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Marc
Marc is a severely disabled young man who lives in a nursing home for disabled adults. His Mother died when he was very young and his Father continued to look after him at home until 6 years ago, then Marc was moved into a long-stay hospital. His Father continued to visit him regularly until his death 4 years ago. Shortly after his father’s death, Marc was moved into his present home, which he shares with 5 other severely disabled adults. According to his old hospital notes, Marc was severely affected by the death of his father, becoming depressed and withdrawn. His parents were Italian and Marc has inherited handsome Mediterranean features that make him a popular resident at the Nursing Home. While it was very apparent that Marc’s physical needs were being very well cared for, there was much more that could be done to enhance his quality of life - when I was appointed Marc’s care co-ordinator, I decided to use Aromatherapy to try to address some of those needs.
Consultation
Marc is a 36-year-old man who suffered brain damage at birth. He is blind, has severe learning disabilities, quadriplegia, and epilepsy. Marc’s epilepsy meant that he was on powerful anti-convulsant (muscle-relaxing) medication (Carbamazepine and Clobazam) with Diazepam prescribed for status epilepticus if required. On average, Marc would have several seizures during the day with 2-3 prolonged seizures a month requiring intervention with Diazepam. The side effects of his anti-convulsant medication were severe drowsiness. Anti-convulsant medication also slows down the muscle action involved in digestion, which leads to slow, and inefficient bowel action and constipation. For constipation, Marc was prescribed an osmotic laxative (Lactulose), and had to undergo a weekly suppository (Bisacodyl) to help clear his bowels. Marc would always become agitated after the application of a suppository until a bowel action occurred, showing his discomfort by crying and moaning, often biting his hands in anguish. Staff would leave him in bed until a successful outcome before giving him his morning bath.
Marc has no verbal language skills, but can communicate his emotions in other ways. He responds to hearing his name with a smile or laugh and enjoys close physical contact such as hugging, teasing and rubbing his hands and arms. He indicates enjoyment by laughing, turning his head to listen, and trying to reach out to touch whoever is nearby. He will shout or moan if in pain, stopping if he hears a response from staff.
Although registered blind, Marc can probably detect light and shade, and will turn his head towards movement and sound. He is doubly incontinent, needing a convene and continence pad 24 hours a day and is totally dependent on others for all aspects of his self-care and hygiene. Skin integrity is good, his position being changed regularly throughout the day and night to help circulation and prevent pressure areas developing. He needs to be spoon-fed and has a restricted gastric reflux, which means his swallowing and coughing reflex abilities are inhibited.
Marc suffers frequent respiratory infections because of his immobility and inability to expel secretions from his respiratory tract due to his inhibited couching reflex. Secretions are allowed to build up in his lungs causing infection (Anderson 1993, p420). For use during periods of wheezing and breathing difficulties, Marc had been prescribed Salbutamol 2mg (a bronchodilator) in tablet form for use when required. To help with expelling excess secretions, he has to undergo postural drainage every day: postural drainage is using a patient’s position to allow gravity to drain excess secretions from the lungs, bronchi and trachea (Webber 1988, p23). Marc’s drainage routine meant that he would often spend between 2 - 2.5 hours during the day lying tilted on his bed. During this time he would moan and cry due to discomfort or boredom.
Spirituality
Even though physically comfortable most of the time, Marc was often bored and needed something to occupy his mind, to bring pleasure and a reason for living, this often referred to as Spirituality. Spirituality is particularly relevant to clients with severe learning and physical disabilities, who may have their physical needs well cared for, but do not have the same quality of life as more able people (Stoter 1995, p112). Spiritual needs are difficult to define and can often be mistakenly confused with religion (O'Brien 1981, p112). A common mistake in a healthcare setting is to assume that if a patient is a member of a church or religion, their spiritual needs are being met. However, this is not always the case: Spirituality can also mean a purpose for living (Labun 1988, p315), a feeling of belonging and comfort (Turner 1996, p59) and the appropriate response to need (Stoter 1995, p111). I have always felt that Aromatherapy can make positive contributions towards all these issues of spirituality, particularly in a learning disability environment where physical needs are often given priority over emotional needs. Using Aromatherapy, Marc’s spiritual needs would be best met by offering attention, comfort and interaction to help occupy his time in a positive and constructive way.
