Addressing the Health Needs of Grandma Sue - Essay Example

Addressing the Health Needs of Grandma Sue Introduction This essay is the second part of the assignment on the assessment of the biospychosocial state an elderly individual with a learning disability. The subject, Grandma Sue is an 85 year old nursing home resident who has been exhibiting symptoms of depression due to feelings of neglect and abandonment by her family, specifically her son. Her alternating states of depression and ecstasy attributed to her family’s visits or the lack of it seem to be progressing to Manic-Depressive or Bipolar Disorder, which needs to be addressed in order for her to maintain her health and well-being. Her mood swings have been getting more frequent affecting her relationships with the other residents and staff of the nursing home as well as her physical health because she can be very stubborn if she does not want to eat or take her medication. This causes her to be physically and mentally weak that she is unable to participate in the group activities of the nursing home which she used to enjoy. As her learning disability nurse, it is in my interest to meet all her biopsychosocial needs and help her manage her learning disability and the impending progression of her depression into Bipolar Disorder. This paper will go through the nursing process of assessment, planning, implementation and evaluation ( Aggleton & Chalmers, 2000) of Grandma Sue’s health needs to come up with a care plan for her. It will address specific needs related to her advanced age and bipolar disorders symptoms. Bipolar Disorder’s Link to Learning Disability Due to the suspicion that Grandma Sue’s condition is progressing to Bipolar disorder, it is but fitting to examine what this mental illness is about. Sometimes known as manic depression, bipolar disorder is a severe mental disorder characterized by intense mood swings which fluctuate from manic highs and depressive lows (Bipolar UK, 2013). The individual exhibits utter joy and excitement on one end, and alternately, very low, depressive states on the other end. This may be brought on by repeated occurrences of family or emotional pressures. Early diagnosis, acceptance of the illness and adaptation to a better lifestyle are ways to control the symptoms and cope with the effects of the disorder. Management of bipolar disorder may be by the use of medication, health care, therapy and self-management (Bipolar UK, 2013; Clarke & Griffiths, 2008). It has been discussed in Part 1 of this assignment that Grandma Sue has been experiencing emotional struggles due to her longing for her family. Her emotional states have vacillated from intense joy when she is visited by her family and intense sadness and disappointment when they do not visit as expected. These inconsistency and instability of emotional states have affected her disposition and outlook as well as how she relates to others. She has also been under medication to manage her emotional states. The combination of these factors has affected her learning capacities, as she shows symptoms of a learning disability as well. Learning disabilities affect an individual’s understanding of information as well as his or her communication skills. This implies that he or she struggles in comprehending new or complex information, learning new skills and/or independently coping with their daily functioning (NHS Choices, 2013; Blackman, 2003). Applied to Grandma Sue, she has lately been inconsistent in understanding some rules and routines in the nursing home and get confused with her schedules, when before she was very organized. She is now very forgetful, like where she left her things or what she just ate five minutes ago. She also mistakes people’s identities. In a study by van Gorp, et al. (1998), persons with bipolar disorder were found to have memory deficits on tasks of declarative memory in the euthymic state. This is substantiated by the study of Thompson, et al. (2005) which found significant neuro-cognitive impairments in bipolar patients when tested in their normal mood states. It is suggested that such impairments in attention, memory and executive function during their remission states may imply underlying neurobiological dysfunction. The cognitive deficits are usually caused by considerable distress which can lead to the individual’s difficulties in psychosocial and occupational functioning (Martinez-Aran et al,, 2004). It is recommended that early intervention is administered to the individual because the degree of dysfunction may increase as the illness progresses (Raghavan & Patel, 2005). The root cause of the underlying neurobiology of the particular neuro-cognitive deficit must be known in order to customize the appropriate therapeutic intervention. Suggested interventions are cognitive and psychoeducational rehabilitation programmes to result in the improvement of long-term outcomes (Thompson et al., 2005). Assessment Following The Roper, Logan, Tierney (RLT) Model of Activities of Daily Living (ADL) (1990), Grandma Sue is assessed on the following areas of activities for daily living (Holland et al., 2008): 1. Maintaining a safe environment: Grandma Sue’s vital signs are regularly monitored and when her emotional states reach depressive and manic levels, her blood pressure is significantly affected. 