Community Nursing in Aged Care - Case Study Example

Community Nursing in Aged Care Introduction Community based health care, a primary health care system, provides health - related services within the context of people’s lives in places where they will spend the rest of their lives. Community care is holistic and provides a good foundation in supporting the ageing population (Kozier, et al., 2004; Allen, 2008)). This growing element of aged care becomes increasingly central to provision of aged care (Allen, 2008). Community care services must acknowledge and support the role of network to persons, and consequently, to remain living in their own home, a balance of self, family, community, environmental and social support is required (Allen, 2008). According to Ford (2004), elderly have been increasingly the focus of health and social care policy, particularly on their continuing needs of care, which are met in a variety of setting such as their own home, supported housing, residential care, nursing home or hospital. History Mrs. Howard, a 72 year old widow, is referred by a concerned neighbor. At the time of visit, it is noted that Mrs Howard is slow to answer the door, and dressed with unkempt appearance. Her house is tidy but her bedroom is unmade. Her gait is slow but steady. It is noted that the refrigerator of Mrs. Howard has no food, and the kitchen is tidy. Mrs. Howard’s medication are sitting on the kitchen bench. Mrs. Howard complained of feeling very tired and she is having difficulty getting out of bed in the morning. She added that she has to get up to the toilet at nighttime. She has not been feeling hungry and has lost a little weight, hasn’t been preparing meals, has not been out for shopping or visiting friends in a few weeks. Mrs. Howard gets confused about how many tablets to take. Her medications were Lanoxin 125, Naprosyn 250 mg, Urex 20 mg, Mylantas, Agarol, Panadol, and Garlic. Effects of Drugs In older clients, the possibility of developing adverse drug events is increased for the reason that several co – morbidities are observed in the elderly whom multiple medications are prescribed (Hamilton et al., 2009; Woodhouse, 1997). Hamilton et al. (2009) added that this risk is compounded by changes related to age such as physiology and composition of the body influencing drug handling and response. It is also important to note that as the person grows old, the sleeping pattern changes as well. A marked heterogeneity in health status and functional capacity in the elderly makes decisions in prescribing more complex and challenging (Hamilton et al., 2009). The following are the drugs prescribed to Mrs. Howard: Lanoxin Lanoxin is indicated in clients with mild to moderate heart failure, arrhythmias, and atrial fibrillation (Woodley and Whelan, 1992; NetDoctorUK, 2008; DrugLib, 2007; The HealthScout Network, 2009; Medscape Journal, 2009). This drug increases the left ventricular ejection fraction and improves the symptoms of heart failure. Diuretic and angiotensin – converting enzyme inhibitor should be concurrently used by clients taking Lanoxin (Woodley and Whelan, 1992; DrugLib, 2007; The HealthScout Network, 2009; Medscape Journal, 2009). Lanoxin inhibits sodium potassium ATPase, an enzyme that regulates intracellular quantity of sodium and potassium, leading to intracellular increase of sodium concentration (Woodley and Whelan, 1992; The HealthScout Network, 2009). Stimulating sodium – calcium exchange results to increase in the intracellular calcium concentration. This is contraindicated in clients having ventricullar fibrillation. In clients with pre – existing sinoatrial or AV conduction disorders, therapeutics doses may cause heart block. Rhythm disburbances are produced with high doses of Lanoxin (The HealthScout Network, 2009; Medscape Journals, 2009). Toxicitiy may exhibit as anorexia, nausea, vomiting, and diarrhea, which is worsened with hypokalemia. The bioavailability of Lanoxin may be decreased by Antacids to 25%. From the history, it is apparent that the client is exhibiting signs of adverse effects of Lanoxin namely: loss of appetite, weakness, and mood changes. The client was also reportedly taking antacids, Mylanta, which may possibly increase the risk of the side effects of Lanoxin (Whoodley and Whelan, 1992).. Naprosyn Naprosyn, a propionic acid derivative related to the arylacetic acid group of nonsteroidal anti – inflammatory drugs, is indicated for rheumatoid arthritis, juvenile arthritis, osteoarthritis, and ankylosing spondylitis (Whoodley and Whelan, 1992). Naprosyn is also used for relief of signs and symptoms of tendonitis, bursitis, acute gout, pain management, and primary dysmenorrhea. The mechanism of action is not completely understood but may be related to inhibition of prostaglandin synthetase. In the