Discussion Postings.

Discussion Postings

Carl Stuart.

Stuart Medical Series.

                                       Myocardial infarction (MI) and quality of life.

The qualitative interview study titled Health-related quality of life after myocardial infarction: An interview study by Roebuck, A., Furze, G. and Thompson, D. R. was aimed at gaining insight on how myocardial infarction affects the quality of life of the patient (2001). The signs and symptoms of myocardial infarction such as dyspnoea, lassitude and chest pain (that sometimes radiate to the left shoulder) have detrimental impact on the ability of the patient to engage in simple physical activities such as walking, driving and even shopping. Moreover, dyspnoea reduces the quality of sleep of the patient as it evokes fear of impeding death and drowning when the patient falls asleep; hence the patient is always physically exhausted and emotionally fragile due to the lack of rest. This resulting fatigue negatively impacts normal daily activities as the patient cannot complete any simple task without taking frequent intermittent periods of rest. Chest pain has the least negative impact on daily normal activities; except for fear of an impending MI when an acute chest pain occurs (Philo, 2010).

The patient experiences insecurity and periodic anxiety which is caused by fear of a shortened lifespan, bleak future health and a general deterioration of his or her well-being. Recurrent MI or fear of periodic MI heightens the feeling of insecurity and anxiety in the patient. These heightened insecure feelings are compounded by the associated functional disability which reduces the probability of the patient returning to work (or any other meaningful economic activity) and this has a direct impact on his/her state of financial stability. Functional disability and easy fatigability leads to loneliness and isolation as the patient cannot go shopping or even visit friends. The patients end up relying on vehicles for mobility; but, this reliance is impeded by the recovery contraindication that requires them to refrain from driving (Roebuck, Furze, & Thompson, 2001).

Most patients suffer from depression and irritability. Irritability predisposes the patient to anger, intolerance and bad temper; and this negatively affects the relationship between the patient and his/her spouse; thus, straining personal and family relations. This is worsened by the dependency of the patient on family members and the over-protective nature of these concerned family members who limit the scope of activities that the patient can engage in; thus, causing the patient to be frustrated. Most caretakers of these patients are not well informed about MI; and, they thus end up being overprotective on their dependants (Philo, 2010).

The plan of management of MI patients encompasses lifestyle modification.  Such modification includes smoking cessation, reduced salt intake and dietary modification (such as intake of low-fat diets). Most patients expressed concern that they were frustrated by their inability to stop smoking. Moreover, the patients are concerned about the side effects of polypharmacy; such as hypothermia (caused by beta-blockers), disturbed sleep caused by frequent nocturnal micturation (an effect of diuretics) and nightmares (caused by statins) (Roebuck, Furze, & Thompson, 2001).

The knowledge gained from this article will enable a nurse to provide beneficial nursing care explained hereafter. The laid down protocols of Canadian Nurses Association requires that the nurse liaise with the social worker in order to provide post-discharge support to the patient. The nurse also needs to advice the patient on the need to avoid depression as research has shown that depression slows down the progression of recovery. The nurse must also involve the family members (or caretakers) in the integrated management of MI patients. The nurse must provide the basic information about MI to the caretakers of these patients, as this will improve the caretaker-patient relations and reduce the patient’s feeling of frustration and depression. The nurse must inform the patient and his/her caretakers on the adverse effects of the prescribed drugs and possible ways of minimizing those side effects (CAN, 2011)                                                                             

                                                References.

Roebuck, A., Furze, G. & Thompson, D. R. (2001). Health-related quality of life after myocardial infarction: An interview study. Journal of Advanced Nursing 34, 787-794. 

Canadian Nurses Association; CNA. (2011). Fundamentals of Nursing Care.  Journal of Advanced Nursing, 25, 1793-1896.

Philo, J. (2010). Myocardial Infarction and its health implications. Cardiology Review, 212, 123-29.

                                                  Atrioventricular graft repair.

Everyone is spiritual in one way or the other. Spiritualism enables an individual to have a positive outlook at life (Waton & Malzahan, 2002). However this is not the case with Mrs.M. Mrs.M is a religious person who has not come to terms with her current condition. This is evident as she queries why God allows her to suffer and she would prefer to die. This shows possible suicidal intents; but fortunately most religion prohibits their adherents from committing suicide; and thus, she may fall into depression (Waton & Malzahan, 2002). This is caused by the poor prognosis of her earlier surgical operation for treating of an atrioventricular fistula. Her apparent manifestation of desperation concerning her health requires the nurse to approach her care management in a holistic therapeutic manner. Her dispirited confused state of mind predisposes her to frustration. Mrs.M spirituality can be utilized by the nurse to assure and encourage her to persevere and understand that her current state of health is only temporary (CNA, 2011).