The advantage of using Aromatherapy with Marc was that as well as addressing his spiritual needs, through the appropriate selection of essential oils, aromatherapy could also complement the care being given to his physical needs. I identified the following needs appropriate for Aromatherapy treatment as:
Aims of
treatment
Spirituality
Use Aromatherapy to offer a purposeful activity.
Skin care
Maintain skin integrity through topical application of essential oils and carrier oils.
Promote surface blood circulation through massage to prevent pressure areas developing.
Constipation
Relieve constipation and promote digestive motility through massage to the abdomen.
Respiratory
Utilise mucolytic effect of essential oils to help breakdown of secretions and help breathing.
Help to expel respiratory secretions after postural
draining through back massage, percussion and cupping techniques.
Planning
I planned to use 2 massage blends with Marc. One for massage during postural drainage to help respiration, constipation and skincare, the other for staff to use with Marc for a hand massage to help occupy his time constructively and add to his quality of life. Due to his many physical disabilities, I needed to be very careful about contraindications for the use of massage and essential oils.
Contraindications
Medication
A side effect of both the Carbamazepine and Clobazam (particularly when used together) is drowsiness, so I wanted to avoid using sedating oils.
Manoeuvring
I needed to be aware of Marc’s manual handling care plan in order to safeguard against injury to both him and myself while manoeuvring him into position for massage. Marc also had scoliosis of the spine and needed particular care to position him comfortably.
Epilepsy
Marc’s epilepsy contraindicated the use of Aniseed, Fennel, Hyssop, Sage (Sanderson et al. 1997, p113), and possibly Rosemary (Price et al. 1999, p342).
Respiration
The inability to expel excess respiratory secretions through coughing also contraindicated the use of some expectorant oils. Expectorants and mucolytic essential oils are both useful in treating respiratory infections and in a normally healthy adult it would not matter using oils from either group. However, as well as making bronchial secretions less viscous, some expectorants will actually increase bronchial secretion (Martin 1994, p234), which would not be desirable in Marc’s case because of his restricted coughing reflex. Oils with a mucolytic action would be more appropriate as they do not increase secretion, but help break it down. This would significantly limit my choice of essential oils as many stimulating oils also have an expectorant action.
Spirituality
In order to offer Marc more purposeful activity during the day, I planned to introduce a massage routine for staff to use at set times during the day when they were least busy. Some staff had found it difficult to initiate interaction with Marc because of his severe disabilities and apparent inability to reciprocate communication. By using a hand massage as a starting point, staff would have something constructive to do with him, thereby developing their relationship with him, and offering him more quality time. I wanted to use oils that were non-sedating in order to increase his awareness during the massage period to stimulate him both mentally and physically (Sanderson et al. 1997, p71). I had difficulty in choosing a stimulating oil which was not an expectorant or contraindicated for epilepsy, (eg: Lemon, Rosemary, Pine, Peppermint, Thyme, Hyssop) but eventually decided to use a blend of Cypress (Cupressus sempervirens) for its safe, neurotonic effect (Price et al. 1999, p323), with Grapefruit (Citrus paradisi) for its stimulating properties (Lawless 1999, p105) and ability to blend well with Cypress. Due to the rapid oxidising properties of the grapefruit, I added 10% Wheat germ and the contents of 4 x 100iu vitamin E capsules to the blend to help preserve it.
Hand massage:
Carrier: 5ml Wheat germ + 45ml Grape seed+: 4 x 100iu vitamin E capsules
(1%) 8 drops Grapefruit + 5 drops Cypress
The blend was to stored with other medication in a locked cabinet and I organised supervision sessions to demonstrate hand massages with Marc with the appropriate documentation in his daily care plan.
Skin care
Marc was a high risk for developing pressure sores (see Waterlow index). Contributing factors towards skin breakdown were his incontinence and immobility (Waterlow 1996, p58). Massage would help with peripheral blood circulation to minimise tissue damage through inactivity. The appropriate use of carrier oils as a barrier to prevent traces of urine and faeces left on the skin would also help deter skin breakdown due to incontinence. Marc’s genital and buttock areas were always liberally applied with Castor oil cream to good effect and I had no intention of interfering with a successful treatment regime. However, at times his lower back and stomach area would become sore due to leakage from his continence pad. I would be able to protect these areas by using Calendula (officinalis) as a macerated carrier oil as part of the for the intended massage blend with Sweet Almond (Prunus amygdalis) for its slow penetrating properties (Price et al. 1999, p104) which would help to act as a protective barrier to urine leaking from Marc’s continence pad and convene.
