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Functional decline is experienced by 30 – 60% of the older hospitalized patients, resulting in decreased independence and other adverse health outcomes (Hoogerduijn, Grobbee, & Schuurmans, 2014). We as nurses play a critical role in preventing such a decline in this specific population. With this prevention comes the ability for elders to keep their independence for as long as they possibly can. Functional decline can be defined as the ability to perform activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs). Another identifying factor for functional decline is a decrease in cognitive functioning. Ageing itself or age-related problems can initiate an individual’s functional decline. Age related problems that could affect the functional abilities of an elderly man or women include vision and hearing deficits, balance problems, and/or bone weakness such as osteoporosis. Progression can start subtly, but suddenly progress and result in the individual becoming more dependent on his or her family members and care providers. One of the main causes of functional decline in the elderly population is hospitalization. This can change the prognosis of the older patient in a negative way by changing their life from independent to dependent. There are programs designed to help prevent this decline in older hospitalized adults. One of which is the Nurses Improving Care for Healthsystem Elders (NICHE). This is an international nursing education and consultation program designed to improve geriatric care in healthcare organizations (NICHE). The NICHE program provides the necessary resources and technical support for nursing and interdisciplinary teams to achieve organizational goals for the care of older adult patients. Although there are several geriatric models and chronic care models, NICHE has been the most successful in recruiting hospital membership as well as contributing to the depth of geriatric hospital programming (Capezuti et al., 2012). Another program that aides in this prevention is the Hospital Elder Life Program (HELP). This program is wanting to achieve that their patients are maintaining their functioning both physically and cognitively and overall maximizing their independence by their discharge date. The Client at Risk for Functional Decline M.P. is a sixty-five-year-old male who was admitted to the hospital for a right foot cellulitis infection. Prior to his admission he received an amputation of his right third toe. During his stay he underwent a debridement and closure. Mr. M.P. is at risk for functional decline because of his adequately large past medical history, which includes end stage renal disease (ESRD), diabetes mellitus type two, peripheral neuropathy, chronic obstructive pulmonary disorder, obesity, alcohol abuse, and anemia due to his chronic kidney disease. Assessment As stated previously, the client’s past medical history is what rose a red flag while reading the H&P notes in his chart. More specifically, M.P.’s diabetes mellitus type two, obesity, and peripheral neuropathy are what stood out the most in his past medical history. All three of these factors can lead to impaired skin integrity. The skin is the body’s first line of defense, meaning the patient would also be at risk for developing an infection. The Braden Scale is a tool used to help nurses and other healthcare professionals determine who is at risk for developing pressure ulcers and those who are not. This tool consists of six categories which include activity, mobility, sensory perception, moisture, nutrition, and friction/shear. The lower the score the patient receives the greater risk they are at for development of a pressure ulcer. Along with the Braden Scale, while performing the shift assessment it will be important to assess the skin. With the skin assessment you will want to look for the color of the patient’s skin and what is normal for them. Temperature would be the next thing to assess, meaning if the skin is cold, possibly due to poor tissue perfusion, or hot due to infection or fever. Next is texture and assessing if the skin is moist or thin. Lastly is integrity, as in if there are any broken areas such as tears, wounds, blisters or pressure ulcers. With any of the above findings one would want to document the anatomical location along with the appearance. If assessment and treatment is not undertaken in a timely manner there is risk of tissue damage with associated cost and care implications (Rush & Muir, 2012).Nursing DiagnosisM.P’s priority nursing diagnosis is risk for impaired skin integrity related to diabetes and peripheral neuropathy as evidenced by decreased sensation in his feet. Skin integrity is vital for older adults, especially in a hospital setting. The skin is the body’s first line of defense against nosocomial infections. As adults age, they become more susceptible to infections. There are several factors that support this, which include more frequent comorbidities, arthritis, or renal insufficiency. Along with those factors comes a decreased function of the immune system, which is responsible for fighting off infection. Older adults are more prone to infection due to a combination of comorbidities and a suppressed immune system. Planning/Interventions The nursing interventions that will be the focus of this section will include skin care practices, proper nutrition, and repositioning. All three of these are going to have an impact on improving and maintaining Mr. M.P.’s skin integrity. Monitoring Skin Condition Assessing the skin and providing the proper care to the skin is going to be essential in maintaining its integrity and reducing the risk of cuts or pressure ulcer development. At least once a shift the skin should be assessed. With this assessment it will be important to note the color or texture of the skin and any changes associated to the findings or if there are new lesions present. If new lesions are present, it will be important to note the size, location, if there is any drainage, and the drainage characteristics. Frequent inspection of the skin can identify impending problems early and significantly decrease the development of an infection. Aged skin is particular prone to dryness. Dry skin is prone to superficial cracks that can eventually allow irritants and allergens into the skin. Poor hygiene can be associated with impaired skin integrity so proper hygiene is going to be important. Using a skin cleanser that reduces irritancy is recommended and proper drying is going to be essential while giving the patient a bath or a shower. However, after the