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.

THEORIES OF AGING

In this post, I’ve made a brief summary of the main theories of aging. There are many theories to explain it.

I've looking for some information about free radical theory which is probably the most used.  There are so much products have been developed for anti-aging and antioxidant diets based in this theory, for these reason I want to outline some points of free radicals theory as well as antioxidants.

First of all I want to describe the biologic theories, because we must know all of them. After this, I’ll try to explain something about free radicals theory.

There is no single universally accepted definition of aging. Theories of aging have been considered throughout recorded history as mankind has sought to find ways to avoid aging. Theories abound to explain and give some logical order to our observations. Observations, like theories, including physical and behavioural data, are collected and studied to scientifically prove or disprove their effects on aging.

 

• Biologic theories, each theory attempts to describe the processes of aging by examining various changes in cell structures or function.
• The programmed theory proposes that every person has a “biologic clock”
• The rut- out- program theory: every person has a limited amount of genetic material that will run out over time.
• The living theory: proposes that individuals have a finite number of breaths or heart- beats.
• The gen theory proposes the existence of one or more harmful genes
• The molecular theories: propose that aging is controlled by genetic materials
• The error theory: Proposes that error in ribonucleic acid cause errors to occur in cells in the body.
• The somatic mutations theory: Is similar but proposes that aging results from deoxyribonucleic acid ( DNA)

The free radical theory: I consider this is the most significant theory on aging, perhaps the most extended and applied at many anti-aging products.
 

 

The free radical theory provides a one explanation for cell damage. Free radicals are unstable molecules produces by the body 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 accumulations of free radicals are suspected to cause free damage to the cells, DNA, and the immune system. Excessive accumulation of free radicals in the body is purported to cause or contribute to the physiologic changes of aging and a variety of diseases .One free radical named lipofuscin, has been identify to cause a build up of fatty pigments granules that cause age spots in older adults. Individuals who support this theory propose that the number of free radicals can be reduced by the use of antioxidants such as vitamins A, C, and E carotenoids zinc, selenium, and phytochemicals.

I want to emphasize the activity of antioxidants and how they act on free radicals.

Antioxidants are substances that may protect cells against the effects of free radicals. Free radicals are molecules produced when body breaks down food, or by environmental exposures like tobacco smoke and radiation. Free radicals can damage cells, and may cause heart disease, cancer and other diseases.

Antioxidant substances include:

• Beta-carotene
• Lutein
• Lycopene
• Selenium
• Vitamin A
• Vitamin C
• Vitamin E

Antioxidants are found in many foods. These include fruits and vegetables, nuts, grains, and some meats, poultry and fish.

I believe that we should give more importance to proper nutrition as well as the removal of certain toxic habits to provide an adequate supply of antioxidants to our organism. In the other information I’ve found is recommended taking supplements of vitamins C, E and D, at this respect, I disagree, perhaps because of my training as a nutritionist I don't think it's a required contribution, I think it's enough a diet of foods rich in these vitamins, the practice of regular exercise and the removal of smoking, this all can provide the necessary amounts of these vitamins.

The Antioxidants and Disease Prevention:

Heart Disease: Vitamin E may protect against cardiovascular disease by defending against LDL oxidation and artery-clogging plaque formation.

Cancer: Many studies have correlated high vitamin C intakes with low rates of cancer, particularly cancers of the mouth, larynx and esophagus.

Individuals who support this theory propose that the number of free radicals can be reduced by the use of antioxidants such as vitamins A, C and E, carotenoids, zinc selenium and phytochemicals.

This is the antioxidants therapy. Antioxidant therapy include dietary changes as well as specific dietary supplements generally, antioxidant supplements are seen as relatively safe. High doses of some antioxidants may cause more harm than benefits. Anti Aging Foods:

This is a brief list of  antioxidant-riched food :

1. SALMON
2. OLIVE OIL
3. BROCCOLI
4. ACAI
5. BERRIES, CHERRIES and GRAPES
6. GARLIC AND ONIONS

This theory is the base of some products that treat the physical changes of aging.

Consulted bibliography and links:
 

http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1972.tb27853.x/abstract

http://www.healthchecksystems.com/antioxid.htm
http://www.nlm.nih.gov/medlineplus/antioxidants.html

AGING: A THEORY BASED ON FREE RADICAL AND RADIATION CHEMISTRY
DENHAM HARMAN, M.D., Ph.D.

