Transcript How many specialists does one patient need

Collaborative Care in
Nursing Practice
A Case Presentation
Dementia
There is no conflict of interest that may have a
direct bearing on the subject matter of this
presentation.
Mary Ritchie, R.N., B.Sc.N.
Seniors Mental Health
Capital Health
Mental Health Program
How Many Specialists Does One
Patient Need?
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Brief clinical and family history
Overview of care providers involved
Rural health care
Community Mental Health Nurse role
Client update
How many specialists does this patient need
Cognitive
Impair
Neurology
Family
Physician
Geriatrician
Assessor
Client
Functional
Disability
Family/
Informal
Care
Home Care
Nova
Scotia
Care Givers
Adult
Protection
Seniors
Mental
Health
Psych.
Nursing
Assess
Family
Physician
Nursing
Home
Staff
Geriatrician
Palliative
Care
Psychiatrist
Problem
Behaviours
Psych.
Fellow
Fellow
Family
Neurology
In-Patient
Admission
Nursing
Home Staff
Initial Home Assessment
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60 yr old male, neatly dressed, watchful, anxious
Speech slowed, delayed response to questions, flat
affect, does not initiate conversation
No evidence of psychosis
Low mood
Slowed gait, no falls reported; continent with cuing;
feeds himself
Drinks rum; recently stopped smoking cigarettes
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Recognizes memory loss and feels sad and angry
On interview no intention to harm self or others
Feels helpless but not hopeless
Yells because he’s frightened and angry
Wants someone with him 24/7
Will go to nursing home, feels he needs help
MMSE 14/30 GDS 7/30 MADRS 10/60
Collateral
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Lives in son’s house; on a main road and has water
frontage with a wharf
Strong outdoorsman; good relationships
Glass installer: disability pension 6 years
Wife managed things for him
Wife died two years ago
Brother shot himself several years ago (90’s)
Collateral
(Current )
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Accepts help from HCNS and family
Needs prompting or full care for ADL
Not able to manage IADL (sons have PA)
Rapid change in memory and function over past two
years
Stopped smoking two weeks ago (AP)
Drinks rum weekly (Hx heavy drinking)
Not physically aggressive; verbally aggressive,
threats of self harm
Medical History
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Hypertension
Diabetes
Hypercholesterolemia
Positional vertigo
Smoker
Heavy alcohol consumption (HX)
Remote history of Bells Palsy
Episodes of blacking out since 96
Diagnosis
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1999
 Difficulty with mental functioning
 Mild cerebral atrophy
 (L) carotid stenosis
2000 No evidence of progressive dementia
2001 Parkinson’s disease
2004 Alzheimer’s disease
2005 Alzheimer’s disease (possibly mixed
with vascular dementia)
Medications
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Vitamin E 400 IU od
Novasen 325 mg od
Aricept 10 mg od
Allopurinol 200 mg od
Lipitor 10 mg od
Nadolol 80 mg od
Glyburide 5 mg od
Seligilne 5 mg od
Novoamilor 50 mg am
Clonazepam 0.25 mg hs
Family
X
?dementia
X
X (03) dementia
X
C
X (02) cancer
suicide
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Two adult male caregivers
Grandmother, mother, father
Rural Care
Health Beliefs
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Rural
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Role performance (health
as function)
Do what you can do
Seek help when you can
no longer do
Continue usual actions
Consider medical advice
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Urban
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Medical model (absence
of disease)
Treat symptoms
Seek R for Sx
Follow medical advice
Mixed Model
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Couple sought medical help
Dad can’t live alone, we’ll move him
Dad can still go out on Tuesday and have a rum
We can’t do all the care, HCNS
This is the limit of our ability
Local nursing home
Continued family involvement
Community Mental Health Nurse
Role
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Identify health beliefs of client and family
Recognize strengths/capacity
Facilitate communication
Assessment (collaborative)
Identify options
Support formal and informal caregivers
Support local resources
Close the case
Client’s Current Status
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Lives in local nursing home
No longer able to ambulate
Recently recognized a friend who visited
Had a birthday party and requested
‘a beer’……..so he had one
Meds: Allopurinol 200 mg od
Vitamin D 1000 IU od
Ranitidine 150 mg bid
Rispiridone 1 mg am and hs
Cognitive
Impair
Neurology
Family
Physician
Geriatrician
Assessor
Client
Functional
Disability
Family/
Informal
Care
Home Care
Nova
Scotia
Care Givers
Adult
Protection
Seniors
Mental
Health
Psych.
Nursing
Assess
Family
Physician
Nursing
Home
Staff
Geriatrician
Palliative
Care
Psychiatrist
Problem
Behaviours
Psych.
Fellow
Fellow
Family
Neurology
In-Patient
Admission
Nursing
Home Staff
How Many…
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Family Physician
Neurologist
Geriatrician
Home Care Assessor
Home Support Staff
Community Mental Health Nurse
SMHS Psychiatrist
Fellow SMHS
Fellow SMHS
Geriatrician (admission)
Consult to Neurology
Palliative Care Physician
Nursing Home Staff