Pain: State in which the individual experiences and communicates the presence of severe discomfort or an uncomfortable feeling.
Related factors: Pain resulting from musculoskeletal disorder; in this case, osteoarthritis; immobility
Features: Verbal communication of pain descriptors, level 8-9 pain reported by patient
Evidence: Mrs. Hardy experiences great knee pain when climbing stairs, a symptom associated with her osteoarthritis. Osteoarthritis cannot be cured, but pain can be controlled.
The primary client-centred goal for Mrs. Hardy is pain management (Bijlsma, Berenbaum and Lafeber, 2011). Expected measurable outcome is that Mrs. Hardy will experience relief of pain as evidenced by Mrs. Hardy’s verbal report.
Nursing-Centred Healthcare Goals
Plan: Provide Pain Relief
Intervention 1: Assess Characteristics of Pain
The first nursing intervention is to evaluate Mrs. Hardy’s severity of pain (level 8-9, on a scale of 1-10), type (musculoskeletal, osteoarthirtis), frequency (chronic), precipitating factors (climbing stairs), and relief factors (abstaining from exercise) (Nanda).
Intervention 2: Determine Current Treatment Regimen
Mrs. Hardy’s physician prescribed acetaminophen as an analgesic. Mrs. Hardy reports that acetaminophen provided pain relief, and yet she is not adhering to her medication protocol. That should be explored.
Acetaminophen is the right therapeutic choice because it has fewer side effects than other medications (Richmond, Hunter and Irrgang, 2009). However, if Mrs. Hardy does not experience short-term pain relief, her physician should be consulted for a change in therapy to a different analgesic, like an nonsteroidal anti-inflammatory drug (NSAID) (Hunt and Yuan, 2011). However, long-term NSAID medication have been shown to damage the gastric mucosa, especially in elderly patients, so it would be prescribed along with prophylactic medications, like proton pump inhibitors or prostaglandins (Hunt and Yuan, 2011). This treatment protocol should be explained to the patient.
Another option would be to explore non-traditional analgesics like dietary supplements such as glucosamine sulfate or chondroitin sulfate, as these have been shown to alleviate pain related to osteoarthritis, as well as slow disease progression in patients with osteoarthritis of the knee (Gregory, Sperry and Wilson, 2008). Mrs. Hardy might adhere to this therapeutic protocol, as she seems inclined towards naturopathic medicines.
Outcome
Short-term Pain Relief
Mrs. Hardy should experience pain relief within 1-3 days after her start of therapy as evidenced by verbal reports.
Long-term Pain Relief
Mrs. Hardy should experience continuous pain relief for one month after her start of therapy as evidenced by verbal report.
Self-management strategies
The most critical issue is Mrs. Hardy’s failure to comply with a treatment protocol; thus, any treatment protocol must include self-management strategies for effective long-term treatment of pain (Hunter and Lo, 2009).
Impaired Skin Integrity
Impaired Skin integrity: State in which the skin of an individual is altered unfavorably.
Related factors: Pressure ulcers, physical immobility, state of nutrition, poor circulation.
Features: Disruption of epidermis and dermis.
Evidence: Erythema, or Reddened areas on bony prominences
Mrs. Hardy’s pain has impaired her mobility causing her to spend long periods of time sitting and exerting constant pressure on bony prominences in her body. The primary client-centred goal for Mrs. Hardy is to treat her present erythema and prevent its occurrence (Reddy et al, 2008). Expected measurable outcomes would include (1) the disappearance of Mrs. Hardy’s erythema, and (2) no recurrence of erythema.
Nursing-Centred Healthcare Goals
Plan: Heal the Skin and Increase Caloric Intake
The nursing goal is to (1) heal the ulcers by increasing blood flow to the affected areas, and (2) increase caloric and protein intake. Good blood circulation and high protein intake are necessary in the tissue repair process (Reddy et al, 2008).
The first step in pressure ulcer management is to assess and chart the patient’s skin integrity to assess the stage of ulceration (Stotts, Rodeheaver and Thomas, 2001). Mrs. Hardy’s has reddened areas on bony prominences, but no abrasion, blisters, or shallow craters, suggesting a Stage One pressure ulcer (Stotts, Rodeheaver and Thomas, 2001).
Intervention 1: Eliminate the Source of Pressure
There are no pharmacologic interventions that have been shown to be effective for pressure ulcers. The standard remains elimination of the source of pressure and appropriate wound care (Reddy et al, 2008). However, Mrs. Hardy’s fondness for naturopathic medicines may predispose her for Aloe vera topical agents or Aloe vera dressings as therapeutics. Dat, Poon and Doust (2012) found that Aloe vera therapy was successful in treating acute and chronic wounds.
