Case Study Analysis

Student’s name 

Student’s number 

Date 

Introduction 

This assignment aims to critically examine the case study of a female old aged patient “Elizabeth”. In this report the pseudo name of the patient i.e. Elizabeth will be used to maintain the confidentiality rights of the patient. The NMC Guidelines, , 2018 states to maintain the safety and protection of the patients and ensuring to safeguard the rights of the patients in terms of ethical, legal and health aspects. This case study will explore the issues surrounding urinary incontinence in an older person and will critically analyse biological and social aspects of care provision. Elizabeth is a 75- year’s old patient who was suffering from Parkinson’s disease, and was also experiencing urinary difficulties and changes in intimacy with her husband. I evaluated this case during my placement in a current role as Parkinson’s disease nurse and a non-medical prescriber for managing, evaluating and supporting patients and their families. Moreover, this report will also provide aspects regarding the biopsychological model and its impact on the overall health and wellbeing of the older patient. At last, the strategic approaches will be discussed that may help in improving service delivery areas for effective care to the older patients with Parkinson’s disease. 

Overview Of The Case Study 

Elizabeth is a seventy-five-year-old female with Parkinson’s disease. She attended a nurse-led clinic and we discussed her current concerns. It was identified that Elizabeth had been experiencing urinary incontinence and changes in intimacy with her husband but had been reluctant to disclose this. She had been hesitant to report these problems; thus, her scores of The Parkinson's Disease Questionnaire (PDQ-39) assessment revealed that she felt highly embarrassed and ashamed of her symptoms like bad odour, frequent urination, difficulties in memorising and Tremor in hands, arms, legs, jaw, or head. By agreeing to seek treatment at the nurse-led clinic, Elizabeth was able to express her concerns and share her problems freely with the practitioners. This helped Elizabeth to trust me as I took time to assess her and build a medical report with her. This made Elizabeth feel at ease, with open and improved communication of her sensitive issues, which enhanced her physical and psychological health assessment. This urinary incontinence such as frequency of urination, urgency, or incontinence were most probably a result of Parkinson’s disease since the condition is known to affect bladder control. I have suggested the following techniques of managing the aforementioned symptoms, including intake of more water, or use of bedside commodes, and dopamine agonists for managing issues of PD. Also, the nurse has advised her to visit a urologist, for instance an urologist for a more comprehensive treatment on the problem. The fluctuations in intimacy with her husband were also among the key concerns raised by Elizabeth. This is not very surprising as those diagnosed with Parkinson’s disease are bound to have their physical capability diminished and emotional health compromised. During the consultation the nurse seemed to be responsive to patient’s emotions and clearly understood that being sick causes a lot of stress to the patient. 

Rationale Of The Case Study 

Parkinson’s disease (PD) is a chronic progressive neurodegenerative disorder that affects the motor system and manifests itself in movement disorders like resting tremor, rigidity, slowness of movements and postural instability, and non-motor symptoms like urinary incontinence (Rawat and Pandey, 2022). Reportedly, in patients aged 60 years and over, PD progresses more rapidly and is associated with more severe disability than in the younger patients (Hustad et al. 2021). This is in the case of PD which can significantly alter the patient’s quality of life by affecting their physical wellbeing. Patients with PD and incontinence should therefore receive close attention and management for various reasons like, First, the nature of the incontinence such as urge, overflow, functional and the like must be assessed clinically with a view of being in a position to prescribe for the correct remedy (Vaughan and Markland, 2020). Second, the contributory factors to incontinence might be; disease severity; cognitive function; co-morbid conditions; and pharmacological management options (Zaki et al. 2022). It also provides a systematic assessment that helps in the identification of factors that have contributed to PD condition. Then, the urinary symptoms are known to appear in advance of the motor symptoms, and hence, maybe used as an early indicator of the disease. Bladder, urodynamic studies, and routine tracking of symptoms are all useful in terms of gaining insights on progression. Moreover, urgency also leads to fall and fractures, pressure ulcers and infections, skin breakdown and urinary tract infections. A reduced ability to toilet without assistance also results in higher dependence ratings and thus increased caregiver demand. 

