Nursing Care Plan: Implement And Monitor Care Of The Older Person
Implement and monitor the care of the older person
1) Mr. John Woods was diagnosed with hypertension thirteen years ago and suffered a myocardial infarction eight years ago. He was also diagnosed with anxiety and depression two years ago and has more recently been diagnosed with Alzheimer’s dementia and urinary urgency incontinence, for less than twelve months. Mr Woods’ medical conditions ultimately affect his quality of life due to the loss of memory and physical function due to Alzheimer’s dementia and osteoarthritis and gout in his left knee.
2) The Wear and Tear Theory would be appropriate for Mr Woods, which proposes that tissues and cells decrease over time will wear out and ultimately die. This theory relates to the body systems that have decreased in function in Mr Woods’ case including the musculoskeletal, cardiovascular, neurosensory and urinary systems due to the gradual loss of tissue, muscle mass, neurons and cells throughout the body.
3) As a person ages, all of the body systems gradually exhibit reduced productivity and there are expectations for each of the body systems; integumentary, skeletal, muscular, nervous, endocrine, cardiovascular, lymphatic, respiratory, digestive, urinary, and reproductive systems. In Mr Woods’ case, there are particular body systems that have been affected by illness.
- Integumentary: during the ageing process, the skin loses sensitivity, vascularity and cellularity and therefore becomes increasingly fragile and wounds take longer to heal.
- Respiratory: as we age, gas exchange becomes inefficient which makes it difficult to take part in activities requiring medium-high levels of exertion. Lung disease becomes more common due to a decrease in lung function and lung tissue, as well as chest walls becoming inflexible.
- Endocrine: there is a notable decrease in hormone production as the body ages, affecting metabolic processes within the body.
- Musculoskeletal: Mr Woods has been diagnosed with gout and osteoarthritis, particularly in his left knee. Loss of muscle mass occurs gradually with age and consequently, muscular activity becomes less operative and requires more energy from the individual to accomplish simple tasks.
- Cardiovascular: Mr Woods had a myocardial infarction eight (8) years ago and was diagnosed with hypertension thirteen (13) years ago. Cardiovascular disease becomes more common as we age as the blood vessels within the body become less flexible and reduce blood flow. Plaque can accumulate on the walls of the arteries resulting in the slowdown of cardiac blood flow and potentially a myocardial infarction and other complications.
- Neurosensory: Mr Woods was diagnosed with anxiety and depression two (2) years ago and more recently been diagnosed with Alzheimer’s dementia. The nervous system alters with age due to a reduction in neurons in the spinal cord and brain therefore the sense of touch, taste, smell, hearing and sight are all reduced. Age-associated memory impairment is also considered a normal part of ageing and can be related to dementia.
- Urinary: Mr Woods has had urgency incontinence for less than twelve (12) months. Structural changes in the ageing process to the urethra and bladder can predispose the elderly to the progress of urinary issues and ultimately, incontinence.
2) Two primary health services that would be appropriate for this for Mr Woods would include an occupational therapist and a psychologist. Occupational therapists work to assist the resident in coping with functional implications of dementia, they often work with residents with dementia, are able to identify impairments, strengths and occupational areas that the resident may need assistance in. The signs of dementia generally include, but are not limited to, decreased short-term memory, decreased problem-solving skills, decreased perceptual skills, problems with communication and language, and personality changes. (AOTA, 2020) The resident may establish an improved function through their adjustment to new aids or techniques implemented by the occupational therapist. A psychologist can assist in the management of the behaviour and mood changes associated with dementia. They are able to suggest and plan appropriate living spaces, offer techniques and suggest measures that can improve the physical and cognitive function of a person with dementia. Psychology Melbourne offers counselling to individuals diagnosed with dementia, to help them understand the diagnosis as well as work through the emotions that may be encountered, such as feelings of depression and anxiety. (Psychology Melbourne, 2020)
3) Strategies and interventions that may be able to assist in the care plan for Mr Woods may include:
Make sure Mr Woods’ environment is safe. Leave a light on in the toilet if possible, or install a small, dim nightlight. Remove any trip hazards and keep mobility aids within reach and in the same position every day to avoid confusion. Ensure Mr Woods has access to direct communication with the nurses at all times with the use of a call bell and frequent visits to his room.
Mr Woods has been seen getting ready for lunch at 0100hrs and this can be seen as non-productive behaviour. It would be appropriate to offer opportunities for engaging in tasks that fulfil the person’s need to be productive as much as possible during the day. Productive activities can include puzzles, a board game they personally enjoy. Increasing activity during the day can also lead to an extended and uninterrupted sleep during the night. All pain medication should be administered to ensure a comfortable sleep.
Mr Woods had been upset in the morning, stating that he was looking for his sister. It would be imperative to increase empathetic communication with Mr Woods in situations where he is distressed or confused. It would be appropriate to attempt to determine any triggers, nonverbal behaviours and identify any the emotional state of Mr Woods at the time. A psychologist and general practitioner can assist further in the management of mood changes, anxiety and depression.
