Patient Background
Symptoms
The patient is a 78-year-old female who has a history of diabetes, obesity, bruises on her upper left and right abdominal area, and poor sleep quality because of pain and related bad dreams. Her current complaints include the dog’s bite outcomes on her right leg, which is healing as the patient feels something there, but there are no feelings and no pulses on her left leg. The right lower extremity is warm and moving, and the left lower extremity is hot with no movement but pain.
The range of motion is limited, painful, and absent in the left lower extremity, but the other three extremities are within normal limits. During the assessment, the patient is positive, calm, cooperative, alert, and oriented (person, place, time, and situation). Her husband is the main source of support, being present all the time, and they need some antimicrobial recommendations to manage her left knee prepatellar bursitis.
Medications
The patient takes several medications to achieve specific goals and manage symptoms. Tylenol, 650 mg every four hours orally, is effective in relieving leg pain. Apixaban, 2.5 mg two times daily orally, is used to prevent thromboembolic events, which are more common in diabetic patients. Atorvastatin, 40 mg at night orally, helps lower cholesterol levels and normalize fats in the blood. Ceftriaxone, 1000 mg every 24 hours intravenously, is required to treat infections and kill bacteria resulting from a dog’s bite.
Cilostazol, 100 mg two times daily orally, is necessary to prevent peripheral vascular disease complications. Clonidine, 0.1 mg three times daily orally, is prescribed to lower blood pressure and control heart rate in diabetic patients. Dextrose 50%, 12.5-25 g injection, is used to restore blood glucose levels and predict liver depletion.
In addition, Furosemide, 20 mg daily orally, is necessary to treat edema and swelling provoked by diabetes. Another diabetic complication, seizures, is prevented with Gabapentin, 600 mg every eight hours orally. Hydralazine, 10 mg injection, helps to treat diabetes-provoked hypertension. Isosorbide mononitrate, 30 mg daily orally, is prescribed to predict chest pain risks in obese people with diabetes.
Finally, Insulin injections of 0-6 units four times a day and 12 units two times a day (regular) are obligatory to manage diabetes and relieve symptoms. The patient reports that she is allergic to Codeine and Meperidine. No other surgical interventions except her diabetic therapy are mentioned.
Vital Signs
The patient’s vitals are 5’2” (height), 178 pounds (weight), with a BMI of 32.6 (obesity). The HEENT assessment is within normal limits, the chest and lungs are clear, without abnormal sounds, and capillary refill is normal (2 seconds). Active bowel sounds and regular radial pulses (2+) are reported. A Doppler is applied to detect the pulse and blood flow in the patient’s legs. No flow, no clot, and no pulses are on the left leg (totally occluded).
Appropriate Geriatric Patient-Specific Tools and Rationales
The Braden Scale
Two specific tools were used to complete the current assessment: the Braden Scale for Predicting Pressure Sore Risk and the Geriatric Depression Scale (GDS, short form). The Braden Scale was developed at the end of the 1980s to assess the risks of pressure injuries in six areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear (Ayello, 2017). Its essence is to talk to the patient and obtain information about potential risks (summing up the items and clarifying if there are health problems). The scale ranges from 6 to 23: 15-18 (insignificant risk), 13-14 (moderate risk), 10-12 (high risk), and less than 9 points (very serious risk) (Ayello, 2017).
Physicians ask patients six questions and offer 3-4 options for answers. If patients can read and make notes at the moment of assessment, they take the test independently with supervision if necessary. The Braden Scale becomes a part of a comprehensive assessment to identify the patient’s relevant risks and decide on significant preventive interventions, with special attention to chronic diseases and recent traumas.
The Geriatric Depression Scale
When depression is recognized early, it is possible to choose an appropriate treatment plan and help the patient. A short form of GDS was developed in 1986 and is currently used for an older population assessment (Greenberg, 2012). It consists of 15 questions and takes about 5-7 minutes among physically ill older patients with short attention spans or fatigue (Greenberg, 2012). A physician explains that feelings during the last week should be addressed. “No” answers in 1, 5, 7, 11, and 13 questions and “Yes” answers in other questions deserve one point each (Greenberg, 2012).
