Quadro clínico de idosos em uma instituição de longa permanência

RESUMO Objetivo: determinar o perfil sociodemográfico e clínico de idosos institucionalizados e identificar os diagnósticos de Enfermagem. Método: trata-se de um estudo quantitativo, exploratório e descritivo. Aplicou-se um questionário estruturado a 59 idosos e, para discutir as variáveis selecionadas, foi utilizado o programa Statistical Product Service Solutions. Apresentaram-se os resultados em forma de tabela. Resultados: aponta-se a prevalência do sexo masculino, em 52,5% dos idosos, da faixa etária de 70 a 79 anos e dos solteiros; a média de tempo de institucionalização é de 4,1 anos, sendo o principal motivo para a institucionalização a insuficiência familiar (mulheres = 60,7%; homens = 67,7%). Registrou-se, em relação às doenças prevalentes nos idosos, que 61% eram hipertensos e 23,7%, diabéticos, sendo que 76,3% utilizam medicamentos. Destacam-se, entre os diagnósticos de Enfermagem, a dentição prejudicada (67,7%), a síndrome do idoso frágil (59,3%) e o risco de quedas (52,5%). Conclusão: reconhece-se que a identificação dos diagnósticos de Enfermagem favorece a continuação do cuidado, indicando quais intervenções são necessárias para realizar uma assistência de acordo com as necessidades de cada idoso. Descritores: Enfermagem Geriátrica; Instituição de Longa Permanência para Idosos; Diagnóstico de Enfermagem; Assistência a Idosos; Idoso Fragilizado; Habitação para Idosos.ABSTRACTObjective: to determine the sociodemographic and clinical profile of institutionalized elderly and to identify nursing diagnoses. Method: this is a quantitative, exploratory and descriptive study. A structured questionnaire was applied to 59 elderly people and, to discuss the selected variables, the Statistical Product Service Solutions program was used. The results were presented in tabular form. Results: the prevalence of males was found in 52.5% of the elderly, in the age group 70-79 and in the unmarried; the mean time of institutionalization is 4.1 years, the main reason for institutionalization being family insufficiency (women = 60.7%, men = 67.7%). In relation to diseases prevalent in the elderly, 61% were hypertensive and 23.7% were diabetics, and 76.3% used medications. Among the Nursing diagnoses, the impaired dentition (67.7%), the fragile elderly syndrome (59.3%) and the risk of falls (52.5%) were highlighted. Conclusion: it is recognized that the identification of nursing diagnoses favors the continuation of care, indicating which interventions are necessary to perform care according to the needs of each elderly. Descriptors: Geriatric Nursing; Long-Term Institution for the Elderly; Nursing Diagnosis; Assistance to the Elderly; Fragile Elderly; Housing for the Elderly.RESUMENObjetivo: determinar el perfil sociodemográfico y clínico de ancianos institucionalizados e identificar los diagnósticos de Enfermería. Método: se trata de un estudio cuantitativo, exploratorio y descriptivo. Se aplicó un cuestionario estructurado a 59 ancianos y, para discutir las variables seleccionadas, se utilizó el programa Statistical Product Service Solutions. Se presentaron los resultados en forma de tabla. Resultados: se apunta la prevalencia del sexo masculino, en el 52,5% de los ancianos, del grupo de edad de 70 a 79 años y de los solteros; el promedio de tiempo de institucionalización es de 4,1 años, siendo el principal motivo para la institucionalización la insuficiencia familiar (mujeres = 60,7%, hombres = 67,7%). Se registró, en relación a las enfermedades prevalentes en los ancianos, que el 61% eran hipertensos y el 23,7%, diabéticos, siendo que el 76,3% utilizan medicamentos. Se destacan, entre los diagnósticos de Enfermería, la dentición perjudicada (67,7%), el síndrome del anciano frágil (59,3%) y el riesgo de caídas (52,5%). Conclusión: se reconoce que la identificación de los diagnósticos de Enfermería favorece la continuación del cuidado, indicando qué intervenciones son necesarias para realizar una asistencia de acuerdo con las necesidades de cada anciano. Descriptores: Enfermagem Geriátrica; Instituição de Longa Permanência Para Idosos; Diagnóstico de Enfermagem; Assistência a Idosos; Idoso Fragilizado; Habitação para Idosos.

