The psychological approach focuses on the factors affecting individuals that produce abnormal thoughts, feelings and behaviours and then provide therapies to try and reduce the stress caused by these. Whereas the sociological approach concentrates on factors external to the person, viewing the mental illness as an inability to cope when faced with overwhelming environmental stress. (A handbook for the study of Mental Health, 1999) This model fits well with current thinking on tacking social exclusion in areas such as education, housing and access to services, which is an issue high on the Government’s present agenda.
When looking at the work of Szasz (1984) he believed that mental illness was not a disease because it lacked a physical alternation in body tissue, but it was therefore a wilful behaviour that was socially deviant. I disagree with Szasz’s opinion as I feel there is an overlap with all ailments, whether physical or mental, for example if someone has suffered a stroke they can have emotional difficulties as well as physical limitations. This also applies to someone who has an illness that is classified as a mental illness such as Anorexia, although described as an irrational dread of becoming fat coupled with a relentless pursuit of thinness, it effects the body in physical ways such as fatigue and dramatic weight loss, over time, anorexia can cause hair loss, infertility, stunted growth, osteoporosis, heart problems, kidney failure, and eventually death. Therefore I think each of the three approaches have a place in the diagnosis and treatment of all mental health illness and should also be taken into consideration when someone is diagnosed with an illness.
Case Study
My current placement is in the Cardiac Unit, this is a 29 bed cardiology/acute unit incorporating male and female monitored and non-monitored areas. Patients who experience heart related problems are generally nursed on this unit.
The case study I have chosen is a 83 year old lady (Mrs White) who was admitted on the 23rd October 2010, via A&E, with pedal oedema and chest pain, she also had a troponin level of 0.13, which diagnostic criterion for myocardial infarction. Mrs White had been complaining of epigastic tightness from the previous morning, later that afternoon she and her husband noticed sudden pedal oedema.
Mrs White normally lives independently with her husband and copes with everyday living as well as mobilising independently, but does have a medical history of type 2 diabetes, hypertension and hypercholesterolaemia. On admission her observations were blood pressure of 150/80, pulse 95, temperature 36.6, respiration rate 22 and oxygen saturation on 4 litres via nasal specs of 97%, her ECG showed that she was tachycardia and in atrial fibrillation. Mrs White also presented very confused and her family reported that this had started about four weeks ago along with slurred speech and limb weakness.
On admission Mrs White was commenced on intravenous frusomide and sliding scale insulin, she was referred for an Echo and for review by the diabetes nurses, her U&E were monitored everyday because of being prescribed frusomide. Unfortunately on the 31st October 2010 Mrs White had a fall in the bathroom, whilst on the unit, resulting in a swollen left knee, she was unable to weight bear and a displaced patella was queried. Following an x-ray this was ruled out but Mrs White was referred to the Stoke team due to increased confusion and slurred speech. She underwent a CT scan of her head on the 2nd November 2010, this concluded small vessel disease.
Small vessel disease or vascular dementia is the second most common cause of dementia; it usually results from a series of strokes within the brain. Sometimes these are so tiny that no one is aware of any changes but all together they can destroy enough of the brain tissue to affect the person’s memory and other intellectual functions. Vascular dementia is also known as ‘hardening of the arteries’. There are a number of conditions that can cause or increase damage to the vascular system. These include hypertension, heart problems, high cholesterol and diabetes. People with dementia may also have other illnesses. (The 36 hour day, 2006) This is certainly the case for Mrs White who has other medical conditions the can cause or increase the damage to the vascular system. Dementia can also make the affected person vulnerable to other health problems.
The symptoms of dementia tend to appear gradually and Mrs White is displaying the common symptoms of vascular dementia which includes periods of acute confusion and physical weakness.
Further into her stay on the unit Mrs White became disoriented , sometimes she would refuse to go to bed until her husband joined her, she would have loud, long conversations with ‘people’ who were not there. As time progressed Mrs White became more agitated, aggressive and her speech was unclear at times.
During her stay on Dedham Ward Mrs White underwent a complete medical and neurological examination. This included a detailed history, which was taken from Mrs White’s husband and other family members, about how she had changed, what symptoms she had had and the order in which they had developed, as well as information about her other medical conditions. She underwent a detailed physical and neurological examination to reveal any changes in the functioning of the nerve cells of the brain or spine. The doctor also performed a mental status examination. This is an important diagnostic tool used to obtain information to make an accurate diagnosis and involves a direct observation of the individual’s current state of mind. It assesses the range, quality, and depth of perception, thought processes, feelings, and psychomotor actions. ( Behavioural Health, 2003) All these tests supported the diagnosis of vascular dementia and the doctors decided that Mrs White was to be transferred to a bed on one of the care of the elderly wards, this happened on 25th November 2010.
During Mrs White’s month long stay on Dedham Ward we as nursing staff where faced with a number of challenges. To begin with Mrs White was mobile but after her fall she became bedbound and required all care. Although at times she displayed some aggressive and challenging behaviour which caused a lot of frustration for the whole team, it was important that Mrs White was seen as an individual, we remained sympathetic and patient at all times remembering that she was not being deliberately difficult, lazy or demanding, it was highly possible that she was frustrated as her world was changing and becoming increasing confusing.
