Idoso em tratamento conservador de fratura proximal de fêmur e o cuidado de enfermagem numa perspectiva fenomenológica

Objective: Develop a theoretical-philosophical reflection on conservative treatment of elderly person with proximal femoral fracture as a phenomenon of nursing care in light of Heidegguerian phenomenology. Methods: Study based on an integrative literature review, with theoretical and philosophical reflection of the findings in the light of reference of Martin Heidegger. Results: The findings were organized and discussed in two categories. The first related to biological adaptations, psychological and social of the elderly and family facing the phenomenon of conservative treatment of proximal femur fracture; the second reflecting the nursing care aimed at this phenomenon in a phenomenological perspective that helps the elderly to migrate the condition of being in the world to the condition of coming-to-be in the world. Conclusion: Reflect and understand the meanings of elderly and family experiencing this phenomenon allows the nurse support and specific care for the needs that they have this experience.


INTRODUCTION
Fractures in elderly are considered a major health problem due to their high incidence, complications and high costs of treatment for the health care system 1 .
It is noteworthy that the increasing incidence of fractures in the elderly has been increasing due to the growth in the senior population and the years lived by them 2 .Added to that is the lack of accessibility to prevention campaigns of the osteoporosis and of falls (main causes of fractures), even the old age being recognized as a priority issue in the context of Brazilian public policies 3 .Also, there are inherent factors that favor the elderly fractures that are natural of the physiological decline that is characteristic of the aging process, such as changes in the vision, hearing, smell, walking, balance, coordination and reaction time 1 .The use of medication such as antidepressants, psychotropic, anxiolytic, sedatives, antihypertensives and diuretics also increases the predisposition to traumas, due to possible side effects or drug interactions 1 .
Among the main fractures that occur in the elderly population, we emphasize the femur fractures that may occur in the proximal region (femoral head), distal (linked to the joint with the patella and tibia) or the femoral shaft (body and femoral neck), where the proximal femur fracture (PFF) is the most common 4 .These data are supported by a study on morbidity due to external causes carried out with the elderly from the South of Brazil, in which it showed that the most prevalent types of fractures in the elderly are on their thighs and hips (61.5%) 5 .Another Brazilian research aimed at identifying the incidence and the characteristics of elderly patients hospitalized due to fractures has concluded that among them, 52.19% were hospitalized because of femur fractures 6 .
For all types of femur fractures in elderly adults, the treatment usually indicated is surgery.The choice for the best technical and bone fixation method is based on the age, degree of mobility, mental status and pre-existing diseases that may affect the surgical process and/or the rehabilitation of the patient 7 .
When the elderly needs to undergo surgical procedure to correct the fracture, they are hospitalized for some period and if there are no complications, a few days later they get discharged.
Conservative treatments without surgery are indicated only in some fractures classified as incomplete or without deviation, and in cases where the elderly patients would not bear the surgical procedure, since they have comorbidity conditions that put them at an unacceptable risk to the anesthetic and surgical procedures 8 .Among the contraindications for surgery are, mainly, the neurological, cardiovascular and pulmonary deficits and the disorders brought by the old age 9 .
In cases where the elderly do not have clinical conditions to receive surgery and opts for conservative treatment, normally, they are sent to home care and become bedridden individuals.Thus, it is important to emphasize that the elderly and their family need to adapt themselves to the new condition, and have to make structural adjustments in their home and in the family organization in order to carry out the necessary care, differently than in patients that undergo surgery and usually tend to recover faster.In this context, the necessary home care must be understood as a form of health care that is alternative or additional to the existing ones, and that is characterized by contiguous actions (changes in the bandages and evaluation of the wound, motor and respiratory therapy, nutritional counseling) aimed at the health promotion, the prevention and treatment of disease, and rehabilitation provided at home 10 .
Added to this, one must understand that the coming-to-be elderly with PFF under conservative treatment is a delicate and complex process that requires a redefinition of their way of being in the world 11 .
This approach is fundamental to the nursing care practice, especially for those working in primary care and who perform care through home visits, seeking the maintenance of physical autonomy and the functional capacity of the elderly, with family help.
In addition to physical autonomy, it is necessary to stimulate the existential autonomy that is based on the deep understanding of freedom of the elderly.Such thought is not an immediate awareness that appropriates the content, and the formal standards that already exist, but it is a critical-interpretative self-creation of the mode being in the world, that is manifested in the "to-be-thought-of" 12 .
This broader view of the living and health conditions of the elderly inserted in their social and family context favors the practice of care 13 .Thus, the care may stem from the reorganization of their existential project and the adoption of an authentic existence of the elderly.
Therefore, it is necessary for the elderly be questioners and interpreters of their way of being, in interaction with the world, otherwise the autonomy will be on reception of facts, negating thus their place of autonomy, while participatory freedom emancipatory, because there is no liberation without engaging in all manifested in its historicity and in constant reinterpretation of the way of being in the world 12 .
In this context, it is necessary to understand how the conservative treatments occur in elderly patients with PFF and thereby reflect on the adaptation of the elderly and their families experiencing this phenomenon.It is noteworthy that, even where there is the offer of formal support services, the family continues to play the leading role in supporting the dependent elderly, although, generally with limited physical, financial and human resources 14 .
Associated with this, social, biological, psychological and existential consequences generated from situations of dependance by the elderly will change the way they open themselves to the world, that is, how they understand the world and answer 15 their demands, among them, the disability by the fracture, which can hinder the relationship their with family and the health care team.
Reflecting about the meaning of existence held by the elderly under traditional treatment of FPP is of high importance and so is understanding that the only oneself is capable of building their

