Introduction
The patient is Keri’s father, Mr. Joshua Vertigo, who is 82 years old and is living at the back of Keri’s house in a self-contained granny apartment for almost six years since his wife died. Mr. Vertigo does his own activities of daily living or ADL’s like taking a bath, going to the toilet and cleaning the apartment. However, the patient sometimes needs supervision and assistance in order to get the work done properly. To ensure a healthy diet for the patient, the couple (Keri and his husband) prepares his meals. The patient himself prepares his snacks.
Mr. Vertigo’s only means of transport is Keri and her husband. The patient requires some assistance to aid him with his shopping, banking and his weekly trip to the Returned Services League or RSL to catch up with some friends who are his only social contacts.
Mr. Vertigo is suffering from several medical complaints which have considerably complicated his capability to carry out his ADL’s. In 1985, Mr. Vertigo had had a heart attack and after a number of tests, he was found to have atrial fibrillation – an abnormality in the rhythm of the heart (also known as cardiac arrhythmia) which involves two small, upper heart chambers or the atria (Benjamin, et al., 1998). In a normal heart, heartbeats begin after the electricity which is produced in the atria by the sinoatrial node spread through the heart and causes the heart muscle to contract and the blood to pump whereas in atrial fibrillation, the electrical impulses of the sinoatrial node are replaced by disorganized, rapid electrical impulses which causes the irregularity of heartbeats (Greenlee and Vidaillet, 2005). Even though both the heart problems of the patient have no long-term effects, the patient as to take lifetime medication such as Warfarin – to reduce the rate of stroke – and Digoxin, Slow K and Lasix – to assist his cardiac problems.
Aside from the patient’s heart problems, he is also suffering from diabetes. Mr. Vertigo has to inject himself with insulin everyday. Twice a day, the patient takes his blood sugar to adjust the degree of his insulin intake, as well as his dietary necessities. The patient has had diabetes for already thirty years; nevertheless, his diabetes has brought about some problems that have affected his vision. The patient has been diagnosed to have diabetic retinopathy – damage to the retina caused by complications of diabetes mellitus which could eventually lead to blindness (Bradford, 1999). The patient’s diabetic retinopathy has greatly affected his carrying out of his ADL’s as well as his reading – his other only activity. In addition, his dramatic deterioration of his eyesight has also caused him an increased difficulty in his administration of insulin.
Moreover, the patient is also suffering from leg ulceration which has also been brought about by his diabetes. Leg ulceration is actually a common chronic recurring condition and a major cause of morbidity and suffering (Callam, et al., 1988; Roe and Cullum, 1995). Leg ulcers are areas of “loss of skin below the knee on the leg or foot which take more than six weeks to heal” (Dale, et al., 1983). It is important to note that other cases of leg ulcers do not even heal at all.
In addition to the patient’s medical complaints is his osteoarthritis of the spine and upper limbs. It is a common condition where the joints are affected by degeneration wherein the joints are red, hot, swollen and painful (Horstman, 1999). As for the patient’s case, a district nurse visits him every other day in order to dress his small leg ulcer. The complication that the patient’s osteoarthritis has brought about is his restricted range of movements. His osteoarthritis has greatly affected his balance and because of this, he his already unsteady when he walks. Therefore, the patient needs a walking stick. However, due to his visual problems, the patient has a high probability of falling and, in turn, may break some bones. Furthermore, the patient is also suffering from chronic lower back pain.
Keri reports that the main problem of Mr. Vertigo is his increasing inability to undertake his ADL’s as well as his drug administration. This paper will be providing a detailed nursing care plan for Mr. Joshua Vertigo. The Resident Classification Scale or the RCS will be used as a tool and the outcomes for the patients will be analyzed as to whether the patient needs to be placed in residential care or may only stay at home. After which, a detailed nursing care plan will be made for the patient. At the end of the paper will be a conclusion which will summarize the major points and themes of the paper.
