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Borges CL, Freitas MC de, Guedes MVC et al. Nursing clinical practice in the frail elderly...
English/Portuguese
J Nurs UFPE on line., Recife, 10(Suppl. 2):914-8, Feb., 2016 914
ISSN: 1981-8963 ISSN: 1981-8963
DOI: 10.5205/reuol.6884-59404-2-SM-1.1002sup201629
NURSING CLINICAL PRACTICE IN THE FRAIL ELDERLY CARE: REFLECTION
STUDY
PRÁTICA CLÍNICA DO ENFERMEIRO NO CUIDADO AO IDOSO FRAGILIZADO: ESTUDO DE
REFLEXÃO
PRÁCTICA CLÍNICA DEL ENFERMERO EN EL CUIDADO AL ANCIANO DEBILITADO: ESTUDIO DE
REFLEXIÓN
Cíntia Lira Borges1, Maria Célia de Freitas2, Maria Vilani Cavalcante Guedes3, Maria Josefina da Silva4, Saul
Filipe Pedrosa Leite5
ABSTRACT
Objective: to reflect about the clinical practice of nurses in the care of frail elderly. Method: this is a
theoretical reflection supported in the literature. Results: the fragility syndrome has reached worldwide
repercussions; even so the frail elderly still lacks many strategies to maintain their autonomy and
independence. To promote clinical appropriate practice to the frail elderly, nurses must be knowledgeable of
the aging process and be updated with regard to the scientific evidence of weakness: the concept, diagnosis,
prevention measures, interventions, assessments and results. Conclusion: this reflection puts us ahead of the
nursing performance challenge in the transformation and adaptation of their clinical practice in the care of
the frail elderly or fragility process. Descriptors: Geriatric Nursing; Frail Elderly; Evidence-Based Practice;
Patient-Centered Care; Nursing Processes.
RESUMO
Objetivo: refletir sobre a prática clínica do enfermeiro no cuidado ao idoso fragilizado. Método: trata-se de
uma reflexão teórica apoiada na literatura pertinente. Resultados: a síndrome da fragilidade tem alcançado
repercussões em nível mundial, mesmo assim o idoso fragilizado ainda carece de muitas estratégias para a
manutenção de sua autonomia e independência. Para promover a prática clínica adequada ao idoso
fragilizado, o enfermeiro deve ser conhecedor do processo de envelhecimento e estar atualizado com relação
às evidências científicas sobre fragilidade: o conceito, o diagnóstico, as medidas de prevenção, as
intervenções, as avaliações e os resultados. Conclusão: essa reflexão nos coloca à frente do desafio da
atuação da enfermagem na transformação e adequação de sua prática clínica no cuidado ao idoso frágil ou em
processo de fragilização. Descritores: Enfermagem Geriátrica; Idoso Fragilizado; Prática Baseada em
Evidências; Assistência Centrada no Paciente; Processos de Enfermagem.
RESUMEN
Objetivo: reflexionar sobre la práctica clínica del enfermero en el cuidado al anciano debilitado. Método: se
trata de una reflexión teórica apoyada en la literatura pertinente. Resultados: el síndrome de la debilidad ha
alcanzado repercusiones a nivel mundial, sin embargo, el anciano debilitado aún carece de muchas estrategias
para la manutención de su autonomía e independencia. Para promover la práctica clínica adecuada al anciano
debilitado, el enfermero debe conocer el proceso de envejecimiento, y estar actualizado con relación a las
evidencias científicas sobre debilidad: el concepto, el diagnóstico, las medidas de prevención, las
intervenciones, las evaluaciones y los resultados. Conclusión: esa reflexión nos coloca al frente del desafío de
la actuación de la enfermería en la transformación y adecuación de su práctica clínica en el cuidado al
anciano débil o en proceso de debilidad. Descritores: Enfermería Geriátrica; anciano debilitado; Práctica
basada en evidencias; Asistencia centrada en el paciente; Procesos de Enfermería.
1Nurse, Master degree in Nursing and Health Clinical Care, Ph.D. in Public Health, State University of Ceará/UECE. Fortaleza (CE), Brazil.
