NUR104 Biophysical And Psychosocial Processes

Bob Cameron is 81 years of age, retired and lives with his wife Margaret (65 years) in a small coastal town in rural New Zealand. Margaret was a midwife prior to meeting Bob and during marriage they purchased a yacht, lived on board and eventually sailed around the world together. Previous to their adventure, Bob worked in various occupations, mostly outside and often independently or in his own business. Lila, Bobs former wife, is 75 years old and lives alone in Auckland.

 

They separated after three children left home. The GP diagnosed Bob with hypertension and prescribed oral antihypertensives. Bob believes that he does not need to take his antihypertensives unless he feels unwell and that he can control his blood pressure by eating garlic and drinking cider vinegar. Of most concern to him is his belief that taking antihypertensives will make him impotent; their sexual relationship is very important to this couple. Bob is very good at building and making things and loves to be outside in his shed or maintaining the house. He prides himself on his ingenuity and independence; he would never hire a professional or tradesperson to do a job, believing that he can do everything himself.

 

In addition to his passion for sailing and the ocean, Bob loves cars and has owned some beautiful classic cars in the past. Currently he drives what he describes as a boring 10 years old sedan. They love to eat out or meet friends for a coffee at the local café, go for a drive in the country or a weekend away, but they have to budget as they live on the New Zealand universal superannuation pension of $ 576.20 per week (work and income New Zealand, n.d.). Margaret notices that Bob is becoming increasingly forgetful as he misplaces objects. Recently, he left some tools out in the rain and they were damaged, causing him to become very angry and frustrated with himself. As a result, Margaret researched the Alzheimer’s New Zealand website (Alzheimer’s New Zealand, n.d.) and concerned that he may have mild dementia. Her suggestion to see the GP leads to an argument, with Bob angrily accusing her of thinking that he is a ‘loony’. Margaret has been trying to encourage Bob to remain well by suggesting that they go on walks together for exercise and meet friends for social stimulation; she has also been trying to get him to take his antihypertensive medication more regularly.

 

Recently, matters come to a head when Bob become distracted when driving Margaret to visit a friend. The car went over the curb and hit a brick fence, causing some damage to the car, the fence and to his fore head when the impact of the airbag deploying forced his spectacles against his forehead and caused small laceration. After taking a careful history of the accident and the events leading up to it, the GP suggested to Bob and Margaret that it would be worthwhile doing a more through assessment of Bob’s cognitive function.

 

1 Discuss the biophysical and psychosocial processes pertinent to the case. 
2 Identify an assessment tool appropriate for use in this case and discuss key elements of the tool.
3 Discuss 3 priorities of care for this person. 
4 Discuss any equity, rights and access issues relevant to the case. 

Sadly, Tom (dolly husband) declined quickly after the stroke and passed away. To support her while she grieved, Dolly’s daughter invited her to stay with her and family for a few months. She enjoyed the chance to keep cooking for her family and encouraged her grandchildren to join in the kitchen. However, when it was time for dolly to return home, she struggled to adjust her lifelong cooking and shopping habits – now it was just her, and she was used to cooking such large meal. Meal times were quit and simple, when they had once been raucous and busy.

 

The familiar and loved rituals of planning what to eat each day, shopping for ingredients, then preparing, serving and enjoying the meal now seemed like an elaborate and taxing chore. In the past dolly would have chastised any of her family members that a cup of tea with vegemite on toast was not a healthy balanced meal, but nowadays it was a common item on her menu. Her neighbours regularly tried to tempt her to share a meal with them, but dolly did not want to be a burden or sadden her friends with her grief. She found herself spending more and more time inside. Over time, dolly family start noticing a few worrying changes in her behaviour. She starts forgetting family events, forgets where is at time and has trouble remembering family members names. After a trip to the doctor, dolly is diagnosed with the early stages of dementia and moves in with her family permanently.

 

1 Discuss the biophysical and psychosocial processes pertinent to the case. 
2 Identify an assessment tool appropriate for use in this case and discuss key elements of the tool.
3 Discuss 3 priorities of care for this person. 
4 Discuss any equity, rights and access issues relevant to the case. 

