Aging is a natural part of human life. With modern technologies and medical innovations the society has been able to prolong life and thus increase the number of older adults in the society. Normal part of aging are inevitable physiological and psychological changes which need to be understood and addressed by nurses in order to provide appropriate care for older adults. Presenting patient’s description with appropriate data, I will utilize Watson’s Caring theory (2008) to assess the lower order need of activity-inactivity relative to this older adult patient cared for in the hospitalized environment. The integration of theory, research and best practice guidelines will be used to plan nursing interventions and strategies to meet the health needs of older adults in health care. Watson’s (2008) fourth caritas process of developing and sustaining a helping-trusting caring relationship will be used to describe the nursing implementations which were utilized in providing safe and competent care for older adult.
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Mr. X is 84 years old. He was admitted to the hospital on January 4, 2014 due to hematuria in his urine and a suspected Transient Ischemic Attack (TIA). After the admission, he was sent for a CT scan, which confirmed Mr. X’s TIA in his right hemisphere. On January 5, 2014 Mr. X was transferred to CP1, an acute care stroke unit. His first TIA episode had been on August 28, 2012. His comorbidities include hypertension and type II diabetes. His activities are limited to bed rest as he has risk of falls; also he is on input-output with a Foley catheter. He has left side weakness and mild facial drooping on the left side. He is alert and oriented; however, he has trouble focusing on many people at one time. His care plan states bed rest, assist with bath, diabetic diet, on intake and output. The vital signs obtained on the morning of January 28, 2014 were 36.7ï‚°, 85, 20, 92% and B/P 136/65. Mr. X’s Foley was taken out on January 24, and he was on intermittent catheterization every six hours. During catheterization the patient’s urine was dark amber with particles, and totalled 519 ml. The patient is on bed rest and can be lifted to sit using the Hoyer lift. Mr. X’s diet is diabetic with 1600 calories and a regular texture; he eats with 50% assistance, and usually finishes half of his entire meal. Mr. X. is a good candidate for motor recovery; however, his baseline cognitive status may affect his ability to participate in the recovery process. Mr. X scores 13/30 on the Mini-Mental State Examination (MMSE), which indicates moderate cognitive impairment, and 8/30 on Montreal Cognitive Assessment (MoCA) which also signifies cognitive impairment.
In order to be able to provide safe and competent care I had to research the diagnosis of my assigned patient. During the research the high correlation between his comorbidities and TIA was found. Transient ischemic attack (TIA) is a transient stroke that lasts only a few minutes, usually when the blood supply to part of the brain is briefly interrupted (Touhy, Freudenberger, Ebersole, & Hess, 2012, p. 354). The blood supply interruption is commonly caused by arteriosclerosis, which in Mr. X’s case is potentially caused by his present conditions of type II diabetes and high cholesterol. Type II diabetes is a disease in which the pancreas does not produce enough insulin and the body does not properly use the insulin made (Canadian Diabetes Association, 2012). Mr. X is also a heavy man, which puts him into a high risk category for stroke since the excess weight destabilizes the body’s cardiovascular system. Mr. X’s Foley catheterization was due to stroke and diabetes, since them along or together as comorbidities are associated with urinary incontinence (Touhy et al., 2012, p. 141). In order to provide my patient with safe and competent care I had to maintain the patient in high Fowler’s position during breakfast and lunch to reduces his risk of aspiration and promote effective swallowing (Potter, Perry, Stockert, & Hall, 2014, p. 1089). I also had to check for pocketing while I assisted Mr. X with his meal to prevent aspiration. Since Mr. X is assigned on bedrest a head-to-toe skin assessment was carried out with each bed bath to assess for skin break down “particular attention should be paid to vulnerable areas, especially over bony prominences” (RNAO, 2005, p. 9). In order to prevent the development of ulcers, I repositioned patient every two hours, used pillows to protect bony prominences and heel pressure ulcer guard for extra protection of heels (RNAO, 2005, p.10). Further to ensure the skin integrity, the adult briefs were changed frequently, and the barrier cream was applied to the perennial area. After two weeks the Foley was taken out to see if the patient is able to void by himself and to allow the bladder sphincter to function on its own. The intermittent catheterization to drain residual urine was introduced in order to prevent a UTI, since the “in-dwelling urinary catheter remains in the bladder for an extended period, making the risk of infection greater than with intermittent catheterization” (Potter et al., 2014, p. 1156). As mentioned previously, on the MoCA Mr. X scored 8/30 which is just above the score of “0 to 7= severe cognitive impairment” (Touhy et al., 2012, p. 91). Likewise, on the MMSE Mr. X scored 13/30, where the score between 13 and 20 suggests moderate dementia (Touhy et al., 2014, p.92). Consequently, Mr. X is a good candidate for motor recovery; however, his cognitive impairment may affect his ability to participate.
