Challenges and Prevention of Pressure Ulcer in Hospital Settings for Dementia Patients
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This literature review addresses the challenges and prevention of pressure ulcers in hospital settings for dementia patients. It discusses the impact of dementia on patient care and the strategies to prevent pressure ulcers.
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Quality and Safety in Healthcare Practice
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INTRODUCTION...........................................................................................................................1 PROBLEM.......................................................................................................................................1 BACKGROUND.............................................................................................................................1 STRATEGY.....................................................................................................................................2 LITERATURE REVIEW................................................................................................................2 1. Problems of dementia in UK..............................................................................................2 2. Pressure Ulcer.....................................................................................................................3 3. Hospital practices for controlling the problem...................................................................4 4. Responsibility of care providers in UK..............................................................................5 5. Challenges of nurses...........................................................................................................6 6. Pressure Ulcers in Ireland and steps to overcome..............................................................7 DISCUSSION..................................................................................................................................9 CONCLUSION..............................................................................................................................10 REFERENCES..............................................................................................................................11
INTRODUCTION Quality in healthcare is a term which shows the level of care offered by hospitals to their patients at the need of need in an affordable price. Their main objective is to provide best services with qualitative products for controlling the worst conditions of patients. There are number of practices which are design by governing bodies for directing health care sector about the actions that they need to take at hospitals (Wooand et. Al., 2017). Thus, this project is going to conduct a literature review for accumulating the information related to the “challenges and prevention of pressure Ulcer in hospital settings especially for dementia patient”. Therefore, main objective of this review is to address the issue of dementia patients at hospital settings who developed pressure ulcer and due to their dementia status nurses ignore changing their position as it might disturb their sleep. PROBLEM Health care quality is an effective level of value that is provided by various healthcare professionals. In fact, with appropriate quality in other areas, it is an assessment of whether a thing is sufficient enough for the meeting the patient needs. However, certain key problems are also associated with the organizations that are affecting the health of people, staffs and other members working within the centre (Dye, Reeder and Terry, 2013). Problem related to dementia is state where there is damage in cognitive function of an individual means that he/she is not having an ability to think for performing day-to-day activities. Pressure ulcer is also named as a bedsore which means the damage of skin or underlying tissue that mainly incurred over a bony eminence because of long term pressure. BACKGROUND In the recent time, it has been seen that dementia and pressure ulcer problems are creating a lot of negative implication to the patient health condition. These problems are resultant into several diseases and injuries which initially or secondly affect the brain like Alzheimer’s disease or stroke. Simply, it’s a major cause of disability and dependency among aged human beings across the worldwide. It means that risk of this health issue is very high in older people because few aged people are having difficulty in moving. Along with this, if there is an additional problem of dementia then the possibilities of pressure ulcers increased too much (Mah'd Alloubani, Almatari and Almukhtar, 2014). Generally, elders whose are restricted to bed also 1
face complications related to bedsores due to the minimized mobility of limbs such as; infection in chest, pressure sores and contracture in muscles. All these problems emerge due to the improper positioning. Therefore, it’s essential for care providers to enhance their nursing skills in ordertoguideelderspeopletowardspositionchangingcontinuouslyforcontrollingthe possibilities of pressure ulcers which really dangerous for their existing life. However, it is important to have an effective quality and services should be delivering to the affected patient so that chances of health problems could be overcome in the future. STRATEGY Health care practices can go for foot cradle which is a kind of tool in a tent shape that will protect the sheets as well as blankets from resting directly on the patient feet whosoever is lying on bed. Health care organization must provide protective foam to the patient for placing it under a foot while resting instead of just lying down on mattress. It’s a responsibility of nurses whose are taking care of dementia patient to guide them about continuous turning or shifting of positions in order to make sure that blood can supply in every area of body parts instead of blocking at one place.There are number of people whose are suffering from dementia issue has developed incontinence and use qualitative incontinence pads as well as pull-ups