CWJ is an 85 year old male with a chinese ethnic background, weighs 115 pounds, 65 inches tall, christian, bed bound patient in HJC hospital. His mouth and lips are moist, no signs or symptoms of dehydration. Patient has a history of cancer thirty years ago. He is status post chemo and XRI. Patient is alert, oriented to person and place, responds to stimuli, is on trach and on ventilator, was admitted on 3/29/17 with admitting diagnosis of respiratory failure, Afib, COPD, CHF, hypothyroidism.Code status is DNR.
. Lung sounds are clear to auscultation, no cardiac/respiratory distress noted. Abdomen soft non-tender, bowel sounds x 4 quads. Gtube intact, +ve placement. No signs or symptoms of pain/discomfort. Positive pedal pulses.
Patient is total, assist x1, uses hearing aid to the right ear. Patient is a tube feed NPO, on Jevity 1.5 at 60ml/hr, his vital signs at the time of assessment, temperature is 97.5. Blood pressure is 152/64, pulse is 62, respiration is 20, SPO2 99% (via ventilator). Patient was status post IV fluid day number three at the time of assessment, IVF secondary to low blood pressure.
He has left foot hep lock. Skin is intact, with intermittent pressure compression (IPC to bilateral legs to prevent DVT). . Patient has generalized edema, is on lasix to reduce edema. Skin show physiological process of aging, color of skin is normal for his ethnic background. Problems identified during assessment,
– Problem understanding patient needs, patient is non – verbal even though he can refuse care by gestures he may have other needs that he may not be able to present,
– patient may be at risk for altered nutrition – patient is on tube feed, patient need assistance with ADLS, such as transfering, personal hygiene, turning and positioning
– Patient needs assistance with ADLs therefore is at risk for falls.
– Patient may have altered skin integrity if not turned and position every two hours and as needed
. Patient will be able to communicate and receive care, call bell should within reach.
patient will receive adequate nutrition and hydration.
Patient will be free of pressure ulcer and will remain clean and dry.
Providing adequate staff to support during ADLs, to prevent falls.
Patient will be able to communicate and receive care.
Patient will receive adequate nutrition and hydration.
Patient will be free of pressure ulcers.
Provision of adequate staff to assist with ADLs prevent falls and also to employ the services PT and OT.
Implementations and rationale for nursing actions;
Pressure ulcers can be prevented, it is one of the most important safety measure considered in the most medical facilities and this can save the health care facilities a lot of money. Implementation of measures to prevent pressure ulcer is by patient and staff education. Educating the staff on the need of turning and positioning patient especially when they are bed bound. Care planning provides a plan for what is to be done to prevent pressure ulcers, it is important to match patients with their specific needs. Even though a score shows that a patient is not at risk does not guarantee that the patient will not have pressure ulcer.
Geriatric patient with inadequate caloric and protein intake may suffer different illness such as, poor healing, pressure injuries and may lose weight. In severe case may have increased risk for fracture. There are various types of feeding formula ,before a feed is be administered to a patient dietician/ nutritionist should choose formula that best fits the nutritional demands of the patient, feed formula varies with age, weight, height, lab values as well as activity. With this in mind, patient will maintain a good health.
Most geriatric patients have hearing difficulties, are at risk for falls, have acute illnesses , limited mobility, diminished, mental status,some are on medications such as ACE inhibitors, diuretics, antidepressants and anti anxiety medication are also at risk for falls. Patient should be assessed on medications and the side effects before administering the medications.
Activities of daily living – Most geriatric patient need assistance with activity of daily living. The goal for geriatric patient that are bed bound is to provide to prevent pressure ulcer and other skin issues. The activity of daily living include, transferring personal hygiene and patient at risk for falls. The main goal is promoted physical mobility in bed with assistance can turn and position.`
Some of the Signs Normal Aging Include –
Slow or inability to perform activities of daily living (ADLs), personal care, such as bathing, eating, toileting may be done slower or not be able to perform such activities and may need assistance.
Aging Skin – The skin of older adults become paler and thinner, the skin loses elasticity, and forms large pigmented spots and become prone to skin injuries.
Loss of bone density also occurs in older adults which leads to osteoporosis. Use of vitamin supplements helps reduce these problems.
Loss of sensation and speech changes due to certain illnesses such as stroke and this can be controlled by diet, medications, and exercise.
Geriatric patient’s tend to develop more problems, and illness as the grow old. This decline in the ability to do things for themselves has lead to loss of independence. When these older adults are on ventilator bed bound with the tube – feeding and non – verbal, the situation can lead to acute and chronic health problems. Some problems with this decline as mentioned earlier include skin impairment, poor nutrition, risk for falls, incontinence, cognitive impairment. It is necessary to focus awareness on these problems and to focus on ways of preventing each to the specific individual. Implementation of prevention measures should be the focus of medical facilities, as these will fo a long way to reduce cost.