E-mail: cintialiraborges@yahoo.com.br; 2Nurse, Doctor Professor (Post-doctorate), Vice-Coordinator of Post-Graduation Course in Nursing
and Health Clinical Care, State University of Ceará/PPCCLIS UECE. Fortaleza (CE), Brazil. E-mail: celfrei@hotmail.com; 3Nurse, Ph.D. in
Nursing, Coordinator of the Post-Graduation Course in Nursing and Health Clinical Care, State University of Ceará/PPCCLIS UECE.
Fortaleza (CE), Brazil. E-mail: vilania_guedes@hotmail.com; 4Nurse, Doctor (Post-doctorate), Associate Professor, Federal University of
Ceará/UFC. Fortaleza (CE), Brazil. E-mail: mjosefina@terra.com.br; 5Community and Family Doctor. Fortaleza (CE), Brazil. E-mail:
saulfpl@yahoo.com.br
REFLECTIVE ANALYSIS ARTICLE
Borges CL, Freitas MC de, Guedes MVC et al. Nursing clinical practice in the frail elderly...
English/Portuguese
J Nurs UFPE on line., Recife, 10(Suppl. 2):914-8, Feb., 2016 915
ISSN: 1981-8963 ISSN: 1981-8963
DOI: 10.5205/reuol.6884-59404-2-SM-1.1002sup201629
The elderly as ontological being, with
needs and peculiarities, as the protagonist of
aging and as a social actor in their history,
needs care in all areas, being healthy or in the
disease process. This individual is more
susceptible to diseases since their
physiological reserves decline and therefore,
requires integrated and multidisciplinary care
to prevent loss/damage over the years.
The nurse as participatory professional,
including the aging process, as well as the
conditions that lead the elderly to fragility,
should make use, in their clinical practice,
technological tools to facilitate care and
evidence-based practice (EBP); developing
strategies for a better health care. A special
attention should be given to the frail elderly,
who lives in Long-Stay Institutions, bedridden,
was recently hospitalized, has illnesses
causing disability, has compromised functional
capacity or living in situations of domestic
violence.1
In this context, the study aims to reflect
about the clinical practice of nurses in the
care of frail elderly.
This is a theoretical reflection developed
by consultation in printed books and materials
available online. Journals consultations were
held in the databases LILACS (Latin American
and Caribbean Health Sciences Literature),
Scopus (larger database with abstracts and
SciVerse da Elsevier references) and CINAHL
(Cumulative Index to Nursing and Allied
Health Literature), in the period from August
to September 2013, through the descriptors:
aging and frail elderly.
In general, to select descriptors, a consult
was held in the Health Sciences Descriptors
(DeCS) and Medical Subject Headings (MeSH)
for the purpose of a language/common
terminology in the three studied languages
(Portuguese, Spanish, English).
To support the search, it was used the
PICO-strategy, Pacient-Paciente, Intervention-
Intervenção, Comparison-Comparação or
control, Outcomes-Resultados, which aims to
assist in the construction of the question and
to organize the problems proposed in the
review, maximizing the research evidence,
avoiding unnecessary searches and focusing on
the study problem.2,3
Also, studies published in English,
Portuguese and Spanish were included,
without time restriction; full articles; and
articles that portray the theme. The exclusion
criteria were: articles in the form of
experience report and literature or integrative
review; theses, dissertations, various
documents and in summary format.
This integrative review allowed a wide
literature on synthesis and conclusion of a
particular area, integrating a set of updated
information4, directly impacting the evidence
body about fragility in the elderly and its
nuances.
The clinical nursing practice
The clinical practice can be understood as
an integrated and interrelated set of
activities, practices, and actions aimed to
comprehensive health care. In the context of
Nursing, consists of a Nursing systematic care,
private of the nurse, operationalized at
different levels of complexity, at scheduled
specific areas or not, on individual or family
form(5). For its implementation, the nurse
makes use of the nursing process, which
requires critical thinking and clinical
reasoning to decision-making in the care.
For nursing, clinical practice occurs in the
daily care activities, according to human
needs. In a study performed by nine nurses of
primary care in Ribeirão Preto, in a vision of
what would be the clinical practice in
everyday life, experienced by them in the
Family Health Strategy (FHS), it was found
that would be characterized by the service at
reception; in nursing consultation; in home
visits; in group work; in guiding to assistants
and nursing technicians and community health
workers; and in the doctor's care support.
