LTC assignment #2 PDF

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LTC assignment #2 Shana M. Hollopeter [email protected] BADNAP NS1 OCCC

Geriatric case study Answer these questions about Julia: 

What are Julia’s strengths? o Positive attitude – feelings of happiness, pride, and accomplishment o Readiness for Change with Self-direction - ”I'm ready...”, “Would have liked to stick around a little longer, but I know it’s not to be.” o Strong relationship - 25 year partners with Lucy with lasting and vivid memories

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What are your concerns for this patient? o Her concern for the future of her partner Lucy and how it will affect her decisions o Support for her decision with the next steps in her healthcare and the couple's ability to sustain them mentally and physically

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What is the cause of your concern? o Julia is worried about Lucy’s health after the knee surgery and her ability to continue with an engaged lifestyle

o Because of these concerns Julia may not feel confident in her palliative care and possible end-of-life decisions o These can cause undo stress on their relationship and decrease the quality of life for all involved 

What information do you need? o Are the couple at a similar level of acceptance in their future roles in Julia’s healthcare, both mentally and physically? o What outside help do they have? Even though the son and niece have offered help, what will they bring to the team. o Have they explored options with Julia’s healthcare team for palliative care and hospice? o Does Julia have an Advanced Directive?

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What are you going to do about it? o By having an open and honest discussion with Julia and Lucy, I would hope to gain insight into what their expectations are for Julia’s remaining time. o By supporting open communication with the family, an avenue for understanding what the family is offering for support can be established. i.e. is this to be daily meals/errand running or a chance for respite care. By setting reasonable expectations the stress of assuming information can be averted. o By encouraging an open discussion with their healthcare team and provider, timely and appropriate care can be established for both Julia and Lucy. o Ask Julia and Lucy about Advanced Directives and provide them with information so that they can discuss their wishes and document appropriately.

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What is Julia experiencing? o Acceptance. Julia is reminiscing and validating her life. o Concern. How will her partner, Lucy, handle the inevitable.

Scenario 1 1. How can we assess Lucy’s caregiver strain? a. By maintaining open communication with Lucy, the healthcare team can approach the concern of caregiver strain with Lucy and inform her that she has options. This can also assist Lucy in supporting Julia’s decisions when family may have questions or even objects. b. The Modified Caregiver Strain Index (MCSI) would allow Lucy to selfadminister a screening tool that would help her assess her areas of strength and need. By allowing Lucy to have control over how she handles her role as caregiver, she may be more open to offers of assistance. Follow-up by a healthcare team member will help solidify Lucy’s assurance she is making good decisions for her and her partner. 2. How can you explain what hospice care means for the patient and family? 1. Hospice care is a combination of palliative care, sometimes called comfort care, and end-of-life care. This type of care is offered to terminally ill patients who do not wish to pursue curative care for their illness. 2. This type of care includes multiple disciplines from home health, nursing, supportive medical care, pain mitigation, to spiritual care. 3. Hospice is covered by Medicare under Part A and does require a physician to evaluate and prescribe this care. There are limitations to this type of care and it is

best to be informed about these to avoid confusion. Always ask questions of the providers, if you have any concerns or are confused about what is being provided.

3. Review the assessment tool, Informal Caregivers of Older Adults at Home With our over 65 population growing at such a fast pace, many individuals are being put into caregiving roles that they are not prepared for. With an honest assessment of needs and abilities, guidance and access to services can help to limit the burden and sometimes create a more reliable environment for care at home. The Let’s PREPARE tool seems to be a concise and informative guide to what caregiving at home can encompass. Safety for a caregiver and their family member can be established by addressing each other's strengths and limits therefore creating attainable and sustainable expectations. This tool is a great introduction to the demands of caregiving and would allow for productive communication to be created between the caregiver and healthcare team.

Scenario 2 1. Explain typical nursing interventions for the dying patient. a. Per our textbook, Fundamentals of nursing, nursing interventions include: i. Therapeutic communication-being aware of the patient's individual and cultural approach to death and dying and including family and community as appropriate. ii. Being present for the patient and family-allowing for the many ways grief is expressed in a safe and secure environment for the patient and family.

iii. Treating symptoms that cause discomfort-having standing orders to address the symptoms and signs of a dying patient to allow for a comfortable and dignified death. iv. Educating patient and family-being available for any questions or mental/physical support the patient or family may have during this process. 2. What is typical physical care of the patient’s body after death? a. Per Fundamentals of nursing textbook, in general: i. Place body in supine position, arms to side with head elevated slightly. Replace dentures and/or other prosthetics, close the eyes and remove any jewelry (except for wedding ring). ii. Clear all medical paraphernalia according to policy or state regulations. Remove extraneous movable equipment from room. iii. Prepare body per patient’s religious/cultural procedures. This may or may not include the family or religious representatives. Washing the body, brushing hair. iv. Offer or prepare clean gown and linens. Place absorbent pads under buttocks for feces and urine. Clean soiled areas and remove any soiled linens from the room. v. Ensure the morgue or funeral home has been contacted to allow for appropriate removal of body. Ensure Death Certificate has been signed. Follow thru with organ donation. Leave patient ID in place.