The nurse cannot properly understand her situation, but the nurse can empathize with Mrs.M; hence, the nurse must be frank, honest and candid with Mrs.M concerning her current situation; as this will enable Mrs.M to accept her situation. The nurse must therefore inform her about the possible prognosis after surgery, the associated health effects and what can be done to mitigate some of these adverse related health effects. Mrs.M requires palliative care and this can only be provided by a compassionate nurse can gain the trust and confidence of Mrs.M. This trustworthy nurse-patient relationship lays the foundation for communication between Mrs.M and the nurse through their combined conscious effort. This enables the nurse to provide competent and ethical healthcare to the patient and this will improve Mrs.M’s general wellbeing. Moreover, this nurse-patient relationship will enable Mrs.M to express her concerns and fears; and this will enable the nurse to allay some of her fears while concurrently informing her of what she can do to mitigate some of her unfounded fears. Nurses are prohibited from practicing discrimination on their patients due to religious beliefs of these patients; and thus considering the fact that Mrs.M is evidently religious, the nurse can refer her to the hospital chaplaincy (or to the relevant religious leader or scholar) in order for her to receive spiritual guidance. Thereafter, Mrs.M can use the knowledge that she has received from the nurse to make decisions. The nurse will take into account her decisions as CNA code of ethics requires the nurse to promote and respect the informed decision made by the patient. The nurse can thereafter discuss her decision with the aim of showing her how her decision will possibly impact her post-operative recovery and future general wellbeing (CNA, 2011).

Moreover, the nurse must inform Mrs.M that mood swings are a common emotional adjustments that a patient experiences prior to dialysis. Thereafter, the nurse must adequately prepare the patient for dialysis by reassuring her and allaying her possible unfounded fears. Her spirituality can be used to augment this reassurance and assuagement (CNA, 2011). This is because spirituality is an intrinsic force that acts as an inner life-giving force which inspires an individual to live a meaningful balanced life (Waton & Malzahan, 2002). Hence, the knowledge that Mrs.M receives from the nurse and spiritual guidance from a spiritual leader will enable her to have a good post-operative prognosis, and a healthy life thereafter. This fact exemplifies the need for nurses to approach their patients through holistic therapeutic perspectives.

                                                                

                                                                       References.

Walton, J., & Molzahan, A.E. (2002) Finding a balance. A grounded theory study of spirituality in hemodialysis patients. Nephrology Nursing Journal, 29(5), 447-456.

Canadian Nurses Association (CNA). (2008). Code of Ethics for Registered Nurses. Ottawa: Author.

                                                  Congestive heart failure (CHF).

Mr.M is suffering from depression and hopelessness which are caused by the poor prognosis of his condition. CHF is a chronic condition affecting cardiac function; and, it also causes multiple organ dysfunction symptoms, thus complicating its therapeutic management and significantly reducing the probability of a good prognosis. Its symptoms include pain, lassitude, dyspnoea and generalized oedema (anasarca). The resultant co-morbidities associated with CHF and the resultant related hospitalizations negatively affects the physical, social and psychological aspects of quality of life. Moreover, these co-morbidities worsen the status of CHF; and, may ultimately cause heart failure. Sometimes, these co-morbidities may manifest physically earlier than CHF; and therefore mask the insidious CHF, thus causing sudden death which results from the worsening masked CHF (Brawer, 2011).

The recent advanced modes of treatment of CHF have significantly reduced the mortality rate attributed to it; and, increased its long-term survival rate. However, it has increased the duration that a CHF patient has to live with some of the severe intractable symptoms of CHF; and this reduces the quality of life of CHF patients. This poor quality of life causes the CHF patients to have poor mental health; and, this predisposes them to depression, frustration; and suicidal intents that are clearly manifested by this patient. This poor mental health negatively impacts healthcare provider-patient communication (with frequent conflicts occurring) with the nurse withholding vital information about CHF from the patient in order to prevent the patient from falling into even deeper depression and committing suicide. This inappropriate nurse-patient relationship reduces the chances of survival because disease symptoms are not relieved. Most CHF patients disclose their symptoms and co-morbidities to the nurses; but unfortunately little is done to alleviate the symptoms (Jones,O’ Connell & Gray, 2003). Thus, the functions of the nurses must be aimed at symptom control and provision of palliative care which will improve the quality of life of the CHF patient and reduce domiciliary referrals. This palliative care must be provided on the basis of need not diagnosis (Glick, 2011).

Patients who have severe CHF suffer from social isolation (including lack of community support), worsening functional disabilities and co-morbidities especially when their caretakers have a poor understanding of CHF and its associated symptoms. Most of these patients have inadequate information about CHF. Moreover, the decisions of the patients are disregarded by the nurses due to the fact that most of these decisions are made by a relatively uninformed person. The above factors make the patient to feel unwanted and therefore wish to die earlier. However, a vast majority of CHF patients would prefer alleviation of symptoms (among other comfort measures) to death (Jones,O’ Connell & Gray, 2003).