They reported that together with these
factors, were added the structural and
economic problems of the public health
system, which compromised the offer of
nursing services, and even experiencing
difficulties, professionals through its creative
and innovative skills, recognized the
rewarding return and satisfying of the users,
which strengthened the bond between the
individual and the community. 6
It is understandable therefore, that the
clinical practice, even being hampered by
bureaucratic and organizational issues,
contributes to a continuum of dynamic
contexts and for making decisions, mediated
by the clinical and critical thinking of the
various evidence that comprises the scientific
literature about the needs identified and
addressed to the care of individuals, the
family and the community.7
RESULTS AND DISCUSSION
METHODOLOGY
INTRODUCTION
Borges CL, Freitas MC de, Guedes MVC et al. Nursing clinical practice in the frail elderly...
English/Portuguese
J Nurs UFPE on line., Recife, 10(Suppl. 2):914-8, Feb., 2016 916
ISSN: 1981-8963 ISSN: 1981-8963
DOI: 10.5205/reuol.6884-59404-2-SM-1.1002sup201629
The Evidence-Based Clinical Practice
To assist in thinking and doing clinical
practice, integrating nursing knowledge and
other professionals, arise the Evidence-Based
Practice (EBP). Through this, the best
evidence can be selected, based on gold
standard studies, providing a better quality
care and assistance. The EBP must originate
not only from observation, existence or
experience with the patient but of systematic
clinical surveys with power to define
preventive, curative and rehabilitative
approaches.8
As well as the nursing process, the clinical
practice based on evidence depends on
ordered and systematized steps. These steps
constitute: 1) identification of individual
needs; 2) dialogue to clinical problem
clarification in order to determine the type of
evidence to be raised; 3) survey of the
evidence in the databases; 4) critical
evaluation of information obtained by the
dialogue with the patient and the evidence
found, based on the principles of scientific,
epidemiology and biostatistics methodology,
to accept or reject the conduct to be applied;
5) application of evidence guiding care,
including observing the more appropriate
health public policies; 6) evaluation of the
results(8).
Thus, one of the main goals of the EBP is to
encourage the use of scientific research
results for application in clinical nursing
practice. It is noteworthy that the EBP refers
challenges, especially for the field of practice
nurses, since they have difficulties such as
lack of time and the inability to understand
statistical terms and jargon used in scientific
articles.9 This makes them prefer to consult
colleagues to obtain the necessary
information.10
It is worth noting that the clinical practice
and the EBP, while incorporating different
approaches, the first preconizes for care to
others, and the second consider the
technological aspects of clinical practice, one
needs the other and can not come
dissociated(11).
Nurses Clinic Practice and actions
directed to the frail elderly
The frailty syndrome is a complex disorder
that has several clinical outcomes, such as
dependency, institutionalization, falls,
worsening of chronic disease framework,
acute illnesses, hospitalization, slow or absent
recovery from a clinical framework and
death(12). The great challenge, today, in the
context of fragility, is to know the right time
to intervene and anticipate negative effects
on health. The fact is that the frail elderly
needs a differentiated approach to meet their
needs.
To promote appropriate clinical practice to
the frail elderly, nurses must know the aging
process, be updated about the scientific
evidence of fragility, regarding the concept of
the syndrome, diagnosis, interventions,
assessments, and results. Additionally, they
should be aware of the possibility of
prevention, performing a comprehensive
global assessment or multidimensional
assessment, identifying the real needs and
potential to provide referrals to the
multidisciplinary team.
This professional must think and organize
care, guided by the direct and specialized
assistance to the elderly, their
family/caregivers and the community/place of
residence, and also must be able to manage
the problems related to the lack of
preparation and inadequate care of their
staff; tolerance of waiting for elderly users;
the minimum infrastructure for consultations;
worry with information from medical records
systems; use work tools that provide or
facilitate the continuance of elderly health,
as the Health Handbook of the Elderly and the
nursing process; and manage the environment
in which the elderly is inserted, either
hospital, Long Term Care Institutions or
domicile.