Janie is a 72- years old women who has had multiple falls in the last 12 months. Her last fall resulted in her badly spraining her right shoulder; this has limited her ability to undertake a lot of her general household duties. When presenting to her local doctor about her shoulder injury, she commented that she often feels very unbalanced and dizzy, especially when getting out of bed, and is worried it might have something do with her blood pressure medication. Janie also indicates she has been having trouble walking because of the arthritis in her feet. Janie’s last fall has really had a significant impact on her confidence and she tells her doctor that she is frightened that the next fall will do some major damage. As a result of this fear and her injury, she has not been getting out much. She also had to cancel her last optometry appointment because she could not drive herself with her shoulder.

 

1 Discuss the biophysical and psychosocial processes pertinent to the case. 
2 Identify an assessment tool appropriate for use in this case and discuss key elements of the tool. 
3 Discuss 3 priorities of care for this person. 
4 Discuss any equity, rights and access issues relevant to the case. 

Case study 1

Biophysical and psychosocial processes

Bob is also much concerned about his relationship. He is critical about his sexual life and doesn’t want to take medication as he feels it will make him impotent and affect his relationship with his wife. In dementia cases, a person struggles to maintain his or her identity. Bob is also struggling to maintain his identity by engaging in his hobbies, traditional roles, and occupation. He gets agitated when his wife tells him of his current condition. He also feels frustrated with himself for being forgetful. People with dementia may lose confidence in completing their tasks. For a person with dementia, he or she tends to withdraw from public activities which affect the identity, independence, relationships, social roles and self- esteem. Margaret is trying to motivate Bob to enhance his identity, self- esteem, and independence through social activities and interaction(Öhman, et al, 2014). Bob once led a very active life in his early ages. Physical activity to him can help reduce behavioral disturbances like aggression, agitation and noisiness. It will also lower depressive symptoms. Margaret is helping him exercise more, visiting friends and take the antihypertensive so that his health can be well.

The appropriate tool for assessment and its key elements

Bob is becoming forgetful and also caused an accident when he recalled some matters while driving.In this case, a Montreal Cognitive Assessment test shall be used(Lam, et al, 2013). The test is used to detect cognitive impairment. It contains thirty questions which take around twelve minutes to complete. The score of the test range from zero to thirty. The scoring is usually as follows: visuospatial and executive functioning is 5 points, animal naming is 3 points, attention is 6 points, language is 3 points, abstraction is 2 points, delayed recall is 5 points and orientation 6 points. The test helps determine if a person has an abnormal cognitive function. For the people with Mild Cognitive Impairment, it can predict dementia(Hsieh, et al, 2015).

Care priorities

Dementia people should be supported in their careers, health, and social care. The care should be person-centered by responding to their actual needs. Care can include knowing the person, offering meaningful activities in a flexible manner that is continuous. In the case of Bob, Margaret is trying to provide all these(Brooker and Latham, 2015).

They should also be provided with needs that are of their own skills, preferences, and abilities. These help them in communication, attention, and recalling of memories. The social and friendly environment helps them feel socially accepted. Engaging Bob by visiting friends makes him express himself and feel socially accepted.

Another priority care is the provision of information to empower dementia persons and the caregivers.

Its awareness helps people appreciate and care for their loved ones without any embarrassment. Margaret is aware of Bob’s situation and is not discouraged but determined towards improving his health.

Equity, rights and access issues

People with multiple needs should be recognized and be supported to acquire their needs from different systems(Johnson, Ling and McBee, 2015).

A person’s choice and control should be accessible. Their needs should be developed and the information provided. They should also be encouraged to go for appointment to discuss on their memory which will help them greatly.

The services and support should be maintained to cater to a person’s needs. This can be achieved through increasing knowledge and reducing the stigma associated with dementia.

Equity and inclusiveness should be practiced and the community encouraged in coming up with supportive environment for dementia people.

Healthcare should emphasize on screening and diagnosis to diverse populations and not merely assume just because the patient has not requested for it.

Case study 2

Biophysical and psychosocial processes

Death of loved once especially to the elderly is a devastating experience to their life. This makes many experience a decline in health and passes away shortly after their spouse. Many end up resulting in stress cardiomyopathy. Hence proper physical and emotional care is needed. The social activities for the case of Dolly have been withdrawn and she is experiencing social isolation. She doesn’t want to meet friends anymore or invite anybody. Since she returned to her home from her daughter’s house, she lost confidence in the completion of task like cooking which she enjoyed while there. Her husband’s death was also causing grief to her and affected her social life. Physically, it resulted in sleeplessness and loss of appetite and consequently depression (Sobal, Bisogni and Jastran, 2014). Dolly despised a cup of tea and vegemite as an unbalanced diet but had now become her usual meal. She had also lost independence and interest in her own care.

