Residential Care
Welcome to the Residential Care module.
This module will provide you with an interactive case study in which you will learn about assessment for residential care and consider the palliative care needs of both patient and family.
This module is a continuation of the case study presented in the Geriatric Assessment module. It is recommended that you complete the Geriatric Assessment module before commencing this module on Residential Care.
Please review the objectives and complete the Pre-Module Test before commencing the case study
Module
- Interactive Case Study
- Patient Interview
- Assessment
- Investigations
- Medication Review
- Functional Assessment
- Advanced Care Planning
- Family Meeting
- Care Plan
- Multidisciplinary Care
- Case Progression
- Palliative Care
- Breaking Bad News
- Communication Guidelines
- Advance Care Plan
- Mr Doherty’s Care Requirements
- Support of Mr Doherty
- Physical Assessment
- End-Of-Life Care
- Family Support
- Bereavement
- On-going Support
- Case Conclusion
Katherine Doherty is an 81 year old lady with multiple medical conditions. She was assessed by the Aged Care Assessment team (ACAT) 5 years ago, at which time she was diagnosed with a prepyloric ulcer and was H Pylori positive. She was successfully treated with triple anti-biotic therapy, pantoprazole and blood transfusions for anaemia.
She was discharged home and a Home Care Package was established to support Mrs Doherty and her husband in their home environment.
Review Mrs Doherty’s history through the links below before moving on to her assessments.
- History of presenting complaint
- Medical History
- Medication History
- Social History
Eight years after Mr and Mrs Doherty’s care package was introduced, Mrs Doherty’s health has regressed significantly. She has had a myocardial infarction, with subsequent severe symptomatic heart failure. She recently fell. She fractured her right wrist in the fall. To make matters worse, Mr Doherty was in hospital for a cataract operation. Mrs Doherty has left sided weakness from a previous stroke and was unable to get up, spending most of the night on the floor before being found by her neighbour. Mr Doherty states that his wife has also been more forgetful of late, and with his poor vision, doesn’t think he will be able to look after her. He is worried that she needs 24 hour care and has asked the ACAT to visit again to discuss other care options.
Mrs Doherty has a complex medical history including heart disease, renal impairment, hypertension and diabetes. She has a history of stroke, the most recent one being two years ago. She now has severely impaired systolic function as a result of a recent myocardial infarction (8 months ago) and is short of breath and fatigued. Her legs are uncomfortable due to moderate peripheral oedema. She has been told by her cardiologist that her heart failure can only be treated with medications and has been difficult to control due to her concurrent renal impairment.
Mrs Doherty is currently on the following medications:
- Perindopril 5mg od – prescribed for high blood pressure and congestive heart failure
- Clopidogrel 75mg od – to inhibit blood clots
- Gliclizide 80mg bd – to stimulate the release of insulin and diminish the peripheral resistance to insulin in order to treat diabetes
- GTN spray prn – to reduce the pain of acute angina attack
- Simvastatin 20mg – for high cholesterol
Mrs Doherty is 84 years old and with the aid of a Home Care Package, still lives at home with her husband, Benjamin (87). They have been married for 60 years but were unable to conceive any children. They have a dog, Maroney and a cat, Tinker, whom they regard as their family.
Mr Doherty is otherwise well but has advanced glaucoma causing severe vision impairment.
Mr and Mrs Doherty enjoy reading together in the afternoons. She used to read aloud, but finds this more difficult now due to shortness of breath. They were quite social, although it has become difficult for them to participate at the local senior citizen’s centre since Mrs Doherty’s health deteriorated.
To assess Mrs Doherty’s health and how she is coping at home, you will need to ask her a series of questions.
Please click on the questions below to obtain Mrs Doherty’s answers.
- You seem to have been quite unwell since I last met you 8 years ago. Tell me about your general state of health Mrs Doherty.
- How do you spend your free time?
- Who does your shopping and cooking?
- And are you able to feed yourself Mrs Doherty?
- Do you have any difficulties showering or dressing yourself?
- And how about using the bathroom? Can you manage OK on your own?
- And are you still managing the household affairs?
- Are you experiencing any memory problems?
- Tell me about what is bothering you the most?
- Are you taking all your medications as directed by your doctor?
- Have you had any falls recently?
Physical Assessment
General Appearance:
Height: 178cms
Weight: 62kg
Temp: 36.9
Respiration Rate: 28
Please move your mouse cursor over Mrs Doherty as if you were examining her. You must complete the examination before you go on.
