This clinical integration assignment deals with the case of Mrs. Janet McKay, an 86 year old women living in the sunset residential aged care center. She underwent a hip replacement surgery after a fall and she has been diagnosed of Dementia and Alzheimer’s. She showed signs of forgetfulness and a recent episode of injury to her right lower leg. The patient is however strong willed and emotionally resilient and strong. The purpose of this report is develop a care plan for her using the clinical reasoning cycle where condition of the patient would be assessed, followed by the collection of vital clinical information, processing the information to identify key problems or issues faced by her. Such information would be used to develop a care goal and implement an action plan, outlining the interventions and their rationale. The outcome of each intervention would be assessed and reflection would be made on the key learning outcomes from the process (Dalton et al., 2015).
Considering patient situation
Mrs. Janet McKay (86) had hip replacement surgery after her episodes of fall and time in the rehabilitation ward and hence, her movement is confined to wheelchair. However, due to this she has become intermittently incontinent as she is unable to reach to the toilet most of the times. Further, she also had several injuries due to bumps because of her wheelie walker and has a large tear on her right lower leg. Further while assessing her medical condition, it was observed that she has mild Alzheimer’s and vascular dementia and all these conditions are in slow progression. Further, it should also be noted that she is very opinionated that made her involved in several rounds of arguments with the healthcare staff of the aged care center. These are the patient condition, within which, specific conditions require healthcare interventions directed to it (T O’Brien & Thomas, 2015).
Collection of cues and information
Patient had a hip replacement surgery; diagnosed with dementia and Alzheimer’s; facing intermittent incontinence problems; she incurred an injury to her lower right leg; she is an independent woman with strong opinions and often refuses to take help.
Processing information
Her restricted mobility and gait is caused due to vascular dementia and Alzheimer’s, which secondarily leads to incontinence problems and causes her to forger her walker. This also increases her risks for further fall related injuries such as the skin tear on her right leg (T O’Brien & Thomas, 2015).
Identify problems and issues
The main problems and issues that can be identified for the patient, in order to develop a care plan for her includes care for Dementia and Alzheimer’s (which might be affecting her memory and cognitive processing), problems with mobility and gait (which has increased her risks of accidental injuries while movement) and urinary incontinence issues (which is also due to her limited mobility). These problems can affect the quality of life of the patient, and therefore adversely affect her mental and physical wellbeing. The care goals therefore needs to address these selected problems (Sharma et al., 2018)
Care goals:
The care goal priorities that needs to be considered for the patient in the given scenarios includes: a) Supporting her in cognitive and decision making process, memory, b) Improving her mobility and gait in order to avoid accidental injuries while moving, c) Helping her to overcome incontinence problems (Religa et al., 2015)
Objective 1:
Supporting her cognitive and decision making process and memory. Patient will be able to demonstrate the ability to navigate through her environment without getting any injuries. Patient will be able to participate in activities that can improve her functional levels (Snyder et al., 2015).
Diagnosis:
Impairment in the decision making process and memory due to vascular dementia and Alzheimer’s shown by altered memory and impractical decisions (Snyder et al., 2015).
Interventions:
The interventions that can be suggested for the patient includes: assessment of how the patient is able to meet her basic necessities; observing her appearance for proper dressing, problems with her gait and balance, movement and for injuries; assessment of her cognitive performance, memory and spatial orientation; developing a therapeutic relation with the patient through frank and supportive approach while helping the patient; develop a routine that can schedule her activities in order to maximize her independence; using notes and stickers to aid the memory; assessing the environment for any hazards; ensuring the environment has proper lighting; assessing the ability of the patient to conduct her ADL, and assisting her when needed; monitoring intake of food and fluids and frequently checking the weight of the patient.
Rationale:
It is important to understand if the patient is facing any challenges following her daily routine and to analyze the level of support she needs. This intervention is important because patients with cognitive dysfunction can often show changes in appearance, with improper dressing that can increase their risks of tripping and falling. Assessing whether the patient is able to successfully complete tasks can help to understand the extent of cognitive support needed by the patient and indicate proper functioning of her cognitive faculties. Therapeutic relation can help to communicate with the patient and improve her comfort level to take assistance with her daily activities. Developing a routine or a schedule can help the patient remember and follow them on time and help her to be more independent thereby improving her sense of independence and wellbeing. Sticky notes, stickers can help the patient to remember important things and therefore aid her memory and prevent forgetfulness. It is also important the environment of the patient is properly assessed to identify any hazards of tripping such as loose rugs, obstructing furniture and staircases. Improving the lighting of the place can also help the visibility and help her to navigate around the house in a better way preventing risks of injury. Limited mobility can also affect the ability of the patient to conduct her ADL, which can reduce her quality of life, and thus it should be assessed whether she is able to properly conduct her ADL. The patient’s condition can also affect her ability to take food and fluids on time, which needs to be monitored to ensure she is eating and drinking properly and on time. Dementia patients also has a risk of suffering from malnourishment due to forgetting to eat on time, therefore her weight should be measured from time to time to assess if the is losing weight (T O’Brien & Thomas, 2015).
