SITUATION
Week three on a dementia ward at a large
tertiary hospital in the UK.
TASK
Initial assessment on an 82-year-old
gentleman with a background of dementia who was initially admitted on
another ward with a diagnosis of dehydration. The patient had subsequently had
a fall with a bump to the back of the head and a laceration on the right
forearm. Although no adverse behavior was noted, the patient is transferred to
our ward, which is more specialized to dementia patients.
ACTION
I receive a hand-over from nursing staff,
who stated the patient appears unstable on his feet but determined to walk
independently with no aids. I
check the patient’s medical history, which stated the patient had been
previously independent using a stick and living at home with his wife. I noted
the falls incident report and that the last physiotherapy entry prior to the
fall had cleared stated he was back to baseline and required no further input.
The doctors on the ward have not had a chance to review the patient. I approach
the patient’s bed and check his most recent observations, which are stable.
I
introduce myself to the patient who is sitting up in bed. I begin my subjective
questioning by asking if how he is feeling and if he has had any falls
recently. The patient confirms that he has had a fall the previous evening. He
also confirms that he usually walks independently with a stick and he lives
with his wife in a two-story home. I am finding the patient coherent and
orientated so I progress with the mobility review. I check the patients sitting
balance, active range of motion (ROM) and strength. During the ROM assessment I
notice the patient appears slightly ataxic so I conduct the finger-nose and
heel-shin test. The patient displays significant past-pointing and is unable to
complete the heel-shin test due to an inability to follow the instructions. I
feel it is safe to attempt a stand so I instruct the patient to stand up. He
completes this task safely but requires support from the bed to maintain
balance. As I get him to step forward the patient becomes unsteady. I sit the
patient back down and ask if he is feeling okay. He tells me his is fine and
that he would like to check on his car. I ask where his car is and the patient
starts to become confused and agitated. He is no longer orientated to time,
person or place. He believes that his wife has just been in and he still has
the car keys. I ask if he knows where he is and the patient states that he is
in a room. I ask if he knows he is in hospital, which alarms him. The patient
stands up and begins to walk, saying that he has to leave. I manage to get a
frame from another patient’s bedside and convince him to lean forward and use
the frame as support. The patient agrees stating that he uses one at home. I
request assistance from my supervisor who is close by and we are able to
ambulate the patient with use of the frame. I ask the patient to demonstrate a
turn with the frame and return the patient to his bed. I ask the patient to
remove his shoes and return to bed. The patient removes one shoe and then
replaces it, and then lies himself diagonally across the bed. When I ask if he
could position himself in the centre on the bed he is unable to co-ordinate the
movements to complete this task. I assist the patient to the centre of the bed
and raise the bed head. I thank him for his time and update his mobility chart
to mobilize with frame and two assist. I make comment that mobility could be
variable, with the patient being impulsive and unstable.
I inform the nursing
staff that the patient is a falls risk and must not mobilize
without a frame and 2 assist. I liaise with the medical team prior to their
ward round and inform them of the patient’s mixed historical accounts, unsteady
gait and expressing a wish to leave the ward. I enter my initial assessment findings in
the integrated progress notes with a plan to gain collateral history from
family members and follow up on any new medical findings.
RESULT
The patient continues to display erratic
behavior throughout the day displaying signs of short-term memory loss, ataxia
and dyspraxia. The medical team requests a CT image of the patient’s head and a
full blood screen and urine dip.
EVALUATION
My assessment of the patient’s mobility was
effective. I knew that a fall the previous evening and the information from the nursing staff indicated another fall could occur. Having had experience on the ward with ‘variable’ patients, I
was able to adapt and guide the session without completely distressing the
patient. I was able to re-assess the patient’s mental state when I realized
that his cognitive ability had changed. Where I feel I was unclear on
reflection, was the patient presenting with new symptoms post fall, secondary
to a possible urinary tract infection (UTI) or as a complication from his
dementia. On subsequent discussions with the consultant, the differentiation is
very difficult to define clinically. The combination of the fall and a UTI
could temporarily added symptoms to his dementia, but currently the patient does
not have capacity and needs to remain on the ward. A collateral history from
caregivers would give a better insight into his current deterioration. Further
physio input may be required to help prescribe walking aids or mobility
strategies.
STRATEGIES
Being extra prepared is important on a
dementia ward. Make sure to check the surroundings, have additional mobility
aids close by and staff close by if assistance is needed. Knowing the patient's background and the multiple complications that go with dementia and the risks of anonther fall
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