Through critical reflection, I felt that I needed to explore this further as this was an area I did not consider as much as I should when reviewing the patient. Incontinence is rarely mentioned in public and people are frequently unwilling to seek further information, there are many misconceptions regarding the condition. Watters and Boyd , 2009 argued that healthcare professionals rarely address sex an intimacy. Additionally, Gott (2003), highlighted several survey participants who stated they had never before had the chance to talk about sex with a professional. This could be due to insufficient knowledge or confidence to discuss a sensitive subject (Garrett and Tomlin, 2015). Unfortunately, clinicians have limited time with patients. Alarmingly a staggering 94% of NHS healthcare practitioners surveyed said short appointment times put patients at risk. Over half of clinicians feared that patients felt unheard or unvalued (Hazlegreaves, 2019). The World Health Organisation (WHO, 2022) highlights the emergence of several complex health states commonly called geriatric syndromes. They are often the consequence of multiple underlying factors including urinary incontinence. The ability of older individuals to perform the things they value will not differ much from that of a younger person provided they can live these extra years in good health and in a supportive environment. The effects on elderly persons and society as a whole will be more detrimental if these extra years are mostly attributed to reductions in physical and mental ability (WHO, 2022). Unfortunately patients who report urinary symptoms are frequently denied assessment or care, which serves to perpetuate the belief that incontinence is an inevitable and incurable aspect of ageing. In order to avoid the increased risk of chronic incontinence after six months and a decreased possibility of long-term resolution, it is critical to seek timely and adequate treatment for incontinence (Farage et al, 2007). 

Critical analysis 

Areas Of Improvements In Practice 

Elizabeth had admitted to becoming obsessed with planning her day and felt her urinary difficulties affected her daily activities. Some individuals can develop maladaptive coping strategies, such as limiting fluid intake, which can exacerbate the problem or lead to dehydration. She would admit to drinking enough fluid at times, particularly if she was going out. When she did go out she was worried about odour or if anyone could see if she was wearing a pad or even worse she had an accident. She admitted to avoiding some social situations. Because social behaviours are adjusted to minimise possible embarrassment due to loss of bladder control in public, incontinence can have a significant negative impact on social function. It is more preferable to focus on a more global and individualistic approach. 

From Elizabeth’s case, there are some key issues that may need to be addressed in the healthcare services in the UK. Firstly, more attention and care concerning mental health difficulties in compared chronic physical illnesses patients might be helpful. This appears to be the main reason why Elizabeth feels distressed and isolated due to Parkinsons and how it affects her intimacy and continence. Evidently, using higher-frequency mood check-ins and greater accessibility to psychological therapies could aid patients like Elizabeth in managing these potent side effects. Secondly, the provision of further educational materials for health care providers that would involve information concerning how to approach the subject, may contribute to the improvement of communication between the patients who seek medical advice on certain issues. With regards to the study by Walters et al. (2020) stated that there is a decline in health literacy with the progress of age mainly because of the changes in cognitive processes. Patient education means that even in medical terms, which could take a long time to explain to a patient, the information is broken down and given in a simple and easy to understand manner. This helps the elderly patients understand their condition fully. Teaching can include information on diseases and their progression, prescribed drugs, their repercussions, methods for maintaining personal hygiene, and guidelines regarding food and nutrition. It is assumed that explaining such things as the need for a catheter or facing sexual desires and problems can be challenging because of the culture, the patient belongs to or the gender differences of the patient and the healthcare provider. While, another aspect was reported by Winter et al. (2022) that the indications from participants were that capacity building of staff in intimate care discussions via dignity and empathy-orientated workshops may have the potential to facilitate increased patient reporting. Might be same cause has affected her confidence in discussing her personal issues, resulting in severity of her urinary incontinence and mental health issues. For such reasons, the study by Taberna et al. (2020) pointed out that, the enhancement of communication among the members of the various disciplines comprising the Multidisciplinary teams that may be involved in the care of a specific patient may enhance continuity as well as the assessment and meeting of multifaceted patient needs. In reference to ELizabeth, improved integration of her neurology treatment team, primary care physician, nurses, and specialty continence and intimacy care services could enhance her care plan. Another possible strategy is to ensure that the records of a patient are clear within each healthcare setting and that the information is properly shared while respecting the patient’s confidentiality. Therefore, improvements in terms of patients’ psychological support, healthcare staff’s communication abilities and integrated teamwork in the UK health systems would be useful for clients, such as Elizabeth, experiencing the multifaceted effects of chronic illnesses. As the population age rises, these aspects of what can be described as ‘golden, empathic, and patient-centered age care’ will only grow in significance.

