Mdm Lee is an 84-year-old Chinese lady with a background history of ischemic heart disease (IHD), hyperlipidaemia, asthma and cognitive impairment for the past 5 years. She does not have a smoking and drinking history. She was recently admitted to Singapore General Hospital (SGH) on 30 August for the following issues: Infective exacerbation of asthma secondary to Community Acquired Pneumonia (CAP) complicated by sepsis that led to further complications of myocardial infarction, lactic acidosis, and hyperglycemia. Upon assessment by the speech therapist, she was advised a soft diet with chopped sides and soft fruits. She was then discharged on 5 September, stable and well, with the following new lifelong medications: Aspirin 100mg, atorvastatin 100mg and enalapril maleate 5mg. She is scheduled for several follow-ups with the departments of Geriatrics, Cardiovascular and Respiratory Medicine in SGH at the end of the year.
Mdm Lee is community ambulant with a walking stick and is independent in her Activities of Daily Living (ADL). Yet, she is heavily reliant on her helper for day to day necessities such as preparation of meals and other household chores, scoring a 2 on the Instrumental ADL scale. She attends day care at St. Andrew’s Senior Care every Monday and Friday together with her husband where she exercises and interacts with the elderly there. Occasionally, she goes for strolls around her neighborhood with the assistance of her helper. Mdm Lee is married with 3 children (1 son and 2 daughters) and currently lives in a 3-room HDB flat with her husband, son and helper. Her son is the main caregiver and sole bread winner of the house. However, he recently quit his job in July to focus on taking care of both parents especially his father, who has dementia and anger management issues. He is also responsible in ensuring that his mom follows her medication regime and expresses some concern about the new lifelong medications. He is financially stable now but would be actively looking for a job from October. He also noted that his mother is now more reserved and unwilling to share her feelings with her children while adopting an indifferent attitude towards her daily activities. He claims to be coping well but opens up about the frustrations faced as a caregiver to both elderly parents. He attends support groups for caregivers and has applied for a foreign domestic worker grant for his helper.
Continual Home Management Plan
The post-discharge phase is a crucial period of transitioning for the patient and their caregivers. Those who do not cope well tend to have frequent readmissions and relapses which affects the patient’s trajectory to recovery. Thus, it is imperative for community nurses to follow up with post-discharge patients and develop a continual home management plan to ensure a smooth transition from hospital to home. As for Mdm Lee’s case, home visit was conducted 6 days post-discharge from SGH. Upon assessment during the home visit, there were four main issues that needed to be addressed. These include: keeping asthma in control; risk of depression; risk of falls; and caregiver stress.
Keeping Asthma in Control
Firstly, good asthma control prevents severe exacerbations from occurring and thus, this decreases hospital readmissions and improves Mdm Lee’s lung function. To achieve this goal, the community nurse needs to conduct patient education on avoidance of triggers, proper inhalation techniques, cleaning of space chamber and peak flow monitoring. Avoidance of triggers such as respiratory infections (e.g. CAP) requires proper hygiene etiquette. For example, washing of hands with soap and water before food, coughing into a tissue to prevent the spread of germs to her hands and avoidance of contacts with upper respiratory tract infection. Additionally, she can take the Pneumococcal Polysaccharide Vaccine (PPSV23) which demonstrated reduced risks of all causes of CAP; and the influenza vaccine which is effective in preventing hospitalization from pneumonia and influenza. Next, thorough assessment should be done to determine whether the spacer should be used and to ensure proper inhalation techniques. Nurses must reinforce that a new space chamber needs to be primed with 10 pumps of the prescribed inhaler and washed once weekly in lukewarm water with 2 drops of detergent before allowing it to air dry. No rinsing and rubbing dry is allowed as it introduces static which results in unnecessary re-priming. Also, the community nurse can introduce the peak flow meter which can be used in conjunction with the “AsthmaCare Buddy” mobile application to monitor Mdm Lee’s asthma patterns and progress at home. It will guide her caregivers on the medications and dosages to control her asthma depending on the different colored zones (green, yellow, red) obtained during assessment by the peak flow meter. With all these teachings in place, Mdm Lee and her caregivers would be equipped in the management of asthma which results in good asthma control.
Risk of Depression
Secondly, Mdm Lee’s sudden withdrawal from social interactions puts her at risk of depression which warrants immediate attention. She could be harboring feelings of hopelessness and helplessness which leads to suicidal thoughts and ideation as the only way out. This could be due to her cognitive dysfunction which resulted in confusion and the possibility of getting lost. Hence, she could have lost her independence and self-esteem in the process as she requires assistance getting around the neighborhood. Besides that, she could be stressed out by her husband’s daily episodes of unwarranted violent anger which usually turns into heated arguments between father and son. This is further compounded by her small social circle which prevents her from sharing her innermost thoughts with others leading her to think that no one understands her. As a result, this disengagement leads to a downward spiral of isolation and despair.