which will wick the moisture away from skin and change it consistently (Kondrotaitė, 2012). Moreover, it’s important for patient to gently wash the bodily skin by using clean washcloth in place of just rubbing it. Additionally, nurses can also use or suggest patient for using creams like; Baza as it prevent the skin of patient from incontinence(Boyko,Longakerand Yang,2018). However, there are some treatment that involves management of local as well as distant infection, removal of necrotic tissue and possibly surgery to cure the patient. In case of dementia patient, the nursing practitioner needs to make use of cognitive decline strategy, meditation and psychosocial stress management techniques to cure the patient. LITERATURE REVIEW 1. Problems of dementia in UK According to the facts of World Health Organization, 2019, dementia can be influences the memory level of an individual, orientation, calculation, destroy the learning potentiality, language and lost the decision making process. However, person who are facing a dementia problem influence every individual in distinct ways as it fully depends upon the impact of sickness as well as person’s character before becoming ill. As per medical science, this problem 2
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has been caused due to the damaging of nerve cells and this cell is connected with brain which resultant into deterioration of individual cognitive functions. Along with this, number of problems and issues has been faced by the person such as; emergence of pressure ulcer that created due to longer pressure on a specific body part(Ticinesiand et. Al., 2016). This problem is a very dangerous for a person health because in some cases it starts becoming more black or swollen which is an indication of tissue death. Simply, this problem mainly incurred over bony regions that are very close to the skin as this ulcer forms when there is a reduction in supplying of blood to specific skin area due to which that area becomes starved of oxygen and nutrients. For example; sitting or lying in similar pose for a longer period of time is a most common cause which create pressure ulcers for many dementia patients. This problem is mainly encountered by old age people as their skin are very thin, dry or weak due because of ageing or numerous disease pressure. Some of the major reason due to which pressure ulcers increased in dementia patient are; problem in moving, walking, improper diet or dehydration, incontinence, improper supply of blood, agitation, restlessness, facing a problem in sharing their pain with other member and so on. All these issues are encountered by the patient of dementia which resultant into pressure ulcers(Chamangaand Ward,2015). According to the given scenario, dementia patients are encountering a major health issues that is; pressure ulcer due to the continuous pressure on a skin because of their current cognitive problem. Nurses are also avoiding to change them because they get scared that disturbances affect their sleep due to which patients are facing a pressure ulcer. Instead of this, dementia patients are also encountering many more challenges from which some are very straightforward and easy to manage but few are undefeatable that really hard to address. Although, every individual whose are suffering from dementia problem are having unique journey but some face similar experiences such as; forgetting routes, anxiety, fear and so on. Pressure ulcer is a somehow common problem that is faced by Dementia patients because they don’t know how to take care of themselves but it’s a responsibilities of family members to take care of person whose are having a mental problem (Schoeps,Tallbergand Gunningberg,2017). 2. Pressure Ulcer Mainly, pressure sore is considered as ulcerated part of skin over bony areas and this situation incurred when the part of body is continuously pressurized due to lying down in a same position. As a result, supply blood stopped in that particular area and it develop pressure sore. 3
However,thesesituationsmainlyhappenwiththosepatientswhosearechronicallyill, overweight, underweight, not able to move from one position to other, gone through any bodily operation, mentally ill etc. Some of the common sites due to which this problem occurred are shown below(Ellis,2017). According to theRezaei and et.al., 2016, it has been understood that these positions plays a very significant role in creating sores but somehow these are necessary also due to which nurses doesn’t disturbed their patients as it might disturb their sleep. Although, it’s hard to control these kind of issues for nurses but still it’s important to take some prevention for reducing the localized pressure. Initially, nurse need to enforce patients to adopt suitable positioning for controlling the pressure over bony areas. Secondly, need to alter the positions and turn in every 2 hours for maintaining a proper blood supply over the entire body parts. Care providers need to ignore friction between body and bed while lifting or transferring of elder people. It’s imperative for hospitals to arrange appropriate kind of chair and instruct the elder person who is sitting on chair that kindly change their posture in every 30 minds by taking support from upper limbs. Moreover, requisite to acquire suggestion from health professionals in context with the use of pressure-reliving devices which are shown in below image(McGraw, 2019). 3. Hospital practices for controlling the problem Olin and et.al., 2014, it’s important for hospitals to make available these above products for supporting those patients whose are suffering from pressure ulcers as this will maintain a proper supply of blood in every body parts of a patient. Additionally, nurses need to take some other measures also for resolving the issues related to pressure ulcer such as; significant to maintain clothing and bed linen fully clean or dry, control the placing of heavy objects over the body part like; hot-water bottle, make sure that dressings of wound or bandages must not so tight and nurses need to keep their nails shorts while treating elder patients or remove their jewelleries as it may cause injury to patient (Barnes and et.al., 2012). Apart from this, some of the hygiene related to the person will also help in reducing the probabilities of pressure ulcers such as; need to clean the skin or dry, change the napkins frequently for minimizing the possibilities of infection related to skin in elders whose are suffering from incontinence, be attentive towards the condition of skin, identify the signs of pressure sores and acquire medical suggestion at the time of need. Furthermore, dementia patients whose are having a high probability of pressure ulcers 4
