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The person I have chosen for this assignment is Marcus Tyrone H. He is my neighbor’s brother. He is married and has 4 children and 2 grandchildren, all of which live in Philadelphia. Marcus has just relocated in Trevose PA in his sister’s family because of some health related issues. So, at present, Marcus lives with his sister, her husband and his niece. He also has a support from his other 3 nieces who live down the street. He is a veteran with a 10th grade education and he also earned his GED while in the Army. After he had retired from the military he worked as a blacksmith. He lost his job in 1996 and had been received Social Security Disability until his retirement. Speaking about his way of life, Marcus was not a very meticulous in taking care of his health. He was a smoker and a heavy drinker and also used to take drugs. However, his lifestyle changed when he had moved because of those he lived with. When he came to the city, Marcus was objectively active. He was able to walk to the bus stop to catch the bus to the mall and to the senior center. However, in spite of this he had a diagnosis of congestive heart failure, and his condition seemed to deteriorate quickly. So, in 2004, he had a pacemaker and defibrillator implanted. In 2005 he began undergoing breathing difficulty and could no longer walk a full city, block or climb a flight of stairs without stopping to take a breath. At that time he was diagnosed with COPD. In 2009, he was placed on at home oxygen, oxygen condenser and CPAP. He was taken to the hospital numerous times during the year because of his breathing difficulty and chest pain. Recently he was diagnosed Hepatitis C. Since he is a veteran, he receives most of his heath care at the VA Hospital in University City, but is regularly taken to Einstein Medical Center.
Having no medical upbringing, it is difficult for him to understand his disease processes. When he goes to the hospital, he has no one there to be with him while receiving information, so those people who support him are not aware of many issues. Presently Marcus does not have any advanced directives in place. All the members of his immediate family, being spread over Tennessee and Mississippi, are not involved in his care.
Having observed all the available information concerning this person’s health, it seems reasonable to consider the diseases he has. First of all, let us try to understand the Congestive heart failure, its symptoms and treatment.
According to the article Heart failure – Overview (2011), heart failure is a chronic condition, which sometimes can be characterized by sudden development. It may affect just one of the sides of the heart. In such case the failure is called left-sided heart failure or right-sided heart failure. However, usually both sides of the heart are implicated.
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According to the muscle activity, there are the following types of the heart failure:
If the heart muscle cannot pump the blood out of the heart well, this condition is called systolic heart failure; if heart muscles are inelastic and cannot be full of blood easily, it is diastolic heart failure. Is such cases, the heart is unable to pump enough oxygen-rich blood out to the rest of your body, particularly when a person is very active. So, as a result of such a loss of heart’s pumping action, blood can back up in other areas of the body, such as the lungs, liver, gastrointestinal tract, and the arms and legs. It creates congestive heart failure, (Heart failure – Overview, 2011).
Symptoms of heart failure often begin sluggishly. At first, they may only occur when very active and over time breathing problems and other symptoms are evident, even when resting. The most common symptoms of heart failure are cough, weariness, weakness, faintness, loss of appetite; need to urinate at night, weight gain, irregular pulse, shortness of breath, swollen ankles and feet, and enlarged liver or abdomen (Heart failure symptoms, 2012).
As for testing the heart failure, there are several tests which diagnose this disease. An echocardiogram (echo) is considered to be the best test to diagnose heart failure, which learn the cause and monitor. Among other tests there are heart catheterization, cardiac stress tests, MRI and nuclear heart scans. Lab tests that are performed are BUN, creatinine clearance and urinalysis to check kidney function, CBC for anemia, sodium and potassium. According to the article Brain natriuretic peptide (BNP) (2013), a brain natriuretic peptide measures the amount of the BNP hormone in the blood. BNP is made by the heart and shows the work of the heart. As a rule, just a low amount of BNP should be found in the blood. In the case of harder work of the heart for a long time, such as from heart failure, thereare more BNP, released by the heart, which increases the BNP blood level. The BNP level can decrease if there is a treatment for heart failure. (Brain natriuretic peptide (BNP)). A BNP greater than 100 may indicate heart failure.
Speaking about the treatment of this condition, the first thing that needs to be said is that medication and even occasionally surgery is needed to treat heart failure. Angiotensin-Converting Enzyme Inhibitors (ACE inhibitors) are a vasodilator that benefits to open the blood vessels, lower blood pressure and improve blood flow. The major side effect of ACE inhibitors is a persistent cough. For many people the cough is irritating, and because of it different medications are used. Angiotensin II Receptor Blockers (ARB) has the same effects of the ACE but do not cause the cough. Beta Blockers are used to slow the heart which in turn reduces blood pressure. Diuretics are used to help rid the body of accumulated fluid. Coronary bypass surgery or valve repair may be needed if damage to the heart has occurred. Pacemaker and defibrillators are implanted to help the heart maintain a normal rhythm.
One more disease needed to be observed is the chronic obstructive pulmonary disease. As the article Chronic obstructive pulmonary disease – Overview (2011) affirms, chronic obstructive pulmonary disease (COPD) is considered to be one of the most common lung diseases. It is progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Inflammation causes changes and narrowing to occur in the airways. The changes include increased numbers of goblet cells and enlarged sub mucosal glands cause increased secretion of mucous to occur. There are two main forms of COPD. The first one is chronic bronchitis, which is characterized by a lingering cough with mucus. The second type is emphysema, which implicates lungs. More often people suffer from a combination of both types. At present, COPD cannot ne cured. However, there are some medical treatments which relieve the symptoms and prevent the development of the disease. People should stop smoking as it leads to the prolong effect of COPD. (Chronic obstructive pulmonary disease – Overview).