Mr Woods tends to wander around the facility and often forgets where his room is and requires staff to redirect and reorientate him often, several times a day. It would be helpful to set up Mr Woods’ room to prevent falls, including moving mobility aids within safe limits and installing any additional technology available such as a door alarm when it is opened past 2100hrs. All nurses on duty should be made aware of Mr Woods’ tendencies to leave his room, as well as his room number, so that he can be escorted back to his room quickly and safely.
4) Mr Woods requires one staff to assist with personal care, including dental care (full lower/partial upper dentures). As Alzheimer’s progresses, it is possible that Mr Woods may forget how to care for their dentures or why it is important. A nurse will be required to provide oral and dental care in order to prevent infection, digestive problems and eating or swallowing difficulties. In regard to this care, a nurse should rinse Mr Woods dentures with clean water after mealtimes, brush them daily to remove any food debris and soak in a cleanser or mouthwash during the night. It would be appropriate to utilise a soft toothbrush or gauze pad to clean the gums, tongue and other soft mouth tissues to prevent any complications with oral health mentioned previously. Along with nursing care, a dentist should be involved in the management of Mr Woods’ oral and dental health. The dentist should be provided with all of Mr Woods’ medical history and medication list to ensure that there are no medications causing further oral health issues such as dry mouth.
5) Mr Woods’ pain may be a result of the musculoskeletal issues such as gout and osteoarthritis. In order to determine if Mr Woods was in pain, regular assessments such as a PQRST assessment and vital signs observations would be necessary. It would also be appropriate to notify Mr Woods’ doctor regarding his complaints of pain or organise an appointment for Mr Woods to explain his experience with pain to his preferred general practitioner. A referral to physiotherapist and administration of pain-relief (PRN Panadol 1gm TDS, Voltaren Emulgel daily to left knee, Endone 5mg PRN) can also assist in the management of Mr Wood’s pain.
6) Complementary therapies that may assist Mr Woods can include Art Therapy and Meditation/Relaxation techniques. Art therapy can be carried out by a trainer, in groups within the aged care facility. It can involve safe art materials and allows the participant to express themselves, relax and enjoy completing an activity without direction or instructions. This form of therapy can result in heightened self-esteem and positive thinking. Relaxation and meditation are both complementary therapies that can be taught in many different ways. Simple meditation techniques can be taught by a nurse to a participant, but a trainer can also run sessions in small groups within the aged care facility. There are many psychological benefits that result from this form of therapy and the techniques can be re-taught in sessions as well as used independently as many times as needed.
- Establish goals (with timeframes)
- Take Action
- Evaluate outcomes (has it worked)
- Reflect on process
Achieve a pain score less than 2/10 related to gout and osteoarthritis in left knee.
- Administer pain relief and gel to left knee and monitor John’s response to medication.
- Ensure John is not walking on his knee when in pain. Encourage bed rest for the period of time he Is experiencing pain.
- Utilise assistive mobility devices. Place aids near John’s bed and chair.
John is experiencing pain from OA and his pain level begins at a 7/10, on average, when he wakes up in the morning. With frequent pain relief and emulgel, John’s pain level decreases to a 3/10 during the day and night.
John’s doctor has been notified of the frequent pain and has prescribed additional pain relief.
Impaired urinary elimination
John has frequent assistance when toileting and receives immediate assistance following an incontinence episode.
- Change incontinence pads regularly.
- Ensure John is aware of how to call a nurse and what device to use.
- Assess incontinence episodes for aggravating factors, duration and frequency.
John often calls a nurse after he has had an incontinence episode. Pads are changed frequently.
Encourage John to call a nurse as early as he can following an incontinence episode so we can change his incontinence pad quicker and make him more comfortable.
Achieve Pulse rate/rhythm and Blood Pressure within normal range
BP and Pulse has remained individually acceptable range
- Monitor BP in both arms every hour and record findings in observations chart
- Perform skin assessment including capillary refill, skin colour, skin temperature and moisture.
We are monitoring John’s vital signs hourly to avoid hypertension.
John remains in normal ranges for BP and Pulse.
John is always compliant with vital signs observations.
Risk for falls
John will have no falls or trips
- Ensure John’s environment is safe and free of trip hazards.
- Place mobility aids within reach and in the same place daily.
- Keep John’s bed in the lowest position.
- Orient John to his surroundings.
- Assist John when standing or changing positions.
John has had no falls thus far. He often wonders but uses the side rail and occasionally, mobility aids. John needs continuous assistance when repositioning and standing up.
John needs to be monitored as he does not ring the call light when he needs assistance standing up. We have observed that he likes to go for a walk in the morning at 0800hrs, midday at 1400hrs and during the night and early hours of the morning.