Strategy For Nursing To Prevent Discrimination Of People with autism - Case Study Example

Specialised nursing: Summative Assessment Word count 3280 Introduction: This is the account of the summative assessment of John, who is a 40-year-oldgentleman with the diagnoses of autism and recurrent depression. He has an additional diagnosis of carcinoma stomach. He has been admitted to the hospital for further evaluation and possible palliative surgery. This assignment has been completed fulfilling all ethical requirements of confidentiality. Broad Issues: He is a client with dual diagnosis, namely, autism and recurrent depression. He has been admitted to the hospital with a diagnosis of gastric cancer. His care management needs will be complicated his diagnoses of autism, depression, and gastric cancer. The delivery of care will follow mainly the care pathway of mental health nursing with inclusion of elements in palliative care for gastric cancer. Evidence: People with autistic disorder have significantly increased rates of depression and bipolar affective disorder. Diagnosis of psychiatric disorders is more easily made in those who are verbal than in those who are severely handicapped, and therefore diagnosis, monitoring, and communication would be very challenging with John while conducting his care (Ghaziuddin, Ghaziuddin, and Greden, 2002, 299-306). Most patients with gastric cancer present in an advanced state. It has been found that palliative surgery is the only possible way. He is facing death without knowing its implications. From the nursing perspective, one of the main reasons for measuring the patient satisfaction is to provide information to facilitate care, which is impossible in this patient. For autistic patients admission to a hospital may be detrimental due to fear of exposure. The care management must consider nursing him in a special quiet room near the nursing station with frequent monitoring (Aylott, 2004, 828-833). Palliation is an emerging model of care that emphasizes the supportive role of healthcare practitioners throughout illness with the main strategy being symptomatic control with the care being holistic so that suffering can be relieved at all stages of the illness (Dell et al., 2008, 177-182). Autistic persons with depression often show an increase in social withdrawal. When depression sets in, the level of isolation and withdrawal gradually increases. The problem may arise in the area of communication, which is an essential part of holistic care. It is important to note that the patients with autism are difficult to manage, and the care planning and management becomes more difficult in the given situation. Due only to his autism, he can become anxious and agitated when his routine environment changes. His admission to the hospital creates such a situation, since hospital is an unfamiliar environment for him. Special care must be taken to ensure an optimum care environment (Aylott, 2001, 166-172). Gastric Cancer: The main feature of a cancer cell is loss of regulation of the process of cellular multiplication. The growth of normal cells is rigidly regulated. In cancer cells, however, this growth control mechanism is lost or altered, causing cancer cells to divide continuously and without regard for the tissue requirements. As malignant cells replicate they grow in an irregular pattern, infiltrating surrounding tissue. This can result in infiltration of the lymphatics and/or blood vessels. By gaining access to these vessels malignant cells can be carried to other sites within the patient's body, where they will replicate and grow. To ensure that these malignant cells receive nourishment to thrive, angiogenesis occurs, which is the formation of new blood vessels. If left untreated, these cells will result in localized recurrence of the cancer and eventual spread. The spread of the malignant cells extends outward from the original tumour (Gilbey et al., 2004, 903-911). Surgery is the main modality of treatment of gastric cancer with very poor survival (Balmain, 2001, 77-82). The development of an individualized treatment plan for a patient must take into consideration the following factors: (1) the biology and natural history of the cancer; (2) the extent of disease dissemination including specific sites of involvement outside the stomach; and (3) the potential of surgery, radiation, chemotherapy, and biotherapy to eradicate all viable cancer cells. Modern treatment programmes are designed to maximize the curative potential of each modality by utilizing each to exploit the different biological characteristics of each cancer. Surgery and radiation are often integrated with chemotherapy and biotherapy in order to preserve bodily function and to prevent distant metastases (Alberts, Cervantes, and van de Velde, 2003, ii31-ii36). Gastric cancer is associated with an increased incidence of severe malnutrition. He has chances to develop cancer cachexia with weakness, anorexia, weight loss, derangement in water and electrolyte metabolism, and eventual impairment of vital functions. A simple assessment of nutritional status should be performed on him on admission to the hospital. Since he is at risk of developing malnutrition, he must be referred to a dietician. There must be provision of nutritional supplements (Pacelli et al., 2008, 398-407) Palliative care is the active total care of patients and their families, usually when their disease is no longer responsive to potentially curative treatment. It is designed to provide relief from pain and other symptoms and aims to achieve the highest possible quality of life for patients and their families. It responds to physical, psychological, social and spiritual needs and extends necessary to support in bereavement. Each person's pain is unique and needs individual nursing management. When nursing a patient in pain, empathy, caring and accountability must be the prime considerations and the sound foundation on which further theoretical knowledge will be built. Any