Conservative treatment of elderly with fractures
Argenta C, Zanatta EA, Lucena AF own existence as being in the world, living their own limitations that result from this treatment.The existing, as Dasein (being there), means a constant opening in order to be able to grasp the meanings of what comes forth for both the elderly and for their families.The being-there is the elderly located in the world, relating, dwelling, mediating and interrogating the world and their existence 16 .In this case, the world of the elderly, most of the time, is their home that sometimes has been modified/adapted to facilitate the care and the maintenance of their life quality after the event, i.e. the PFF.Thus, a challenge or a continuous exercise of seeking the right word to use with the elderly arise for the family and the nurse.Along with the appropriate gesture, the respect for their new condition and in relation to the elderly as an authentic being, as a being in the world in the most literal and complex sense of the term 11 .
This Heideggerian perspective instigates health professionals, especially nurses, to think about this elderly under the traditional treatment of PFF and their family, about their constitution and understanding of being in the world and being-among-others, seeking to establish relations of care before the conservative treatment.These cannot reduced to a relationship between subjects, as it is born of a dependency between human beings derived from their occupation as people 15 .
Thus, this study aims to reflect on the conservative treatment of proximal femur fractures in the elderly and on the nursing care in light of Martin Heidegger theory.

METHODS
It is characterized by a theoretical and philosophical reflection, from an integrative literature review (ILR) 17 , to understand the phenomenon of conservative treatment of PFF in the elderly and the nursing care of those in such situation.To this end, it was elaborated the following guiding question: What are the implications of the care for the elderly conservative treatment of proximal femur fracture through a phenomenological perspective?
The search for the studies was conducted in the period from November 2014 to February 2015 in the databases of the Latin American Literature in Health Sciences (LILACS) and Scientific Electronic Library Online (SciELO), PubMed, Cochrane Library and CAPES Periodicals Portal, through the key-words: senior, nursing, and the terms proximal femur fracture and conservative treatment.
The inclusion criteria for the selection of publications were: full papers and available online in Portuguese, English and Spanish, on conservative treatment for elderly patients with PFF and the nursing care for such condition.It wasn't established a time limit for the selection of publications, because the works about conservative treatment for seniors with PFF are recent, as well as the ones about the care for the elderly in the same condition.Works that referred solely to the surgical treatment of PFF were excluded.
After selecting the articles, there was the categorization of the data, from the organization and summarizing of key information in relation to the theme, conservative treatment of PFF in the elderly.
As a result, we carried out a critical and detailed analysis of the articles seeking to answer to the main question, generating results which were organized into two categories to finally develop the theoretical and philosophical reflection based on the reference of Martin Heidegger, which allowed us to look at things like they manifest, describing the phenomenon closely, seeking to capture its essence 14 .

RESULTS AND DISCUSSION
The search for the meaning of the phenomenon of the existence of the elderly in conservative treatment of PFF, i.e., the the Dasein (being there) made it possible to reflect on the changes experienced by the elderly and their family during the process that begins with the PFF and permeates the decision for the conservative treatment and the adaptation to it, because the elderly do not live alone, and they are beings in the world that influence and are influenced by the environment in which they live, which implies the being-with-others 15,16 .
From this perspective, the care for the elderly through conservative treatment PFF should be construed as an ontologicalexistential phenomenon that enables human existence, because the man is a being that if not taken care of, will no longer be a human being 15 .
Thus, the analysis of the productions selected from ILR, allows to point that that conservative treatments of the PFF require adaptations and modifications in the lives of seniors and their families.These adaptations are described in the literature in a multidimensional way, i.e., biological, psychological and social characteristics.
Thus, the theoretical-philosophical reflection on the phenomenon under study was divided into two categories 17 : the first permeated the biological, social and psychological dimensions as well as the elderly and their family needs to adapt to the new condition experienced, and the second reflects on the nursing care aimed at this phenomenon in a phenomenological perspective.

