Goal: To identify the care practices performed by the nurse to the elderly in the emergency services.

Method: Integrative review carried out in the CAPES database, selecting publications in English, Portuguese and Spanish from January 2011 to September 2018. The descriptors used were: Emergency Nursing. Geriatric Nursing. Health Services for the Aged. Elderly. Nursing Care.

Results: Fifteen articles were analyzed in English, being the majority of the qualitative approach (55.2%). Australia stands out as the country with the highest number of publications (30.2%).

Conclusion: The care practices performed by nurses are aimed at identifying their main problems in relation to the care of the elderly, adaptation and planning of their work routine. Another strategy has been the implementation of specific evaluation instruments for the elderly patient and the involvement of the family in all stages of care.

Keywords: emergency nursing, geriatric nursing, health services for the aged, elderly. nursing care

It is known that the need for emergency care for the elderly is increasing significantly, some events are considered essential, as well as the aging of the population and the change in the profile of epidemics. A study conducted in the emergency departments of a foreign country shows that older people, especially those over 70 years of age, have a higher entry rate in urgency compared to other age groups, which tends to increase As the population ages over time.¹ It is pointed out that the increase in life expectancy allows the occurrence of problems arising from morphophysiological changes, inherent to the aging process. Therefore, there is an increase in chronic diseases, morbidity and functional disability. Therefore, the elderly are more likely to seek emergency care, and are often admitted to the hospital twice as often as young individuals. Because they present more complex health problems, the elderly need specialized care, constituting the largest consumers of the main health services.² This is due to the clinical heterogeneity of these types of patients, which is associated with the depletion of physiological reserves and the factor of decreased cognition that result in the uncommon manifestation of "common" diseases, generating doubts about the effectiveness of the standard approaches and constituting as a challenge for the implementation of care by urgency nurses.³n In this perspective, the present study aimed to identify the nursing practices performed by the nurse to the elderly in the emergency services for a better understanding of the thematic and problematization of the study.

It is a study of the character of integrative revision, following the six integrative stages suggested by Mendes et al.⁴ⁿ the first step, the following research guiding question was defined: What are the nursing care practices for the elderly attended at the emergency service addressed in national and international Nursing publications? In the second stage, inclusion criteria were established: articles in English, Portuguese and Spanish available online in full, published from January 2011 to September 2018, to address nursing care for the elderly assisted in the emergency services. And the exclusion criteria: systematic, integrative reviews, case studies, reports of experiences and editorials.^4,5

In the third step, it was defined that the online search platform of the Coordination of Improvement of Higher Level Personnel (CAPES) for the research of scientific productions would be used, since it covers several national and international databases and be available for public access.^4–6

The online search occurred in September 2018, using the following descriptors: Emergency Nursing. Geriatric Nursing. Health Services for the Aged. Elderly. Nursing Care. To search for articles, the English descriptors were used according to the following combination: “Emergency Nursig” AND “Elderly”, “Emergency Nursing” AND “Health Services for the Aged”, “Emergency” AND “Elderly”, “Emergency” AND “Geriatric Nursing”, “Nursing Care” AND “Elderly”.^4,7,8

Firstly, two researchers independently evaluated the titles and abstracts of the publications in the database for selection of potentially eligible studies. From these, full texts have been traced for a thorough reading. After exclusion, those who did not meet the inclusion criteria.⁴ In the fourth stage the data analysis was performed, organized by categories. In the fifth stage the discussion was developed according to pertinent literature and in the sixth stage elaborated the synthesis of the review.^4,8

The integrative review includes the analysis of relevant research that supports decision making and improvement of clinical practice, enabling the synthesis of the knowledge state of a given subject, and pointing out knowledge gaps that need to be fulfilled with the accomplishment of new studies.^4,6 This research method allows the synthesis of multiple published studies and allows general conclusions regarding a particular area of ​​study. It is a valuable method for nursing, since professionals often do not have the time to read all available scientific knowledge due to the high volume, besides the difficulty to perform the critical analysis of the studies.^4,5,8 Although the inclusion of multiple studies with different research designs may complicate the analysis, a greater variety in the sampling process has the potential to increase the depth and breadth of the review findings. The richness of the sampling process may also contribute to a comprehensive picture of the topic of interest.⁴

It is noteworthy that the emergency and emergency services follow a curative model that aims at quick treatments and short stays of the patient. This model is inconsistent in the management of elderly care with chronic and complex conditions, requiring health services more integrated to multidisciplinary health care models.^9,10