need to focus on their diet and make sure that he/she must have nutritious food with full of protein like; egg, milk and beans for maintaining the skin healthier(Carlssonand Gunningberg, 2017). On contrary to this,Elderly Health Service, 2016states that contracture in muscles also an outcome of prolonged immobility and improper positioning which leads to stiffness in joint as well as minimize the range of movements especially in those patients whose are suffering from stroke, Parkinson’s disease or those whose are involved in a state of bedridden. Hence, prevention for resolving muscle contracture is that nurses have to make sure that the dementia patient who is facing this issue must adopt suitable positioning and try to alter their positions in every next 2 hours. Some of the measures that might take by nurses in their clinical practices such as; provide a support in affected side with the help of pillows during sleep, elbow and fingers need to be straight with palm fronting upwards (Abelha and et.al., 2015). Secondly, nurse can also reduce the probabilities by placing a pillow under the knee of patient specially on affected side and keep the knee bent slightly. Additionally, nurse can instruct the patient to follow lateral position while lying on bed like; use a pillow for supporting those side which is influenced by a problem with elbow straight and using of pillow for maintaining a direct contact of knees with each other for protecting deformity. Along with this, sitting straight is also a best position by acquiring a support from back side and pillow can use by a patient for supporting upper limbs by placing the feet on floor. 4. Responsibility of care providers in UK AccordingtoArmijo‐Olivoandet.al.,2012,careprovidersofUKhospitalsare responsible to make sure that all the above instruction must aware by patient whose are not in their senses either by teaching in a polite way or showing picture is also a best option for nurses. An elder people can understand the things through images and nurses can use these images for motivating them to adopt these postures while sleep for resolving the problems related to pressure ulcers. Interestingly, nurses are also having an opportunity to conduct motivational programmes for encouraging the patients towards healthy life (Dinesh and et.al., 2013). For example; promoting elders or dementia patient for performing regular exercise like; stretching of body for maintaining a proper circulation of blood, joint flexibility and protecting their muscles from contracture. In fact, healthcare organization can also use some useful measures such as; utilizingfirmpillowwhichishavinganappropriatethicknessof almost5cmto 10cm, 5
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comfortable mattress for giving adequate support and selecting of wheelchair for resting the back or neck. Hence, all the above mentioned strategies and prevention is really useful for health care associations in controlling the probabilities pressure ulcers of dementia patient in corrective manner (Nakanishiand et. al., 2017).In most part of the UK, it has been estimated that 676000 people have been suffering from Dementia. According to the UK report, the number of dementia patient in the UK is being estimated to increase over 1 million by 2021. It happens to be more worse case situation, under an assumption that there are less number of public health intervention along with the changes that are been driven by an aging population. However, the total population prevalence of dementia between 65s is 7.1% which equals one in every 79 (1.3%) of the entire UK population. For the purpose of providing cure to these people, NHS picks up£4.3 billion of total cost for the treatment of dementia people. 5. Challenges of nurses Accordingtothe viewpoint ofDaniel Press, MD, Michael Alexander, 2020 number of challenges are encountered by nurses while handling the patient of dementia because they are not in their senses due to which care providers need to be very attentive towards them as single mistake might resultant into heavy loss (Middleton and et.al., 2013). Mainly, patients whose are suffering from dementia issue are having a very low potentiality to make corrective decisions due to which major issue that is face by nurse is a safety problem. Thus, concerns related to safety are emerging at higher extent and predictable way due to the growth in dementia. Therefore,resolvingtheproblemsrelatedtosafetycanhelphealthcareorganizationin controlling several major serious accidents. Esther Heerema, Shaheen Lakhan, MD,Phd, 2020 mention in their article that care providers whose are dealing with dementia patient requisite to be attentive for protecting them from pressure ulcer. Some of the measures that need to take nurses and health practices for overcoming the challenges of dementia patient include several things. Initially, it’s important to conduct regular skin assessment test for visually inspecting the skin of a dementia patient especially on those body points where pressures are very high such as; heels, coccyx and buttocks (Kim, 2013). Most suitable time period for performing this assessment activity is when nurse is instructing the patient during bathing. For remembering this step, it’s vital for nurse to schedule both activities one is bathing and assessment of skin on calendar as it aids in memorizing the procedure. Secondly, nurse can also go for the option of floating heels on a 6