Cognitive Assessment
Click on the links below to see results of the cognitive assessment
- MMSE
- Clock Drawing Test
Mrs Doherty's Clock Drawing Test result is normal
Interpretation of Results
Click on each of the tests below to see which are indicated for Mrs Doherty and if so, what the results are.
- FBC
- Serum cholesterol
- Blood glucose
- Electrolytes
- Liver function tests
- Thyroid function tests
- ECG
- Chest xray
- Brain MRI
- Cardiac enzymes
- Echocardiogram
Hb 122 g/L (normal range 115-160 g/L for adult females)
MCV 88 fl (normal range 80-100 fl)
Platelets 247x109/L (normal range 150-400x109/L)
WCC 6.6x109/L (normal range 4.0-11.0x109/L)
It is useful to ensure breathlessness is not related to anaemia (as she has previously been anaemic).
There is no neutrophilia to suggest infection.
These tests are less useful in the current setting.
It might be possible Mrs Doherty has poorly controlled diabetes mellitus to explain her lethargy, although the congestive cardiac failure is more likely.
BSL 6.4 mmol/L (normal range 3.0-5.4 mmol/L)
Given the high dose of diuretic medication, a check of urea and electrolytes is indicated.
Na 132 mmol/L (normal range 134-146 mmol/L)
K 3.4 mmol/L (normal range 3.4-5.0 mmol/L)
Urea 9 mmol/L (normal range 3.0-8.0 mmol/L)
Cr 130 µmol/L (normal range 50-95 µmol/L for adult females)
A check of LFTs is reasonable to ensure no evidence of hepatic congestion from the CCF (although no evidence of hepatomegaly on examination), and also to check Mrs Doherty’s albumin level given her peripheral oedema.
Bilirubin 6 µmol/L (normal range <20 µmol/L)
ALT 32 U/L (normal range <30 U/L for adult females)
ALP 63 U/L (normal range 35-135 U/L)
GGT 40 U/L (normal range <40 U/L for adult females)
Albumin 34 g/L (normal range <30 g/L)
Abnormalities in thyroid function can worsen CCF so it worth checking.
TSH 1.2 mU/L (normal range 0.40-4.0 mU/L)
Free T4 13 pmol/L (normal range 9-19 pmol/L)
A very good test to order as often people with CCF can have conduction abnormalites or rhythm disturbances.
Mrs Doherty’s ECG demonstrates a Left Bundle branch block that has not changed since her MI.
Pleasingly she remains in sinus rhythm.
A chest xray would be helpful in this situation as the respiratory examination was not normal.
Mrs Doherty’s chest XR confirms she has small bilateral pleural effusions and evidence of mild interstitial oedema.
This is a good test to organise if you are concerned about Mrs Doherty’s memory and feel it is currently warranted.
Presently, her main concerns are her shortness of breath and functional abilities.
You decide therefore that given she would distressed at having to lie flat on her back for 45minutes you will defer this test at present.
These tests would be unlikely to provide assistance.
Mrs Doherty had an echo done at time of discharge from the hospital following her myocardial infarction and subsequent heart failure.
This demonstrated mild tricuspid regurgitation and mild mitral regurgitation with an akinetic left anterior wall.
Ejection fracture is 31%.
tricuspid regurgitation
mitral regurgitation
State of health
Based on the results of investigations, the following medications are added to Mrs Doherty’s blister packs. Click each one to see why it was prescribed.
- Frusemide 120 mg mane 80mg
- Bisoprolol 2.5mg od
- Spironolactone 12.5mg od
A diuretic prescribed in order to improve fluid overload
Prescribed to help with congestive heart failure
Prescribed to help relieve the symptoms of heart failure
Mrs Doherty is no longer able to perform the majority of ADL’s or IADL’s. She no longer feels she can remain at home when Benjamin is away. Based on your assessment, you feel that residential care could be considered.
Advance care planning is a way for health care professionals to help patients and their families make known and record their thoughts, feelings and wishes regarding future health care. Consideration of these feelings, thoughts and wishes can then direct ongoing care planning.
Advance care planning involves discussions with patients about their medical history and condition, values, and preferences for future medical care. This is done in consultation with health care providers, family members and other significant people in their lives.
Please see www.advancecareplanning.org.au and https://palliativecarewa.asn.au/advance-care-planning/ for more information.