The cross line: Also called connective tissue theory

The clinker theory: The clinker theory combines somatic mutation, free radicals, and crosslink theories to suggest that chemicals produced by metabolism

The neuroendocrine theory: The neuroendocrine theory focuses on the complicated of chemical interactions set off by the hypothalamus of the brain.

The immunologic theory: proposes that the increase in autoimmune diseases and allergies seen with aging is caused by changes in the immune system.

Guerra-Araiza C, Alvarez-Mejía AL, Sánchez-Torres S, Farfan-García E,Mondragón-Lozano R, Pinto-Almazan R, Salgado-Ceballos H. Effect of NaturalExogenous Antioxidants on Aging and on Neurodegenerative Diseases. Free RadicRes. 2013 Apr 18. [Epub ahead of print] PubMed PMID: 23594291.

 

CARACTERISTICS OF DISEASES IN ELDERLY

First of all, I want to talk about geriatrization of medicine, something that anyone who has visited a hospital can see. Hospitals are becoming more full of elderly patients with chronics diseases and they could not stay at hospital. For look after chronic situations of aging there are home nursing...

 

It is very important to know common aspects of geriatric syndromes that determine the specificity of care:

1. Heterogeneity of the population over age 65 : healthy elderly, sick old man, frail elderly and geriatric patient.
2. Peculiarities of disease: atypical presentations of disease.
3. Fragility and signs of vulnerability in older people.
4. Comorbidity and polypharmacy: differents diseases can affect different organs or systems related to each other.
5. There are many factors in aging: impaired ability to maintain a constant internal environment, interaction  between internal organs, long latency diseases periods become asymptomatic, immunological and iatrogenic. Increased drugs consumption is often resulting in prevalent iatrogeny. 
6. Tendency to chronicity and frequent disorders: promote independence. High prevalence chronic and degenerative diseases cause dependence.
7. Less favorable prognosis of disease: due to changes of old age, such as flu
8. Diagnostic and therapeutic difficulties: both diagnostic and therapeutic activities in geriatrics should be guided by the risk / benefit always keeping in mind benefit, and after dogin an integral geriatric valuation that justify the medical actions to perform.   
9. Most useful health resources: hospitalization rate twice of the general population.
10. Increased need for rehabilitation: our outcome, maintain autonomy  
11. Frequent need to use social resources: in the elderly ofte diseases aggravate social and family problems. 
12. Frequent ethical problems: taking diagnostic and therapeutic decisions in the final stages of life, longer life artificially .... 

I want to highlight and summarize one of the symptom of geriatric syndromes, the pain. Pain is a experience that have a three-dimensional character. Chronicity is usually.Often the healthy personal do not give the necessary importance to pain. Response to pain differs between persons. There are factors such as culture, sex, spiritual and age that can change the response to pain.

 

Older adults have increased pain risk as a result of  higher incidence of disease conditions joined with aging. Some older adults have decreased their ability to sense pain, whereas others are highly sensitive to painful stimulus.

 

Many older adults deny pain because they fear they will be avoided or lose their independence. They live with pain because they think that it is a normal part of aging and sometimes nurses thinks that pain is normal too.

I attach an example of VAS (visual analog scale), this the scale to meassure pain.

 

 

I would like explain some nurse´s interventions to controll the patient and help our patients. Well, as I have explained in other post to do our job like nurses we have to considerer 14 basic needs accordin to Virginia Henderson and we have to suggest nursing goals and a nursing interventions to meet the outcomes with our patients.

 

For this reason I want to explain some nursing outcomes and their nursing intervention.

The nursing outcomes for acute or chronic pain are to resport an improved comfort level or decrease in pain, verbaliza the ability to cope with pain and demonstrate techniques that provide relief from pain.

Some possible nursing interventions are:

• Evaluate kind of pain. Not all pain is the same, for this reason is important assess the pain with differents types of scales like VAS. I change the mnemonic PQRST (provocation or palliation, quality, region, severity, timing) I think that it is very interesting to do an accurate measurement.
• Provides comfort measures such as repositioning, giving a backrub, providing a noiseless environment...Listening patients could decrease  them fear and anxiety and could decrease  pain.
• Administer medications as erdered
• We could recomended non pharmacologic approaches like a meditation
• If movement increase pain, we try to reduce that.
• Teach our patients to breath when they are in pain, long, slow and focused breathing helps relaxation and takes attention away from pain.

