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Sources to Retrieve Medical History

1. Case Study 1

Mrs Walker is a 72 year old lady who lives alone and until recently was in her own home with a care package.

Mrs Walker has a diagnosis of Alzheimer’s dementia (4 months) and has deteriorated both physically and mentally over the last 8 weeks, she habitually paces up and down even though she has very poor balance and appears very pale and tired.

Mrs Walker has been deemed to have ‘lost capacity’ by her Psychogeriatrican and the Enduring Power of Attorney has been enacted.

Mrs Walker’s family and the health team caring for her have all agreed that she is a danger to herself and others, a decision has been made to place her in a residential facility within a secure environment.

Mrs Walker has had to be physically escorted into the residential facility and is very distressed.

Mrs Walker has a severe contracture of her right hand caused by burns received in her kitchen 11 months ago, her noncompliance with physiotherapy have rendered that hand useless.

Mrs Walker weighed 62kgs a year ago, today she weighs 34.5kgs. Her family advise you that she is refusing to eat and that they often find Mrs Walkers dentures in bizarre places around the house, they tell you that Mrs Walker is still drinking plenty. 

1a) You are the nurse receiving Mrs Walker and as such, you will need to complete a health assessment.

Discuss sources that you might access to retrieve information about Mrs Walkers past medical history. 

1b) In detail, discuss what the interview stage of a health assessment is.

1 c) Discuss why the use of assessment tools specific to the older person are important in a health assessment and name at least 2 you would consider using for Mrs Walker. 

2a). You are concerned about Mrs Walker who seems very anxious and emotional. You have tried various types of communication, however, Mrs Walker is not engaging and her family are distressed. 

Identify the person you would immediately discuss your concerns with, what you would need to relay and any assessment tools you may consider using. 

2b). Identify and provide a brief explanation of the Standard for the Enrolled Nurse which relates to decision making and provision of care. 
3a) Define restraint and describe who is ultimately responsible for authorising its use. 
3b) Discuss the type of restraint used for Mrs Walker and describe your obligations once it is in place.
4a) You are unable to weigh Mrs Walker as she is not compliant. Discuss in detail at least 4 possible reasons for Mrs Walkers weight loss. (Please note that it is not acceptable to produce a list without detailing giving reasons) 
4b) Discuss how Mrs Walker’s physical disability may be a contributing factor to her weight loss. 
4 c) Discuss the specialist health professionals Mrs Walker may be referred to (at least 3) for her weight loss. 

5 With her daughter’s help, you are finally able to get Mrs Walker to sit down and have a drink. You decide to try and take the opportunity to complete an oral assessment. 

a) Create a list detailing at least 4 examples of how poor oral care can contribute to poor health in the older person 

6 Mrs Walker is unsteady on her feet, discuss what type of assessment you might refer Mrs Walker for and who might undertake this. 

7 a) you are discussing the diagnosis of Alzheimer’s disease with Mrs Walker’s son, he tells you he doesn’t understand what dementia means and asks you if there is a cure. Provide a definition of dementia with particular reference to what Alzheimer’s disease is. 
7 b) Mr Walker asks you if his mother will die soon, discuss the difference between palliative and end of life care 

8 a) After 2 weeks of residing in the facility, Mrs Walker has not engaged in any activities and continues to pace the corridor, although not with the same level of anxiety. You discuss your concerns with the activity officer, what therapies might she suggest for Mrs Walker?
8b) Discuss the need for the Mrs Walker to feel as though her environment is both physically and emotionally safe

Sources to Retrieve Medical History

1. Health assessment is an evaluation process in which the health status of the patient is evaluated by performing physical examinations and gathering information regarding patient’s health history. While conducting the health assessment of Mrs. walker information related to her past physical and mental health will be collected from her past medical documents, test reports and her past hospital admissions will be included in health history. Further, her family members will also be included in the health assessment process to obtain patient’s health history. 

1 b)Prior to health assessment, it is important for the nursing professionals to build rapport and create a relationship of trust, honesty and belief between them and their patients. The interview stage of health assessment is one such phase which enables patients and nurses to indulge in conversation and in the course patient reveals his preferences for care process, cultural preference and others (Scheidt-Nave et al., 2012). Nowadays, the importance of this phase has become subjective, however the importance of an interview phase of health assessment with high quality open ended question is supported by researchers due to the presence of aspects such as effective listening, adaptive enquiring and effective communication between both the stakeholders (Estes, 2013). 

1c) Health assessment for older patients is known as comprehensive geriatric assessment using which health professionals assesses the psychological, physical and functional limitations and abilities of the patient and in the later stage develops a coordinated care plan so that overall health of the patient could be improved. As the patients develop several risk factors due to their aging, it is important to identify the risks and their degree so that further health management could be implemented. Two assessment tools which will be used to assess the health condition of Mrs. Walker will be cognitive impairment and malnutrition. These two tools will help to understand the cognitive ability of the patient using which her self-harm activities could be understood and her diet pattern and food requirements could be assessed. 

