Nursing care of hospitalized
geriatric patients

Authors: Sara Ayra Mayo and Bárbara Martínez Hiriart

Tutor: Alberto Hernández Jiménez, M.D.

Advisor: Elisa Andreu Cordero, M.D.

ABSTRACT:  The authors studied 20 geriatric patients diagnosed with non-tuberculosis inflammatory lung disease and admitted to the internal medicine ward of the Manuel Ascunce Domenech Hospital, in Camagüey Province.  The nursing care of these patients was evaluated.  The study was conducted using data from the first three months of 1992, indicating that the majority of the patients were white men and that those over the age of 75 had a higher incidence of this disorder.

Introduction

Changes in the structure of the population pyramid have taken place worldwide in the last few years, especially in developed countries, primarily as a result of improved health, increased life expectancy and improved economic and educational conditions. (1)

Life expectancy has risen to over 70 in many countries.  This has brought about an increasing scientific interest in old age as well as in population aging patterns for different social groups. (2)

This holds true for Cuba as well, which has shown a progressive increase in the numbers of elderly inhabitants in recent years.

In Camagüey Province, for instance, there are 87,000 elderly people,  representing 11.4% of the province's population.  This age group has the highest incidence of morbidity and mortality due to non-tuberculosis inflammatory lung disease. (1)

Since nursing care plays an important role in the health-disease process of hospitalized geriatric patients, this study was undertaken primarily as an assessment of the nursing care of these patients in day-to-day practice.

Table 1.  Distribution of Patients by Sex

Sex	Number of Patients	%
Female	9	45.0
Male	11	55.0
Total	20	100.0

Table 2.  Distribution of Patients by Race

Race	Number of Patients	%
White	20	100.0
Black	--	--
Mestizo	--	--
Total	20	100.0

Table 3.  Distribution of Patients by Age Groups

Age Group Studied	Number of Patients	%
61-65	1	5.0
66-70	4	20.0
71-75	0	--
76-80	10	50.0
over 80	5	25.0
Total	20	100.0

Table 4.  Distribution of Patients by Area of Residence

Area of Residence	Number of Patients	%
Urban	17	85.0
Rural	3	15.0
Total	20	100.0

Table 5.  Fulfillment of Physician's Instructions for Nursing Care as Reflected in Case Histories

Fulfillment of Physician's Instructions	YES (number of patients)	%	NO (number of patients)	%
Nurses properly reflect fulfillment of instructions for nursing care on patient charts	3	15	17	85
Total	3	15	17	85

Table 6.  Measurement of Vital Signs and Their Recording on Patient Charts

Aspects of Vital Sign Measurement  and Recording	YES (number of patients)	%	NO (number of patients)	%
1. Vital sign measurement reflected on patient charts with the frequency indicated by the attending physician	6	30	14	70
2. Vital sign measurement reflected on the charts with required readability	3	15	17	85
3. All vital signs are measured	4	20	16	80

Table 7. Quality of Patient Evolution Report Prepared by Nurses

	YES (number of patients)	%	NO (number of patients)	%
1. Evolution not reported as frequently as the patient's condition required	1	5	19	95
2. Patient's evolution not correctly reported	5	25	15	75
3. Date and time of entries not reflected in reports	10	50	10	50
4. Reports include management instructions and admission and/or referral information	6	30	14	70

Table 8.  Distribution of Patients by Complications

Complication	Number of Patients	%
Hepatomegaly	5	25
Hydromineral Imbalance	1	5
Pressure Sores	6	30
No Complications	8	40
Total	20	100

Table 8. Distribution of Patients by Hospital Stay 

Hospital Stay  (days)	Number of Patients	%
1-5	3	15
6-10	6	30
11-15	5	25
16-20	2	10
over 20	4	20
Total	20	100

Objectives

General Objective

To assess the nursing care of hospitalized geriatric patients diagnosed with non-tuberculosis inflammatory lung disease.

Specific Objectives

1. Describe distribution by age, sex, race and area of residence.

2. Describe hospital stay and possible complications.

3. Assess the quality of nursing care for these patients and define specific measures to prevent possible complications.

Material and Methods

In coordination with the Statistics Department of our hospital, 20 clinical records were randomly selected recently discharged elderly patients.  A survey form was developed, including variables such as age, sex, race, area of residency, hospital stay and complications.  The following data regarding nursing care of these patients was gathered: nurse's assessment of patients, fulfillment of doctor's instructions, measurement and recording of vital signs.  This data permitted us to draw specific conclusions regarding nursing care of these patients.  Descriptive statistical methods were applied, as well as data tabulation. 

Discussion of Results

Of the 20 geriatric patients admitted to our hospital with a diagnosis of non-tuberculosis lung disease, 9 were women (45%) and 11 were men (55%).  The higher prevalence of male patients coincides data from the medical literature consulted. (1)

All of these patients (100%) were white, which corresponds with data obtained in other studies conducted both in Cuba and abroad.

With regards to age, there is a higher prevalence of non-tuberculosis lung disease in the senile group over 75 years of age (50%) due to the fact that these patients are more vulnerable to both community-acquired and nosocomial (hospital-acquired) infections.

 Eighty-five percent of the patients in this study come from urban areas  reflecting the higher  population concentration in the cities, and as a corollary, greater exposure to agents affecting the respiratory system (more industry, carbon monoxide from exhaust fumes, etc.).

Regarding nurses' fulfillment of doctors' instructions for patient care, we found that in 17 cases (85%) nurses failed to do so adequately;  and that in only 3 cases (15%) nurses adequately fulfilled physician instructions.  Therefore, we concluded that both the confection of patient charts and quality of nursing care itself were insufficient.