The frail elderly care should be performed
primarily, based on autonomy, independence,
and quality of life. It is important that during
the care and clinical practice for the frail
elderly or in a fragility stage, that their
participation is valued in decision-making
through subsumed measures and health
strategies, in the process of promotion,
prevention, recovery and rehabilitation of
health, allowing them to be knower of their
care, enabling their empowerment.
It is noteworthy that the frail elderly, given
their level of physical, emotional,
psychological and social vulnerability, they
often have limited access to healthy food, to
medical care and adheres less to diets and
drug treatment, which confirms
decompensation of comorbidities and to the
advancement of fragility.13
Nursing, faced with this complex situation
caused by the frailty syndrome, may use
simple strategies to prevent and delay the
severity of the syndrome, in its practice
through EBP.
Among the actions directed to the frail
elderly, the guidance of physical activity is
emphasized, which carries many benefits,
Borges CL, Freitas MC de, Guedes MVC et al. Nursing clinical practice in the frail elderly...
English/Portuguese
J Nurs UFPE on line., Recife, 10(Suppl. 2):914-8, Feb., 2016 917
ISSN: 1981-8963 ISSN: 1981-8963
DOI: 10.5205/reuol.6884-59404-2-SM-1.1002sup201629
such as increased maximal oxygen
consumption and increased muscle mass,14
preventing sarcopenia; the improvement in
aerobic capacity, balance, mobility and
reducing falls, besides the reduction of
inflammatory mediators15 ,as well as the
supervision of poly-pharmacy and sub-
prescription of medications for frail elderly,
which can result in therapeutic redundancy,
drug interactions , iatrogenic, hospitalizations
and unnecessary expenses;16 the use of some
drugs, for example, the therapy with diuretics
in frail elderly can easily generate urinary
incontinence, electrolyte imbalance,
progression of renal dysfunction, delirium,
and falls, as well as therapy with vasodilators
can cause orthostatic hypotension more
easily.13 Moreover, the importance of
strengthening a healthy diet, since protein-
energy supplementation, particularly in the
frail elderly with low socioeconomic status,
can reduce the progression of functional
decline, providing increased physiological
capacity and functional performance.17
Thus, for clinical care to the frail elderly
occurs, it is imperative the nurse being
inserted into their reality and acts
conscientiously, competently, technical-
scientific, and provide qualified and
humanized care. It is noted that the clinical
care refers to actions for people in different
age groups, considering the human responses
to health conditions changes with the purpose
to promote, prevent and restore health and
well-being.
Caring is part of life in all circumstances,
whether from illness or health. The elderly
population, especially the frail, worth
mentioning about care and nursing care and
other professionals, to their demands in
health and increased susceptibility to
impairment, disability, and death. Nurses,
specifically, demand and require skills and
expertise to provide the everyday clinical
practice focusing on their quality of life, well-
being, autonomy and independence.
Clinical nursing practice directed to the
frail elderly is still a subject little explored in
the Brazilian context. It is necessary to
rethink the care geared to that individual,
starting from the knowledge of the subject
through scientific evidence and existing public
policies, to discuss and provoke the issue. This
reflection puts us ahead of the nursing
performance challenge in transforming and
adapting their practice to the care of the frail
elderly or fragility process.
Also, it is necessary to implement the
Evidence-Based Practice, as a routine in the
nursing service, to provide the opportunity for
contact with scientific literature and optimize
the critical thinking and health practices. This
approach will provide the quality and safety
of care provided to more clearly defined
practices, causing beneficial changes in the
promotion of care and improves of the quality
of life and well-being of the frail elderly.
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FINAL REMARKS
Borges CL, Freitas MC de, Guedes MVC et al. Nursing clinical practice in the frail elderly...
English/Portuguese
J Nurs UFPE on line., Recife, 10(Suppl. 2):914-8, Feb., 2016 918
ISSN: 1981-8963 ISSN: 1981-8963
DOI: 10.5205/reuol.6884-59404-2-SM-1.1002sup201629
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Submission: 2015/02/17
Accepted: 2015/01/22
Published: 2016/02/15
Correspondence Address
Cíntia Lira Borges
Universidade Estadual do Ceará
Avenida Filomeno Gomes, número 860, Ap.
703
Bairro Jacarecanga
CEP 60010-281 Fortaleza (CE), Brazil