2. Communicating: There are no communication barriers with Grandma Sue as she understands messages conveyed to her as well as she expresses her messages clearly unless she is in a crying fit. Then, her language is not clearly expressed. So far, she has no need of communication aids, but people need to speak to her with a slower pace and in a louder voice. 3. Breathing: Grandma Sue’s breathing is generally fine except when she is on a crying fit or when she complains of chest pains due to difficulty of breathing when she is in a depressive state. 4. Eating and drinking: Her appetite has significantly been affected by the inconsistency of her emotional states. The nurses make sure she is always hydrated and given food but lately, she can be stubborn in not eating when she does not feel like it. Because of that, she has lost about 5 lbs. Fortunately, she has no food allergies, so the nutritionist can come up with something that would appeal to her gustatory senses to entice her to eat. 5. Eliminating: Grandma Sue has no problems with elimination of wastes as she is very regular with her urination and bowel movement. Her adult diapers are regularly changed when she needs to wear them at night or when she indicates a need for it. 6. Personal cleansing and dressing: She has always been very neat and always practices good hygiene. However, lately, she needs assistance with brushing her dentures and in dressing herself. 7. Controlling body temperature: The nurses are efficient in regularly taking her temperature. A blanket is always on hand whenever she needs it because she easily feels cold. 8. Mobilising: She can still walk, but limps due to a fall she endured 5 years ago. So sometimes, she requests for a cane or a wheelchair to get around. She can be very slow in her movements. 9. Working and playing: She used to enjoy the games she plays with her co-residents such as Bridge or Bingo. She is also consulted by the nutritionist for some ideas in the diet plans as she is a former nutritionist herself. However, lately, she refused to socialize with her peers and is often seen on her own in the garden. 10. Expressing sexuality: Not applicable to Grandma Sue as she seems to have become an asexual person due to her old age. 11. Sleeping: She has lately complained of problems sleeping at night that she keeps napping during the day. She requests for medication to promote sleep as well as a hot glass of milk before sleeping time at night. 12. Dying: She has often expressed her desire to die so she can be with her dead husband especially during her depressive states. She keeps saying she is tired and just wants to go home. Planning Upon the assessment of her health needs, a care plan to ensure her biopsychosocial health and well-being while she is in the nursing home must be created and implemented (Aggleton & Chalmers, 2000). From the assessment, it has been found that she needs management with her breathing and blood pressure especially when she manifests symptoms of bipolar disorder. Her appetite needs to come back to normal and she should be urged to socialize with her peers to rekindle her harmonious and congenial relationship with them. This is also to distract her from being depressed all the time and keep her preoccupied with pleasant activities. Her sleeping patterns also need to be corrected so that she gets enough sleep. Finally, her desire to die may pre-empt a suicidal tendency, so she must be monitored at all times of self-inflicting activities. Implementation A care plan should be done to incorporate all the identified needs of the patient after assessment (Gates, 2006). Goals should be set for the patient to meet such needs as well as the actions and outcomes expected when the care plan is implemented. This plan should be collaborated upon by the nurses and the patient (Barrett et al., 2009). Based on the assessment of ADL’s, the following care plan is to be implemented. Identified Patient Need Action(s) to Achieve Need Expected Outcomes 1. Grandma Sue needs to be able to manage her breathing during her bipolar episodes She should be given instructions on slow inhalation and exhalation. Teach her to think of positive thoughts and retrieve them when she is in a depressive state. Rubbing her back helps her relax. Give her mood stabilizing medication prescribed by her doctor She will demonstrate a reduction in her anxiety, relax and her breathing shall return to normal. All this should happen a few minutes after she is observed to have trouble breathing. 