establishing a therapeutic relationship with the older adult
TRANSCRIPT
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Running head: AS EXPERIENCED: THE OLDER ADULT 1
Establishing a Therapeutic Relationship with the Older Adult: A Touching Experience
Joshua Scholz
Central Maine Medical Center College of Nursing and Health Professions
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Establishing a Therapeutic Relationship with the Older Adult: A Touching Experience
The purpose of this paper is to focus on the task of building a trusting and therapeutic
relationship with a specific age group. In this case we will be examining the techniques, barriers
and facilitating factors of cultivating a rewarding relationship with the older adult population. As
one could well imagine there are many factors that could easily hinder the process of developing,
nurturing and maintaining rapport. The source of the experience happens to be a 77 year old
female who, for the sake of anonymity we will call Audrey Hepburn, or AH from this point on.
As you read on, you will find the experience with AH humorous, touching, reflective and at
times, depressing. The point is that after reading this paper you, as the reader can separate the
emotions and wade through the disparity that at times can be as frightening as being lost at sea,
drifting away aimlessly and identify the techniques needed to keep an interview on course while
navigating through pertinent and non-pertinent data. The destination, or end goal is building a
relationship and most importantly trust.
Erik Erikson, a well-known psychologist described eight developmental stages, each
characterized by challenging developmental crises. Erikson named two extremes, polarized on
the spectrum of development. At each stage however, he recognized a wide range of outcomes
between these opposites. For most people, development at each stage leads to neither extreme,
but something in between (Berger, 2008). Hope and will are derived from the earliest stages
Trust vs. Mistrust and Autonomy vs. Shame and doubt respectively. Throughout the lifespan
we acquire particular ego strengths based on the stage of development mastered. These strengths
include, in order from toddler to elder: purpose, competence, love and wisdom (Erikson, 1968).
Audrey or Mrs. H, along with her family has decided to live out the rest of their years
right where they are next door. She states that she and her husband are content with their lives
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and have been to nursing homes, which they never want to see again. When asked if her
relationship with her spouse is fulfilling the response was What do you mean by that dear?
Rather than ask this elder, the neighbor about her sexual fulfillment with her husband, the
hastened response to her question was Are you two happy? Wisdom the last virtue to acquire
according to Erikson was evident in her quizzical eyes as she said mm-hmm.
Ego Integrity vs. Despair - the last of eight ego virtues states that this stage is a
culmination; a sense of oneself as one is and of feeling fulfilled (Erikson, 1964). The question
whether this is sexual or not is of no concern; however, what is important happens to be the
maintenance of her integrity and therefor her ultimate happiness. The assessment of this older
adults resolution to these well-known stages of development was crucial in determining where
she was in life and thus, the foundation of the experience as a therapeutic relationship was
established. This is that story.
Interview One: Communication/Safety
It was a sunny afternoon the first time I met AH. She was rocking on a bench swing in
her front yard with her husband whom we will call Andrea Detti, or AD. She and he were
basking in the late summer sun, feeding the resident chipmunk leftover nuts no doubt from a
batch of cookies she had previously baked. As I retrieved the mail from my mailbox for the first
time since the move I glanced over to my right and was greeted with a loud hello! Not without
manners, I strode over to introduce myself to the elderly couple next door the neighbors. This
project in mind, I introduced myself and asked if I could visit and get to know her a little better
a quasi-interview I called it. With a hand-shake and a smile the deal was sealed. We would meet
for the first encounter the following Saturday. I turned around and took but one step before AH
exclaimed Wait! and insisted that I take with me, a plate of cookies she had just baked.
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Saturday came quickly in the life of a nursing student. Wondering where the last six days
had gone I was pleased that during that time the neighbor and I had shared several casual
conversations, one of which was how wonderful those cookies were. I knocked on the door for
the meeting we solidified with a hand-shake a week prior. A male voice shouted from atop the
stairs, Come on up! Each of the twenty-seven steps leading up to the living area seemed more
distant than the last, all the while noting that there were slip-resistant pads carefully tacked down
on each stair. With perspiration evident on my brow I gathered my thoughts and overcame the
final step. With sincerity I said, Thank you for allowing me into your home. The response was
touching as the climate of trust was increasing: Thanks for coming over, we dont get many
visitors these days please, have a seat.
Feeling well prepared for this visit after reading the textbooks, paying extra attention to
the sections pertaining to how to effectively communicate with the elderly. After carefully
formulating a list of questions and pseudo-rules to follow I was ready to set the tone for this
experience. The purpose of this visit was explained with care, and I was hyper vigilant of my
gestures, posture, tone and rate of my speech. I purposefully shared with AH how this interaction
was designed to give us, as future nurses, insight in how to effectively build and maintain a
therapeutic relationship and develop interviewing techniques. I asked if it were okay that we
meet a total of three times, each gathering with a different intent behind it and each lasting about
an hour. With a glimmer in her eyes she replied, Of course dear. With that I began gathering
data.