Potential impact of service improvements on biological, psychological and social wellbeing of the older patients

Enhancing the services for elderly patients could also make a positive difference and improve their health by fulfilling their health needs. In biological terms; improvements in the early detection, prevention, diagnosis, and management of age related diseases and disorders would enable elderly patients to lead more productive healthful lifestyles (Guzman-Martinez et al. 2021). For example, enhanced options for preventive care, cancer check-ups, and a better approach to chronic ailments like urinary incontinence, and improved availability of reactivation and physical therapy, among others, can all assist the elderly to either stabilise or increase their physical capability and decrease health issues (Ogden et al. 2012). It enables them to live independently for as long as possible and avoid being admitted to hospitals or being placed in nursing homes. Psychologically, the changes in the system and the improvements that are made in the delivery of health care services to the elderly are likely to enhance the mental health of the elderly population (Moreno et al. 2020). Additional reimbursement for supports to enable the provider, staff or facility to prepare for age changes in sensory, cognitive or mobility abilities can build confidence in the abilities of the care giver. It also reassurance to the older person that they will receive the respect and care they need and deserve. Even more social work and counselling services provide care in the regular difficulties of elderly people, such as bereavement, loneliness, health/money worries, and major life adjustments, decrease conditions such as depression. Policies/contexts that work against ageism and negative stereotyping contribute to improving seniors’ perceived worth and personal roles. Simple things such as having extra time with patients, signs and forms that are easy on the eyes for people with poor eyesight are something as small as these that make it become slower but it is a good thing (Gilbert and Van Dijk, 2012). 

Socially, the helpful services that address the ability of the elderly to move around within the community and engage in social activities reduce the feelings of loneliness that the elderly experience. Better access to local transport and helping them get amenities they need made them be able to engage in activities, membership in organisations, and relationships that make life worth living (Banister and Bowling, 2004). More funds for adult day services, community services, leisure for elderly and even technology-assisted communication even when physical mobility is challenging ensures the elderly remain socially engaged. One thing is certain; improving social, psychological, and biological care for such vulnerable populace ensures that older adults remain active in community living as this positively impact their wellness (Fernández-Ballesteros, 2008). It can be stipulated that healthcare systems are under obligation to enhance access, quality and experiences for elderly patients in the later life. It can substantially assist and enhance wellness promotion for seniors in multiple spheres of their aging lives.

Functionally, it is apparent through previous literature that services could be enhanced to more effectively screen Elizabeth for numerous age-related medical conditions such as urinary incontinence. They could find such problems during yearly examinations and follow up visits; moreover, they could enhance her physical well-being with the help of such amenities as pelvic floor therapy or medications. Co-ordination with her neurologist might also help in the proper medications for improving symptoms of PD that are precipitating urinary issues. If Elizabeth has better control of biological factors such as weakened bladder muscles, damage to the pelvic floor, and menopause that contribute to continence and intimacy, then she may actually have enhanced physical health. In the psychological aspect, services could help Elizabeth if there were no taboos speaking about sexual health. Therapeutic communication by nurses and doctors in explaining ways to maintain intimacy with chronic illness could offer her the approaches to outline expectations, and strengthen bond in her relationship. Elizabeth could benefit from feeling comfortable discussing certain matters without shame as it may lead to an improvement of her self-esteem. Further, a session of individual or couples counselling facilitates professional assistance in managing change due to aging and diseases (Knight, 2004). Perhaps, the personalised focus and the willingness to discuss it and address her psychological state would make her mental health better. Thus, it is clear that, in the care services, more attention should be paid to Elizabeth’s need in companionship and relationships rather than only medical ones. Chores can be done by home health aides and they can also act as social companions to the elderly, this can be done by employing the services of an adult day program which organises group activities to ensure the elderly do not feel lonely (Sims-Gould and Martin-Matthews, 2010). It is also suggested that Elisabeth’s husband should join support groups for caregivers as these organisations help people adapt to the changes in their lives. Engagement with other people is a crucial aspect of life which people with restricted ability to improve their psychological and physical health (Menichetti et al. 2016). Integrating social content with health care services enhances the maintenance of social relations for patients (World Health Organisation, 2018). Thus, a more comprehensive understanding of needs biopsychosocial would significantly enhance quality care for older patients such as Elizabeth as it is crucial now, as with any other aspect of life, to maintain one’s physical health, lack shame regarding infrequent communication and need for support, as well as focus on preserving relationships with close ones in old age. Health services need to move from the more familiar disease-focused and treatment hospital-oriented approaches to include true patient-centered care.