It is well known that, throughout history, care for the elderly has been attributed to their descendants and is generally destined for the woman, but Brazilian society is experiencing an accelerated fall in fertility levels and mortality, as well as changes in family arrangements. It is understood that this occurs in parallel with the generalized increase in female schooling, the massive insertion of women in the labor market and changes in their social role and value system. In sum, it is argued that there is an increase in the number of elderly people, while a decrease in the availability of family caregivers. 1 It is observed that families are the support of the elderly, who are increasingly sensitive to the environment, needing a caregiver. It is noticed that, when families have difficulty in caring for the elderly in their own home, they resort to their insertion in a Long-Term Care Institution for the Elderly (LTCIE), which appears as an unfamiliar alternative to meet the housing needs care of this population. For the National Sanitary Surveillance Agency (ANVISA), these institutions, such as governmental or non-governmental, of a residential character, shall be designated for the collective domicile of persons aged 60 or over, with or without family support, in condition of freedom, dignity and citizenship. [2][3] Only six institutions of this type were identified in Piauí, where 205 residents were found, of which 94.0% are elderly, corresponding to 0.07% of the total population of the state's elderly population. The predominance of men is indicated, except in the age equal or superior to 80 years, in which the women are majority. It is also verified the predominance of non-religious private philanthropic institutions. 1 LTCIE is understood as a residence that offers specialized care according to the needs of each resident, providing continuous care actions. Care is understood as an activity that goes far beyond the needs of the human being, also involving self-care, self-worth and self-esteem. It is necessary, for this, that the institutions have access to the services of a qualified multiprofessional team. 4 It is required, through the integral promotion of the health of the elderly, that LTCIE nurses know the aging process and, in their commitment to the care of the human being, program strategies that seek to maintain the autonomy and independence of the elderly, of individualized care. Nurses can be used to improve the quality of care provided to residents of LTCIE's, through the use of nursing diagnoses, interventions and results, to apply technical-scientific knowledge in a systematized way, underpinning the work of this professional and favoring organized care. 5 It is pointed out that the nurse develops her activities with the elderly person through a caring process that considers the biopsychosocial and spiritual aspects experienced by her and her family. The performance of the role of the nurse responsible for LTCIE is relevant, so that this mode of residence is as satisfactory as possible for the elderly person. Thus, the nurses of an LTCIE develop management/administration, care, research, education and teaching functions. It is essential, therefore, that the professional is aware of this role, the actions of his competence, as well as the activities of the team of workers under his leadership. 4 It is suggested that Nursing performance be based on the Nursing Process (NP), which implies benefits for providing a systematized, oriented and organized assistance. The NP is composed of interdependent and interrelated stages: Nursing History; Nursing diagnosis; Nursing Planning; Execution of Nursing Planning and Nursing Evaluation. It is pointed out that the NP, when implemented in the institutions, enables the organization of care by reducing the risk of physical dependence of the elderly person, by enabling health determinants through the continuous assessment of functional capacity and by establishing the required goals against the needs of the elderly, individually. 6 • To determine the sociodemographic and clinical profile of institutionalized elderly following inclusion criteria were listed: the elderly should be residents of the institution, be 60 years old or older, accept to participate in the research and sign the Free and Informed Consent Term. Exclusion criteria were chosen: people aged less than 60 years, who refused to participate in the study or were prevented for some reason, such as hospital admission, isolation, among others.
The data was collected by analyzing the medical records and the physical examination. After the signing of the Informed Consent Term, the participants were submitted to the interview and physical examination, according to the form that was produced by the researchers, and the Nursing Diagnosis (ND) was the aid of Taxonomy II of the North American Nursing Diagnosis Association 2015-2017.
It should be noted that the president of the shelter allowed the analysis of medical records after the signature of the Faithful Depositary Term, making it possible to collect data regarding the time and reason for institutionalization, clinical diagnoses, medications in use and age group.