One of the lower order needs defined in Watson’s Caring theory (2008) is the activity- inactivity. As Watson’s Caring theory (2008) describes, “a person’s need for activity-inactivity is fundamental and central to one’s life, as it affects the ability to move about and interact with his or her environment and to control one’s external and internal surrounding” (p. 160). The need for activity-inactivity is strongly connected with the life satisfaction, since the restricted activity puts one into high dependence of the caregiver. While providing care for patients who are limited with ambulation it is necessary for the nurse to remember to preserve patients’ dignity, enabling, and encourage them to perform necessary everyday living activities by themselves. Other psychological factors such as routine repetitiveness while patient is on the bedrest, may result in a functional loss of degree of mental status which may interfere with ability to perform and accomplish daily living activities (Gillis & MacDonald, 2005, p.17). Mr. X low score on MoCa and MMSE may be a result of prolonged bedrest in which case the mental stimulation is needed to exercise the brain and break through the everyday routine. The possible nursing intervention for mental stimulation would be Snoezelen room, where the patient is exposed to different stimuli such as sounds, lights and colors, music and touch. The Snoezelen room has a potential to improve concentration, attention, mood and provide a necessary stimulation to the central nervous system to preserve balance (Van Weert et al., 2006, p. 658). The other very important factor of activity-inactivity need is the physical factor of muscle atrophy and deconditioning. According to Gillis and MacDonald (2005), “deconditioning is a complex process of physiological change following a period of inactivity, bedrest or sedentary lifestyle” (p.16). The process of deconditioning affects the musculoskeletal system, decreasing the muscle strength, leaving the person frail and unable to ambulate on their own. Normal musculoskeletal system changes for older adults include changes such as total muscle mass decrease, increase rigidity of joints, and loss of strength (Touhy et al., 2012, p.76). Even though these changes are not life threatening, they have a potential complication of falls for frail older adults whose health has been compromised to the point where they have to be admitted to the hospital. In order to avoid any further disturbance of the organism and prevent injuries, patients such as Mr. X are placed on the bedrest. According to Kuromoto (1989), “bedridden or inactive patients require range of motion exercises to maintain joint mobility and muscle flexibility and to minimize contractures that prevent recovery and make care more difficult” (p.283). Therefore, recognizing extensive need of activity-inactivity, I incorporated the range of motion exercises into Mr. X’s daily routine. The second nursing intervention for physical activity was the resistance training with elastic band. According to Topp et al. (2003), “elastic bands exercise […] was designed to improve upper and lower body strength” (p. 155). The third nursing intervention to promote physical activity was the hip-flexion and keen extension exercises while in the wheelchair, both of which are both recommended for older adults in order to increase strength and balance (Topp et al., 2003, p. 157). For additional nursing intervention I encouraged Mr. X to dress by himself, brush his teeth and eat on his own, all these activities helped Mr. X gain confidence in his performance, exercise his muscles on the regular basis. All of the physical exercises where targeted toward muscle strength increase, upon building confidence in strength I would encourage Mr. X to get up of the wheelchair for standing in order to gain balance. If all the interventions are successful, further activities would include aerobic walking to improve lower body strength, pedal exercise for muscle strengthening and blood circulation improvement (Grando et al., 2009, p. 13). The advantage of exercise according to Straub, Murphy, and Rosenblum (2008), “include reduced risk for cardiovascular mortality, improved blood pressure control, better glucose control in those with diabetes, and improved psychological well-being and physical functioning” (p. 470). Body is a multifunctional system where decrease in activity result in multidimensional deteriorations. According to Watson’s Caring theory (2008), “activity and meaningful work and service through activity bring satisfactory and purposive meaning to life” (p.160). The prolonged bedrest increases the necessity to satisfy the lower order need to activity-inactivity in order to increase patient’s satisfaction with quality of life and potentially reduce the hospital stay.
