Establishing a Therapeutic Relationship With the Older Adult

8/3/2019 Establishing a Therapeutic Relationship With the Older Adult

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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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AS EXPERIENCED: THE OLDER ADULT 2

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.

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Establishing a Therapeutic Relationship With the Older Adult