elderly, the unbound plasma fraction of naprosyn is increased (Woodley and Whelan, 1992; RxList, 2009; Stewart et al., 2009). Caution and adjustment of dosages is required in elderly clients since this will cause peptic ulceration and toxic reactions in clients with impaired renal function and renal toxicity. Naprosyn is noted to cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and fatal stroke as well as serious gastrointestinal effects such as bleeding, ulceration, and intestinal perforation, hypertension and worsens pre – existing hypertenstion, which may later lead to increased incidence of cardiovascular events (RxList, 2009; Stewart et al., 2009). In some clients, fluid retention, oedema, and peripheral edoema may be observed. Others are exhibiting anemia, prolonged bleeding, and severe bronchospasm (RxList, 2009; Stewart et al., 2009). The client must be closely monitored during the initiation of Naprosyn therapy and throughout the course of treatment. Concommitant use with other antacids delays the absorption and because of its adverse effects in the elderly, it is recommended that Naprosyn must be given only at the lowest effective dose (RxList, 2009; Stewart et al., 2009). Urex Urex, a urinary tract antiseptic, is known to reduce drug resistant bacterial development and maintains the effectiveness of other antibacterial drugs. Urex is used in treating and preventing bacterial infections, for prophylactic and suppressive treatment of recurring urinary tract infection (RxList, 2009; Stewart et al., 2009). Its antibacterial activity is greater in acidic urine; therefore, alkalinizing foods and medications are restricted. The efficacy of Urex treatment must be monitored by repeated culture of urine. Side effects include nausea, anorexia, vomiting, pruritus, rashes, diarrhea, abdominal cramping, hematuria, and urinary frequency and dysuria (RxList, 2009; Stewart et al., 2009). Mylanta Mylanta, aluminum hydroxide – magnesium hydroxide compound, is indicated for treatment and relief of peptic ulcer symtoms, gastritis, hiatus hernia, hyperacidity, and gastrointestinal disorder management. Mylanta is contraindicated in clients with alkalosis, hypermagnesemia, abdominal distention secondary to partial or complete intestinal obstruction. Mylanta is also not recommended in pateints who are severely debilitated or those with impaired renal function. Mylanta can cause CNS depression and therefore, must not be taken for more than two weeks, unless recommended by physician. This drug interferes with absorption of iron preparations, tetracyclines, and other antibiotic. It is highly recommended that Mylanta must not be taken within two hours of another medication because it might alter the effeciency of other medications (Woodley and Whelan, 1992; RxList, 2009). Agarol Agarol provides relief from constipation, and promotes regularity. Known side effects of Agarol include anorexia, confusion, irregular heartbeat, muscle cramps, and usual tiredness or weakness (Woodley and Whelan, 1992; Stewart et al., 2009). Panadol Panadol, a paracetamol based analgesic, is a drug used to treat mild to moderate pain, tension headaches, periodic pain, symptoms of colds and flu, migraine headacs, arthritis, osteoarthritis, backache, toothache, and fever. Known side effects include anorexia, vomiting, and diaphoresis (Woodley and Whelan, 1992; NetDoctor, 2008; Stewart et al., 2009). Garlic Garlic is among the oldest cultivated plants used as food and medicine and is used for body’s strength and energy, a potent inhibitor of heart disease and hypertension with antiviral, antifungal, and antibiotic properties (Izzo et al, 2004). It is also effective in preventing and curing sore throat, colds, cough, and congestion. Assessment Subjective: Mrs. Howard was feeling very tired, has difficulty getting out of bed in the morning, has to get up to the toilet during night, not feeling hungry, lost little weight, has not been preparing meals, has not been out for shopping or visiting friends in few weeks, gets confused on proper dosage of medications. Objective: Unkempt appearance and slow steady gait. Description of Assessment and Findings For the assessment of risk, the client is noted to be at medium risk because she was still able to assess her own situation as evident in her subjective complaints noting difficulty getting out of bed in the morning, going to toilet at night, not feeling hungry, weight loss, social withdrawal, and confusion (Department of Health Social Services and Public Safety, 2001). For the assessment of complexity, client is noted to have medium complexity as her physical and mental needs are moderately complex, her mechanical and therapeutic assistance requires regular need, and interventions requires regular assessment (Department of Health Social Services and