Delirium, characterized by a change in cognition and a disturbance in consciousness, is a common problem that nurses encounter when caring for the elderly. Approximately half of hospitalized patients are older than the age of 65, and 56% of these patients will either have delirium on admission, or will acquire delirium during their hospital stay (Dahlke and Phinney, 2008). If left untreated, delirium can lead to harmful outcomes, changing the lives once had by elderly individuals. The following represents an example of an older adult acquiring delirium during her hospitalization: “Ms. Cotes, age 77, is in hospital after a knee replacement surgery due to osteoarthritis. She developed a UTI in hospital and required opioid pain medication for back neck pain. Her discharge to a rehabilitation facility is on hold because of new issues. She has tried to leave her room on her own and seems to forget about her operation. She says that the staff is stealing her clothes and the food is poisoned; she refuses to eat or drink. Prior to hospitalization, Ms. Cotes lived at home, worked as a volunteer, was a keen gardener, and played cards often at the senior’s center. Her home was immaculate.” Studies show that one of the major reasons why delirium is still a common issue in the older adult population is the lack of efficient care given by the nurses (Dahlke and Phinney, 2008).
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According to nursing theorist, Jean Watson, the artistic domain of nursing emerges as transpersonal caring-healing modalities which “correspond to providing comfort measures, helping the cared-for to alleviate pain, stress, and suffering, as well as to promote well-being and healing.” (Cara, 2003). By focusing on the case study of Ms. Cotes, the application of Watson’s caring theory will allow nurses to give efficient care to patients with delirium by promoting effective healing, and to help decrease the risks of acquiring delirium in the future. First, one of Watson’s assumptions states that caring promotes self-knowledge, and self-healing processes and possibilities (Cara, 2003). It is important to care for Ms. Cotes through engaging in health promotion and teaching her about her health in order to achieve wellness and healing. Also, according to Watson, the nurse’s creativity contributes to making nursing an art (Cara, 2003). Nurses can come up with a variety of nursing interventions to help Ms. Cotes with her difficulties of delirium and help her heal. Last, it is important for nurses to acknowledge the elderly population and avoid negative attitudes towards them; instead, nurses should apply Watson’s theory by being “authentically present, and enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for.” (Cara, 2003). As a result of applying Watson’s caring theory into a practice, nurses can provide efficient care to clients like Ms. Cotes who are suffering from the negative outcomes of delirium.
One of Watson’s assumptions states that caring promotes self-knowledge and self-healing processes and possibilities (Cara, 2003). To apply this assumption, nurses can give care to clients like Ms. Cotes through engaging in health promotion and teaching them about their health in order to achieve wellness and healing. An important step in order for a nurse to give care is to know about the client’s conditions and how to prevent it from becoming worse. Dahlke and Phinney’s (2008) study shows that nurses lacked the knowledge to efficiently care for older adults with delirium; as a result, “nurses often found themselves intervening in ways that contradicted the best interests of the older adults in their care.” To prevent the development of delirium in elderly patients, nurses must be “equipped with the skills and knowledge to identify and assess for delirium. The reduction on the incidence of delirium can be obtained through meticulous assessment and early recognition of symptoms.” (Feazah, 2008). The first step to prevent delirium is to identify the risk factors that lead to it. In the case of Ms. Cotes, several factors were presented which may have caused her to develop the disorder. For instance, her knee replacement surgery played a major role in the acquisition of delirium because it led to her attaining a UTI, an infection known to induce delirium (Feazah, 2008). A knee replacement surgery would have kept Ms. Cotes immobile for a long period of time, resulting in urine incontinence and the use of urinary catheterizations, both a leading cause of UTI. To prevent the risk of attaining the infection, it is highly important for nurses to assess “after a set period of time, whether an indwelling urinary catheter is still indicated for the patient” (Bernard, 2012), to decrease the risk of attaining a bladder infection. Moreover, care can be given by promoting health by informing Ms. Cotes about the risks of urinary catheters and the importance of urinary continence, so that she will have self-knowledge and will be self-informed of the possibilities of wellness and healing. Another risk factor of delirium in the case of Ms. Cotes is the use of opioid medication for her back neck pain. Nurses should minimize the dosage of pain medication to help reduce the symptoms of delirium: “Opioid use has been associated with delirium in several large prospective studies in hospitalized patients. Some data suggest that the risk of opioid-induced delirium is dose related…” (Alexander, 2009). By attaining knowledge of associated risk factors, and applying Watson’s theory of caring by sharing data with the client in order for them to be self-knowledgeable and self-informed on healing possibilities, nurses will be able to provide effective care to patients with delirium.