Maintaining eye contact and practicing active-listening I respectfully asked her if it was
okay if I walked around her home and assessed possible safety hazards. With that same shine in
her eyes she replied, You would do that for me? Attentively I responded, Of course. With
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rapport diffusing through the air I sauntered through their small home looking for safety risks.
Knowing that this visits primary objective is to focus on safety and communication I carefully
examined my notes and began my safety inspection. Electrical cords and telephone cords were
placed out of the flow of traffic and all cords appeared to be free of frays. The electrical outlets
were not overburdened with appliances. Knowing the older adult has undergone some normal
physiological changes associated with age such as alterations in vision (presbyopia) and hearing
(presbycusis) along with slowed reaction times, decreased range of motion, slowed reflexes,
nocturia and incontinence, impaired memory, and a high prevalence of chronic conditions
resulting in poly-pharmacy (Lewis, 2011). Understanding these changes allowed me to focus this
assessment tailored to the specific needs of this older adult.
There were no throw-rugs on the ground posing tripping hazards and AH was educated
that if small rugs were to be used slip-resistant material should be adhered to the bottom to
prevent accidental slipping. The hallways albeit narrow, were free of obstructions that could
cause potentially catastrophic injury. AH was asked if she had ever fallen, which she looked
down humbled and muttered Yes, I have fallen which is why I think I am going to die soon.
Feeling my stomach next to my Adams apple I managed to squeak out a comforting and
empathetic response. AH, just because you have fallen doesnt mean you are going to die
please tell me more about these feelings you are having. After several moments of therapeutic
silence our eyes broke contact briefly as she replied, All my friends who have passed
recentlyWell; prior to their passing they all suffered from a fall. Elated that there has been
enough trust built up for her to share these intimate thoughts I carefully listened to her concerns
while formulating my next question, eager to lead her away from this topic.
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I took a deep breath and continued with my safety assessment, asking where her
telephone was. I was delighted to see that this couple owned a cordless phone. This meant that
the accessibility to a communication device in an emergency was increased. I asked AH to
demonstrate what she would do in an emergency, and she replied rather frankly: I would call
911. This simple statement gave me insight into her judgment. I promptly replied, Excellent!
Continuing with my environmental assessment I quickly learned that AH does not sleep in a bed,
but rather on the couch. She stated she does this because her husband, AD snores too loudly and
she has difficulty sleeping as a result. Glancing to her right as she lay on the couch I noticed the
base of the cordless phone. I asked if she was able to reach it without difficulty, which she
replied Im not lame followed by a jovial laugh. Knowing I have much more to cover, I smiled
back at her and asked if I could test her smoke alarms.
There are a total of five smoke alarms in their small upstairs apartment home. There is
one in each of the two bedrooms, one in the hallway, one in the living area and one in the
kitchen. Each were tested and noted to be in fine working condition. I asked AD when he would
change the batteries in the smoke detectors, which he looked at me coyly, and shrugged his
shoulders. I picked up on his embarrassment and minimized it by stating that recently the
Government came out with recommendations to change the batteries in your smoke alarms when
daylight savings takes place. Knowing that this has been a long standing recommendation, my
hope was to reinforce the information without making him feel inadequate. This seemed to work
as his face brightened and he said, Thats a damn good idea, never occurred to me to do it that
way.
The cozy apartment appeared to be quite safe for this couple. There are few interventions
that could be implemented to make the home safer. Of particular concern was that there was but
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one egress. Not that there was much that could be done about that without substantial
construction work and frankly, at this point in their lives that is futile. The one exit is down the
stairs that brought me to this couples home. Although slip resistant, the stairs would pose a
significant problem given the impaired mobility of AH should an emergent situation arise. The
comforting flip-side to this fact is that there are no small stoves, heaters or appliances in this
home and without these items the risk of fire is greatly reduced. The primary source of heat is oil
and there was no woodstoves or fireplaces present. When asked about an emergency exit plan in
the event of a fire or natural disaster AH responded, If it is my time to go the Lord will take me,
if not I suppose I will get down them stairs. Filing the information away that she just provided
about her religiosity I asked she could show me the kitchen and how she stores her food.