Strategic Approaches To Improve Quality Of Life Outcomes For Older People

Analysing the care needs of a patient “Elizabeth”; some of the areas that can be enhanced by a well-developed strategic care plan. Like, it shows that being a patient with PD; she has to struggle with physical, emotional and social issues affecting her dignity and self-esteem. This means that policy makers should adopt a highly sensitive and patient-oriented strategy so that the patients with such health issues could get better health care assistance. First of all, Elizabeth requires specialised care for the following symptoms that are related to Parkinson’s disease and urinary incontinence. Enhancing the diagnostic accuracy and management of Urinary incontinence is crucial in enhancing quality and longevity of life of older persons with Parkinson’s disease in UK (Waller et al. 2021). Engaging in enhanced and more systematic care of patients with PD is the willingness to apply the NICE national clinical guidelines for managing urine control issues in these patients (NICE, 2023). Another factor that could contribute to early interventions is increased training of medical professionals to identify incontinence in PD. Enhanced integration of care by professionals from the fields of neurology, urology, geriatric medicine, and nursing specialties is also necessary to produce the most ideal treatment plans for the patient (Burhenn et al. 2016). It is therefore important to develop an individualised approach based on patient’s needs that can also address bladder dysfunction along with motor symptoms. Using continence advisors and adding the conservative treatments such as pelvic floor muscle training while on medications can enhance the results (Ayeleke et al. 2013). Lastly, more money and efforts should be directed towards the development of new and combination pharmacological and interventional management of incontinence in PD patients. Decreasing the stigmatisation of people with bladder disorders and increasing awareness to the ways in which they can impact a person’s life negatively but often invisibly, could inspire political mobilisation for reforming health policies and increasing research funding for this problem. This could be achieved by conducting awareness programs regarding the topic so as to ensure people have adequate information.

Urinary incontinence is a very multifaceted problem, which can have an emotional impact on any elder individual. The most important thing is to focus on their needs and not to criticise them. It is necessary to indicate urinary management strategies that can be considered as safe and feasible for Elizabeth considering her reduced dexterity, such as the use of protective underwear, bed pads, or portable commodes that can be easily operated. Contrary to this, Zeng et al. (2020) stated that the cause related factors such as UTI or side effect of medications should be considered while treating old aged patients with urinary incontinence. The above case indicates that depression can worsen other health complications, thus, Elizabeth should seek counselling and emotional support to strengthen her dignity and optimism. Specifically, the author Van Niekerk et al. (2021) states that one of the potential reasons for such changes could be issues with intimacy and emotional closeness of patient with their partner, for which it is necessary to provide open and empathetic communication. Possible causes may be disease related, such as the progression of the disease, or they may be related to individual concerns, or a patient’s ability to understand what practitioners are saying, or medication adverse effects (Tariq et al. 2018). The other issue Elizabeth may need to be reminded is that intimacy is not solely an aspect of passion. Becoming sensitive to what makes them most content, loved and supported is an important idea to follow. There is help for those who want to improve their sex life and be intimate safely and comfortably despite Parkinson’s disease. For instance, support groups works in providing care and support to the patients are easily approachable within the communities. But over and above all of this, constant expressions of one’s continued loyalty will help to strengthen the bond of affection. Loving family will also guide solutions along with her strength and knowledge that has been developed in her own life. Following her from time to time will make her feel that someone is keen to listen to her and care for her while they go through these difficult changes in their later years. Similarly, the study Rosenbaum et al. (2014) has supported the idea of family based approaches that involved family members, especially partners and parents to look after the patient with supoiort, care and attention. Likewise, it is assumed that the involvement of Elizabeth’s husband can bring improvement in her mental and physical health. For instance, research by Margareta et al. (2009) demonstrates that husbands can also play useful role in enhancing their spouses urinary incontinent and sexual relationship. First, the best thing to do is to read up on her condition so that they could know what the patient is going through and what they feel. Consult with her and help her to obtain the necessary professional attention, which might be Kegel exercises, medications, or surgery. It would be wise to be understanding and not push her to engage in sexual relations when the symptoms have not cleared up. Be willing to take part in such procedures as Kegel exercise if the doctor advises on it. In addition, Park et al. (2014) supported Kegel exercise and stated that this exercises are used to improve the pelvic floor muscles which assist in controlling of urinal bladder and bowels. The muscles involved in the process include the pelvic floor muscles and the anal muscles. When these muscles are contracted and relaxed in succession, they help minimise incidences of urinary incontinence among women. Above all, it is suggested that Elizabeth’s family members should be sensitive, calming and positive with her, and set realistic intimacy goals as they both learns to deal with this embarrassing and sensitive medical condition. 

