University of Calgary, Faculty of Nursing
Calgary, Alberta, Canada
Discharge planning by nurses for clients who have been hospitalized for an extended period requires special attention. If these clients are elderly, the challenge is even greater. Comprehensive assessment and care planning are essential for the successful transition of elderly clients back to the community following a lengthy hospitalization. In the course of assessing each client, it is important to maintain that individual’s goals central to the overall planning process, recognizing that their participation is paramount to the success of any care plan.
This paper includes a review of the current research on issues and strategies for diabetic management and the prevention of social isolation and depression in the elderly following hospitalization. Orem’s Self–Care model (1991) is used as a framework to develop a discharge plan. The nursing interventions will focus on the knowledge and skills required by the hypothetical client, Mr. Smith, following his hospital discharge.
Mr. Smith, a 76-year-old Caucasian male was admitted to hospital with uncontrolled Type II Diabetes requiring stabilization. While Mr. Smith was hospitalized, the unexpected death of his spouse of 52 years triggered a normal grief reaction in the client. This complicated discharge planning and ultimately delayed his discharge.
Orem’s Self-Care Model
Orem (1991) describes nursing interventions as treatments based on valid and reliable measures that are developed and continually refined to assist clients to keep their functioning and development within levels compatible with life. Interventions should be directed to maximizing each client’s potential for self-care. Orem divides nursing interventions into three categories: wholly compensatory, partly compensatory and supportive educative. These categories describe the amount of nursing assistance required by clients to complete their self-care needs.
The wholly compensatory category includes nursing interventions that provide total assistance to clients for all of their self-care activities. By contrast, partly compensatory interventions provide assistance only in identified areas of self-care deficit. The third type, supportive educative interventions, refers to assistance designed to support and educate clients in relation to their ongoing health maintenance needs. To determine the type of nursing interventions to be used, the nurse needs to identify the client’s self-care deficits, as well as the barriers the client has in regard to achieving self-care (Orem, 1985).
For an elderly client like Mr. Smith, it is important to assess for developmental barriers related to aging such as alterations in vision, memory, mental status and physical limitations. Age-related limitations might interfere with a client’s ability to meet his or her self-care needs. All human beings throughout their life cycle have needs associated with life processes, those processes that are associated with the maintenance of an individuals human structure, functioning and general wellbeing. Orem (1985) describes these processes as ‘universal self-care requisites’.
Assessing for Self-Care Deficits
In order to identify areas of self-care deficits related to Mr. Smith’s diabetic management, a comprehensive review of his dietary habits, the nurse completed knowledge related to food choices and ability to prepare meals. Additionally, the client’s ability to independently manage insulin and oral medication regimes on discharge was assessed. Blood glucose monitoring was not a new skill for him. Other areas that the nurse reviewed with Mr. Smith included the common times to monitor blood sugar levels, and the optimum range for maintenance blood sugars (Meidenbauer, 2000).
Prior to his hospitalization eight months ago, Mr. Smith’s spouse had prepared all the meals and, as a result, he possessed limited knowledge of diabetic diets or meal preparation. Having been widowed during his hospitalization, Mr. Smith would now be required to manage his own dietary needs on discharge. After completing a comprehensive nursing assessment, universal self-care deficits were identified in dietary management, medication management and altered social interaction. Nursing interventions based on a partly compensatory nursing system (Orem, 1985) would be required on discharge.
Interventions to Facilitate Diabetic Management in the Community
Donaldson, Rutledge, and Pravikoff (2000) identify education as the core to diabetic self-management. This is supported by Christensen and Kenny (1990), who emphasizes that assessment of each individual’s capacities, is required in order to tailor educational programs to one’s specific needs. Nurses need to work collaboratively with the patient to ensure that they have common educational goals. An educational plan developed in isolation may be contrary to the beliefs of the patient. Acceptance of the educational plan is essential to facilitate ‘buy in’ by the client. Clients should therefore be included in the overall planning process whenever possible (Meidenbauer, 2000).