The kitchen is neatly kept, without dishes needing tending to. The cupboards are at a
height that facilitates ease of access. The floor was clean and smelled of a recent application of
Mr. Clean scrubbing bubbles. AH willingly opened her cupboards for me and I noted how her
range of motion was fully functional in her upper extremities. For the ADL of accessing food
and dishes, she appears to be without impairment. Food was appropriately and properly stored
and there was no trash lying around for the man of the house to lug down the stairs. Additionally,
the cupboards, both the upper and lower ones did not reveal any evidence of unwanted guests or
vectors of disease. There were towels hanging on the handle of the oven which incidentally is
away from the stove itself posing little risk for ignition. Lighting was adequate and thankfully
neither of these elders is using any kind of step-stool to access out of reach items. Feeling much
like an inspector rather than an interviewer I pilfered through her cupboards noting that there was
not much food. With that information tucked away for later exploration we moved on to the final
room of the house to be assessed.
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The bathroom was a shade of blue I have never seen before. It was not periwinkle nor
was it royal. The color was somewhere in between. The shower was equipped with non-skid
stickers as well as two grab bars. Impressed, I asked if either of them had trouble or had fallen in
the bathroom. AH was quick to respond, There aint nough room to fall in here. I noted that
there were several safety interventions being implemented in this room in particular. There was a
shower chair neatly folded up and tucked away in the corner closest to the shower. With interest
I asked if it were ever an issue to use this chair to which AH replied Oh no, not all in fact I
use this all the time you see, I would much rather sit in the shower than stand; helps with my
knee pain. Pondering what she just said I replied, Pain? I certainly would like to talk more
about that with you. OK she said with a crooked smile. Before we leave the bathroom I
said, Can you get in and out of the shower and use the toilet safely and without assistance?
Again, with years of wisdom and wit behind her she exclaimed If I ever need help getting on
the toilet the last person I want helping me is AD! We both laughed for a moment and she led
me back out to the living area where she laid back down on the couch. Pulling a blanket just
below her chin she asked What else you need to know?
Tell me about the medication you currently take I said. AH encouraged me to retrieve
the basket of medication from her medicine cabinet in the bathroom. Knowing exactly where this
was as we were just in that room I was happy to do so. The basket contained an array of
medication bottles haphazardly placed inside. The more I looked into this system of storage the
more I was shocked AH, I said, How do you know which ones to take and when? She
glanced my way and replied, Dunno, I guess I just know which ones to take and when. Seeing
this as a prime opportunity to provide some impromptu education I separated her and ADs
medication. While teaching where to look for expiration dates on various bottles we came across
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some very old antilipidemic medication. I encouraged them to take these and any other expired
medication to the local pharmacy for proper disposal. I also highly encouraged them both to read
the bottles and take the medications as directed. This was in response to the answer AH gave me
when she was asked if she took her medication as prescribed. She was quick to confess to me
that at times she doesnt take her diabetes medication because she feels fine. This was also true
of her antihypertensive medication, for the same reason. Lastly I pleaded with them both to
acquire pill boxes that contain the days of the week on the top. It is too easy to miss a dose
when there are multiple medications to take, I said. Knowing that polypharmacy is a serious
problem with the elder population (Lewis, 2011). Not only is it imperative to take medication as
ordered it is equally important to separate medications to avoid erroneous consumption of
potentially harmful substances, (Lewis, 2011).
Feeling inspired for being able to teach something on my first visit I asked if we could
meet again in the coming weeks. AH excitedly answered Of course! We set up another
experience two weeks from this date. I explained that I would be assessing health history and
nutrition. I gave AH a log to fill out regarding her diet, asking for her to keep track of her oral
intake for two days. I explained that we will be discussing the information she enters upon our
next meeting. With a confident agreement between us I stated that upon my departure I would be
looking at the exterior of the home noting safety hazards, if any. Feeling that this first interview
went fantastic, I thanked them both for allowing me into their home and their lives. I am quite
certain I forgot to ask a question or two but overall I was pleased with the information I gathered.
Most importantly, I was elated that through preparation and research I was able to establish a
relationship with this couple. It was heartwarming to know that as I left both they and I would be
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looking forward to the next visit. Knowing that the seed of trust has been sowed, I couldnt wait
to cultivate, nurture and harvest the fruits of my labor.
Interview two: Health history and Nutrition Screening
Preparing for this interview was easier than the last. There were a few things I wanted to
make sure I included this time such as applying the techniques of S.O.L.E.R (Potter & Perry,
2009) This acronym includes a specific formulated approach to active listening and is as follows:
S sit facing the patient to give the message that the interviewer is listening and interested in
what she has to say; O observe an open posture to suggest an open attitude; L lean toward the
patient to get involved in the interaction; E establish and maintain intermittent eye contact to
convey active listening and that the interviewer is listening; R relax and be comfortable to
convey interest and a sense of ease with the surroundings. And, perhaps most importantly, I need
to remember to speak to A.H. not like a child, but in a clear and concise manner, using
appropriate words while eliminating medical jargon (Potter & Perry 2009).
