Lucille Mckenzie Case Summary

Lucille Mckenzie, a 72 year old female accompanied by her stepdaughter/ sole carer Marjorie Wilson was admitted to the ward on the 17th January via Accident and Emergency (A&E), following a fall at home. X-rays revealed healing fractures of several ribs and arthritic changes, but no bony injury of her right hip.
Presenting features included, a recent history of unexplained falls spanning over 9 months, mild confusion, a productive cough with yellow sputum, dyspnoea, indigestion and acute urinary incontinence over the last 3 days. Abnormal observations included an increased respiration rate of 24 per minute and mild pyrexia of 37.8 degrees Celsius (Kozier et al., 2008). A Modified Early Warning Score was charted as 2 and hourly observations scheduled. I n addition lying and standing blood pressure were taken as postural hypotension is an intrinsic risk factor for falls (DOH 2001).
Baseline urinalysis confirmed the presence of Leukocytes, protein and keotones, which could indicate possible infection, dehydration or malnutrition. Nazarko (2009) believes Urinary tract infections (UTI’s) may be a transient cause of incontinence and confusion additionally, yellow sputum could indicate infection. A
midstream urine sample (MSU) and sputum sample were sent for microbiological culture and antibiotic sensitivities’ NICE (2006a). The results were discussed with the doctor and appropriate treatment started. As multiple aetiologies can cause confusion a blood sugar was taken to exclude hypoglycaemia (NICE 2010). To prevent further falls and injury to patient or staff, a falls and manual handling risk assessment were completed within 6 hours of admission.
This assignment will discuss Lucille’s holistic care through to discharge based on best practice, including critical analysis of a continence assessment tool. Lucille Mckenzie is a pseudonym, therefore confidentiality is maintained in accordance with the NMC (2008). In particular I will be focussing on Lucille’s continence.
On admission Lucille was placed in a hi/low bed due to her acute confusion and fear of falling without bed rails. MHRA (2007) found that older adults with confusion have a greater risk of entrapment in bed rails. In contradiction Healey et al., (2008) argues that bedrails do not result in an inherent risk of fatal entrapment. The latter uses weak evidence, meeting only 4 out of 10 quality criteria with no randomised controlled trials.
As light problems can affect balance, mobility, and as incontinence is an intrinsic risk factor for falls Lucille was placed in a well lit single sex bay, near to the nurses’ station and the toilet to promote continence, facilitate mobility, observation, and dignity (RCP 2009), (DOH 2001). Dignity is promoted when individuals are enabled to do the best within their capabilities and is an important aspect of spiritual care (Moore 2010).
In order to build rapport and trust and set the foundation for the relationship, the author introduced herself to both Lucille and Marjorie on arrival and explained that she would be responsible for Lucille’s care.(Kennedy-Sheldon 2009).
Lucille was orientated to the ward ensuring that she knew the location of the toilet. The call bell, walking aid and a jug of water were placed within reach. To reduce confusion an orientation to the ward care plan was implemented which included 24 hour reality orientation. This ensured staff introduced, re-orientated and reminded Lucille of the date and time with the aid of a clock at each visit (NICE 2010). To promote comfort Lucille was offered the services of the hospital chaplain. Marjorie was asked to retrieve Lucille’s spare glasses and items which Lucille had requested.
Hampton (2005) argues that pressure damage may occur from 30 minutes to 2 hours in the vulnerable patient. Lucille was assessed for risk using the Waterlow score and combined with clinical judgement pressure relieving equipment was ordered for both her bed and chair (NICE 2005a). A skin inspection and turns chart were implemented as recommended by NICE (2005b). Despite this recommendation, there is no guidance on frequency of turns therefore Lucille was advised to change position hourly and re-evaluated daily. In contrast Moore, and Cowman (2010) argue that little evidence exists that repositioning affects healing of pressure ulcers.
Nurse’s have a legal and ethical principle to obtain consent for treatment or for information to be shared with different agencies (DOH 2009). Consent was therefore obtained from Lucille before any treatment or referral and a chaperone was offered during any physical examination (RCN 2006). Curtains were drawn to maintain privacy and hand washing was completed before and after patient contact.
The NHS Trust’s (name withheld, 2009) Urinary Continence Assessment Pathway for use in Hospitals was utilised to assess Lucille’s continence (Appendix 1). The tool was chosen as it forms part of a Continence Care Pathway and aims to promote continence instead of employing containment measures.
Winder (2001) argues there is no single validated continence assessment tool therefore methods of assessment across secondary care differ and are sometimes missed. The Royal College of Physicians ( 2006) audit reinforces these findings. Only half of older incontinent patients had a history and specialist continence assessment , 58 per cent were not actively treated
Essence of Care (DOH 2010) clearly states that “assessment tools should be evidence-based”. Why then, 10 years after Good Practice in Continence services (2000) was published is there no nationally validated tool to ensure all trusts are providing the same level of care?.. The development of continence care pathways however is a step forward.
Chamang (2010) argues an assessment tool should be quick and easy to use however Nazarko (2008) disagrees and believes a continence assessment needs to be more focussed.
The tool I have chosen is lengthy but thorough and includes a symptom profile with facilitates which care pathway to use. It involves a physical and external vaginal examination to help rule out retention, abdominal mass and oestrogen deficiency, this is not evident in the assessment tool itself but is explained in the care pathway. It also helps identify any fluid restriction the patient has placed upon themselves. This was evident in Lucille due to cracked lips, increased pulse and dry mucus membranes. Particularly advantageous is the use of a bladder scanner to measure post void
residual.
