting.

To reduce episodes urinary incontinence a important intervention is reduce enviromental barriers by providing grab bars in the bathroom, installing toilet risers, keeping the urinal or bedpan readily available, and providing a call signal for assistance. 

Fluid restriction increases the risk for problems with fluid balance and bowel elimination. For this reason we havo to assess fluid intake patterns. 

From my point of view the most important thing related to urinary incontinence is that it is not a psysiologic change. Urinary incontinence is a unconfortable situation for elderly. Episodes of incontinence are embarrasing and can lead to frustation and loss of slelf-esteem. We have to make talking about incontinence episodes easier to the patient. 

The use of absorbent pad when they are no necessary boost urinary incontinence to patients. In case of the use of absorbent pad we have to highlight the importance of good skin care and hygiene to prevent pressure ulcers.

Bibliography:
Hoffman. G. Basic geriatric nursing. 5th edition. Ed. Elsevier. 2012 St. Louis, Missouri.
Martinez. E: Ruiz. J.L: Gómez. L: Ramírez.M: Delgado. F:Rebollo.P: González. D:Arumi. D. Prevalence of urinary incontinence and oberactive bladder in spanish population: results from EPICC study. 2009. Grupo de estudio cooperativo EPICC.

PALLIATIVE CARE

I am very interested in this topic. I think that it coul be very difficult and a nurse have to be very strongh for paliative care but the feeling of give to the patient a dignified death have to be very special.

I want highlight some points of  clinic practice handbook that on my point of view a lot of nurses haven´t into account :

• Palliative interventions should be based on needes of the patient and his family rather than within expected survival
• All terminal patients have to right to palliative cares any level care.
•  The palliative care have to be provided, preferentiall, for a suitable multidisciplinare team. 

  
I found an article that on my point of view it resume some points that I think that it is very important have into account in the palliatives care. There are that the objetive of palliative care are to relive, in patients suffering a crhonic disease or in end life, symptoms of physic, phychical, mental and spiritual levels. For this reason it is necessary a multiple and interdisciplinary team of specialist whit specific capacyties and conected between them.

An important concept in palliative care is refractory symptom, there is a symptoms that can not be controlled  by hreatment. There is one the principal problems in this patients.
In my point of view, a palliative care nurses have to :

• be comprehensive
• empathize with the patient
• get dignified death to the patient
•  accompany patient and family  in death phases

One of the most important thing about palliative care from my point of view, is that we have to get a good support to patient decreasing the suffering.
Other point that I would to explain is grief, is the emotional adaptation process that following any loss. There are physic and emotional symptoms.
Sometimes when we talk in grief only think in the loss of a person, that is important thinking in:

• chronic o terminal disease diagnostic
• a short vital prognosis or reduce in quality of life
• loss of autonomy or independence
• loss of part of the body

Bibliography:
Pessini. L: Bertachini. L. Nuevas perspectivas en cuidados paliativos.2006; Acta Bioethica. Interfaces. 
Muñoz Cobos.F; Espinosa Almendro. J.M; Portillo Strempell. J: Benitez del Rosario.M.A.Cuidados paliativos:atención a la familia.2002. Publicado en atención primaria. Vol 30 Núme 09

 

ELIMINATION

The two major systems involved in waste elimination are urinary and gastrointestinal systems.
A large percentage of the older adult population suffers elimitation problems. One of the most common elimination problems experienced by older adults is constipation. This problem may result from changes in the function of the GI system or may be related to changes in other body systems such as musculoskeletal and nervous system.
Well, I want with this introduction make a short resume of the relationship between body systems and the gastrointestinal problems.

