Download 2. Features care of elderly patients.

Ministry of Health of Republic of Belarus
Education establishment
«The Gomel State medical university»
Chair of Internal Disease №1 with Endocrinology Course
It is discussed at the meeting of chair 30.08.2016
Protocol № ___________
METHODICAL REVIEW
for practical training of foreign students of the 1st course
« Supervision and hygienic care of patients of elderly and senile age.
Supervision and hygienic care of patients with self-service deficiency and
movement break »
Theme 11 (Lesson 18)
3h.
1. Training and educational goals, motivation for theme learning,
requirements of initial level of knowledge
1.1 Aim of training: Explore the features of monitoring and care of patients with
deficiency of self-service and violation of physical activity, elderly, to
distinguish between stage and clinical signs of terminal states, to master the
technique of chest compressions and artificial respiration heart.
1.2 Requirements to initial level of knowledge: during the training the student
should
To know:
1. Fundamentals of hygienic care of patients with deficiency of self-service and
a violation of motor activity.
2. Features of patient care elderly.
3. Stages, clinical signs of terminal states.
4. Signs of biological death
To be able to:
1. Perform chest compressions and artificial respiration.
2. To provide hygienic care of patients with deficiency of self-service and a
violation of motor activity.
3. Perform patient care elderly.
2. Checklist from related subjects
1. Anatomy of the cardiovascular system.
2. Physiology of the cardiovascular system.
3. The anatomy of the upper and lower respiratory tract.
4. The normal physiology of the respiratory system.
3. Questions on an occupation subject:
Lesson 18:
1. Monitoring and hygienic care of patients with deficiency of self-service and
a violation of motor activity.
2. Features care of elderly patients.
3. Terminal states. Stages of clinical signs. Signs of clinical death. Caring for
dying people.
4. Technique of chest compressions and artificial breathing.
5. Signs of biological death
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4. Materials for self-preparation:
Lesson 18:
1. Monitoring and hygienic care of patients with deficiency of self-service
and a violation of motor activity.
A feature of the care of seriously ill patients is to monitor their appearance, heart
rate and blood pressure levels. It is desirable to isolate the seriously ill in a single or
double room, where it is easier to ensure peace both at night and during the day, or
bring them into the hall and fence off a screen.
The patient, who is a long time on bedrest, needs special care: a change in body
position, timely change of linen, use of anti-bedsore mattresses, rubbing the skin
disinfectants, the treatment of the oral cavity.
Feed should be seriously ill often, small portions of warm liquid food using a
feeding cup. Due to the fact that it is impossible to raise a patient's head, at the end of a
feeder cup wear rubber tube is introduced into the patient's mouth, raise and lower
feeding cup - in the amount of food one drink enters the mouth. unconscious patients is
powered by the parenteral route (the introduction of nutrient solutions through a vein).
A nurse should monitor the physiological settings of the patients, as they have
often paralysis of the pelvic organs, which leads to involuntary urination and defecation.
In such cases, under the buttocks need to put a rubber boat, under the sheet - oilcloth.
In the morning the nurse must make a full suite of seriously ill: wipe the teeth and
tongue, mouth wash, wash his face, wipe the whole body, undercut. Then, with the help
of nurses needed perestelit bed.
The nurse must be able to read the information from the instruments that control
some of the parameters of life of patients who are in the House of the ICU. On the
slightest deviation of the level of blood pressure and heart rate must be immediately
reported to doctor.
Cleaning the critically ill
Necessary equipment: sterile - tray, forceps, cloth, oil cloth, craft, pitcher of water
(water temperature 37-38 ° C) or mug douches.
The order of execution of the procedure:
1. Put oilcloth, and put the vessel under the sacrum of seriously ill.
2. Ask for the seriously ill to bend his knees slightly and spread them apart.
3. Take the rubber tube from a mug Esmarch or a jug in your left hand, and
forceps with gauze - in your right hand.
4. Process the external genitalia and perineum, pouring in the following sequence:
the pubic area, vulva, perineum, anus region in the direction of the external genitals to
the anus.
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5. Change the cloth and wipe dry the skin in the same sequence and the same
direction.
2. Features care of elderly patients.
The age of human development is the interaction of two major processes: aging
and vitaucting. Aging is a universal endogenous destructive process, which manifests
itself in increasing the probability of death. Vitaucting (from the Latin «vita» - life,
«auctum» - increase) is the process of stabilizing and enhancing the vitality of life.