Assessment tool and key elements

Early dementia detection requires primary care which requires the detection of symptoms other than memory loss complains. In this case, Early Dementia Questionnaire (EDQ) can be used and then compared with the Mini-Mental State Examination (MMSE) assessment tool(Lam, et al, 2013). Inclusion criteria include a score of five or less in the Geriatric Depression Scale(GDS) with the presence of a reliable caregiver(Hsieh, et al, 2015). A face-to-face interview is also done using the EDQ with the caregiver and the patient to bring out any symptoms of dementia. For the cases where a caregiver is not present a telephone interview is used. Dolly’s family noticed some changes in her behavior such as being forgetful of the family evens and having trouble to remember some of the family members.

Priorities of care

Feeding and diet monitoring. For the dementia cases, there is a need for help in feeding. Changes in appetite or health should be monitored. Most aged people do not also take enough water hence the caregiver should remind and encourage them to increase water intake (Brooker and Latham, 2015).

Impaired memory cueing.  Anxiety, memory loss, depression, and confusion are devastating effects to the patient and the whole family. Reminding them gently and in a discrete way maintains their dignity and independence. A patient’s approach prevents the patient from being disheartened or frustrated(Barnes, et al, 2013).

Monitor vital signs and medication. When it comes to seniors, swallowing of pills is difficult. With the help of a pharmacist, some can be dissolved in liquids or crushed to ease swallowing. Pulse, temperatures, and respiration can also be measured to keep track of their condition.

Equity, rights and assess issues

Aged care and education training should be accessible. Their training should be included in the curriculum to ensure their special needs are communicated and met(Johnson, Ling and McBee, 2015).

Representatives should advocate for the evaluation of the systems and ensure their needs are identified, appropriate and meaningful information is provided in single or mainstream services.

Data on characteristics of the users of service care of the aged should be made available publicly checked to ensure planning and practice.

Case study 3

Biophysical and psychosocial processes

Janie is facing various biophysical and psychosocial processes. She has developed fear which has dominated her psychology. This has resulted to lack of confidence to herself after the frequent falls with the last fall spraining her shoulder which led to subsequent pain and suffering. Her risk of falling again has also made her not carry out her duties or interact with the outside environment(Pfortmueller, Lindner and Exadaktylos, 2014).She has also developed a mental conditioning that the next fall will cause a greater harm. Physically her injured arm cannot function hence she forgoes her appointment. Her considerations draw attention to those practices which inform the personal importance and social responses to being in pain. The sensation of pain is entirely subjective, explained, configured, perceived and communicated it affects a person’s relationship to others and themselves. It is shaped by cultural beliefs, social practices, prevailing medical practices, and their beliefs(Stubbs, et al, 2014).

Assessment tool and key elements

In the case, Janie has encountered many falls for the last twelve months. To assess the causes of the fall, a multifactorial falls risk assessment should be carried out. The assessment examination is carried out by a health professional with the required skills. The multifactorial has the following key elements where assessment is carried out; a detailed identification of falls history, followed by assessment of balance, gait and muscle weakness, bone disease risk, assessment regarding perceived functional ability and fear relating to falling, visual impairment, cognitive impairment and neurological examination, ability to contain urine, risk factors at home and a cardiovascular examination followed by review on medication(Phelan, et al, 2015).

Priorities of care

One can ensure she is safe and able to manage on themselves in their home. They can also be helped with any assistance they need if they aren’t capable of themselves.

Exercise and walking programs; By the fact that Janie has a care it means that she spends most of her time driving whenever she is out of her home. This has increased stress on her feet leading to arthritis. Strong leg muscles prevent falling. Daily walking exercise also reduces swelling, increases blood circulation and helps in maintaining the density of the bone(Voukelatos, et al, 2015)

Assistance in medical appointments; Caregivers should get the patient ready for appointments either by car or taxi and help in giving the doctor the necessary information on medication, medical history, and symptoms.