Disadvantages include a bothersome score which is the tools attempt at assessing quality of life (QOL). UI is consistently associated with adverse effects on QOL such as social isolation, psychiatric illness and impact on sexual relationships (Hope 2007). A bothersome score between 1-4 does not give enough insight. NICE (2006a) recommend using a validated QOL assessment tool
By using the tool there appear to be three likely reasons why Lucille has become incontinent. A UTI, mixed UI or outflow obstruction due to possible constipation. If microbiology reports no UTI then NICE (2006a) recommend that treatment be given to the predominant symptom. As patient centred communication encourages patients to be part of the decision making process, a care plan was discussed and agreed with Lucille and the urge incontinence care pathway implemented (McCabe 2004).
Nazarko (2007), argues that side effects of some medications may contribute to UI. This wasn’t relevant in Lucille’s case. A combination of Ibuprofen and Aspirin can increase gastrointestinal disturbances, possibly causing her indigestion (BNF 2010). Lucille’s pain was not managed by this combination and contributed to reduced mobility, adding to her functional incontinence so was referred to the doctor.
A bladder diary was completed for 72 hours as recommended by NICE (2006a). This enabled staff to identify patterns, types and restriction of fluids, engaging Lucile to overcome her symptoms. Additionally a urinary elimination care plan was individualised with prompted voiding which determined the length between voids to implement bladder retraining. NICE (2006) and SIGN (2004) guidelines recommend the use of bladder training as an intervention to improve urge incontinence symptoms. However Wallace et al., (2009) believes there is little rigorous evidence to support this and more research was needed on the subject matter.
Dehydration can exacerbate incontinence by irritating the bladder. Additionally ageing results in an impaired thirst mechanism. Lucille is at increased risk therefore a fluid balance chart was introduced. Clear fluids were encouraged little but often and monitored whilst drinking to ensure accuracy of the chart. Urine output was subsequently weighed when possible (NICE 2006b). Advice was given on limiting caffeine and fizzy drinks. Caffeine is a diuretic and may cause increased urgency and frequency. A recommended intake of at least 2 litres was implemented ensuring adequate hydration and to prevent UTI. (Smeltzer et al., 2009). Cranberry extract was also recommended to Lucille as Jepson and Craig (2008) found it can significantly reduce recurrent UTI’s.
Welch (2008) believes that malnutrition can lead to loss of water and electrolyte balance leading to a reduction in muscle bulk. Lucille was screened for malnutrition using the malnutrition Universal Screening Tool (MUST). Both a food diary and red tray were implemented to ensure that she received structure and supervision throughout meals.(BGS 2009).. Additionally she received a “Don’t go hungry in hospital” leaflet which is part of a pack recommended by Age Concern (2007). Written information reinforces teaching and gives a resource to refer to at home (Peate 2010). Due to the presence of keotones in her urine and a low haemoglobin level, indicating possible anaemia Lucille was referred to a dietician for nutritional plan.
Lucille was advised to lose weight as it may reduce the intrinsic pressure on the bladder and improve her UI and mobility therefore improving her falls risk (NICE 2004). Additionally increased mobility can lead to more frequent opening of bowels. (De-Schryver et al, 2005) A bowel elimination care plan was implemented as Lucille could not distinguish when she had last opened her bowels. Although Lucille didn’t have constipation as assessed by the Bristol stool chart the importance of good bowel management such as increasing fibre slowly to prevent obstruction and faecal impaction, straining and its effects on the pelvic floor were discussed (Pellat 2007). Lucille exhibited possible signs of neglect which included several unexplained bruises/abrasions to her body, healing fractures of several ribs, and an unkempt state.. A Grade 1 pressure ulcer was observed on her sacrum. All injuries were marked on a body map and reported to health and social care within 12 hours in accordance with the NHS Trusts (Name withheld 2005 ) Safeguarding Vulnerable Adults Policy.
Patient education should include risk factors and basics of skin assessment therefore Lucille and Marjorie were advised on how to inspect the skin and vulnerable pressure areas (Wilson and Logan 2005) General hygiene was re-enforced. A common cause of UTI’s is the transfer of bacteria from the anus to the vagina. (Nazarko 2009) Voegeli (2010) argues that Ammonia produced by urea in urine causes the skin to break down and result in incontinence dermatitis therefore Cavilon was applied to ensure a protective barrier between the skin and the irritant cause (Doughty 2006). .Lucille was given an opportunity to shower and get changed into a clean set of clothes.
As planning for discharge should start on admission to reduce delay Lucille was referred to social services for a package of care to be implemented before going home (DOH 2004). This included recommendations that Lucille required carers during the day to help with her hygiene needs. Meals on wheels were recommended to assist the dieticians attempt to promote better nutrition. In addition social services may be able to take some of the pressure from Marjorie as respite care could be offered. Lucille was also referred to an Occupational Therapist who would be able to do a home assessment and arrange for suitable equipment such as grab rails to ensure smooth transition to the toilet or a commode if access to the toilet was too difficult (Supyk and Vickermann 2004).
A referral to the district nurse was made to ensure continuity of care with recommendations to see a specialist continence advisor if no improvement was seen (DOH 2010). Lucille was also referred to a Physiotherapist who could provide strength and balance training to improve her mobility, assess for correct walking aids and therefore reduce her functional incontinence (NICE 2004). Regular exercise is known to improve mood, wellbeing and improve mobility. In order to facilitate smooth discharge a multi disciplinary team (MDT) meeting was held to ensure all patient goals were met. (Evanoff et al., 2005)
Continence needs to be promoted and not contained, this can only be achieved, through holistic care using best evidence with MDT members to ensure patient goals are met.