Become a Clinical Nurse Specialist - Priority Problems - Research Paper Example

Become a Clinical Nurse Specialist - Priority Problems Abstract Tom W. is a 47 year old patient with advanced ALS. The following interventions will describe the interventions that are appropriate for Tom individually and the interventions that are appropriate for Tom's family. Additionally, a description of health care providers that would provide unique care for Tom's needs are described. Introduction Tom W. is a Cuban immigrant who lives with his wife and two daughters, with a son who is away from home attending college. Tom W. has been battling ALS for the past 18 months. He also has a healing tibia fracture sustained in a fall down the basement steps two weeks before the assessment. Because of his ALS, Tom has difficulty swallowing, which has led to a 10 lb weight loss. Tom also appears to be suffering from depression, as he is withdrawn, irritable, does not want to spend time with family, does not want to participate in his own care and is impatient with his children. His functional abilities are declining remarkably, as Tom has experienced weakness, fatigue and coordination difficulties. His wife is overwhelmed – working full-time with two children at home, one of whom is a teenager who would rather play soccer than babysit her younger sister. Additionally, the wife has the burden of caring for Tom. Because of his advancing illness, Tom chokes sometimes when he eats, experiencing this three times in the last week and is afraid of choking again. The recommendation is for a feed tube to be installed, but Tom is against this measure. Mrs. W. is afraid because Tom is not eating, and is afraid that he will die if he does not eat. The main problem is that Tom has ALS, which only has a mean length of survival from on-set of 2.4 to 4.1 years (Bach, 2002, p. 92), and Tom has had the disease for 18 months, so he is probably at the end-stage of his disease. Also, his depression is a common co-occurrence with illness, especially in patients with neurological illnesses (Katon, 2003, p. 217). ALS is a “progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord” (ALS Association), therefore is a neurological illness, which makes Tom much more prone to depression than other populations. These two major problems, and the resultant issues that stem from these problems, such as Tom not being able to swallow or eat, Mrs. W. having to do all the work caring for Tom and the family, and work full-time, because of an uncooperative teenage daughter, has left this family on the brink. Priority Problems The main problem is that Tom is dying, and probably very soon. Therefore, the priority problems identified will be centered around this fact. He might have a few years left, but his disease seems to have progressed rapidly. His family needs to be prepared for this eventuality. Of interest is the fact that Tom does not have an advanced directive on file. This needs to be on file, so that the family will be able to carry out Tom's wishes for his care should he become incapacitated. The family also needs to explore what kind of benefits they will get after Tom passes away – life insurance or any kind of survivor benefits that he might have accumulated during employment. Tom needs to make sure that his will is drawn out and updated, and that all bank accounts have a payable on death designation so that these accounts do not have to go through probate. He needs to see a qualified attorney about these issues as soon as possible, as he is increasingly unable to speak and communication with an attorney might soon be very difficult, if not impossible. Also, Tom will probably need some spiritual counseling. The case study states that Tom is very religious, so spirituality and the promise of heaven are no doubt important to him and central to his faith. It is unclear whether or not Tom has sought spiritual counseling because of his illness, or if he has become too discouraged and depressed to do so. However, it would be helpful if he could re-connect with his religious side, as research has shown that “individuals scoring higher on the spiritual measure were less depressed” (Chochinov, 2007, p. 85). Studies have also shown that those who are spiritual do not desire a hastened death, are less hopeless and have fewer suicide ideations than those who are not spiritual, which leads researchers to believe that a strong faith lessens end-of-life despair (Chochinov, 2007, p. 85). Therefore, it would do Tom well to get back into religion if he has abandoned it, and seek counsel from the church elders. Outcomes One of the needs that must be addressed is that Mrs. W. needs help. She not only has Tom to deal with, but three children, none of whom appear to be at all helpful, and her elderly mother. On top of this, she is working full-time. All of this while her husband is dying. She needs help, or she will not be able to handle the strain. One of the things that can help her would be to have a live-in nurse come into the home to help with Tom's care. This will at least relieve the major burden so that she can focus on keeping it together and paying the bills. The nurse