An initial holistic assessment, looking at all contributing factors such as mobility, continence and nutrition will provide a baseline that will identify his level of risk as well as identifying any exist pressure damage. According to pressure ulcer is defined as, a localised injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure. (NICE, 2005)
Edward is more vulnerable to pressure sores due to his age and his skin is more fragile and thinner. There are risk factors associated to the integrity of the patient’s skin and also to the patient’s general health.
Skin which is already damaged has at high risk of developing the pressure ulcers that healthy skin. Skin that is too dry or moist due to incontinence is also at high risk of developing pressure ulcers. Elderly person such as Edward is always at high risk developing pressure ulcers due to his age and immobility. (Boore et al 1987) identify the following principles in caring for the skin and prevent pressure damage.
Skin should be kept clean and dry to prevent any accidental damage. Due to Edward spending most of the time sitting in his chair, he is subject of high risk of developing pressure sores as his mobility is reduced.() If Edward continue sitting without releasing the pressure, this resulting of cells to die leaving an area of dead tissue which will cause pressure damage to the skin. (Nelson et al, 2009) indicate that pressure ulcers can trigger functional limitations, emotional distress and pain in patient.
According to (Nakrem, 2009) state that ulcer development is often seen as a sign of the care that has been provided to the patient. To provide effective and quality of care to Edward, nurse has to recommend strategies, which include frequent positioning and air flow mattress in managing prevention of pressure damage (pressure damage)
The assessment used in prevention of pressure damaged in Edward’s case is Waterlow Scale. the Waterlow was developed by Judy Waterlow in 1985, it was originally designed to be used by health professionals to measure the risks of patients developing pressure sores. It is also be used as a guide for the ordering of effective pressure relieving equipment. The important of using the Waterlow, it enables the nurse to assess each patient according to their individual risk of developing pressure sores (Pancorbo-Hidalgo et al, 2006)
During the assessment a skin inspection take place of the most vulnerable areas of risk, such as heels, sacrum and part of the body where sheer or friction could take place. Elbows, shoulders, back of the of the head, ears and toes are also considered to be more vulnerable areas (NICE, 2001).
Dementia is likely to have a big physical impact on the person in the later stages of the condition. They may gradually lose their ability to walk, stand or get themselves up from the chair or bed. They may also be more likely to fall. These problems can be caused by dementia loss of sight, balance problems and the environment. However, not all people will have problems with mobility.
Many people with dementia, especially in the later stages the find themselves staying in one position for a long time such as sitting in a chair, laying in bed in one position not moving around as much. This will put them at risk of pressure ulcers (bedsores). As a person’s mobility decreases they are also at risk of infections and blood clots. The person should be supported and encouraged to move around as much as they are able, for example through support to walk or chair-based exercises. An occupational therapist or physiotherapist can help with this.
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