ANSWER QUESTIONS 1-8 AND REPLY FOR POST 1 AND 2

Case Study

Read the following case description, and post your responses to the questions below on the discussion board:

Mrs. M. T., age 82, was admitted via ambulance to the hospital emergency department due to respiratory problems. She is bedbound due to an old CVA and is being cared for at her home by her granddaughter. When she was admitted, her blood pressure was low and she had a normal temperature. Lab tests and X-Ray revealed urinary tract infection, dehydration, anemia, decreased renal function and pneumonia. Upon physical examination it was discovered that the patient had infected stage IV pressure ulcers on her lower back and hips, which the caregiver stated she was not aware of. According to the granddaughter, the patient has had a recent change in mental status and has “quit eating”. The patient is left alone all day while the caregiver is at work. Since the patient is bedbound, she cannot get up to the bathroom or reposition herself independently.

Problem list: (not necessarily in order of importance)
1. Right sided paralysis secondary to old CVA
2. Contractures of hips and hands
3. Bedbound
4. Malnutrition & anemia
5. Dehydration
6. Pneumonia
7. UTI
8. Very recent onset confusion/ change in mental status
9. Bowel and bladder Incontinence
10. 3 stage IV pressure ulcers on coccyx and both hips which are infected
11. Hard of hearing- no hearing aides
12. No teeth or dentures
13. 50% decrease in renal function
14. Lack of ability to perform ADLs or IADLs
15. Weakness
16. Weight loss as reported by caregiver

1.Is this woman a fall risk, and if so why do you think so?

2. What clues were there to her UTI diagnosis that might have prevented her hospitalization if identified early enough?

3. What indicators of Frailty does this patient have?

4.What Geriatric Syndromes does she exhibit?

5. What do you think are contributing factors to her pressure ulcers and what might be done to prevent them in the future?

6.What do you think nursing should do to prevent the patient from entering the downward spiral of the geriatric cascade after she is admitted to the hospital?

7.When she is ready for discharge from acute care, what issues should be addressed in discharge planning?

8.What services might she require upon discharge?

REPLY TO THESE TWO POSTS

POST #1

M.T. is not a fall risk because is the case study states, she is contracted, bedbound, and has pressure ulcers due to lack of turning. She is probably to weak to to even attempt to get out of bed.

The clues that might have prevented her hospitalization were poor appetite and dehydration, along with the confusion. Had her grandaughter noticed she wasn’t eating and drinking enough and that acute confustion is a sign of infection, she could have taked her to the doctor before her infection was so bad that she needed hospitalization.

M.T. has these indicators of frailty: contractures of hips and hands, bedbound, lack of ability to perform adls, weakness, and weight loss.

M.T. exhibits these geriatric syndromes: pneumonia, UTI, malnutrition, and incontinence.

The contributing factors of her pressure ulcers are: right sided paralysis and contractures of her hips and hands, malnutrition and dehydration. She is bedbound and left alone all day. With her paralysis and contractures, she is unable to turn and reposition herself. Without proper nutrition, her wounds will never heal. She needs a caregiver that is available 24 hours a day to assure she is fed all meals and turned at least every 2 hours with passive/active range of motion performed. She also needs wound care to prevent infection and allow healing of her pressure ulcers. Caregiver teaching is imperative of her future care. The caregiver needs to know how to properly care for and prevent skin breakdown and contratures.

Upon hospital admission, nursing should be agressive in implementing therapuetic interventions that promote mobility and nutrition. Active and passive ROM should be done at least every 2 hours. A physical/occupational therapy consult should be ordered. A comprehensive review of the patient’s medications should be done. Hydration status should be addressed. A dietary and wound care consult should be done. The staff also needs to show care and concern to the patient. She should be encouraged to participate as much as possible in her adls and care plan. Patient and family teaching she start upon admission.

The issues that must bed addressed in the discharge planning are where will the patient go and who will care for her. The grandaughter needs to decide if she is able to properly care for the patient. She may have to get home health or other family members to come stay with the patient when she is working. If this is not a possibility, the patient needs to go to a patient care facility where there are training staff 24 hours a day to meet the needs of M.T. She also needs assistance to obtain dentures and hearing aids to increase her quality of life.

M.T. will need ongoing physical therapy and wound care upon discharge. She will need assistance with mobility, toileting, and meals around the clock. She will also need any equipment that will make home care a possibility such as a hospital bed, shower chair, etc. Home health is warranted if the patient goes home to assist the family and assure that proper care is given to M.T.

POST #2

It is my opinion that M.T. is as risk for a fall. There is no other use of assistive devices or rails mentioned by the granddaughter in the home. Many times I have seen contractured patients turn to a favored side, use their heads to shift in bed or even have spasms in the contractured limbs and violently hit themselves.

The early clinical signs that would have indicated medical treatment was needed for a UTI with M.T. were: recent signs of confusion (delerium), decreased blood pressure, decreased aappetite, weight loss.

Ms. M.T.’s signs of Frailty were: low activity levels: patient was bed bound with contractures following a CVA; decreased functional abilities: unable to perform activities of daily living or independently perform activities of daily living , weight loss; decreased appetite, malnutrition & dehydration.

M.T. exhibited the Geriatric Syndromes of: delirium, immobility, cognitive impairment, isolation, hypotension, respiratory distress, pneumonia, and poor physiological reserve following her CVA.

Contributing factors for the skin breakdown pressure ulcers and how to prevent them in the future for M.T. are: immobility, malnutrition, anemia, incontinence, skin frailty that could benefit from turning the patient every two hours, wound consult and wound care treatment every shift or as needed if dressing is soiled, foam dressing with silicone borders to add cushion over the bony prominences of the hips and lower back, specialty hospital air mattress, making sure linens do not have wrinkles and carefully turn patient to prevent shearing, perform PROM every 2 or 4 hours, OT/PT consult, request dietary consult requesting protein shake for wound healing, assess/address patient with incontinence needs and avoid placement of urinary catheter. Education of patient and family.

To prevent M.T. from entering a “downward spiral of the geriatric cascade” in the hospital, nurses could encourage family presence outside of visiting hours, reorient the patient, reassess medication needs and worsening renal function (sometimes medications makes worse or an obstruction can cause), develop a plan of care to include activities for early mobility (get the patient out of the bed to a chair) to prevent worsening functional decline, perform PROM.

Upon discharge from acute care M.T. may need more support than her granddaughter alone can provide upon discharge; the granddaughter needs to be informed of the legal responsibilities she has assumed in the sole care of M.T. in order to make an informed decision of what is best for M.T. Perhaps she has a support system in place and has not reached out for help before now.

Family and the patient should decide or plan for the need upon discharge, how soon the additional services are available and if the granddaughter can physically provide what M.T. needs through the additional services of her family and community, home health for wound care, OT/PT, Nutritional and physiological needs, need for careful medical maintenance following her recent illness and specialty equipment, and provide a safe environment that does not risk patient safety. Often when patients arrive for medical treatment and found to be neglected or their safety in the home at risk, adult protective services notifications are required.