Public Safety, 2001). The client is also noted to be unstable and unpredictable as evidenced by her emotional, physical, behavioural, and psychosocial conditions that results to regular health intervention (Department of Health Social Services and Public Safety, 2001). Factors that Enhances Communication In a nurse – client relationship, communication is an effective means of developing better relationship with the clients (Kozier, et al., 2004). The following are the factors that influence or enhance the process of communication: (1) Development – older clients are known to have wider understanding with health care system; however, changes in visions and hearing acuity that comes with aging process affects nurse – client interactions (Kozier et al., 2004). (2) Gender – in adulthood, women are known to seek confirmation, minimize differences, and establish intimacy than men (Kozier et al., 2004). (3) Values and Perception – Kozier et al. (2004) noted that it is important for a nurse to be aware of the values of his client and to validate or correct perceptions to avoid creating nurse – client relationship barriers. (4) Territory – it is of utmost importance that nurses needs to obtain his client’s permission to remove, rearrange, or borrow objects in their area (Kozier et al., 2004). (5) Roles and Relationship – nurses who meets with clients for the first time must communicate in a different manner from nurses who had developed relationship with a client. (6) Environment – distraction in the environment can impair as well as distort communication. (7) Congruence – nurses must communicate with their clients in a congruent manner in order to readily gain the trust of their clients (Kozier et al., 2004). Analysis of Relevant Aging Changes against Presenting Problems Changes in the senses are perceptual changes commonly related to aging population. The taste, smell, touch, vision, and hearing are visible enough to give information of the changes in the elderly (HealthCentral, 2009). Changes in the sensorium have a tremendous impact in the elderly resulting to problems in communication, enjoyment of activities, and social interactions (HealthCentral, 2009). A sense of isolation may be contributed by changes in sensorium. Hearing may also decline (HealthCentral, 2009). Although, this was not indicated in the history, reduced peripheral vision also limits social interaction and activity in the elderly. The sense of taste and smell closely interact to help an individual appreciate food; however, this is usually decreased among individuals ages 60 and above. As a person ages, the mouth producess less saliva causing dry mouth making swallowing more difficult and slightly less efficient digestion (HealthCentral, 2009). The sense of smell diminishes after 70 years of age. Moreover, the interest and enjoyment of eating decreases taste and smell regardless of the cause (HealthCentral, 2009). When the sense of smell is decreased, some people may become less aware of personal hygiene, which is evident in the client. On the other hand, primary or secondary insomnia is very common in the elderly and may coexist with client’s illness and use of medication (Wolkove et al., 2007). Chronic illness incidence increases with age resulting to disproportionate number of medications taken by the elderly (Roehl et al., 2006 cited in Edlund, 2007). In 2002, a survey published revealed that in adults more than 65 years old, 50% of them used more than 5 prescriptions and OTC medications, and 12% used 10 or more (Kaufman et al, 2002 cited in Edlund, 2007). Inappropriate prescription is noted as one of the most common cause of adverse drug reactions which should be considered when evaluating new symptoms in the elderly (Edlund, 2007). Nursing Diagnosis (1) Sleeping disturbance secondary to frequent urination (2) Tiredness secondary to lack of sleep and weight loss (3) Weight loss secondary to decreased in appetite and aging (4) Decreased appetite as a result of decrease of senses in the elderly (5) Loss of appetite, weight loss, confusion, frequent urination, tiredness secondary to side effects of medications (Lanoxin, Naprosyn, Urex, Mylanta, and Agarol). (6) Lack of social interaction secondary to tiredness and lack of sleep Expected Outcomes After 8 hours of nursing intervention, the client is expected to increase her appetite after promoting social interaction especially during mealtime. The client is also expected to interact with friends, sleep soundly, and take her medications as directed after complying the aforementioned nursing interventions. She is also expected to verbalise her understanding on the proper dosage of her medications. Nursing Intervention Decreased Appetite and Social Interaction: A nurse practitioner must promote appropriate social interaction especially at meals