| PART B: |
| Please read the following case scenario and answer the questions below:
Mrs. Alice Wright is an eighty-two (82) years old female resident who has been living in Pines aged care facility for last three (3) years.
Past history:
Mrs Alice Wright is very well educated and worked at ABC bank for forty-five (45) years as a financial planner. Her job role was mostly to maintain check and balance of the company finances and provide strategic advice. Mrs Wright’s husband passed away thirty (30) years back post AMI and heart attack. She has been very independent throughout her life span and used to live with her only son Mark and her dog Charlie. 5 years back Mark started to observe changes in Mrs Wright’s behaviour, when she used to become very aggressive and abusive with the family/friends. Mark took her to a local GP and after the ACAS assessment, cognitive and neuropsychological tests she was referred for permanent care into residential aged care facility for the diagnosis of Alzheimer’s disease. Mrs Wright felt very isolated and depressed when she was transferred to Pines aged care facility. Her son Mark was feeling guilty of letting her mum go into aged care. It took Mrs Wright 3 weeks to settle in the facility. She resided in a dementia specific unit, to make sure her and others safety. Her dementia was getting worse, she had days when she would not participate in any activity and times when she would become verbally and physically aggressive. She had aged related hearing loss and her non-compliance with hearing aid was making the situation more challenging. She was transferred to hospital twice for physical aggression towards staff and other residents and was diagnosed with UTI and BPSD (Behavioural and psychological symptoms of dementia).
Medical diagnosis:
Dermatitis (Specifically on B/L arms) for 1 year Age related hearing loss for 2 years IHD and angina 10-year back AF 10 years’ back Re-current chest infections (3 episodes in last 4 months) Alzheimer’s disease with BPSD (Diagnosed 5 years back) Osteoarthritis in B/L knees for 20 years Re-current UTIs (12 years) on SPC Hypothyroidism (45 years) |
| Renal failure post renal cell carcinoma (10 years back)
Current medications:
Sorbolene lotion daily PRN Waxol for ear wax removal every 6 months GTN 25mg patch daily PRN Ventolin nebs PRN N/S nebs Oxazepam 7.5 mg BD Memantine 10 mg daily Panadol 1g BD Ural sachet once daily Levo-thyroxine 2 tabs before breakfast
Complex care needs: SPC (suprapubic catheter), Pacemaker, PRN supplementary oxygen 2L and BPSD
Current situation: You are an enrolled nurse working on a morning shift. At around 08:00 hrs you started your medication round when you pass by Mrs Wright’s room and find her distressed and crying sitting in the corner of her bathroom. On attending her, she started yelling and throwing towels and soap. You decided to maintain a distance and gave her sometime to settle, making sure to monitor her from the distance even. You saw that she removed her SPC, clothes and hearing aids in the room. Her room looked cluttered and all her personal belongings were on the floor. You saw her incontinent of urine and faeces. You informed your registered nurse on shift and certainly wanted to help her in the best possible way. | |||
| Questions to be answered by student | Satisfactory Response | ||
| Yes | No | ||
| Question 1. | How can nurses communicate with people with sensory impairment (Mrs Alice Wright’s case scenario)? | ☐ | ☐ |
| Answer: Nurses should always try to keep eye contact with her when communicating and try not to look away or cover their mouth. People with hearing loss rely on lip-reading to help them understand you. The nurse attending to her should consider using visuals such as objects and pictures. Writings would also be of great benefit in enhancing communication. The nurse should check noise and lighting in the room, turn off or move away from background noise reduces distractions to effective communication. Consequently, nurses should make sure their faces are not in shadow, and there are no strong lights so that the patient can see them clearly to facilitate lip-reading. Repeating and re-phrasing when necessary would go a long way in enhancing communication. Speaking clearly, slowly, and steadily without mumbling or shouting helps not to distort your lip pattern. | Comment: | ||
| Question 2. | What can you do as a nurse to dealing with social isolation and to socially include them? (3 points) | ☐ | ☐ |
| Answer: Social isolation can have a toll order on the patient’s wellbeing, especially mental wellbeing. As a nurse attending to this patient, I would befriend the patient. Being friendly makes the patent feel loved and valued, and it would go a long way in reducing the feeling of isolation. Greeting the patient and smiling at them as well as introducing myself would help in creating rapport with them. Involving the patient in a conversation of their choice helps keep them engaged hence reducing the feeling of neglect and isolation. I would engage the patient in activities she liked doing, such as walking, singing, art, or any other activity they used to enjoy doing. Engaging the patient in things they used to like doing can bring joy to them and may even bring back a memory or two! For instance, if they liked reading, I would take a book to the patient to read and ask for feedback on the book. I would encourage social interactions with others, especially family members and friends. This would help the patient feel loved as they can see the familiar faces of people they know. Active social life improves the physical, mental, and emotional health of an individual, especially the elderly struggling with isolation and feeling of neglect.