Anxious to return home, Mr. Smith was motivated to participate in educational sessions. In preparation for his discharge, a medication-teaching plan was completed. It included a review of concepts related to insulin therapy, particularly the importance of exact dosages and rotation of sites for maximum absorption (Patrick, 1997). To minimize pain at injection sites, Mr. Smith was taught to store insulin at room temperature, wait for the alcohol that was used to cleanse the site to dry before injecting, inject at a 90° angle and not to reuse needles (Patrick, 1997). Due to Mr. Smith’s decreased vision, the nurse conducted a trial with an insulin pen to determine if this device would allow the client to be independent with his insulin therapy. However, the client was unable to learn the processes to successfully manipulate the insulin pen. Therefore, the nurse arranged for Mr. Smith to have preloaded syringes, which he could manipulate successfully upon his discharge to home.
In addition to insulin therapy, Mr. Smith had an extensive oral medication regime. McGraw and Drennan (2001) have reported non-adherence to medication regimes by the elderly. Illustrative examples of reasons identified for the latter include decreased memory and vision, poor social support and unpleasant side effects from the medication. As memory and vision deficits were identified as potential barriers for Mr. Smith to successfully manage his oral medications, the use of a medication dispenser was initiated to facilitate his adherence to the prescribed oral medication regime. Weekly filling of the medication dispenser by a community pharmacy with additional monitoring to be done by the Home Care nurse was organized.
The nurse reviewed diabetic diet requirements with Mr. Smith by using a food pyramid, which assists clients to understand recommended food groups and choices (Meidenbaur, 2000). Barry (2000) identifies the need for ongoing reinforcement of education with older people because they require additional time to integrate new knowledge. To reinforce diabetic education for Mr. Smith, the nurse provided written literature about the value of insulin therapy, self-injection techniques, rotation of injection sites and a copy of the food pyramid.
Evaluating the Mr. Smith’s assimilation of the discharge education is also very important. The nurse evaluating this determined that although he was capable of participating in his self-care, he would require nursing intervention through a partially compensatory nursing system in order to return to community living without the support of his spouse. As indicated by his numerous demonstrations to nursing staff, Mr. Smith was proficient with self-injection of insulin. Due to decreased visual acuity, he was unable to prepare the syringes accurately and Home Care nurses would be required to preload insulin syringes on discharge. Diabetic Meals on Wheels was suggested to ensure appropriate food choices, particularly because the client had limited knowledge and no desire to cook. Regular review of the clients’ actual food consumption should also be included as part of the overall diabetic monitoring completed by the Home Care nurse.
The ongoing review of education, related to Diabetes, required by Mr. Smith would be provided by staff at the outpatient diabetic clinic and supported by regular home visits by the Home Care nurse. Comprehensive record keeping of insulin dosages, food intake and blood glucose levels would assist the Home Care nurse in identifying issues that could be impacting Mr. Smith’s diabetic management. Given the importance of monitoring all factors that could impact his diabetic management, the nurse provided him record books teaching about how to complete the necessary information.
Interventions to prevent social isolation and depression
Social support plays a significant role in health promotion and an individual’s ability to cope with illness (Peterson, 2000). Therefore, it is imperative for the nurse to assess Mr. Smith’s social support network to determine his risk for social isolation and depression once discharged from hospital. Peterson (2000) emphasized that the nurse should assess the level of social support by not only the presence of resources, but also by how much time each resource is available to the client. Once the informal support network (e.g., family, friends, neighbors, etc.) has been assessed, the need for formal support assessment can be more easily determined.
Several risk factors for depression and loneliness for clients like Mr. Smith have been identified. For example, Ciechanowski, Katon, and Russo (2000) found that depression among diabetic clients was associated with inadequate diet, non-adherence to the medication regimen and the presence of a functional impairment. Walton, Schultz, Beck, and Walls (1991) found that older adults are especially vulnerable for depression and loneliness secondary to age related losses. Given the recent loss of his spouse and the resulting new challenges in managing his diabetic condition, Mr. Smith was at risk for depression and social isolation. To assess Mr. Smith’s current emotional state and to provide a baseline for future monitoring, a Geriatric Depression Scale (Brink, 2000) was completed. Mr. Smith scored 10/30 on the GDS indicating he was indeed at risk for depression in the future.