can be hired right away. While the family does not necessarily have money for this, somebody needs to help the family in finding a way to get a nurse if they do not have the funds. If this is impossible, then perhaps a nurse may be hired to look after Tom while Mrs. W. is working. This is not an ideal situation, but it would be still be helpful, as Tom probably needs full-time care. The family also needs counseling. The children seem to not be handling this very well. They are avoiding their father, and the teenager is whining about not playing soccer because of what is going on. It is unclear whether they know that their father is dying. But they need to be counseled about how to handle it, and how to handle their father while the father is still alive. Ignoring him during his last years is not doing anybody favors. Counseling should also be provided to Mrs. W. She is probably at the breaking point with all that is going on, and she needs a way to vent her frustrations as well as find solutions. The counseling can start right away, and maybe 10 sessions can be provided for either free or at a low-cost, or subsidized by a charity. Interventions The interventions with Tom will focus on four major aspects – dealing with his depression, helping him communicate after he is unable to speak, helping him get nutrition and control his excess saliva, and palliative care that prepares him for the eventuality of death. The first thing is that Tom needs to seek help for his depression. The case study states that Tom is on an antidepressant. This antidepressant needs to be reviewed to determine if the dosage is still correct or if maybe a different antidepressant or a combination of antidepressants is needed. Additionally, Tom needs to meet with a therapist who specializes in patients facing end of life. The reason that this is so important is because depression is associated with increased mortality (Katon, 2003, pp. 221-222). Depression also is a problem that will only get worse as Tom gets more debilitated, as depression tends to escalate as patients' disability, illness and pain get worse (Chochinov, 2007, p. 86). Anxiety also increases during this period of time (Chochinov, 2007, p. 86). Therefore, Tom needs to get all the help he can get to help him with his feelings about and fears about “the disease process, the clinical course, possible treatment outcomes, and death” (Chochinov, 2007, p. 87). Concurrently with getting help for his depression should be assistance with eating and controlling saliva. The case study indicated that Mr. W was drooling. As drooling affects Mr. W's quality of life, and drooling causes “significant social stress” (Miller et al., 2007, p. 1316), effort should be made to assist Mr. W. with this problem. Pharmacological interventions for drooling include the use of Amitiptyline, which is a widely used drug to control drooling in ALS patients (Miller, et al., 2007, p. 1316). Also, if the cause of the drooling is the result of a problem with mucus, extracting excess mucus by manually assisted coughing techniques and mechanical insufflation-exsufflation cough machine can aid with this (Miller, et al., 2007, p. 1316). As for nutrition, a percutaneous endoscopic gastroscopy (PEG) device should be used. The benefits of using a PEG are “adequate nutritional intake, weight stabilization, and an alternate route for medication” (Miller, et al., 2007, p. 1317). Because PEG is indicated when a patient has dehydration, insufficient calorie intake, or prematurely ends meals because of choking on food, this is definitely indicated in this situation, as Tom has all of these symptoms, a PEG is definitely indicated. The risks of a PEG include the possibility that there will be respiratory inefficiency, which happens with a PEG as it employs procedural sedation (Miller et al., 2007, p. 1318). Another intervention strategy would be to explore the use of a brain-computer interface (BCI), a device that helps severely paralyzed users communicate and “control without motor responses” (Nijboer, et al., 2010, p. 1). The device consists of “several functional components: the input for a BCI originates from a user who 'produces' brain signals...the output of a BCI (e.g. commands for a spelling program) and the translation of input into output (signal detection, feature extraction, classification)” (Nijboer, et al., 2010, p. 1). This intervention is indicated by the fact that Tom is having difficulty communicating and, if he loses all communication ability due to inability to speak, because of throat paralysis, or write, due to increasing weakness, it is vital that he still be able to communicate his thoughts and needs with this family. A BCI might be expensive, but research aims to provide these machines at a low-cost in the near future (Nijboer, et al., 2010, p. 2). The family might inquire about how these machines may be purchased, if they can be loaned, or sold used, or perhaps subsidized. At any rate, the family should look into getting this machine so that Tom can communicate when his speech and writing faculties are gone. Lastly, Tom needs palliative care. With an ALS patient, palliative care is focused upon