An 86 year old male patient was admitted to the hospital-based on the diagnostic complaints of fall and urosepsis. He was admitted as he was suffering from post-fall due to Urinary tract infections (UTI) complications with septic stock. The associated clinical conditions observed were a multi-organ failure, and atrial fibrillation with the repetitive ventricular response (RVR) complicated with non-ST elevation myocardial infarction (NSTEMI), functional decomposition, iatrogenic bladder perforation, and anemia.
UT I occurs due to infections of various parts of the urinary tract that involves the bladder, kidneys, ureters, and urethra(Urinary tract infection, 2008). It was described that patients who had a history of a fall also develop UTI In addition (Rhoads, Clayman & Nelson, 2007). Similarly, patients with UTI are likely to develop acute coronary syndrome where non–ST-elevation MI is common (Sim et al.,2005). The present 86 year old male patient had a medical history that is in agreement with the complications studied in the research evidence.
Need
To provide care to the patient, there should be awareness on investigation approaches which is lacking about the UTI case conditions relevant to this patient. I felt the need to provide some teaching-based resource assistance to the patient analogous to an expert clinical practitioner. The basis for this strategy is the problem the patient has been confronted with. In older people, urinary tract infections (UTI) are the most frequent infections that occur in long-term care settings and at the community level. The variety of UTIs ranges from symptomatic bacteriuria to bacteremic infection. In the older individuals, UTI with bacteremia has high mortality in the older population, at a rate of 5% for 28 days.
Diagnosis of UTI was very often done without considering the clinical history and signs and as result, 40% of older individuals have become hospitalized (Beveridge et al., 2012) In addition, the absence of specific evidence-based practice criteria for UTI has also contributed to the misdiagnosis of the older population with UTI. The present patient is in the hospital as he needs a remedy from UTI-associated complications that are seriously making him frail. He needs to be taught from the teaching perspective. The patient needs are more relevant to treatment and complications, improving the quality of life, medication awareness, living activities, feelings about condition, skincare, and community follow-up (Bostrom et al., 1994). His selection is the major determinant of learning outcomes.
We identified the learning needs of the patient by observing him for clinical symptoms and through questionnaires. To better accomplish this, the assistance of baccalaureate program students proved very influential. The attitude of students was judged by giving the work assignment on client selection and their interest to work with the older adults. Their positive set of mind and level of gerontological knowledge were additional key factors.
Based on Kogan’s Attitude Toward Old People Scale, the students were categorized into groups. Palmore’s Facts on Aging Quiz was used to measure the knowledge of students. A 50% of students were familiar with the elderly population (Greenhill & Baker, 1986). These students were utilized for approaching the older patients and understanding their needs. The patient was in an urge to talk to the intervening student group and reveal the problems he has been confronted with. He needs a precise diagnostic remedy such that he could return home.
As such, students were being given a chance to become acquainted and flexible in dealing with the old patients. This was done to enhance their awareness levels on the aging process and implement that knowledge within the domain of nursing, by recognizing the vital components of development utilized in the health assessment of the old patients (Ross, 1985). Hence, motivation from the student group seemed very important to better prepare the client and make him ready
Principals of Motivation and Readiness
Initially, the conditions surrounding the patient were made positive by advising the patient to withstand the negative beliefs, assumptions, and expectations eliminating the failure contributing components of the learning environment. This was made feasible by developing a congenial ad conducive atmosphere that facilitates prolonged efforts and constructive spirit towards learning. The patient was shown certain posters, booklets that serve as visual aids to draw his curiosity and attention for motivation. Occasionally, the patient was subjected to receive incentives in the form of praise and privilege from the students which was determined by the teacher. This could be because in the absence of rewards self-motivation would fail. Motivational interviewing was done to enable the patient learn novel skills of behavior.
This was mostly focused on open-ended questions, reflective listening, affirmation, and summarization in order for the patient to tell his opinion about change (Miller,2010). It was observed that through the course of time, the patient has shown readiness which made the teacher to promote its development. An expected change, at the earliest moment, in the behavior of patient was supervised to guarantee its occurrence. Very often, when the patient was not ready to learn and unreliable in assimilating the given instructions, he was supervised and the instructions were said again (General principles of motivation, n.d.).
The patient was exposed to a neatly organized instructional material by making the information appear lucid at his level. Here, specific tasks were given in relation to the already familiar ones, assessment was made of the expected outcomes and the patient was finally advised to make comparison of old and new ideas. During the readiness, the patient was not feeling well and emotionally upset with anxiety. It was understood that learning may induce variations in behavior and beliefs and leads to mild anxiety. So, the patient was regularly monitored for the identification of anxiety and its impact on the learning process.
To lessen the anxiety, the patient was not given any unclear and unrealistic goals of high level (General principles of motivation, n.d.). This has strengthened a report that described the reliability of written and verbal information on health while during patient communication on care issues and hospital discharge. Satisfied care in a standard format is the outcome expected from the combination of written and verbal health information.
In addition this approach enhances knowledge not only in patients but also in care providers. The literacy level of the patient determines the communication approach of motivation and needs thorough evaluation (Johnson, Sandford &Tyndall, 2003). In the present context, the information imparted or instructed to the patient was in agreement with his literacy level. It is essential to understand that the motivation strategies implented for the present client may coincide with the research evidence provided through studies on other age groups, very often. Hence, while implementing the principles of motivation, a balance was maintained between the
patient’s active participation stimulation and respecting his autonomy in the care. More probably, face-to-face coaching sessions has worked out regardless of written materials (Wetzels et al., 2007). On the whole benefit derived was more in the patient identification of needs.
