Introduction
The delivery of holistic care in nursing is a fundamental principle that acknowledges the interconnectedness of physical, psychological, social, and emotional needs in patient wellbeing. This essay focuses on the case of Lilian Moore, a 77-year-old woman who has recently experienced an ischaemic stroke affecting her left side, resulting in moderate hemiparesis, expressive aphasia, and anxiety. Her complex medical history includes atrial fibrillation and chronic kidney disease (Stage 3), while her social circumstances—living alone in a second-floor flat with intermittent family support—add further layers of challenge to her care and impending discharge. The purpose of this essay is to critically evaluate the interventions, frameworks, and risks associated with Lilian’s care, while considering the broader social determinants of health that impact her situation. By doing so, this analysis aims to inform effective discharge planning and highlight the importance of a person-centered approach in nursing practice.
Lilian’s presentation raises several holistic complexities. Physically, her hemiparesis and limited mobility necessitate ongoing support with transfers and personal care, while her expressive aphasia complicates communication and her ability to articulate needs. Psychologically, her anxiety and reported low mood suggest emotional distress, potentially exacerbated by her recent stroke and reduced independence. Socially, her living arrangements and reliance on her grandson for financial management—without a formal Power of Attorney—introduce safeguarding concerns and highlight potential vulnerabilities. Additionally, her medical regimen, which includes Apixaban, Ramipril, and Simvastatin, underscores the need for robust medication management post-discharge. This essay will explore these issues through a critical lens, drawing on relevant nursing frameworks and evidence-based interventions to address both immediate care needs and long-term risks. By examining these elements, it seeks to contribute to an understanding of how nurses can navigate complex cases to ensure safe, dignified, and effective care. The analysis will focus on interdisciplinary collaboration, risk assessment, and the application of social determinants of health in shaping Lilian’s outcomes.
Analysis of Care
Interventions for Physical and Communication Needs
Lilian’s moderate hemiparesis and limited mobility are immediate priorities in her care plan. Evidence suggests that early rehabilitation following a stroke significantly improves functional outcomes (National Institute for Health and Care Excellence [NICE], 2013). Interventions such as physiotherapy to address her hemiparesis and occupational therapy to adapt her environment are critical. For instance, the use of a standing hoist for transfers, as currently implemented, ensures safety but also highlights the need for equipment provision or adaptations in her home post-discharge. However, her second-floor flat poses a significant barrier to accessibility, potentially delaying or complicating a safe return home. Nurses must collaborate with social services and occupational therapists to explore options such as rehousing or installing aids like stairlifts, though funding and logistical constraints often limit such solutions (Stroke Association, 2018).
Her expressive aphasia further complicates care delivery, as it impairs her ability to communicate needs or consent to treatment effectively. Speech and language therapy (SALT) is a recommended intervention, typically involving tailored strategies to enhance communication, such as picture boards or gesture-based techniques (Royal College of Speech and Language Therapists [RCSLT], 2014). Nurses play a pivotal role in facilitating these interventions by ensuring consistent communication strategies are used across the care team. Importantly, patience and empathy in interactions can mitigate frustration for Lilian, reinforcing her dignity despite communication barriers. Nonetheless, the effectiveness of SALT can vary, and progress may be slow, necessitating ongoing support beyond discharge.
Psychological Support and Anxiety Management
Lilian’s anxiety and low mood are notable psychological concerns that warrant targeted intervention. Post-stroke depression and anxiety are well-documented, affecting up to one-third of stroke survivors within the first year (Hackett et al., 2014). These conditions can exacerbate physical recovery challenges by reducing motivation for rehabilitation. A person-centered approach, as advocated by the Nursing and Midwifery Council (NMC) Code (2018), prioritizes understanding Lilian’s emotional needs through active listening and validation of her fears. Referral to a clinical psychologist or counseling services may be beneficial, though access to such resources is often limited in community settings.
Furthermore, non-pharmacological interventions, such as mindfulness or relaxation techniques, can be introduced by nurses to manage anxiety, provided they are adapted to Lilian’s communication difficulties. Pharmacological options, such as selective serotonin reuptake inhibitors (SSRIs), may be considered if her symptoms worsen, but these must be carefully evaluated given her chronic kidney disease, which could affect drug metabolism (NICE, 2019). Nurses must monitor for signs of worsening mental health during discharge planning, as isolation in her flat could intensify feelings of anxiety, highlighting the need for regular follow-up care.
Frameworks for Holistic Care and Discharge Planning
To address Lilian’s multifaceted needs, the application of nursing frameworks such as the Roper-Logan-Tierney (RLT) model of nursing is appropriate. This model emphasizes activities of daily living (ADLs), providing a structured approach to assess Lilian’s independence in areas such as mobility, personal care, and communication (Roper et al., 2000). Using the RLT model, nurses can identify specific deficits—such as her reliance on support for personal care and meal preparation—and tailor interventions accordingly. For instance, arranging home care services for daily assistance could mitigate some risks associated with her living alone. However, the RLT model is not without limitations; it may overlook broader social and environmental factors, such as accessibility issues in her flat, which are critical to her discharge plan.