relief from dyspnea (labored breathing) and anxiety. Dyspnea is treated with opiates, continuous IV morphine infusion, diazepam or mizolam, hypoxia and chlorpromazine (Nijboer, et al., 2010, p. 11). Anxiety may be treated with the proper pharmacological intervention and therapy. Also include in palliative care is spiritual counseling and psychiatric care to address the dying patient's fears about dying, his hopelessness, his feeling about being a burden to others, loss of dignity, and possible loss of will to live (Chochinov, 2007, p. 87). Health Care Professionals The health care professional that would be most helpful in this situation would be that of a clinical nurse specialist who specializes in ALS patients or patients with neurological disorders. Clinical nurse specialists have either a master's degree or doctorate in their chosen specialty. They are case managers, so they can organize and coordinate services and resources while controlling costs. They can “provide expert consultation to other nurses and leadership to improve health care delivery systems” (Become a Clinical Nurse Specialist). In addition to diagnosing and treating, they also build multidisciplinary teams, collaborate with others to improve patient care, conduct research, provide coaching, review alternative approaches and implement changes (Become a Clinical Nurse Specialist). This kind of nurse would be uniquely qualified to deal with the situation because he or she is specifically trained to handle patients that have ALS. A specialist will know how to deal with the unique situations of an ALS patient, and he or she is probably also trained to deal with the specific emotional needs of a dying patient and the dying patient's family, as ALS is almost always a fatal disease. Another kind of health care provider who might be called upon would be a parish nurse (Parish Nursing or Faith Community Nursing). A parish nurse combines traditional nursing with religious beliefs and encourages physical and spirtual health and wholeness by developing and leading programs within faith communities. A parish nurse is a trained nurse and gets a specialty beyond the nursing degree. A parish nurse might combine a nursing degree with a master's or doctoral degree that integrates nursing and faith ministry. Along with usual nursing duties, a parish nurse gives personal health counseling, organizes health support groups and assess congregational and community health needs (Parish Nursing or Faith Community Nursing). This nurse would be especially helpful in that he or she will be trained to handle the spiritual needs of a dying patient. Tom is religious, and this is central to his life. He is going to need spiritual guidance during this period of time, in addition to help with his physical needs. A parish nurse combines these two, and this will probably provide a measure of comfort to Tom, as he is going to need somebody to talk to about these issues. Conclusion Tom, his wife and his entire family are in desperate need of intervention. Tom is dying, and he is hastening this by not eating. He is also depressed. It is unclear whether he has accepted the fact that his life can probably be measured in months at this point. In light of the fact that Tom has not put an advanced directive on file, he probably has not. He also has specific physical needs that need to be addressed – drooling, speech becoming unclear, not eating. These can all be addressed with specific intervention strategies tailored to the patient with ALS. Beyond this, he needs spiritual counseling. He is said to be very religious, so he will need this during this time. The family also needs intervention. The wife is at her breaking point, with too much on her plate. The children do not seem to want to help, and ignore their father when he needs them the most. The mother is also living there, and has needs of her own. There needs to be somebody there to assist Tom, and there also needs to be some kind of family therapy that needs to take place. Sources Used Become a clinical nurse specialist. Allnursingschools.com. Available at: http://www. allnursingschools.com/faqs/become-clinical-nurse-specialist Chochinov, H.M. (2007). Dying, dignity, and new horizons in palliative end-of-life care. CA: A Cancer Journal for Clinicians, 56(2), 84-102. Katon, W.J. (2003). Clinical and health services relationship between major depression, depressive symptoms, and general medical illness. Biology and Psychiatry 54, 216-226. Miller, R.G., Rosenberg, J.A., Gelinas, D.F., Mitsumoto, H., Newman, D., Sufit, R., Borasio, G.D., Bradley, W.G., Bromberg, M.B., Brooks, B.R., Kasarkis, E.J., Munsat, T.L., and Oppenheimer, E.A. (1999). Practice parameter: The care of the patient with amyotrophic lateral sclerosis. Neurology 52, 1311-1329. Nijboer, F., Birbaumer, N. and Kibler, A. (2010). The influence of psychological state and motivation on brain-computer interface performance in patients with amyotrophic lateral sclerosis – a longitudinal study. Frontiers in Neuroscience 4(55), 1-13. Parish nursing or faith community nursing. Allnursingschools.com. Available at: http://www.allnursingschools.com/faqs/parish Read More