For the discussion of the selected variables, the Statistical Product Service Solutions (SPSS) program -version 20.0 was used, in which the data were inserted, analyzed, grouped and presented through tables.
The minimum risk was considered, since there was no need to interrupt the research, however, some intercurrences, such as the pause for feeding, medication administration and the satisfaction of physiological needs were listed as risks for the research, being necessary postpone the study steps to suit participants' availability.
Participants benefited indirectly because, by contributing to science, it is possible to wake up so that the health professionals' glances turn to them and that other studies are carried out.
The study was composed of two stages, the first of which was the analysis of the records of the institutionalized elderly, whose purpose was the characterization of the elderly in relation to the variables gender, age group, time and institutionalization reason (Tables 1 and 2). Prevalent diseases and medications in use (Tables 3 and 4) were also evaluated in the medical records. The second stage allowed the evaluation of the elderly to construct the Nursing diagnoses ( Table 5).
The study was carried out with 59 elderly people, of which 28 were female, corresponding to 47.5%. It was observed that the predominant female age group was between 70 and 79 years (39.3%), followed by 80-89 years (28.6%), and the presence of six elderly women of equal or over 90 years, with a limit of 105 years. 31 are males, corresponding to 52.5%, the predominant male age range was also 70-79 years (45.2%), with age limit of 91 years.  In this research, we chose to divide the reasons for institutionalization into five categories: family insufficiency -a category that treats the elderly who were admitted to the institution for various reasons, such as living alone, lack of family caregivers, nonaccountability of the family by the elderly or the lack of family structure to care for; illtreatment -in this category, elderly people who suffered some form of physical, psychological, moral or sexual violence or omission of care were included; street dwellers -most of whom arrived at the institution through the senior citizen's office or anonymous requests, and were referred by CREAS (Specialized Reference Center for Social Assistance); others -in this category were the elderly who sought the institution for their own account or judicial decision; as well as the category not informed, since there were some medical records that did not have this information.
It was observed that, in terms of the time of institutionalization, a large part of the elderly women resided in the LTCIE between two months and five years (75%), followed by those who lived in the institution of six 21 years ago (25% ). Women's longer life expectancy is related to less exposure to risk factors, increased health concern, as they seek health services more frequently, and healthier lifestyles. 6 It is worth noting that, for men, a large part of them live in LTCIE during a period between one month five years ago (77.4%), followed by those who have lived six years ago (22.6%). The mean time of institutionalization is 4.1 years for both sexes.
It was noticed, in relation to the marital status, that, in both sexes, singles predominate. This phenomenon is attributed to the fact that institutionalization is a means of survival for the elderly, considering the lack of spouses.
It is shown that, according to table 3, 76.3% of the elderly use drugs. In a study of 78 institutionalized elderly people, 30.4% of the elderly had a minor polymedication (one to four medications) and 67.03% had a larger polymedication (more than five drugs). It is known that the increase in the prevalence of chronic diseases triggers the growing consumption of drugs, leading to the polymedication, defined by the simultaneous and chronic use of various medications. 1-2,7 The most prevalent diseases were identified (Table 4), their signs and symptoms were recognized and it was verified that their correct treatment is of paramount importance to perform the care in order to meet each need of the old man.  The objective of the second phase of the study was to evaluate critically, carefully and thoroughly the elderly, to formulate the Nursing Diagnostics. A form was used that was completed at the time of the evaluation of the elderly, in which the main needs of each participant.
According to Taxonomy II of NANDA-I, Nursing Diagnosis (ND) is a clinical judgment about a human response to health conditions/life processes, or a vulnerability to such an answer by an individual, a family, a group or a community; thus, nurses diagnose health problems, states of risk and the willingness to promote health. It should be emphasized that the nurse plays an important role in the admission of the elderly in the institution, and should introduce him to the routine, show him the whole institution, get him to know the physical structure, introduce him to other residents and staff, because the elderly person needs to be welcomed in order to provide him with a better and faster adaptation. 8 The reasons for this category (women = 60.7%, men = 67.7%) were identified as the most frequent reason for institutionalization in both sexes. It is recommended that the elderly with no family present the greatest probability of institutionalization in the National Policy for Elderly Care, expressed in Law N. 8,842/94 and regulated by Decree N. 1,948 / 96, when it is specified that asylum institutionalization occurs in cases of family non-existence, abandonment and lack of financial resources of the family or the family.