Constipation
I planned to offer Marc massage to the abdomen to help his constipation. This would include circular massage over the intestinal are in a clockwise direction to follow the direction of the intestinal tract. Essential oils reported as being useful for constipation include Neroli, Mandarin, Basil, Black pepper, Rosemary, Savory (hortensis, montana), and Ginger (Price et al. 1999, p77). Tisserand (1999, p299) also suggests Black pepper, Camphor, Fennel, Marjoram and Rose. Lawless (1999 p202) suggesting Cinnamon leaf, Fennel (sweet), Marjoram, Nutmeg, Orange (unspecified type) and Black pepper.
Respiratory infections
Respiratory infections are caused by inflammation of the lungs or respiratory tract by bacteria. Infection of the bronchial tubes causes bronchitis with symptoms of coughing, temperature and generally feeling unwell. Respiratory infections are normally treated by antibiotic medication. Doctors preferring nowadays to identify the specific bacteria responsible before prescribing an antibiotic in order to safeguard against bacteria becoming resistant to medication. There is no reason why essential oils with proven antibacterial action cannot be used in conjunction with conventional antibiotics, but in order for them to be effective, the type of bacteria needs to be identified. Many publications list essential oils as having an anti-bacterial action but do not identify which bacteria they are affective against.
Suggested essential oils for Bronchitis
Aniseed, Cypress, Eucalyptus (type not specified), Hyssop, Lavendin, Niaouli, Pine (Price 1998, p268).
Basil, Benzoin, Bergamot, Camphor, Cardamon, Cedarwood, Eucalyptus (type not specified), Frankincense, Hyssop, Lavender, peppermint, Rosemary, Sandalwood, Camphor and Hyssop (Tisserand 1999, p298).
Benzoin, Eucalyptus (globules and dives), Frankincense, Marjoram (sweet), Myrrh and Sandalwood (Lawless 1999, p202).
Camphor (Bartram 1995 p343)
Infection of the air sacs (alveoli) in the lung result in more serious symptoms of pneumonia, which include high temperature, cough, chest pain, and general illness. The most common organisms causing respiratory infection are Streptococcus pneumoniae, Diplococcus pneumoniae, Haemophilus influenzae, Staphylococcus aures, Klebsiella pneumoniae, Legionella pneumophila and Mycoplasma pneumonae (Martin 1994, p519).
Essential oils that have been used on the above bacteria include:
Staphylococcus aures: Caraway; Cinnamon bark; Petitgrain; Eucalyptus (globules, citriodora, dives); Sandalwood (Australian; Lavender (angustifolia); Tea tree; Cajaput; Niaouli; Peppermint; Pine (sylvestris); Savory (hortensis, montana); Clove bud; Oregano (Spanish); and Thyme (vulgaris) (Price et al. 1999, p70-71).
Manuka (Coast Biologicals 2000 – no page number).
Tea tree (Carson et al. 1995, p424).
Klebsiella pneumoniae:
Manuka (Coast Biologicals 2000 – no page)
Cinnamon bark; Coriander; Eucalyptus (globulus); Cajaput; Peppermint; Nutmeg; Pine (sylvestris); Rosemary; Savory (hortensis, montana); Oregano (Spanish); Thyme (vulgaris) (Price et al. 1999, p70-71).
Diplococcus pneumoniae:
Cinnamon bark, Eucalyptus (globulus), Hyssop, Lavender (angustifolia), Tea tree, Cajaput, Geranium, Pine, Savory (hortensis, Montana), Clove bud, Oregano (Spanish), Thyme (vulgaris) (Price et al 1999, p70-71).
Steptacoccus infections
Eucalyptus (globulus) (Leung et al. 1996 and Wichtl et al. (Types unspecified) 1994 (no page numbers).
Mucolytic oils:
Yarrow, Frankincense, Caraway, Cedarwood (atlas), Eucalyptus (dives), Everlasting, Hyssop, Juniper (communis), Lavendin, Niaouli, Peppermint, Black pepper, Rosemary, Sage, Savory (hortensis, Montana), Tagetes, Thyme (vulgaris) and Ginger (Price et al. 1999, p354-356).
