I have recently undertaken a student nurse placement in a community hospital in North Wales. I was mainly employed on the care of the older person ward. This ward dealt with older people awaiting or recovering from surgery or awaiting re-housing into care facilities or their own modified house. Many of the patients could be considered vulnerable. Normal aging, illness and life experiences had increased the vulnerability of many of the patients and the coping skills of many had been severely diminished.
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In this essay, I will examine one of the patients I came into contact with regularly. In accordance with the Nursing and Midwifery Code of Conduct (NMC 2008) all names and placement details will be concealed, and I will refer to the patient as Mr. A at all times. I will discuss Mr. A’s medical conditions and how and why these medical conditions have led Mr. A to be regarded as vulnerable, covering physical, social, psychological and environmental factors.
Mr. A was a 67 year old gentleman who was morbidly obese. He had a BMI of over 40 kg/m2 and was bed bound. He also suffered with Asperger’s Syndrome which is a type of autism mainly affecting social and communication skills. Both of these in addition with being an older person would have led to him to be vulnerable in various aspects.
Vulnerability is the susceptibility to physical or emotional injury or attack. Vulnerability refers to a person’s state of being liable to succumb to manipulation, persuasion or temptation. (Bankoff, et al. 2004). A vulnerable adult is one who due to Age, Physical injury, Disability, Disease or Emotional or Developmental disorders is unlikely to be able to provide for their own basic necessities of life; they may also have an increased risk of harm or injury. This would include, but is not necessarily limited to adults who reside in long-term care facilities such as nursing homes, adult family homes, boarding homes, assisted living facilities or those who receive health care or other assistance in providing for the basic necessities of life while residing in their own home.
Roper, Logan and Tierney(1980) published a nursing model outlining 12 activities of daily living that are crucial to a person basic needs, some of which are essential such as breathing, eating and drinking and others which enhance the quality of life such as work and play and expressing sexuality. When an individual becomes old, frail, ill and immobile they may be dependent on others to help them with the 12 ADLs. This can result in people feeling vulnerable.
Fernandez LS et al (2002) states that impaired physical mobility, diminished sensory awareness, chronic health conditions, and social and economic limitations can result in vulnerability of the elderly to disasters such as falls or accidents. Frail elderly with serious physical, cognitive, economic, and psycho-social problems are at especially high risk. Mr. A was 67 and according to the Geriatric Pharmacology Research Group in Newcastle upon Tyne, ‘The frail elderly are individuals, over 65 years of age, dependent on others for activities of daily living, and often in institutional care’. As with Mr. A, he was 67 years old and was reliant on carers for many if not all of the Activities of Daily Living. He was also in institutional care for pressure sores. Due to all of these points Mr. A would be classed as frail elderly.
Mr A’s problem with weight was the main cause of his hospitalisation, he stated he had weight consistently put on more and more weight over the years. He felt very responsible for his weight gain but was reluctant to do anything about it even though he was classed as morbidly obese. Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. Body mass index (BMI), a measurement which compares weight and height, defines people as overweight when their BMI is between 25 kg/m2 and 30 kg/m2, and obese when it is greater than 30 kg/m2.
Mr. A’s obesity led him to be largely bedbound and incapable of maintaining his health, his home or personal hygiene. When Mr A was living in his own home district nurses would regularly come in to tend to his pressure sores. Pressure sores are lesions to the skin caused by many factors such as unrelieved pressure and friction. These pressure sores were the result of Mr A being unable to move so constantly having to stay in the same position and thus having unrelieved pressure on different parts of his body. As Mr. A was bedbound he could not tend to his own housekeeping and his house became so untidy the district nurses found it too hard care for him in the chaotic surroundings so referred him to a community hospital. While he was in a community hospital a council funded cleaning team organized his house in order for him to be discharged back to a manageable house.