 In this post I make a brief summary of diferents gastrointestinal problems:
Constipation, is defined as hard, dry stools that are difficult to pass. It is important bring out that constipation is not a disease but rather a symptom of some other problems. A diagnosis for constipation must include two or more of the following symptoms during 3 months:

• straining
• hard and lumpy stools
• sensation of incomplete evacuation or anorectal blockage
• less than three defecations per week
• loose stool rarely present without use of laxatives
• use of manual maneuvers such as digital stimulation to facilitate defecation

 
We have to keep in mind the importance of this geriatric syndromes because they affects patient's quality of life, and they have lots of importants consequences for older adult like fecal impactation, anal fissure....
Nurses have to help the patient and we have to give some advices to prevent or resolve constipation, some of them are:

• rich fiber diet and intake 2 liters of líquids
• make regular exercise
• go to the bathroom after breakfast
• make pelvic floor exercises
• provide privacy for elimination

ostomies, in this topic I want to bring out the importance of the education about ostomy patient. This intervention lead to suppose a great challenge fot the patient and for him social enviroment because it is a difficulty related with the disease process.As nurses we have to try to understand the difficulties that the patients could have.

Ostomy is a new "style of life" for the patient, fot this reason I think that it is important that we know some advices for the ostomy patient such as:

• eat and chew slowing
• a correct stoma hyigiene.
• increase progressively intake
• try and eat new food sparingly.
• intake 1,5 liters of water
•  do not abusse of fried food or spicy.

Bowel Incontinency, from my point of view this is the elimination problem that could produced major numbers of problems to quality of life. A lot of older adults haven't go out because they have fear for the possibilite of maybe have a bowel incontinence situation. 

Dysphagia, difficult to swallow liquids or solid food for the affectation of one or most swallowing phases. It is important in this disease adjust the differents consistency depending on lesion places.
Some general advice for the patient that suffers disfasia are:

• present small quantities of food in the dish
• no mix solid and liquids
• take food in small pieces  
• avoid contact spoon with teeth to let lose reflex to bite this.
• enrich foods
• no force
• calm enviroment

It is important bring out the most important consequences of dysphagia, they are malnutrition and dehydration. For this reason, we have to pay attention to dysphagia symptoms.
We have to improve patient's quality of life, for this it is important that we manage a good nutrition and if we observe some desnutrition symptom we have to dismiss dysphgia syndrome early.











Bibliography:
Wiskur. B; Greenwood-Van Meerveld. B. The aging colon: the role of enteric neurodegeneration in costipation. December, 2010. Springer science bussines media.
Galan. N. Recomendaciones al paciente ostomizado. 2011. Enfermería gastroenterología.
Neuman HB, Park J, Fuzesi S, Temple LK. Rectal cancer patients' quality of life with a temporary stoma: shifting perspectives. Dis Colon Rectum. 2012 Nov.

 

FALLS AND INESTABILITY

Falls are the most common safety problem in older adults. Consider the following statistical facts revealed in the literature:

• one-third to one-half of people older than age 65 are prone to falling.
• any fall is the best predictor of future falls.
• the older a person becomes, the more likely he or she is to suffer serious consequences, such as a hip fracture, from a fall
• falls are a leading death caused injury in people older than age 65.
• approximately one- fourth of older adults who experiences falls will die within a year and another 50% will never return to their previous level of independence.
• the occurrence of falls is higher among those residing in long-term care facilities than among those who live independently

I attach an article that I find very interesting, it is a study on falls and their consequences. In the article they use 3 groups of elders: elderly practicing regular exercise, sedentary elderly and institutionalized elderly.

 

They made a questionnaire which recorded all incidents of falls, near-falls, fear of falling, impact on basic activities of daily living (ADL), and self-perception in health.

 

Exercise can be a good strategy to increase the self-perception of health and to prevent the decline in ADL due to fear of falling.

 

The results obtained in the article shown the differences on number of falls between elderly who did exercises and elderly that did not, but there was no differences on consequences, that attract me.

 

Another specially aspect is that in terms of ADL limitations nearly 25% are ADL limited as result of a fall.

 

On the other hand, the restriction of ADL for fear of falling is considerable, demonstrating the importance of this point in the aging. 

 

In conclusion we can say that the elderly have a high risk of falling, this is reduced if they do exercise, but we have to keep in mind the complications of a fall are the same for any type of elder.