Tea tree (Lawless 1999, p202)
After examining all the information, I planned to treat Marc’s susceptibility for respiratory infections and help break down secretion from the lungs with a blend of Manuka (Lepstospermum coparium), Tea tree Melaleuca alterifolia) and Eucalyptus (dives), all chosen for their anti bacterial actions, Tea tree and Eucalyptus dives also being mucolytic. I had some considerable difficulty in choosing the appropriate Eucalyptus due to their expectorant effect, Eucalyptus dives with its high piperitone content being the only type which was mucolytic but not expectorant in action (Price et al. 1999, p324, 354-356) and can be useful for bronchitis (Lawless 1999, p202). It is also cited as being anti-asthmatic (Beckstrom-Sternberg et al. 1996 p324). I had used Manuka in a hospital environment as an antibacterial agent with some success but it can have a strong and possibly unpleasant fragrance. To modify the strong scent, I added Sweet orange (Citrus sinensis) which is also antiseptic and antibacterial, useful for constipation and a digestive tonic (Lawless 1999, p146). The Sweet orange blended well with the other oils to make a more pleasing fragrance. The blend would be used for massage to the chest, back and abdomen during postural drainage using a massage technique to help dislodge and expel secretions from the lower pulmonary lobes towards the upper tracheal tract. Marc would also benefit from inhaling the anti-bacterial and mucolytic effects of the oils as well as the mechanical effects of massage to his abdomen to help with intestinal motility. I planned to use a blend of Calendula and Sweet almond for the skin area around his continence pad to act as a protective barrier to any moisture leaking from his continence pad.
Massage blend
Carrier: 10 ml Calendula + 30 ml Sweet Almond
1 drop Manuka (Lepstospermum coparium)
1 drop Tea tree Melaleuca alterifolia)
2 drops Eucalyptus dives
6 drops Sweet orange (Citrus sinensis)
Massage oil for skin barrier
10 ml Calendula + 30 ml Sweet almond
Offering a back, abdomen and chest massage to help with postural drainage and constipation would involve specific massage techniques which could do more harm than good if not done correctly, particularly if massage was carried out against the natural direction of the intestinal tract. I decided not to demonstrate the massage routine to other staff but to treat Marc myself on the days I was on duty. With help from the Physiotherapist, I devised a massage routine that would help loosen and expel pulmonary secretions through percussion and cupping movements, followed by a more gentle massage to the abdomen to utilise the therapeutic effect of the essential oils and help to make postural drainage a more tolerable experience.
Massage routine for
postural drainage (taken from Marc’s care plan)
Aim
Good respiratory care reduces and removes excess secretions, maintains a clear airway and prevents infection (Phoenix NHS Trust 1994, p3).
Rationale
Postural drainage is using a patient’s position to allow gravity to drain secretions from specific areas of the lungs, bronchi and trachea (Webber 1988, p23). It reduces the accumulation of secretions to enable removal through coughing or mechanical massage techniques (Anderson 1993, p420).
Method
Postural drainage to take place daily with Marc lying on his bed with his legs elevated higher than his head (10-15°)
45 minutes for left lobe drainage with client positioned on his right side using pillows for support if necessary followed by 45 minutes on the left side to drain the right lobe.
After 10 minutes in elevated position, apply massage oil to the client’s body to help prevent friction from massage.
Perform percussion massage to the back with gentle cupping to loosen and expel secretions. The client’s body can be protected with towels during cupping.
Percussion and cupping to start at the waist and release at the shoulders in order to expel secretions upwards from the lungs.
Perform percussion for 15 minutes to each side followed by gentle massage to chest, back and shoulders using prescribed essential oils.
Level the bed and reposition client on his for a 5-minute massage with essential oils to the lower abdomen to help relieve constipation. Massage movements to be circular, following the direction of the ascending and descending colon to work with peristalsis movement of the smooth muscles of the intestinal tract.
Finish by applying plain carrier blend on a cotton pad to areas around continence pad for skin protection from pad leakage.
Treatment
It took several weeks to run supervision sessions for staff on how to massage Marc’s hands using the prepared massage blend. By the end of the 4th week, all the staff had been shown and several were practicing it enthusiastically.