| Comment: | ||
| Question 3. | How will you identify and respond to challenging behaviours exhibited by Mrs Alice Wright? (3 points) | ☐ | ☐ |
| Answer: Brain damage due to dementia can cause behavioral changes which can be upsetting to the patient. Mrs. Alice has aggressiveness, both verbal and physical. I would first try to identify and try to address internal stressors such as care needs or pain and external stressors such as noise and glare. Actively listening and responding to the patient would really help calm her. I would provide activities that reduce agitation and quiet areas where the patient would retreat to, to avoid overstimulation. Mrs. Alice has disinhibited behavior. This is evidenced by fecal and urine incontinence, as well as her being naked. This could be as a result of disorientation or discomfort. I will approach the patient in a gentle, matter-of-act manner, reassure and comfort her and gently remind her that the behavior may be inappropriate. Additionally, I will provide clean clothes that are comfortable, lead her to a private place and distract her by providing something to do. The patient exhibits restlessness and anxiety, as evidenced by the disorganization of her room with her personal belongings on the floor. This exposes the patient to the risk of self-harm. I will make sure that her room is convenient for observation. However, if all non-pharmacological interventions fail, I will use pharmacological strategies such as anti-anxiety drugs and other psychotropic drugs. | Comment: | ||
| Question 4. | What health assessments need to be done for the Mrs. Wright? (3 points) | ☐ | ☐ | ||||
| Answer: Cognitive and neuropsychological tests; These tests will help to assess memory, problem-solving, language skills, and other abilities related to mental function. Mental health assessment; This would be vital to help determine if an underlying psychiatric condition could aggravating the presenting symptoms. Head to toe physical exam; This help to look out for unseen boy injuries to the patient so as appropriate intervention can be taken. It would also help assess kidney functioning by looking out for edema of the legs as the patient has a history of kidney failure . | Comment: | ||||||
| Question 5. | How you can assist Alice with self-care and ADL’s in discussion with resident and family? (2 points) | ☐ | ☐ | ||||
| Answer: I will assist her in personal hygiene, such as cleaning her and explaining to her how and when to clean. This includes teaching the patient how to use the bathroom. Repetition is key, as the patient can forget. I will as well assist in feeding her and reassuring the patient. This will help the patient feel encouraged. I will help the patient to be as independent as possible while helping her in case she does not succeed. This would make the patient feel useful and not completely dependent on others. I will involve the family in making a schedule, a routine of doing things with simple, precise instructions on what to do at a given time. | Comment: | ||||||
| Question 6. | What are the aged related pathophysiological changes to the body systems, considering the medical diagnosis, medication management and nursing interventions for Mrs Wright as discussed with family and client (case scenario)?
– Integumentary – Sensory – Cardiac – Respiratory – Neurological – Musculoskeletal – Genitourinary – Endocrine – Renal – Oncological | ☐ | ☐ | ||||
| Answer: | Comment: | ||||||
| S.No | Body System | Pathophysiological change/ Medical problem | Medication management | Nursing interventions | |||
| 1 | Integumentary | Dermatitis | Sarbolene | Using aseptic technique when applying medication on the skin lesions | |||
| 2 | Sensory | Hearing loss | Waxol for ear wax Hearing aid device | Ensuring no wax in the ears. Ensuring the device is in place. | |||
| 3 | Cardiac | Angina pectoris | G.T.N 25m.g patches daily | Monitoring blood pressure, and pain scale | |||
| 4 | Respiratory | Breathing difficulties | PRN Ventolin nebulization | Nebulizing, Monitoring breathing patterns, assessing oxygen saturation | |||
| 5 | Neurological | Memory loss | Mementine | Administer drugs. Monitor for effects | |||
| 6 | Musculoskeletal | Muscular atrophy | Physical exercise Balanced diet | Assisting in ensuring a balanced diet to the patient | |||
| 7 | Genitourinary | Urinary tract infections | Ural sachets | Drug administration. Pain assessment during urination, | |||
| 8 | Endocrine | Hyperthyroidism | Levothyroxine 2 tablets | Ensure medication is taken as per prescription. Monitor for adverse effects | |||
| 9 | Renal | Renal failure | Dialysis | Initiating and monitoring dialysis. Monitoring patient’s vital signs | |||
| 10 | Oncological | Chronc pain | Panadol | Assess pain on a scale of 1-10 Reassure patient. | |||
| Question 7. | What are the impacts of complex needs on Mrs Wright’s care including carers and family? (2 points) | ☐ | ☐ | ||||