Also, according to Watson, the nurses’ creativity contributes to making nursing an art (Cara, 2003). Nurses can come up with a variety of nursing interventions to help Ms. Cotes with her difficulties with delirium and help overcome the disorder to decrease her hospital stay. For example, nurses can be creative by applying Watson’s 6th carative factor in practise: “a caring environment preserves human dignity, wholeness, and integrity; they offer an authentic presencing and choice.” (Cara, 2003). A nurse can apply this carative factor by altering the environment to suit the needs of Ms. Cotes, aiding in the healing process. There are a number of creative ways in which a nurse can perform therapeutic environmental modification to help reduce the risk of delirium episodes. A nurse can: Modify Ms. Cotes’ environment by keeping the physical environment consistent and by maintaining routines; provide continuity of staffing for accurate assessment of her health status and consistent care; involve family in care and providing frequent orientation to promote a sense of well-being; using a no-restraint or least-restraint policy to reduce worsening of delirum; promote familiarity such as the encouragement of using personal items; create well-lit surroundings; maintain appropriate room temperature; and reduce noise levels on the unit (Gillis & Macdonald, 2006). According to Gillis and Macdonald (2006), nursing environmental interventions focuses on balance – “between sensory deprivation and sensory overload, and between patient independence and supportive care.” The balance of rest, exercise, and consistent nursing designates nursing as a science and an art. By maintaining balance in the environment of Ms. Cotes, the application of Watson’s caring theory of a healing-environment is achieved. Watson discusses how the “healing space or environment can expand the person’s ‘awareness and consciousness’ and promote mindbodyspirit wholeness and healing.” (Cara, 2003). Therefore, by applying Watson’s theories, nurses should be creative by modifying the environment of the delirius elderly, and to provide routine care to promote wellness and healing success.
Lastly, it is important for nurses to acknowledge the elderly population and avoid the negative attitudes towards them. Instead, nurses should apply Watson’s theory of being “authentically present, and enabling and sustaining the deep belief system and subjective life world of self and the one-being-cared-for.” (Cara, 2003). In order to give efficient care to patients like Ms. Cotes, nurses must understand that delirium is an acute illness, not the elderly’s personality. It is noted that “nurses who believed confusion was normal in older adults would be less likely to recognize symptoms of delirium as a medical emergency requiring their attention and intervention.” (Dahlke and Phinney, 2008). Dahlke and Phinney’s (2008) study also showed that nurses perceive delirious elderly as children who require babysitting, and consequently a burden in their work. Furthermore, nurses fail to provide efficient care when they focus on collecting physical data while ignoring the subjective experiences of the client. Watson suggests that when collecting physical data about the patient, nurses should inquire about his mind and spirit as well (Cara, 2003). She strongly believes that spirituality “upholds a foremost importance in our profession. In fact, she ascertains that the care of the soul remains the most powerful aspect of the art of caring in nursing.” (Cara, 2003). In the case of Ms. Cotes, a nurse can enter her phenomenal field by asking her a number of questions about herself such as life experiences, bodily sensations, spiritual and cultural beliefs, and goals and expectations (Cara, 2003). This method of transpersonal caring may encourage Ms. Cotes to share her life story, and help her to find harmony and meaning to her life crisis. Therefore, it is important for nurses to disregard the negative attitudes towards clients with delirium and provide care by being authentically present.
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In conclusion, nurses can provide delirious clients with efficient care utilizing Watson’s theories: promoting care by engaging in health teaching to allow clients to be become self-informed and self-knowledgeable of healing possibilities; providing nursing care artistically through creative interventions like therapeutic environmental modification; and by disregarding negative attitudes towards the elderly and providing transpersonal caring by being authentically present. Certainly, by using Watson’s caring theories, nurses can provide efficient and effective care to the elderly with delirium, and allow them to reach harmony, wellness and healing.
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