With these principles in mind I set out for the long yet, short distance walk to my
neighbors house. Again I knocked on the door, and like before I heard from a superior distance,
a males voice yell, Come on up! I advanced up the twenty-seven stairs with a certain
confidence that was lacking the last time I encountered this ascent. I had carefully reviewed
nutrition information to include what type of caloric intake AH may need as well as given her
history of hypertension what types of foods to avoid. As I stepped passed the twenty-seventh step
I saw a familiar scene, AH laying on the couch with AD sitting just to the right of her in a Lazy-
Boy recliner. I know that I must assess AHs self-esteem/self-concept along with the bio-
psycho-social aspects of her life. First however, I wanted to discuss the nutritional component as
I caught a glimpse of the dietary log I had left two-weeks prior completely filled out. After
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receiving a very warm welcome from this couple and seeing the homework I had left for her
completed, I was certain that a trusting and therapeutic relationship has been established.
Knowing that AH is female, with a present weight of 71.8 kg and height of 167.6 cm it
was easy to calculate her body mass index, or BMI using the USDAs website
www.dietaryguidlines.gov. This resource states that given her height and weight AHs BMI is
25.5 which is overweight by these standards. Sharing this information with AH she was in
disbelief as she reported that prior to her fall she weighed 106.8 kg. Knowing this is a significant
weight loss, I wanted to explore her nutritional situation a bit further. I asked AH why she felt
she has lost so much weight in the past 180 days. She stated that it was simply due to a loss of
appetite. Before we got into her diet recall log it was important to identify factors, if any that
would contribute to her poor appetite.
She reported that she is not allergic to any foods, and that her only allergies were to
morphine sulfate. Ruling out allergies as a possible source of weight loss we discussed her
dentition. AH reported that she does in fact wear dentures, both upper and lower. She stated that
her dentures have a poor fit and that the adhesive junk makes her sick. I asked when she last
had a dental exam and she reported about 5 years ago was the last time she saw a dentist. I
reiterated what she already knew and informed her that it is recommended to see the dentist on a
regular basis, at least every six months if there are no acute problems (Lutz, 2011). We explored
whether or not there was any problems with chewing or swallowing, which there was none.
Medications were reviewed as often times polypharmacy can contribute to problems such as
poor appetite, anorexia and in some cases, malnutrition (Lewis, 2011). There were no
medications that she currently takes that would indicate a significant loss of weight or poor
appetite as a side effect (Deglin, 2011).
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AH also denied any current health problems that affect her diet. She did state that she is
supposed to be following a diabetic diet as well as a low sodium diet which a tribute to her
honesty she confessed she does not follow, and has not for many years. She described her
appetite as poor and her food preference as pretty much anything. AH described her physical
activity as little-to-none as she has limited mobility since the fall and pain prevents her from
walking even a short distance. She reported her alcohol use as none as well as no tobacco use.
Although she did admit to smoking in the past as an adolescent; pack year history does not apply
in this case. AH reported that she prepares all meals for her and AD and while he has a good
appetite and can easily eat three meals-a-day she only consumes at best, two per day. She stated
that she drinks one Ensure per day at noon and takes iron supplements twice-a-day. Before we
investigated her dietary recall I asked if she routinely used laxatives, which she denied.
AH painstakingly reached with her right hand to the coffee table on her left side. She
whimpered ever so slightly as she retrieved the dietary recall log I so eagerly wanted to dissect.
After handing me the log it was clear that she does, without a doubt have a very poor appetite.
Her recall of meals for two consecutive days included:
y Day one:Breakfast: An 8 ounce glass of orange juice, half of a banana and a piece of wheat
toast spread with butter.
Lunch: 8 ounces of Ensure
Dinner: Macaroni and cheese with diced ham and 8 ounces of tea
y Day two:Breakfast: An 8 ounce glass of orange juice, half a banana and a bowl of cereal.
Lunch: 8 ounces of Ensure
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Dinner: Beans and Franks and tea
It would appear that we have found the culprit behind her weight loss. I encouraged her to speak
to her physician regarding this development and to bring the log she created for me in with her to
aid in determining the whole picture and hopefully refer her to a dietician or prescribe an appetite
stimulant. I explained to her that although she is considered to be overweight as indicated by her
BMI results, proper nutrition in essential in healing the bodys injuries and assists in maintaining
overall well-being (Lutz, 2011). I changed gears and went on to discuss her health history with
her.