Jones (1997) found that clients who are dealing with frailty, bereavement, decreased eyesight, or mobility issues often do not join in activities and this lack of participation in activities may result in social isolation. Indeed, Mr. Smith’s chronic illness and recent bereavement also place him at significant risk for suicide. MacIntosh (cited in Morrow-Howell & Becker-Kemppainen, 1998) identified lack of social support as one of the risk factors impacting elderly individuals who consider suicide. Given the impact depression has on the overall functioning of an individual, preventative strategies to combat depression and potential suicide are required for Mr. Smith. Opportunities exist for both the client’s informal and formal support networks to counteract the risks of depression, social isolation and potential suicide. Therefore, an integrated plan to identify the roles of both the informal and formal support network for Mr. Smith was prepared prior to his discharge. Regular assessments by the Home Care nurse need to include evaluation of the clients risk for depression. The Geriatric Depression Scale, which is a 30-item scale, can be administered by the Home Care nurse and compared to the results obtained when Mr. Smith was in hospital.
Andersson (1998) found that clients normally turn to family for support. This support provided by the family is commonly referred to as the ‘social network’. To determine the level of Mr. Smith’s social network a family conference was held. Discussions with the client’s family revealed that 3 of his 5 daughters lived in the same city worked however they all had young families and worked outside the home. Given this situation, it was determined that Mr. Smith’s informal network would be unable to provide him adequate social contact and they would not be able to assist him in developing new relationships within the community after discharge. As a result, intervention by the formal support system was indicated.
Community options were evaluated to determine the most effective method of assisting the client to adapt to his new role as a widower. Those options included social support provided through home care, outpatient day programs, and friendly visits by volunteers. It was determined that the most appropriate interventions on discharge would be through support by a home care nurse and attendance at an adult day program. Interventions by the home care nurse would include periodic monitoring using the 30-item Geriatric Depression Scale (GDS) to screen for depression, as well as general monitoring of the client’s diabetic management and coping at home without his spouse. Assistance was provided for Mr. Smith to develop new relationships and social contacts and to establish new routines by arranging for his attendance at an outpatient day program on a twice-weekly basis. If he adjusts to his new role and develops new relationships, the Day Program may no longer be required.
Preventative strategies to combat depression are required for Mr. Smith because of the significant losses that he had experienced during his three months in hospital and the limited support his informal network would be able to provide after discharge. Limited research has been done using social support as a nursing intervention. However, Stewart and Tilden (cited in Peterson, 2000) have identified some evidence of positive outcomes. The expected outcomes of social support interventions they mentioned included improved problem solving, decreased depression, increased coping ability and increased self-esteem.
Interventions need to be individualized, safe and based on sound rationale. They require ongoing reassessment and revision to ensure client needs are being met (Christensen & Kenny, 1990). Interventions targeted at providing social support can be evaluated by determining how supported Mr. Smith feels and by assessing the impact new relationships have had on his overall ability to cope with life stressors. One method of assessing the success of interventions aimed at decreasing depression is through periodic reassessment using the Geriatric Depression Scale. Baseline GDS testing was completed prior to discharging Mr. Smith to the community. Regular reassessment using the GDS can be completed and compared to those baseline results. Differences in scoring can be reviewed to assist the nurse in monitoring for changes in Mr. Smiths level of depression and potential suicide risk.
Monitoring interventions implemented to assist the client in diabetic management include assessment of records tracking insulin dosage and corresponding blood glucose levels, review of diabetic diet knowledge, assessing adherence to diabetic diet and oral medication regime. A reassessment showing Diabetic instability evidenced by unstable blood glucose levels, decreased ability to manage insulin therapy and inappropriate food choices would, for example, emphasize the need for revisions of the current interventions. Improper diabetic management by the patient would raise issues of increased self-care deficits and potentially indicate a need to move to a wholly compensatory nursing care plan as opposed to the current partly compensatory plan.
Nursing frameworks together with evidenced based nursing interventions provide nurses with the tools required to care plan for clients in a changing health care system. The value of Orem’s framework is the ability to utilize it across a variety of settings while maintaining the underlying philosophical principal of maximizing client independence that ultimately is the overall goal of patient care.
As the number of elderly adults increases in the coming years, the health system and particularly nurses must recognize the complexity of needs this population presents. The potential for successful transition of elderly clients to the community can be improved by ensuring discharge planning includes a comprehensive assessment of the real and potential physical, mental and social issues that could impact the clients at discharge.
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CAIT Book:/Glenda Stein: A Discharge Care Plan for the Elderly Diabetic Client 2002-05-20
Glenda Stein, RN, B.N. candidate is the Regina Risk Indicator Tool Coordinator for the Calgary Health Region.
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