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The aim of the assessment item is to provide students with an opportunity to discuss best practice in relation to the nursing care of a particular client.
Ethel Ritter, an 85 year old woman, presents to the ED via ambulance from an aged care facility, with a three day history of dehydration, poor appetite, lethargy, dysuria and urinary urgency. She smokes 20 cigarettes a day, has no allergies, takes no medication and has a GCS of fifteen. She states that she has no vaginal discharge or flank pain. On arrival in ED, Miss Ritter is mildly febrile (temperature 37.8 C), and her remaining observations are within normal parameters. Intravenous fluids (N/Saline @ 125 mls/hr) have been commenced by QAS prior to her transfer to hospital. Her BMI is 42, and her skin is slightly clammy and tissue paper thin. The Waterlow Pressure risk assessment score is 16. Miss Ritter is to be admitted to the medical ward for intravenous fluid rehydration and antibiotics.
TOPICS: Choose ONE
INTRAVASCULAR DEVICE-ASSOCIATED PHLEBITIS
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The ensuing part of this discussion seeks to answer several questions that relate to the client details adopted in the facts of the question. As a matter of fact, the essence of this essay mainly dwells on discussing and elaborating on the best practices as it relates to the nursing care of Ms. Ritter.
To begin with, as pertains to the pathophysiology of pressure injury development in Ms. Ritter, it is vital to note that pressure injuries result from a continuous pressure being exerted on a specific part of the human body (Victorian Government Health Information 2009). Furthermore, Ms. Ritter's risk factors for pressure injuries such as dehydration, old age, heavy smoking among others, a pressure point may be created in the internal tissues of Ms. Ritter. Consequently, the pressure point thus created augments tissue injury by amplifying the permeability of the capillaries particularly when the pressure is released, causing a tremendous increment in the level of interstitial oedema, instigating blockages in the venous and lymphatic drainage on top of occlusion of blood vessels resulting to hypoxia tissue necrosis and ischemia (Victorian Government Health Information 2009). What's more is the fact that the manner in which pressure induces the death of tissues is not well fathomed by scientists. Nevertheless, it is widely believed that ischemia which is predominantly caused by the occlusion of capillaries is the most dominant causative factor (Allman et al 2012). Additionally, lymphatic flow blockage may lead to great accumulation of noxious waste products. In addition, reperfusion injury combined with the concomitant radical development, which occurs freely, tends to most times than not damage cell. Moreover, it is scientifically proven and accepted that pressure that is prolonged may cause cell damage, which results in the death of tissues or necrosis (Rowe et al, 2010).
It is worth noting that very high pressures are fathomable in tissues deeply seated particularly those about bony prominences (Kable et al, 2011). As a matter of fact, these tissues are the most susceptible to injuries associated with pressures. In order to prevent a pressure injury to this client, the most appropriate prevention plan should be adopted. The ensuing part of this section seeks to capture the best preventive plan in order to ameliorate Ms. Ritter from the tendency of suffering from pressure injury. First and foremost, analysis of literature divulges that one of the risk factors for pressure injuries is immobility or reduced mobility. Therefore, Ms. Ritter should be encouraged to constantly change positions in order to avoid a great deal of pressure being exerted on one particular point, hence causing pressure injuries on that particular point (Andersen et al 2012).
Furthermore, Ms. Ritter should adopt a healthy and nutritious diet. This is dint of the fact that, it is decipherable that she has had a very poor appetite. Moreover, Ms. Ritter should be helped to maintain a hygienic lifestyle as a second preventive measure. In fact, proper hygienic practices are indispensable as far a prevention of pressure injuries is concerned (Gupta, Loong, & Leong, 2012). An intricate analysis of the literature as it pertains to this particular ambit of the study reveals that failure to maintain proper hygiene enhances the particular person's probability of developing pressure injuries by 30 percent. Hence, due to that fact, Ms. Ritter as a result of her old age should be assisted to maintain high standards of hygiene.
Further, another best practice to adopt in a bid to prevent pressure injuries is to carry out the risk assessment using the Risk Assessment Tool. Ms. Ritter should be subjected to scrutiny using this tool so as to gauge the probability of developing pressure injuries. Once such probability is established, necessary measures should be put in place in order to prevent or reduced the chances of Ms. Ritter developing the injuries. According to scientists, this is the best preventive plan that ought to be adopted (International Symposium on Intracranial Pressure and Brain Monitoring & Poon, 2005).
Additionally, Ms. Ritter should be advised to adopt a change of lifestyle. For instance, she should quit the intense smoking. From the facts thus presented, it is evident that Ms. Ritter is a heavy smoker (Gupta, Loong, & Leong, 2012). According to the literature review tabulated in the earlier sections of this discussion, it is decipherable that smoking is a major risk factor for the development of pressure injuries. Thus, as a preventive measure Ms. Ritter should completely quit smoking and if that is not possible because of the inevitable addiction, she should tremendously reduce the daily intake of cigarettes.