3. How can nurses manage their own emotions and self-care after the death of a patient? Healthcare team members usually do not take time for self-care. This is a disservice to not only themselves but ultimately to their patients. By acknowledging our boundaries and seeking care, nurses can begin to learn coping skills that will help them thru their emotions. There are many types of counseling and support groups that can assist nurses in this journey. But ultimately, we have to learn to care for each other as well as those we have sworn to care for. 4. What are some supportive interventions to help the family with healthy grieving? a. If Hospice has been employed, remind the family of the bereavement care that is provided to the family by Hospice. This is underutilized by families, they do not want to be a burden. b. Assisting families with access to bereavement counseling, this could be thru the religious establishment, support groups or professional counseling services. c. Helping the family understand that grief is a part of normal living and it is ok to grieve. It is also ok to ask for help and to get support thru this time of adjustment. Answer these questions about Lucy: 

What are Lucy’s strengths? o Stable housing and access to external communication (phone) o Minimal contact with community and family members o Stable physical health, however this is being compromised by her unaddressed mental status, possible depression.

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What are your concerns for this patient? o Unaddressed grieving/bereavement, possibly leading to depression and anxiety.

o Isolation and focus on the past, there seems to be no future plans. o Nutrition and hydration, with isolation she may not be eating and drinking enough. o Reliance on the emergency system to address symptoms of depression and anxiety, no formal therapy plan to address these new health concerns. o Lucy is a fall risk due to age, health status and living conditions. 

What is the cause of your concern? o Lucy seems to speak mainly of the past focusing on the loss of Julia. o Lucy seems to be mourning the loss of the relationship with Julia and what that brought to her life. She is not looking forward to future events in her life. She seems to be decreasing her contact with family and friends. o The dizziness and confusion could be manifestations of decreased nutrition and self-care. o Lucy is utilizing the 911 system instead of engaging her healthcare team for her health concerns. This is in the moment thinking and is not showing that she is planning for future health concerns. o Lucy reports falling multiple times. With the increased anxiety, dizziness and confusion this will become a greater risk for her at home.

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What information do you need? o Lucy is an at risk elder and needs a Social worker referral. This would include assessing her access to good nutrition, socialization opportunities and home safety.

o Lucy needs a health assessment to establish her new health status baseline. This would include therapy for possible depression. o Lucy needs a mental health assessment, she would benefit from grief/bereavement counseling. 

What are you going to do about it? o Discussing these concerns with Lucy and assessing her willingness to participate in the process. Asking if we could include her family, Nora, in these discussions. o Contacting Social Services for an evaluation for possible referral for elder services. i.e. Meals on Wheels, RSVP. o Contacting Lucy’s PCP to schedule a health assessment and possible referral to a mental health counselor, with Lucy’s consent.

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What is Lucy experiencing? o Lucy is experiencing unresolved grief which is leading to isolation, anxiety and depression.

Finish the story: Lucy did have difficulty overcoming her grief. She accepted the referrals that were recommended and began working thru the therapy plan that was established for her thru her PCP. Although it wasn’t an easy road, talking with a grief counselor helped Lucy to establish better coping skills. She understands her anxiety stemmed from her loss and is trying to look forward with positive remembrances of Julia. Nora is a stable part of Lucy’s life. She tries to visit at least once a week to check on how Lucy is doing. She helps with her medications and brings groceries. If she is unable to come, Lucy’s

neighbor, Adele, is a quick call and can assist if needed. Adele will come over occasionally to catch Lucy up on the latest news about her grandkids. The Senior Services helped Lucy to sign up for Meals on Wheels and she enjoys receiving the daily meal deliveries. They were also able to help Lucy with some community involvement by getting her in contact with the local library. With her love of travel, the library would deliver travel books which Lucy enjoyed reading. Lucy now tries to engage with her community. She volunteers at the local library reading to children once or twice a week. She loves to talk about her adventures and encourages everyone to travel as much as they can. You can see her smile when she remembers those adventures with Julia....