Audrey Hepburn was born September eighteenth nineteen thirty four in Lisbon Falls,
Maine. She is 77 and of Caucasian race and Maine culture to the core. She has an occupational
history that includes working at various local mills, a cook at a local nursing home and running a
daycare out of her home for ten years. Her marital status is reminiscent of Facebooks its
complicated. When asked to elaborate she simply stated that she and AD have lived together
many years and shared many memories however, marriage was not one of them. Once this
historical and demographical information was obtained we quickly moved on to sensory
perception, overall past health and review of her medications.
AH wears glasses for reading only. She states that she has adequate vision otherwise and
I would have to agree. She lives over 100 yards away and can spot what we are doing through
the open windows with ease, making some situations more awkward than others. AH is awaiting
a vision check and reports having cataracts in both eyes. She maintains that she has no loss of
hearing, although asks to have sentences repeated to her throughout the interview. She does not
wear hearing aids and denies frequent prolonged exposure to excessive environmental noise
Lawnmowers is all Ive ever been exposed to. When asked about her method of cleaning her
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ears she reported she achieves this activity of daily living by using a Q-tip after showering.
Again, seeing an educational opportunity I pointed out that currently the accepted guidelines are
to put nothing bigger than your elbow in your ear as the risk of damaging the eardrum is greatly
increased. This task can be completed effectively by using a wash-cloth soaked in warm water.
Excessive cerumen build-up should be treated by health-care practitioners (Lewis, 2011).
Gathering that her sensory perception is grossly intact I pursued obtaining information regarding
her overall past health.
AH reported that generally, she would describe her overall health as good. She stated
that she succumbed to normal childhood illnesses of her time. This included mononucleosis at
age eight, measles, varicella and two bouts of whooping cough. Recently she suffered from a fall
at home which left her with an injury to her left knee. At this time she has not sought medical
treatment for this condition. Chronic illnesses include diabetes mellitus type II. She stated that
she recently received the pneumovax vaccine and has not received the flu shot for this season at
this time however, she does plan to get it once its available. Using the pneumonic G.T.P.A.L. I
queried her obstetrical history (Lewis, 2011). She has a total gravida of seven; seven of which
were brought to term; no pre-term deliveries; no abortions; and three children are currently
living. I could tell this was a sensitive subject for AH and decided to continue rather than inquire
further into the circumstances of the four children who are no longer living. There was no
therapeutic gain by obtaining this information.
AH recounted at least five hospitalizations, most recently was a total knee replacement to
her right knee. She rehabilitated at a local nursing home without complications. Further into her
surgical history she revealed that she had her gallbladder removed, inguinal hernia repair,
appendectomy, and caesarian-section. I probed into her medications once more, this time in
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greater detail. I asked if she had gotten a pill box that would allow her to keep her and ADs
medication separate and aid in compliance. Much to my surprise she stated she had! We
reviewed her current medications (still in that same basket) and I asked her if she could tell me in
her own words what each was for. I was impressed with her responses which are as follows:
y Omeprazole 20mg po every day in the morning, This is my stomach acid pill.y Paxil: 12.5mg po every morning, For my mood with a chuckle she went on to
say, My happy pill.
y Amlodipine Besylate (Norvasc) 2.5mg po bid My blood pressure medication.y Cozaar (Losartan) 50mg po every day More blood pressure pills.y Metformin (Glucophage) 500mg po every day For my diabetesy Ferrous sulfate (Iron) 325mg po every day I dont know a vitamin I guess
As I carefully returned her medications one-by-one into the basket from which they originated
from, she asked me in a very shy manner, So howd I do? With a smile reminiscent of a
proud parent at a Shakespearean play I replied Just fine, Audrey. Just fine.
Providing reassurance and positive reinforcement I was sure that my intent to build a
therapeutic relationship was right on course; no compass or lighthouse needed to navigate to the
goal of building trust. I asked AH if she could tell me about her family health history, primarily
first degree relatives such as father, mother, brothers and sisters. She told me that her father had
cancer of the lymph system and ultimately passed away as a result. Additionally, AH reported
that her mother suffered from diabetes mellitus type I and also passed away as a result of
complications from that disease. I was preparing to terminate this visit, but before this
therapeutic end is to take place I needed to conduct a functional assessment based on her which
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activities of daily living (ADLs) she can do independently and how her mood, affect and self-
esteem affect the aspects of her daily life.
AH seemed eager to tell me more about her life. I used this to my advantage to collect
further data. She told me that her self-esteem had never been an issue and that she generally felt
pretty good about herself and what she has accomplished in life. I asked about her
activity/exercise on a daily basis - which she reported that she simply does household chores and
that is more than enough activity for her. AH indicated that she does not require any assistance
with any of her ADLs and that she prefers to do the majority of the cooking. She stated that her
leisure activities include making photo plates and crocheting pillows. I inquired about her value
belief system to which she replied with pride, I am Christian and attend the Church of the
Nazarene every Sunday without fail. I believe that the Lord Jesus Christ is in charge of my life
and I gladly give it to Him. After hearing how strong her conviction to her faith was I was
certain that she is maintaining her ego integrity.
