The case study presents facts that must be critically considered while proceeding with the designing of an appropriate care plan. The case study mentions the client to be an eighty nine year old female who at present is residing in the Minnows Aged Care facility. Apart from her medical complications, the patient has recently been diagnosed with Alzheimer’s Dementia. Research studies show that the Dementia is a common mental illness that manifests itself with advancing age. It should further be noted in this regard that Dementia cannot be categorized as a specific physical health condition but is marked by a group of conditions. The disease condition primarily affects two major functioning areas of the brain that includes memory retention and lack of judgement (Scher & Hsu, 2013). Some of the common symptoms include, forgetfulness, limited social adjustment and thinking ability along with fragile physical health (McLaren et al., 2013). The patients often require assistance with the activities of daily living. It should also be noted in this context that the medical condition cannot be completely cured but the symptoms can be managed so as to enhance the standard of living of the elderly patients.
This paper intends to devise an appropriate nursing plan for the client. It would critically consider a number of aspects with respect to ageing in section A, so as to formulate an appropriate plan.
In order to proceed with the critical designing of an appropriate care plan, it is important to consider the past medical history of the client. Miss Alice Jones (the client) had been diagnosed with Myocardial Infarct 10 years ago. She had also been diagnosed with Hypertension 10 years ago. She has also been diagnosed with Osteoarthritis in her right knee. In addition to this, it should also be noted that, Miss Alice Jones has been diagnosed with mental health conditions that include Anxiety and Depression almost two years ago. Miss Jones has recently been diagnosed with Alzheimer’s Dementia and Urinary incontinence and ambulates with the help of a 4-wheeled frame. She has recently encountered two episodes of fall but that resulted in no injuries. She requires assistance with her activities of daily living and has lost weight. She is often found confused and wandering to other areas of the care home. She has to be redirected to her ward with assistance. Her present medication routine comprises of the following:
Prn Panadol 1grm tds
Voltaren Emulgel daily to right knee
Tramadol 50mg PRN
Atenolol 100 mg mane
Therefore on the basis of the medical history of the patient it can be predicted that the condition of the patient is worsening and the medical condition of Alzheimer’s Dementia is rapidly progressing. Also, on evaluating the cognitive score of the patient along with the DSM-V Dementia criteria, it can be said the patient is susceptible to develop severe forms of sleep apnoea, eating disorders and complete cognitive impairment. Based on the recent medical health condition, it can be said that the client already has developed mild forms of these medical conditions.
According to Bratic and Larsson (2013), ageing has been defined as a universal, continuous and a deleterious process which advances with age and cannot be voluntarily controlled. In close association with the case study, it must be mentioned that that the programmed theory of ageing can be used to explain the worsening condition of the client. According to Bractic and Larsson (2013), the programmed theory of ageing suggests that ageing is controlled by the changes in genetic expression that is governed by the biological timetable. The alterations in the genetic expression affects the ability of the body to perform functions of repair, regenerate and maintain defence responses. Research studies have suggested that advancing age leads to brain damage and deterioration in the normal functioning of the neuronal cytoskeleton (Scher & Hsu, 2013). Senescence also damages the mitochondria which further diminish the neuronal energy. In addition to this, researchers have also suggested that the impact of the external environment also determines the progression of ageing (Bratic & Larsson, 2013). Therefore, in this context, the advancing age of the client is responsible for the normal physiological functioning of her body. This can be verified through the medical history of the client which presents diagnosis of Alzheimer’s dementia and Dementia 2 years ago.
The process of ageing is primarily governed by two factors which include, genetic ageing and environmental influence. Ageing refers to perpetual deterioration of all the major organ systems of the body (Scher & Hsu, 2013). This includes weakening of the integumentary system, immune system, cardiovascular system, nervous system, respiratory system, Digestive system, Urinary system, Endocrine system and skeletal system. Ageing causes reduction in the bone density, reduction in perception ability and responsiveness to stimuli. It further affects the endocrine system and hampers the hormone synthesis mechanism (Richardson et al., 2013). Hence, it can be said that patient’s present medical condition is characterized by the deterioration of the major organ systems within the body.
Considering the present medical health condition of the client, it should be suggested that the client would be referred to primary health service providers for support and care. As the client is experiencing the rapid progression of Alzheimer’s dementia, it would be feasible to recommend a Dementia care nurse to offer assistance to the client. The rationale behind the recommendation of a Dementia care nurse would facilitate the client to remember vital information and manage activities of daily living. According to research studies, it has been mentioned that effective management of the symptoms of Dementia involve slowing the progression of the symptoms and preventing the severity of the disorder (Richardson et al., 2013). The dementia care nursing professional would offer complete assistance to the client so as to effectively help her in managing cognitive functioning and activities of daily living that would include helping the client managing toilet continence, washing, and grooming. Further, the carer would also emphasise on the psychological well-being of the subject and would instil confidence in her so as to motivate her and make her socially active.