Although not a disease, aging creates preconditions age pathology. The aging
process is a continuous gradual transition from stage to stage: the optimal state of health
- the presence of risk factors for disease - the appearance of signs of disease - disability
- death. The rate of aging can be quantified using indicators reflecting the decreased
viability and increased damage of the body. One such parameter is the age.
Age is the duration of the existence of the body, from birth to the present day.
Applicable to date the age of man had been taken by the European grading a regional
WHO office in 1982.
Age-grading human (WHO)
- Antenatal period - from the moment of conception until birth.
- Early neonatal period - from birth up to 7 days.
- The neonatal period - from 7 to 28 days.
- Postnatal period - from 29 days to 1 year.
- Early childhood - 1-3 years.
- Preschool age - 3-7 years.
- School age - 7-15 years.
- Youth age - 15-30 years.
- Young age - 30-45 years.
- Middle age - 46-60 years.
- Transitional age - 60-65 years.
- Increasing age - 65-75 years.
- Senile age - 76-90 years.
- Centenarians - older than 90 years.
It is assumed that the species human lifespan is 92-95 years.
Currently, there are more than 380 million people older than 65 years. In Russia,
the fifth of the population is elderly. In Belarus, the elderly and the elderly make up
21.8% of the population. In the next 10 years is expected to increase the number of
older people is about 2 times, ie, already 40% of the population will be in the category
of middle and old age. The incidence rate in the elderly compared to younger persons to
2 times higher in old age - 6 times.
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Gerontology studies human aging process (from the Greek «gerents» - old man,
«logos» - teaching science). Gerontology is border area of biology and medicine dealing
with old age is not so much as the process of human aging. Gerontology includes such
large main sections as geriatrics, gerogygienu, geropsihologiyu, social gerontology, etc.
Geriatrics (from the Greek «gerents» -. Old man, «atria» - treatment.) is a border
section of Gerontology and Internal Medicine, studying particular diseases in humans
elderly and to develop methods of treatment and prevention.
The main features of the elderly sick
Pathological changes characteristic of elderly and senile age, begin to appear
already from 40-50 years.
1. Involutional (associated with regression of) functional and morphological
changes in the various organs and systems. For example, with the age of declining
performance in vital capacity, bronchial obstruction, the value of the glomerular
filtration in the kidneys, increased fat mass and muscle mass decreases.
2. The presence of two or more diseases in the same patient. On average, during
the examination of the patient or elderly senile he reveals at least five diseases. In this
regard, the clinical picture of "smeared" diseases, reduced diagnostic value of different
symptoms. On the other hand, co-morbidities can reinforce each other.
3. Mostly chronic diseases. Progression of most chronic diseases contribute to
age-related adverse endocrine-metabolic and immune changes.
4. Atypical clinical course of the disease. Often reveal disguised slower and
course of the disease (pneumonia, myocardial infarction, pulmonary tuberculosis,
neoplastic processes, diabetes, and others.). For example, a fever in older patients may
be one of the main, abscesses of the abdominal cavity, if not the only manifestation of
tuberculosis and infectious endocarditis.
5. The presence of "senile" diseases (osteoporosis, benign prostatic hyperplasia,
Alzheimer's disease, senile amyloidosis, etc.).
6. Change protective primarily immune, responses.
The general principles of care elderly
If you are caring for the sick elderly is of particular importance compliance with
the rules of medical ethics and deontology. Often, the nurse becomes for the patient,
especially the lonely, the only friend. Each patient requires an individual approach
taking into account the personal characteristics of the patient and its relationship to
disease. To establish contact nurse should talk calm friendly voice, be sure to greet the
sick. If the patient is blind, it should be every day, going in the morning to the Chamber,
submitted. For patients should be treated with respect, by name and patronymic. It is
unacceptable to call the patient's familiar "Grandma," "Grandpa". Geriatric patients
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often "go into yourself", "listen" to their condition, they appear irritability, tearfulness.
Therefore, the psychological preparation of the patient to a variety of medical
procedures, the ability to listen, empathize and give advice are important factors in the
successful treatment and care for the elderly.
Insomnia problem
Elderly patients often complain of insomnia, their sleep patterns change - often
they sleep longer during the day and at night are more active lifestyle (eating, walking
about the ward, reading). Commonly used by patients in this case, sleeping pills can
quickly addictive. In addition, the intake of hypnotics may appear weakness, headaches,
feeling of the morning "weakness", and constipation. If necessary, hypnotics prescribed
by a doctor. The nurse may recommend that the patient receiving medicinal herbs (such
as motherwort decoction of 10-15 ml 40 minutes before bedtime), 10-20 drops
"valokordin", a glass of warm milk with honey dissolved in it (1 tablespoon), and so on.