Using the acronym S.I.G.E.C.A.P.S (Spitzer, 1994) I was able to assess her S: sleep
which she stated she sleeps five to seven hours on average a night of restful, rejuvenating sleep;
I: no change in her interests of lack of (anhedonia); G: she denies excessive guilt or guilty
feelings; E: she reports having an adequate amount of energy with no significant loss of vitality
or motivation; C: she denies loss of concentration and states that if she desired, she could in fact
sit down and read a book or magazine without distraction; A: she did report a change in her
appetite, as a loss and recent significant weight change; P: Objectively I did not note any
psychomotor agitation or retardation and she subjectively denied she or others noticing these
symptoms as well; and lastly S: she denied any recent thoughts or desires to commit suicide.
This gave me an accurate albeit broad analysis as to whether or not she is suffering from
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depressive symptoms. One could reasonably assume that her mood is adequately controlled with
Paxil, or as she so eloquently stated, her happy pill.
Lastly, for this visit I wanted to know what her definition of health was. The best way to
assess this is simply to ask her (Wilkinson, 2011). AH defined health rather abstractly as Look
at people and think, boy youre lucky not to be in a nursing home. This bleak and frank
definition allowed by to ascertain that she is deeply afraid of not being able to care for herself
and that she fears placement into a nursing home. To further understand her own health I asked
what she fears most when it comes to health and her reply was humbling: Cancer. I am afraid to
die of cancer. I asked her to elaborate by explaining her current view of her own health. She
remained silent for an uncomfortable amount of time. Understanding that silence can be very
therapeutic in its own rite I allowed this absence of words to continue for as long as she needed
(Wilkinson, 2011). After what seemed like an eternity she made eye contact with me and
answered what would be my last question for this visit. She swallowed once in almost a
theatrical manner and said, I could be better, but I could be a lot worse too. As long as I keep
the few remaining friends I have left, I suppose Ill be ok. We all know that our time is coming
I just dont know that I can watch those who I love keep dying all around me. I love my family. I
love my friends. That said, I concluded this visit.
Thanking her for reminiscing about her past with me, I confirmed that we would meet
once more. I informed her that this would be the last visit for this project however; I would be
available to visit again without so many questions. Perhaps I could bring my daughter by. She
looked at me with lit-up eyes and said, I would love that. We made arrangements to meet in
one months time. A Sunday afternoon I shook hands with AD and attempted to politely grasp
AHs hand which she ignored completely and gave me a hug.
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I exited the door by way of the twenty-seven steps I had originally dreaded climbing. I
left with a feeling of happiness and a great feeling of humility. I not only accomplished what was
planned, I seem to have forged a relationship with AH that was fulfilling for her. I was delighted
that she could trust me with some of her most intimate facets of her life and share with me those
fears that haunt her the most. I knew that there was much preparation needed in order to teach
her something she could hold on to and recognize as beneficial to her life. With this as my final
thought as I let the door close behind me I walked home and began preparing for the final visit.
Interview three: Teaching
I prepared for the third and final interview almost immediately after the second. First and
foremost I needed to review the data I collected from the two previous visits. Sifting through the
immense amount of knowledge gained from those prior two visits was no easy feat. I recalled
that AH was diabetic, iron deficient as evidenced by her prescription for ferrous sulfate and
hypertensive again, evidenced by her prescription for two different hypertension medications. I
decided to approach her from several fronts based on her knowledge -or lack of - as well as her
nutritional imbalance and fear of nursing homes and cancer. Initially, I want to educate her on
why iron supplementation is important. She demonstrated a knowledge deficit by indicating she
was not sure why she was taking this medication, only that it was a vitamin. Second, I saw a
need to promote proper nutrition. This decision is based on her diagnosis of chronic diabetes, her
recent weight loss along with her history and risk factors for hypertension. I also found it
necessary to address her anemic 24 hour diet recall log. Lastly, I was able to obtain information
regarding home services and how to acquire said services in Maine. With research complete, and
direction determined I gathered the pamphlets you will find in the appendices. I set out on my
third and final journey to the neighbors house; my older adult experience near and end.