use of bed bath wipes, drying is not necessary. Although the purpose of cleansing the skin is to remove any dirt or bacteria, this action can lead to a weakened skin barrier function. According to Cowdell, F et all., 2014 emollients, such as petrolatum, are used regularly to temporarily restore the skins hydration. It would be best to apply emollients after a shower to help restore hydration. Although, over hydration is not going to be beneficial because it can cause an increase in softness and break skin integrity. Factors that increase the risk of skin tears in older adults include increased dryness of the skin, which can be further exacerbated by frequent washing with soap, which reduces intrinsic skin lubrication. Also, a loss of independence to perform activities of daily living can be considered a risk factor because of the assistance required by others may result in inadvertent injuries.Proper Nutrition Skin integrity and nutrition have a strong correlation in the older adult population. Not only does nutrition have an impact on the integrity of the skin, but also has a role in skin healing. Frequently researched antioxidants such as carotenoids, tocopherols and flavonoids, as well as vitamins (A, C, D and E), essential omega-3-fatty acids, some proteins and lactobacilli have been referred as agents capable of promoting skin health and beauty (Liakou, A. I., Pappas, A., & Zouboulis, C. C. 2016). To be sure M.P. is receiving the proper nutrition a dietician could be consulted. The dietician is going to know in great detail what vitamins or supplements will be useful for each individual’s differences. The main goal for supplements are for those who are not able to change or unmotivated to change to a healthier diet. With peripheral neuropathy, it may be hard to notice any cuts or sores on the foot related to a decrease in sensation. Protein is a nutrient that is essential for wound healing. Foods that could be suggested to M.P that are rich in protein are beans, nuts, eggs and chicken. Vitamin C is also considered good source for wound healing due to it being helpful in aiding the body to make the protein collagen. This protein is found in blood vessels, bones, muscles, tendons, skin, and the digestive system. Collagen plays a role in tissue development, supporting cell structure and strength of the skin. Dark green leafy vegetables would be a good suggestion for Mr. M.P to add to his diet. Foods with vitamin A, such as carrots and sweet potatoes, help restore damaged collagen fibers. RepositioningRepositioning a patient at least every one to two hours will reduce pressure and shearing force to skin. This is going to involve changing the patients position from lying to sitting or from side to side. When the patient is in a lying position it is recommended that the head of the bed is at thirty degrees because it reduces the amount of pressure on the sacrum. Sitting poses a real challenge, as pressure is more concentrated on the bony prominences of the ischial tuberosities (Miles, Nowicki, & Fulbrook, 2014). When repositioning, the heels should also be taken under consideration. Although it may be difficult to reposition the heels based on the initial position, using a pillow to prop them up and elevate them would be substantial. Repositioning is beneficial in improving skin integrity but turning and lifting alone can tear or shear the elder’s delicate skin. Elders skin is more fragile because of the decreased elastic fibers and lower adherence of the skin. NICHE and HELP Incorporation to Functional Decline The Nurses Improves Care for Healthsystem Elders (NICHE) help maintain physical function by educating staff that are a part of their program techniques on how to specifically prevent skin breakdown. They state the importance of repositioning at least every one to two hours to relieve pressure on certain points. Another intervention mentioned is assessing the skin thoroughly at least once a day and document the findings. Although M.P. did not currently have this issue of incontinence, they stress the importance of cleansing and drying the skin immediately if soiled by urine or stool. The Hospital Elder Life Program (HELP) uses trained volunteers stimulate the patients to perform their activities of daily living along with exercises approved by the physician or by physical therapy. Since these volunteers are highly trained individuals, they are going to be able to intervene and address the proper care of the client. They may also be able to advocate for the client and make sure that they are getting the most out of their stay. Our results indicate that only 8% of admissions involved patients who declined by 2 or more points on MMSE and only 14% involved patients who declined by 2 or more points on ADL score (Reuben et al., 2000). Although this journal is over ten years old, it strongly suggests that HELP successfully prevents functional decline in older adults who are at risk. Implementation The cumulative effect of the aging process is that the skin becomes a less effective barrier, risk of infection increases, and wound healing becomes delayed. All of these listed changes significantly make the skin more vulnerable to damage. Since M.P. discharged before the end of the day, providing information of how important it would be to follow his recommended diet was implemented. The diet that he was on would correlate to the proper nutrition he would need to help maintain and promote good skin integrity. EvaluationFor every day spent in bed it can take two-and-half days to regain the strength to walk (NICHE). This quote from the Nursing Improving Care for Healthcare Elders stood out to me because M.P. was admitted to the hospital on January twenty-fifth and was discharged February fourteenth. Maintaining your patients skin integrity during their hospital stay is one of the most fundamental and critical goals you should have as a nurse. In order to prevent this from happening the biggest thing that could have been done is patient education. Instructing M.P. to be sure to assess his skin regularly, note any abnormalities including new lesions and take action before the lesion gets worse. You would also want to instruct the client or family member to every one to two hours to relive pressure on certain pressure points of the body. Providing a printout with all of this information would also be beneficial. Impaired skin integrity can potentially lead to functional decline later on down the road. With that being said, even though the challenge is there, maintaining any patients skin integrity is an important factor relating to functional decline.