Please conduct a virtual family meeting by clicking on the questions below in order to reveal each answer.
Your goal is to formulate a current advanced care plan.
- Mrs Doherty, I’d like to know what you think the future may hold for you health wise. Has anyone told you what to expect?
- What are your goals for care?
- Mr Doherty, how do you feel about your wife’s state of health?
- How would you like to see your wife’s care proceed?
- Mrs Doherty, given what we now know about your medical condition, how can we help you live well? What makes you happy?
- What fears or worries do you have about your illness or medical care?
- If you have to choose between living longer and quality of life, how would you approach this balance?
- What sustains you when you face serious challenges in your life?
- In the future your husband may need to help make decisions on your behalf if you become very unwell. Have you talked to Ben about what sort of care you would like?
The Aged Care Assessment Team (ACAT) recommended that Mrs Doherty be eligible for a residential aged care home. Considering that Mr and Mrs Doherty had previously thrived with the assistance of a Home Care Package (Level 2) and taking into account their expressed concerns regarding separation and wishes for her future care, you decide to consult with the local care providers to review the possibility of a extending the level of her Home Care Package to level 4, combined with regular in-home and residential Respite Care to support Ben.
A multidisciplinary team are involved in planning and delivering Mrs Doherty’s Home Care Package.
Please click on each of the services below to find out more.
- Social Worker
- Carer
- Nurse
- Allied Health
- Volunteer Driver
The social worker ensures that Mr and Mrs Doherty have access to necessary support services, legal advice and counselling, in order to help them during this difficult time and to assist them in preparing for the future
A carer visits twice a day to:
- assist with showering
- assist medication administration
- help with cooking/cleaning
- perform shopping
- provide some social contact
A registered nurse may visit as required to:
- assist with continence issues
- review wound care needs
An allied health professional visited to:
- set up and monitor a structured exercise program
- review any environmental requirements such as rails or equipment
Transport was provided for:
- appointments to medical appointments
- social visits
Six months after the introduction of the higher level Home Care Package, you are contacted by the general practitioner. She was asked to review Mrs Doherty by the care coordinator at home as Mrs Doherty’s breathing had deteriorated. She believes Mrs Doherty has left lower pneumonia with a productive cough, fevers, worsening shortness of breath and crackles over the left base. Admission to hospital is recommended.
You attend to review Mrs Doherty in hospital. Unfortunately she seems too drowsy to speak with you. You thus decide to assess her physically.
Physical Assessment
General Appearance:
Drowsy, looks unwell
Height: 178cms
Weight: 62kg
Temp: 37.9
Please move your mouse cursor over Mrs Doherty as if you were examining her. You must complete the examination before you go on.
Investigations
Click on each of the tests below to see which are indicated at this stage in Mrs Doherty's case and if so, what the results are.
- FBC
- Serum cholesterol
- Blood glucose
- Electrolytes
- Thyroid function tests
- ECG
- Chest xray
- Arterial blood gases
Given your clinical findings of fever and left lower zone crackles, a review of the white cell count is appropriate.
Hb 132 g/L (normal range 115-160 g/L for adult females)
MCV 88 fl (normal range 80-100 fl)
Platelets 360x10^9/L (normal range 150-400x10^9/L)
WCC 18.4x10^9/L (normal range 4.0-11.0x10^9/L)
Neutrophils 16x10^9/L (normal range 2.0-7.5x10^9/L)
Not appropriate
Given Mrs Doherty’s drowsiness it is important to check she is not hypoglycaemic or in a hyperosmolar coma. Pleasingly, her BSL is 12 mmol/L (normal range 3.0-5.4 mmol/L).
This is high but not uncommon in someone with an acute infection.
Na 143 mmol/L (normal range 134-146 mmol/L)
K 4.5 mmol/L (normal range 3.4-5.0 mmol/L)
Urea 17 mmol/L (normal range 3.0-8.0 mmol/L)
Creatinine 240 µmol/L (normal range 50-95 µmol/L for adult females)
Mrs Doherty is probably dehydrated because of her acute illness.
Not currently appropriate as medically unwell. It has also recently been checked and is unlikely to have altered significantly.
No new changes.
Demonstrates a left lower lobe pneumonia with worsening of bibasal effusions and interstitial oedema. Cardiomegaly persists.