Application of the Resident Classification Scale (RCS)
The Resident Classification Scale (RCS) is used in Australian residential aged care as a relative resource allocation instrument. It is applied to all individuals entering residential care and is reviewed at least once a year. Since 1997, the RCS has been the grounds for Commonwealth Funding in all residential care facilities (Stepien, et al, 2006). The RCS constitutes of twenty items which contribute most to the differences in the cost of care with each item given a weighted score depending on the cost of providing the level of care necessitated (Please refer to table 1). Each of the questions in the RCS has a choice of four ratings which may be A, B, C or D. It is important to note that the elements in the RCS have been selected as those elements of care that best discriminate between relative care needs. Hence, the RCS provides a ranking which ranges from the patients with the highest care needs to those with the lowest care needs.
The RCS has been designed for the residential care setting. In this paper, the RCS has been used as a tool to determine the degree of dependence of Mr. Vertigo, taking into consideration the physical function, family and social functioning, supervision and the time required by the staff to encourage independence where possible. in order to determine the subsidy level of Mr. Vertigo, each RCS item is scored using the corresponding weights given in table 1 and are then summed up to give a total between 0 to 140. The higher scores represent higher degree of dependence and must be placed in residential care.
Questions
A
B
C
D
Communications
0.00
0.28
0.36
0.83
Mobility
0.00
1.19
1.54
1.82
Meals and Drinks
0.00
0.67
0.75
2.65
Personal Hygiene
0.00
5.34
14.17
14.61
Toileting
0.00
5.98
10.65
13.70
Bladder Management
0.00
2.22
3.82
4.19
Bowel Management
0.00
3.32
5.72
6.30
Understanding and Undertaking Living Activities
0.00
0.79
1.11
3.40
Problem Wandering or Intrusive Behavior
0.00
0.80
1.58
4.00
Verbally Disruptive or Noisy
0.00
1.19
1.75
4.60
Physically Aggressive
0.00
2.34
2.69
3.05
Emotional Dependence
0.00
0.28
1.50
3.84
Danger to Self and Others
0.00
1.11
1.54
1.98
Other Behavior
0.00
0.91
1.82
2.61
Social and Human Needs – Care Recipient
0.00
0.95
1.98
3.01
Social and Human Needs – Families and Friends
0.00
0.28
0.55
0.91
Medication
0.00
0.79
8.55
11.40
Technical and Complex Nursing Problems
0.00
1.54
5.54
11.16
Therapy
0.00
3.64
6.10
7.01
Other Services
0.00
0.71
1.46
2.93
Table 1. The RCS and their Corresponding Weights
Source: Stepien, et al., 2006
In the proceeding part of this paper, the researcher will explore the questions in the RCS and will rate the patient basing on the guidelines from the Documentation and Accountability Manual of the Department of Health and Ageing of the Australian Government <www.health.gov.au>.
In the first question which is communications, this refers to the degree of assistance that the patient needs in communicating with staff, relatives, and friends for whatever reason. For this question, the researcher has rated Mr. Vertigo with an A, which means that the patient does not require any assistance in communication. The researcher has assessed this because the case study does not mention that Mr. Vertigo has any problem with regards to communication. Although his vision has rapidly deteriorated, he still capable of communicating effectively.
The second question is mobility. This refers to the degree of assistance that the patient needs in association to his mobility. This basically includes: (1) assistance in walking, on a one-on-one basis which includes provision of supervision, encouragement or physical support; (2) assistance in the use of mobility aids like wheelchairs and walking frames; and (3) assistance with moving to and from chairs, wheelchairs or toilets. For this question, the researcher has rated Mr. Vertigo with a B, meaning he needs some assistance in order to be mobile. This has been evaluated based on the findings that the patient needs a walking stick due to his osteoarthritis of the spine and upper limbs and his chronic back pain. The patient needs some assistance because of his unsteadiness as he walks. In addition, the patient has visual problems which further complicate his mobility. He needs someone to assist him walking to prevent tripping and falling and breaking of bones.