The biological, social and psychological adjustments to the elderly and their family when facing the conservative treatment of the proximal femur fracture
Given the situation of an elderly under conservative treatment of the PFF who is sent to home care, the first adaptations in their life and their family begin.The everyday life of the family living with a dependent elderly is complex, due to the demand for special care, strong family dependence, task variation, and the presence of intense and conflicting feelings that are often hard to deal with and which characterizes this elderly as being-in-the-world and being-among-others 18 .
The being-among-others is characterized by the adaptation of the family to the new situation.It is a critical event so that they can take care of the elderly in order to meet all their needs.Also, it can't be forgotten that the elderly under the conservative treatment of the PFF is a being in the world that is exposed the Conservative treatment of elderly with fractures Argenta C, Zanatta EA, Lucena AF changes and daily reconstructions in both the biological aspects, as in the social and psychological ones.
In what concerns the biological aspects, the main changes lived by the elderly with PFF under conservative treatment is the loss of autonomy and independence resulting in activity restriction, decreased mobility and physical activity 19 .Autonomy, dependence and independence are conditions that intertwine, however, it is possible that a person be physically dependent, but without losing their autonomy.For this, the being-among-others should be established so that nurses, family and caregivers, provide the elderly with means being who they used to be, aware of their possibilities and, as far as possible, take over their own autonomy 15 .
This care can be compromised when, in addition to physical complications occur cognitive changes that affect the elderly's performance in carrying out activities until then considered simple, specially those which raise the need for the presence of others for long periods, where the family is the main source of care.
The probable and, consequent dependence of the elderly brings with it an emotional factor of regression, emphasizing feelings of weakness, insecurity, social isolation and depression 18 , which are psychological aspects that can affect both the elderly and their family.
The existence of the elderly, while experiencing this phenomenon, may cause distress for themselves and may lead them to being anguished by their existential situation of human being, who realizes their finite existence and assumes the fact of being-there in the world.The anguish can make one go further, and within the existential possibilities to which they are exposed to as being-in-the-world 20 , may unveil ways to overcome the adaptations to the new condition of life caused by the conservative treatment and the PFF.
The anguish in this context is a necessary condition so that the being-there can be projected into the world with a new perspective 21 , with a new way of seeing and living life.In face of such phenomenon, the anguish may be good for the fractured elderly as it can push them up in an attempt to react and get along with the treatment in a better way.
The anguish creates fear.However it forces the being, in this case the elderly under conservative treatment of the PFF, to move towards a moment of discomfort, which will assist them in the search for an authentic existence, able to overcome social massification, because the man is a symbolic being, a being in the world -the world of human meanings, the symbolic world, the world of culture 22 .
However, the way the fractured elderly and their family will deal with the conservative treatment and with the imposed adaptations will depend on their previous experiences, beliefs, the values of each of the members, besides the influence and the space that they occupy and develop in their organizational network 11 .
In this context, social adaptations arise, that is, the social relationships of the elderly may be adversely affected depending on how the family copes with the situation.Social networks of informal support, such as friends, work relationships, community integration and social practices are collective structures that help in building the autonomy of its subjects and, therefore, the family is the link capable of redefining the structure of the elderly 23 .
Support organizations should then work as constructive support to the family that takes the role of carers, considering that the situation of the elderly requires the understanding of all their family members and members of their social relations 23 .
However, it is believed that even with the changes that happen in the lives of the elderly in conservative treatment of the PPF, their family is able to help them reflect and seek explanations about the meaning of their existence and can help the elderly to reinvent themselves in order to encourage them to change their way of seeing the world and acting on it through their ability of reflecting about things 11 .
The nurse and the family may seek to preserve the dignity of the elderly and assist them in coping and through recognizing their existence.For such purpose, it is fundamental that the elderly find the meaning of their own being, i.e., the being-there will be authentic in self-care 24 .
Thus, it is important to highlight that the nursing care to the elderly and the family that experiences the conservative treatment of PFF should be targeted on the biological, psychological and social needs of the elderly and the families, for care for someone is to ensure their autonomy, through their independence in all care dimensions 25 .For this, the care should be guided by the bond between the fractured elderly, their family and the nurse who assists, supports and instrumentalizes them in facing the daily adaptations in order to minimize the complications that arise from such treatment and the immobility that originates from the same.
The nursing care is given based on the identification of the needs and particularities of each elderly person and their family and it is anchored in the aid and guidance in carrying out daily life activities of the elderly, such as, feeding, grooming, brushing, encompassing also, the skills to use phone, write and manipulate books.For the elderly to have progress in self-care it is necessary for nurses to establish, along with the family and the multidisciplinary team, the pharmacological success and the non-pharmacological management of pain.