 

I would like to highlight some exercise benefits:

• exercise can help to keep the joints flexible
• maintain muscle mass
• control blood glucose level and weight
• promote a sense of well-being

Consulted bibliography :

Curcio. C; Gomez. J.F; García. A. Caídas y capacidad funcional entre ancianos que realizan y no realizan ejercicio.Colombi médica. 1998.
Hoffman. G. Basic geriatric nursing. 5th edition. Ed. Elsevier. 2012 St. Louis, Missouri.

DEMENTIA AND DELIRIUM

I want to start this post defining three concepts:

  

The concept of  "ALTERING / MILD COGNITIVE IMPAIRMENT" refers to a clinically apparent intellectual decline, functional disability but carries NO apparent functional disability.

Dementia is a slow, insidioud process that results in progressive loss of cognitive function Acute confusion, often called delirium, is characterized by disturbances in cognition, attention, memory ans perception. This type of confusion is usually caused by a physiologic process that affects the I give you one classification table of dementias:

IRREVERSIBLE	REVERSIBLE
Vascular Dementia Posttraumatic Dementia Alcoholic Dementia Degenerative Diseases: Alzheimer Pick Parkinson Huntington Infectious Diseases: AIDS Creutzfeldt-Jacob Other: Multiple sclerosis Dialitic Dementia	Metabolic Disturbances Diseases: Thyroid Adrenal Pellagra B12 and float deficit B1 deficit Uremia Wilson Porphyria Hepatic encephalopathy Calcium upset Inflammatory and infectious diseases Syphilis Meningitis Encephalitis Vasculitis Intracraneal Procesess: Neoplasya Subdural Hematoma Hydrocephalus Depression

On the other hand I think that is important to know some nursing intervention for delirium and dementia:

DELIRIUM:

• designded to treat underlying pathologic condition and mantain physiologic integrity.
• includes administration of fluids, nutrition, oxygen, antianxiety medications, and so on.
• designed to control enviromental stressors, to protect safety and to promote comfort.

DEMENTIA

• designed to maintain or maximize level of function
• includes enviroment modification, activity-based therapies, and communication strategies.

I want to pay attention on one of the primary cortical degenerative dementias, alzheimer's disease: this is a progressive brain disorder, characterized by degenerative changes of cortical nerve cells and brain nerve endings. This causes an irreversible deterioration of memory and destruction of intellectual functions.

I didn´t know the relation between level of education and dementia. I look information about this point and I want to summary two article that I found.

First of all, it is important to know the therm of cognitive reserve. Cognitive reserve could be defined like brain's ability to tolerate dementia pathology's effects may be the result of an innate ability or the effects of their experiences, such as education or occupation. Low education could be a risk factor for dementia.

The level of cognitive reserve attained by an individual is influenced by both genetic and life experience factors such as educational attainment and occupational history. I would talk about an information that I found in one article that I think that is interesting, The Tasmanian Healthy Brain Project (THBP) is a world-first prospective study examining the capacity of university-level education to enhance cognitive reserve in older adults and subsequently reduce age-related cognitive decline and risk for neurodegenerative disease.

Do you know about this?

In other article I found two types of reseve: cerebral reserve, this term be based on characteristics individual such as brain size, the number of neurons or synaptic densitythat help offset possible degenerative Central Nervous System diseases; and cognitive reserve that I explained before.

I think that it is very important because the cognitive reserve explain the possibility that two patient may have the same amount of AD pathology, but one of they may appear much demented than the other.

I didn´t know nothing about the cognitive reserve, for this reason I have tried to explain some information about this. I hope that you were interesting in this topic.

I include a trailer about a documental of the process of the alzheimer disease in a public personage such as Pascual Maragall. I saw all documental and I think that it very interesting for our profession to watch this.