If there are more than five points in the test, depression is suggested (Greenberg, 2012). Pressure injury risks should be properly prevented in older adults with respect to their mental health status. The GDS results play an important role in developing further treatment options for the patient.
Findings of Screening, Significance to Patient and Modification of Nursing Care
The Braden Scale
The results of the Braden Scale for the patient under analysis were 11 points, proving high risks of pressure injuries. In six areas, three (activity, mobility, and nutrition) obtained two points, two (moisture and friction/shear) got one point, and one (sensory perception) had three points. The patient was eager to cooperate and tried to answer each question properly, examining her current needs and problems. For example, the results of her sensory perceptions were the most positive, but the patient could not admit no impairment was observed; thus, slight limitations were chosen. Activity, mobility, and nutrition risks were identified as high due to severe limitations, evident inabilities, and inadequate habits.
Finally, the patient’s moisture and friction/shear assessment revealed the most serious problems because the skin was always moist, and movement assistance was constantly required. It was noticed that the patient needed some time to answer some questions as she felt helpless or hopeless to change something and prevent her health deterioration.
Taking into consideration the answers given by the client, certain pressure sore risks should be identified. First, the results mean that the patient has weight problems, making her unable to complete most regular activities, use a chair (or a wheelchair), and do significant changes independently. In addition, her skin is constantly moist, and her movements are limited, provoking friction and supervised shears. Her dietary habits are not healthy or stable because she cannot eat complete meals, and the level of proteins in her food is minimal.
Finally, the test revealed that the patient responded to all verbal commands, but sometimes, her movements were limited due to pain or discomfort related to a recent trauma. Certain disabilities can make the patient unsatisfied with her life or current health status. Thus, the decision to take the GSD was made to identify if there were other psychological or emotional risks.
The Geriatric Depression Scale
The GSD was also helpful in examining the patient’s feelings and attitudes toward her current health problems. Although it was impossible to complete the whole test (two questions remained unanswered because of time limitations), the first 12 answers proved her concerns about her health and overall well-being. The current score was 5 points, meaning mild depression symptoms had to be addressed. There were concerns that something bad could happen because of her health. Sometimes, the patients felt worthless and helpless or lacked energy, preferring to stay home. All these results could be explained by her diabetes complications, weight challenges, and age-related fears. However, her husband and constant family support made her life complete and happy, underlying the need for effective treatment and preventing pressure score risks and other health complications.
The current screening results show that the patient has serious problems with her lower extremities because her left leg has no motion, pulse, or flow and causes pain when moving. Animal bites are commonly reported causes of external trauma in diabetic patients and peripheral neuropathy when nerves are damaged and provoke pain, weakness, and frequent urination (Abu-Qamar et al., 2022). Infection-related complications, obesity, diabetes, and age-based depression are additional elements to be indicated for modifying nursing care and healing. The patient needs dietary improvements to predict pressure injuries and manage diabetes. The nurse needs to assist in improving the range of motion because the patient cannot make significant changes independently. Communication and education are also necessary as the patient is cooperative and positive to recovery and following medical and healthcare recommendations.
Geriatric Tools’ Value
The validity of the chosen geriatric tools is relatively high. The GDS has 92% sensitivity and 89% specificity in relation to depression diagnostic criteria among older adults, but this test cannot assess suicidality risks (Greenberg, 2012). The Braden Scale’s sensitivity rate is 83-100%, and its specificity is 64-90% to examine pressure injury risks among older populations (Ayello, 2017).
Attention to patients’ physical and emotional states allows healthcare professionals to identify current risks and choose interventions that can improve well-being and predict pressure sore-related complications. Communication with the patient helps cover a large portion of her activities and clarify why some tasks may be performed independently, while additional help with turning and changing positions is required. In both tests, the results prove that specific physical and emotional care should be offered to the patient immediately.
References
Abu‐Qamar, M. E. Z., Kemp, V., & Whitehead, L. (2022). The reported external traumas among people with diabetes‐related foot ulcers and their outcomes: A systematic review of case reports. International Wound Journal, 19(6), 1370-1388. Web.
Ayello, E. A. (2017). Predicting pressure injury risk. General Assessment Series: Try This, 5. Web.
Greenberg, S. A. (2012). The geriatric depression scale (GDS). General Assessment Series: Try This, 4. Web.