Therefore, with the constant visits from the community nurses, it allows easier identification of these depressive attitudes that might lead to the downward spiral. Any noticeable difference would warrant referrals to the relevant specialties for further expert assessment. It is thus crucial that the nurses gain her trust through good communication and empathy. In prevention of such foreseeable problems, nursing goals can be aimed at increasing Mdm Lee’s confidence and social interaction by keeping her engaged in meaningful activities that provides purpose in her life. For example, applying for the Eldersitter Program that Mdm Lee’s husband qualifies for, benefits both Mdm Lee and her husband. The eldersitters are trained in basic dementia caregiving and would engage seniors with dementia at their homes on a weekly basis through structured activities that include reminiscence, memory, linguistic and other tasks based on the seniors needs and preferences. This would stimulate Mdm Lee’s cognition and improve her memory skills, thereby increasing her confidence and social interaction. Moreover, it decreases her stress levels as her husband would be cognitively stimulated and preoccupied with the activities that fewer anger episodes ensue. Also, having the eldersitter visit them at their home gives the elderly couple something to look forward to while providing respite for caregivers simultaneously. Therefore, this service is advantageous to all in Mdm Lee’s household. Additionally, Mdm Lee can also apply for befriending services where befrienders make regular home visits and provide her with social and psycho-emotional support. Both services provide opportunities to increase her self-esteem and develop interpersonal relationships which in turn, decreases Mdm Lee’s risk of depression.
Risk of Falls
Thirdly, during the home visit, the community nurses observed that Mdm Lee’s toilets are not equipped with grab bars, non-slip flooring or a stool for her to sit on when showering. This could be a potential risk of falls especially since she showers independently with no supervision from her helper. Furthermore, she is currently taking enalapril maleate, an anti-hypertensive drug which is classified under high fall risk medications. Thus, applying for the Enhancement for Active Seniors (EASE) scheme will provide them with subsidies for installation of grab bars and non-slip flooring in the toilets. Non-slip mats should also be placed outside toilets instead of old clothes. Additionally, the nurses should educate Mdm Lee on fall risk precaution measures. For example, if she feels dizzy after sitting up in bed, they can advise her to move her toes for a few minutes first and wait for any dizziness to stop completely before standing. Caregivers can also be involved by measuring her blood pressure daily from lying to standing within 3 to 5 minutes to observe for any orthostatic hypotension. With these fall precaution measures in place, it makes her home a safer environment and decreases her risk of falls.
Lastly, Mdm Lee’s son, who is the primary caregiver of both parents, is experiencing a high level of caregiver stress. Despite claiming that he is coping well, he is indeed overwhelmed having to deal with his father’s daily anger episodes, his inadequate knowledge about his mother’s diseases and concerns over the helper’s willingness to work in this household. Moreover, insecurities and uncertainties loom ahead as he is currently unemployed. Thus, can negatively affect his physical and emotional well-being. As such, the community nurses can help him to cope by first, empowering him with adequate medical knowledge on Mdm Lee’s medications and on what he should do when she has a heart/asthma attack. They should further reassure him that the new lifelong medications are bundle medications prescribed which has proven to decrease mortality in patients post myocardial infarction thus, it should be adhered strictly.
Next, the nurses can educate the helper to modify Mdm Lee’s diet to keep her hyperlipidemia and IHD in control. This can be done through the reduction of fatty food (e.g. removal of skin from fish and meat) and decrease in high cholesterol food (e.g. organ meats, seafood and egg yolks). Instead, increasing the fibre intake by eating more fruits, vegetables, grains and soluble fibre food (e.g. oats, barley, beans and peas) are good in decreasing cholesterol. Additionally, the helper can be enrolled in courses such as the ‘Essentials of Dementia Care’ organized by Alzheimer’s Disease Association which would equipped her with the techniques to care for Mdm Lee’s demented husband. Financing such courses would not be an issue as Mdm Lee’s son can apply for the Caregiver Training Grant which provides $200 each year for both the helper and him to attend such courses. Hence, this provides opportunities for the helper to interact with others from her country and upgrade her skills simultaneously which in turn increases her confidence and satisfaction. Therefore, leading to the helper’s increase willingness to work in this household.
Finally, should Mdm Lee’s son require respite care, he can apply to the selected nursing homes which would provide caregivers relief of between 7 and 30 days per year. During which, he can be relieved from his caregiver duties and maybe, focus on finding a job that best accommodates to his needs. With these multiple home health interventions in place, he is better able to cope and thus, the level of caregiver stress decreases.
My home visit experience has truly been an eye-opening experience for me as it is only through such close and personal interactions at their homes that I get to fully understand the story behind each patient. In acute hospital settings, we tend to hold a myopic view that our patients have one responsibility of getting their disease in control by obeying the health advice given by Healthcare Professionals. Thus, we often get frustrated when they are readmitted due to poor compliance and control over their disease. However, we tend to forget that our patients are just like anyone of us, with multiple responsibilities and non-medical related challenges they must face as soon as they are discharged from the hospital. This is where the role of community nurses is critical as they are the ones that best understand the patient’s situation and thus, they can develop management plans that are best suited to the patient’s needs. These plans do not just focus solely on healthcare needs but encompasses the bio-psycho-social health of the patients and their caregivers. Sadly, this is something that is lacking in the acute hospital setting despite the push for holistic care. Hence, this fresh perspective enables me to adopt a fresh pair of lenses when I step into the wards in the future.
Furthermore, I have often used the term ‘caregiver stress’ during my tutorials without truly understanding the meaning of it until I had seen it for myself during this home visit. It is definitely not easy for them having to assume the role of a caregiver without prior preparation and training. If not for the support provided by the community nurses, most caregivers would be suffering alone without knowledge of the available community resources they can utilize to optimize care and health outcomes. Therefore, community nurses play an integral role as they leverage on the various community resources to empower and aid patients/caregivers through their health journey. This provides a seamless transfer of care, beyond hospitals to the community.
To sum up, community nursing involves building sustained partnerships with the patient, family and the community while empowering them to play a part in ensuring that the patient is on route to a holistic recovery. Despite community nursing’s various challenges, it is definitely rewarding, and I am excited to be a part of it when I graduate.