Care of a Confused Patient

Introduction

The first FETAC Level 5 Assignment in Care Skills module requires that learners produce an assignment on the care of a confused person. This confusion can be the result of any number of causes – from an illness such as dementia or Alzheimer’s disease or the long term use or an abuse of drugs and /or alcohol. The assignment must be completed answering very specific points (as outlined in the table of contents). This assignment was compiled using various methodologies including:

• Classroom lectures and feedback sessions
• Class notes and Manual, hard copy manuals and books
• One to one sessions with Work Experience Skills Coach
• Previous life experience of caring for an ill family member
• Online research and library research

For the purpose of this assignment the author has decided to highlight one particular client who is in the Nursing Home in which the author is completing her work experience module. The clients name has been changed in order to respect her rights to privacy and dignity.

The client in this example has been diagnosed with Stage 4 Lung Cancer (T4, N3) which denotes that she suffers from a malignant tumour which has invaded the oesophagus, epicardium, pleural cavity, T5 and T6 vertebrae with Metastasis to the supraclavicular lymph node. She also suffers from osteoarthritis of L2-L5 and S1-S5, Type 2 Diabetes and Psoriasis.

She is currently on a variety of medications which are listed in her Care Plan, along with creams and ointments for the Psoriasis. Presently she suffers from severe bouts of confusion as a result of her pain medications and needs constant monitoring and care. In conjunction with her family, and a multi-disciplinary team Catherine has decided to move to a Nursing Home where she will receive the type of holistic care she requires. Catherine has also documented her specific wishes regarding her death and funeral arrangements and all of which has to be respected by all involved, the details are listed in her Care Plan along with the emergency contact details if her condition should suddenly decline.

INDIVIDUAL NEEDS ASSESSMENT

Initial assessment of Catherine’s needs using the Logan Roper Tierney model of assessment an individualised, client-centred holistic approach to Catherine’s care has been devised.

Physical

Catherine loves the outdoors and she should be encouraged to continue this through gardening – taking her out for walks, especially during spells of confusion. Ensure she has her walking stick and bring the wheelchair as she gets breathless very easily.

Shower rails and chair must be available in her room and always ensure that the non-slip mat is on the ground. When she is confused she forgets how to wash herself properly and will need assistance.

Intellectual

Catherine loves to read and complete quizzes and cross words – these are very good for stimulation and they should be made available to her in her room and in the day room.

The news and primetime are two of her favourite programs – ensure that they are on the TV in her room and the day room.

Diversional therapy of card games and jigsaws are great for completing when she is confused.

Emotional

As a result of the illness and her pending death Catherine can become depressed – she must be encouraged, made feel wanted loved, needed and always try to support her decision to move into the nursing home

Social/Spiritual

Socially, Catherine has a lot of friends with whom she plays cards – they are going to come visit her once a week to continue this tradition, the other residents should be encouraged to join in also as it will help integrate her more. Her large family of 8 children and 63 grand-children/great-grand-children/great-great grand-children all visit her when she is at home and will continue to do so. It is amazing the Catherine remembers all their names and dates of birth – during spells of confusion though she does tend to forget them a little.

Catherine is very religious and attends mass every Sunday when she is well – the angelus must be said at 12pm and 6pm and the rosary at 9pm.

Identify the level of assistance required

Catherine has very low level needs when she is not confused. She needs help sitting up in the bed and cannot use the remote control as her fingers are very badly damaged from the arthritis and as such will need assistance getting out of bed. She cannot manage small buttons when dressing and most days she just wears t-shirts but on Sundays she wishes to wear a blouse going to mass and will need assistance with that. Catherine dose not wear dentures and is on a chopped diet for now, she can manage to use cutlery but prefers to use a spoon. When she is confused she forgets when to eat and sometimes forgets that she has eaten so she will need monitoring when eating rather than assistance.

MAINTAINING A SAFE ENVIRONMENT

During confused spells Catherine likes to walk and as such walkways will have to be completely compliant with the Health and Safety Regulations for care as set out by the Health and Safety Authority. (HSA.ie, 2014) It would also be a good intervention to ensure that her walking aid is always within arm’s reach and that her shoes/slippers have rubber soles and are well maintained.

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For showering, the shower stool must be readily available and ensure that the hand rails are well maintained. The toilet in her room has a raised toilet seat and rail which must be cleaned and maintained regularly. Catherine will also use a commode, but when she is confused does not realise where she is when trying to urinate therefore she should be encouraged to go to the bathroom to protect her dignity.

When going on outings with her family Catherine’s wheelchair must accompany her always and kept well maintained and ensure the wheels are pumped.

PROMOTE CLIENT INVOLVEMENT IN SOCIAL EVENTS AND THERAPIES

Catherine likes to play cards therefore she would enjoy it as part of the available diversional therapies. The HCA can have table quizzes added to the curriculum of activities by the activities co coordinator and help her participate by writing the answers to the questions and holding the cards – when she is confused one to one games such as Patience or Snap are very helpful.

