The following paper looks at the issues and concerns of a frail elder from my clinical placement. Based on the discussions presented in respective sections, the paper also analyzes nursing roles that would help him cope with his health conditions. In order to protect the confidentiality of this resident, I will replace his real name as Mr. J.
Mr. J is a 96-years-old widowed man who is allergic to quinine, and he has resided in a long-term care setting for 1 year. The resident has no drug use history and seldom partakes in alcohol. The only harmful habit that has had a significant consequence on his health has been his smoking habit, which he has quit since. He has complex health conditions, including osteoporosis, coronary artery disease, heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, and a stage 2 pressure ulcer. Currently, he uses a cardiac pacemaker and has atrial fibrillation as his underlying condition. Additionally, he has stable vitals, and he has some dullness to percussion at the left base, as well as some superimposed atelectasis crackles, with 1+ dependent edema. Although alert and oriented, Mr. J has major deficits in her ability to perform daily living tasks because of peripheral vascular disease in his lower extremities. He also depends on a wheelchair for ambulation and has a history of failing, including a fall that resulted in a hip fracture and his admission to a long-term care setting. Mr. J’s support system is limited. His son lives in the state and provides some telephone reassurance. His two daughters live locally but only visit him a few times monthly to help with meal preparation and grocery shopping.
Two major concerns for Mr. J
The first concern that is a priority for Mr. J is his pressure ulcers because of immobility and urine incontinence. Currently, he shows itching signs all over the body with ulcers on the dorsum of his right hand and bilateral lower leg. Also, he got a stage 2 pressure ulcer on his right heel, and there are black and white patches on the soles of both feet. Immobility can be a major risk factor for the development of pressure ulcers as he is unable to easily change position while seated or in bed, and thus it can place sustained pressure on a particular part of his body (Waugh, 2014). Additionally, urinary incontinence can cause certain areas of his skin to become moist and vulnerable to infection, which can slow down his healing process (Waugh, 2014).
Secondly, Mr. J is at great risk of falls due to his medication and previous fall history. Polypharmacy can be an independent risk factor for falls, and Mr. J with more than four medicines is at greater risk of having a fall (Kojima et al., 2012). At the moment, he is prescribed Aripiprazole, Furosemide, and Gabapentin, which can cause drowsiness and dizziness as side effects (Skidmore-Roth, 2014). And based on his previous history, he has experienced four falls in the last two years and has broken his hip. Recently, he sustained a fall at night while attempting to transfer himself without assistance. As a result, he got five small skin tears on his both arms.
A frail body hinders active participation in ordinary life activities. In the case of Mr. J, the potential of being injured due to pressure ulcers and fall risks limits his mobility and makes it difficult for him to perform routine functions, like bathing, dressing, and even walking. Although Mr. J can do some of these things with assistance, he is still bound by the condition and cannot independently determine what happens to his body as far as regular movements and obligations are concerned. The fact that he is a war veteran may arouse in him a desire to offer demonstrations of physical exercises that he performed in his young adult years. However, the present condition limits him to regular light movements and activities as a form of exercise.
Concerning the issues of impaired skin integrity and fall risks, the consequence that Mr. J faces is that he suffers a lot of pain from his leg ulcers and hip fracture, and thus he is forced to remain indoors most of the time because of difficulty in ambulation. Consequently, he has limited opportunity for interaction, which can affect his emotional wellbeing. Mr. J needs to feel in control of his life, but his current health problems make him susceptible to low self-esteem, depression, and feelings of helplessness due to his altered body image (House, 2015). Often, this frustration can result in a short temper characterized by agitation, ineffective coping, and verbal aggression.
Mr. J told me that one of his fun moments is when he is with his family and peers. However, many of his close friends and family members may not be available to stay with him for long given his frail condition. Unfortunately, some of his hobbies like outdoor walks and tinkering with machines may no longer be feasible due to his health conditions. The fact that he has weakening bones contributes to his issue of fall risks; therefore, he has to find other ways of enjoying life. For example, he should put off many walks in exchange for extensive hours watching TV.