2. She needs to eat and drink regularly and increase her appetite. Start with a liquid diet until she gains her appetite back. Give her appetite stimulants Engage in conversation with her while she eats her meals. Maintain a regular schedule of her meals. Slowly bring her to the mess hall to eat with her peers during meal times. Her appetite will come back after a week or two. She will join the others in the mess hall during meals. She will gain back the weigh she has lost, and hopefully, more. 3. Grandma Sue needs to re-establish her social ties with her peers in the Nursing home. Let her seat with her peers during a passive activity like watching television or just chatting. Introduce a new game and let her join. She will eventually rejoin her peers during group activities. 4. Grandma Sue needs to be able to sleep at least 6 hours at night. Keep her busy with activities during the day so she is tired at night. Do simple physical exercises with her in the morning. Teach her relaxation techniques and keep activities low key a few hours before she sleeps. Make her room conducive to sleep by controlling the lighting and temperature to be very comfortable for her. Give her calming tea or milk before sleeping. She will eventually be sleeping soundly every night. 5. Her bipolar episodes should be managed well. Provide the required dosage of mood-stabilizing and anti-depressant medication to manage her bipolar disorder. Anticipate bipolar episodes by keenly observing her behaviour patterns (A-B-C model). Should a depressive state be oncoming, distract her with conversation and other pleasant activities like watching comedy movies or shows. Her bipolar disorder will be managed accordingly through conditioning her to think of positive, happy thoughts and relaxation techniques (CBT and Positive Psychology) 6. Grandma Sue should be monitored at all times if she has suicidal tendencies Keep sharp or any harmful objects away from her. Store medication in places that are out of reach. Constantly monitor her behaviours of suicidal tendencies. Do pleasant things with her such as gardening or singing so she feels pleasure in her life. Any suicidal tendency whatsoever shall be eliminated. This care plan should be discussed with all the nurses and staff working with Grandma Sue as well as her and her family and each should be furnished with a copy. Whenever nurses and staff have a shift with her, this care plan should be carried out. They should each have in their charts Grandma Sue’s A-B-C chart where details of their observation may be written. A-B-C charts note the Antecedent, Behaviour and Consequences of an individual’s behaviours especially Grandma Sue’s agitated behaviours (Gates, Gear & Wray, 2000). In the chart, the nurse can write down what was going on before a significant incident like a crying episode happened (A- antecedent); What she did (B-behaviour) and what was done to support or end the behaviour and its corresponding consequence (C) (Gates, 2006). Apart from the implementation of the care plan, Grandma Sue shall continue with the pharmacology and psychotherapy (she has been provided with, as discussed in Part 1 of this assignment (Cottis, 2009). She is still given mood stabilizers and anti-depressants and undergoes Cognitive Behaviour Therapy (Beck, 1975) with the resident psychologist in the nursing home. All the nurses and staff continue to practice Positive Psychology (Seligman et al., 2005) with her and all the other residents of the nursing home. Most importantly, since her depressive states have been caused by her intense longing for her family, they shall be enjoined to be part of the care plan and encouraged to be present for her on a more regular basis, either by communication by phone or Skype or personal visits at least twice a month. It is believed that their visits will eventually be the key to help ease her depressive symptoms and support her to reach her optimal health and well-being (Razza & Tomasulo, 2005). Evaluation To evaluate if the care plan or intervention to support Grandma Sue in her condition, one should look at the outcomes expected in the care plan. Evaluation is an ongoing process that happens every time one interacts with Grandma Sue. It should be a collaborative process among the nurses as well as with Grandma Sue herself so she gets feedback on her progress. Because her needs are typical of the elderly, somehow they are also related to her bipolar disorder and it is important that these needs are understood by the nurses and why they manifest themselves. The success of the intervention care plan of Grandma Sue shall be evaluated with the achievement of the goals stated in the care plan. Is she breathing regularly again even during her bipolar episodes? Is her appetite back and did she gain a few