Exemplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 071 - 072
Article Text
Gerontic challenge
Wendy Morey RN Gerontic Nsg Cert
Mr G who is 87 years of age, came to our nursing home seven months ago. He has long standing Bipolar Affective Disorder. The outreach service of a major metropolitan mental health hospital had been involved with Mr G for many years and the community mental health nurses (CMHNs) knew him well. Following Mr G's admission to the nursing home the CMHNs maintained their contact with him and became valuable resource people to the registered nurses in the nursing home.
Over a period of months, we began to understand Mr G's behaviour and became creative in our approach to his care. He frequently displayed a fixation about his bowels or wearing no clothes and we soon learned that it was counter-productive to argue with him. A recognition of his comments and a redirection of the conversation were more helpful. We began to observe a pattern of 'peaks' and 'troughs' wherein Mr G would develop a touching sense of community in his offers of practical assistance to other residents but then his moods would deteriorate. He would withdraw and negative behaviour would ensue.
On one such occasion, we noted that Mr G's moods were beginning to deteriorate. Over a period of two weeks he became more agitated, unsteady on his feet and quite disgruntled. He ceased his social interactions, developed quite a resistance to nursing care and fell over twice. Our assessment of him indicated another chest infection may have been contributing to his behaviour changes. Following our request for a medical assessment, Mr G was commenced on oral antibiotics.
I was rostered on over the weekend when Mr G's antibiotic therapy commenced and thought it reasonable to monitor his progress for forty-eight hours. By Sunday afternoon, it was clear however, that his depressive mood had deepened and he began to express suicidal thoughts. Mr G's doctor considered that a readmission to the mental health hospital for assessment and management of this depressive phase was indicated. Mr G was adamant that he should not leave the nursing home because he had a medical condition and that the mental health service would not accept him. He was correct. What then followed was a trip by ambulance to this service which then redirected Mr G via ambulance to a major public hospital. Many phone calls later, in the small hours of the morning, Mr G was finally admitted for a three day course of intravenous antibiotics for his chest infection. His depression was considered a secondary diagnosis.
From a nursing perspective, Mr G's care could have been enhanced if the registered nurse in the nursing home had been able to offer management of intermittent intravenous therapy. Mr G would have been saved the anguish of removal from his familiar surroundings coupled with the experience of hospitalisation. The disruption caused by three days in hospital for an elderly person simply for intravenous antibiotics must surely be questioned from both a cost perspective and in terms of maintenance of continuity of care. The latter can mean a great deal in terms of quality of life for the elderly. This whole experience highlighted for me, the fact that gerontic registered nurses must continue to seek empowerment by both skills enhancement and request for appropriate resources in order to improve the nursing care outcomes for nursing home residents. With the increased frailty and complexity of nursing home residents' conditions, gerontic nurses will more often face the challenge of providing nursing care which will stretch the boundaries of that traditional provided in nursing homes.
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