ilary ChiwereraCohort: 18BID No: 1802627The Scope of Adult Nursing -NAD002-1This is a narrative account in one of the National Health Hospitals (NHS) by a nursing student for a duration of 5 days. Pseudonyms will be used to adhere to the Nursing & Midwifery Council code of conduct (NMC,2015) on confidentiality. The aim of this essay is to discuss the journey of a patient admitted in hospital with multiple needs and will focus on pressure ulcers and effective communication between family and the members of the Multi-Disciplinary team (MDT) to successfully coordinate plan of care. This essay will be about a gentleman who was admitted with Atrial Fibrillation (AF). But was found with pressure sores. He will be addressed as Larry. The patient had multiple needs, but this essay will focus on pressure sores, incontinence and pain. Larry was an 83-year-old who was admitted onto the ward was found with a grade 4 pressure ulcer on his sacrum during a routine body map inspection. This is done to check skin damage as part of the admission process. A pressure ulcer is defined as damage to skin mucous membrane lining caused by constant pressure resulting in the mutilation of underlying tissues (Stinson et al 2013). All the relevant information was gathered from Larry’s wife, who was also his next of Kin. According to his wife, Larry had tripped a few months ago leading to a fall and a fractured neck of femur. This is also known as broken hip (NHS,2016). Consequently, Larry lost confidence and became reluctant to walk and spent most of his time either lying on his back or sitting in a chair.He had since become incontinent of urine and complained of a sore bottom. National Institute for Health and Care Excellence guidelines (NICE,2014) identified decreased mobility prolonged lying in supine position, incontinence and frailty as some of the risk factors contributing to the occurrence of pressure ulcers. The nursing assessment identified that his diet and fluid intake was poor. Larry’s wife had indicated that he had lost 10kgs since the fall. This was evident when he was weighted; his Body Mass Index (BMI) was 18.3. According to Lacobellis (2009), BMI is a screening tool which determines if one has a healthy weight or is at risk of diseases such as diabetes and heart disease. It is calculated by adjusting body weight to height. It is also a useful tool in identifying malnourished adults. Larry’s Malnutrition Universal Screening Tool (MUST) score was 2 which means he was at high risk and protocol stated that he should be referred to Dieticians (Bapen, 2018). The essay will also look at services accessible for Larry and his family as outlined by Sitzman and Eicheberge (2010). There are five most important reliant foundations of nursing process that must be included; assessment, diagnosis, planning, implementation and evaluation (Royal College of nursing,2016). They are used to generate a patient’s needs and how to accomplish them to endorse recovery (Radhakrishnan,2011).The first phase of the nursing process is to assess through gaining personal details like their name, date of birth and address on admission (Royal College of Nursing,2015). It is very important to ask for their consent before gathering their details. Observations need to be completed, blood pressure, temperature, pulse and oxygen saturations are carried out and documented accurately and will be retrieved by other professionals who might have a diverse approach or assessments on policies (Haynes,2015).Due to the complex nature of Larry’s pressure sore, the nursing assessment made a referral to the Trust’s Tissue Viability Nurse (TVN) for support on wound care planning and management. The NHS policy (2015) encourages staff caring for patients with complex wounds to seek TVN advice and intervention to promote effective treatment and management in a timely manner with recovery as a desired outcome. A referral to the pain management team was done to help Larry with physical and psychological wellbeing to promote his independence (Royal Free Hospital,2015). The essential aspects of nursing are to work in partnership with the multidisciplinary (MDT) to sustain effective patient care (Nursing & Midwifery Council (NMC),2015. The team needs to work well by applying effective communication skills as specified by Shari (2015). Larrys’ needs were met by planning a nursing process and evidence-based practise by setting goals to encounter medical needs, administering the right medication and dosage for pain relief (Asset Care Planning,2013). The doctor prescribed analgesic for pain relief, even though signs of improvement were starting to show. Pain is part of communication it was evident by Larry’s facial grimacing appearing tense and uneasy. Effective communication seemed effortless between patient and the nursing team, they had built a professional therapeutic relationship created by asking open questions on both sides (Essential Communication Skills for nursing and Midwifery,2010). After day 3 signs of improvements were showing as Larry was interacting and engaging well with staff, showed positive signs of recovery. Towards achieving continuity of care and person-centred care, care plans and risk assessments were put in place (Department of Health, 2014). Person centred care involves gaining consent from patient and discussing all decisions to promote his independence and the medical team having good clinical knowledge.When considering treatment for pressure ulcer, a dietician will put a plan in place for good healthy skin and overall health (Stinson et al,2013). Dietary needs were met by considering cultural and religious beliefs (Barrett et al 2013). The dietician also recommended fortified and nutritional supplements to be taken daily as per care plan and should be documented in the diet and fluid charts. It was evident that the dietician had raised his concerns to Larry about the importance of input and output. Diet and fluid charts provide vital information that forms the foundation of nutritional assessment. The physiotherapist did a risk assessment on equipment to find what would be suitable to help Larry improve his mobility. A sleep and turning chart were introduced to release