Sep 12, 2019 in Medicine
Acute Care Nursing: Reflections on Practice

Mrs. Jones is an elderly woman who is relatively strong for her age. At 81, she lives alone and is able to take care of herself most of the time. The reason she was at the hospital was that she had fallen down the stairs in front of her house during wet weather, thus implying she had had an accident. The pain she was experiencing qualified her for the use of morphine implying that it was indeed intense. In fact, treating an elderly patient who is in pain is a considerably challenging task considering the strength of pain medications as well as their ability to handle the aches. Although once the patient was treated and responded well to the treatment, she started developing symptoms of delirium. The problem is, thus, that she has never experienced such feelings before and her daughter needs an explanation on what is happening with the patient. Apparently, Mrs. Jones is in a mental state in which she exhibits a disturbance of cognition, with an accelerated development implying very fast changes. Thus, her main symptoms include confusion, hallucinations, agitation, incontinence of urine and dehydration among other things. The condition can be perceived as either dementia or delirium, both of which often remain undetected for patients who are hospitalized. In this case, Mrs. Jones at her age is unlikely to be diagnosed with either despite the fact that her age puts her at risk of these and other similar mental ailments associated with reduced cognitive abilities. The problem is that Mrs. Jones had been very capable of taking care of herself until she underwent surgery when she was expected to get better.

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Nursing Management for Mrs. Jones’ Condition

Mrs. Jones was encouraged to treat her dehydration by stopping the IV fluids to get her thirsty. As a consequence, this would help achieve a balance between electrolytes in her system, thereby eventually allowing her brain chemistry to return to a normal condition. In addition, she had already been placed in a dark room to curb her confusion and regulate her circadian rhythm to make her sleep. Tanner (2006) recommends that the nursing management for this case is first to assess the patient and establish a diagnosis before explaining to her and her daughter what is really happening. In fact, the need to understand the patient’s condition is the focus of the management practice, given that her condition is new. The condition was neither expected nor preexisting. Once the condition is determined, the nurse will be responsible for establishing a course of action that will help the patient to overcome her condition and possibly return to the normal one. Taking into consideration Mrs. Jones’ age, Alfaro-LeFevre (2009) notes that she is likely to feel stressed and even depressed in her new condition since she was used to taking care of herself and now she cannot even remember her daughter. She will, thus, need strong support to cope with the delirium until it subsides. The nurses informed Deborah that they think her mother may be in need of home-based nursing care for the aged, implying that her condition was terminal in some way. In this case, the work of the nurse is to ensure that the accurate diagnosis is provided so that the patient and her daughter can be fully aware of what to expect in their new circumstance.

Signs and Symptoms

Considering Mrs. Jones’ case, a number of signs and symptoms could provide an explanation for the patient’s condition. The patient came in with a fractured elbow and severe pain; however, after surgery, she became delirious to the point that she needed dark therapy and a withdrawal from the IV fluids to make her drink something. The major signs and symptoms expressed include confusion, agitation, incontinence of urine and dehydration.

Confusion implies the state of not being able to distinguish one thing from another, and in this case, it can be seen that Mrs. Jones is unable to recognize her own daughter Deborah. She seems to have lost her ability to understand and cannot be left alone anymore. Agitation is yet another symptom that implies restlessness and possibly some amount of anxiety seeing as the patient is unable to relax despite being assured of her location by the nurses. Moreover, she is very agitated and seems to be unable to trust anyone at the moment, thereby requiring due caution and patience when dealing with her. The nurse also reported that she had been unable to control her bladder during the night. Apparently, this could be a symptom of an infection in her urinary tract as much as it is a symptom of delirium or any other irregularity in her brain chemistry. Owing to the fact that she had refused to consume any more liquid possibly because she had experienced the incontinence during the night, Mrs. Jones was likely to be dehydrated as well. Thus, stopping her IV fluids would trigger complete dehydration after a while and then she might be compelled to start ingesting fluids again.

Our Process

Assessment Tools Used for Mrs. Jones

A number of tools could be useful in verifying the patient’s condition in this case. Considering that she is over 65 years, the first step before admitting her to the hospital would have been to take her through a cognitive functions test to determine her alertness. In fact, in this case, an MMSE test was used that she scored quite well posting 27/30. An MMSE test is a mini-mental state examination that is a series of questions drawn from various areas that when answered correctly enable the health practitioner to rate the patient’s cognitive alertness. It is often contended that a score above 27 implies normalcy in one’s alertness and cognitive functions, although a score below this could imply distraction or other challenges, including hearing difficulties. Mrs. Jones’ MMSE score, however, implies that upon admission, she was fully alert, her cognitive functioned in full and the condition must have become evident during the course of her stay at the hospital. After the surgery, her condition was ‘different’ from the previous one, having changed from getting better to needing dark therapy. Her assessment would, thus, be as per her condition. Thus, she needed another MMSE test in which a decline by 2 or more points would reflect a credible possibility of delirium in the patient. She had obviously deteriorated due to the fact that she needed dark therapy and could not recognize her daughter Deborah, with whom she is reported to have a close relationship.