2 a) The patient is stressed and anxious and is not responding to my communication efforts therefore, the priority will be assessing her anxiety reasons and for this depression related assessment tool will be implemented in care process. This will help the patient to communicate with me and she will be able to share the reason for her stress. However, if the patient is still unable to communicate with me regarding her anxiety concern, then I will communicate with a psychiatrist immediately

The Interview Stage of Health Assessment

b) The Enrolled Nurse standards are the core nursing practice assessment that help them to provide the patients with direct and indirect care and are able to engage themselves in analytical and reflective care and makes the care process analytical, professional and collaborative. Further, it helps the professionals to take decision on their own depending on the patient’s ability and the involvement of the family members in the care process.

3 a)Restraint is an action using which patients, who are impossible to control in normal conditions, are controlled and provided with medications. This is a strategy which is used to maintain certain circumstances within the healthcare facility. However, once applied in a patient scenario, it is the responsibility of the healthcare professional to determine that these restraints does not affect the patient negatively (Tolson & Morley, 2012).

3 b) I will use chemical restraints for Mrs. Walker as her health condition is deteriorating every day and she is suffering from malnutrition, which makes her suffer from tremendous weight loss. Therefore, physical restraint may affect her health condition negatively. So, chemical restraints such as her medications, meal replacement supplements and other medications will be used as chemical restraints in case of Mrs. Walker.

4 a) Dementia and malnutrition is one of the major reasons due to which, Mrs. Walker is losing weight tremendously and currently she weighs around 34 kilograms. Loss of appetite and food choice related issues she is unable to consume ample amount of food which can be one of the reason for her weight loss. Further, due to burning of extra calories due to the extra motion and striding, Mrs. Walker attempts high metabolic activities due to which mass loss occurs. Further, the dental issues and abdominal pain could be another set of reasons due to which she is suffering from severe weight loss.

4 b) Mrs. walker is suffering from multiple disabilities such as inability to move, inability to balance herself in movement, her self-harm related activities could be reason for her excessive weight loss. Further, it has also been seen that her teeth are decaying and she is unable to swallow the food properly which could be increasing the sense of appetite loss.


4c) To understand the need of Mrs. Walker and her nutritional needs, she will be referred to a dietician or nutritionist so that the professional can understand the macro and micro nutrients required for health and wellbeing of the patient. the professional further, will be able to understand the food compositional and nutritional factors required for her speedy recovery.

Importance of Geriatric Assessment Tools

5) Poor oral condition and health condition is one of the important factors which should be taken care of by older adults as it may lead several complications. As per the research of Lockhart et al. (2012), it has been seen that poor oral care is associated with increasing rate of heart rate. Further as per the American academy of periodontology, patients with periodontal disease are more likely to suffer from coronary artery diseases and increases the cholesterol related blockage in arteries (Paganini?Hill, White & Atchison, 2012). Secondly, it has been seen through researches that gum diseases, which occurs due to poor oral hygiene can lead to diabetes as it hinders the body’s ability to use insulin. Thirdly, due to gum and oral hygiene related issues dentures and stomatitis occurs which eventually leads the patient suffer from root decay (McCloughen et al., 2012). Finally, poor oral hygiene leads to stomach infection in older adults which can affect primary health condition of the individual by increasing the risk of dental diseases (Noble, Scarmeas & Papapanou, 2013).

For Mrs. Walker, her oral assessment will be inclusive of several factors such as gum health, the level of dentures and hygiene within the oral cavity. Further her gum health will be assessed and the presence of bleed gums or sore gums will be noted. Furthermore, the presence of wrongly fitted dentures will be assessed so that the reason behind gum bleeding and soreness could be justified. With these, presence of plaques and other impurities within the dental dentures will be assessed and tongue cleanliness will also be assessed.

There are several precautions which could be used to maintain dentures, however failing which could lead to severe implication in oral health of the patient and increasing the chance of unhealthy gums. The firth way to maintain clean and healthy dentures are proper washing and sanitizing techniques which should be followed every day. Cleaning the dentures with fresh water and soft brush and keeping it in cold water overnight would impart in the healthy gums and clean dentures (Beech et al., 2014). It should be noted that dentures should never kept dry as it can harm the quality. It should always be noted that dentures should be kept in water when it is not being used by the patient and cleanliness of it should always be maintained by the user as it will help to prevent the shape loss or denaturation of the composition (Ramage et al., 2012).