failure to meet targets, however unrealistic, increases both patients' and nurses' feelings of despair. Although it is desirable that pain is patient controlled, in this case there is no such probability, and the nurse will have to understand the intensity of pain depending on other cues and respond accordingly. Although, this patient is not able to understand, increasing physical and/or mental decline imposed by illness would further aggravate his social isolation. Nursing care, when planning a palliative form must include the basic nursing care and care that involves a detailed social understanding of the body (Clark et al., 2002, 375-385). It is important to accommodate holistic care within the framework of palliative care. Moreover, this care must be provided with dignity. Empathy is an essential prerequisite for palliative nursing. When this approach is combined with supportive medical treatment suitable for the end stages of lives, the goals of holistic nursing care would be achieved (Carpenter et al., 2008, 16-20). Depressed Mood: The main role of the nurse is to build a collaborative relationship with the person experiencing depression. It is a relationship that must be built on genuine respect and openness in which the nurse is seen as a partner in the depressed person's recovery. Individuals with depression need to be able to seek help and feel able to discuss their feelings, but in this patient that is impossible. Many of the feelings and thoughts engendered by depression are intensely personal and difficult to discuss. Nursing staff needs to be aware of this and should take time to build a relationship with depressed people and enable them to discuss their problems. It is therefore important that the nurse recognize this need and ensure that adequate time is allowed for spending with the patient. The starting point for the nursing care of a person with depression is the preparation of a care plan. The key role of the nurse is to continually monitor mood as part of an ongoing assessment. It is only through monitoring of mood and other symptoms of depression that the effectiveness of any treatment plan can be assessed. It is important to assess mood within three inter-related domains: physical, cognitive and behavioural. With respect to physical signs, particular note should be made of a disturbed sleeping pattern especially difficulty in falling asleep or waking particularly early. A careful eye should be kept on any change in weight, as depressed people may not eat. Very depressed people may even not drink and therefore careful observation should be made of their fluid status and any signs of dehydration should be noted. Cognition can only be assessed indirectly through noting an individual's conversation and interactions with others. This would pose a challenge to the nurse since the baseline autism would have altered this. It is particularly important to note the attributions that people give the events around them and negative attributions should be noted and, if appropriate, challenged. As noted earlier, people with depression will often have very negative views of them and often attribute negative meanings to everyday events. Behavioural signs are assessed mainly through observation and are closely linked to the previous two domains, especially physical signs. However, what is being observed here is behavioural style rather than specific behaviours. Information about mood can be gathered from the depressed person himself/herself in response to the important open question, 'How do you feel' This information together with information gathered within the three domains can be used by the competent nurse to make an accurate judgment of the person's mood (Williams and Payne, 2003, 334-338). Any assessment of depression requires that the risk of self-harm or suicide be assessed. It is particularly important that health staff is competent at assessing suicide risk especially as people experiencing depression are at a greater risk of suicide and self-harm than the non-depressed population. When individuals talk about suicide and self-harm they should never be ignored. Anyone showing symptoms of severe depression, especially psychomotor retardation and/or psychotic symptoms should be regarded as at high risk of suicide, as should anyone who has previously attempted suicide or self-harm. It should be noted also that a person determined to self-harm may not discuss their intentions for fear that they will then be prevented. Paradoxically, depressed people are at highest risk of suicide when they begin to recover. As their mood begins to lift, psychomotor retardation decreases and motivation increases, the individual may become more able and motivated to carry out a suicidal act, because they may still feel profoundly depressed. Therefore, as a depressed person begins to recover, assessment of suicide risk becomes increasingly important. Although this patient would not be able to express so much, it is important to assess from the signs. The concept of valuing the individual is an extension of the point made above. Often when the depressed person does engage in conversation they will be profoundly negative and self-blaming, and they may also apparently resist attempts to engage in treatment. It is important to try to respect and value what the person says even if it appears damaging or self-blaming. This can be difficult for the nurse who is trying to maintain a one-sided conversation, when even the most apparently positive event is cast by the depressed person in a negative light. This does not mean that the nurse has to agree or reinforce the depressed person's negative or damaging beliefs about himself or herself, rather the nurse can explain that they respect their beliefs but, that from their perspective, events have different attributions and meanings and that perhaps, as their mood lifts they too will feel differently. In summary, the role of the nurse in working with a depressed person is essentially that of support