The third question is meals and drinks. Here, Mr. Vertigo has been rated by a B because he does not prepare his meal by himself. His meals are prepared by the couple, Keri and her husband, to ensure a healthy diet. However, his snacks are prepared by himself in his small kitchenette. He, therefore only needs little assistance – only in the preparation of his meals. In addition, he is also capable of eating and drinking by himself.
For the patient’s personal hygiene, he has been rated by a B which means that he needs some assistance in his activities for his personal hygiene. Because of his poor eyesight and his unsteadiness in walking, he will need assistance in showering because there is a relatively high likelihood that he might fall and break his bones because of the wet floor.
Similar to the patient’s hygiene, the researcher has assessed that the patient also needs some assistance in going and using the toilet, which is the next question. For the same reasons as cited above (poor eyesight and unsteadiness in walking), Mr. Vertigo is rated a B.
The next two questions are bladder and bowel management which refers to the continence of urine and feces and its maintenance, as well as its reduction. However, the researcher has assessed that Mr. Vertigo does not need any assistance in his bladder and bowel management, thus rating the patient A.
The eighth question has something to do with the patient’s understanding and undertaking his daily activities. This question refers to the capability of the patient in remembering, understanding, planning for, initiating and performing general activities and reacting accordingly to information provided. For this question, the researcher has recorded a B for the patient. As noted earlier, due to the medical complaints of the patient, the patient is less able to carry out his daily activities. He needs some assistance and supervision in order for the jobs to be done properly.
The next six questions all associate to the needs of the patient which have been caused by the patient’s behavior. The ratings for these questions are associated to the frequency of observations and interventions which has been designed to: (1) avoid recurrence of the behavior itself or the triggers for the certain behaviors; (2) minimize the frequency or duration of the behavior; or (3) minimize the impact of the behavior on the patient or others. Questions nine to fourteen are: (a) problem wandering or intrusive behavior – patient’s wandering, absconding or interfering with other people and their properties; (b) verbally disruptive or noisy behavior – includes abusive language and verbalized threats directed at another person, may be family or friends or strangers; (c) physically aggressive behavior – covers any physical conduct which threatens and has the potential to harm another person, may be family or friends or strangers, including (but not limited to) hitting, pushing, kicking or biting; (d) emotional dependence – one-on-one interventions needed by the staff to respond to, manage and alleviate behaviors resulting from a patient with strong attachment or reliance on another person, may include active/passive resistance other than physical aggression, attention seeking, manipulative behavior and withdrawal; (e) danger to self and others – covers high-risk behavior necessitating observation or intervention and strategies to prevent, minimize or manage the behavior such as unsafe smoking habits, walking without required aids, leaning out of windows, self-mutilation and suicidal tendencies; and (f) other behavior – behaviors not covered in questions nine to thirteen which necessitates the staff to spend time and effort and to support for daily activities.
For all of the behavioral questions, the patient has been rated an A except for emotional dependence. Even though, Keri notes that her father is very independent, on the contrary, this may represent that the patient is emotionally dependent. His stubbornness and unwillingness to admit that he needs outside help may be signs of emotional dependence; hence, for this question, the researcher has rated Mr. Vertigo with a C.
The next two questions relate to the patient’s social and human needs, the former referring to the patient himself, the latter to his families and friends. For these two questions the researcher has rated Mr. Vertigo with a B because the patient needs some support other than physical care and needs the support less frequently than weekly. Although, he meets with his friends weekly in the Returned Services League, they are his only social contact. He will need some degree of support from other people as well.
The next question has something to do with the patient’s medication. This question refers to the degree of assistance that Mr. Vertigo needs in administering his medications. As mentioned in the case study, Mr. Vertigo has difficulties in administering his insulin because of his visual problems. He needs someone to assist him. Thus, the researcher has rated a C for this question. In addition, the patient is also on Warfarin, Slow K, Digoxin and Lasix for his cardiac problems. He also needs someone to remind him and make him take these medications.
The eighteenth question is technical and complex nursing procedures that the patient needs. For this, the researcher has rated Mr. Vertigo with a B which means that Mr. Vertigo needs some assistance in technical and complex procedure. This has been evaluated on the basis of the fact that the district nurse comes every other day to dress his small leg ulcer, meaning he is not capable of doing it himself.