Ensuring personal hygiene measures
Often for sick elderly is difficult to take care of themselves. It should assist him
when changing bed clothes, if necessary to care for hair, nails, etc. It is necessary to
monitor the state of the patient's mouth. The nurse must after every meal the patient to
give him boiled water, so that he can carefully rinse the mouth. Seriously ill patients a
nurse is required to wipe a mouth swab dipped 1% solution of hydrogen peroxide or
sodium hydrogen carbonate. When caring for a patient, long-term are on bedrest, you
must carry out a thorough skin care and to prevent bedsores. The nurse must help the
patient to change position in bed from time to time, if it allows the state sit on the bed,
for the stability of propping pillows on all sides, slightly massaging the back, feet and
hands. It is necessary to control the physiological functions of patients and, if necessary,
adjust the diet bowel function (inclusion in the diet of dried fruits, milk products, and
others.) Intended use of laxatives or doctor enema formulation. Any deterioration in the
patient's state of health, appearance of new symptoms nurse should immediately inform
the doctor. Prior to his arrival is necessary to lay the patient or help him take the
appropriate position (for example, asthma patient should adopt a sitting position or
half), to ensure peace, if necessary - to provide first aid.
Injury prevention
With special attention should be taken for the prevention of possible injury.
Injuries and fractures (especially femoral neck) immobilize patients, accompanied by
the development of lethal complications, such as pneumonia, pulmonary embolism.
When washing the patient in the bath need to maintain it, helping to enter the bath and
out of it. On the floor is to be fitted with a rubber mat so that the patient does not
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slipped. The nurse is required to monitor the condition of the hospital premises, they are
sufficient illumination. The floor should not be foreign objects is unacceptable presence
of liquid spilled, as the patient may not notice them and fall down. Corridors geriatric
department should be spacious, not cluttered furniture, along the walls of the corridor
need to fix a railing that patients might hold for them.
Control of medication
The nurse should monitor patients receiving prescription drugs. By reducing the
memory and the development of dementia (from Lat «dementia» -. Dementia) patients
may forget to take the medicine or, on the contrary, to take it again. Therefore, patients
are elderly should be provided with clear instructions given by the doctor not only
verbally but in writing. It is necessary to monitor the water balance as inadequate fluid
intake can increase the concentration in the body-prescription drugs, side-effects and
development of drug intoxication.
Changing social and psychological status
The main causes of social exclusion of older people are the retirement, the loss of
loved ones and friends because of their death, loneliness and limiting communication
capabilities, self-service difficulties, the worsening economic situation, the
psychological perception of the age limit above 75 years, regardless of health status.
Against this background, often develop anxiety, depression, hypochondria syndrome
(abnormally exaggerated concern for their health, belief in the presence of a disease by
its virtual absence).
Rational management of the elderly patient requires mandatory mutual
understanding and harmony in the triad of "patient - nurse - physician." The extent to
which the patient medical recommendations designated by the term "compliance" in the
medical literature. By itself, the old age does not serve the cause of the lack of
compliance because it is the right approach achieves the latter, the use of verbal and
written instructions, reducing the number of drugs prescribed, preference depot dosage
forms, combined preparations and others.
3. Terminal states. Stages of clinical signs. Signs of clinical death. Caring
for dying people.
Conditions boundary between life and death, have a common name terminal
(from the Latin «terminalis» - Final) Dying process involves several stages.
1. Predagonal, or extremely heavy, a condition occurs on a background of severe
hypoxia, the internal organs and is characterized by the gradual suppression of
consciousness, breathing and blood circulation disorder. Predagonal period ends
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terminal pause (brief cessation of breathing) lasting from 5 to 10 seconds to 3-4
minutes.
2. Agonal state or agony (from the Greek agonia -Struggle) is a step in the
process of dying prior to onset of clinical death, lasting from a few seconds to several
minutes. During the agony of going medulla centers excitement.
Initially, blood pressure (BP) increases, breathing rate increases, sometimes
maybe even a short recovery of consciousness. Then there was a sharp drop in blood
pressure, slowing heart rate, respiratory depression, loss of consciousness. One of the
clinical signs of agony acts so-called agonal breathing, are rare short deep spasmodic
respiratory movements. Disappears pain sensitivity, lost reflexes, pupils dilate, occur
involuntary urination and defecation, reduced body temperature.
3. Clinical death. Status of clinical death is reversible stage of dying with an
average duration of 5-6 minutes. A patient in a state of clinical death, there are no
visible signs of life (heart activity, breathing), extinguished the central nervous system,
but still continuing metabolic processes in tissues.
