The Plan of Care
Mr. A. had a long-term care plan in place that covered all aspects of his dementia care involving his dementia nurse, GP, carers and social worker. As mentioned, the key nursing goals were promoting his independence and social interaction to improve his quality of life and reduce his anxiety and distress, with pain management for cancer. Due to his progressing cancer, he was under the care of an oncologist, saw specialist oncology nurses during outpatient appointments and was now referred for additional nursing assessment in his care home. His dementia nurse saw him every 6 months and provided summarised notes and key points in his care plan every three months. Mr. A’s carers were most involved in his daily care at the nursing home and contributed to the care plan, so far supporting any nursing interventions and providing information for assessments. As noted by Mr. A’s nurse, the progression of his cancer was a complex addition to his case management and now needed to be considered in his future care planning. This meant maintaining consistent pain management and introducing assessments for swallowing as his cancer progressed further and his symptoms got worse. It was already highlighted in his care plan that carers should observe for any difficulties in swallowing due to his dementia; however, as Mr. A.’s dementia nurse only visited every 6 months and he now had two serious conditions that can affect speech and swallowing, Mr. A.’s community nurse thought assessments should be each month. This was amended in his care plan accordingly. The nurse also spoke to a senior carer and explained that staff should pay greater attention to Mr. A’s swallowing now his cancer was progressing, outlining the risks and additional assessments that would take place. Managing this risk was a crucial part of the nurse’s role in Mr. A’s care, increasing assessments to reflect the increasing risk (NMC, 2008, pp.2).
Throughout Mr. A.’s care plan and the nursing appointment, there was evidence of engagement with his carers at the long-term home and this was an aspect of care that appeared to be managed very well. Collaboration with primary caregivers as well as other healthcare professionals during the care planning process supports the professional values of nursing (NMC, 2008, pp.8). Moreover, nursing collaboration with carers of patients with dementia improves caregiver and patient satisfaction while reducing hospital admission rates for the latter (Dang, Badiye, and Kelkar, 2008, pp.1246). Regarding Mr. A’s distress and anxiety, his care plan noted that he was being encouraged to spend time in the resident’s day room and take part in some of their activities and trips but only spent a limited amount of time in the day room. His room was also quite sparse and didn’t have many personal items or photos to look at. He did have a window with a nice view of the gardens. Mr. A.’s carers had moved his chair next to the window and had been encouraging him to look outside, talking to him about the weather. They said this seemed to calm him at times so his nurse also highlighted this in his care plan as a regular daily routine. Interestingly, recent research has shown that scenic views can reduce agitation in patients with dementia, as a form of art therapy. Images can also be used where natural views are not possible (Chancellor, Duncan, and Chatterjee, 2014, pp.1). Displaying images of nature has been reported to improve neuropsychiatric symptoms, social behaviour and self-esteem in patients with dementia while positively influencing well-being (Hannemann, 2006, pp.60). Although evidence is still emerging, art therapy could be a useful, easy and cost-effective way of improving the well-being of patients with dementia who struggle to interact.
Effective pain management has been shown to improve mobility, lower hospital admission rates, increase patient satisfaction, reduce health care costs and can improve quality of life (Carr and Goudas, 1999, pp.2051; Glowacki, 2015, pp.33-41). It also reduces sleep deprivation, which is associated with fatigue, impaired cognitive and physical functioning, mood instability, emotional distress and an exacerbation of concurrent symptoms (Friese, 2008, p.697; Matthews, 2011, 205). Guidelines recommend a stepwise approach to pain management for patients with cancer, using the World Health Organisation’s analgesic ladder (Mercadante and Fulfaro, 2005. n.p.; National Institute for Health and Care Excellence, 2012. n.p.). Mr. A. had gone up the ladder from a single non-opioid medication for chronic pain to the addition of an opioid for breakthrough pain (Davis, Glare and Hardy, 2005, pp.126). This was maintained following Mr. A.’s nursing visit, although perhaps with a thorough assessment, Mr. A. may have needed an increase in his analgesia, receiving an opioid for chronic pain instead of only receiving stronger relief on demand from his oral morphine solution. Mr. A.’s nurse did, however, note in his care plan to see if he would enjoy cold or warm drinks or snacks such as ice lollies that may ease any discomfort in his throat caused by his tumour. This was also mentioned to the carer present who fetched Mr. A. an ice drink which he seemed to enjoy. Cold or warmth on painful areas has been shown to be effective in relieving pain and discomfort to injuries. Therefore, recommending interventions such as warm baths or ice compressions can be useful and easy non-pharmaceutical ways of providing some pain relief for any patient experiencing chronic or acute pain (Dehgan and Farahbod, 2014, LC01.