Summer is 81 years old,she is still mobile but is showing early signs of dementia, malnutrition and has a low body weight. She has been living with her husband, who has been caring for her until a few weeks ago when he brought her to the Nursing home, because he could not cope anymore. On initial evaluation the nurse has established that Summer has grade one pressure ulcers.Pressure Ulcers or bedsores are when the skin has been put under too much pressure, which affects the skin and the underlying tissue and causing injury.This consistent pressure disturbs the blood flow to the skin, deprives it of oxygen and nutrients and without a blood flow the skin is starting to break down, which leads to pressure ulcers.It is very common in elderly over 70 years of age to develop pressure ulcers due to their aging skin, reduced mobility or reduced blood supply.There are 3 different types of pressures:Shear pressure-is when layers of skin are forced to slide over each other, when a person is sliding down from a bed or being pulled up and out of bed/wheelchair.Interface-is the pressure when the skin is being pressed down onto a hard surfaceFriction-is the pressure of something being rubbed against the skin, like a mattress or clothingThere are 4 different types of grades for pressure ulcers:Grade 1- the skin might feel itchy, warm, hard, or hurt, it is slightly on the skin and it can appear discoloured.Grade 2-the skin looks like a blister or open wound, where some of the inner layers or outer layers of the skin are damaged.Grade 3-the whole thickness of the skin is being broken down and the tissue underneath is damaged.Bones and muscles are not damaged and the skin looks like an open hole.Grade 4-is the most serious of all the pressure ulcers, where the skin is so badly damaged that the tissue around it begins to die. Bones and muscles may also be affected. People with grade 4 pressure ulcers have a serious risk of developing life threatening infections.Pressure Ulcers are also affected by Intrinsic Factors like aging, immobilization, poor nutrition, chronic illness,mental health conditions or urinary/bowel incontinence.Or Extrinsic Factors like pressure from beds or wheelchairs, moisture/humidity, or pressure put onto the skin through reflex, like muscle spasmCLIENTS NEEDS:Healthcare needs:Summer underwent a risk assessment on admission to the nursing home. She was assessed for her mobility, posture, symptoms that may cause infection, her mental health,general health, diet and if she had any pressure ulcers in the past. On evaluation she has been assigned a special mattress, as she has very frail skin, she is being put on a rotational chart, when laying in bed and on a nutritional chart with vitamin supplements to monitor her intake.Physical needs:Summer does need reminding to wash/shower herself, which she is able to and she is encouraged to use topical creams and ointments to speed up the healing process and to stop developing more pressure ulcers and talcum powder for areas that have excess moisture.The Healthcare assistant can also provide her with the shampoo/lotion that she normally uses, to make her feel more comfortable in her new surroundings. Since Summer is so frail and thin, it is advisable to routinely check her skin for discolouration, hard/cool skin,blisters or any damage to the skin and always ask for her constant.Nutrition:Summer has been put on a nutritional chart, which monitors her intake of food and fluids,that it will increase her intake of calories, proteins and vitamins like vitamin c and zinc, which are all helpful in improving her skin. It is also very important for Summer to be drinking adequate amounts of fluid to avoid dehydration, which can be assessed by the Healthcare assistant in checking if Summer has dry or sticky mouth, dry skin, is constipated or by her decreased/discoloured urine output.She likes to be in the dining room with the other residence and needs reminding to drink her fluids.Mobility:Summer is mobile but tends to sit in a chair for a very long time and the Healthcare assistant is reminding her to shift her weight frequently every 15-30 minutes. She is also being provide with a cushion to relieve her of pressure and make sure that she is sitting well positioned. There are various forms of cushions for pressure ulcers, some are made of foam, gel, water or air filled. Summer is also being encouraged to walk around as she needs reminding because of her early onset of dementia.It is very important that she stays as active and mobile, as with the number one cause of getting pressure sores is when a person in imobile.Positioning:It is very important that Summer is being repositioned, due to her frail skin and forgetfulness and has been put on a positioning chart. The Healthcare Assistant should encourage her to change her body position every two hours. She has been prescribed with a special foam mattress pad to help with her positioning,which will relieve some pressure and protect delicate areas of the skin.The bed can also be elevated, no more than 30 degrees, which will prevent shearing. It is also advisable to use cushions on Summer due to her frail skin, to protect her from lying on her hip and protect ankles/knee/calves, any bony areas.Hygiene:The Healthcare Assistant is inspecting Summers skin daily, after she has given her consent , as it is very important to detect early signs of pressure ulcers. Summer is helping with the process and always voices any concerns she has with new areas that are of discomfort to her.She is being reminded to use talcum powder on moist areas of her skin and to apply lotion, as such an everyday task can be easily forgotten in her condition. Skin can be protected by inspecting that the sheets are wrinkle free and her clothes should be checked for buttons. Toileting:When skin is being exposed to too much moisture it becomes prone to infection which can lead to pressure ulcers. Summer does not have any bladder problems or incontinence which can expose areas to become moist, but the Healthcare Assistant will report any changes to the supervisor or nurse.Skin Care:Ageing skin is more susceptible of pressure ulcers due to the elasticity lost in skin, which increases damage. Summers skin is very thin and due to her low body weight,her skin losses fat which reduces the blood flow. Bacteria and infections can enter the skin easier when it is being broken down.  