Chapelhow et al, (2005) states that when a novice nurse looks to become a competent practitioner all the following enablers are fundamental to excellent nursing care these are: assessment, communication, decision making, managing uncertainty and managing risk. For the purpose of this essay Communication and Assessment are the two enablers of care that will be used. The framework states that Communication is an essential part of the assessment and it should be person centred however we must understand that different factors can affect our ability to communicate successfully chapelhow et al, (2005). For example, the Person’s ability to communicate, how to overcome any barriers that may be present i.e. language barriers, deafness or the capacity to make meaningful decisions, the persons setting and the barriers that could affect the chain of communication including any surrounding sounds, poor lighting and resources i.e. time appropriateness, staffing levels and medication that may hinder an ability to communicate successfully. Chapelhow et al, (2005) also states that documentation is linked to communication which ensures continuity of care professional requirements and code of conduct are upheld and followed. For the purpose of this essay I have changed the details of the person I have chosen to use for my study to be in line with the NMC code (NMC, 2015) this will protect their identity and confidentiality. I have chosen to use an elderly resident I am supporting at my current placement. I’m going to call her Glenys P. Glenys P and her family have kindly agreed and consented to me using them within my study. Glenys P is a ninety three year old lady who self-admitted to her current place of residence initially for rest bite following the death of her husband she was admitted to her new home on the 14/07/1998. As Glenys felt that she was becoming a burden on her family being a very independent person she decided it was time to accept support, this was a hard decision for her to make being from a generation that had lived through the 2nd World War.
On admission to her new home Glenys had a pre-diagnosis of depression, hypertension and a history of duodenal ulcers, the latter being caused by the helicobacter pylori bacterial infection which was treated with a course of anti-biotic and a proton pump inhibitor as recommended. She has had re-occurring ulcers over the years and has used the following medicines at different periods throughout her time at her home, amoxicillin, clarithromycin and metronidazole this is due to some strains being resistant to prescribed antibiotics, Rooney et al, (2009). She has always had an issue with her blood pressure and more recently ‘duodenal ulcers’ which have impacted her mental health (depression) (Jung et al, 2013) as a result of her depression Glenys can have mood swings where one minute she is very nice and softly spoken and the next very loud, she can become very abusive and has been known to hit out with her walking aid. This is likely due to a combination of the ulcers and her diagnosis of depression the later being one of the more common mental health conditions in the elderly Fiske et al., (2009).
Glenys does have an issue with maintaining her weight usually due to her having zero appetite and is a very poor sleeper she has been proscribed temazepam 10mg, Tramadol 50mg. Co-Dydramol 50 mg to
help with the pain that can cause her sleepless nights. Roth H, (2012) A study showed that residents with mental health disorders who were prescribed psycho-active drugs before being admitted to a residential setting had not spoken to a nurse or medical professional which shows the importance of communication between residents and MDT’s (Multi-Disciplinary Teams). Holmquist et al, (2005)
Since her admission to her supported setting she has a diagnosis of vascular dementia which developed suddenly when she suffered a stroke in 2012. She received a diagnosis approximately 6 weeks later. Current literature suggests that two-thirds of patients will have cognitive impairment at 3 months post-stroke. Post-stroke cognitive impairment is associated with impaired function and increased mortality. UK guidelines recommend all patients that have suffered a stroke have a cognitive assessment within 6 weeks. There is no ‘gold standard’ cognitive screening tool, although the Montreal cognitive assessment (MoCA) is more sensitive than the Mini-Mental State Examination (MMSE) in mild cognitive impairment and for cognitive impairment in the non-acute post-stroke setting. Yan et al, (2015)
Over the last few years or so Glenys has begun to develop more severe symptoms including more frequent confusion and disorientation she has developed problems with communication and suffers frequent memory loss, this is a very common occurrence in people who have vascular dementia and the frequency of mental confusion is correlated with the patient’s age: more than 55% of cases have been noted in the group aged over 70 years. Mental confusion develops 6 times more frequent in patients with moderately severe and severe dementia than in those with mild dementia, Sampson et al, (2013). Timely diagnosis and adequate treatment are predictors of favourable outcome in most patients, however treatment of this syndrome should be strictly differential. Antipsychotic treatment is needed in case of persistent psychotic symptoms and severe behavioural disturbances. Kolykhalov et al, (2013). Glenys can become very aggressive an example of this is when she thinks that she has not had her lunch and thinks that staff are trying to starve her, part of Glenys care plan stipulates that she has her weight monitored weekly due to past weight loss and her fragility, she appears to be maintaining an even weight and although she does have food issues this would indicate that she is receiving adequate nourishment. The last 6 weeks shows her being approximately around the 44KG mark (7Stone) this is a 5lb improvement since the start of my placement. Glenys visits her daughter at the weekend and can often says that she has not had a meal all day. Her daughter documents any food or liquid that she provides her mum for when she says that she has not been fed. This appears to be a useful assessment tool and can be used alongside the residential homes own care plans for Glenys.