In order to change the model of care there is a period of time, which begins when professionals become aware of the drawbacks. A study of nurses in an emergency sector in a given country in 2016 showed that although there was no specific evaluation for the elderly, these professionals knew that their main problems with care were adequate control of pain, hygiene, psychosocial care and maintenance self-reliant patient.¹¹

In order for new practices to take place, nurses had to make decisions about new problems, such as using appropriate language when talking to the elderly without forgetting them as a person, promoting patient independence and providing close observation. Another key role is that of the key element such as trust and self-efficacy, which need to be stratified by nurses in the emergency department to ensure correct targeted care.¹²

Respectful actions, honest and understandable information, allowing patients to express their opinions, anxieties, are some key actions in the emergency sector. The approach of nurses to the family is essential, because often the elderly can not provide accurate information about their health status and participate in the decision-making process, the family assumes this role.¹³

Two-thirds of patients admitted to the emergency room have cognitive impairment and are unable to report their personal history, medications in use, as well as allergies, dates, and reasons for recent hospitalizations. The use of forms, such as high summaries that contain records of the history of the visits by the elderly, improves the transmission of essential information to the nurse who admits the patient to the emergency room.¹⁴

Access to accurate patient information can help nurses identify their limitations and plan care with an emphasis on promoting autonomy. Even if they spend more time, the benefits of this practice are vital to prevent the patient from becoming dependent on intensive care.¹⁵ In this process the elderly and their families can be considered active agents in the construction of care, the family assumes the role of supervising the state of health, making decisions and accompanying their loved one.^15,16 Therefore, the elderly and their family need special attention of the nurse, which contributes to the development of a relation of trust and respect and to a quality and humanized care.¹⁷

It is known that the use of evaluation tools of the elderly has also been reported in the studies as an element that can contribute to the improvement of the care in the emergency sector and in the direction of the interventions to which the elderly must be submitted. One of the tools identified in the studies is the Timed Up and Go test, which evaluates the gait and balance of the elderly, which are predictive factors for the risk of falls. The author points out that approximately one third of individuals over 65 years old will fall at least once a year, such falls may result in fractures, surgeries, hospital admissions, prolonged rehabilitation and death.¹⁷

These events are considered common among elderly people, which increases even more over the years due to decreased muscle strength, gait changes and maintenance of posture, resulting in a greater chance of stumbles and falls. They represent a public health problem, since they can result in fractures and injuries, which implies in the care of the elderly in the emergency room and even in hospitalization.^15,16 The emergency department can act to prevent these events and alter the trajectory of the functional decline of the elderly, identifying those with a high risk of falls at the moment they seek care.

One of the important aspects in the provision of nursing care is the creation of a therapeutic environment, understood by the author as a place without stimuli, protected by nursing and with a minimum of comfort. He adds that establishing dialogues with patients can contribute to the therapeutic environment.¹⁴

The following measures should be considered to be general in emergency care: Rapidly assess the situation • Serve patient support • Listen carefully • Ask for help when necessary Carefully assess the situation Before any intervention, situation as a whole. Evaluate the physical condition of the patient to verify that the patient is not in danger of life or requires any immediate somatic intervention.¹⁵,¹⁶ Make sure the patient is very anxious or aggressive before give any guidance or even try to reassure you verbally. Remember that anxiety causes decreased attention, memory and orientation, which will not allow them to memorize or remember guidance or even give information very complex.¹⁷

In order to guarantee the success of the implementation of the nursing process in a service, it is essential the participation and adherence of the entire nursing team. There has been a degree of resistance on the part of nurses' technical and auxiliary categories to perform the interventions prescribed by the nurse, which may be related to the lack of capacities that promote the understanding of the process. The nursing team organizes the service and optimizes the care to be provided.¹⁷

Faced with the increase of the elderly population with multiple comorbidities and chronic diseases, the emergency service has been the main access of these patients to health care, evidencing the need to change the paradigm of care. Thus, nursing care practices carried out by nurses in these services are directed to the adaptation of routine and work organization to meet the needs of these patients. In general, environmental risk factors are present in most of the falls, irregular surfaces, wet/slippery, loose objects/rugs and unevenness on the floor/problems with steps were the most prevalent in the studies analyzed. The place occurrence of falls seems to be influenced by of intrinsic factors, since the active elderly physically tend to fall in outdoor environments, while elderly people with functional impairment fall within their own home. The difficulties identified in the study have challenged nurses to perform an incisive systematization in their care. The starting point has been the identification of the main problems related to care for the elderly, the implementation of specific evaluation instruments and the involvement of the family in care. Communication stands out as the main tool used.

None.

Author declares that there is no conflict of interest.

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