| Answer: It is very challenging for the caregivers to be left with the burden of taking care of the patient. This can be overwhelming to the caregivers leading to burnout and compassion fatigue. There is emotional and physical strain of the caregiver while trying to remain professional at the same time. Sometimes the caregiver can get frustrated by the patient’s hostility. More often than not, the caregiver develops an emotional attachment to the patient, and it could lead to psychological disturbances to the caregiver in the unfortunate event the patient passes on. Family members are the worst affected by the condition of the patient. They have been with the patient throughout their lives when the patient was healthy. Some families can develop medical conditions such as depression due to the challenging complex needs of the relative. They tend to suffer from strong emotions of anger, guilt, grief, and distress. Both the caregivers and family members should undergo counseling from time to time to help them cope well. | Comment: | ||||||
| Question 8. | What are the signs of physical, emotional and mental distress and underlying triggers that you can observe for Alice which may cause it? (2 points) | ☐ | ☐ | ||||
| Answer: Signs of physical distress include; depression, loss of inhibitions, and self-control. The patient has incontinence, removes her clothes, and has aggressiveness as she is throwing soap and towel to the caregiver. Signs of emotional and mental distress exhibited by the patient include; crying, anger, and refusing to participate actively in any activity. This could have been triggered by the inability to communicate effectively. Nobody seems to understand what she wants hence resulting in such behavior. The patient could be feeling embarrassed or frustrated as she cannot perform even the simple tasks she used to do for herself before. She could be asserting her own wishes when the caregiver tries to make them do what they don’t want. In this case, she may not want to be disturbed as she is soiled; she wants to be alone, hence becoming hostile. | Comment: | ||||||
| Question 9. | How will you respond to challenging behaviors considering resident and others safety? (2 points) | ☐ | ☐ | ||||
| Answer: I will try and find the immediate cause or trigger of the behaviour. For instance, pain and physical discomfort can trigger aggressive behavior in a patient, in this case, the patient is in physical distress as she is soiled. Most adults with dementia cannot communicate clearly. I would approach her gently and help her out cleaning up while reassuring her. I will make sure she is alone in her room if nothing else works to calm her down. Giving he some space alone to calm and regain balance. I will make sure the environment is safe and that she is not likely to hurt herself or others. | Comment: | ||||||
| Question 10. | List some strategies to prevent and control challenging behaviours. (3 points) | ☐ | ☐ | ||||
| Answer: Playing her favourite music. Music is food to the soul and it has a calming effect on an individual. Listening to her favourite song can be therapeutic in controlling challenging behaviour. If for instance, bathing triggers challenging behaviour, putting on her favourite song would help calm her. Social interaction and stimulation; Human beings are social beings and being alienated from social interactions can lead to stress. This can make a person unhappy and isolated. I would make sure she is regularly visited and have some one-on-one interactions. Identifying something that she likes and keep repeating it key. Exercise; Physical activity and exercise help reduce agitation and anxiety, as well as improving sleep. Moreover, it helps to use up spare energy and act as distraction. It provides a chance for interaction with others and provides the caregiver with the much- needed break. | Comment: | ||
| Question 11. | Write four (4) nursing intervention for Alice that are applicable to a nursing care plan for Alice. | ☐ | ☐ |
| Answer: Enforcing with positive feedback. Give positive feedback when thinking and behaviour are deemed appropriate. This increases self-esteem and enhances the desire to repeat appropriate behaviour. Patient orientation. Frequently orienting the patient to reality and surrounding is important. Allow the patient to familiarise herself with the objects around her. This should be frequently done as the patient have memory loss due to her condition. Avoid cultivation of false ideas. The patient should be discouraged from false ideations. If it happens, divert the discussion to real people and real events. This will help in keeping the patient in touch with reality. Implement measures to promote independence but intervene when necessary. Providing assistive care can prevent injury from activities without causing frustrations to the patient. | Comment: | ||
| Question 12. | Which theory of ageing best suits Mrs Wright? | ☐ | ☐ |
| Answer: Programmed aging theory. This theory asserts that aging is genetically programmed to occur with time. Deterioration of this process eventually leads to death. Mrs. Wright case is a classic example of this theory. | Comment: | ||