and monitoring and working with them towards recovery while keeping them safe. The importance of simply being with the depressed person and valuing their experience, while supporting medical treatment and interventions cannot be overemphasized (Lee and Knight, 2006, 138-142). Needs of the Patient due to Autism and ID: There is no single cause of autism. It is described as a multifactorial disorder in which both genetic and environmental factors play a role. While the extent to which each of these factors operates in any single case depends on the individual case, there is a consensus that autism is a neuropsychiatric disorder that is caused by some as yet undefined biological factor. This factor, perhaps in combination with a pre-existing genetic vulnerability, results in the clinical syndrome of autism. Several neuropsychological abnormalities characterize autism. Most autistic patients show problems with abstraction, and on IQ tests most have a better ability to focus on parts of a puzzle rather than the whole. Likewise, verbal IQ scores are often suppressed in comparison with performance IQ scores. In addition, there are abnormalities in the ability to read other peoples' emotions and feelings. Behaviourally, these patients are rigid, mechanical, and emotionally distant. People with autism have reciprocal social deficits. They lack the ability to interact in a to-and-fro manner with others. Their quality of interactions lacks flexibility and spontaneity. Although autistic persons are able to form relationships, it is the way those relationships are formed that is distinctly different from normal human relationships. Perhaps the most common symptom that arouses parental concern is the person's inability to communicate. Speech is often delayed, and those who eventually speak, show a variety of abnormalities both in the form as well as in the content of speech. Several types of speech abnormalities may occur, including a tendency to repeat the speech of others, and sometimes to repeat phrases and sentences heard in the recent past. Problems with eye contact, facial expression, and other aspects of nonverbal communication are often present. The tone and pitch of the voice may also be different. Sometimes the person may speak in a loud voice; at other times, the voice may have a sing-song quality. Restricted and ritualistic interests form the third main clinical feature of autism. These depend on the level of intelligence. Patients who have mental retardation often show fixation on simple routines. These may consist of lining up objects, such as pencils or sticks; arranging pieces of furniture; or insisting on performing routines in a certain way. This discussion is an important guide to the needs assessment since these patients would not be able to voice their needs. Training in social skills is based on the premise that social interactions can be successfully accomplished in a positive manner. Techniques include modeling, coaching, and role-playing. Deficits in social skills forman integral part of autism, and promoting appropriate social interaction remains a central feature of care. This particular patient may show an increase in social withdrawal due to associated autism. Sometimes an increase in ritualistic behaviors is seen with the onset of depression. At times, this may be accompanied by feelings of distress and sadness. When these patients get depressed, the quality of their fixations and preoccupations often changes. With the onset of depression, the patient's preoccupation may assume a depressive flavor. When asked, he may admit to feeling sad and depressed and worried about recurrent thoughts of death. These persons become irritable when depressed. This is similar to the irritability that occurs in dysthymia. They tend to lose their temper for no apparent reason or after minimal provocation. This may or may not be accompanied by physical aggression, especially in those who suffer from the milder variants of autism. These patients often do not express their sadness and unhappiness. Some of the features that suggest their depression are extreme regression of learned skills, weight loss, and incontinence. Psychotic symptoms can also occur in depressed persons, and a marked slowing of movements and thinking often complicates the clinical picture (Volmar, Klin, & Schultz, 2005, 3164-3175). The key to the diagnosis of autism lies in the clustering together of the three different types of symptoms - reciprocal social problems, communication deficits, and restricted interests - all of which start early in life, usually before the age of 3 years. The autistic patients do not form interpersonal relationships with others. They do not respond to or show interest in people. They have impairment of communication and imaginative activities. Both verbal and nonverbal skills are affected. Language may be totally absent, or characterized by immature structure or idiosyncratic utterances whose meaning is clear only to those who are familiar with the person's past experiences. Activities are restricted since even minor changes in the environment are often met with resistance, or sometimes with hysterical responses. For these people, routine may become an obsession, with minor alterations in routine leading to marked distress. Stereotyped body movements, such as hand-clapping, rocking, whole-body swaying and verbalizations such as repetition of words or phrases were typical in him. Diet abnormality would be a specific concern since that may include eating only a few specific foods or consuming an excessive amount of fluids. Behaviors that are self-injurious, such as head banging or biting the hands or arms, may be evident. Combined with depression, these are the areas that the care needs may ve concentrated. The needs would be to protect him from the risk of self-mutilation related to neurological alterations, help him through attempt to boost his impaired social interaction related to inability to trust, related to neurological