Mr.M is severely depressed and has suicidal intents which can probably be attributed to unmet needs of palliative care provision. Mr.M can be assisted by a nurse (who is part of an integrated specialist palliative care team) who will provide palliative care to him. Palliative care approach does reduce the incidence of co-morbidities (and associated symptoms) affecting the circulatory system. Better communication between the nurse and the patient (or caretaker) will improve the quality of life of Mr.M. moreover, there is need for the nurses to be trained on how to effectively communicate and care for CHF patients (especially those who have severe symptoms). This will enable the nurse to educate the patient on CHF; and thus the patient can make an informed decision which he can discuss with the nurse.  Symptom relief in severe CHF can be achieved through administration of anxiolytics, morphine (or any other effective opioid analgesic) and supplementary oxygen PPV (positive pressure ventilation). Nurses can also act as sentries of the multidisciplinary team that is managing the patient, by assessing the Mr.M’s condition and report any unusual features to the team. Moreover, the nurse can provide physical and psychological support to the patient and his caretaker. Also, the nurse can liaise with the social worker to ensure that the patient receives adequate social support (Glick, 2011).                                                                References.

Jones, A.M., O’Connell, J.E., & Gray, C.S. (2003). Living and dying with congestive heart failure: Addressing the needs of older congestive heart failure patients. Age and Ageing, 32(6), 566-568.

Brawer, P. (2011). Congestive Heart Failure in Men. Cardiology review, 82(9), 756-68.

Glick, C. (2011). Nurses and Heart Failure. Journal of Advanced Nursing, 89, 289-301.

                                             Theory of Comfort and Nursing care.

Mr.C had a severe respiratory disease whose symptoms were not adequately managed; hence his condition worsened to the point that he became semi-conscious, and thus requiring ICU (Intensive Care Unit) care. A patient in a semi-comatose state experiences a lot of pain and suffering which is worsened by the fact that he cannot physically manifest the intensity of his pain (Geller, 2011).

 One of the core duties in the nursing profession is the relief or alleviation of disease symptoms. An ideal nurse must assist his or her multidisciplinary management team to educe positive whole person outcomes. In turn, the multidisciplinary management team must achieve a holistic outcome (Kolcaba, 1994).

The theory of comfort lays down the foundation of a holistic outcome. The theory of comfort has three basic postulations that are outlined hereafter. The first postulate states that complex stimuli elicit a holistic response in human beings. The second postulate states that comfort is a fundamental desirable holistic outcome in the nursing profession. The third postulate states that humans endeavor to satisfy (or have satisfied) the basic comfort needs. An attempt to enhance any aspect of comfort automatically improves the other unrelated aspects of comfort. Thus, an effect on a single effect affects other aspects (Kolcaba, 1994).

 Comfort is organized in a two-dimensional grid. The first dimension encompasses the three states of transcendence, relief and ease. These states are overlapping, continuous and interdependent on each other. Relief occurs when a specific need is met. Relief is thus vital for the restoration of normal function and/or peaceful demise. Ease refers to a state of contentment or calm. Hence, it is important in efficient human performance. Transcendence refers to a state whereby ordinary human powers are enhanced. It determines the potential of extraordinary performance by an individual. These three states have positive correlation with optimal human performance; thus the first dimension of comfort facilitates gains in psychological and/or physical performance. Moreover, this dimension is necessary for a peaceful death since it bestows the psychic strength in the patient; and this facilitates acceptance and release. Dimension two of comfort encompasses the four contexts within which comfort occurs. These contexts are physical (which is related to bodily sensations), psychospiritual (intrinsic awareness of oneself including sexuality, self-esteem, purpose of life and religion), social (related to level of education; family, cultural and interpersonal relationships; and, financial security); and environmental (related to ambience, noise, temperature, natural versus synthetic elements, and, color). Thus, juxtaposition of the two dimensions of comforts creates the 12 basic facets of comfort. The total comfort score is achieved by adding together the scores of all individual facets (Kolcaba, 1994).

Nursing care is aimed at promoting comfort. According to the ANA (American Nursing Association), its position statement with regards to comfort in the dying patient is that nursing care offered to dying patients must be aimed at maximizing comfort as per the wishes of the dying patient. Comfort is directly related with both external and internal health seeking behavior; hence it directly promotes health (Kolcaba, 1994).

Comfort will enable Mr.C to achieve relaxation, analgesia and alleviation of symptoms; thus increasing his quality of life. These will probably eliminate his desire to die. But, if he strongly desires to die; he should be accorded the necessary comfort that will ensure his peaceful death (Kolcaba, 1994).

                                                  References.

Geller, T. (2011). Respiratory Diseases and Nursing. Journal of Advanced Nursing, 23, 59-81.

Kolcaba, C. (1994). A theory of holistic comfort for nursing. Journal of Advanced Nursing, 19, 1178-1184