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I assessed factors that may be a barrier to learning by asking her if she could read the
handouts I provided to her. She attested that she could so I asked her to repeat the information
back to me in her own words. She did comprehend the information as she accurately recited in
her own words the importance of iron and how it carries oxygen and a lack of this mineral can
manifest as fatigue and shortness of breath. Grateful, she stated So its much more than a simple
vitamin isnt it. This was one of the outcome goals I had hoped for. I had planned that by the
end of this visit she could accurately recite the need for iron in her diet and verbalize risk factors
such as excess sodium in her diet could increase the risk of high blood pressure. With one goal
being met we were well on our way for a rewarding learning experience.
It is important to note that AHs willingness to learn greatly increased the likeliness of
retaining the information presented. I was fortunate to have a participant so eager to engage in
the learning process. Next, we explored the importance of nutrition. I provided her with several
handouts that can be found as appendices of this paper. She wasnt as understanding regarding
this concept and after having her tell me what she knew about nutrition it was evident that there
was a knowledge deficit present in this area as well. AH stated that throughout her entire life she
had learned that with diabetes the less you eat the lower your glucose levels will be. Seeing this
as a prime opportunity I engaged her and through evidence based literature I was able to
introduce the idea that its not the amount of food consumed, but the type. This will likely take
quite a while to take hold if ever. My goal was to introduce the notion that a well-balanced diet
will promote well-being, facilitate healing and keep glucose levels and blood pressure under
control.
Lastly, I encouraged her to look into the information I provided to her regarding home
care services and where to find it and how to obtain it. I was able to introduce to her just one of
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the various alternatives of nursing homes and provide a resource printed by the Department of
Health and Human Services regarding home care services which is found in the appendices. She
was elated to know there was an alternative. I knew I wouldnt be able to quell her fears entirely,
I only wished to provide maintenance of hope one of the first ego virtues we acquire and
quite often the first we tend to abandon.
Conclusion
Throughout this paper the focus has been on the task of building a trusting and
therapeutic relationship with a specific age group. In this case specifically we examined the
techniques, barriers and facilitating factors that aided in cultivating a rewarding relationship with
the older adult population. Beginning with the very first encounter, rapport was established. With
every subsequent visit the developed rapport was built upon this is the foundation of every
encounter demonstrating clear understanding of the working phase of communication. With
rapport came trust and with trust came confidence and with those factors combined the
relationship developed was a meaningful one for all parties involved.
The most difficult phase of this entire process was the termination phase. Once a
purposeful and reciprocal dialogue was established the experience became meaningful to the
older adult and for me as well. It became evident during the last visit that the subject of this
paper valued the opinion and information presented by this writer. She was genuinely interested
in the educational material provided and verbalized that she would employ some of the
techniques presented to her regarding her diet, specifically related to her diabetes and
hypertension. She also verbalized that she understood how her diet can impact her overall health.
Knowing that we live in close proximity to one another was no doubt comforting, as she had
stated this. It was important to me to establish clear boundaries and enforce them on a regular
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basis. Since the last visit, there have been a handful of encounters with AH, all of which were
strictly friendly in nature indicating to me that the boundaries set forth in the termination phase
were not only heard but understood as well.
The health and nutritional needs of the older adult are complex, dynamic, and ever
changing and cannot be discounted. This experience has showed me that the elder population has
hopes, fears and dreams like their younger counterparts. We must not assume that because
someone has lived a long fruitful life or that because an elder may be wrinkled and frail that they
are now less important and need to be garaged like an old 1957 Chevrolet.
As one could well imagine this experience has benefited me in many facets of my life.
Personally it helped me establish a working relationship with someone who has been the focus of
a project which required the sharing of intimate details of ones life. Knowing that by simply
asking and employing therapeutic communication techniques a person will likely see the
interviewer as a competent, empathetic and caring professional. The older adult experience has
additionally benefited me with the knowledge that with rapport, trust and empathy accurate
information regarding ones lifestyle and needs can be assessed. I can honorably say:
Establishing a therapeutic relationship with the older adult has been a touching experience.
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AppendixA
Nursing Diagnoses:y Knowledge Deficit r/t lack of understanding re: prescribed medications, purpose
and proper administration m/b patients statements of lack of understanding how
medication can benefit current health status.
y Imbalanced Nutrition: less than body requirements r/t deficient knowledge re:appropriate caloric needs for age and activity level, how consumption of a
balanced diet can assist in controlling blood glucose levels and foods to avoid in
order to decrease hypertension m/b anorexia, significant weight loss in past 180
days and statements made by subject confirming deficient knowledge.
y Fear r/t change in health status, perceived threat of death d/t recent death ofseveral close friends m/b statements indicating that irrational fear exists regarding
placement in nursing home and that death is likely to follow a fall which took
place within 180 days.
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Appendix B
Client Teaching
Introduction/Thesis: The techniques and materials used to teach the client about medication, diet
and available services regarding home care services and how to obtain them.
