Eating and drinking
Elimination
Washing and dressing
Controlling temperature
Mobilisation
Working and playing
Expressing sexuality
Sleeping
Death and dying.
These twelve activities of daily living often served as a useful structure for patient or service user assessment and resultant care planning, usually within a hospital setting. However, mental health, neurological issues such as epilepsy, emotional care and spiritual care appeared to be missing from this particular care model and any holistic health care assessment and resultant care and support package must take these elements into account. As Thomas is likely to experience and express a need for a high level of support in virtually all areas of his life, this model of assessment and support will be utilised.
The role of the nurse
Within this current context, the first role of the nurse, nursing student and HCA is to reassure Thomas, who is likely to be anxious if not downright scared. Do not forget that Thomas is likely to be in pain and confused as he is in an unfamiliar environment and among people that he does not know. All of these are likely to increase his anxiety levels.
Their second priority is to assess holistically Thomas’s needs with a ‘strengths and needs’ model, using the framework suggested by the twelve activities of daily living. Parts of this assessment may be relatively straightforward to complete and record, whilst other aspects may be less so. Do not forget to involve Thomas, any care staff from his care home and his family (if appropriate) in this assessment as much as possible, as not only will much useful information be gathered this way but it is also good practice. After all, if you (the reader) were a hospital patient, would you like your own care needs assessed and planned for without your involvement? Ideally, any care assessment and resultant care planning should be done on a multi-disciplinary basis, and this must include the views of the patient. Check and use any ‘hospital pass-book’ that may accompany Thomas, as this is likely to contain much useful information about Thomas’s likes, dislikes and needs as well as how his needs are usually met. Any resultant care plans must likewise be holistic and incorporate Thomas’s views, likes and dislikes.
Maintaining a safe environment
Thomas, along with everyone else, needs a safe environment in which to live. Maintaining a safe environment for Thomas is likely to include many of the following:
Does Thomas have a history of falls, epilepsy or ear infections that may affect his balance?
Does Thomas have any known allergies that could impact upon the care and support that he receives whilst in the hospital?
Does Thomas require any specific manual handling equipment and if so, is this equipment such as hoists and slings regularly serviced and maintained?
Does Thomas require mobility assistance, such as wheelchairs?
Does Thomas require assistance to maintain healthy skin and prevent the occurrence of skin tissue breakdown such as pressure sores and ulcers?
Does Thomas require any specific ‘feeding equipment’ such as percutaneous endoscopic gastrostomy (PEG) equipment in order to maintain optimum nutrition and if so, is this feeding equipment regularly cleaned, serviced and maintained?
Are nursing and other care staff adequately and appropriately trained to use any equipment that Thomas needs to maintain optimum health?
Is Thomas’s immediate environment free from unacceptable and inappropriate risks, such as clutter?
Communication
Thomas has very little verbal communication skill and is limited to grunts, groans, cries and the occasional scream. Thomas communicates through facial expression, body language, basic Makaton and the occasional ‘verbalisation’. Makaton is a sign language that was derived from British Sign Language and is used with and by people with a learning disability and, more recently, those with Alzheimer’s dementia. Makaton is a language programme using signs and symbols to help people to communicate. It is designed to support spoken language and the signs and symbols are used with speech, in spoken word order (Makaton Charity, 2014).
Thomas has a variety of communication problems and needs (Griffiths and Doyle, 2009). These include making himself understood, understanding others, and having to rely on others to interpret what he is trying to say.
It is imperative that, at least initially, Sally take her cue from the care home staff that have accompanied Thomas. Once Sally gets to know Thomas, she should build upon her observations of Thomas and the way that he communicates with his care home staff and initiate conversations with him. Never forget, communication is a basic human right.
Breathing
As Thomas has had a heart attack, the quality and quantity of his respiration may be affected. This must be monitored and appropriate support offered. Thomas’s posture may also impact negatively upon his ability to breathe properly. Therefore, the input of a physiotherapist or occupational therapist may be required to ensure that Thomas is sitting or lying correctly and that his posture is not impeding his ability to breathe.
Eating and drinking
Thomas, like many other people with a PMLD, experiences dysphagia (difficulty in swallowing) and requires all of his food and drink to be the consistency of a ‘thickish’ paste. This involves having his meals puréed and his drinks thickened with a proprietary thickener such as ‘Thick & Easy’. It must never be forgotten, however, that the consumption of food and drink is not just a mechanical or bio-physical process as it involves the physical, emotional and psychological sensations of taste and touch, as well as incorporating socio-cultural and memory elements. Having a PMLD must not preclude Thomas from engaging in eating and drinking as social and cultural activities and experiences.
In order to maintain optimum nutritional levels and balance and for the optimum administration of medicines, the possibility of percutaneous endoscopic gastrostomy is being considered. For Thomas this is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient’s stomach through the abdominal wall and through which nutrition/food, drinks and medicines will be passed (PEG feeding).
Elimination
PAUSE FOR THOUGHT 3.1
“…Good morning Thomas. Oh, you’ve messed your bed again.”
I know, it’s not my fault and anyway I have had to lie in it for the last hour.
(paraphrased from Griffiths and Doyle, 2009, p. 285)
How do you think Thomas feels at being told that he has messed his bed again?
How do you think Thomas feels about not being checked, cleaned and changed before now?
Those with PMLD, like Thomas, are very likely to experience both urinary and fecal incontinence (Griffiths and Doyle, 2009). As a senior staff nurse, Sally is likely first of all to participate in the
