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The following case study concerns one of our service user here at Thames House. The Lady whom this is about is one in her early 70’s, and has the following health issues;
The Lady came to us from Hospital; she had been admitted due to a fall down the stairs at home for a second time after one in her mid 60’s. The second fall caused a subarachnoid haemorrhage and caused her to acquire a brain injury. After the second fall she lost consciousness which led to an admission to hospital.
While in hospital recovering it was found that she could no longer feed, dress or wash herself without prompting or assistance. During her hospital stay she lost a considerable amount of weight and was at risk of dehydration. It was decided at the hospital that a PEG insertion would be in her best interest after which she regained consciousness and her strength, however was seen to be very confused and neglectful of her own personal needs; her walking gait was very poor and she again became deteriorated. It was at this point that she was diagnosed with Dementia with Lewy-bodies with a further diagnosis of Huntingtons disease not long after.
After lengthy discussions her husband decided he would not be able to cope at home with his wife’s dramatic changes in demeanour combined with a PEG regimen that his wife was not compliant in – she physically removed the PEG that was inserted numerous times whilst in hospital to which it was re inserted and again removed. Due to none compliance of a bolus feed regimen the paitient again lost a considerable amount of weight; she also became more confused as her health deteriorated due to poor nutritional and hydration intake. A PEG was again inserted whilst on ward 15 in order for her to be discharged to ourselves.
In 2013 she was admitted to Thames House. She had a PEG still and was compliant with the regimen for a number of weeks before pulling it out and needing a re-insertion, unfortunately she again pulled the newly inserted PEG out. As she would be at risk of malnutrition and of dehydration the S< team were contacted. During the S< assessment it was found that the service user did not need a PEG as she still had a good swallow reflex. This was good news!!! It meant that with support, time, lots of patience and understanding of her condition, the service user was able to eat and drink as any person in the community would. Her diet was modified and she began to gain weight, it was also found that she could feed herself independently. As the months progressed the service user became a lot stronger and more healthy as she was encouraged at all times by the staff at the home.
Due to her diet and fluid intake being oral and much improved, her mobility and skin condition improved considerably and she was able to mobilise independently around the unit as and when she pleased. She did still need assistance with eating and drinking, personal hygiene needs and dressing.
As most of the activities of daily living are carried out on behalf of a person the training received needs to be of a person centred and holistic nature. So with keeping this in mind our service user was offered a whole range of foods that were tailored to her likes and dislikes. She was also given nicely presented meals that looked appetising although they were modified. The fact that the dining room was communal and she was able to socialise with people that she lived with, having no limit as to how much time she could take over a meal and so wasn’t rushed, all aided the service user in gaining weight and remaining hydrated.
Personal hygiene and skin integrity are just two of the areas we here at Thames pride ourselves in. There are no set times as to when somebody ‘has’ to be changed or ‘has’ to be toileted. If our service user requested assistance with continence wear, staff would help her when ‘she’ requested, not when ‘they’ thought it was required. Whilst carrying out personal cares the staff are constantly observing for any changes to skin on a persons body whether minor or major. During her time here at Thames this service userr has never had a pressure ulcer and staff work very hard to maintain this.
Unfortunately over the past two years, this service users condition has deteriorated dramatically. She can no longer mobilise independently or feed herself and her swallow reflex is very poor. However, it was noticed very quickly by staff that this service user was taking longer, and longer with meals.
By December 22nd 2014 this service user again had a PEG insertion in, as this was gfelt to be in her best interest, the decision was made by her husband with support from all professionals involved in her care as well as ourselves.
Although she is mainly hydrated via PEG and a regimen for bolus feeding is in place, this service user still maintains oral intake of small tasters of food and fluid. This has proved to be very successful as her weight has increased two fold and she has an improved appetite. Since PEG insertion she is a lot brighter and a lot more alert.
With hand/ foot massages alongside passive movements of her legs, feet and arms we as a team have been able to maintain viability of these limbs and ensure that she has even a small amount of movement. This service user also has regular pressure relief so that integrity of her skin is maintained.
This service users husband visits his wife on a regular basis. Within the first week of PEG insertion he came and told us how impressed and pleased he was with how his wife looked and how much she looks like she did before the accident, as she has gained a considerable amount of weight. But as she still is able to really enjoy small amounts of fluid and diet, her husband is able to spend 1:1 time with her helping his wife(as it is something he likes to do) whilst getting enjoyment out of seeing his wife happy and contented instead of being worried about what she will look like when he comes on his next visit.
Since the insertion of PEG this service users husband comments to us and compliments us regularly on how well his wife looks as compared to past experiences and how hard we have worked to support him and his wife at all stages of the deterioration of her condition. He especially enjoys that we include her in the home activities as well as the community ones even though her dementia has progressed. We endeavour to include her in all activities even if she only wants to participate in a small part of it.