Precautions to Maintain Oral Health


For the balance related issues of Mrs. Walker, geriatric gait equilibrium related evaluation will be performed. This will help to assess the ability of patient move freely without any risk of fall. Further, this assessment will be able to provide details of gait, imbalance, and ability of movement and fall risks and healthy joint of the patient.

7a) Dementia can be defined as a health condition that is characterized by a specific group of disorders that impair the normal functioning of the memory. The condition is affected by improper cerebral functioning that causes severe problems with the activities of daily living in the patients. Dementia can also be induced due to somatic changes and can be classified into a number of types. Alzheimer’s can be defined as a type of Dementia that affects the normal memory, thought process and behavioural trait of the affected patients. Initially, the signs and symptoms are weak and might seem coincidental but with time, the symptoms develop and affect the patient’s ability to manage everyday activities. During, the initial stage the symptoms generally include mild memory impairment, however, with time, the patient’s ability to converse or follow a conversation might get completely impaired. Unfortunately, there is no absolute cure for Alzheimer’s, however, there is a scope for improving the deterioration of the symptoms in order to ensure a decent standard of living to the patients and the related care providers of the patients.

7b) Palliative care and end of life care are starkly different from one another in their objective and outcome. Palliative care focuses on dispensing treatment intervention to an affected patient who is suffering from a grave infection (Zimmermann et al., 2014). Palliative care effectively manages the symptoms of the patient and at the same time also considers the welfare of the patient across all important domains that include, spiritual, mental, social and psychosomatic wellbeing. It should further be noted in this context, that palliative care focus on rendering effective treatment across the identified domains in order to alleviate the standard of living of the patients. On the other hand, end of life care is administered to patients who are nearing death and are affected with critical health conditions that have no scope of improvement. End of life care is generally administered to the patients for a period of 6 months and covers legal and lawful matters that are associated with the wellness of the patients. The governing criteria of administering end of life care is to make sure that the patient can die peacefully and with self-respect (Quill & Abernethy, 2013).


8a) Research studies reveal that administration of cognitive behavioural therapies and psychometric therapies can be of great help while dealing with patients who suffer from dementia (Knapp et al., 2013). These therapies are tried and tested and have provided positive results to treaty problems of depression and anxiety. A large number of research studies have emphasised on the efficacy of cognitive behavioural therapy to provide relief to Dementia patients from pertinent problems of depression and anxiety. At the same time, it should also be noted that the administration of psychological counselling offered to the patient can help extensively in assisting the patient to acquire composure. It should also be noted that, the effectiveness of the therapies are subjective and can vary from one person to another (Brooker & Latham, 2014). Therefore, the appropriate intervention should only be devised after critically recording the response of the patient towards the devised intervention. On the basis of the responsive nature of the patient, the therapies should be combined and managed in order to acquire positive outcomes.

8 b) Recovery is majorly dependent upon mental wellness. According to Borson et al. (2013), in order to ensure an accelerated recovery, it is important to consider that the patient feels safe and secure within their immediate care environment. As has already been mentioned above, that dementia patients are primarily sufferers of anxiety and depression. It becomes increasingly important to emphasise on the mental health of the dementia patients in order to ensure an effective treatment outcome. In order to ensure this, care givers need to ensure that the environment is safe and harbours an emotionally positive feeling for the patient and at the same time, accelerates the process of recovery. It should also be crucially noted in this regard, that an unsafe impact of the physical and the emotional environment can elicit feelings of fear and agony that would pile up the disease burden and make it difficult for the care givers to administer an effective and a culturally safe recovery.

Complete the following short answer questions

  1. Why was the Carer’s Recognition Act 2010 implemented?

 The Carer Recognition Act 2010 was implemented for the exquisite purpose of creating an awareness about the role of carers in providing critical care to patients dealing with mental illness, disability and other physical health comorbidities (Carergateway.gov.au, 2018). The Carer Recognition Act ideally recognized the care professionals and aimed to assist the Australian Public Service Agencies and Commonwealth Government funded service providers to enhance their quality of services dispensed to the patients and meet their treatment expectations.

  1. List 3 legal or ethical considerations included in the 10 key principles in the Carers Recognition Act 2010.

The three legal and ethical considerations that were included in the Carers Recognition Act, 2010, included the following (Carergateway.gov.au, 2018):

  • In compliance with the act, the carer as well as the patient is protected by the Federal, State and the territory laws and policies.
  • The carers who are unpaid are supported by the Carer Recognition Act, 2010 that offers funding ti various government agencies and ensures that non-paid carers acquire adequate assistance
  • The act also assures the right to complain and supports the rights of the family and friends and the carers of all individuals who are living with a condition of disability. On encountering, an inappropriate incident, the concerned individuals can immediately register a complaint and seek help. 
  1. What organisational policies and procedures do you need to pay attention to when caring for a deceased client?