Legal, Ethical And Professional Issues Related To The Best Practices In The Areas Of Service Delivery 

In case of Elizabeth, issues of health care concern health needs, as well as her preferences or any values she may uphold. Nurses are legally limited on what they can reveal about Elizabeth and therefore must respect her right to privacy under data protection laws such as the Data Protection Act in the UK. In addition to this, the study by Nelson-Nilsen, (2016) stated that the healthcare systems in the UK are obliged to follow Data Protection Act and Equality care Act 2010 to maintain equality and protection rights of the patients. Her medical information and history should not be revealed without her permission and should remain limited to her healthcare providers when necessary. Care plans must also consider legal requirements for equality, diversity and non-discrimination as any assumptions made regarding Elizabeth’s preferences and circumstances may be unlawful due to her dementia. Ethically, there is recognition of Elizabeth’s self-governance and self-determination in the care decisions that should take into consideration her values and views. This process entails the use of acceptable, non-emotional language to explore her unique concerns and goals in relation to urinary incontinence and relationship intimacy concerns. As per the study by Gazarian et al. (2021) put forward its findings that the care plans should respect the patients’ dignity, promote comfort and support their relationship with their partners to bring stability in their quality of life. In addressing the clients, the nurse should understand that urinary and sexual issues are sensitive areas of concern. It is important to ensure that they create a favorable atmosphere that promotes openness, trust and emotional safety during these discussions. By using the communication techniques such as questioning without imposing the answers, listening without judging and by providing with understandable choices helps both patients and the care providers to build mutual understanding (Leonardo, 2020). Consultation with other professionals such as the pelvic health physiotherapist may offer practical guidance for coping. In general, it is crucial to bring together people and work together focusing on the person. The care plan has to address the continence care needs and the therapeutic interventions in terms of continence products, lifestyle modifications, and any potential therapies alongside the important client-centred and personable perspective on Elizabeth’s life and her interpersonal relationships. Nursing care should provide patient privacy and equality in compliance with legal requirements while honoring patient’s rights to self-determination, dignity and values. Honesty, respect, and discretion along with the provision of the appropriate support to Elizabeth allow her to feel comfortable in tackling this challenging condition. Professional caregivers should also periodically reassess her goals and objectives and modify treatment plans accordingly.

Conclusion

This report has presented the case presented is of a 75-year-old female patient diagnosed with Parkinson’s disease who went to a nurse-led clinic to talk about the urinary and intimacy problems she was reluctant to bring up before. The nurse was allowed to establish a good working relationship and make Elizabeth comfortable to discuss various personal health issues. Based on the findings, it was concluded that the urinary frequency, urgency and incontinence that Elizabeth suffers from are actually symptoms of Parkinson’s disease on bladder functions. Of course, the nurse advised to make changes in the lifestyle, drink more water, use a bedside commode, and consult a urologist. Elizabeth also had concerns about sexual relations with her husband and stated that due to her physical disability and psychological state change due to Parkinson’s, she lost intimacy with her husband. After greeting her, the nurse offered suggestions as to how they could continue to express affection while engaging in activities that met Elizabeth’s physical limitations. In total, the nurse was receptive to listening to the patient and acknowledged the fact that stress is brought about by an illness. As suggested by the nurse, Elizabeth should consult with urologists as instructed and follow the recommendations that were made concerning her urinary problems and symptoms. Furthermore, it is suggested that the intimacy recommendations should be used by Elizabeth and her husband, although he should be ready for changes when her Parkinson’s develops. Management is also recommended to ensure that continuity of care with the nurse is maintained to attend to any emergent issues.

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