maximising health through assessment
... pressure applied to her sacrum area as a result of decreased mobility and the inability to change her position regularly enough. Dealey (1997) defined a pressure ulcer as ‘localised damage of the skin following a disruption of the blood supply to the area, usually caused by friction or shear or any combination of these.’ With reference to Dealey’s statement the disruption of the blood supply caused by friction could be an extrinsic cause such as a reduction in mobility, and the inability to change positions to relieve pressure around the area, as was the case with Lucy. For this assignment Lucy was the chosen patient as the author thought it would be effective to demonstrate how decreased mobility can affect the development of pressure ulcers. Lucy was admitted to hospital with nausea, vomiting and a general unwell feeling. From the initial assessment that was conducted on admission, the author found that Lucy was a 60 year old lady who lived with her husband and had a very large family consisting of four sisters, two brothers and four of her own children. Her medical history showed that she suffered with asthma and hypertension and had had previous complaints of stomach, bowel discomfort and a slight decrease in her mobility. 3. 0353065 Assessment is the first stage of the nursing process. Without a thorough assessment, patient care can become challenged and the nurses may not be able to plan efficiently. The multi-disciplinary team assist in producing the rationale of future care for the patient. Walsh (2001) suggested that assessment should not be seen as the duty of completing forms. Even though the admission document is a very efficient tool it can also have its disadvantages of use, suggesting that nurses should not use the assessment tools and rely on them fully but use their own clinical judgement and initiative. The nursing assessment should be seen as the nurse building an effective relationship with the patient. During her hospital stay Lucy was diagnosed with Liver metastasis, with no primary cause identified. Liver metastasis is defined as ‘the distant spread of disease, especially a malignant tumour, from its site or origin. This occurs by three main routes; 1, through the bloodstream; 2, through the lymphatic system; 3, across body cavities.’ (Oxford mini-dictionary for nurses, 5th Ed. 2003) The deterioration of her condition effectively reduced her ability to mobilise independently. With reference to Roper et al (1996) mobility is the movement produced by groups of large muscles, enabling people to stand, sit, walk and run as well as groups of smaller muscles producing movements such as those involved in manual dexterity or in facial expressions, hand gesticulations and mannerisms; all of which are non-verbal communication. 4. 0353065 The effects of not being able to move can happen following trauma (e.g. Spinal injury) or inflammatory diseases, which can have an impact on the individuals lifestyle and social activities. The author realises with reference to Roper et al (1996) that the activities of living are closely related and when illness compromises one activity then this will undoubtedly have an impact on the other activities. Roy (1976) talks about how nurses evaluate data regarding the patient to make their assessments on existing potential problems and from this they can select an ‘approach to solve the patient’s problem or to meet the patient’s need.’ Using the appropriate nursing assessment tools the author identified that Lucy was at a very high risk of developing pressure ulcers. The admission assessment pack consists of a front sheet, Waterlow scale - pressure area risk, risk screening tool, continuation sheet and a discharge plan. Using the Waterlow assessment tool the author assessed Lucy’s potential and existing problems and this showed that she was at a potential risk of producing another pressure ulcer because of the amount of pressure being applied to one area and the inability to fully mobilise independently. The author concluded from Lucy’s Waterlow assessment score that she required a specialised mattress to relieve pressure to certain areas and regular two hourly assisted turning programs because of decreased mobility. One of the most important aspects of planning future care for patients is the evaluation that should be included the care. This is ...