Glenys can at times act inappropriately around other residents and staff members a study suggests that Over 80% of people with a dementia exhibit behaviours that are perceived as challenging. Scott et al., (2002), this may include verbal/Physical aggression, wandering and self-injury. Managing challenging behaviour is demanding and can be associated with staff burnout, sub-optimal care and can compromise the successful running of a care setting. Hayward et al, (2012). According to Zilbergeld, (2004) Sexuality is with us from the moment of birth to the moment of death and is a fundamental part of being human. When a person’s sexual expression is affected by dementia confusion, distress and embarrassment may ensue, leading to social isolation for familial caregivers and reluctance to accept social support. Robinson, (2003). Indeed, inappropriate sexual behaviour (ISB) has been identified as a significant corollary of the dementias (National Institute for Clinical Excellence & Social Care Institute for Excellence (2006) and although less frequent than other challenging behaviours, it is still clinically significant with over 60% of staff working in aged care facilities reporting inappropriate sexual behaviour at least once a week (Cubit, Farrell, Robinson, & Mayhill, (2007).
Glenys uses a walking aid to help with her day to day chores which are mainly made up of walking to the garden where she will read a book and feed the pigeons. This has however become an issue as she is attracting more and more pigeons which are leaving they’re faeces all over the garden which can carry such germs as Histoplasmosis. Mims et al, (2013) which if ingested can cause fatigue chest pains and fever. As an alternative we have purchased a bird table and encouraged her to feed the birds using this.
Every day the nursing staff and the HCA’s (Health Care Assistants) organize group activities that residents can participate in these activities can be for example: baking cakes, painting or looking at old pictures from year’s gone bye, this is something that most the residents enjoy and many take part in. On observation I felt that she was interested in the activities but only for short periods of time and when I assisted her in making scones she was enjoying the activity but very quickly became bored and left the table. Having a very low attention span in people with dementia is very common. Jiwa, (2010).
Recently, Glenys unfortunately had to be admitted to hospital after a fall within her care setting. Due to her age and fragility it was important for her to be monitored within a hospital setting due to complications that can arise from a fall to an elderly person. Typically when older people fall in most cases no lasting effects will arise but occasionally injury can occur with broken bones and concussion. It is also possible that confidence can be affected which result in them becoming withdrawn and even may feel like they have lost their independence Hartholt, (2011). In the case of Glenys this is a distinct possibility. Appropriate social and medical interventions may help maintain independence in older people like Glenys P. Determinants of functional decline, disability and reduced independence is recognized and specific interventions target the treatment of clinical conditions, multiple health problems and geriatric conditions, prevention of falls and fractures, and maintenance of physical and cognitive function and social engagement. Beswick, (2010)
To summarise; Glenys is coping very well in her environment and is supported effectively with her medical needs through the effective use of her care plan that clearly outlines what she requires from her support team. She lives very independently and has total control of her own life. She is able to participate in usual activities even if only for short periods and has access to her family which she appears to enjoy. I have spoken to some of her family members whom are very happy with the level of care she requires and feels that she is happy and content in her current care setting. They are confident that any required changes to the care plan or the care setting will be implemented immediately to minimise the risk of falling in the future. She recently had her care plan reviewed and it was concluded that her care needs are being met and no changes are required at present. She is aware that if she feels something is not as she would like that she can complain to the manager at her residential home or if necessary the CQC (Care Quality Commission). How much longer she can make these decisions is unclear due to her dementia. I am satisfied that she is receiving the care she deserves and the staff at the home where she resides are treating her with dignity and respect. Due to her recent fall I’m confident that a suitable amendment will be made to her care plan to minimise the risk of this happening again. However it is more likely that this could happen again according to Muchane et al, (2012).
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