Evaluation:
Patient is able to conduct her basic functions, she is able to dress herself properly and shows functional gait and balance, her cognitive functions are normal and she is able to remember things using the memory aids. She is comfortable communicating with the nurse and asks for help if she needs it. She is able to follow the schedules and routines set for her on her own. Her environment is free from falling hazards and proper lighting is installed to prevent injuries. She is able to conduct her ADL’s. Her intake of fluids and food is on time and is adequate, and she is not losing weight.
Objective 2:
Improving her mobility and gait
Diagnosis:
Vascular dementia and Alzheimer’s can cause restricted mobility and improper gait, which can increase the risks of falling and injuries (Tolea et al., 2016).
Intervention:
Checking functional level of mobility; evaluating the ability to perform ADL; assessment of mobility impediment; evaluate the need for assisted devices; involve exercise routines to improve gait and mobility such as tai-chi, qi-gong and free hand exercises (Tolea et al., 2016).
Rationale:
Checking her functional level and mobility can help to understand the extent to which her mobility is affected by her condition. This can also help to understand the extent to which her ability to perform ADL is affected. Assisted devices might be needed if the patient is significantly affected by the limited mobility and improper gait or balance. Exercise routines are important since it can help to regain certain level of functionality, improve her mobility and gait and counter the adverse effects of vascular dementia and Alzheimer’s (Tolea et al., 2016).
Evaluation:
Patient is unable to walk properly on her own, which is affecting her ability to perform ADL (such as walking up to the bathroom). He needs assisted devises such as walking stick and wheelchair, as well as modifications in the bathroom fittings. She is able to follow the exercise routines, which has helped to improve her mobility and gait to some degree.
Objective 3:
Helping the patient with her incontinence issues, voiding the bladder on time and educate on strategies to prevent incontinence issues.
Diagnosis:
Due to her restricted mobility, she is unable to reach the toilet on time, leading to incontinence problems and untimely emptying of the bladder (Sanses et al., 2017).
Intervention:
Maintaining a voiding diary by the patient to register the time she usually goes to the bathroom and following a voiding routine that is developed based on the voiding diary. Not waiting until she feels the urge to go to the bathroom. Avoiding caffeine and emptying the bladder before going to sleep (Sanses et al., 2017).
Rationale:
A voiding diary can help to understand her voiding patterns, which can be used to develop a voiding routine that can be followed by the patient. Also the patient should be educated on strategies to avoid incontinence problems such as not waiting until she feels the urge to empty the bladder and instead going to the toilet according to the schedule. Emptying the bladder before going to sleep can help to prevent the urge to void mid-sleep and avoiding caffeine can help to ensure better sleep (Sanses et al., 2017).
Evaluation:
The patient is able to maintain a voiding daily and follow the voiding schedule and she no longer faces incontinence problems. She also voids before going to sleep and does not drink coffee before bed time.
From the outcomes I was able to learn that the problems of gait and incontinence were caused due to her limited mobility caused due to vascular dementia and Alzheimer’s. Her slowly progressing dementia also caused memory problems which was affecting her quality of life. Working with her I was able to realize the inter relatedness of her physiological conditions which led to her limited mobility, memory problems and the risks of injury. It was therefore important to address all the three issues of cognitive dysfunction and memory, mobility and gait problems and incontinence problems which are affecting her ADL.
Conclusion:
Vascular Dementia and Alzheimer’s are neurodegenerative disorders that can affect the patient in various ways, creating several difficulties and hazards for the patient. I was able to learn that due to her condition her risks of falling increased greatly. She underwent a hip replacement surgery following a fall, and also have shown signs of injury on her lower right leg, which can be related to her limited mobility. She was also unable to reach toilet on time leading to incontinence problems. Following the care plan that focused on helping the patient on the three identified care goals helped the patient to improve her quality of life and she was able to live more independently. It can therefore be suggested that patients suffering from neurodegenerative disorders be thoroughly assessed for such risks in order to identify them more effectively and address such risks in the care plan. Using the clinical reflective cycle was vital to achieve success in her care plan.
References:
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to’flip’the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29.
Religa, D., Fereshtehnejad, S. M., Cermakova, P., Edlund, A. K., Garcia-Ptacek, S., Granqvist, N., … & Mattsson, U. B. (2015). SveDem, the Swedish Dementia Registry–a tool for improving the quality of diagnostics, treatment and care of dementia patients in clinical practice. PloS one, 10(2), e0116538.
Sanses, T. V., Kudish, B., & Guralnik, J. M. (2017). The Relationship Between Urinary Incontinence, Mobility Limitations, and Disability in Older Women. Current Geriatrics Reports, 6(2), 74-80.
Sharma, S., Mueller, C., Stewart, R., Veronese, N., Vancampfort, D., Koyanagi, A., … & Stubbs, B. (2018). Predictors of falls and fractures leading to hospitalization in people with dementia: A representative cohort study. Journal of the American Medical Directors Association.
Snyder, H. M., Corriveau, R. A., Craft, S., Faber, J. E., Greenberg, S. M., Knopman, D., … & Schneider, J. A. (2015). Vascular contributions to cognitive impairment and dementia including Alzheimer’s disease. Alzheimer’s & Dementia, 11(6), 710-717.
T O’Brien, J., & Thomas, A. (2015). Vascular dementia. The Lancet, 386(10004), 1698-1706.
Tolea, M. I., Morris, J. C., & Galvin, J. E. (2016). Trajectory of mobility decline by type of dementia. Alzheimer disease and associated disorders, 30(1), 60
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