An Exercise in Developing a Holostic Care Plan: Fill in the Gaps :-)

26
May

I had to break this holistic care plan table for nursing students into two sections. Keep in mind that columns are meant to be read across, from left to right. To aid in navigation I have numbered each column, so follow the path…

Fill in the gaps for a practical exercise in critical analysis, systematic planning, justification, implementation and evaluation.

Have fun~

Diagnosis 1	Assessment 2	Nursing Diagnosis 3
The patient has had an aortic valve replacement and has a history of Transient Ischemic Attacks		Stable (or does he have high blood pressure?) Valve working adequately (or not?) TIA strokes similar in sign to that of an actual stroke ² Blurred vision in both eyes, brief blindness, or double vision Difficulty speaking Weakness, sometimes on only one side of the body Vertigo (a whirling or spinning feeling) Strange sensations, such as burning or tingling Trouble with coordination and balance Loss of consciousness Temporary memory problems Headache Confusion³
The patient has a history of dementia and has been diagnosed with Alzheimer’s Disease
The patient experiences urinary incontinence	Loses control of his bladder Incontinence is not an inevitable symptom of dementia, but there are a number of reasons why someone with dementia could become incontinent. These include various medical conditions, a number of which are treatable. Medical causes include: Urinary tract infections - These usually respond to treatment with medication. Prostate gland trouble - This affects men, and may be resolved with an operation. Side-effects of medication- The GP can address this by changing the person’s prescription or altering the dose. Severe constipation- Constipation can put pressure on the bladder, and can also lead to faecal incontinence. Eating foods that are high in fibre, drinking plenty of fluids and keeping physically active can help prevent this. Non-medical causes may include: forgetting to go to the toilet; not recognising the need to go to the toilet because of the damage caused by dementia forgetting where the toilet is.	A urologist specializes in diseases of the urinary tract, and will perform the necessary tests to clearly understand the specific cause of one’s incontinence. Urinalysis. A sample of urine is examined for the presence of infection, blood, or other abnormalities. Physical Examination. A thorough examination by a physician will give a great deal of information regarding possible causes of incontinence, such as weak pelvic muscles or an enlarged prostate. While the patient’s bladder is full, the doctor can also directly examine for and assess leakage during coughing or straining. Post-void residual measurement. After the patient urinates, the amount of urine left over in the bladder is measured. This can be done by placing a small catheter into the bladder through the urethra and measuring the urine that comes out, or by examining the bladder with ultrasound. Ultrasound. Ultrasound can be used as a more comfortable way to measure the post-void residual amount of urine. Ultrasound also demonstrates the size and shape of the kidneys, ureters, and bladder to evaluate whether urine has backed up within the kidneys (hydronephrosis). Urodynamic testing. This in-depth examination evaluates bladder and urinary sphincter function as the bladder is filled and emptied. A small tube (known as a catheter) is placed through the urethra into the bladder to measure the pressure inside the bladder. At the same time, a catheter is place inside the rectum to measure the pressure in the abdomen. This test also assesses whether a patient has normal bladder sensation and capacity. The whole evaluation takes about 30-45 minutes. Pad tests. The patient begins an oral medication (Phenazopyridine) which temporarily turns the urine orange. Then, a sanitary pad is placed inside inside the underwear, and is changed every six hours for one 24-hour period. The amount of orange staining on the pads gives the urologist a rough estimate of the severity of the incontinence. The amount of urine leaked can also be estimated by weighing the pads. Voiding diary. The patient keeps a close record of when the urge to void occurs and when voiding and leakage occur. The amount of leakage is also recorded. This allows the physician to better understand the patient’s incontinence. Cystoscopy. The urologist places a cystoscope into the bladder through the urethra. The cystoscope is a long, narrow tube with a lens at the tip, which allows the urologist to thoroughly inspect the inside of the bladder for any abnormalities²¹

Goals

4

Nursing Interventions

5

Rationales

6

Keep the patient stable

Lower risks of TIA stroke⁴

Educate The patient to recognise triggers of TIA¹

Educate The patient in strategies to make lifestyle changes to lower his risk of TIA⁴

Educate family and other supports (e.g., multidisciplinary team) as to The patient’s unique needs⁷

Aspirin⁴

For atrial fibrillation (irregular beating of the heart)⁴

The doctor may recommend drug therapy or surgery to reduce the risk of stroke in people who have had a TIA⁴

As TIA is indistinguishable from a stroke it is better to lower the risk for either²

TIA can damage areas of brain cells (though not always; this can lead to the decrease in production and availability of acetylcholine (contributes to reasoning and retention of new info)^1.