by encouraging the client to take interest in preparing foods, perhaps as an activity the client can do with her friends. If food preparation is not possible, “Meals on Wheels” is highly suggested. Picnics in the yard or inviting friends over meals is highly suggested (Kozier, et al, 2004). Loss of Appetite: Encourage client to eat small frequent meals instead of three large meals. Review dietary restriction within these guidelines, and must be able to find ways to make meals appealing. Suggest to eat foods that are essential and nutrient dense to be followed with desserts and foods with low nutrient density (Kozier, et al., 2004). Difficulty sleeping at night: Encourage client to have major meal at noon instead of having it in the evening, and must avoid diuretics such tea and coffee in the evening (Kozier, et al., 2004). Gets confused on how many tablets to take and which time of the day: A community nurse practitioner must help the client organise her things by putting her medications in a separate container and appropriately label them with the name of drugs, dosage, and specific time of day a particular medication must be taken. Disturbance of sleeping pattern, tiredness, weight loss, decreased appetite, confusion, frequent urination: Advise the client to review the medications with her primary physician and to inform her physician the effects of those medications to the activities daily living. Patient Education Explain to the client the importance of following the proper dosage of medications and the importance of client’s cooperation in achieving the desired outcome. Impact of Information to Nursing Practice A nurse practitioner must be knowledgeable enough to present the effects of improper intake of medications and how its side effects affects the activities of daily living of the patient in the area of practice (i.e. community). A nurse practitioner is also expected to help the client live a longer life through the application of preventive medicine, early diagnosis, and treatment. As a nurse practitioner, changes can be made by giving importance of good relationship with the client and helping them have a good grasp on the disease process, the effects of the medications, and needed intervention. Conclusion A nurse practitioner can help Mrs. Howards live a happy and eventful life despite of her current illness by teaching her the importance of socialisation, proper information about illness and proper intake of medication as well as the importance of public awareness, lifestyle modification, prevention, early diagnosis, and treatment. References Department of Health Social Services and Public Safety. (2001). Nursing Needs Assessment Tool. Retrieved 20March 2009 from http://www.dhsspsni.gov.uk/nnat.pdf. DrugLib (2007). Digoxin. Retrieved 20 March 2009, from http://www.druglib.com/druginfo/lanoxin/pharmacology/ Edlund, B. (2007). ‘Pharmacotherapy in Older Adults: A Clinician’s Challenge’, Journal of Gerontological Nursing, 33(7), 3 Ford, P. (2004). Nursing Assessment and Older People. Retrieved 19 March 2009 from http://www.rcn.org.uk/__data/assets/pdf_file/0010/78616/002310.pdf. Hamilton, H., Gallagher, P., and O’Mahony, D. (2009) ‘Inappropriate Drug Prescribing and Adverse Drug Events in Older People’, BMC Geriatrics, 9(5), 1471 - 2318 HealthCentral. (2009) Aging Changes in the Senses. Retrieved 20 March 2009 from http://www.healthcentral.com/ency/408/004013.html HealthScout Network. (2009). Lanoxin. Retrieved 21 March 2009 from http://www.healthscout.com/rxdetail/68/29/7/main.html Izzo, A. Capasso, R. and Capasso, F. (2004). ‘Eating Garlic and Onion: A Matter of Life or Death’, British Journal of Cancer, 91(2004), 194 Kozier, B., Erb, G., Berman, A., and Synder, S. (2004) Fundamentals of Nursing, 7th Edition. New Jersey: Pearson Education, Inc. Medscape (2008) Digoxin. Retrieved 21 March 2009 from Medscape Database. NetDoctor (2008). Digoxin. Retrieved 21 March 2009 from http://www.netdoctor.co.uk/medicines/100001456.html RxList. (2009). Drugs and Medications. Retrieved 21 March 2009 from http://www.rxlist.com/naprosyn-drug.htm# RxMed (2002). Mylanta Preparations. Retrieved 21 March 2009 from http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20M)/MYLANTA.html Sakano, L. and Yoshitome, A. (2007) ‘Nursing Diagnosis and Interventions on Elderly Inpatients’, Acta Paul Inferm, 20(4), 495 – 498. Stewart, J. Thornton, P., and Wilson, K. (2009). Urex. Retrieved 21 March 2009, from http://www.drugs.com/sfx/urex-side-effects.html Wolkove, N., Elkholy, O., Baltzan, M., and Palayew, M. (2007) ‘Sleep and Aging’, CMAJ, 176(9), 1449 - 1454 Woodhouse, K. and O’Mahony, S. (1997) ‘Frailty and Ageing’, Age and Ageing, 26(1997), 245 -246 Woodley, M. and Whelan, A. (1992) Manual of Medical Therapeutics, 27th Edition. USA: Little Brown and Company. Read More