Given Mrs Doherty’s drowsiness, it is important to ensure she has not developed type 2 respiratory failure.
pH 7.30 (normal range 7.35-7.45)
pC02 52 mmHg (normal range 36-45 mmHg)
p02 140 mmHg (on oxygen) (normal range 85-110 mmHg)
Bicarbonate 23 mmol/L (normal range 21-28 mmol/L)
02 saturation 100% (normal range <95%)
Diagnosis
What conclusions do you make regarding Mrs Doherty’s condition based on the results of the physical examination and laboratory tests/imaging?
Medication Review
Based on these conclusions, review Mrs Doherty’s medications in relation to her current state of health. Consider dosage, appropriateness of each drug, drug administration and possible drug interactions.
Click on the medications below to see if they are still indicated or if they may now need to be modified, given Mrs Doherty’s worsening condition
- Perindopril 5mg od prescribed for high blood pressure and congestive heart failure
- Clopidogrel 75mg od prescribed to inhibit blood clots
- Gliclizide 80mg bd prescribed to manage type II diabetes mellitus
- Insulin
- GTN spray prn prescribed to reduce the pain of acute angina attack
- Simvastatin 20mg prescribed for high cholesterol
- Frusemide 120 mg mane 80mg lunch prescribed to improve fluid overload
- Bisoprolol 2.5mg od prescribed to help congestive heart failure
- Spironolactone 12.5mg od prescribed to help relieve the symptoms of heart failure
Advise to discontinue this medication given worsening renal function and hypotension.
Still appropriate for Mrs Doherty’s condition.
Advise to withhold this medication as Mrs Doherty is currently too unwell to eat.
Monitor BSLs consider regular insulin if needed.
Still appropriate for Mrs Doherty’s condition.
Still appropriate for Mrs Doherty’s condition.
Reduce to 80mg od to see if renal function improves, although be aware that this may worsen heart failure.
Still appropriate for Mrs Doherty’s condition.
Advise to cease this medication given worsening renal impairment.
Despite antibiotic treatment, physiotherapy and changes to medications, Mrs Doherty’s health continues to be poor with progression of her renal failure and difficulties managing her shortness of breath. It is unlikely that she will recover and be well enough to return home. You feel that this illness is likely to be terminal.
Eight of the following statements about palliative care are true. Can you identify which ones they are?
WHO Definition of Palliative Care
WHO definition: "Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and families".
Initiation
Having established that Mrs Doherty’s condition is deteriorating and that palliative care is warranted, you must now break the difficult news to Mr and Mrs Doherty.
Take a moment to read and consider which of the following statements would be the most appropriate way of initiating a conversation involving bad news?
Once you have decided which opening statement you would use, click on the tab to obtain feedback. You may then click on the others to see feedback for each approach.
- Mrs Doherty, unfortunately I have some difficult information to give you. Is this a good time to talk about it? Is it okay if we talk about it in front of your husband? Would you like anyone else to be here too?
- Mrs Doherty, what are your concerns at the moment?
- I know you would like me to be honest with you, so I’ll start by telling you that you are experiencing multiple organ failure. Your lungs, kidneys and brain are very unwell. You will not be able to go home.
- Mrs Doherty, I’m afraid that your test results don’t look too good. I’m very sorry to have to give you some bad news - your condition may be terminal.
This is a sensitive way of starting a conversation about bad news. It allows the person to decide if they are ready to discuss it and makes it possible to wait until loved ones/family members are present if need be.
This is an open-ended question and appropriate for initiating a discussion that will involve bad news. You allow the patient to talk about what is concerning them at present, before leading in to delivering bad news. Asking questions about what the patient knows also allows you to use the same language when breaking the news.
This is probably the best apprach to use.
This is too abrupt to begin the conversation. The patient may feel unprepared and may not have time to ‘steal themselves’. A “warning shot” may help Mr & Mrs Doherty feel like they are more in control of the situation.
Although attempting to be sensitive, this statement may be too abrupt to be a suitable way to begin delivering the bad news. Patients and families often latch onto a powerful word like “terminal” and often do not hear any more of the conversation.
Delivery
Think about whether these statements are appropriate ways of delivering bad news?
When you have read the statements, click on the reasoning comments to obtain feedback.