Another reason that district nurses were finding Mr. A hard to manage was that he suffered from Aspergers Syndrome and would often be aggressive with the district nurses. Aspergers syndrome is a type of autism that is characterized by difficulties in social interaction, along with restricted and repetitive patterns of behaviour and interests. It differs from other autisms as sufferer’s linguistic and cognitive development are often fine and develop well. The exact cause of Aspergers is unknown. There is no single treatment but interventions are used to improve sufferer’s symptoms and functions. The main treatment used is behavioural therapy, focusing on the specific insufficiency of the patient. These tend to consist of poor communication skills, obsessive or repetitive routines, and physical clumsiness. Most individuals improve over time, but difficulties with communication, social adjustment and independent living can exist and continue into adulthood. Some people with Aspergers syndrome may become angry and aggressive, either to themselves or to other people.
Sometimes when a person with Aspergers feels angry, they cannot easily pause and think of alternative strategies to resolve the situation. ‘The rapidity and intensity of anger, often in response to a relatively trivial event, can be extreme and can get so intense, they may go into a blind rage and unable to see the signals indicating that it would be appropriate to stop.’ (Attwood, 2006).
At the community hospital Mr. A would often get aggressive or rude when more than one nurse would be in the room. If he felt he wasn’t being listened to not being involved enough he would become very agitated and start shouting. The nurses took this into account and made sure Mr. A was involved at all times with anything going on in his room. I feel this condition may have led Mr. A to inadvertently isolate himself from people and people to him. When people do not understand something they can take a negative approach to it. Mr. A’s outbursts would have offended some people and cause them to detach themselves. This would quite possibly be due to the fact they did not understand or know about the condition and ‘fear of the unknown leads to negativity in some cases’. (Campbell, 2006)
A person who is vulnerable to isolation or social pressure may be considered as suffering from social vulnerability. When people become isolated due to illness or reduced mobility they may find it difficult to access essential services. Mr. A had a job translating books from various foreign languages into English. He did this from his laptop every day and when he was transferred to hospital he left his laptop at home. This made his feel low all the time as he said he had no purpose to his day. The nursing staff through Multi Disciplinary Team meetings reviewed his situation and decided to let him have his laptop delivered to the hospital along with internet connection and had his mail transferred, this all to allow him to continue to work which elevated his mood greatly for the remainder of his stay. He reported he was much happier at the community hospital now that he could continue with his day to day life.
Mr. A also said he felt isolated due to his obesity. As people age, they often become more vulnerable, their social circumstances particularly impact their health. As with Mr A, due to his obesity he was confined to his bed and this impacted on his social circumstances. It limited anything he wanted to do socially, for example, he could not venture out of the house, and could only find small ways of interacting with society. One of these ways was through his online job; this allowed him to interact through the internet without having to leave his bed. This had both a positive and negative side. Although it allowed Mr. A to interact with people, all be it virtually, which was important in developing his social skills it did however mean he did not have to move and so made little effort in changing his lifestyle.
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Mr. A’s lifestyle choices were undoubtedly the main cause of his hospitalization. He refused to try to diet at the hospital and stated he had always been this way, never wanting to diet. Family members would bring in unhealthy food for him; they were advised against doing this but made no attempt to stop. A dietician came to evaluate Mr. A and a plan was made but not stuck to by Mr. A. He was also offered physiotherapy in the form of help to start doing small movements with his arms and legs daily but he declined. This weight problem made him vulnerable to all sorts of illnesses; one in particular that was being managed at the hospital was his pressure sores. In hospital a special bed was required to accommodate his weight and relieve his pressure sores, along with bariatric chairs, wheelchairs and hoists.
Mr. A’s weight and inability to move made him physically vulnerable. Many of the elderly are admitted to hospital due to something caused by a physical vulnerability. A physical vulnerability is when a person has an increased risk of injury. E.g. easily brakes bones, has reduced strength, reduced movement or dexterity. Many of the patients in the community hospital were there as a result of such vulnerability and had suffered injuries resulting from falls. Some had reduced mobility which meant they needed assistance in performing one or more daily tasks such as getting in and out of bed, preparing meals and eating them, doing housework, dressing, and performing personal hygiene.