The second primary carer who would be appointed for providing assistance to the client would include a dietician. As has already been mentioned in the case study, the client has lost appetite and invariably forgets to consume her every day diet. It has further been highlighted that the client has lost weight. Hence, in order to ensure that the client is taking a balanced diet, it is important to appoint a dietician. The dietician would ensure that the client is taking the meals at the proper time and would keep a track on the water intake of the client. In order to deal with the weakness of the body, it is exceedingly important that the client consumes proper meals at the correct timings of the day in order to gain energy and stay fit. Therefore, the rationale of referring a dietician would facilitate proper dietary intake and constant body-weight monitoring of the client so as to accelerate the recovery process.
Dementia is associated with a number of complex behaviours that are challenging for both the patient as well as the care providers. In close association with the case study, it should be clearly noted that the client presents a number of challenging behaviours that must be managed appropriately in order to avoid further worsening of the health condition. In this section, four major challenging behaviours would be outlined and along with the same, appropriate interventions would be suggested that would serve as guidelines to manage the challenging behaviour of the patient.
The first set of challenging behaviour that has been identified is the aimless wandering of the client. According to research studies, it has been mentioned that clueless wandering is a common problem witnessed in Dementia patients. In order to proceed with an effective intervention, it is essential to first identify the cause of wandering. Wandering can be an outcome of multiple reasons that include, need for food, water, toileting and exercise. The managing strategies would include, maintenance of security and companionship (Payne, 2017). Equipping the patient with alarm and bells so that the patient can ask for assistance whenever in need. Proper handing over of nursing notes at the end of the shift so as to clearly direct the next carer to assist the patient in an appropriate manner (Mioshi et al.,2013) .
The second set of challenging behaviour would include managing the aggressive behaviour of the patient. In order to develop an effective strategy to manage the problem related with anxiety, the first step would involve identifying the problem that is causing the anxiety and accordingly manipulating the environment to reduce the negative impact. Strategies such as effective communication and using the reminiscence therapy can help in managing the anxious behaviour of the client (Lima et al., 2016).
The third set of challenging behaviour would include effectively directing the patient to manage and improve urinary continence. Administration of pelvic muscle exercises in combination with the administration of antimuscarinic drug can help in improving the problem of urinary incontinence (Huang et al.,2013) .
The fourth set of challenging behaviour would include effectively managing the cognitive functioning of the client. This would be done through administration of Hormonal therapies and monitoring cognitive training (Edwards, 2015). In addition to this, the maintenance of a safe environment would help in the prevention of cognitive impairment.
The client has been reported to be non-cooperative with the healthcare professionals. It has also been mentioned that the client needs complete assistance with the activities of daily living. The client is dazzled and confused and often forgets things that she has done or either needs to do. On many occasions the client forgets taking her meals and hence, it is obvious that the minimal oral hygiene requirements of the client would remain unmet. On account of the forgetfulness the client cannot communicate appropriately with the nursing professionals and hence it can be assumed that her oral hygiene routine might be overlooked. In order to ensure that the oral hygiene is maintained on a regular basis, a helper nurse would be appointed who would brush the teeth of the client during morning and night. The carer would ensure that a soft brush is used for the brushing procedure along with a Fluoride paste. Care would be taken to make sure that there is no bacterial infection within the oral cavity and chlorhexidine would be applied to manage the bacterial infection (Drazenka et al., 2014). The client would be fed on a low sugar diet to ensure that there is no microbial flora flourishing inside the oral cavity and the mouth would be kept moist through hydration. In order to assist the client with oral hygiene the client would be made comfortable within a caring environment and treated with respect to promote healthy recovery.
The client has continuously complained to experience pain in the right knee. In order to assist the client with pain relief, the first step that would be performed would include a pain assessment. On the basis of the pain score collected after the successful pain assessment pharmacological intervention would be devised. At the same time, it would be made sure that the client is comfortable in the presence of the carer and is able to communicate effectively (Drazenka et al., 2014). Through the process of counselling, the information about the psychological status of the client would also be estimated that would help in understanding whether the sensation is physical or emotional. The personal pain might be caused on account of loneliness and isolation from the family members, separation from her sister due to her demise. The personal pain management would be done through continuous counselling.
In addition to the above mentioned therapies, devising mindfulness based therapy such as meditation and assisting music therapy can help the patient with a faster recovery. The administration of mindfulness based therapy would help in effectively taking care of the spiritual needs of the patient and at the same time facilitate composure over the pertinent anxious behaviour of the client. Further, music therapy would help the client in gaining relief from the continuous sensation of pain (Chiao,Wu &Hsiao, 2015).
Nursing Plan:
In order to effectively assist the patient with the recovery process, an appropriate nursing plan would be designed which would highlight two actual problems and the two potential problems. Along with the problems, the intervention strategies would also be highlighted in order to design an effective care plan for the client. It is expected that the client would slowly recover, however the process would extend over a considerable period of time and must be continued so as to ensure positive recovery.