Physiotherapy; It is needed to help in gaining strength after an injury or surgery and also strengthen muscles for balance. The caregiver can evaluate proper body ways and the need for a walker, cane or other devices which can help reduce the risk of injury or fall again(Okubo, Schoene and Lord, 2016).

Equity, rights and assess issues

Prosthetic devices have been developed to help improve postural balance in the elderly. Vibrotactile device fit around the waist and give information regarding body tilt through vibration. Also, there is a tongue- placed device which helps in providing information on the head’s position.

Professionals coming up with fall prevention programs should ensure the programs are flexible to fit the different needs and preferences of the people involved. It should also add value to them socially(Pfortmueller, Lindner and Exadaktylos, 2014).

Programs of fall prevention should ensurerelevant information is available in different languages. Barriers like fear of falling, low self- efficacy should be addressed and activity change encouraged to the participant(Vieira, Palmer and Chaves, 2016).

The professional involved in the assessment should consider discussing changes a participant is willing to make in preventing falls.

References:

Barnes, D.E., Santos-Modesitt, W., Poelke, G., Kramer, A.F., Castro, C., Middleton, L.E. and Yaffe, K., 2013. The Mental Activity and eXercise (MAX) trial: a randomized controlled trial to enhance cognitive function in older adults. JAMA internal medicine, 173(9), pp.797-804.

Brooker, D. and Latham, I., 2015. Person-centred dementia care: Making services better with the VIPS framework. Jessica Kingsley Publishers.

Hsieh, S., McGrory, S., Leslie, F., Dawson, K., Ahmed, S., Butler, C.R., Rowe, J.B., Mioshi, E. and Hodges, J.R., 2015. The Mini-Addenbrooke’s Cognitive Examination: a new assessment tool for dementia. Dementia and geriatric cognitive disorders, 39(1-2), pp.1-11.

Johnson, H.L., Ling, C.G. and McBee, E.C., 2015. Multi-disciplinary care for the elderly in disasters: an integrative review. Prehospital and disaster medicine, 30(1), pp.72-79.

Lam, B., Middleton, L.E., Masellis, M., Stuss, D.T., Harry, R.D., Kiss, A. and Black, S.E., 2013. Criterion and convergent validity of the Montreal cognitive assessment with screening and standardized neuropsychological testing. Journal of the American Geriatrics Society, 61(12), pp.2181-2185.

Öhman, H., Savikko, N., Strandberg, T.E. and Pitkälä, K.H., 2014. Effect of physical exercise on cognitive performance in older adults with mild cognitive impairment or dementia: a systematic review. Dementia and geriatric cognitive disorders, 38(5-6), pp.347-365.

Okubo, Y., Schoene, D. and Lord, S.R., 2016. Step training improves reaction time, gait and balance and reduces falls in older people: a systematic review and meta-analysis. Br J Sports Med, pp.bjsports-2015.

Phelan, E.A., Mahoney, J.E., Voit, J.C. and Stevens, J.A., 2015. Assessment and management of fall risk in primary care settings. Medical Clinics, 99(2), pp.281-293.

Pfortmueller, C.A., Lindner, G. and Exadaktylos, A.K., 2014. Reducing fall risk in the elderly: risk factors and fall prevention, a systematic review. Minerva Med, 105(4), pp.275-81.

Sobal, J., Bisogni, C.A. and Jastran, M., 2014. Food choice is multifaceted, contextual, dynamic, multilevel, integrated, and diverse. Mind, Brain, and Education, 8(1), pp.6-12.

Stubbs, B., Binnekade, T., Eggermont, L., Sepehry, A.A., Patchay, S. and Schofield, P., 2014. Pain and the risk for falls in community-dwelling older adults: systematic review and meta-analysis. Archives of physical medicine and rehabilitation, 95(1), pp.175-187.

Vieira, E.R., Palmer, R.C. and Chaves, P.H., 2016. Prevention of falls in older people living in the community. bmj, 353, p.i1419.

Voukelatos, A., Merom, D., Sherrington, C., Rissel, C., Cumming, R.G. and Lord, S.R., 2015. The impact of a home-based walking programme on falls in older people: the Easy Steps randomised controlled trial. Age and ageing, 44(3), pp.377-383.