This essay will examine the nursing care for an older person with Parkinson type dementia. To achieve this I will define dementia and describe the impact of the problem created by the disorder on an elderly patient whilst on my clinical placement. The care objectives implemented for the patient including how they were implemented will be discussed. I will finally describe the effect of the patient’s mental health problem on both the informal and the formal carers and ways of minimising this impact will be discussed. I will conclude this essay on how my personal knowledge, skills has improved as a result of my involvement in this patient’s care.
Throughout this essay in other to maintain confidentiality and protect the patient’s identity, which is in line with the NMC Code of Professional Conduct (2004), the patient will be referred to as John.
Dementia is a condition that can be caused by different diseases but how it occurs in Parkinson’s disease is not yet understood. Alzheimer’s disease is the most common cause. Dementia is a global impairment of the functioning affecting the intellect, memory, language, skills, personality, affect, behaviour and sense of self. (Evan and Garner, 2004: p216). Those affected with Parkinson type dementia are often forgetful and can not think thinks through clearly. Sometimes, these affected patients remember things from the past, but does not remember what has just happened. Dementia usually affects people over the age of 65. Usually people with dementia gradually get worst and there is no cure. (Alzheimer’s society, 2003).
John is a 72 year old man with Parkinson type dementia. He is married to Mary, 68 and they both used to live together. John worked with as a Police officer before retiring at the age of 60. John was referred to the ward after a domiciliary visit by the doctor. The effects John’s illness on him were impaired thinking and communication, incontinence, difficulties with his memory, and often aggressive. John is fully dependent on his carers as he is been nursed in bed and need help with most of his activities of daily living. His wife, Mary is his informal carer.
Ageing is associated with changes in the human body through phases. John had dried skin as result of reduced collagen fibres which is a sign of ageing. (Nazarko, 2002). Aging also affect the ability to maintain continence in an older person. John was also doubly incontinent. John could not mobilise due to the advanced stage of his condition and his age because physically, ageing affect one’s locomotion. (Goldsmith, 1996). Psychologically, John had impaired concentration and memory. Concerning the social development of his illness, John had a good relationship with his wife but sometimes aggressive towards her.
A carer is someone who looks after a relative or friend, who, because of disability or the effects of old age cannot manage at home without help. An informal carer consists of family, friends and neighbours and volunteers (Alcock, 1996). The care they provide is always unpaid. A formal carer is someone who is trained and paid for the care they render to clients. Formal carers often experience physical and verbal abuse from informal carers. This could lead to lack of motivation and negative attitude towards patient.
John’s illness caused various problems for his informal care. Mary visited John on a daily basis. She experienced ill health and abuse as John often became aggressive towards her. This made her distressed. She never complained about the care delivered on her husband. Whenever she felt things were not done the way she wanted them, she tend to do it herself and often called for assistance. Caring for an older person with mental health problem is more stressful then caring for those who are physically disabled (Livingstone et al, 1996).
To minimise these effects, both the formal and informer carer of a patient(s) can work in partnership in the case of dementia care. There are also legislation and strategies to help carers. Standard 7 of the National Service Framework for Older People (2001) emphasises carers should have access to support. According to DOH (1999) as cited by Hirst and Arskey (2000): pg33, government strategy Caring About Carers emphasises the importance of providing carers with information, supporting and maintaining their health and wellbeing.
Mary was supported by the multidisciplinary team by informing her on her right to assessment, which is in accordance with the Carers (equal opportunity) Act, sec.1:clause12. She was also educated on dementia, medications and also how to communicate with John by taking about past events and pictures. She was also offering respite care in order to take out time in maintaining her health and wellbeing. The aim of respite care is to ensure that carers have a break from caring (Nazarko, 2002). Mary also attended care support and counselling groups where she found other carers and had a chance to express her feelings.
Formal carers can be supported through clinical supervision which gives them the chance to address feelings of emotional distress; and also enable them talk about their subjective feelings towards people with dementia and their informal carers (Barker, 2004)
When I met John an assessment had already been done so I looked into his note for his identified needs. John’s needs were discussed by the multidisciplinary term and Mary, and it was agreed that he should be admitted permanently on the ward as Mary could not cope with caring John at home.
Whereby clients can not make decisions as their mental illness has affected their competence to give informed consent; “consulting relatives is often sensible but carries no legal authority”. (Evan and Garner, 2004: p124). Mary consented to my care study on John
John’s identified problems relating to his activities of daily living were communication, maintenance of a safe environment, eating and drinking, personal hygiene, and elimination. A nursing plan was written by the nursing team on how these needs were to be met and Mary signed on it in agreement. A nursing plan provides a guide for individual patient care, the focus being placed on the patient as a person rather on his illness (Carpenito, 2000).
The first intervention was to establish a therapeutic relationship based on trust, honesty, respect, empathy and nod judgemental attitude. “The aim is for the client to begin to feel that the nurse has a realistic and non judgemental appreciation of his needs and can be trusted” (Wright and Giddey, 1993: p205). John was allocated a single room in order to felicitate the carrying out of close observation and less disturbance from other wondering patients. John required mental stimulation as remained in his room; the rationale was to alleviate his boredom. I made an appointment with John through Mary to spend time in conversating and showing him old pictures, which he seemed to enjoyed. “Keeping client’s appointment increases the sense of importance and worthiness”. (Fortinash and Worrent, 2006: p84).
Due to his impaired communication, I approached John in a calm and gentle way and spoke in low tone. A non verbal cue (i.e. smile, touch) was also used in communicating with John; the rational was to show warmth, acceptance and interest. “As the nurse relate with the patient, the main concern is to establish a climate of trust and acceptance”. (Hardy and Cutting, 1997:p39)
In order to maintain a safe environment for John, who was unable to comprehend his own safety. I made sure I checked on him regularly to ensure he did not fall out of his bed. I also made sure that John was comfortable, lying on a clean, dry and comfortable bed; the rationale was to avoid and prevent the risk of him falling out of his bed.
John was unable to feed himself because of the advance stage of his condition. He was therefore fed by the staffs. I made sure that John had adequate balanced meal. I fed him on pureed meal because John had no teeth to chew. I also ensured John was sitting on an upright position for his entire oral and dietary intake; the rational was to prevent choking.
Being nursed in bed, John was unable to go in the bath as he has resisted the use of hoist, making it dangerous to use. I ensured that John personal hygiene needs were met by assisting a male nurse on John’s bed bath. During these periods, John’s privacy and dignity was maintained by closing the door to his room. Due to John’s doubly incontinence. I ensured John was clean and dry at all times by maintaining his hourly check. I also used appropriate incontinence aid i.e. pads; the rational was to prevent bed sores.
John was on Selegiline (5mg daily) for the management of Parkinson disease. John is also on other medication given when required, (PRN). Metoclopramide (10mg) and Morphine sulphate (2.5mg-5mg) for pain relieve. John displayed some side effects of these medications such as constipation, rashes and dry skin; senna liquid (10ml 2x daily) and aqueous cream was used on his dry and scaly skin. (BNF, 2005)
Evaluating plans that were for John to ascertain whether they have been achieved, I realised his mental state in terms of awareness, aggressiveness did not improve because of the advanced stage of his dementia but his physical needs were met. John appeared clean at all times. I observed that his pressure sores were all gone. There was also no case of choking and he was alert when been spoken to.
In conclusion, people with dementia are human beings who are vulnerable and in need of protection and support; their right should be preserved and respected. This experience has made me realised that caring for patient with advanced dementia could be both physically and emotionally stressful as they solely dependent on the carers, but it was worth it. My involvement with John has improved my skill and attitude especially my non verbal communication skills.