Signs of clinical death are following.
1. Lack of consciousness: the loss of consciousness usually occurs after 10-15
seconds after circulatory arrest.
2. Lack of response to external stimulationg.
3. The lack of reaction of pupils to light (by opening the patient's doctor century
pupil remains wide, "fills in" virtually all of the iris); dilated pupils with loss of
response to light starts in 40-60 seconds after circulatory arrest, the maximum
expansion through a 90-100.
4. Stopping breathing or superficial rare breathing: decrease in the frequency of
breathing to 5-8 per minute.
5. The absence of a pulse at the radial, carotid, femoral arteries.
6. The emergence of cyanosis of the lips, fingertips, earlobes.
7. Blanching of the skin with the development of cyanotic marbling.
If clinical death can still be effective resuscitation, the ability to revive the person.
Following a near-death biological death occurs, which is characterized by such
disorders in the central nervous system, in which the life of the organism can not be
restored. When biological death occurs muscle relaxation, body cooling to ambient
temperature. Later appear corpse spots on the lower parts of the body.
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Caring of dying people
Treatment of patients in terminal states, as a rule, is carried out in the intensive
care unit or intensive care wards. Intensive care is, above all, the urgent fulfillment of
prescribed emergency manipulation, therapeutic measures and their high professional
level. It takes a very good organization of work of medical staff on duty. The principle
of operation in the intensive surveillance is different from the principle of working in
general wards. ICU (Intensive care unit) medical staff have to work in particularly
difficult circumstances. Places high demands on their professional training, moral
qualities and endurance. Unbalanced and indifferent people should not be allowed to
work in these offices. An essential quality of paramedic intensive monitoring should be
care, courage, kindness, accuracy and love of the patient's ability to concentrate and be
calm in an emergency.
On nurses working in intensive care it depends largely success of treatment. In a
short time a nurse has to perform a wide variety of fixed-term manipulation, medical
appointments, procedures, prepare the tools to carry out direct patient care.
Intensive Care Unit consists of intensive care room, which is carried out the
necessary resuscitation since the patient's admission to the improvement of his
condition, and several chambers. Intensive care unit equipped with central oxygen
supply, an audible alarm. Intensive care units should be provided with prepared
veinesection, veinepuncture, intra-arterial injection of blood and its substitutes, readyto-use systems for intravenous drip of medicinal solutions, different brands of
respirators. All of these should be in strictly designated areas. There has to be a nurse
emergency supply necessary pharmacological agents.
In intensive care units often there are situations requiring urgent diagnostic and
therapeutic measures, therefore, on duty at the nurse must have all the necessary items
of patient care: head restraints, bedpans, vessels, ice bags, hot water bottles, colonic
enema supplies, gas tubes. By entering on duty, the nurse is obliged to ensure that all
machinery and equipment in a state of full readiness. Washer is desirable to put on
mobile carts. You need to have a pacemaker and a shield placed under the patient's
back, if there is a need for chest compressions.
4. Technique of chest compressions and artificial breathing.
The basic resuscitation when clinical death is indirect (closed) heart massage and
artificial respiration to be carried out simultaneously. However, if assistance is
provided by lay rescuers (untrained people), it is permissible to conduct only chest
compressions without artificial respiration. The immediate task of chest compressions is
to restore blood circulation in the body, that is to support the circulation in vital organs
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in the absence of cardiac activity. The earlier you start heart massage, the better the
effect.
Keep in mind that by the time the development of heart failure to no more than 46 minutes passes in irreversible changes in the brain. It was during this period of time
must be initiated and carried out resuscitation (see. Fig.).
For the success of the chest
compressions you must place the patient on a
hard surface (floor or table). The doctor
becomes the side and put one hand on the
lower third of the patient's sternum and the
other hand imposes the first. Your arms should
be straight and the shoulder belt should lie
over the patient's chest. Compression
performed with a frequency of about 100
times per minute energetic sharp pressure on
the patient's sternum using your body weight so that the sternum was displaced by 5 cm
(but not more than 6 cm) to the spine.
At the same time the heart is squeezed between the sternum and the spine, and the
blood ejected from the ventricle into the aorta and pulmonary trunk, ie, performed
cardiopulmonary bypass. Upon termination of the pressure on the sternum it rises, and
the heart fills with blood from the vena cava. Massage is considered to be effective if
there are pulsations of the carotid arteries in the rhythm of the massage, breathing
movements, cyanosis disappears, it constricts dilated pupils before. Currently
resuscitation is recommended to begin as early as possible with chest compressions.