I. Technique
A. Assess level of prior knowledge by asking what she knows about her medication, diet, and
available services for home care and how to obtain them.
B. Determine motivation and readiness to learn by asking for verbalization of understanding
of presented material in own words.
C. Address each of the topics individually, in a simple fashion letting the client control what
information needs to be provided based on previous knowledge.
D. Maintain a respectful warm attitude during teaching.
E. Provide handouts that further explain in detail the information presented ensuring they are
at a reading level she can understand. This facilitates learning using different modalities and
engages client in the learning process. Also aides in determining reading level by asking her to
read back some information in the handouts given.
F. Determine comprehension by asking for specific examples of how she can apply the
knowledge during teaching.
G. Clarify any question client may have after teaching has occurred.
II. Reading Materials
A. Medical Surgical Nursing by Sharon L. Lewis
1. Hypertension
2. Iron deficiency anemia
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B. Under nutrition in Older Adults Across the Continuum of Care: Nutritional Assessment,
Barriers, and Interventions. Journalof GerontologicalNursingII.
C. Davis Drug Guide for Nurses
D. Verbal teaching from research
E. Handling hypertension with methods other than medication
1. Diet
2. Exercise
3. Stress
F. Coping with fear and anxiety
1. Knowing support systems
2. Researching options to treat
3. Sharing concerns with Physician
G. Social life, after the death of loved ones
1. Talking to friends and family
2. Including plenty of other people in daily activities
3. Having therapy sessions if necessary
Conclusion/Closing: These were the learning aids and techniques used for the teaching session.
See attached handouts for source of information presented to client.
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References
Berger, K. S. (2008). The Developing Person Through the Life-Span.New York, New York
Worth Publishers.
ChooseMyPlate: Steps to a healthier you. (September 30, 2011). Retrieved November, 20 2011,
from United States Department of Agriculture website: www.choosemyplate.gov
Deglin, J.H., Vallerand A.H., & Sanoski, C. A. (Eds.). (2011).Daviss Drug Guide for Nurses
(12th ed.). Philadelphia: F.A. Davis.
Furman, E.F. (2006) Undernutrition in Older Adults Across the Continuum of Care: Nutritional
Ass
ess
ment, Barrier
s,and Intervention
s. Journal of Gerontological Nursing, 32(1), 22-28
Grymonpre, R., Cheang, M., Fraser, M., Metge, C., & Sitar, D. (2006, May). Validity ofa
Prescription Claims Database to Estimate Medication Adherence in Older Persons.
American Journal of Nursing, 44(5), 471-477.
Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., OBrien, P. G., & Bucher, L. (2011).
MedicalSurgicalNursing: Assessmentand Management of ClinicalProblems
(8th ed., Vol. 2, pp. 1561-1575). St. Louis, MO: Mosby.
Lutz, Carol A. (2011). Nutrition and DietTherapy ( 5th
ed.) Philadelphia: F.A. Davis.
Potter, P.A., & Perry, A.G. (2009). Sensory Alterations. In A. Hall & P.A Stockhert (Eds.),
Fundamentals of Nursing(7th
ed., p. 1346). St. Louis, Missouri: Mosby Elsevier
Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3d, Hahn SR, et al. Utility ofa
New Procedure for Diagnosing MentalDisorders in Primary Care. The PRIME-MD
1000 study. JAMA. 1994;272:174956.
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United States Department of Agriculture Center for Nutrition Policy and Promotion. (October
21, 2011). Dietary Guidelines for Americans, 2010.
www.cnpp.usda.gov/dietaryguidelines.
Wilkinson, J. M., & Treas, L. S. (2011).Fundamentals of Nursing(2nd ed., Vol. 1).
Philadelphia, PA: F.A. Davis Company.
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NAME: Joshua J Scholz Date: 11.28.11
An A paper is a pleasure to read. Please attach this form to your paper.
Weight Information and Content Comments Grade
15 Paper is well organized
y introduction, discussion, conclusion
15 Thesis (focus) of the paper is clearly presented
30
Demonstrates intellectual depth &
Integrates concepts from pertinent, supportive,
complementary courses
y with citations to support
20 Information literacy
y demonstrate competency by accessingapplicable scholarly and non-scholarly
information from various sourcesy use of appropriate citationsy current research articles (within past 5
years)
Information and Content total points achieved
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AS EXPERIENCED: THE OLDER ADULT 28
Weight Writing Mechanics Comments
8 Follows APA Format for title page, in-text citations
and reference page
5 Correct Spelling
5 Grammatically correct
y language, punctuation, sentence structure
2 Paragraphs reasonable length and flow from one
to another smoothly
Writing Mechanics total points achieved
Points achieved in Content and Writing Mechanics Final Grade