I think that the most important thing to understand pain is try to put yourself in someone else's place. The chronic pain results in a reduction of quality of life. We have to become more empathy. 

 

 

AGE-RELATED PHYSIOLOGICAL CHANGES

The changes in body function are part of a continuum that begins the moment life begins. We can observe many normal changes in the body´s physical structure and function during the aging process. There are also changes that indicate the onset of disease or illness. Nurses are expected to be able to tell the difference between normal changes and abnormall changes that signify a need for medical or nursing intervention.

As a nurse, i think that is very important how to distinguish between physiological aging changes and diseases derived from aging. We should not attribute diet or changes in the elderly due to age, many cases are not related to aging but a disease process.

For this reason I want to do a brief description of the main changes in body due to aging. I pay special attention to those aspects that I didn't know and that I I found most interesting.

• The epidermis becomes more fragile, increasing the risk for skin damage. Skin repairs more slowly, increasing the risk for infection. Melanocyte activity declines with age, and in lightskinned individuals, the skin may become very pale.

• The major bone- associated change related to aging is the loss of calcium, increasing osteoporosis. Decreased mobility and flexibility of ligaments and tendons. Decreased strenght; increased risk for fallls.
• The respiratory system; decreased in elastic recoil of the lungs leads to dimished air exchange. Mucose membranes in the nose become drier as the fluid content of body tissue decreases; thus, the incoming air is not humidified as effectively. Decreased muscle strengh and endurance; thus decreased ability to breath deeply.
• The cardiovascular system; the heart does not atrophy with aging as other muscles do. The heart muscle mass increases slightly with age, and the thickness of the wall of the left ventricule also increases slightly. The aging heart my function less efectively even when no pathologic changes are present.
• The hematopoietic and lymphatic changes; Plasma viscosity increased. Blood cell prodcution in the bone marrow decreases slightly, resulting increased incidence of anemia. Increased immature T cells response.
• The gastrointestinal system. In the oral cavity, increased dental caries and tooth loss. Decreased thirst perception. Decreased gag reflex. Decreased muscle tone at sphincters. Decreased saliva and gastric secretions. Decreased gastric motility.
• The urinary system,decreased number of neprhons for this reason decreased filtration rate with decrease in drug clearance. Decreased blood supply and decreased removal of body wastes. Increased incidence of incontinence and the risk for infection. 
• The nervous system, I want to list the changes that occur with age in the nervous system because I think that knowing deeply these changes is essential. These changes are the base to detect any alteration of the higher functions also allow detection of potential geriatric syndromes.

Dementia is a syndrome that have to be interpreted such as deterioration of higher functions, including memory from the previous patients level.

Additionally, the psychological and behavioral changes result in patient progressive disability.

I have included this definción to capture more clear the importance of knowing the changes of aging, in this case the change of nervous system and the complications that can occur by and the importance of detecting cognitive impairment fast as possible.

Nursing assessment	Care strategies
Decreased number of brain	Slowed thought processes Decreased ability to respond to multiple stimuli and tasks.
Decreased number of nerve fiber	Decreased reflexes, decreased coordination, decreased propioception.
Decreased amount of neuroreceptors	Decreased perception of stimuli
Decreased perhireal nerve function	Decreased motor response Increased risk for ischemic paresthesia in extremities
Assess balance and reflexes	Educate regarding safety precautions and use of assistive devices Structure tasks to reduce confusion Allow adequate time to perform tasks
Assess alertness	Report abnormal findings to pshysician. Refer for neurologic evaluation

 

Mental and physical exercise can help your brain stay sharp. Mental exercises include reading, doing crossword puzzles, and even stimulating conversation. Physical exercise promotes blood flow to your brain. It also helps reduce loss of brain cells.

 

I wanted to make this little summary to see the physiological process of aging, and be aware that certain changes in the elderly are "normal" and other changes that often attribute to age are part of a pathological process.

I share this link from the WHO (World Health Organization)
 

Hoffman. G. Basic geriatric nursing. 5th edition. Ed. Elsevier. 2012 St. Louis, Missouri.