If you would know more about thats point,I leave you some interesting articles:  

Conde J.L.Personalidad premórbida y factores de riesgo en la enfermedad de alzheimer. 1999.  Revista Española Geriatria Ferontología.  Vol 34 núm 3. 
Summers MJ, Saunders NL, Valenzuela MJ, Summers JJ, Ritchie K, Robinson A, Vickers JC. The Tasmanian Healthy Brain Project (THBP): a prospective longitudinal examination of the effect of university-level education in older adults in preventing age-related cognitive decline and reducing the risk of dementia. Int Psychogeriatr. 2013 Mar
 

IMMOBILITY

It is essential to promote regular exercise in elderly to maintain them active and become more agile, that all helps them to prevent possible falls and immobility  situations consequence of falls.

I want to tell you about an activity that I discovered in one of my practices, in the health centre there has been created a group called "healthy walks" this is a group open for all the people that would like to walk, the only thing you have to do is to sign up you in  health centre. These walks are on Mondays, Wednesdays and Fridays. When I went with them on one of these walks, I discovered that it was a group of elders from 65 to 80 years.

From the health center,  a health professional go with this group to encourage and control  new participants. Before starting the walk, they do some warm-ups and when they finish they do stretching. The walk takes about an hour. That make elders felt more healthy and agile, and it encourages communication between them by recreational activities. They felt the benefits of exercise, they "felt younger". 

I think it's an interesting activity and it should be promoted on primary care level in all centers because this walks promotes exercise, stimulates elderly patient to go outside, encourages social interaction .... too much benefits only for a walk.

In these walks, they sometimes also do some cultural activities such visiting museums, discover new areas ....

In addition to this personal experience I want to left an article that I found to expose changes that occur in aging, such as a Increased incidence or incontinence, and how they can result in geriatric syndromes known, in this case, malnutrition, dementia and immobility.

The prevalence of urinary incontinence increases with age. In this study we assessed the severity of urinary incontinence and comorbidities of nursing home residents.

I find this article interesting for the relationship mentioned before, for that reason I want to give a global vision about immobility , we have to keep in mind the interrelations between changes of aging and geriatric syndromes. I want to highlight that if aging changes are not controlled it could result in geriatric sindormes.

Rose A, Thimme A, Halfar C, Nehen HG, Rübben H. 

Severity of UrinaryIncontinence of Nursing Home Residents Correlates with Malnutrition, 

Dementia andLoss of Mobility. Urol Int. 2013 Mar 8. PubMed PMID:23485721.

 

PRESSURE ULCERS

From the beginning of my studies and practises I've been interested in and worried about pressure ulcers, I think this common affection have too little attention.

Pressure ulcers are skin lesions that appear as a result of a continuous skin pressure over a hard surface and independent of the position. The most important factor is prolonged pressure over certain skin area. There are many state to evaluate ulcers:

• State I: epidermis is intact, affected area shows an erythema that not disappear.
• State II: sore with graze. Red-coloured area.
• State III: loose of skin thickness, lesion or subcutaneous tissues necrosis
• State IV: Apo neurosis, support tissues, muscle and bones harm.

During my practices I saw that when sores appear, it's so difficult to heal them, I think prevention is so important, because it's easier and less costly make simple steps to avoid ulcers. Often making simple position changes during patient disease will help to prevent them, change patient position every two or three hours will be enough. There are more steps to check:

• Inspect skin at least once per day checking bone protuberance and wet areas, specially perspiration and incontinence areas.
• Keep skin hydration and maintain good hygiene.
• Use of neutral soaps.
• Dry the skin without rubbing.
• Often Apply moisturising cream.
• Protein diet support.

All of this steps are easy to apply in contrast of necessary cures when sore appears. We must know that it's nurse's role.

Besides postural changes there exists some devices to minimize pressure over skin areas like cushions, air cushions, special-fibered cushions, duvets..

It's important to highlight that to heal a sore is necessary treat the main disease such breathing, circulatory and metabolic disorders.

Regarding ulcer treatment, I saw many differences between one professionals and other, that question attract me and make me think about. As a future nurse, I'm still thinking which is the best way to treat sores. Which is the best treatment?, surgical debridement or enzymatic treatment?, during my practices I saw nurses applying the two methods without any rule, and cases in that the doctor gave a warning to the nurse to apply surgical debridement instead enzymatic.