I found it very difficult to purchase the correct type of Eucalyptus, which delayed the start of treatment for 3 weeks with Eucalyptus as part of the blend. I substituted the Eucalyptus with Cedarwood atlas (Cedrus atlantica) for its safe and similar mucolytic properties (Price et al 1999, p317, Lawless 1999, p75). I treated Marc twice a week during postural drainage using essential oils and massage, substituting the Eucalyptus for the Cedarwood atlas after 3 weeks, leaving other staff to supervise drainage on the days in between. Treatment was under constant review but I saw no reason to adjust the blend again after the introduction of Eucalyptus. After 7 weeks, Marc had a cold infection requiring Salbutamol medication during 2-3 days of wheeziness. During this time I used 3 drops of undiluted Eucalyptus dives on his pillow for 3 nights to break down mucous secretions and help him breath easier. The infection stayed away from his lungs and I was pleased with the outcome. I was able to continue treating Marc for a period of 3 months until I was reallocated as Care Co-ordinator to another resident. During that period there were short breaks in treatment when I was on holiday or on a course but overall I was satisfied that there was enough continuity to have a positive therapeutic effect. Marc enjoyed his sessions with me and they developed into our special time together. After a few days I introduced music into the routine and found that he had a liking for opera, probably reminiscent of his Italian childhood. Other staff took up playing music during his drainage sessions, and while they could not offer percussion massage, some of them started to give Marc a hand massage while he was lying on the bed – this with the music helped to pass the time more constructively.
Evaluation
To evaluate the effectiveness of Marc’s respiratory care, I compared the number of respiratory infections in a 3-month period previous to Aromatherapy intervention with the 3 -month period of treatment. Both were over the same winter months when I would expect the number of respiratory infections to be most frequent. I found that since starting Aromatherapy treatment, the number of infections had reduced from 2 in the previous period requiring antibiotic intervention (one of which involved hospitalisation with intravenous antibiotics) to one minor cold during the treatment. There was also a 58% reduction in the use of the bronchodilator Salbutamol over the same period. While not conclusive due to the short comparison times available, the results were very encouraging.
Evaluating the effectiveness of using essential oils and massage to help relieve constipation was subjective, based on my own observations and those of other staff members. After 2-3 weeks, comments were made that Marc seemed not to be so anxious and uncomfortable in the period after his suppository was administered. After 5 weeks, the time for a complete bowel action after the administration of a suppository was noticeably shorter, suggesting that regular massage was significantly contributing to increased motility and more efficient peristalsis.
The effect on skin care was again subjective with no episodes of skin irritation to the risk areas around his continence pad during the treatment period. Regular massage and the application of carrier oils as a barrier would have contributed to maintaining a healthy skin due to the increase in surface blood circulation and oxygen supply to the dermal layers of the skin to help combat local infection and stimulate cell growth.
Addressing Marc’s spiritual needs was the most
difficult to evaluate. Effectiveness
was based on the assumption that by occupying his time more positively, some of
his spiritual needs were being met. I
was please with the interest and enthusiasm shown by staff in using hand
massages to offer quality time with Marc. After
a while, some staff asked to use the technique with other residents, and hand
massages soon became a normal part of everyday care at the home.
Staff made positive comments saying that learning massage had given them
a new activity to do with Marc, making them more likely to make the time to sit
and offer purposeful interaction. Massage
and music during postural drainage sessions certainly helped to relieve some of
the boredom and help address the spiritual needs of belonging, comfort, and
purpose to life. The added benefit
of the attention given to Marc’s postural drainage also helped to make the
staff more aware about the value of good respiratory care, and were more likely
to do it correctly with him, further supporting spirituality through the
appropriate response to need.
Conclusion
Using Aromatherapy in a healthcare setting with severely disabled clients can have a synergistic outcome that addresses both physical and spiritual needs. There was a lot of planning involved in Marc’s treatment involving careful research into the appropriate use of essential oils, learning percussive massage techniques, ensuring the comprehensive documentation needed for his care plans, and organising supervision sessions for staff training. It was probably one of the most comprehensive and time-consuming treatment I had attempted so far and would not have been possible had I not already been employed at the home. The combination of Manuka and Tea tree as antibacterial-antiviral oils, with Eucalyptus as a mucolytic seemed to work well in complementing his respiratory care and preventing respiratory infection over the 3-month treatment period. I would not have liked to continue the topical application of the same oils for more than 3 months due to any possible sensitising effects. However, I saw no reason why oils with similar properties could not be used in rotation or the same oils re-introduced over the same high-risk infection period during winter months the following year. Marc’s quality of life had been significantly improved by addressing his physiological needs more effectively, and by addressing his spiritual needs through touch, scent, massage, music, and more opportunities for interaction to help develop the present as a positive experience.