During the interview, Mr. J identified his faith preference to be Ukrainian Orthodox, and he has experienced the desire to trial involvement in pastoral and spiritual care programs, which help him remain spiritually fulfilled. He also mentioned that sometimes he felt abandoned without someone close to him; therefore, visits by his family members become sources of spiritual support. In addition, connecting with other people who share a similar faith to Mr. J can help his spiritual growth process, and this connection helps him cope with his current frail condition. However, if he has to move physically to various locations, then his movement restriction would hamper his spiritual growth.
Role of the nurse
The two key issues nurses must consider in the case of Mr. J are his pressure ulcers and fall risks. For pressure ulcers, nurses pay particular attention to his personal hygiene because Mr. J is incontinent of urine and would not seek assistance from staff for product change. Because of this, he needs frequent changes in clothing and his beddings to prevent wetness. Besides, based on his profile, Mr. J is already receiving wound care on his both legs and arms every three days. His profile highlights that Mr. J is using Triad cream for the skin tears on his arm. He also gets heel protectors to be applied at bedtime and removed daily when he wakes up. For stage 2 pressure ulcers of the right heel, nurses cleanse the wound with normal saline and apply Triad cream covered with Tegaderm waterproof transparent dressing. In addition, he is asked to apply Coloplast Triad Hydrophilic paste to any open areas for his intermittent venous stasis on his both legs and feet (Pan, Li, Chen, Su, & Wang, 2014)). Apart from wound care, there are other nursing interventions related to his diet and nutrition. In order to protect his frail skin, nurses provide him fortified milk at meals, and he gets one scoop of protein powder three times a day. Also, staff would offer him banana at AM snack and a sandwich for PM snack.
To prevent fall risks, nurses check every hour to ensure his safety and make sure the environment is free of clutter to eliminate unnecessary obstacles that can cause difficulty in movement. Besides, they encourage Mr. J to use assistive devices properly. In his room, Mr. J usually has his commonly used articles within easy reach. And every time before leaving his room, nurses always have call bell dipped to his pillow and remind him where the call bell is located (Hammond & Wilson, 2013).
Strategies for the nurse
To deal with pressure ulcers, the nurse in charge of Mr. J need to prevent the risk of a fluid output exceeding intake, which is characterized by dry skin and mucous membranes related to not consuming all liquids or diuretics (Kozier et al., 2014). Strategies are to increase fluid intake during hot months and check for signs and symptoms of dehydration, such as weakness, dizziness, dry mouth, and swollen tongue (Miller, 2015). Also, nurses can offer water or ice every shift when giving medications. Another option is to encourage the resident to use a fan to keep his room cool. Based on these strategies, a resident could decrease the risk of fluid volume deficit and increase his wound healing process.
Another strategy for dealing with his fall risks is to help Mr. J understand his health conditions, despite the fact that his deteriorating cognitive function may take him time to process the information. Therefore, nurses could build and maintain a therapeutic relationship with Mr. J through effective communication skills. The challenge that the nurse should expect is the reaction of Mr. J when he thinks that whatever he is asked to do is not what is best for him, so nurses must provide accurate information so that Mr. J feels like he is taking part in the decision for medical treatments. Besides, being considerate of Mr. J’s spiritual beliefs would also boost his cooperation (Hartikainen, Lönnroos, & Louhivuori, 2007).
An apparent issue for Mr. J is that his health is failing mainly due to aging, chronic diseases, and immobility. He needs close nursing attention to help him cope with two major health issues, which are pressure ulcers and a high risk of a fall. While both concerns are physical in nature, they also affect his emotional wellbeing and his social interactions. The discussion on Mr. J’s health conditions and nursing roles highlights his need for chronic wound care and fall prevention. In the future, there should be additional skin assessments on Mr. J to measure his healing process, and I need to learn how to describe the wound and document the findings.
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