Last two questions refer to therapy and other services that the patient needs. For both questions, the researcher has rated Mr. Vertigo with an A.
Nursing Care Plan
The general problem for the patient is his increasing inability to undertake his ADL’s and administer his medications. With this problem, the nurse is to know the underlying causes of his less capability to undertake his ADL’s and administer his medications. Basing from the findings from the RCS which is summarized in the table below (Please refer to table 2), the researcher has decided that it is not yet necessary for the patient to be placed in residential care since he has scored only 25.77.
Questions
Rating
Weight
Communications
A
0.00
Mobility
B
1.19
Meals and Drinks
B
0.67
Personal Hygiene
B
5.54
Toileting
B
5.98
Bladder Management
A
0.00
Bowel Management
A
0.00
Understanding and Undertaking Daily Activities
B
0.79
Problem Wandering or Intrusive Behavior
A
0.00
Verbally Disruptive or Noisy
A
0.00
Physically Aggressive
A
0.00
Emotional Dependence
C
0.28
Danger to Self and Others
A
0.00
Other Behavior
A
0.00
Social and Human Needs – Care Recipient
B
0.95
Social and Human Needs – Families and Friends
B
0.28
Medication
C
8.55
Technical and Complex Nursing Procedures
B
1.54
Therapy
A
0.00
Other Services
A
0.00
Total ………………………………………………………………………. 25.77
Table 2. Mr. Vertigo’s RCS and their Corresponding Weight
The patient may stay at home and be given community care such as the Home and Community Care or (HACC) Program. It is a central element of the Australian Government’s aged care policy which provides community care services to frail aged and younger people with disabilities and their carers. The type of services funded through the HACC Program include (but not limited to) nursing care, allied health care, meals and other food services, domestic services, personal care, home modification and maintenance, transport, respite care, counseling, support, information and advocacy and assessment <www.health.gov.au>.
Conclusion
To sum up, this paper provides a nursing care for Mr. Joshua Vertigo which bases from the findings of the RCS. From the findings, the researcher has concluded that Mr. Vertigo stay at home and get community services – Home and Community Care – which is provided by the Australian government.
Reference:
Benjamin, E.J., Wolf, P.A., D’Agostino, R.B., Silbershatz, H., Kannel, W.B. & Levy, D. (1998). Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation, 98 (10), pp. 946-952.
Greenlee, R.T. & Vidaillet, H. (2005). Recent progress in the epidemiology of atrial fibrillation. Curr Opin Cardiol, 20 (1), pp. 7-14.
Bradford, C. (1999). Basic ophthalmology for medical students and primary care residents. 7th edition. San Francisco, California: American Academy of Ophthalmology.
Horstman, J. (1999). The Arthritis Foundation’s Guide to Alternative Therapies. Atlanta, GA: Arthritis Foundation.
Dale, J.J., Callam, M.J., Ruckley, C.V., Harper, D.R. & Berrey, P.N. (1983). Chronic ulcers of the leg: a study of prevalence in a Scottish community. Health Bull (Edinb), 41, pp. 310–314.
Callam, M.J., Harper, D.R., Dale, J.J. and Ruckley, C.V. (1988). Chronic leg ulceration: socio-economic aspects. Scott Med J, 33, pp. 358–360.
Roe, B. and Cullum, N. (1995). The management of leg ulcers: current nursing practice. In Cullum, N. and Roe, B. (Eds.). Leg Ulcers: nursing management. (pp. 113-124) Harrow: Scutari Press.
Stepien, J.M, White, H., Wundke, R., Giles, L.C., Whitehead, C.H. and Crotty, M. (2006, March). The Resident Classification Scale: Is it a valid measure of functional dependence? Australasian Journal on Aging, 25(1), pp. 42-45.
Documentation and Accountability Manual, Electronically retrieved from the official website of the Australian Government, Department of Health and Ageing, May 11, 2006, from <www.health.gov.au>.
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