the pressure on the ulcer as specified by Stinson et al, (2013). Larry being immobile, waterlow score, incontinence and profound vein clotting was assessed (Royal Free Hospital,2015). The nursing assessment identified hand wash as a tool of delivering safe effective patient care that reduces cross contamination and spreading of infection (Royal College of Nursing,2015).According to Peterson et al (2010), maintains that the efficiency of repositioning is not as much or not dependable even though it is done by qualified nurses. In addition, they found that after continuing to monitor pressure, there is still a chance of pressure taking place in the risk areas. Although turning the patient they are not protecting all areas prone to pressure effect with the skin. Pressure ulcers start evolving within 1 to 2 hours of compression exposure. Repositioning the patient every 2 hours and making use of plentiful relief devices such as pressure mattresses, pillows, hand rolls, cotton rings and hand rails have been shown to reduce the development of ulcers. Larry was repositioned as per care plan everyday to relieve the pressure and sliding sheets were used to move him on the bed.A care coordinator can be contacted once Larry’s needs have changed, visiting the patient following up on the care they have received and bringing together specialists. They will support the patient as outlined by Active Minds (2015) that care coordinators are there to educate on the benefits of the decision on his future health. Occupational therapist did an assessment on an air mattress and wheelchair (Asset Care Planning,2013). Walking sessions were introduced everyday after breakfast for ten minutes to improve his mobility. Larry was able to sit independently and transfer out of bed with assistance and was progressing when mobilising around the ward and when accessing the toilet. The student sat and talked to the patient about therapeutic activities and watching his favourite wildlife documentaries on an iPad. Larry mentioned that he felt that he did not have independence as there was a timetable for meals and personal care. He felt that he had lost control of his life, but the student reassured him that it is not about his condition, but about him as a person. During the night was the only time when Larry was incontinent of urine due to having difficulties of sleeping the nursing team did not want to disturb him during the night. During the day Larry can ask staff to assist him to access the bathroom. The student spent some time with Larry, and he would reminisce about his life when he was young and how he enjoyed doing gardening but was not looking forward to being discharged as he was not going to be able to mobilise. There was some improvement with his diet and fluid intake, his wife made sure she brought some fruits whenever she visited. Larry lives in a two-bedroom house with his wife, the house will be assessed to make suitable changes to accommodate mobile devices like the hoist or wheelchair accessibility and he might not be able to use the stairs, Barret et al, (2013). Before the assessment is done, they would have to ask Larry for consent. According to (Asset Care Planning,2013), Larry might not like any changes done to his home, this would be done to consider his feelings although his wife has input towards care. Grade 4 ulcer is a complex wound that needs a lot of input from different professional MDT.Larry got a grade 4 ulcer on his previous discharge and he was not followed up by a professional who could have picked up before it deteriorated. It would have to be escalated to the district nurse to follow up when Larry is in community. Package of care would have to be put in place including health care assistants who are trained. That is projection planning ahead making sure everything is in place when Larry is discharged. The student learnt about different assessment tools and that pressure ulcers can be prevented with adequate education both in hospital and community.Incontinence remained a risk issue to Larry; his skin became drenched and that can permit bacterial contaminations from urine and faeces. This causes frustration and the moist situation can lead to fungal contamination, skin over- hydration can be impaired by some skin cleansing means and extreme washing (Bardsley,2013) and when left untouched infection might transpire. Bedsore ulcers are common in the elder patients due to fluctuations in skin integrity, making it more prone to damage (International Review,2010; Public Health England,2015). Malnutrition, dehydration and reduced mobility mean that older patients are at an increased risk of developing a pressure ulcer (Keevil Kimpton,2012), which means that preventive measures are imperious to manage. Education is important to ensure that pressure ulcers are managed, documented and reported accurately and competently. It is significant for the nurse recognise the consequences of moisture damage and its connotation with pressure ulcer growth. Mutilation to the sacrum is most expected to occur through pressure, shear forces, extreme dampness or a mixture of both.Conclusion is that the MDT will continue to support Larry with his ongoing treatment and make a follow up. Larry will continue to receive person centred care to promote recovery. Continuous evaluation to establish good care and services, confidentiality to be maintained and staff must provide efficient care and follow the care plan. The student was able to learn about different assessment tools. The student also learnt that pressure ulcers can be prevented with adequate education both in hospital and community. Effective communication with the patient is very important, including good handovers to make sure relevant information is shared within the team. The student will take this experience to future practice. Working with different professionals to meet the patients needs was also a good experience, involving the patient and empowering them to make decisions about their care is also part of the journey. It was a good experience for the student especially having to come across a complex wound and be able to see different professionals communicating with the same patient.