NURSING CARE IN ELDERLY

 "The only function of a nurse is to assist the individual in health and disease, in the performance of those activities contributing to health, recovery or a peaceful death, that he realized without help if I had the strength, will and knowledge necessary . and do this in a way that will help you become independent as soon as possible ". Virginia Henderson

I want to start this post with this sentence of Virginia Henderson, I think that summarize the work that we can develop as nurses. In addition I find particularly interesting this sentence in the care of the elderly, and we should always try to promote elder's independent soon as possible. 
Virginia Henderson developed her care system  according to 14 needs, satisfying each need is influenced by biological, psychological, cultural and spiritual needs of each of us, this needs are interrelated so that should not be considered a need without taking into account the other. From these 14 needs will derive our basic cares that include all therapeutic interventions that we will make on each patient. This needs are designed to reach outcomes that we establishes to complete the patient's needs.
It is very important in the elders care to valuate the 14 basic needs and valuate if them present any manifestations of dependence or independence, that are specific characteristics of the elderly cares. The manifestations of dependence or independence has not taken into account in other age.
Then to summarize this topic,I want to highlight some possible interventions that we could carry out in some situations.

These are: 
1. Breathe normally : a patient that suffers chronic obstructive pulmonary disease, some interventions that we could make are: 

• Teach to use inhalers to our patient, if he needs it.
• Help this patient to eliminate toxics habits, such as cigarrets.
• Teach patient how to make respiratory rehabilitation exercises.

2.  Eat and drink adequately,  dehydrate elderly patient:

• We have to provide liquids to treat the dehydrate, if the patient is in a severe stage the liquids administration will be intravenous.
• Managing a balanced diet
• Inform patient of the importance of drinking two liters of water a day

  




 3. Eliminate body wastes, a constipation patient:

• Advise the patient benefits of a rich fiber diet
• Avoid irritant foods such as spices, spicy foods, alcohol ... 
• Adequate fluid intake (2 liters a day)

4.Move and maintain desirable postures, patients with impaired physical mobility:

• Encourage exercise
• Correct the cause of physical deterioration
• Awareness of the limitations of aging.

5.Sleep and rest. Patient with insomnia:

• Control proper sleep hygiene (schedules, food ...)
• Control fluid intake at night
• Encourage moderate physical activity

6.Select suitable clothes-dress and undress, unkempt patient:

• Provide recommendations on suitable clothing and footwear
• Promote hygiene
• Valuate periodically dressing ability 

 7. Maintain body temperature within normal range by adjusting clothing and modifying environment, hypothermic patient.

• Controll body temperature
• Treat the fever with antipyretics and other interventions
• Control fluid intake    

              

8. Keep the body clean and well groomed and protect the integument, immobile patient with impaired cutaneous integrity:

• Daily skin revision
• Bathe with neutral soap and water 
• Protein-Rich diet. 

9. Avoid dangers in the environment and avoid injuring others. , patients with cognitive impairment: 

• Periodically assess functional areas
• Control of  enviroment risks
• Teach patient using care devices
  

10.Communicate with others in expressing emotions, needs, fears, or opinions. , express their sexuality and emotions, social isolation patient

• Listen to patient to find why is he isolated.
• Encourage participation in social groups as neighborhood associations, daily centers ..
• Study the family environment and foster communication with him.    

11. Worship according to one’s faith. , patient death anxiety:

• Reassure the patient
• Help the patient to talk about their fears, anxieties ...
• Encourage communication with his social environment.

12. Work in such a way that there is a sense of accomplishment, patient worthlessness:

•  Study the family environment of the patient and his support enviroment.
• Encourage the patient to attend group therapy
• Encourage the patient to participate in voluntary activities, asocicaciones of neighbors ...  

13.Play or participate in various forms of recreation, patient expresses feeling bored.:

• Encourage the patient to read, write, and stay informed about daily news.
• Encourage the patient to do things that he coludn't do in other ages.
• Perform cultural activities.

14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities. Patient with early Alzheimer's. :

• Teach patient about his disease.
• Promote mental exercises      
• Evaluate mental functions periodically by doing tests.

I want describe with these small examples the valuation process in nursing care as clearly and "graphic" as possible, in this case, focused on elderly patients.

Rodrigo. M.T; Fernández. C; Navarro. M.V. De la teoria a la práctica. El pensamiento de Virginia Henderson en el siglo XXI. 3º edición.Elsevier masson.2005. Barcelona