Catherine is quite a sociable person and will have loads of visitors – they will help to integrate her with the other residents and they play cards, tell stories, Irish dancing and play music some days she wishes not to have any visitors or participate in activities – in order to keep her from this depression the HCA could encourage her to attend the card game or maybe say some prayers with her as her strong beliefs will help to alleviate the depression. Catherine has refused to attend the Cuisle Centre in Portlaoise which has numerous activities and therapies available to cancer sufferers. The HCA could bring her more information on the services provided and explain what they are in detail and answer any questions she may have in order to encourage her to attend. They offer a Gardening Therapy workshop each week which would really benefit her along with the CranioSacral therapy and Holistic Massage would be beneficial for her also and she should be encouraged to go by bringing her down to the centre and having a talk with other clients that attend. (Cuisle Centre, Cancer Support Centre Laois, Cancer Support Portlaoise, 2014)

MOBILITY INDLUDING FALLS AND PRESSURE AREA CARE

FALLS

The results from the Morse Falls Assessment in Catherine’s Care Plan show that on non-confused days she is at low risk, but during spells of confusion she is moderate risk and as such – should be encouraged to walk around more during lucid days and be accompanied outdoors for short walks if her breathing allows – allow her to push the wheelchair for a while will help and support her. The activities co-ordinator has a great curriculum for mobility and Catherine should be encouraged to participate in order to help keep her arms active.

PRESURE AREA CARE

As Catherine suffers from Psoriasis she is even more susceptible to pressure sore development. Her skin should be cared for as per her prescribed treatment – creams and lotions to be applied daily. At the moment she is fairly mobile and does not remain in the one spot for too long – if she suffers bad pain during the day she tends to stay in bed and will need assistance turning and should be encouraged to do so – a second HCA may be needed for this as she has had two hip replacements which have to be cared for also – a hoist may be needed on occasion. Gel cushions should be used when she is playing cards with friends as she could be in the one position for hours, to break this she should be encouraged to get up and walk around every hour – even if for a few minutes.

EFFECTIVE VERBAL AND WRITTEN COMMUNICATION WITH CLIENT AND HEALTHCARE TEAM

Catherine has to attend various appointments for scans and pain medication updates. Any new developments need to be explained in full to her so she can make an informed decision as to what course of action she wants to pursue. Catherine must be kept informed at all times of any changes in her condition and has requested that she be told first so she can decide whether to tell her family. She has stated during meetings regarding her funeral wishes but may want to change these so ensure any changes are documented.

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All daily charts are to be kept updated immediately and inform the staff nurse of any noted changes in her condition at handover. As her cancer is rapid and fast progressing Catherine’s condition can and will change on a daily basis therefore food and fluid charts are vital. At the moment she is normal on the M.U.S.T scale, but as she tends not to eat when in pain this has to be carefully monitored and reported if she is refusing food or fluids.

ASSIST CLIENT WITH ACTIVITIES OF DAILY LIVING

Mobility Assistance

Catherine needs assistance when getting in and out of bed. She can sometimes sit up on her own but during spells of confusion she forgets how to stand up and should be encouraged and supported to do it herself as long as possible without the aid of a hoist. She may also need assistance getting in and out of the shower and needs her hair to be washed as she can no longer raise her arms above elbow height.

If the weather if favourable Catherine likes to go outside – she should be accompanied and ensure her wheelchair is in good working order. Allow her to walk as much as she can pushing the wheelchair but ensure she does not get too tired – encourage her to get into the wheelchair and continue until she wishes to return.

Catherine’s pain medication is prescribed by the GP and monitored by the Palliative Care team. She has certain pain killers that are available to her without the nurses supervision – please record when and what she is taking and report it back to the nurse for monitoring.

At the moment Catherine is normal on the M.U.S.T scale and we have to endeavour to keep her that way – she is on a chopped diet but needs to be monitored as the tumour is pressing on her oesophagus – it could cause a choking hazard – any noted changes to her swallow must be reported back to the nurse for further investigation by the MDT. When she is confused Catherine needs assistance eating as she forgets how to use the cutlery.

PROMOTE THE RIGHTS OF THE CLIENT TO DIGNITY, PRIVACY, INDEPENDENCE, POSITIVE SELF IMAGE

As Catherine is very self-conscious about her body – every effort must be made to give her as much privacy as possible when dressing and showering. She will need assistance dressing on occasion especially when she is confused as she gets the order of clothing mixed up. The HCA can discuss her wishes with her and come to an arrangement regarding the assistance she requires.

Catherine is very independent and likes to take her own medications and feed herself. She has expressed her wishes numerous times to all her family and multidisciplinary team regarding her funeral wishes and insists that she not be left alone from now on and even when she passes she does not want to be alone until she is buried with her husband.

Catherine needs to feel in control of the disease and wants to be informed if there is any changes being made to her medications or if the multidisciplinary team think that she is declining in any way regardless of the news make sure she is kept informed and involved in all decisions – it is best practice to inform Catherine first and let her decide when and how much information he and the rest of the family is to be told.

BIBLIOGRAPHY

http://www.upledgerclinic.com/conditions_symptoms.html

http://www.cuislecentre.com/therapies/

http://www.ahrq.gov/legacy/research/ltc/fallpxtoolkit/fallpxtool3h.htm

http://www.clinicaloncologyonline.net/article/S0936-6555(08)00451-2/abstract

http://www.nurse2nurse.ie/Upload/NA6762article.pdf

http://www.ncbi.nlm.nih.gov/pubmed/19059769

http://www.patient.co.uk/doctor/end-of-life-care-pro

REFERENCES

Cuisle Centre, Cancer Support Centre Laois, Cancer Support Portlaoise, (2014). Therapies – Cuisle Centre, Cancer Support Centre Laois, Cancer Support Portlaoise. [online] Available at: http://www.cuislecentre.com/therapies/ [Accessed 19 Dec. 2014].

Knott, D. (2014). End of Life Care | Doctor | Patient.co.uk. [online] Patient.co.uk. Available at: http://www.patient.co.uk/doctor/end-of-life-care-pro [Accessed 15 Dec. 2014].

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