Discharge planning itself should be guided by the principles of the Care Act 2014, which mandates local authorities to assess and meet the care needs of vulnerable adults (Department of Health and Social Care [DHSC], 2014). This framework underscores the need for a comprehensive needs assessment prior to Lilian’s discharge, involving multidisciplinary input from nurses, social workers, and therapists. Such collaboration ensures that physical, social, and psychological needs are addressed holistically. Yet, budgetary constraints and resource availability often hinder timely provision of support, posing a risk of delayed or unsafe discharge.
Risks and Safeguarding Concerns
Several risks are evident in Lilian’s case, particularly concerning medication management and financial vulnerability. Her complex medication regimen requires strict adherence to prevent complications such as recurrent stroke or bleeding risks associated with Apixaban. Given her communication difficulties and reduced independence, there is a high risk of non-compliance without support. Community pharmacy services or medication dispensing aids, such as dosette boxes, could be implemented, alongside nurse-led education for Lilian and her family (NICE, 2015). However, her ability to manage these independently remains questionable, necessitating regular oversight by district nurses post-discharge.
A significant safeguarding concern arises from her grandson’s control over her finances, especially in the absence of a formal Power of Attorney. The Mental Capacity Act 2005 emphasizes the presumption of capacity unless proven otherwise, but Lilian’s stroke-related impairments may compromise her ability to make informed decisions about financial matters (DHSC, 2005). Nurses have a duty to escalate concerns about potential financial abuse to social services for investigation, while also facilitating discussions about establishing a Power of Attorney to protect her interests. This issue illustrates the intersection of clinical and social care, where nurses must advocate for patient safety beyond the hospital setting.
Social Determinants of Health
Lilian’s situation is heavily influenced by social determinants of health, including housing, social support, and socioeconomic status. Living alone in a second-floor flat without immediate access to family support increases her risk of social isolation, a known contributor to poor health outcomes in older adults (Steptoe et al., 2013). Moreover, her reliance on intermittent family support, primarily from her grandson, limits the consistency of informal care, potentially exacerbating her vulnerability. Nurses must consider these factors in discharge planning, advocating for community resources such as befriending services or day centers to enhance her social engagement.
Economic constraints may also impact Lilian’s ability to access private care or home adaptations, particularly if she lacks the means to fund such provisions. The broader context of healthcare inequalities in the UK suggests that older adults in lower socioeconomic brackets often face delays in accessing support, which could delay Lilian’s safe return home (Marmot et al., 2020). These determinants underscore the need for nurses to adopt an advocacy role, ensuring that systemic barriers do not compromise Lilian’s care.
Conclusion
In conclusion, the case of Lilian Moore highlights the complexities of providing holistic care to an older adult with multiple physical, psychological, and social needs following an ischaemic stroke. This analysis has demonstrated the importance of tailored interventions, such as physiotherapy, speech and language therapy, and psychological support, in addressing her immediate challenges of hemiparesis, aphasia, and anxiety. Frameworks like the Roper-Logan-Tierney model and legislative guidance from the Care Act 2014 provide structured approaches to care planning, though they must be applied with an awareness of their limitations in addressing broader social issues. Significant risks, including medication non-compliance and potential financial vulnerability, necessitate robust safeguarding measures and interdisciplinary collaboration. Moreover, social determinants such as housing and limited support networks underscore the need for nurses to advocate for equitable access to resources during discharge planning. Ultimately, Lilian’s case illustrates the critical role of person-centered care in nursing, urging practitioners to navigate systemic challenges to ensure safe, dignified outcomes for vulnerable patients. Future practice implications include the need for enhanced training in safeguarding and greater investment in community support services to mitigate risks for individuals like Lilian.
References
- Department of Health and Social Care (2005) Mental Capacity Act 2005. London: The Stationery Office.
- Department of Health and Social Care (2014) Care Act 2014. London: The Stationery Office.
- Hackett, M.L., Köhler, S., O’Brien, J.T., and Mead, G.E. (2014) Interventions for treating depression after stroke. Cochrane Database of Systematic Reviews, (8), CD003437.
- Marmot, M., Allen, J., Boyce, T., Goldblatt, P., and Morrison, J. (2020) Health Equity in England: The Marmot Review 10 Years On. The Health Foundation.
- National Institute for Health and Care Excellence (2013) Stroke Rehabilitation in Adults. NICE Guideline [CG162].
- National Institute for Health and Care Excellence (2015) Medicines Optimisation: The Safe and Effective Use of Medicines to Enable the Best Possible Outcomes. NICE Guideline [NG5].
- National Institute for Health and Care Excellence (2019) Depression in Adults: Recognition and Management. NICE Guideline [CG90].
- Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
- Roper, N., Logan, W.W., and Tierney, A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Churchill Livingstone.
- Royal College of Speech and Language Therapists (2014) RCSLT Resource Manual for Commissioning and Planning Services for Speech, Language and Communication Needs. London: RCSLT.
- Steptoe, A., Shankar, A., Demakakos, P., and Wardle, J. (2013) Social isolation, loneliness, and all-cause mortality in older men and women. Proceedings of the National Academy of Sciences, 110(15), pp. 5797-5801.
- Stroke Association (2018) State of the Nation: Stroke Statistics. London: Stroke Association.