"Mrs Doherty, your left sided pneumonia has been unresponsive to intravenous antibiotic therapy, resulting in persistent shortness of breath, productive cough, fever and further chest pain. In addition, your renal impairment, which was recently exacerbated by sepsis, is progressing and it is proving difficult to manage this on account of your heart disease. I’m afraid that we won’t resolve this"
- Some patients will appreciate the health care workers directness
- Patients would value the health care worker’s honesty
Whilst some patients “just want the facts”, it is usually best not to use complex medical terminology when discussing a person’s medical condition.
While this may be true to an extent, it is better to avoid ambiguity and to be clear about the person’s prognosis.
Another alternative way to deliver bad news might be...
"Mrs Doherty, you are right. You do have a nasty chest infection that is making it hard for you to breathe. We call that pneumonia. And you are right that we are giving you powerful antibiotics to try and kill the bugs in your lungs.
But, do you remember how you told me that your cardiologist was having a hard time balancing the medications for your kidneys and your heart failure? Well, since you haven’t been well we have been having a really bad time at getting this right, and I don’t think we are succeeding.
Pause.
Your kidneys and heart are starting to shut down.
Pause.
I don’t think your body can recover from this.
Pause.
And although we are trying our hardest, you are getting slowly worse.
Pause.
Do you understand what I’m trying to say? Do you want to continue talking about it? Do you have any questions Mr Doherty?
(Sometimes patients may want a moment alone with family members. Other times they may have questions about the treatment so far, or questions about alternative therapies they may have seen on the television or read in the paper)
Pause
I want to reassure you this conversation doesn’t mean that we are abandoning you. We want to keep you comfortable and we want both of you to be involved in any decisions that are made about your care"
- This patient may feel they are being condescended to
- This patient may just want the health care worker to get straight to the point!
- This health care worker is asking too may questions
Yes, some patients may feel that the health care worker is trying to avoid direct communication. However it is generally best to discuss the person’s medical condition in a sensitive manner, in easy to understand language and to be clear about the person’s prognosis.
Yes, some patients will not appreciate care workers that they think are “beating around the bush”. But generally, this approach – with frequent pauses – is likely to foster positive communication.
Yes, some patients will find it stressful to be asked questions. If the person appears distressed, pause and seek their permission before continuing.
After breaking bad news
After delivering bad news, which of the following would be the best course of action?
Take a moment to read and consider which of the following would most appropriate.
Once you have made your decision, click on the tab to obtain feedback. You may then click on the others to see feedback for each approach.
- Say nothing
- Say, “is there anything I can help you with right now?”
- Say, “how are you feeling right now?”
It is best to pause for a while after delivering bad news, in order to give the person time to process the information and respond in their own time. Pauses can be uncomfortable for the health care worker, but generally aid effective communication.
Although well intentioned, saying this directly after delivering the bad news gives the person no time to process the information and then respond when they are ready.
Although well intentioned, saying this directly after delivering bad news asks for an emotional assessment before the person has had time to process the information. It may also sound contrived.
Breaking bad news can be one of the most difficult things a health professional must do. It may help to keep in mind the following when breaking bad news
- Pay attention to the physical context. Is the room comfortable and private?
- Assess the person’s current emotional state. Are they frightened, anxious, distraught or angry?
- Assess the person’s verbal and non-verbal responses. How do they respond to the bad news?
- Use clear, understandable language in a sensitive manner
- Assess the person’s coping strategies and needs for support
- Plan future care within realistic expectations and maintain hope
More advice on how to discuss palliative care with the patient and their family can be found on the resources page.
Review Mrs Doherty's expressed wishes for her future care, remembering what she talked about when you discussed advanced care planning prior to her admission to hospital.
Click on each one to see how her wishes might be achieved
- She would like to spend as much time with her husband as possible
- She would like to be able to read
- She would like to be able to enjoy the outdoors
- She would like to be able to see her pets
- She is worried about pain and being severely debilitated in the lead up to death
- She is concerned about how Mr Doherty will cope after her death
- She does not wish for the medical team to artificially prolong her life
- She has spiritual beliefs and would like to see the chaplain/minister before she passes away
- She has prepared a will and all finances are in order
You contact HACC and ensure that transport is available for Mr Doherty to and from the hospital
Ensure that her optometrist prescription is up to date and that she has access to her preferred reading material
Advise staff that Mrs Doherty would like to spend some time outside on sunny days, and see if her bed can be wheeled outside
The social worker arranges for the volunteer driver to bring the pets into the ward on a couple of occasions
You prescribe regular analgesics, including small amounts of opiate medications if required for pain and shortness of breath. You review her pain regularly and adjust medications as required. Non pharmacological treatments are also used, such as heat packs for sore joints, appropriate pressure reduction mattresses and relaxation techniques
Ensure that a social worker comes to see Mr and Mrs Doherty to discuss his ongoing care and address any concerns they might have
Mrs Doherty confirms she would not want cardiopulmonary resuscitation or defibrillation attempted in the case of her heart stopping. She understands that attempts would be physiologically futile and would not work. She wishes to pass from this world with dignity. She and Mr Doherty therefore witness a do not resuscitate order, which is placed in her medical records
Arrange for Mrs Doherty’s local church minister to visit her
You confirm this again with Mr and Mrs Doherty and make note in her medical records that she is legally capable and of sound mind.