alterations. The care plan must include development of a trusting relationship. There is a need to develop verbal communication by preventing withdrawal into the self and by stimulating inadequate sensory stimulation. The need would also improvement of his disturbed personal identity related to inadequate sensory stimulation. It is to be remembered one-to-one interaction facilitates trust. Until that happens, it is important to try to determine if the self-mutilative behavior occurs in response to increasing anxiety, and if so, to what the anxiety may be attributed. Interventions must be attempted with diversion or replacement activities and as anxiety level starts to rise, these interventions must be applied. The person must be protected when self-mutilative behaviors occur. Devices such as a helmet, padded hand mitts, or arm covers may provide protection when the risk for self-harm exists, since client safety is a priority in nursing intervention. While caring, it must demonstrate warmth, acceptance, and availability. The patient would be provided with familiar objects. Positive reinforcements must be provided for eye contact with something acceptable, and it should be gradually replaced with social reinforcement such as touch, smiling, hugging. Since verbal communication is affected, positive reinforcement is provided through anticipation of needs and fulfillment. Clarifications will be sought and validated. Positive reinforcement is given when eye contact is used to convey nonverbal expressions. Since the patient has associated depression, the given clinical situation must be assessed carefully to determine the needs in this particular situation (Beste, 2007, 15-33). Conclusion: The association of autistic disorder and depression would accentuate the associated depression since communication would be difficult. The anxiety related to terminal illness would further aggravate the depression. In this situation the self-mutilative behaviour may get accentuated, and the patient is in a high risk of suicide related to depressed mood, feelings of worthlessness, anger turned inward on the self, misinterpretations of reality. If he is able to understand his disease appropriately and the gravity of his condition this may lead to dysfunctional grieving. and this may enhance his baseline abilities to carry out activities of daily living. This sense of powerlessness related to dysfunctional grieving process or lifestyle of helplessness, evidenced by feelings of lack of control over life situation may lead to overdependence on others to fulfill needs. There may also be an element of spiritual distress in his suffering. He will have imbalanced nutrition, due to intake less than body requirements related to depressed mood, loss of appetite due to cancer, or lack of interest in food, which will be evidenced by weight loss, poor muscle tone, pale conjunctiva and mucous membranes, poor skin turgor, and weakness. He will have disturbed sleep pattern related to depressed mood, anxiety, and fears, evidenced by difficulty falling asleep, awakening earlier or later than desired, verbal complaints of not feeling well rested. Depression will aggravate his isolation and ability to communication. Only a palliative care would be able to support him, but a holistic element with empathic interaction built on trust is the most suitable nursing care for him. Reference List Alberts, SR., Cervantes, A., and van de Velde, CJH., (2003). Gastric cancer: epidemiology, pathology and treatment. Annals of. Oncology.; 14: ii31 - ii36 Aylott, J., (2001). Understanding and listening to people with autism. British Journal of Nursing; 10(3): 166-72. Aylott, J., (2004). Autism: developing a strategy for nursing to prevent discrimination. British Journal of Nursing; 13(14): 828-33. Balmain A (2001) Cancer genetics: from Boveri and Mendel to microarrays. National Review of Cancer 1(1): 77-82. Beste, L., (2007). Autism and nursing. Facilitated communication: significance of and use to the nursing of persons with autism with severe disabilities of action and communication. Pflege; 20(1): 15-33. Carpenter, K., Girvin, L., Kitner, W., and Ruth-Sahd, LA., (2008). Spirituality: a dimension of holistic critical care nursing. Dimensions in Critical Care Nursing; 27(1): 16-20 Clark, D. et al., (2002). Clinical nurse specialists in palliative care. Part 2. Explaining diversity in the organization and costs of Macmillan nursing services. Palliative Medicine; 16: 375 - 385. Dell, DD., Feleccia, M., Hicks, L., Longstreth-Papsun, E., Politsky, S., and Trommer, C., (2008). Care of patients with autism spectrum disorder undergoing surgery for cancer. Oncol Nursing Forum; 35(2): 177-82. Ghaziuddin, M., Ghaziuddin, N., and Greden, J., (2002). Depression in persons with autism: implications for research and clinical care. Journal of Autism and Developmental Disorder; 32(4): 299-306. Gilbey, A M, Burnett, D., Coleman, R E, and Holen, I., (2004). The detection of circulating breast cancer cells in blood. Journal of Clinical. Pathology; 57: 903 - 911. Lee, S. and Knight, D., (2006). District nurses' involvement in mental health: an exploratory survey. British Journal of Community Nursing; 11(4): 138-42. Pacelli, F., Bossola, M., Rosa, F., Tortorelli, AP., Papa, V., and Doglietto, GB., (2008). Is malnutrition still a risk factor of postoperative complications in gastric cancer surgery Clinical Nutrition; 27(3): 398-407. Stewart, ME., Barnard, L., Pearson, J., Hasan, R., and O'Brien, G., (2006). Presentation of depression in autism and Asperger syndrome: A review. Autism; 10: 103 - 116. Volmar, F.R., Klin, A., & Schultz, R.T. (2005). Pervasive developmental disorders. In B.J. Sadock & V.A. Sadock (Eds.), Comprehensive textbook of psychiatry, (8th ed., Vol. II, pp. 3164-3175). Philadelphia: Lippincott Williams and Wilkins. Williams, ML. and Payne, S., (2003). A qualitative study of clinical nurse specialists' views on depression in palliative care patients. Palliative Medicine; 17: 334 - 338. Read More