One of Watson’s caritas process (2008) is, “developing and sustaining a helping-trusting caring relationship” (p.71). Caritas nurse needs to remember that the patient is not just a body that needs to be treated, is it also human-being whose needs go beyond physiological, thus holistic treatment is necessary to addresses physiological as well as psychological needs. Only through this view it is possible to create a “caring moment”, where nurse and client would develop a meaningful, trusting relationship in order to reach optimal health (Watson, 2008, p. 71). While providing care for the patient I was always engaged into active listening, through which I was able to learn about Mr. X’s past, his favourite activities and the food preference. I learned that Mr. X was active, which helped me understand better the extensive need for activity which Mr. X did not get enough. Using this knowledge I modified and incorporated more physical activities into his daily routine. I was trying to provide care for the patient at the most comfortable time “enter into the experience to explore the possibilities in the moment” (Watson, 2008, p.74). One of the Mr. X’s nights was restless and he preferred to rest throughout the morning, I recognized his need and postponed the physical exercise and bed bath until later. I encouraged Mr. X to communicate his expectations of healing process, recognizing client-centered relationship where the patient is actively including into care (CNO, 2009, p.6). Helping-trusting relationship was demonstrated through the non-judgmental attitude, sensitivity and openness. Mr. X disclosed that even though he enjoyed physical activities, his lifestyle was not all healthy; he enjoyed unhealthy foods which contributed to the development of type II diabetes, and after found it hard to follow the diabetic diet. My response to Mr. X was to engage him into teaching of importance to adhere to the diabetic diet, have the consultation with dietician, and referral to the community resources of Canadian Diabetes Association. In order to provide Mr. X with competent care, I needed to gain his trust, which I was able to achieve by preserving Mr. X’s dignity while providing bed bath, allowing him to do as much care as it is possible, exposing only parts of the body that I was working with while washing. In order to be a Caritas nurse, I provided authentic care for Mr. X. by being present in the moment and caring beyond physical needs. Recognizing emotional part of helping-trusting caring relationship, encouraging patient into communication, plan of care development and decision making, I was able to establish and authentic caring relationship, where patient and I where equal participants in establishing healing environment.
In order to be able to care for older adult nurses need to understand the special needs associated with aging, the comorbidities of their patient and how they are interrelated. Extensive research of patient’s history will enable the nurse to provide safe and competent care. Utilizing Watson’s Caring Theory (2008) and the lower-order needs into plan of care development will help prioritize care in order to assist individual with maximize life satisfaction. Recognizing oneself as the Caritas nurse and utilizing Watson’s caritas processes will help develop authentic caring relationship with your client to promote holistic healing and overall well-being.
College of Nurses of Ontario (CNO). (2009). Practice Guideline: Therapeutic Nurse Client Relationship, Revised 2006. Retrieved from http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf
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Grando, V.T., Buckwalter, K.C, Maas, M.L, Brown, M., Rantz, M. J., & Conn, V.S. (2009). A trial of a comprehensive nursing rehabilitation program for nursing home residents post-hospitalization. Research in Gerontological Nursing, 2(1), 12-19. Retrieved from http://search.proquest.com.uproxy.library.dc-uoit.ca/docview/194680830?accountid=14694
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