The social worker arranged for HACC to assist with Mr Doherty’s laundry, housework and home maintenance and food shopping. He is able to prepare his own breakfast and cups of tea, but will receive meals on wheels every day except Sunday, when he has a roast dinner with friends. Arrangements are also made to transport Mr Doherty to and from the hospital on a daily basis so that he can spend time with Mrs Doherty.
Comfort and support is just as important for Mr Doherty at this time as it is for Mrs Doherty.
Take a few moments to think about how the multidisciplinary team can help Mr Doherty during this time? Perhaps jot down a few ideas before clicking on the tab below...
How can the multidisciplinary team support Mr Doherty?
Mrs Doherty’s condition worsens and within 2 days, she is again drifting in and out of consciousness. You review her physical state of health. Please move your cursor over Mrs Doherty as if you were examining her. You must complete the examination before you go on.
General Appearance:
Reduced level of responsiveness.
No sign of distress.
The nursing staff report some grimacing when they perform pressure cares but no other discomfort noted.
Mr Doherty reports Mrs Doherty occasionally squeezes his hand, but does not respond to him in any other way.
Please move your mouse cursor over Mrs Doherty as if you were examining her. You must complete the examination before you go on.
Mrs Doherty's Condition
What do these symptoms indicate?
In discussion with Mr Doherty and the nursing staff, you:
- Cease all oral medications as she is not conscious
- Cease the antibiotics
- Cease performing observations
- Prescribe a small amount of subcutaneous morphine to be administered prior to pressure cares being performed by the nursing staff
- Prescribe a small amount of midazolam subcutaneously on an as needed basis in case she becomes agitated or distressed
- The nursing staff perform regular mouth care to keep her oral mucosa moist
- The chaplain visits regularly to check on Mr and Mrs Doherty
Mrs Doherty appears comfortable and Mr Doherty keeps a vigil at her bedside.
What should you do for Mr Doherty at this time?
Take a moment to consider what you and the multidisciplinary team might do to help Mr Doherty.
Read through the list of options below. Drag each that you feel is appropriate over in to the correct answer column. Correct responses will turn green, and incorrect, red.
There are six correct suggestions. Can you identify them all?
A few days later, Mrs Doherty peacefully passes away.
The palliative care team continue to assist Mr Doherty during this difficult time. After discussion with Mr Doherty, arrangements are made for him to stay with friends for a while, as he needs emotional support and is too distressed to return to his home without his wife.
Mr Doherty is given grief counselling in the days after Mrs Doherty’s passing. He is also given the name of a grief counsellor in case he would like to continue with this in the future.
Mr Doherty is also given details of supports groups near to his home.
A social worker will monitor Mr Doherty to assess and arrange emotional and/or social support as necessary
Mr Doherty struggles for a time as he and his wife had been each others lives for 60 years. With no family support, Mr Doherty attends grief counselling and joins a support group. Due to his inability to perform many of his ADL’s and IADL’s independently and his need for emotional and social support, he is eligible to move to a residential aged care home. After some discussion with Mr Doherty, he decides this is a good idea.
The neighbour’s children have become very fond of the dog, and agree to accept him into their home. A loving family is also found for the cat.
After a period of adjustment, Mr Doherty becomes actively involved in the social community. He enjoys music and singing, loves to go on excursions and has discovered a passion for painting even though he can’t see too well what he’s doing! He misses Katherine and their pets terribly, but gets great joy from the therapy dogs that visit the facility every morning. A volunteer reads to him every afternoon and he has regular visits from his friends.