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A. Two actual problems/ Issues: |
B. Two potential problems/ Issues: |
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Two actual problems that can be identified in relation to the case study would include: · Increased susceptibility to fall and related injuries die to aimless wandering: On account of the aimless wandering of the client during odd hours of the day, the patient is susceptible to accidental falls and injuries. · Intervention: In order to prevent the risks associated with accidental falls and injuries, appropriate care would be taken to monitor the whereabouts of the client and maintenance of a safe and risk free environment (Brown et al., 2016). · Increased weight-loss and deterioration of body strength: The medical reports has already revealed weight-loss of the client. · Intervention: It should be made sure that the client is properly assisted by a dietician and constant monitoring of the food and water intake of the client would help in effective maintenance of body weight. |
Two potential problems that can be identified in relation to the case study would include: · Exhibition of violent behaviour towards caring professionals on account of pertinent anxiety: On account of anxiety the client might be exhibiting violent expression towards the carers. · Intervention: Pertinent counselling and maintaining effective communication with the client would help in providing assurance to the client. It would also help in the maintenance of composure of behaviour. · Complete seclusion and isolation from social circle on account of depression: The case study has also mentioned that the client often looks for her deceased sister and has no family members as her immediate care providers. With the advancing age, the client is bound to feel insecure and depressed. · Intervention: Administration of spiritual therapy and inclusion in social activities can help the client feel positive (Adelman et al., 2014). |
Conclusion:
Therefore to conclude, it can be said that old-age patients placed under Dementia care are extremely vulnerable. The patients are susceptible to vulnerability both in terms of physical health deterioration as well as mental health instability. Caring for the aged patients who do not have an immediate care provider is even more challenging as it involves dealing with complex challenging behaviours. Carers must be extremely polite and sensitive towards the patients. Critical consideration of the medical history of the patients along with the proper assessment of environmental risk factors can help in devising an appropriate care plan. While devising the care plan it is also important to critically consider the preferences of the client along with the consideration of the ethnic, religious and cultural background. This is important to ensure a culturally safe intervention plan and promote positive patient outcome.
References:
Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., & Lachs, M. S. (2014). Caregiver burden: a clinical review. Jama, 311(10), 1052-1060.
Brown, K. W., Coogle, C. L., & Wegelin, J. (2016). A pilot randomized controlled trial of mindfulness-based stress reduction for caregivers of family members with dementia. Aging & mental health, 20(11), 1157-1166.
Chiao, C. Y., Wu, H. S., & Hsiao, C. Y. (2015). Caregiver burden for informal caregivers of patients with dementia: a systematic review. International nursing review, 62(3), 340-350.
Draženka, O., Domagoj, V., Ana, B., Petrana, B., & Vlado, J. (2014). Prevalence of Anxiety And Depression in Caregivers of Alzeheimers Dementia Patients. Acta Clinica Croatica, 53(1.), 17-20.
Edwards, L. W. B. (2015). A Mindfulness and Health Promotion Program to Decrease The Perception of Stress and Burnout in Psychiatric Mental Health Nurses Who Provide Driect Patient Care To Individuals in Mental Health Units With A Diagnosis of Alzheimer’s Type Dementia.
Huang, H. L., Kuo, L. M., Chen, Y. S., Liang, J., Huang, H. L., Chiu, Y. C., … & Shyu, Y. I. L. (2013). A home-based training program improves caregivers’ skills and dementia patients’ aggressive behaviors: a randomized controlled trial. The American journal of geriatric psychiatry, 21(11), 1060-1070.
Lima, S., Gago, M., Garrett, C., & Pereira, M. G. (2016). Medication adherence in Alzheimer’s disease: The mediator role of mindfulness. Archives of gerontology and geriatrics, 67, 92-97.
McLaren, A. N., LaMantia, M. A., & Callahan, C. M. (2013). Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia. Aging & mental health, 17(6), 655-666.
Mioshi, E., Foxe, D., Leslie, F., Savage, S., Hsieh, S., Miller, L., … & Piguet, O. (2013). The impact of dementia severity on caregiver burden in frontotemporal dementia and Alzheimer disease. Alzheimer Disease & Associated Disorders, 27(1), 68-73.
Payne, J. (2017). Mindfulness Based Cognitive Therapy for People with Mild Dementia and Depression: A Feasibility Pilot Randomised Controlled Trial examining changes in Quality of Life and Cognition (Doctoral dissertation, UCL (University College London)).
Richardson, T. J., Lee, S. J., Berg-Weger, M., & Grossberg, G. T. (2013). Caregiver health: health of caregivers of Alzheimer’s and other dementia patients. Current psychiatry reports, 15(7), 367.
Scher, L. M., & Hsu, D. C. (2013). The patient with delirium and dementia A in the emergency department. Behavioral Emergencies for the Emergency Physician, 117.
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