Mrs. Bays skin should be inspected on the parts of her body where the bone is close to the skin e.g. hips, elbows, lower back, tailbone,knee, ankle.ASSESSMENT TOOLS:The use of pressure risk assessment tools is to indicate if the client is at risk of developing pressure ulcers. These assessment tools/scales are:the waterlow, norton and braden which are most widely used.The norton scale determines a client’s mobility/activity, physical and mental condition and incontinence.Low risk ?18Medium Risk 14–17High Risk 10–13Very High Risk <10The client should be categorized into one of the above categories.The braden scales has six categories on which it tests the client's risk of developing a pressure ulcer looking into nutrition, friction, mobility, activity, the person's sensory perception and moisture (incontinence/ sweat) each category is rated from 1-4 and the lower the score the greater the risk is. The waterlow score should be used with the health care assistants/nurse judgement.The primary aim of this tool is to assist you to assess risk of a patient/client developing a pressure ulcer. Use this together with your clinical judgement.The Waterlow consists of seven items: build/weight, height, visual assessment of the skin, sex/age, continence, mobility, and appetite, and special risk factors, divided into tissue malnutrition, neurological deficit, major surgery/trauma, and medication.The tool identifies three 'at risk' categories, a score of 10-14 indicates 'at risk' a score of 15-19 indicates 'high risk', and a score of 20 and above indicates very high risk.(http://www.healthcareimprovementscotland.org/our_work/patient_safety/tissue_viability_resources/waterlow_risk_assessment_chart.aspx)LEVEL OF ASSISTANCE REQUIRED:Summer is still very active in her daily activities and is able to feed, dress, toilet, shower herself unassisted. Due to her malnutrition and low body weight Summer needs to be monitored of her food and fluid intake by the Healthcare Assistant. Since she also forgets to finish her food  quite often and does not like to drink too much, the Healthcare Assistant should remind or/and encourage her to finish her meals and fluids and should be aware of any changes that occur. The HCA should pay special attention if Summers dementia condition is worsening and report to the supervisor or/and nurse.It is very important to have and maintain a safe environment for Summer since she already has a pressure ulcer and she is encouraged to wear her slippers with rubber soles at all times to prevent falling. The Healthcare Assistant can make sure that there is adequate lighting in her room, since she likes to read in the night and that the pathways are tidied away and the HCA can examine that the floor/tiles are not wet or slippery after Summer has showered.It is very important for the Healthcare Assistant to be empathetic with Summer when communicating with her, since moving to a nursing home and having to get used to a new routine is very confusing and hard time for her. Summer likes to be independant and make her own choices and the HCA should encourage her by giving her choices whenever possible, what foods to eat, what activities she likes to do, so she still feels control of her life. It is important that the HCA should communicate efficiently with her, asking her if she would finish her meal rather than ordering her to finish it.Summer is using a high spec foam mattress to provide her with more ease and comfort for her pressure ulcers.  Pressure relieving devices redirect the pressure over an even area such as a cushion, mattress and dynamic air loss system. Since Summer is very mobile she does not require any mechanical aids and is using cushion support when she is sitting for extended period of time.RECOMMENDATIONS:There have been various studies suggesting the link between malnutrition and pressure ulcers. Since Summer is more susceptible in developing pressure ulcers because she is undernourished, has low body weight she should be carefully monitored/ assessed.The HCA should always act towards Summer with compassion, kindness, safety, competence and protecting her from harm by giving her quality care in a safe environment. An alternative or additional care plan for Summer could be put into place eg.Pressure Ulcer Prevention Plan. Where the HCA would encourage Summer to make small changes when she is sitting, to lift her legs, to push herself up with her arms, to have her standing up and being active, eg. walking around, participating in exercises offered in the Nursing home and her skin should be examined daily, by herself and with the help of the HCA.The HCA should report to the supervisor/nurse if there is a drastic change in summers with regards to their nutritional intake and if the clients mentality is getting worse. Also the clients change in skin, usage of mattress/ underlay. It is very important to report and document any changes in Summer and passing them on to the supervisor/nurse for Summers consistent care plan.EVALUATION:Her Pressure Ulcers have healed up and no new ones have been detected.Her Dementia is slightly worsening with her losing concepts of time/place and she is misplacing items often.Since meeting Summers there has been a greater knowledge of the stages of dementia and how to prevent and deal with pressure ulcers.How hard it is for elderly people to integrate themselves into new surroundings and to still have a sense of independance.It is great to see Summer thriving in her new environment, that she gained weight,eliminated her pressure sores and joined social and activity classes, where she made new friends. A new revised care plan and nutrition plan will be put into place for Summer after a new evaluation of what her new condition/needs are.All characters and names are fictional.

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