Intervention 2: Increase and Maintain Caloric Intake
Poor nutrition is associated with pressure ulcers (Samuriwo, 2010). The pain associated with exercise has been preventing Mrs. Hardy from grocery shopping on a regular basis, and it is likely that Mrs. Hardy’s is not getting proper nutrition; thus, dietary supplements are advised.
Outcome
Short-term Erythema Relief
Mrs. Hardy’s erythema should disappear within 3-7 days following intervention as evidenced by visual inspection.
Long-term Erythema Relief
Mrs. Hardy’s will not experience a recurrence of erythema for a period of one month as evidenced by visual inspection.
Alteration in Nutrition: Less than Body Requirements
Altered nutrition, less than body requirements: State in which an individual’s nutrient intake is insufficient to meet metabolic needs.
Related factors: Inability to obtain food, depression, social isolation, stress
Features: Intake below the Recommended Daily Allowances
Evidence: Rapid weight loss of 10%
The primary client-centred goal for Mrs. Hardy is to increase her protein-energy intake (Kirshbaum, 2010). The expected measurable outcome that would show if the goal had been reached would be a rise in prealbumin levels within 7-10 days after nutritional intervention, and a gain in weight of 6kg within a month after intervention (Kirshbaum, 2010).
Nursing-Centred Healthcare Goals
Plan: Improve Nutritional Intake
Intervention 1: Assess Nutritional Intake
The first step is to conduct a nutritional assessment. We already know that Mrs. Hardy has lost 10% of her weight in the last month, what we need to determine is the cause. Therefore the initial evaluation should begin with a series of screening questions. If her answers indicate malnutrition, lab tests should be ordered by her physician to test prealbumin and albumin levels and total lymphocyte count (Morais, Chevalier, and Gougeon, 2006). Blood tests should also be performed to determine any vital nutrient deficiency or anemia.
Intervention 2: Improve Nutritional Intake
If protein-energy malnutrition is found, it may accompanied with vitamin and essential fatty acids deficiency, which disrupt skin integrity (Volkeert and Sieber, 2011). Therefore, Mrs. Hardy should take vitamin and mineral supplementation.
The first step in treating protein-energy malnutrition is to adjust fluid and electrolyte imbalances and to test for and treat any infections (Kirshbaum, 2010). Macronutrient replacement should start within two days, after consulting a dietary specialist. The second step in treating protein-energy malnutrition is to commence nutritional therapy, with intake rates at 60kcal/kg and 2g/kg proteins (Kirshbaum, 2010), that is Mrs. Hardy should aim to consume 3,420 kcal and 114g proteins per day. This might call for the use of appetite stimulants.
One other important factor we need to consider is whether Mrs. Hardy’s reduced nutritional intake is voluntary or due to a lack of food availability. If voluntary we need to consider psychological factors; if due to lack of food availability we need to consider socio-economical factors. Finally, Mrs. Hardy should receive follow-up care with dietary specialists and social services.
Outcome
Short-term Weight Gain
Mrs. Hardy’s prealbumin levels should rise within 7-10 after nutritional intervention as evidenced by lab results.
Long-term Weight Maintenance
Mrs. Hardy should gain 6kg within a month after intervention as evidenced by measuring her weight before and after nutritional intervention.
Quality of Care and Attitudes of Nurses Towards Elderly Patients
A review of the literature shows that the attitudes of healthcare professionals towards the elderly tend to be negative (Courtney, Tong and Walsh, 2000). Soderhamn et al (2001) found that nursing students have ingrained stereotypes and misconceptions about the elderly, which predispose them against geriatric care. This creates a nursing gap in gerontology that impacts the healthcare system (Herdman, 2002).
This negative attitude affects their perception of geriatric care and the type and manner of delivery of nursing care (Wade, 1999). There is also a lack of knowledge of the aging process, representing a serious gap in nursing education that must to be addressed in order to meet the healthcare needs of the increasing number of elderly patients (Herdman, 2002). Yu and Chen (2012) tested the effects of an educational program on nursing attitudes towards the elderly and motivation to care and found that educational intervention could help form a more positive attitude towards older persons.
It is clear that the attitude of nurses towards elderly patients affects the quality of care that they are able to provide. Elderly patients are a vulnerable population and are not getting the proper attention from the healthcare system. Not only must they deal with loss of independence associated with the ageing process but healthcare providers do not spend the extra time required to explain their healthcare options, which further limit their decision-making capabilities and decreases their quality of life (Courtney, 2000).
The perception of nurses of their patients also depends on the mental and physical dependence of the patient, because geriatric care primarily focuses on taking care of the body, not of the person (Cooper and Coleman, 2001). Mc Cabe (2004) suggests that nursing needs to improve the nurse-patient relationship and that the best way to accomplish this would be to move away from a task-centred towards a patient-centred approach to patients care.
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