Dementia is a disorder that affects the person’s ability to communicate therefore it is important when nursing a person who has dementia, to be able to understand how the disorder affects the person’s communication abilities and adapt our ways accordingly. Kitwood (1997) identified the ‘person-centred concept’ in which he identifies dementia as a disability; he also argues that viewing people with dementia in medical terms leads them to be seen as objects and as having no subjectivity or personhood. Therefore Kitwood’s approach may also be known as ‘person-centred care’, but it merely highlights the need for individualised care and the importance of the person with dementia rather than the disease process itself. As a nurse I achieved this by maintaining eye contact when speaking to Mrs White, using short, simple sentences and giving her plenty of opportunity to process the information. Mrs White would not always remember what had been done for her, for example her husband would visit everyday but she would often say ‘all I want is for my husband to care enough to visit’.
Body language like facial expressions can also tell us a lot about how a person is feeling as well as their tone of voice. Angry gestures or unwillingness to do something maybe their way of communicating likewise a smile when something pleases them, (Bupa, 2009) Mrs White would often smile when I took the time to comb her hair and tell her how lovely she looked or a simple hold of her hand to provide reassurance where appropriate.
As an individual’s world becomes more confused, the person can begin to mix up reality and fantasy. (The 36 hr day, 2006) Mrs White would often tell me she had to get up to take the children to school, this is something that is obviously untrue but rather than arguing with her I would try to enter her world and imagine what she was thinking. I did this by asking her things like ‘Did you walk the children to school?’ therefore this doesn’t directly contradict them.
Although older people often have a reduced appetite, weight loss is not inevitable and evidently not eating and drinking enough can worsen the symptoms of dementia and then in turn affect their general health. (, 2009) Mrs White was particularly difficult at mealtimes so encouraging her to eat and drink regularly, little and often was important. Providing her with a red lid on her water jug and a red tray at mealtimes made other staff aware that she required assistance. It was important to make sure that her meal tray was not just dumped on her table and left, I would spend time talking to her about the approaching mealtime and when it did arrive allowing Mrs White plenty of time to eat, if her family were available I would encourage them to take an active part and it wasn’t important how she eat her food, just as long as she eat it.
Personal care is important to everyone but the level of care can vary from one person to another. Personal hygiene is important for maintaining good health as well as affecting how we feel about ourselves and how others react to us. Washing, dressing and other aspects of personal care involve skills which a person with dementia can find increasingly more difficult as the condition progresses. (Alzheimer Scotland, 2000) As Mrs White was bedbound and required complete care, this was done on a daily basis but it was still important to allow her to try and do things for herself, I would involve her in decisions by offering her simple choices, for example pink or blue nightdress, whilst always maintaining the maximum degree of privacy and dignity.
Many elderly patients with dementia exhibit signs of aggression. Aggression is more noticeable in hospitalised patients than those who are taken care of at home. Aggression can be verbal or physical. However, you have to understand that a person suffering from dementia gets frustrated and one of ways to let out this frustration is through anger, physical aggression is quite rare, the person will usually be verbally aggressive. (Baby Boomer Care, 2007) It is helpful to try and work out what is causing the behaviour as it is unlikely to be the disease that is causing the person to be difficult, it is important to try to think about what they might be thinking or experiencing. When a person with dementia is being aggressive try not to react and give them plenty of space as they can rarely remember what they have done. (, 2009) Mrs White was regularly aggressive, mainly verbally but on occasions physically, as a human being it is very difficult not to react or be hurt emotional by this type of aggression. She usually had aggressive outbursts when we were tending to her personal needs and usually when the task involved moving her in some way. I believe Mrs White displayed these aggressive outbursts because moving her caused her pain and I would spend time before, during and afterwards reassuring her, sometimes it would help but sometimes I would still get my hair pulled or my arm pinched.
Conclusion
Mental health is something that affects every member of the population, young and old alike, yet mental illness is often misunderstood. Mental illness is thought of as diseases that are ‘just in the head’. If this is true then surely the Government would not have made mental health an important part of their policy to raise awareness and attempt to change attitudes towards mental health.
Although research has shown that healthy living, which is a combination of many things, including good nutrition, regular exercise and a positive attitude, taking care of your body and feeling pride in your accomplishments can improve both your physical and mental health. Research also suggests that an individual’s biological, psychological and social elements can play an important part in their mental health. These are important approaches that need to be taken into consideration when a person displays symptoms of a mental illness, for example an adolescent who is experiencing mental health difficulties maybe struggling with a social situation perhaps within their family or at school.
Growing old is a natural process that produces a range of reactions in different people. The most common mental health problems in older people are depression and dementia. But there is a widespread belief that these problems are a natural part of the ageing process, this is not the case as only 20% of people over 85, and 5% over 65, have dementia and 10-15% of people over 65 have depression. It is important to remember that the majority of older people remain in good mental health. (Steward & Golding, 2009) Unfortunately Mrs White falls into that 5% and her diagnosis of dementia was emotionally difficult for her family involved especially her husband. People with dementia find it more difficult than others to communicate their needs and wishes, and they are the most vulnerable to inappropriate care, therefore it is important to be a skilled nurse who can combine the best of their nursing knowledge with tender loving care.
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