It was also evaluated the use of medications by the elderly. The medications are prescribed by the institution's physician and administered by the Nursing team.
It is recorded that in the institution 45 elderly people use medications (76.3%), on a scale that starts with the use of at least one medication, reaching a maximum of seven.
It is worth noting that most of the elderly have systemic arterial hypertension 61% and 23.7% have Diabetes Mellitus. SAH is defined as a multifactorial condition characterized by elevated and sustained blood pressure levels and is considered a public health problem in Brazil. It is known that its prevalence reaches more than 50% of individuals aged 60-69 years and 75% of individuals over 70 years of age. It is understood that SAH integrates risk factors for diseases resulting from atherosclerosis and thrombosis, which are manifested predominantly by diseases such as ischemic heart, cerebrovascular, peripheral and renal vascular diseases, cognitive deficits, such as Alzheimer's disease and dementia , and vascular. SAH is considered to be a major risk factor for chronic non-communicable diseases as one of the major causes of decreased expectation and quality of life. 9 It refers to DM as a metabolic disorder of different causes, characterized by hyperglycemia and by the disorder in the metabolism of carbohydrates, proteins and fats, resulting in defects in insulin secretion and/or absorption. It is estimated that Brazil occupies the 6 th world position relative to the disease, with prevalence of 11.3%, in 2030. It was pointed out in a survey that the incidence of DM increases according to the age of the population, and 21.6% of the population over 65 reported having the disease. It should be emphasized that DM and SAH are the main factors responsible for mortality and hospitalization in the Unified Health System. 10 It was found in a survey, from the analysis of medical records, that the morbidity of each elderly person varied from one to six, with a mean of 2.85 per elderly. The diagnosis of SAH was predominant (20.63%), followed by depression (17.04%), psychiatric problems (12.11%), diabetes mellitus (11.21%), heart disease (8, 07%), cataract (3.59%), stroke (1.79%) and others (25.56%). 11 It is understood that knowing the profile of the elderly, their fragilities, the level of dependence and the Nursing diagnoses is of paramount importance for the planning of the care, since, from this knowledge, one can plan an assistance in an individualized way and according to the demands of each elderly person. It is worth noting that all the diagnoses shown in table 4 come from a critical and meticulous evaluation of each elderly person, according to their history.
It is noteworthy that 34 nursing diagnoses found are real and ten deal with risk diagnoses. It was observed that the activity/rest domain covered the largest number of diagnoses, with a total of 14 (31.8%). The most frequent and clinically important diagnoses were chosen for the discussion.
In the field of Health Promotion, risk-prone health behaviors are evidenced by smoking and failure to act in order to prevent health problems. It is pointed out that the second most frequent ND was that of the fragile elderly syndrome (59.3%). According to NANDA-I, this diagnosis is defined as the dynamic state of unstable equilibrium that affects the elderly that goes through deterioration in one or more health domains and leads to increased susceptibility to adverse health effects, in particular the inability. The factors related to other nursing diagnoses, such as impaired walking, the deficit in self-care for the bath, intimate hygiene and dressing, social isolation, impaired memory and impaired physical mobility are highlighted. The syndrome is perceived as a diagnosis of great relevance because it involves physical, functional, psychological and/or social aspects. It is also emphasized that 18.6% of the elderly presented a risk for frail elderly syndrome.