Objectives
Next, the patient admitted to the hospital needs some behavioral change about improved self-care (Alywahby, 1989). So, identifying certain behavioral objectives is a new challenge. The present old patient with UTI is having falls as an important associated complication. Patients with falls are at risk of serious injuries and need some rehabilitation care. In the rehabilitation care center, the old patient was suspected to receive an improper and undiagnosed UTI, and the resulting infection was likely associated with catheter use. A questionnaire was conducted by students in a nursing format about the use of catheters and their removal.
The students were showing interest in deciding about the use of catheters and supporting the patient (Romito, Beaudoin & Stein, 2011). A measurement approach was utilized at baseline and after treatment on urinary parameters like bladder voiding efficiency (BVE), postvoid residual urine volume (PVR), and Q-max, average flow rate (Q-ave) (Hiroo et al., 2009). The screening of old UTI patients for measurable objectives was performed daily for one month.
Especially, this routine screening made the student to learn about the connection between UTI and the amount of post-void residual urine (PVR). In detail, the students measured the PVR with portable ultrasound. It was found that incidence rate correlated with the level of function. The students concluded that good amounts of PVR and decreased functional level are risk factors for prevalence and incidence of UTI in elderly patients in a rehabilitation day-hospital.
Therefore, it was concluded that routine measurement of parameters in UTI patients was important in a rehabilitation setting (Hershkovitza et al., 2002).Fall management is another objective in the UTI risk measurement. It can be overcome by training inbalance and strength related to Tai Chi and Otago Exercise Programme, supplementation of Vitamin D, review of medications to minimize the psychotropic medications, correcting vision defects and its assessment and monitoring of home hazards (Falls in older people,2011).The patient when used the drug phenazopyridine developed side effects like skin rash and unusual tiredness or weakness.
The impact of medication side effect was also considered during rehabilitation care and appropriate monitoring was also done.VI. Teaching/Learning Principals: The patient was able to learn best from the teaching strategies focused on verbal and written communications. He was regularly assessed through questionnaire and feedbacks. Students enrolled for the job are kept under constant surveillance by the teacher. The aged UTI patient may have some barriers to learning.
It was reported that problems related to vision, hearing, memory deficits occur gradually and become unavoidable in older individuals. As such, the principles of teaching are emphasized on assessing and overcoming the interference of these barriers by teaching the client to achieve objectives. This is to expect an enhanced self care and functioning in the elderly patient (Alywahby,1989). Videos that boost the patient’s confidence have been shown to the patient daily for one hour followed by related colorful pamphlets. Videos involve clips on the patient active participation in the UTI management program. Likewise the pamphlets involved cartoons that reflected patient participation.
Overall,the environment provided to the patient was very conducive to learning.
Teaching Plan
The teaching plan of nearly 28 days, proceeded from studying the physical appearance of patient, reviewing the personal medical record, identification of patient problems in the first week; interaction with the patient, motivational interviewing –which is a style of counseling
based on client for invoking a change in behavior by making them discover and solve the uncertainties they encounter in their life (Motivational interviewing,2006), showing patient friendly organized materials for motivation, post analysis of behavior and outcome in a rehabilitation style from second week to fourth week.
Evaluation
Finally, the teaching strategy was evaluated fro several perspectives. Firstly, the identification of patient’s symptom was difficult. It was done through careful monitoring of behavior in relation to the developed symptoms and medication use. The patient was very anxious and emotionally upset in the initial stages of the teaching based intervention. He was appreciated and gradually monitored which made him perfectly fit for the participation. He was ready to move to a new location and hardly needs the interference of care providers. The patient was discharged and at home, the student group used to visit the patient and feedback was obtained. The patient problems have almost subsided and he was able to perform routine tasks of movement.
Differently, I could have concentrated more on the previous history of the patient.An investigation of the conditions that led to UTI might have given much more information like diabetes, hear ailments, reproductive disorders etc. Medication history could have been sought in detail like the dose regimen, any changes in the treatment plan or doctor change. Family members might have approached and questionnaires would have been conducted to find out the actual care provided to the old patient, his behavior, symptom and societal interaction. An evaluation of previous medical visits of unrelated UTI complaints could have been sought to find an association between the previous medical problems and the current UTI. Severities of UTI infection coud have been assessed by the utilization of specific biochemical or modern genetic markers. Nurse care provided to the patient in the past could have been reviewed to asses the actual medical aid he received in the past.
Handout
- Need – There need was to provide some teaching-based resource assistance to the patient analogous to an expert clinical practitioner. The rationale for the need was the UTI problem the patient has been confronting with. The patient needs are information on treatment and complications, quality of life improvement, medication awareness, living activities, feelings about condition, skincare, and community follow-up.
- Principles of Motivation/Readiness: The principles of motivation are more emphasized on looking for the readiness in patients to participate in UTI management intervention led by the teaching staff. For a better outcome, motivational interviewing was applied to enable the patient to learn novel behavior skills and express his thoughts.
- Objectives: The measurable and behavioral objectives for the patient involve looking for the baseline and after treatment analysis of parameters like postvoid residual urine volume and assessing fall severity and movement-oriented tasks by training in balance and strength related to Tai Chi and Otago Exercise Programme.
- Teaching/Learning Principles: The principles of teaching have been emphasized on enabling the patient to achieve goals to expect changes related to vision, hearing, memory deficits that might interfere in the aging old patient with the UTI and become an obstacle to learning.
- The Teaching Plan: It involves patient observation about his physical behavior and mental keenness to cope with the intervening group and review of his past medical history in the initial first week. Implementing motivational interviews and measuring objectives/ clinical parameters in the second week. Analysis of outcome and behavioral change in a rehabilitation model.
- Evaluation: This task involves the assessment of all strategies beginning from the identification of learner’s needs, subsiding symptoms, gain in endurance and strength which were declined due to the combined effect of UTI and fall and behavior change.
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