Realities of Practice – Module 1 – Case Scenario: Elderly Health Concerns

The Realities of Practice
Module 1
NURS23921

Case Scenario

As a homecare nurse, you are scheduled to visit Mrs. Talisker, an 86 year old women living with her daughter in a townhouse complex. Mrs. Talisker has dementia and a Stage III sacral ulcer – she is also extremely frail and unsteady on her feet. Her mental status currently presents as ‘confused’, but she has been described by other nurses to be “pleasantly demented”. Her daughter has been the sole care provider for her mother up to this point, and is relieved to now have the assistance of your nursing homecare agency.

Since Mrs. Talisker is unsteady on her feet, she spends a significant portion of the day in bed, and requires assistance to mobilize to the washroom. The daughter must remain vigilante to ensure her mother does not attempt to use the washroom by herself, given her increased risk of falls.

Upon assessment, you find Mrs. Talisker to be legarthic, but cooperative with your physical assessment. You notice reddening spots on both her heels where they make contact with the bed. Similarly, you take a complete set of vitals and find that her temperature is elevated to 38.1, and her heart rate is tachycardic at 100 bpm. Upon checking her previous vitals record, you notice that these measurements are higher than her normal average.

APPLY

Activity 1

From topics stemming from the case scenario and/or other elderly healthcare situations you’ve experienced, develop five (5) multiple choice examination questions. Structure the multiple choice questions in the same format as those found in the Canadian Practice Nurse Registration Examination Prep Guide (2011).

MY QUESTIONS

Professional, ethical, legal perspectives

1. Mrs. Talisker has an increased risk for falling and her daughter must be vigilant about ensuring that her mother doesn’t use the washroom by herself. What suggestions can you make to reduce the risk of falling for Mrs. Talisker and decrease her daughter’s stress about her mother getting out of bed alone?

a.) Talk to Mrs. Talisker’s daughter about the use of ambulatory aids, such as a walker, and other aids like hand rails; decreasing Mrs. Talisker’s risk of falling.

b.) Suggest talking to the physician about putting Mrs. Talisker on antipsychotic medications to calm her down and make her more sedative; decreasing the likelihood of her wandering or getting out of bed.

c.) Tell Mrs. Talisker’s daughter to install bed rails and keep them up at all times so that Mrs. Talisker can not get out of bed by herself; decreasing the risk of harm to herself.

d.) Suggest that Mrs. Talisker’s daughter stay by Mrs. Talisker’s bedside more often; it is her moral obligation as a daughter to take care of her mother and make sure she’s not hurt.

2. Mrs. Talisker’s daughter is having company over tomorrow evening and is concerned that this may excite her mother, disturbing her dementia state. She tells you she has some Ativan that she had been prescribed a few years ago up in her cupboard and asks if you can administer a safe dose to Mrs. Talisker to ensure she stays calm while visitors are in her home. What is the best way to respond to this request?

a.) Tell Mrs. Talisker’s daughter you can not prescribe this medication because it is probably expired.

b.) Explain to Mrs. Talisker that no one must ever take prescription medication that was not prescribed to them.

c.) Educate Mrs. Talisker on how unethical her request is and that using this medication is a form of chemically restraining her mother.

d.) Administer a safe dose of Ativan to Mrs. Talisker after referring to your drug guide.

Medical/surgical/biomedical perspectives

3. Based on the results of Mrs. Talisker’s vital sign assessment presenting an increased temperature of 38.1 and an increased heart rate of 100bpm, what should be the next step taken by you as a nurse?

a.) Perform a neurological assessment on Mrs. Talisker
b.) Call the physician and report these findings
c.) Assess Mrs. Talisker for signs of infection
d.) Administer antipyretic medications to reduce fever

4. Mrs. Talisker has a Stage III sacral ulcer and seldom gets up from her bed due to an unstable gait. Erythmous skin on the heels of her feet indicate Mrs. Talisker is at risk for additional bed sores in these areas as well. What is the primary step you as a nurse will take to aid in the healing of the sacral ulcer, as well as the prevention of pressure ulcers on Mrs. Talisker’s heels?

a.) Turn Mrs. Talisker from side to side q4hr, use pillows to reduce pressure and change dressings 3 times per day.
b.) Educate Mrs. Talisker on the importance of ambulating when ever possible and apply lotion to her heels.
c.) Explain what a Stage III ulcer is to Mrs. Talisker’s daughter and tell her it would be wise to purchase a water bed to reduce pressure and prevent ulcers.
d.) Reposition Mrs. Talisker frequently, apply moisturizing lotion to heels, assess existing ulcers to ensure a decrease in size, apply new dressings 2-3 times per week.

Collaborative and interprofessional considerations

5. You share shifts caring for Mrs. Talisker with another homecare nurse. When you show up for your shift and begin to care for Mrs. Talisker at 0600, she insists that she has a doctor’s appointment this morning at 0900 that was scheduled yesterday by the other nurse. When reviewing the second home care nurse’s documentation, you see nothing that mentions a doctor’s appointment. What is the best step to take in this situation?