Once during practises I were surprised when a nurse put a silver dressing over the sore, the sore was not infected, but nurse says 'That feel good to the patient'

I understand that it's difficult to standardize and setup a guideline over sore treatment, but I think that is necessary more collaboration and agreements between all nurses to setup basic rules about sores healing keeping in mind that prevention is more important than healing. I think giving nurses and patient good education about that will contribute avoid sores. It's nurses work.

  

I try to find out information how to resolve my doubts in pubmed, among all I like to highlight two texts that have attract me, in the first one it shows how can be the treatment modified by patient features and types of ulcers, the second one is a review of the different types of cares. I put below some bibliography if you like to go in depth.

Declaración de Rio de Janeiro sobre la prevención de las Úlceras por Presión

Consulted bibliography :

Levine SM, Sinno S, Levine JP, Saadeh PB. Current thoughts for the prevention and treatment of pressure ulcers: using the evidence to determine fact or fiction. Ann Surg. 2013 Apr

Greer N, Foman N, Dorrian J, Fitzgerald P, MacDonald R, Rutks I, Wilt T. Advanced Wound Care Therapies for Non-Healing Diabetic, Venous, and Arterial Ulcers: A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs; 2012 Nov.

INTEGRAL GERIATRIC VALUATION

Integral Geriatric Valuation is an interdisciplinary and multidimensional structured process intended for describe, detect and clarify many physical, functional, psychology, social and settings problem affecting patient.

Objectives are:

• Detection in elderly population, those who are in critical state and needs an exhaustive specialised geriatric valuation.
• Maximize means of assistance in medical centres
• Set up a care plan
• Improve diagnostic accuracy
• Improve quality of life
• Set up a multidimensional diagnostic
• Plan the best way to apply care
• Decide the best location for the elderly patient
• Identify persons in danger
• Make sanitary resources profitable

Integral geriatric valuation uses different measures due nature of patient to make an exhaustive valuation ,it's divided in four big areas:

• Physical valuation
• Functional valuation
• Mental and social valuation
• Emotional valuation

Biological changes are not the unique changes we have to look for, there are others that we have to, this others will define patient independence.

A nurse must be able to recognise the problems that comes from cognitive, emotional, functional and social to get a global vision for evaluation.

Besides of clinic valuation (history, examination, scales), we have to keep in mind features in elderly like:

• Heterogeneous of elderly population.
• Atypical disease appearance
• Fragility
• Pluripathology and poly-pharmacy
• Homeostatic Disability, organ interaction, large diseases latency become asymptomatic, immunology disability and iatrogenic
• Less favourable prognosis due to aging
• Prognosis and therapeutic difficulties
• More sanitary resources use
• Frequently needs Social resources
• Ethic problems

Geriatric symptoms are important as this features, below I'll go in depth. 

In the functional valuation area I would highlight that to get it is necessary distinguish between basic daily activities like taking a shower, waking up,

eating and basic tools activities such use telephone, driving a car, once this concept is clear, we have to know that elderly patient could be functional

disabled, that put the limit on privacy and autonomy of the patient, that could result into paralysis.

Taking a look into mental and social area, it's important to take special care about presence of cognitive variations, that means that exists pathologies.

Physiology changes are well known and we can not attribute mental variations to elderly typical changes.

In emotional area, depression detection, anxiety and lonesomeness are important to evaluate, elderly situations such retirement and other can result in it.

   

I have to mean with this brief post that we must go in depth on each valuation, we have to keep in mind elderly diseases properties, geriatric symptoms, medical valuations and the relationship between all of them to know and get a good integral geriatric valuation. 

Consulted bibliography :

Hoffman. G. Basic geriatric nursing. 5^th edition. Ed. Elsevier. 2012 St. Louis, Missouri Valero, C.; Regalado, P J; González Montalvo, J I; Alarcón Alarcón, M T; Salgado, A.