Post-Module Test
Module Feedback
Select the appropriate user group to ensure that your feedback is delivered appropriately:
- WACHS Users
- ECU Nursing
- All other users
The physiotherapy consult finds her Berg balance scale is 27/56. She has difficulty transferring, turning, reaching and balancing on one foot. The physio recommends some lower limb strengthening and gait exercises and some mild exercises to help rebuild her wasted quadriceps. It is important that Mrs Scott maintains participation in physical activity, in order to maintain muscle strength and joint range of movement and to improve her balance.
The physiotherapist prescribed specific mobility exercises (including stretches in prone lying) and specific strengthening exercises for hands and her leg extensors (which can be performed as a home program).
The physiotherapist uses models of anatomy to explain the physiology of voiding and bladder control problems. To help reduce stress incontinence, Mrs Scott’s pelvic floor muscles are assessed and found to be lax. Mrs Scott has been performing the exercises prescribed by the NCA, so the physiotherapist checks her technique to ensure she is doing them correctly. Further advice was needed to refine technique. Mrs Scott is aware that she needs to do these exercises at least 5 times per day, every day in order to recondition her pelvic floor.
To further address urge incontinence Mrs Scott will perform timed voiding, as advised by the NCA.
Fortunately, Mrs Wood has a normal CT scan.
CT is a relatively inexpensive, quick and non-invasive scan that produces images of brain structures such as the grey matter, white matter, cerebrospinal fluid cavities and blood vessels. These images may also reveal abnormalities such as tumours, strokes, and head injuries. The role of CT imaging in the diagnosis of dementia is primarily one of exclusion. Evidence based guidelines suggest that structural neuro-imaging with either CT or MRI scan is appropriate in the routine initial evaluation of patients with dementia.
MRI is a structural neuro-imaging method that provides images of the brain and other anatomical structures. Some studies using MRI have demonstrated that medial temporal lobe (MTL) atrophy can be predictive of Dementia Alzheimer’s Type (DAT) and that has been associated with neuropsychological and post-mortem data. MRI may assist in the diagnosis of DAT.
An MRI may be obtained if it is suspected that the patient has dementia, however MRI is not required to make a diagnosis of dementia
Dr Zheng’s brain MRI is provided below:
Brain imaging indicates volume loss, consistent with dementia. No evidence of masses or vascular disease.
General Appearance:
Mr Thomas is sweating and looks short of breath. His legs are constantly moving and he appears confused and agitated. His skin is moist and tribal scarring is noted on left and right upper arms, midline of chest and left and right thighs. His eyes are wandering and he appears to have trouble maintaining attention, although this does fluctuate. Admission staff report that his speech was slow and at times, incoherent. Mr Thomas also exhibited impaired orientation. His wife reports that he had trouble sleeping last night.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 28 shallow
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Observations:
Patient answered greeting when approached. He is sitting in a chair with no evidence of agitation or distress. Mr Thomas is now eating a full diet, opens bowels daily and urine output is in keeping with fluid intake. His mouth is moist and mucosa intact. The IV access is removed.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 18 even
Cognitive Testing
MMSE – 25/30 – may indicate resolution of delirium
KICA – 35/39 –Improvement in KICA score supports diagnosis of delirium.
Mrs Thomas does not think Mr Thomas is quite back to baseline, but is improving day by day.
General Appearance:
Mr Scott looks well. His affect is reactive but be appears to be slightly anxious.
Height: 184cms
Weight: 98kg (which has remained constant)
Please move your cursor over Mr Scott as if you were examining him. You must complete the examination before you go on.
General Appearance:
Mrs Scott looks well. She is reactive but has restricted mobility.
Height: 164cms
Weight: 76kg (which has remained constant)
Please move your cursor over Mrs Scott as if you were examining her. You must complete the examination before you go on.
Please move your cursor over Dr Zheng as if you were examining him. You must complete the examination before you go on.
General Appearance:
No tremor is observed. He is well groomed and does not appear anxious. He has normal attention and affect.
Height: 160cms
Weight: 70kgs
Temperature: 37.1
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Appearance:
General Appearance: Mrs Browning looks well. Her affect is reactive and she doesn’t appear to be distressed or anxious.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning looks happy and healthy.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning appears well. She is well presented, and is in high spirits.
Height: 178cms
Weight: 66kg (an increase of 1 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Your general observation is that Mrs Browning appears to be a very alert, independent and capable elderly woman. She is cheery, well presented and easily mobile.
Height: 178cms
Weight: 67.5kg (an increase of 1.5 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