Nursing care to the elderly and family proximal fracture after conservative treatment of femur
The care can be thought of as what characterizes the predominance of nursing actions, so it can not be considered only as a science but as all that relates to the human being, i.e., the care for and with the human being 26 .
Understanding the elderly under the conservative treatment of the PFF can be characterized by the attempt to decipher the way of being reported by them, their viewing of the phenomenon that is revealed and how they deal with it.
For this, it is considered necessary to promote a phenomenological thinking through reflection about the way of

Conservative treatment of elderly with fractures
Argenta C, Zanatta EA, Lucena AF being-there-in-the world, and to understand the care through Heidegger's perspective, which is described as a way to offer terms to the other one to grow and take their independence from an installed phenomenon, its own existence and the adaptive process, surpassing thus the design of a simple technical care 19 .Also, it is considered necessary for nurses to understand the meanings and the meanings attributed by families and seniors to their ways of being in the world in relation to their process of health and disease, as well as their biological, psychological and social adaptations.
Thus, through the philosophical referencial of Martin Heidegger, subsidies that can assist nurses to reveal this understanding by entering the homes of the elderly and approach their world were sought, in order to understand beyond what it's displayed in their conditions of housing, family relationships and existing support network.Because the bonding established between the nurses and the elderly and their family is critical to the development of a therapeutic approach aimed at solving the needs of these people.
The bond can be strengthened by frequent home visits with the use of an accessible language to the elderly and family with the appreciation and answering of questions and the offer of necessary information.It is also important that the nursing care to these elderly people should provide existential possibilities able to stimulate their authentic existence and the development of their power of being.
Understanding, observing and paying attention to the elderly people who are experiencing this phenomenon allows nurses to establish more comprehensive care forms on the necessary adaptations to each one of them, i.e,.they assist each one of them to find their maximum autonomy and, possibly, help them obtain more positive results.
Nursing care must be effected through the dialogue with the elderly, family, professional, as an art and not as a role to be played, that is, it needs to be exercised.According Heidegger's perspective, it is understood that the care should offer conditions to the other being grow, take their own path and build gradually their autonomy 27 .In this case, building the autonomy means enabling the elderly individuals under the conservative treatment of PFF to assume their care, supporting them, encouraging them and respecting them in their particularities and difficulties.
The Heideggerian point of view allows the man, as a finite being, to understand themselves in such way and put themselves in the field of possibility, working out, despite their difficulties, the possibilities of their existence, building their future projects and happiness 19 .
Thus, by understanding the needs of the elderly, the nurse can help them in their choices and can aid the elderly to migrate from the condition of being in the world, here understood by the perspective of Heidegger, as the various ways of being human i.e., multiple ways men live and can live 22 , to the quality of comingto-be in the world.
When the elderly migrate from being in the world to comingto-be in it, they are exceeding their limits, so it is crucial to understand that the seniors needs to become themselves and not allow the nurse and family do that for them 22 .
For this, the families who are experiencing this phenomenon, also, need to be cared for, with effective social support that may structure and offer them physical and emotional conditions to stay healthy, caring for elderly family under their responsibility.This includes the awareness of the instructions given by the health staff on how to conduct home care to the elderly and the assistance in their needs on the activities of the daily living 10 .Thus, it is necessary their inclusion in social programs that provide them with basic conditions for reintegration and citizenship so that they can fulfill the role that has been socially and legally assigned to them.Even in bed, the elderly can maintain their cognitive functions preserved, and with that, continue to participate in decisions that are made by the institutions and/or social groups, and thus, maintain the bond.It is up to the society to keep them involved in the activities, although in a non-presencial manner, taking into account the human rights of older people and the principles of independence, participation, dignity, care and selfrealization established by the United Nations 28,29 .
The daily experiences in caring bedridden elderly clarify that nurses can establish partnerships with schools, through projects where young people can contribute to the maintenance of elderly's cognition by proposing reading activities, interpretations, games, among others.this way, young and elderly people can learn with their own experiences.
Therefore, we emphasize once again the importance of the nurse to understand the world of the elderly people under the conservative treatment of the PFF and their families and to experience the many ways of being, in order to promote the care that is based on the context in which it they are inserted.This world/context is usually the home of the elderly or a family member, depending on the form of the family organization and it has its own peculiarities and differences that are cultural, social and spiritual, and that ca influence, directly, the form that the care will be carried out.

FINAL CONSIDERATIONS
The decision for the conservative treatment of the elderly with PFF is not a responsibility of nurses, however, home care after hospital discharge is their competence, and therefore they are fundamental for the success of the therapy applied.
In this sense, valuing the senses of living of the elderly and the family experiencing this phenomenon can help nurses to bond and thereby foster the care needed to the establishment of biological, psychological and social adaptations along with the treatment.However, it is believed that the difficulties encountered can be minimized when there is the establishment of trust relationship between the nurse and the elderly/family.
The phenomenological approach provides subsidies so that professionals may care for the elderly and their family through accepting the necessary changes in lifestyle and at the same time, allows to ensure maximum independence.