Patient Symptoms and History
The resident, a 60 year old retired Army veteran, (name withheld to maintain privacy of the client), having a history of Post Traumatic Stress Disorder, with which he had been suffering for the last 10 years, and have been recently diagnosed with Alzheimer’s disease. The client developed the PTSD syndrome while on duty, and exposed to the different mental stress commonly seen with war veterans. The clients have been recently facing episodes of memory loss. During admittance, he was unable to speak clearly, and explain his symptoms, and was very irritable and moody. His daughter is his primary caregiver, who said that since the demise of her mother (the clients spouse) about a year ago, the client became very isolated, and stopped socializing altogether. She also added that the symptoms of memory loss started about 2 months ago, along with speech difficulties. In addition, of recently he is facing trouble with movement, and taking care of himself and fulfilling the activities of daily living. These conditions have had a significant impact on the mental well being of the client, making him feel anxious, confused and even delirious, which PTSD symptom. The actual diagnoses for the patient were confusion and disorientation, lack of motivation, memory loss, risk of falling and nutritional deficit/dehydration. Additional potential diagnoses included a sense of isolation of the patient, lack of confidence, irritability, and sensory overstimulation. Berry (2014) also related confusion and disorientation as symptoms of dementia, and showed the importance of cognitive support in their care. The identified diagnoses highlights the neuro cognitive effects of the clients condition, that contributes to the deterioration of the patients well being.
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The client had re experiencing symptoms like flashbacks, disturbing thoughts and dreams, avoidance symptoms like avoiding travelling in cars which reminded him of certain traumatic events as well as avoiding talking about the incident, arousal and reactivity symptoms like chronic tension and stress, sleeping problems and outbursts of anger. The client also shows a significant feeling of guilt, and a disinterest in activities he previously enjoyed like socializing with his friends at local pubs. symptoms of memory loss started about 2 months ago, along with speech difficulties. In addition, of recently he is facing trouble with movement, and taking care of himself and fulfilling the activities of daily living. He used to stay alone; however, his daughter is concerned about his mental health and well-being, and therefore wanted residential care for her father, since she cannot provide constant supervision for her father.
Nursing Theory – Dorothea Orem’s Self Care Theory
The nursing theory that I believe is the most appropriate for the client is Dorothea Orem’s Self Care Theory, as such will help the client to develop the ability of taking care of himself, and improve his independency. The reported feeling of irritability and mood swings can also support this, especially when the patient is in need of help with the acts of daily living, which increased his sense of dependency. Self-care can be understood activities that an individual can perform on their own behalf in order to maintain normal health and well-being. The theory is based on five assumptions:
- Humans need to constantly engage in communication and making connections with each other to live and be productive.
- Ability of deliberate action is important to address self-needs and make independent decisions.
- Life or Function regulating activities supports self-care activities, and can be private for mature individuals.
- A human agency can facilitate discovery, development and transmission of knowledge to others that can assist self or others.
- Humans in groups and structured relation can manage their tasks and responsibilities, and provide care for other members of groups (Dorothea Orem – Self Care Nursing Theory – Nurseslabs 2017).
The theory also assumes that: individuals ought to be self reliant, being able to help themselves and others, nursing is an activity that involves more than one person, meeting the self care requirements is vital for primary care, knowledge of health effects are important for promoting self care, self care and dependant is learnt within a socio-cultural context. The self-care theory is based on three interconnected theories 1) Theory of Self care, 2) Theory of Self Care Deficit and 3) Theory of Nursing Systems.
Orem’s self-care theory essentially outlines the importance of self-care, the activities that are involved in self-care (the normalcy), and identifying deficits in self-care which can be fulfilled by nursing system. Nursing process based on Orem’s Theory can be segregated into three parts: Assessment, Nursing Diagnosis and Planning and Implementation & Evaluation and Assessment Dorothea Orem’s Self-Care Theory, 2017).
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The Bio-psycho-social considers that mental health mental health issues have different factors influencing it, from different inter related domains like biological or physiological (medical condition that causes the mental health issues), psychological (effect of the mental health issue on the psychology and cognition of the individual) and social condition (like isolation and loss of a loved one) (The Bio-Psycho-Social Model, 2017). The biological or physiological factors related to the clients mental health condition is related to the rapid degeneration of the neurons of temporal and parietal lobes of the brain as well as the cingulate gyrus and frontal lobe (Cortes-Canteli et al., 2015). These regions are related to the higher cognitive process like language and thought processing, and the centres of human intelligence. The disease causes dysfunctions in the related regions, thereby affecting the cognition and psychology of the individuals. The other physiological factors affecting the client are memory loss, difficulty in speech and a reduced motor performance that is affecting the client’s ability to perform the acts of daily living by himself. The psychological factors affecting the client include mood changes, depression, isolation, anxiety, and confusion. The increased sense of dependability of the client also if further stressing his mental well-being, as the client is not used to it. The demise of his spouse was a major factor that aggravated his PTSD symptoms. The previous progress achieved due to psychological counselling was undone by this recent episode of loss. The client became completely isolated from his social circle, stopped taking care of himself, and started developing different psychological and cognitive symptoms of mental health disorder. Additionally, mental a cognitive aversion of social interaction further affects the psychological well being of the patient, apart from the fact that it increased risk of accidents of the patient, as he was not able to take care of himself on his own. Hence, the experiences of the client can be understood as a culmination of these multi-dimensional factors affecting the mental and physical well being of the patient.