Alzheimer’s Australia should provide information seminars for all people with memory

loss.⁹

There is a need to establish a community education campaign with a specific day per year as a prompt for people to consider their future planning. ⁹

Issues

associated with decision making in advance of loss of competence for people with

dementia, including the barriers that may inhibit the process.⁹

The recommendations made are consistent with views expressed at the National

Consumer Summit on Dementia in October 2005;⁹

‘people with dementia and their carers need to be recognised as partners in decision

making about care options’ (p. 7; ref 9)

Redesigning of physical environments can aid Alzheimer’s patients in having external memory cues¹⁰

Thickened fluids and energy supplements have been found to be of aid for people with dementia ¹²

Exercise is considered an excellent treatment option to reduce physical disability ¹⁵

Toileting habits change with dementia which can place strain on caregivers as well as increasing the likelihood of infection for the sufferer ¹⁶

Hygiene

Save him from embarrassment¹⁷

Aesthetic and hygienic habits for carers¹⁷

Be sure he is not hiding evidence of incontinence so that his hygiene can be maintained ¹⁷

Decrease humiliation and enhance carer postiveness in the situation ;¹⁷

Approaching the problem with understanding, matter-of-factness and humour can improve the situation for everyone concerned.

If someone has an accident, the three most important things that a carer can do are to:

try to overcome any embarrassment or distaste they may feel

avoid being angry or appearing upset

remember that it’s not the person’s fault.

However, this may not always be as easy as it sounds.

If a carer finds their feelings about incontinence difficult to handle, it’s a good idea talk things through with a community nurse or continence adviser.

It is important not to let dealing with incontinence get in the way of the relationship with the person being cared for ¹⁷

Hygiene is a very personal issue. From a very young age, we are trained to control our urges to go to the toilet, so being incontinent can make it feel as if one is losing control. This can affect a person’s sense of dignity and self esteem. Many people find it very hard to accept that they need help from someone else in such an intimate area of their life- even (or sometimes, especially) if from someone very close to them¹⁷

Make sure the person knows where the toilet is. A sign on the door may help. A visual reminder, such as a picture, may be more effective than words. This must be clearly visible, so put it within the person’s line of vision (not too high on the door), and make sure the image is bright so it’s easy to see.

Make sure that there are no obstacles in the way, such as awkwardly placed furniture or doors that are hard to open, obstructing the way to the toilet.

Leave the toilet door open when not in use so it is obvious when the toilet is vacant.

Make sure the toilet is easy to use. If aids such as handrails might be helpful, ask the GP to put you in contact with an occupational therapist, who will offer advice free of charge.

Consider changing the colour of the toilet seat. A black seat and a white pan can make it easier to see. People with dementia may experience orientation difficulties if the bathroom facilities are all the same colour.

Make sure any clothing can be quickly removed and unfastened. Some people find Velcro fastenings easier to use than zips or buttons¹⁷

Waterproof bedding - This will protect the mattress. However, make sure the sheet doesn’t come into contact with the skin, as it may become chafed and sore. You can also buy special protective duvet covers and pillowcases.

Absorbent undersheets - Reusable undersheets provide a dry surface on beds and chair beds.

Incontinence pads and pants - these can be worn day and night, or during the night only, to keep the area next to the skin dry. It is important to make sure they are the right absorbency, that they do not chafe, and that they are changed as often as necessary.

Most types are treatable ¹⁷

The patient may be using cholinterase inhibitors as part of his AD treatment to keep acetylcholine in the brain; excess acetylcholine linked to incontinence¹⁹

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