pounds? Is she joining her peers again during meals and other group activities? Is she sleeping better at night? Is her bipolar disorder better managed by thinking of pleasant thoughts and relaxation techniques? Are her suicidal tendencies gone? The nurses and staff should also be able to evaluate if they are successful in coaxing Grandma Sue’s family to be more sensitive to her needs and participate in the team’s effort to support her throughout her healing of her bipolar disorder. This involves serious education and communication with them to raise their awareness and understanding that their presence and cooperation are imperative for the achievement of Grandma Sue’s optimal health and well-being at her age (Gates, 2006; Holt et al., 2011; Andrews & Hunt, 1998). Conclusion Working with the elderly can already be a challenge to nurses. Due to their old age, they may be experiencing several physical difficulties such as heart problems, muscle tension, psychomotor difficulties, migraine, etc. in addition to some illnesses they have developed over the years (hypertension, Alzheimer’s disease, diabetes, etc. (Andrews and Hunt, 1998). Add to that their psychological issues related to their psychosocial stage of Integrity vs. Despair and Disgust (Erikson, 1963). They may also have tendencies to isolate themselves and dwell on their own memories and introspection, affecting their social interactions with the people around them. With Grandma Sue, she is generally a good-natured person who is genuinely pleasant to work with. However, due to her loneliness and longing for her family, bipolar disorder seems to be getting the best of her. This developed after repeated instances of excitement and disappointments regarding her family’s visits to her. Hence, it resulted in her depressive states when she would go on crying episodes that seem to be inconsolable whenever she is disappointed with her family not visiting her alternated with hyperactivity and excitement when her family visits her. Her Cyclothymic Disorder, characterized with episodes of hypomania alternating with depressive symptoms for at least 2 years which she was initially diagnosed with, seems to be progressing to Bipolar Disorder, which is a more severe version. This affected her thinking processes as she now exhibits cognitive deficits in attention, memory and executive functions and developing learning disabilities (Clarke & Griffiths, 2008). Assessing her biopsychosocial health state using the (RLT) Model of Activities of Daily Living identified her health needs that were put into a care plan (Roper, Logan & Tierney, 1990). Apart from the Cognitive Behavioural Therapy and medication she has been receiving, the care plan shall be more strictly implemented to help her manage her bipolar disorder. Utmost patience and understanding is required of learning disability nurses working with elderly patients with mental and learning disabilities because not only do they deal with the physical and biological needs of the patient, but they are also instrumental in supporting them with their psychological and socio-emotional needs. However, being able to help good people like Grandma Sue is worth it because it provides much fulfilment and psychic rewards on the part of the nurse. It is a good thing that there are nursing models that one can follow now so that the nursing process is more organized. The RLT Model of Activities of Daily Living has proven to be a good assessment resource that nurses can follow so as not to miss out on any important area of daily living in the patient. Successfully working together becomes a win-win situation for both parties. References Aggleton, P. & Chalmers, H. (2000) 2nd Ed. Nursing Models & Nursing Practice. Basingstoke. Palgrave. Andrews, G. & Hunt, C. 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(2006) Care Planning and Delivery in Intellectual Disability Nursing Blackwell Holland K, Jenkins J, Solomon J, Whittam S (Eds) (2008) Applying the Roper Logan Tierney Model in Practice, 2nd Edition, London, Churchill Livingstone Holt, G., Hardy, S., & Bouras, N (2011) Mental Health in Intellectual Disabilities: A Reader, Fourth edition. Pavillion. Brighton. Martinez-Aran, A., Vieta, E., Colom, F., et al (2004) Cognitive function across manic or hypomanic, depressed and euthymic states in bipolar disorder. American Journal of Psychiatry, 161, 262 -270. NHS Choices (2013) What is learning disability? Retrieved on April 28, 2014 from: http://www.nhs.uk/Livewell/Childrenwithalearningdisability/Pages/Whatislearning disability.aspx Raghavan, R, & Patel P (2005) Learning Disability and Mental Health A Nursing Perspective. Blackwell Publishing Ltd. Oxford. Razza. N. J. & Tomasulo, D. J. (2005) Healing Trauma: The Power of group Treatment for People with Intellectual Disabilities. Washington. 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