Bio-Psycho-Social Model
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Diagnosis or potential diagnosis
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Goal
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Strategies and/or interventions
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Rationale
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Relevant primary health care services
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Complementary therapies
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Evaluation
|
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Confusion and disorientation
(actual)
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To reduce confusion and disorientation experienced by the patient
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1.Assisting the patient in their decision making and sometimes making simple decisions for them
2. Encouraging the patient to orient themselves to their environment and increase their interaction with people.
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Confusion and disorientation can lead to poor cognitive performance, and increase risk of self injury.
The patient is suffering from AD and PTSD, which increases the propensity of mood disorders.
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Primary nurse
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Notification of situations that the patients find confusing, and assisting them on such aspects.
(Mace and Rabins 2017)
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Ability to maintain a good quality of life, and avoid stress.
|
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Lack motivation in self care
(actual)
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To increase interest in self care, and well being, and increase proactive efforts to maintain wellbeing of the patient.
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1 Counselling the patient, and help to maintain the acts of daily living
2. Helping the patient lead a meaningful life.
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Lack of motivation in self care often results from depression and a lowered perception of the quality of living.
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Primary nurse, psychologists
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Exercise and daily activity routines to increase self motivation
(Innes and Selfe 2014; Khalsa 2015; Danucalov et al. 2017)
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The effect can be evaluated by an increased involvement of the patient in self care activities.
|
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Memory loss
(actual)
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To help the patient in remembering important things, and aid the memory of the patient.
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Using notes, colour coding, labels and pictures to help the patient remember important things
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Visual aid can be an effective way of aiding memory.
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Primary Nurse
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Exercise routines
(Snigdha et al. 2014; Duzel, Praag and Sendtner 2016)
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The ability of the patient to remember things, with the help of the different memory aids.
|
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Risk of falling
(actual)
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To ensure the patient does not get injured by falling.
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Eliminating tripping hazards in the environment, like loose rugs, or objects lying on the floor.
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Since the patient is facing difficulties keeping his place organized, the hazards of falling is significantly more, which is aggravated by the poor motor reflex of the patient.
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Primary Nurse, Home care professionals
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Exercise routines to develop motor coordination and reduce risk of falling.
(Franco, Pereira and Ferreira 2014; Paillard, Rolland and Barreto 2015)
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Improvement in condition can be reflected by the improved ability of the [patient to navigate in his environment, and an improved reflex.
|
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Nutritional deficit and dehydration
(actual)
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To ensure that the patient does not suffer from nutritional deficits or dehydration.
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Ensure that the patient is given food on time, and adequate water is available. Also monitoring the quality of food consumed, analysing for any nutritional deficiencies.
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Since AD patients have a lowered health outcomes due to the inability of self care, they often suffer from nutritional deficits and dehydration, which can have adverse health effects.
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Primary nurse, nutrition experts
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Counselling sessions for patient’s family in order to educate them on effective care strategies for the patient.
(Amici et al. 2016; Forstmeier et al. 2015).
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Regular checkups for the patient for vitals and health issues.
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Isolation
(potential)
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To prevent the negative effects of isolation on the mental health of the patient.
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Encourage social interactions
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Isolation can have negative effects on the mental and emotional health of the patient, interactions can alleviate such effects
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Primary nurse, psychological counsellors, family, friends
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Social interactions, volunteer work
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Regular assessment of cognitive dissonance and depression.
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Lack of confidence
(potential)
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To improve patient’s confidence in their ability to take care of themselves and make self decisions.
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Help the patient make independent decisions, and helping the patients when they are facing difficulties in decision making.
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The impeding cognitive performance can make decision making a challenging work, and can reduce the confidence of the patient. The reduced confidence can further affect their ability to take care of their own needs, and make independent decisions.
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Primary nurse
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Indulging in self care activities
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Regular check on the cognitive abilities of the patient.
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Irritability
(potential)
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To reduce the feeling of irritability and aggression in the patient, which can stress their emotional well being?