The credibility of the MMSE test is that it will give the doctors an opportunity to compare the patient’s cognitive functions before and after admission to the health facility. In fact, a number of factors cause elderly patients to suffer from delirium once in a hospital. Hereby, they include stress, depression, the hospital environment, being away from their familiar surroundings and sometimes, their loved ones, using some kind of strong pain medication, especially the opioids like morphine, and even feeling vulnerable and unable to take care of themselves. For Mrs. Jones, there are immensely many risk factors involved considering that her pain was rated as 8/10 and she was given morphine as pain relief. First, she is elderly and is used to taking care of herself for most of the time. Afterward, she experiences severe pain that necessitates the prescription of morphine and intramuscular pain relief to make her situation bearable. It is also important to note that the patient becomes hospitalized, keeping her away from familiar surroundings. The MMSE test will enable the doctors to determine if the patient is truly suffering from delirium and thence the right treatment can be commenced. Currently, she is under dark therapy and withdrawal from the IV fluids in a bid to make her rest well and also to compel her to drink something and treat dehydration.

The urine incontinence problem may also have been a result of an infection contracted after the surgery as it may have been due to the delirium. It would, thus, have been important to get her tested for UTI before concluding that she was suffering from delirium and that it was the cause of the urine incontinence experienced during the night. With so many symptoms pointing toward delirium as the problem, a UTI test would only ensure that the patient does not suffer discomfort any more caused by a pathogen while treating a psychological problem.

Our Benefits

Interventions Undertaken

The patient came in with a fractured elbow, and the pain she was experiencing was overwhelming as expected. The first step toward treating her was to take her medical history and then relieve her of the pain after determining how strong it was and how much pain relief she could handle. The MMSE test was also a mandatory part of treatment as it would determine the kind of care she was to receive at the health facility. Another step was in administering the intramuscular pain relief after surgery. Note that the fact that the pain was numbing and the patient is elderly implies that there needed to be some strong pain relief that she could handle, and intramuscular ingestion was the best option despite the side effects.

In cases such as the above one, nothing was specifically done to aid the patient in dealing with stress. She was largely independent since she had been living alone and taking care of herself most of the time. The idea of being in a hospital made her feel useless like her life was over and, thus, she was exposed to stress due to her vulnerability and need for consistent attention. In addition, she was moved from one room to another as she had to undergo surgery. Another problem is that she was under pain medication that triggered side effects like confusion, agitation, and insomnia, among other things. The patient had all the risk factors for delirium and dementia, and yet the only thing that was done to help her was the use of dark therapy. Li et al. (2009) state dark therapy implies putting the patient in a dark quiet room to ensure that they get enough rest by changing their circadian rhythm and somewhat confusing their time awareness in order to attract the ‘sleeping’ hormones. Apparently, in Mrs. Jones’ case, this was probably done due to the fact that she had not slept at night possibly because of the confusion and agitation, or the incontinence of urine.

Critique for the Interventions Based On International Evidence

When an elderly patient is admitted to a hospital, giving them a test for delirium or dementia is just as important as collecting their medical history. The reason is that this helps the nurse to ensure that the patient is taken care of adequately. Jasper (2006) established that the problem is that most elderly patients actually get delirium or dementia while at the hospital. Mun (2010) reiterates that the test just provides a basis for comparison in the event that the mental state worsens. In Mrs. Jones’ case, the test given to her in the hospital would actually aid in ascertaining Deborah’s claim that her mother is often normal and fully aware of her surroundings unlike what she had been exhibiting after her surgery. Moreover, Meine, Roe and Chen (2005) argue that while this may not save her from needing to be taken to a nursing home sooner or later, it will at least prompt the doctors and nurses to deal with the delirium and endeavor to return the patient to normal life before they can convince her daughter that she needs full-time care and attention. Drennan (2010) affirms that patients suffering from delirium can recover if treated effectively, and the challenge is that over 50% of these cases actually remain unreported despite its high prevalence amongst patients who have to stay in the hospital for long periods.

Croskerry (2006) cautions that pain medication in most cases causes delirium, especially in elderly patients. The fact that Mrs. Jones was considered fit for morphine prescriptions implies that her pain was indeed quite severe. However, she or at least her daughter should have been informed of the possible side effects of the medication. Therefore, the way Deborah reacts to finding her mother in a state of confusion and agitation implies that she did not know that the pain medication could cause such a condition. The nurses and doctors in charge of the patient should, thus, be responsible for informing the patients and their families of the possible side effects of the medication that they are given to avoid panic and doubts as is seen with Deborah in this case.

In his observation, Cottrell (2011) notes that the use of dark therapy to calm the patient and make her sleep is also the right decision made by the nurse, considering that the patient was having a hard time relaxing. In fact, rather than resort to pharmacotherapy, the use of alternative approaches in handling the problem at hand show practitioners’ initiative with respect to improving the patient’s condition. Due to the fact that Mrs. Jones’ condition was seemingly induced by medication, it was best to avoid stuffing her with more medication to counter these side effects. The fact that she is elderly further limits her ability to take a lot of medications due to the frailty of her aged body organs.

White and Stancombe (2003) note that another major intervention would occur while considering nursing home care for the aged. The reason is that the nurses might have been speculating when they informed the patient’s daughter that her mother may need to be taken into a nursing home owing to her new mental state. Considering that delirium is manageable, they should have at least waited the test results analyzed by the doctors before scaring Deborah and making her worry about her mother.

Conclusion

Sometimes, patient’s condition worsens when they come into the hospital not because they are given the wrong treatment but rather because they are exposed to the considerable number of risk factors for a condition like a delirium or dementia. While it is often important to consider the patient’s mental state before and during their stay at the health facility, it is also vital to not only use evidence-based practice but also avoid speculation and always enlighten the patient and their family about the possible side effects of any medication that is prescribed in order to avoid panic and mistrust.

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