A.) Arrange for Mrs. Talisker to get to her appointment at 0900
B.) Contact the home care nurse who also cares for Mrs. Talisker and ask if she made an appointment for Mrs. Talisker this morning.
C.) Assume this is a fabrication caused by Mrs. Talisker’s dementia.
D.) Call Mrs. Talisker’s physician and confirm whether or not she has an appointment.

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ANSWERS & JUSTIFICATIONS
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1. Mrs. Talisker has an increased risk for falling and her daughter must be vigilant about ensuring that her mother doesn’t use the washroom by herself. What suggestions can you make to reduce the risk of falling for Mrs. Talisker and decrease her daughter’s stress about her mother getting out of bed alone?


a.) Talk to Mrs. Talisker’s daughter about the use of ambulatory aids, such as a walker, and other aids like hand rails; decreasing Mrs. Talisker’s risk of falling.

b.) Suggest talking to the physician about putting Mrs. Talisker on antipsychotic medications to calm her down and make her more sedative; decreasing the likelihood of her wandering or getting out of bed.

^ This answer is WRONG because it contradicts ethical practice. Antipsychotics are a form of mental restraints. They are also contraindicated by Dementia and the act of administering them would negate the act of non-maleficence.

c.) Tell Mrs. Talisker’s daughter to install bed rails and keep them up at all times so that Mrs. Talisker can not get out of bed by herself; decreasing the risk of harm to herself.

^ This answer is WRONG because this is a form of restraint, which is an illegal practice.

d.) Suggest that Mrs. Talisker’s daughter stay by Mrs. Talisker’s bedside more often; it is her moral obligation as a daughter to take care of her mother and make sure she’s not hurt.

^ This answer is WRONG because it may be considered judgmental or condescending toward Mrs. Talisker’s daughter, and she can easily take this sentence the wrong way.

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2. Mrs. Talisker’s daughter is having company over tomorrow evening and is concerned that this may excite her mother, disturbing her dementia state. She tells you she has some Ativan that she had been prescribed a few years ago up in her cupboard and asks if you can administer a safe dose to Mrs. Talisker to ensure she stays calm while visitors are in her home. What is the best way to respond to this request?

a.) Tell Mrs. Talisker’s daughter you can not prescribe this medication because it is probably expired.

^ This answer is WRONG because it suggests that if the medication wasn’t expired, you WOULD administer the medication, which is not appropriate.


b.) Explain to Mrs. Talisker that no one must ever take prescription medication that was not prescribed to them.

c.) Educate Mrs. Talisker on how unethical her request is and that using this medication is a form of chemically restraining her mother.

^ This answer is WRONG because it may be misconstrued by the daughter, making her feel judged and degraded. A more therapeutic approach to educating her on why you can’t administer the medication would be more appropriate.

d.) Administer a safe dose of Ativan to Mrs. Talisker after referring to your drug guide.

^ This answer is WRONG because you must NEVER administer medications to patients without a physicians order to do so!

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3. Based on the results of Mrs. Talisker’s vital sign assessment presenting an increased temperature of 38.1 and an increased heart rate of 100bpm, what should be the next step taken by you as a nurse?

a.) Perform a neurological assessment on Mrs. Talisker

^This answer is WRONG because this is not the FIRST step you would want to take

b.) Call the physician and report these findings

^ This answer is WRONG because calling the physician at this point is not exactly necessary.

c.) Assess Mrs. Talisker for signs of infection

d.) Administer antipyretic medications to reduce fever

^ This answer is WRONG because you should really assess what is causing this change in Vital Signs before administer medications to alter your findings. Likely, in this case, Mrs. Talisker may have an infection r/t her Stage III ulcer. Although you will want to reduce the fever, you should assess the cause of fever first.

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4. Mrs. Talisker has a Stage III sacral ulcer and seldom gets up from her bed due to an unstable gait. Erythmous skin on the heels of her feet indicate Mrs. Talisker is at risk for additional bed sores in these areas as well. What is the primary step you as a nurse will take to aid in the healing of the sacral ulcer, as well as the prevention of pressure ulcers on Mrs. Talisker’s heels?

a.) Turn Mrs. Talisker from side to side q4hr, use pillows to reduce pressure and change dressings 3 times per day.

^ This answer is WRONG because you should reposition every 1-2 hours and changing the dressing 3 times a day is excessive.

b.) Educate Mrs. Talisker on the importance of ambulating when ever possible and apply lotion to her heels.

^ This answer is WRONG because Mrs. Talisker has dementia, making it difficult to educate her – also you don’t want to encourage her getting out of bed without assistance. And if you lotion her heels, you’ll make them slippery, increasing her changes of falling!

c.) Explain what a Stage III ulcer is to Mrs. Talisker’s daughter and tell she must purchase a water bed to reduce pressure and prevent ulcers.