The symptoms of COPD are characterized by a gradual progress, though people can have cough with and without mucus as well, fatigue as a result of the breathing difficulty, dyspnea on exertion and wheezing. Some tests are occurred in order to find out how the lungs take in and release air and the way they move oxygen into the circulation of body. Spirometry measures the amount of respired air. It is considered to be the best way to diagnose COPD. Among other ways of testing the illness are chest x-ray, arterial blood gas, CT scan and listening to the lungs.
As for the treatment, some medications such as Spiriva, Serevent and Atrovent are bronchodilators (inhalers) that work by relaxing the smooth muscle of the bronchi of the lungs. This relaxation allows the airway to open and breathing to become easier. Inhaled steroids and anti-inflammatory medications such as Singulair help to reduce tenderness. In severe cases, oxygen therapy, CPAP or BiPAP may be used.
The last condition to look through is Hepatitis C. So, according to the article Hepatitis C malady (2013), hepatitis C is a type of hepatitis, caused by the hepatitis C virus. It is usually spread through the infected blood, though sex with an infected person also can be a cause of this disease. Hepatitis C also can spread from mother to baby during the childbirth. Most of infected people can live without symptoms for many years. It is up to the blood test to show if a person has this disease or no. The infection may last all the life and finally result in liver cancer. Though some medications can help, they can lead to bad side effects. There is no vaccine for hepatitis C (Hepatitis C malady).
Those people, who have a risk to have hepatitis C infection communicating with already infected people, should have a test for this disease in order to let doctors to start some treatment, and also to change lifestyle to prevent liver damage. It is very important, because hepatitis C sometimes begins without symptoms, though it damages liver much. Liver biopsy and blood test should occur to diagnose hepatitis finding out how much damage was done to the liver.
As for the treatment, one should note that even if it is diagnosed that a person has hepatitis C, it does not mean that an immediate treatment is needed. If a person has just a little irregularity, the disease needs just to be monitored. If the damage of hepatitis C is more severe, liver transplant or anti-viral medications should occur.
The plan of Marcus current treatment is slightly complicated because he himself is confuused by it. Currently he is in Willow Crest at Einstein for rehab and he does not know what medications he takes on a routine basis. Before going to Willow Crest, he was in Einstein for 3 weeks for abnormal heart rhythms, blood clots and defibrillator failure. Because of his confusion and reliance on nurses and doctors, I believe Virginia Henderson’s theory of Nursing Need fits him.
This theory emphasizes the importance of patient freedom. Independence of the patients is needed for advancement of their heath after hospital discharge. Virginia Henderson describes the role of the nurse as substitutive, supplementary or complementary. This supports the patient not to rely solely on the nurse. In order for patient individuality to occur, the patient needs to be educated on his disease processes.
Speaking about Marcus’ Clinical Pathway, the two biggest issues in Marcus health that need to be addressed are the COPD and CHF, since they both cause him such breathing difficulty. Breathing difficulty is the cause of his becoming restless and sometimes leads to his calling fire rescue. It is also a reason of his going from living a fairly active life of socializing at the senior center, sightseeing the city and taking walks to play his lottery, to being inactive in his room at present. Communication is a significant part of life and when it is taken away because on an illness, despair can occur. Despair can frustrate the symptoms of illness. Also, living an inactive life causes further wilting of the heart muscle. This cycle of illness despair, deteriorates the symptoms.
The following nursing diagnoses are related to the facilitation of the breathing difficulty that he experiences:
1. Activity intolerance related to unsatisfactory knowledge of adaptive techniques needed secondary to COPD:
• Inadequate Pulmonary Hygiene- teaches a patient proper coughing and deep breathing techniques and explains the importance of such techniques.
• Suboptimal Breathing Techniques- teach relaxation techniques to minimize muscle tension. This will help control breathing and eliminate wasteful motions of the upper chest, shoulder and neck.
• Initiate Health Teaching- teaches a patient to observe for sputum changes. It also teaches a patient about the importance of proper way of cleaning inhaler equipment. People with COPD are susceptible to respiratory infection. Detection of changes can result in early treatment.
The goal of it is that the client will progress activity to walking down or up a complete set of stairs without stopping within 2 months of initiating new breathing techniques.
2. Excess fluid volume related to CHF:
• Diet- teaches a patient how to record daily food and fluid intake. It also teaches how to assess for excessive sodium or inadequate protein intake.
The goal of it is that the client will exhibit decreased edema to abdomen and legs within 2months of teaching.
3. Risk for complications of Cardiac/Vascular dysfunction.
Marcus’ present-day health issues cause a tension on his sister. She is 73 and although she also has health issues, she is mobile. She supports him much and although she is a nurse, she has never worked in a hospital and so she doesn’t understand the complete details of Marcus’ conditions. Apprehension plays a part in his breathing difficulty. He often wants to call 911 because of it. The other members of his family, who he has here, are willing to help when they have time between work and family. They often ask him to join in family gatherings, but because of his inability to walk far, he is afraid of leaving the house. Besides, the lack of understanding of his health is frustrating. The family probably would be more enthusiastic to help if they knew what they could do to help.
Although the diseases that Marcus has are progressive and not curable, they are improvable. Learning how to help himself will allow him to be accessible to learning about his diseases. He needs to be accurately educated on how to cope with his symptoms instead of calling 911 every time he feels he is in trouble. He also needs to have a better affiliation with his doctors. Having a rapport with those involved in his health care will allow for more open communication. It would also be supportive if he had some of his family members to be with him during his appointments. This would help the family comprehend what is going on and since he has two young nurses in the family, maybe they can help him and the other family members to understand his health issues in a proper way.
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