It is suggested that nursing interventions to meet these demands should consider the nature of the change, its potentiators and risk factors; thus, the nurse will have subsidies to direct Nursing interventions, to assist the elderly, to provide maintenance and/or improvement in health status, as well as to prevent injuries. 11 In the field of roles and relationships, the diagnosis of impaired social interaction was found, according to NANDA-I, to be insufficient or excessive quantity or ineffective quality of social exchange, related to dysfunctional interaction with other people, impaired social function , impaired mobility and disturbed thinking processes. Isolation, difficulties in personal relationships and communication problems are listed as factors that may contribute to a psychiatric disorder. 12 In the Perception/Cognition domain, the highest number of elderly people with impaired memory diagnoses and impaired verbal communication were observed. It is important to act in order to prevent, avoid or delay the appearance of cognitive loss in the elderly population, encouraging them to read, play, move, dance, reason, memorize and make them more active, fighting the impression that elderly is no longer useful. 13 In the Activity/Rest domain, the elderly depended to perform daily activities such as bathing, performing intimate hygiene, dressing and feeding, as well as locomotion or transfer of surfaces. It should be emphasized that, although a decrease in the locomotion capacity is expected for the elderly, it is essential to evaluate the level of disability presented by these subjects, since reduced locomotion interferes directly in the development of daily activities and in selfesteem. It is evaluated that Nursing must pay attention to the dimensioning of personnel according to the level of dependence of the elderly. 14 It is pointed out that fragility should not be understood as the direct result of the accumulation of pathologies in the same individual. It is pointed out that, along with these comorbidities, the factors that result from aging and not from the presence of diseases certainly play an important role in the genesis of the clinical picture of the frail elderly. It was found that the ND impaired dentition was the most frequent among the elderly (67.8%), related to tooth wear, absence of teeth or loose teeth. It is known that the oral health of the elderly in Brazil is precarious and the institutionalized elderly live in a context of abandonment and difficulties, making it urgent to implement educational actions, prevention and treatment in oral health for institutionalized elderly. [11][12][13][14] The risk of falls was found in 52.5% of the participants of this study, related to impaired walking, cognitive deficit, impaired physical mobility and history of falls. It was found, in one study, that the occurrence of falls in elderly residents in an institution was 32.5%. Nursing assistance is related to prevention, stimulating or monitoring the practice of physical activity, evaluating the possible risks of falling, such as the use of carpets, slippery floors and medications. 8,15 Altered cognitive function, altered sensitivity, self-care deficit, shear forces, desquamated or dry skin, prolonged immobility on a hard surface and skin moisture are associated with the ND risk of pressure ulcer. These factors are evidenced, mainly, in the bedridden elderly, who use diapers and who are dependent to perform self-care activities; however, in the evaluation, no elderly with pressure ulcer were found.
Three diagnoses were highlighted in the Comfort domain, related to the fact that the majority of the elderly feel lonely because they do not have a family because of their widowhood, or because the family has not assumed responsibility, and the feeling of loneliness arises. are found in a place with unknown people, favoring social isolation, due to the lack of interaction between the elderly.
It is known that the nurse is an indispensable professional in the LTCIE's, possessing the technical-scientific knowledge to perform an integral and humanized care for the elderly. It is considered of paramount importance that nurses know the public with whom they work; for this, the Nursing diagnoses are used to perform a care directed to the individual needs, considering the peculiarities of each elderly person and aiming at the implementation of the Systematization of the Nursing Assistance.
It has been observed that many types of care are needed in the LTCIE, and that the elderly are mostly fragile to perform the basic activities of daily living, depending on a large number of staff, the elderly demand in the institution. It was recorded that the elderly present several pathologies that require specific care and a continuous evaluation of their state of health. It is pointed out that the results of this research contribute to the characterization of the elderly, putting in discussion their needs and the importance of the elaboration of a plan of care for the elderly in institutions of long stay.
The Nursing diagnoses of the elderly were evidenced after a thorough evaluation, resulting in the conception that the Nursing diagnoses are fundamental for the elaboration of the elderly care plan. It is hoped, therefore, to emphasize the importance of NCS in LTCIE's, providing an individual and organized care, through a continuous and planned evaluation. Taking into account the various fields of nursing practice, it is possible to implement the knowledge learned during the course, to perform the NCS and to act in the prevention and treatment of diseases.