This paper will analyze and evaluate an Aged Care Services in Emergency Team (ASET) nurse interviewing Max who is a patient in a rural hospital emergency department (The Division of Student Learning, 2017). Furthermore, it also discuss the impact of age-related physiological changes and how this effects, strength-based nursing assessment, and theories. Supporting this assessment is the identification of four relevant assessment tools and how they could have been utilized to provide optimal care and reduce re-admissions to the health facilities. The conclusion of this report will investigate what strength based nursing is and how the principles during the ASET enabled Max to solve problem and take control of his own care decisions. (Devitt, 2018)
1. Person-centered communication with an older person
Person-centered communication comprises of many facets and is a complex skill that needs to be adaptable to any situation. Patient-centered communication defined by BMJ open journal publication is "verbal, para-verbal and non-verbal communication” (Hafskjold et al., 2015, p. 2). The conversation starts with first impressions, building rapport, establishing a therapeutic relationship and showing empathy. Robyn, on entering the room introduces herself and explains the role of the ASET followed by gaining permission to take a seat and ask a few questions. Max initially had a solid understanding of who Robyn was, and the role and reasoning behind her assessment with appropriate tone and language which was clear and concise.
What should have been established right from the beginning of the assessment was if Max had any hearing or vision impairment. Conversely, Max had left glasses on the bedside table; this was a clue to the patient potentially having vision impairment. Max's visual impairment is likely to be contributed to age-related physiological changes. These changes cause visual impairment through the reduction of pupil size and reaction to light, reduction in tear production, and loss of peripheral vision (Heiting, 2018, p. 260). Robyn overcame this challenge immediately by sitting close to max and in an almost direct line of sight. This was not the only aged related change that was defeated by Robyn at the beginning of the assessment.
Communication from the very beginning of the evaluation could have been obscured or miss construed or even lost if Max was unable to hear adequately. The ability to listen sufficiently is associated with the narrowing of the ear canal, structural changes in the pinna and reduced hairs in the cochlea diminish sound transmission to the eardrum (Bernoth, 2017). Robyn un-intentionally from the beginning used alternative communication methods to strength her assessment. This can be seen as non-verbal communication, using hand gestures and providing visual descriptions to enable Max to understand what was being said (Guest, 2016, p.36). This was evident when explaining to max the process of sitting to standing from his armchair. This visual aid may have enabled Max to gain further more of an understanding of what was being explained.
It was identified that Robyn used the SOLAR model of non-verbal communication. This is defined as “sit squarely, maintain an open position, lean slightly towards the patient, maintain reasonable eye contact and relax” (Guest, 2016, p. 36). It was this SOLAR model from the beginning of the assessment that enabled Max to understand Robyn and partake in the conversation about his care. It was this model of care that enabled Robyn to understand Max as a unique individual and “respect his values, preferences” (Delbanco & Gerteis, 2018, p. 2).
2. The process of assessment of the older man in the video
During the ASET assessment, Robyn disregards facets of the evaluation and or fails to continue to question for further information. These areas include; falls risk assessments medication reviews, alcohol consumption, and mental health assessment. Max at the start of the assessment express’s the knee replacement has been a “slow process, due to complications and swelling” (The Division of Student Learning, 2017). Robyn should have reviewed this area to decipher what the possible cause of swelling and reduced wound healing could be related to. Max explained that he did not have any shower, toilet chair or walking aids. Evidence shows the elevation of a postoperative limb and appropriate aids will benefit recovery rate by reducing swelling, infection risk by increasing distal perfusion and reducing the risk of deep vein thrombosis.(quote)
Robyn should have implemented a falls risk screening assessment to asses Max’s mobility history and need for assistance with activities of daily living. By doing a falls risk assessment, Robyn would have inadvertently taken an additional account that would have been vital for this assessment.
According to Robson (2018) a falls risk assessment is a plan which is individualized, recognizing key risk factors (P. 386). The “Falls Risk for Older People – Community Setting (FROP-Com)” developed by the National Aging research institute would be an ideal assessment tool (Robson, 2018, p. 387). The FROP-Com consists of 13 risk areas, developed for use in the community setting. The FROP-Com looks at falls history, medications, sensory loss, foot wear, cognition, continence and nutrition, environment, and functional behavior. In conclusion Robyn would have had management and referral options for multi-disciplinary areas once completed.