According to Holden and Smeeding sixteen percent of the elderly need help with at least one of these conditions. Elderly persons subject to two or more of the five they deemed “insecure”; those facing three or more were considered “extremely insecure.” Those people who are totally dependent on social services for survival are already economically and socially marginalized and require additional support at all times. Mr. A needed help with all physical activities, he was washed, dressed, fed, and cared for all by nurses and carers. He stated that because he could not do anything for himself he had no quality of life in the community hospital and although he was bedbound at home as well, he did have home comforts and had developed methods of reaching things he needed and wanted, such as a ‘pik-stick’.
These new surroundings may have made Mr. A feel environmentally Vulnerable. Environmental vulnerability is when a person suffers reduced quality of life caused by external conditions and surroundings. The transfer to the community hospital was a major change of environment for Mr. A as he had to get used to new surroundings, new methods, and new people and as he has limited movement he stated he all the new goings on made him feel rather helpless as all he could do was press the bell and wait if he needed something. This was understandable and it was explained to Mr A in great detail the goings on, routines and layout of the hospital to try and overcome his worries. Brubaker (1987) tells of how having a major lifestyle change such as having to come to hospital for a long period of time can make the patient feel as though there dignity is being taken away from them. This was noticeable with Mr. A. When he was first admitted to hospital, he resisted being washed on many occasion. This may have been due to there being many new nurses and carers that he was not used to. He may have felt shy and undignified having to be washed in his hospital bed my many different workers. This was overcome by making sure his door was always closed, windows and curtains shut, nurses and carers would also introduce themselves, ask for consent and talk Mr. A through the procedure, all in order to make him feel more comfortable. This seemed to cease his worries and he started to allow the staff to wash him on a daily basis.
One major concern of Mr. A’s was the time it took from when he pressed the bell in the hospital or the emergency bell in his house to the time a nurse or carer got to him. He would panic during this period and this impacted greatly on his psychological well being leaving him psychologically vulnerable. Psychological Vulnerability is when someone is vulnerable to emotional or behavioural harm. While Mr. A was in the community hospital calming and relaxation techniques were taught to him to try and overcome his anxiety. He was taught deep breathing techniques and stated he found this particularly beneficial. Every time he started to feel anxious and worried he could now use these new techniques which take his mind of the worry and keep him calm. While I was working at the hospital I saw a huge change in Mr. A’s behaviour in terms of anxiety. He became much less aggressive when having to wait for a nurse.
There were many elderly residents at the community hospital that suffered many different types of psychological vulnerability. Many of the frail elderly who had suffered falls lost their confidence completely. One female patient told me that she did not want to go home as she did not feel she could cope. She did not feel safe in her home but would not want to move to a residential home. This must be a very distressing time and it is hard to reassure patients in this mind set.
Through the MDT meetings it was decided that Mr. A would have to go to a residential home as it would not be safe for him to go home. Mr. A felt he would not enjoy being in residential and was completely opposed to the idea. However, three workers from the residential home came to speak to Mr. A, he was taken to view the residential home and his room, the Doctors and Nurses at the community hospital spoke to Mr. A at length and gave him time to voice his questions and concerns. With time Mr. A seemed to come around to the idea and realise it was the best option for him and by the end of my student placement Mr. A told me he was looking forward to moving out of the community hospital and into the residential home.
I have outlined Mr. A’s conditions and how he was affected by physical, psychological, sociological and environmental vulnerability. Over the seven weeks I was in the community hospital alot was done to conquer Mr A’s vulnerability and re-merge him into society.
Community hospitals are designed to reduce the risks to people who are vulnerable to social, physical, environmental and psychological injury. Hospitals have special floors, showers, seats and beds. They have controlled heating, lighting, diets, they encourage interaction between patients and with visitors (at certain times during the day) thus reducing social isolation. Highly trained staff monitor and review patients regularly to ensure they are receiving the best care and the support needed to leave hospital and to prevent their return. This all minimises the risk of patients feeling vulnerable and helps them to have a fast recovery and rehabilitation.
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