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Ensuring the environment is peaceful, calm, quiet
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Irritability can be caused due to an increasing confusion faced by the patent, and can lead to erratic behaviour.
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Primary nurse, psychological counsellors
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Physical exercise can help calm the nerves, and reduce excitability (Bartholomew, Morrison and Ciccolo 2005; Callaghan 2004)
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Regular checkups.
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Sensory Overstimulation
(potential)
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To ensure that the patients live in an environment that does not over stimulate their senses.
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Ensuring the environment is peaceful, calm, quiet
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Sensory overstimulation can also cause erratic behaviour
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Primary nurse
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Exercise and meditation
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Reduced overstimulation and erratic behaviour.
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13 Alzheimer’s Disease and Dementia Nursing Care Plans. (2017). Nurseslabs. Retrieved 31 December 2017, from https://nurseslabs.com/alzheimers-disease-nursing-care-plans/
Amici, S., Iannizzi, P., Di Pucchio, A., Abraha, I., Montedori, A., Chattat, R., & Vanacore, N. (2016). Can early counselling and support for Alzheimer’s disease caregivers reduce burden? Study protocol for a multicenter randomized controlled trial. Clinical Trials in Degenerative Diseases, 1(3), 99.
Bartholomew, J. B., Morrison, D., & Ciccolo, J. T. (2005). Effects of acute exercise on mood and well-being in patients with major depressive disorder. Medicine & Science in Sports & Exercise, 37(12), 2032-2037.
Berry, B., 2014. Minimizing confusion and disorientation: Cognitive support work in informal dementia caregiving. Journal of aging studies, 30, pp.121-130.
Callaghan, P. (2004). Exercise: a neglected intervention in mental health care?. Journal of psychiatric and mental health nursing, 11(4), 476-483.
Cortes-Canteli, M., Mattei, L., Richards, A. T., Norris, E. H., & Strickland, S. (2015). Fibrin deposited in the Alzheimer’s disease brain promotes neuronal degeneration. Neurobiology of aging, 36(2), 608-617.
Danucalov, M. A., Kozasa, E. H., Afonso, R. F., Galduroz, J. C., & Leite, J. R. (2017). Yoga and compassion meditation program improve quality of life and self?compassion in family caregivers of Alzheimer’s disease patients: A randomized controlled trial. Geriatrics & gerontology international, 17(1), 85-91.
Dorothea Orem – Self Care Nursing Theory – Nurseslabs. (2017). Nurseslabs. Retrieved 29 December 2017, from https://nurseslabs.com/dorothea-orems-self-care-theory/
Duzel, E., van Praag, H., & Sendtner, M. (2016). Can physical exercise in old age improve memory and hippocampal function?. Brain, 139(3), 662-673.
Forstmeier, S., Maercker, A., Savaskan, E., & Roth, T. (2015). Cognitive behavioural treatment for mild Alzheimer’s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial. Trials, 16(1), 526.
Franco, M. R., Pereira, L. S., & Ferreira, P. H. (2014). Exercise interventions for preventing falls in older people living in the community. Br J Sports Med, 48(10), 867-868.
Giebel, C. M., Burns, A., & Challis, D. (2017). Taking a positive spin: preserved initiative and performance of everyday activities across mild Alzheimer’s, vascular and mixed dementia. International journal of geriatric psychiatry, 32(9), 959-967.
Innes, K. E., & Selfe, T. K. (2014). Meditation as a therapeutic intervention for adults at risk for Alzheimer’s disease–potential benefits and underlying mechanisms. Frontiers in psychiatry, 5.
Khalsa, D. S. (2015). Stress, meditation, and Alzheimer’s disease prevention: where the evidence stands. Journal of Alzheimer’s Disease, 48(1), 1-12.
Mace, N. L., & Rabins, P. V. (2017). The 36-Hour Day: A Family Guide to Caring for People Who Have Alzheimer Disease, Other Dementias, and Memory Loss. JHU Press.
Paillard, T., Rolland, Y., & de Souto Barreto, P. (2015). Protective effects of physical exercise in Alzheimer’s disease and Parkinson’s disease: a narrative review. Journal of clinical neurology, 11(3), 212-219.
Snigdha, S., De Rivera, C., Milgram, N. W., & Cotman, C. W. (2014). Exercise enhances memory consolidation in the aging brain. Frontiers in aging neuroscience, 6.
The Bio-Psycho-Social Model. (2017). Mentalhelp.net. Retrieved 31 December 2017, from https://www.mentalhelp.net/articles/the-bio-psycho-social-model/
Wilson, R. S., Krueger, K. R., Arnold, S. E., Schneider, J. A., Kelly, J. F., Barnes, L. L., … & Bennett, D. A. (2007). Loneliness and risk of Alzheimer disease. Archives of general psychiatry, 64(2), 234-240.
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