Care of the Confused Client
By Katherine Mahon
The client named William, not his real name for purposes of confidentiality, is 64 and has suffered an acquired brain injury (ABI). An ABI is damage to the brain that was not present at birth and is non-progressive (The Rehab Group, 2014). William has suffered a diffuse axonal injury from a severe head trauma, as a result from a road traffic accident. This is where the axons in the brain were sheared thus damaging parts of the brain. The effects of the ABI on William are that he will require long term rehabilitation, and will reside in a specialised centre for survivors of ABI’s. His multidisciplinary team (MDT), a group of highly trained healthcare professionals that specialise in different disciplines, have assessed William so that a care plan could be developed to provide William with the best care for his individual needs, thus ensuring quality effective practical care to William. The Logan, Roper Tierney model of assessment of nursing care needs was important to determine Williams physical, intellectual, emotional and social needs (Student Manual, 2014). The MUST tool (malnutrition universal screening tool) can be used to check for malnutrition and create a diet plan (BAPEN, 2015).
The MDT meet on a regular basis to discuss Williams progress and make sure his care plan provides him with the best possible chance to maximise his abilities. The impact of ABI in his daily activities are, difficulty with cognitive thought process, memory loss and concentration- causing him confusion. It affects his speech and language, mobility – he has paralysis of the left side of his body. He suffers with dysphagia (difficulty in swallowing) so is on a specialised meal plan. It has affected his personality, where his behaviour can change very quickly in his understanding of situations. His sights visual field has been narrowed, also known as tunnel vision. He requires a healthcare assistant (HCA) at all times to support him in his daily activities.
Maintaining a safe environment for William is crucial in the prevention of accidents or falls. All areas of the building are kept clear, floors, tables (unless in use by another client), spills are cleaned up immediately to prevent slips. He can have epileptic seizures so his bed has padded side rails which are used during the night to prevent him falling should he have a seizure. The bathroom is kept tidy and dry and has railings on the walls to provide him with support whilst moving to the shower chair. Fire safety systems are in place, these are checked as per the Safety, Health and Welfare at Work Act 2005.
William enjoys activities that are quiet in nature most of the time, he is offered any number of activities to partake in, such as looking at books, pictures, magazines- particularly the farmers’ journal. He enjoys group activities that include painting and crafts- of a large nature, making items from clay with assistance from the HCA, he will be smiling for the duration and enjoys these group interactions. Client centered therapies for example, stimulation orientation therapy- such as playing Williams favourite music which happens to be country and western or offering him a country and western movie to watch, are used in support of his daily routine (Work placement, 2014).
To reduce and assess William’s risk of falling, the Morse Fall Scale was used. William uses a walking frame and wheelchair to aid movement and with the correct footwear, with rubber sole to afford grip. Pressure sores are injuries to the skin and can become dangerously infected should they not be taken care of quickly and efficiently, however, pressure sores should never occur and are completely preventable (Tutor notes, 2014) They occur where a person has been lying on a particular area in the same position for a long period of time. The skin area can become red raw, the skin becomes shiny and begins to tear and infection can enter the sore. A good time to check for sores are whilst assisting a client bathing, reporting any skin irritations to the nurse immediately.
As William has an ABI the HCA must take the time to communicate with him respectfully offering him choices and promoting his independence as far as possible, verbal communication is a means to obtain information from William. It is important for the HCA to be able to communicate effectively in both writing, such as updating charts and verbally in order to be able to provide accurate and important information to all members of the healthcare team. HCA’s are the persons working closest with William it is important that changes, for example in behaviour are reported accurately, verbally and if necessary in writing to the CNM. This ensures continuity of care and for daily planning within the team.
William is assisted with all activities of daily living, however, he is encouraged to try himself where he can. When bathing he prefers to clean particular areas himself and allows assistance from the HCA where he cannot reach himself. He needs assistance with dressing for example putting on clothing as he cannot complete this with the use of one hand. William is incontinent and requires assistance with personal care such as changing incontinence pads. Eating can be very challenging for William due to dysphagia, needing to take his time with the food (which is always soft and/or liquidised and all fluids will be thickened) and taken in, in small amounts, which he finds at times, frustrating as he would like larger amounts.
The European Charter of Patients’ Rights, a major piece of legislation (Student Manual, 2014), which legislates in the rights of patients, respect, dignity, independence, choice and positive self-image, must be promoted at all times to the highest quality and to the best of the HCA’s ability. The HCA should be mindful and can promote these by knocking on Williams door, closing it to provide privacy and dignity, gaining consent to assist in tasks and offering him choice in every activity of his daily living, encouraging William at all times should be at the forefront of the HCA’s mind.