Letty is an 85-year-old lady who is newly admitted to a residential aged care facility (RACF) for respite care. Letty’s husband passed away five years ago. Prior to her admission to RACF, Letty lived alone in an independent living unit which is located close to where her daughter Tina lives. Letty’s medical diagnosis include Alzheimer’s dementia (in the mild stage of cognitive impairment – MMSE: 22), type 2 diabetes mellitus, hypertension, gastro-oesophageal reflux disease (GORD), and congestive heart failure. Even with multiple chronic conditions, Letty was managing well and was independent with activities of daily living (ADLs) until she had a fall. Letty sustained a hip fracture from the fall and was in the hospital for three weeks. Letty’s mobility has significantly declined while in the hospital and she has become dependent with most of her ADLs. After discussion with Letty’s medical officer and her daughter prior to her discharge from the hospital, Letty agreed to move to RACF for respite care so she could be better supported until she regains her previous level of functioning.
Since admission to RACF, Letty has been using a 4-wheel walker when mobilising and requires assistance with bathing. Letty is still able to put on her clothes and attend to her grooming needs independently. Letty can go to the toilet on her own but requires assistance with perianal hygiene post toileting due to her limited mobility. Letty is still continent with bowels but has become incontinent with urine since her hospital admission. Letty wears a continence aid/pad (pull-up pants) during the day and night. Letty does not eat much of the food served and often says that she misses her own cooking. Letty is compliant with care and always pleasant towards staff and other residents. However, Letty does not engage in any activities and prefers to stay in her room. Letty only comes out of her room at breakfast and lunch time. Letty’s daughter has been visiting her regularly as Letty often tells her that she feels lonely and she is looking forward to being back home.
Letty’s vital observations on RACF admission include the following: T – 36.6
P – 78
RR – 18
BP – 140/85
Oxygen saturation – 98% BGL (fasting): 6.4 mmol/L Weight: 45 kg (BMI = 20)
Letty’s medications include the following: Metformin 1g BD
Lasix 20mg BD Metoprolol 12.5 mg daily Lisinopril 30 mg BD
Pantoprazole 40 mg daily Paracetamol 1g PRN
Registered nurse Anita meets Letty on her 12th day in the RACF. Letty sustained a stage 2 pressure injury on her right heel while in the hospital and has been due for wound dressing two days ago. Nursing staff reported that for the past few days, Letty has been refusing care including wound dressing. There were also times when Letty refused her medications and the medication competent assistant in nursing (AIN) decided to crush all of Letty’s medications and mixed these with fruit puree. When Anita goes to Letty’s room, Letty is asleep in her bed and her daughter Tina is with her. Tina tells Anita that she is concerned about her mum as she doesn’t seem to be her “usual” self. Tina says that Letty has been talking about seeing strange people and creatures through her window and has not been sleeping well at night. Although Letty has not been eating much since she was hospitalised, she usually has good fluid intake. However, over the past few days, Tina notices that Letty needs more prompting to drink. Tina also mentions that Letty has been refusing shower as she does not want anyone to touch her right foot (with the pressure ulcer). Tina tells Anita “She just likes to lie there (in bed), doesn’t like to get up…doesn’t even like to be repositioned…I don’t know why all of a sudden mum has changed so much”.
Anita checks Letty’s progress notes and charts. Documentation in the progress notes shows that Letty has been settling well in the RACF except for the last three days when she started refusing assistance with ADLs and wound dressing. In some instances, staff documented that Letty yelled “leave me alone” when they encouraged her to get up and have a shower. Letty’s bowel chart shows that she has not opened her bowels for the last three days. Progress notes documentation overnight indicates that Letty’s pad was mostly dry from the start of night shift and when staff changed her pad around 0600 hours, they noted a strong odour; staff further documented that Letty is to be encouraged oral fluids. Letty has not received any PRN paracetamol since admission to RACF. Letty’s pain assessment on admission using the Brief Pain Inventory did not show any complaints of pain; Letty has not had her pain assessed after this. Wound dressing was last attended five days ago; photograph shows slough in some areas of the wound bed and redness in the surrounding skin.
Recent vital observations at 0700 hours that day: T – 37.1
P – 92 bpm
RR – 22 cycles/minute BP – 150/95
Oxygen saturation – 96%
BGL (pre breakfast) – 9.0 mmol/L
If you were the registered nurse caring for Letty, outline the assessments that you will undertake and the plan of care that you will develop for Letty guided by the Clinical Reasoning Cycle.
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