The nursing staff did not reflect the indicated frequency of vital sign measurement on patient charts in 14 cases (70%); did not measure all the vital signs in 16 patients (80%), doing so only in 4 (20%). Vital sign measurement was not reflected with sufficient readability for 17 patients (85%).

Nurses are also charged with recording the patient's evolution in the clinical chart.  Our study shows that this was not carried out with the required frequency in 19 cases (95%), and in 15 (75%), nursing reports did not correctly reflect the patient's condition. 

It is important to note that of all of nursing responsibilities this latter is crucial  inasmuch as it serves as a guide for the doctors on the evolution of patients and is critical to the formulation of an appropriate treatment strategy. (5)       

Among the most common complications in these patients were pressure sores (30%).  This finding serves as a signal of inadequate nursing care of bedridden hospitalized patients. 

Table 9 shows the hospital stay for these patients.  Six of them (30%) stayed in the hospital from 6 to 10 days; and 5 (25%), from 11 to 15 days.  Only 4 patients (20%) stayed in the hospital for over 20 days.

To prevent the appearance of complications in hospitalized geriatric patients with non-tuberculosis lung disease, nursing staff should take the following measures:

• Patients should be isolated during the acute phase of the disease.
• Nurses should wash their hands before and after seeing the patient, to avoid contamination of the patient and/or other patients with the many pathogenic agents on the skin and in the mucosas.
• Nursing staff should see to it that patients' rooms are regularly cleaned to avoid the spread of infection.
• Nurses should elevate the head of the patient's bed so that the patient is in a semi-sitting position.  This provides better thoracic expansion and relieves the patient's dyspnea, thus reducing the anxiety it causes.
• In the first contact with the patient, upon admission to the hospital, nurses should pay special attention to the patient's facial expression, skin coloration and posture.  All of these details are included in a good physical exam of the patient.  Moreover, nurses should monitor the patient's vital signs (blood pressure, temperature, respiratory rate and pulse). (6)   
• A sudden increase, decrease or irregularity in the patient's pulse can predict possible circulatory complications.  The respiration rate is another important sign that must be closely monitored for the appearance of dyspnea or orthopnea, which may indicate rapid advance of the disease.  A typical sign in these patients' respiration is a grunting-like expiration. (10)
• Patients with serious lung inflammatory processes experience difficult respiration.  These patients should be given oxygen through a nasal catheter or a venting mask.  Moreover, asepsis and antisepsis measures should be intensified to avoid infection with other germs. (9)
• Patients with non-tuberculosis lung disease tire quickly drinking liquids; therefore, they should be administered in very small amounts and at regular intervals.  To stimulate appetite, these liquids can include fruit juice, bouillon, consommé or milk.  Nurses should also make sure that the patient's clothing and bed linen are dry, to avoid cultivation of various bacteria in the humid environment. (6)
• Nurses should offer psychological support to relieve anxiety-a typical sign in these geriatric patients. (4)
• Nurses should assist patients-who, due to their age, often become forgetful-in maintaining appropriate personal and environmental hygiene. (6)      
• Circulatory disorders and diminished skin sensitivity are common in elderly people, and require nursing staff to pay special attention to moisturizing the skin, among other measures.  (Creams with alcohol content should be avoided, since this astringent tends to increase dryness in already affected elderly people's skin.) (10)
• Bedridden patients should be helped to change their position frequently, and creases in their bedding must be avoided to prevent the appearance of pressure sores.
• Nurses should closely follow doctor's instructions and note the results of their work on the patient's chart, in order to avoid complications in these patients. (8)

Conclusions

1. Our study shows  that the majority of patients who suffer from non-tuberculosis lung disease are male and white, with a higher incidence in the over 75-year old group.  Most of these patients come from urban areas.

2. In 17 patients (85% of the cases studied), nurses failed to adequately record their monitoring tasks on patient charts.

3. Nursing care of bedridden hospitalized patients was inadequate.

4. Measurement and recording of vital signs was problematic.

Recommendations

1. Due to the high incidence of inflammatory lung disease in elderly people, emphasis should be placed on preventive measures to avoid such disorders.

2. Provide specialized nursing care to people over 60, especially to the senile (over 75) as well as to those with extended longevity (over 90).

3. Provide nursing staff in internal medicine wards with continued education and training.

4. Assign nurses with more seniority and better preparation to internal medicine wards.

References

1. Hernández Jiménez A.  Diagnóstico geriátrico .  Thesis for exam as First Degree
    Specialist in Geriatrics, 1991.

2. Hernández Castellón and others.  La población.  La Habana.  Ed. Ciencias Sociales; p.42,     1978.

3. Ancada Roque, María and others. "Psicogeriatría y Psicoballet". Rev. Cub. Enfermería
    6(2):198-204.  Mayo, 1990.

4. Valdés Mier, M.  Psicogeriatría.  Ciudad de La Habana, 1987.

5. Seminario Metodológico Nacional del Sistema de Anotaciones en Historias Clínicas. 
    Ciudad de La Habana, 1985.

6. Germain Smith.  Enfermería Médico-Quirúrgica. Vol. 1, 1987.

7. Rigal Ricardo O; Pérez Carballos F; Perea Garral O; Fernández Sacasas J; Fernández
    Mirabal J.  Medicina General Integral Vol. 2, 1986.

8. Calonga Blanca T.  Enfermería Médico-Quirúrgica .  Vol. 7; pp.1-12, 1985.

9. Professors of Nursing, Instituto Superior de Ciencias Médicas.  Enfermería
    Médico-Quirúrgica.  Vol. 2; pp.206-208, 1984.

10. Klussk H.  Procedimientos de Enfermería.  Editorial Pueblo y Educación; p.190. 
      Ciudad de La Habana, 1989.

This article originally appeared in Spanish in 16 de Abril journal, No. 191
(pp. 37-39), 1996.