Only by following in the beginning of 30 chest compressions, airway prepare and
perform two energetic inspiration.
In modern conditions to improve the effectiveness of chest compressions is used
special equipment and accessories, including pneumatic vest CPR (CPR) CPR is
inserted with abdominal compression, active compression - decompression, and others.
Artificial respiration
Currently, artificial respiration directly by the method of "mouth to mouth" is not
recommended. For this purpose, a variety of simple disposable face mask with the valve
one-way (non-reversing type) air flow ( "Key of Life" and others.), S - shaped duct
mouth nasal mask with facial obturator, esophageal-tracheal obturator, Ambu bag. It is
effective to use the laryngeal mask. The mask-duct enables reliably disconnect the
respiratory tract from the pharynx and esophagus, to carry out artificial respiration, as
well as to the toilet of the tracheobronchial tree.
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The main condition for the effectiveness of
artificial respiration is the maximum throwing the
head back, and the root of the tongue and
epiglottis move forward and offer free access of
air into the larynx.
Under artificial respiration rescuer are
laterally from the patient. One hand tighten the
wings of his nose, the other slightly open mouth chin, is inserted into the oral cavity of
the patient's S-shaped duct pushes the tongue and epiglottis, pressed his lips to the duct
after a deep breath, and then make a vigorous blow, and then assign your head in side.
Breathe is performed within 1 second.
It is recommended during CPR to adhere to the compression ratio / breath as a
30 : 2, regardless of the number of rescuers as long as the victim is not intubated. If
airways are protected with the endotracheal tube cuff, the chest compression should be
constant and independent from the respiratory frequency of 100 cycles per minute.
Breathe is performed every 6-8 seconds, so the frequency of artificial respiration will be
8-10 times per minute. More rapid breathing is not justified.
If resuscitation carries one person, he must every 30 compressions sternum stop
massage for the production of two artificial breaths. In the case where resuscitation
carries one person who is not trained or is unable to perform CPR, it is sure to continue
chest compressions with a frequency of 100 per minute. Resuscitation should not be
terminated before the arrival of ambulance, or the arrival of medical professionals.
However, if 30 minutes after the start of massage and resuscitation cardiac activity is
not restored, no evidence of effective and sufficient cerebral blood flow (the pupils are
broad and not react to light), continued resuscitation can be considered impractical due
to irreversible changes in the brain cells.
5. Signs of biological death
If resuscitation measures do not lead to the restoration of circulatory and
respiratory functions, biological death occurs.
Signs of biological death: the complete cessation of breathing, no pulse and
heartbeat, deathly pale skin, relaxation of muscles, including the omission of the lower
jaw down, the disappearance of the eyes shine, lack of sensitivity, the gradual cooling of
the body, dilation of the pupils and their lack of response to light. Later comes the
stiffness of muscles, starting with the lower jaw and neck, covering the muscles of the
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body after 6-8 hours and lasts for several days, there corpse spots, first on the back, the
outer surfaces of the shoulders.
The death of the patient's doctor says, noting in history the exact time of its
occurrence. The corpse stripped, put on his back to straighten limbs tied up the jaw,
eyelids lowered, covered with a sheet and left in a separate, isolated from the other
patients, the room for 2 hours. Only after the establishment of cadaveric spots nurse
writing on the tag name, first name and patronymic of the deceased, medical history
number, duplicating the data in a special accompanying note to the mogren, which also
indicates the diagnosis and date of death. The corpse is delivered to the mogren, where
an autopsy produce.
Things deceased and values must be handed to relatives on receipt. This makes
the senior nurse, who must ensure that the value of things and were removed from the
dead and are listed in a special notebook.
5. LITERATURE
1. Krivenya, MS Fundamentals of anaesthesiology and intensive care: studies.
allowance. / MS Krivenya. - Mn .: Belarus. Entsykl. imya P. Broўki 2009.
2. Obukhovets, ETC. Nursing in therapy with a course of primary health care: a
workshop. - Ed. 2nd. / TP Obukhovets. - Rostov n / D: Phoenix, 2009.
3. Fundamentals of nursing: Proc. Benefit / LV Roman'kov etc... - Minsk .:
Elaida, 2012. - 200 p.
4. Oslopov, VN General nursing care in a therapeutic clinic: Tutorial / VN
Oslopov, OV Epiphany. - M .: GEOTAR - Media 2008.
Head of the department of Internal Diseases No.1
with Endocrinology Course,
PhD, assist. of Professor
E.G. Malaeva
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