pillow by placing a pillow under the calves for making sure that heel of a person maintained in a floating position in air rather than resting directly on bed.Hospitals are having an opportunity to conduct physical as well as occupational therapy services by paying at home or hospitals in order to evaluate or to identify the most suitable position and seating interventions for comfort or skin prevention (Howard-Anderson and et.al., 2012). Nurses have to organize a suitable place in hospital for assessing the contractures in order to identify that where the contact of skin of a dementia patient is constant as it will maximize the risk of pressure sores. For instance; if arms of an individual have tightened up and involuntarily bends at the elbow due to the stroke then that part of body is at higher risk because of moisture and heat has been imprisoned there. Consequently, it has been understood that numerous of options are available that needs to follow by health care organization and requisite to change their hospital settings accordingly in order to protecting dementia patients from pressure ulcers (Pomey and et.al., 2015). 6. Pressure Ulcers in Ireland and steps to overcome Inotherwords,DANIELBLUESTEIN,MD,ASHKANJAVAHERI,MD,2015, mentioned that pressure ulcers are also known as decubitus which is identified from reddening of skin at severe, deep craters with uncovered muscle or bone and this problem mainly threaten the growth of patients whose are having limited mobility. This article states that almost 70% of ulcers are identified in older people whose are age of 65 years as compared to younger one. Therefore, it’s really significant for every health care practices to set the risk assessment program at their hospital services in order to preventing individuals or dementia patients from the probabilities of pressure ulcers. Mainly, this tool helps an organization of health care by identifying the risky elements and inspecting the skin of patients such as; assessment of body internally as well as externally (World Health Organization, 2017). Moreover, firm needs to make sure that appointed nurses are educated and registered under the national council bodies so that she can treat the patient in a corrective way by understanding her duty towards sufferer. Risk factors for pressure ulcers Internal Limited mobility Injury of spinal cord Accident of cerebrovascular 7
Fractures Pain Improper nutrition Lack of dentition Dietary restriction Poverty Dehydration Comorbidities Depression Diabetes Minimization in pain sensation Ageing skin Loosing elasticity Alteration in dermal Ph Minimization of dermal-epidermal flow of blood. External Pressure due to hard surface such as; stretcher Inability of patient for moving properly in bed Cut off from muscle movements These above factors are the signs which will show the possibilities of pressure ulcers in a body part of a person through risk assessment process. After knowing this, nurses need to take instant steps for controlling its spreading or infection which might resultant into very dangerous effects. Therefore, hospital practices need to act accordingly on these above identified factors for making suitable interventions.Interestingly, there are number of foreign countries such as; Australia, Canada, France, Norway, Sweden and the Netherlands which are compared with Ireland care practices. During Autumn 2013, Service information and development center has conducted a survey of almost 602 Irish Nursing Homes for identifying the facilities which are provided by specialist care units. As a result, it has been observed that maximum number of dementia patient is located in rural and town regions instead of cities. 8
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DISCUSSION According to the suggestion from Agency for health Care policy and research, patients whose are suffering from bedsores must be repositioned in every two hours. Furthermore, for controlling the shear, its indispensable for nurses to make sure that head of the patient bed will not be elevated more than 30 degrees and must be maintained at a minimum degree of elevation in order to protect the person from other medical complications like; aspiration or worsening of congestive failure of heart. On the other hand, Susan L Mitchell, 2019 states that advance care planning is a most vital in managing the patients which are on advance stage of dementia. However, care providerswhose are giving servicesat primarystage are having a great opportunity to design patients with early disease and their families about what needs to expect in future stages of dementia (Algaet and et.al., 2014). Lastly, it has been understood that health care associations have to change their settings in a systematic way for controlling the probabilities of risky situations at prior stage. For example; implementing safety measures in hospitals by providing safeguardenvironmenttothe dementiapatientsfor controllingthe chancesof accidents, brief the nurses about individual’s current situation in a corrective manner, requisite to be attentive while handling the complicated situations of dementia patient with pressure ulcers and so on(Boyko,Longakerand Yang,2018). DATA EXTRACTION Data sourcesConnectorsETL processProcessed data Journal/ PDFURL LinkAnalysis- Evaluation- Interpretation SQL server Challenges of nurses Articles/ paperURL LinkAnalysis- Evaluation- Interpretation Prevention or hospital practices Blogs/Official Websites URL LinkAnalysis- Evaluation- Interpretation Informationabout pressure Ulcer Google scholarURL LinkAnalysis- Evaluation- Interpretation Problemencountered bydementiapatient suchas;pressure ulcer. JournalURL LinkAnalysis- Evaluation-PressureUlcers: 9
InterpretationPrevention, Evaluation,and Management. ArticleURL LinkAnalysis- Evaluation- Interpretation Care of patients with advanced dementia CONCLUSION From the above project report, it has been concluded that quality is an utmost important aspect in health care organization. It is vital to have an effective tools and techniques to deal with the critical problems such as dementia and pressure ulcer. However, these problems are having negative impact on the mental as well as behavior of the affected person. Therefore, it is important to have proper cure planning to overcome these problems by providing valuable services according to their requirements. 10
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