^ This answer is WRONG because you are basically demanding that she buy a water bed. It would be wise to educate her and let her know that a water bed will help, but be careful with wording.

d.) Reposition Mrs. Talisker frequently, apply moisturizing lotion to heels, assess existing ulcers to ensure a decrease in size, apply new dressings 2-3 times per week.

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5.) You share shifts caring for Mrs. Talisker with another homecare nurse. When you show up for your shift and begin to care for Mrs. Talisker at 0600, she insists that she has a doctor’s appointment this morning at 0900 that was scheduled yesterday by the other nurse. When reviewing the second home care nurse’s documentation, you see nothing that mentions a doctor’s appointment. What is the best step to take in this situation?

A.) Arrange for Mrs. Talisker to get to her appointment at 0900

^ This answer is WRONG because you should confirm the appointment first, Mrs Talisker does have dementia and may not be correct in stating she has an appointment.

B.) Contact the home care nurse who also cares for Mrs. Talisker and ask if she made an appointment for Mrs. Talisker this morning.

^ This answer may be acceptable, but with it being 6:00 AM you may not be able to contact the nurse. It would be best to call the physician’s office to confirm the appointment.

C.) Assume this is a fabrication caused by Mrs. Talisker’s dementia.

^ This answer is WRONG because you should not assume Mrs. Talisker is always wrong just because she has dementia.

D.) Call Mrs. Talisker’s physician and confirm whether or not she has an appointment.

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Activity 2
Generate recommendations for Mrs. Talisker’s care, from the images in the video and the written case scenario. In a few sentences on your blog, describe:
a. your professional implications as an RPN caring for Mrs. Talisker;
b. the medical/nursing interventions that should be addressed immediately and longitudinally for Mrs. Talisker;
c. the other interprofessional healthcare team members who should be consulted/contact to assist Mrs. Talisker’s immediate care.

A. Professional implications that can be applied to the care of Mrs. Talisker as an RPN include: using therapeutic communication to increase the quality of her care, ensuring hygiene measures are upheld, making her as comfortable and free of pain as possible, optimizing her state of health, maintaining a sufficient nutritional status, advocating for her as a patient, and more. It is also important to include her daughter in the plan of care and providing her with client education on her mother’s health.

B. Immediate nursing interventions: Because Mrs. Talisker’s temperature and heart rate are higher than her baseline, a priority would be to assess why this is happening. Assessing her Stage III sacral ulcer may result in finding infection. In this case, after checking doctor’s orders, analgesics and antipyretic medications can be administered to reduce pain and fever. Next, the sacral ulcer should be taken care of by changing the dressing, noting the discharge and recording the size of the ulcer. Monitoring the ulcer for a decrease in size or infection over time is important. Other interventions such as turning Mrs. Talisker q1-2hr, using soft pillows to reduce pressure, and increasing her nutritional status should be implemented. These steps should also be taken to prevent the pressure ulcers on her heels from advancing in severity. Follow up with vital sign assessment afterward to compare results.

Longitudinal nursing interventions: Referring Mrs. Talisker and her daughter to an occupational therapist to consider the use of ambulatory aids, such as a walker or wheelchair. Monitoring her nutritional status and referring to a dietician will also be beneficial. Suggesting stimulating activities for the client such as listening to music or social engagement. Monitoring her response to medications. Encouraging independence (eg. having her button up her own shirt instead of doing it for her). Performing active and passive ROM exercises each day.

C. Other interprofessional healthcare team members: Occupational therapist, dietician, physician, other nurses, etc…

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Self-reflection questions
a. What are your thoughts regarding geriatric nursing?
b. Could you see yourself working with geriatric populations in the future?
c. Could Mrs. Talisker’s washroom be set up differently if she is at risk for falls?
d. What other services could Mrs. Talisker’s receive to assist in her care?

A. Before I started my education in the RPN program, I honestly felt a little frightened of the elderly. I honestly felt they were just “old”, “boring” and “grumpy”. However, after having worked with them for three semesters, I have a huge understanding for geriatrics now. I respect the elderly population and feel they are really overlooked in our society. Geriatric nursing is important because, although elderly, we are still dealing with human lives – they deserve to have optimal health care just as much as you and I.

B. I could see myself working with the geriatric population, however there are many other areas that I am very interested in. Geriatrics wouldn’t be my first choice, but I wouldn’t be morally opposed to it.

C. Mrs. T’s bathroom could feature a raised toilet with hand bars, a rubber mat on the floor for grip, and a hand rail on the wall for balance. A sliding door may also be helpful to provide privacy with ease.

D. Other services may include a consultation with a dietician, perhaps “meals on wheels”. An occupational therapist as well as a physiotherapist to help with ADL’s and ROM exercises.

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