While caring for a deceased client it is the responsibility of the nursing professional to take care of the religious and cultural wishes of the patient and then complete the verification process timely so that family and close relatives could be provided with opportunity to show their gratitude and wished towards the patient. In this situation, the nurse may apply the Non Medico legal Post-mortem will be applied and if the patient’s family is not willing to take the dead body, the body will be provided with proper cremation so that respect and dignity of the dead body could be maintained. Hence, these will be applied in such care circumstances. 

  1. What specific standard precautions do you need to apply when caring for a deceased body?

While caring for a deceased body, it is important for the nursing professionals to understand the type or tag of the dead body. After that, all the appropriate personal protective equipment should be followed and all the nursing professionals should wear them to protect them from infections. After understanding the type or category of dead body and respective personal protective equipment, all tubes, drains, and catheters present in the dead body should be removed. This will help the nursing professionals to save themselves from infections and they will be able to protect the dead body with compliance to governmental policies.

Part of your role is to provide support and comfort for the grieving family or carer. Within your scope as an Enrolled Nurse, list 2 ways you can achieve this.

While communicating with a family who is suffering from such loss is an important part of nursing profession and in this case, I will also try to communicate with the family by empathizing them for their loss. The first way will be communicating with sympathy for their loss and I will be consoling them for their grief. Secondly, I will try to provide them their personal space so that they can share their grief and pain among their family as it will help them to connect to each other emotionally and socially.

References

Beech, N., Robinson, S., Porceddu, S., & Batstone, M. (2014). Dental management of patients irradiated for head and neck cancer. Australian dental journal, 59(1), 20-28.

Borson, S., Frank, L., Bayley, P. J., Boustani, M., Dean, M., Lin, P. J., ... & Stefanacci, R. G. (2013). Improving dementia care: the role of screening and detection of cognitive impairment. Alzheimer's & Dementia, 9(2), 151-159.

Brooker, D., & Latham, I. (2015). Person-centred dementia care: Making services better with the VIPS framework. Jessica Kingsley Publishers.

Carergateway.gov.au. (2018). {{meta.og.title}}. Retrieved from https://www.carergateway.gov.au/legal-rights-for-carers

Estes, M. E. Z. (2013). Health assessment and physical examination. Cengage Learning.

Knapp, M., Iemmi, V., & Romeo, R. (2013). Dementia care costs and outcomes: a systematic review. International journal of geriatric psychiatry, 28(6), 551-561.

Lockhart, P. B., Bolger, A. F., Papapanou, P. N., Osinbowale, O., Trevisan, M., Levison, M. E., ... & Wilson, W. R. (2012). Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association? A scientific statement from the American Heart Association. Circulation, 125(20), 2520-2544.

McCloughen, A., Foster, K., Huws?Thomas, M., & Delgado, C. (2012). Physical health and wellbeing of emerging and young adults with mental illness: An integrative review of international literature. International journal of mental health nursing, 21(3), 274-288.

Noble, J. M., Scarmeas, N., & Papapanou, P. N. (2013). Poor oral health as a chronic, potentially modifiable dementia risk factor: review of the literature. Current neurology and neuroscience reports, 13(10), 384.

Paganini?Hill, A., White, S. C., & Atchison, K. A. (2012). Dentition, Dental Health Habits, and Dementia: The L eisure W orld C ohort S tudy. Journal of the American Geriatrics Society, 60(8), 1556-1563.

Quill, T. E., & Abernethy, A. P. (2013). Generalist plus specialist palliative care—creating a more sustainable model. New England Journal of Medicine, 368(13), 1173-1175.

Ramage, G., Zalewska, A., Cameron, D. A., Sherry, L., Murray, C., Finnegan, M. B., ... & Jagger, D. C. (2012). A comparative in vitro study of two denture cleaning techniques as an effective strategy for inhibiting Candida albicans biofilms on denture surfaces and reducing inflammation. Journal of Prosthodontics: Implant, Esthetic and Reconstructive Dentistry, 21(7), 516-522.

Scheidt-Nave, C., Kamtsiuris, P., Gößwald, A., Hölling, H., Lange, M., Busch, M. A., ... & Hapke, U. (2012). German health interview and examination survey for adults (DEGS)-design, objectives and implementation of the first data collection wave. BMC public health, 12(1), 730.

Tolson, D., & Morley, J. E. (2012). Physical restraints: Abusive and harmful. Journal of the American Medical Directors Association, 13(4), 311-313.

Zimmermann, C., Swami, N., Krzyzanowska, M., Hannon, B., Leighl, N., Oza, A., ... & Donner, A. (2014). Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. The Lancet, 383(9930), 1721-1730.

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