If a falls risk were done, it would have led to a review of Max’s medications. Max explained “I did not forget as I have my wife who happens to be a nurse” (The Division of Student Learning, 2017). Postoperative medication such as pain relief is often given to ease pain and swelling, in-turn increasing the person’s ability to mobilize. Pain management medications such as opioid derived depress the respiratory and central nervous system by suppressing the neural transmitters, thus increasing the falls risk. When coupled with Max’s own medication it will affect absorption, distribution, metabolism, and excretion of the medication (QUOTE).
Robyn, establishes that Max’s alcohol consumption as, three sometimes four alcoholic drinks per day for most of his life. The alcohol and drug foundation guidelines state; “that reducing the risk of alcohol-related harm over a lifetime, you should drink no more than 2 standard drinks on any given day” (Alcohol and Drug Foundation, 2017., para. 6). Alcohol withdrawal symptoms l can start approximately six to twelve hours post last drink
Early recognition coupled with clinical and critical thinking of the registered nurse would be able to recognize withdrawals symptoms of mild to severe such as “perspiration, tremors, anxiety, agitation, axilla temperature, hallucinations and orientation” (Canberra Hospital and Health Services: Health Directorate, 2017, p. 8). Clear evidence between alcohol intake of more than three standard drinks and postoperative complications such as infections and bleeding at surgery site has been reported. Thus intervention and clinical documentation on an alcohol withdrawal scale (AWS) should have been commenced (Oppedal, Moller, Pederson & Tonnesen, 2012).
Robyn, slightly touched on Max’s mental state asking what his mood was like. Max’s stated he suffered from depression and explained that he is “not socially active” (The Division of Student Learning, 2017). Robyn could have implemented The Geriatric Depression Scale (GDS-15), comprising of 15 questions to establish what Max’s mood is like now and a risk of a mental health crisis. The GDS-15 evaluates Max who lives in a rural area with potential little support networks and three children who live a considerable distance away.
Max has a polypharmacy issue with possible antibiotics, pain medication which has the potential to increase the risk of a mental health crisis (Macmillan & Gardner, 2018). The GDS-15 would also provide great clarity to areas of Max life that he may wish to seek additional social support and networking groups. The GDS-15 can also be used as supporting documental and evidence for further referrals and consultation.
3. Strength-based assessment
Strength-based nursing assessments have been developed to draw attention to the person being able to see their abilities (Moyle, 2014, p. 41). This works on eight core based values; “uniqueness, health & healing, self-determination, holism & embodiment, subjective reality & created meaning, person & environment, learning & timing & readiness and collaborative partnership” (Gottlieb, 2014, pp. 24-32). The ROPES assessment model has identified some strengths of Max, however greater details could have been gained.
Robyn established that Max had a wife living with him and three sons who live interstate. There was an assumption that was prompted by Robyn that support could be gained from the sons if required. Social environment was identified as limited by Max stating “not social” (The Division of Student Learning, 2017). Max displayed a little emphasis on choice or what services had been tried. Robyn as a registered nurse should have been able to provide evidence-based interventions and service for Max such as recovery and physiotherapy support services (Active Recovery, 2014).
Max expressed is enjoyment for individual creativity through woodwork and personal interest of the Australian Stock exchange. Robyn was very short with her answers of “yep, good, ok” however failed to investigate if Max had any thoughts for any additional creative hobbies and potentially provided support and guidance to foster Max’s self-determination.
Robyn’s questioning about Max and his activities of daily living were basic but did offer a brief list of what max is responsible for within the household. Robyn failed to establish if Max required assistance or support while recovering from surgery as it was identified that he was responsible for shopping, cooking, bins and mowing the lawns. If this area were discussed, Robyn would have had a significant lead into detecting if there were areas of his life that were providing him success or regions requiring the collaborative partnership of community service and self-determination. By following the above suggestions Robyn could have given resource, options, possibilities, exceptions & solutions based on the ROPES model of assessment (Moyle, 2014, p. 44).
This paper has critiqued and investigated a comprehensive aged care assessment. It identified age-related changes associated with the ability to communicate. Empathy, building rapport, maintaining therapeutic relationships and verbal and non- verbal communication was recognized to circumvent physiological changes. Accordingly, this critique showed various assessment tools that could have been utilized to provide greater strength based nursing and support strategies. Small interventions in an older- person’s life can offer a substantial difference and support for a more significant life trajectory.
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