This assignment is a case based written report. The case involved is case three and is based on a 50 year old man by the name of Cedric who was diagnosed with COPD five years ago. He has presented with worsening dyspnea, cough and also increasing purulent sputum production over the past three days. Throughout this assignment there will be information on the pathophysiology of the presenting conditions, education and psychosocial support for the patient, diagnostic tests that need to be done, nursing and risk assessments and the discussion of some of the medications that Cedric is on. This assignment also consists of a nursing care plan for this patient.

PATHOPHYSIOLOGY OF DYSPNOEA, A COUGH AND PURULENT SPUTUM.

The occurrence of dyspnoea is when the ventilatory demand is not and cannot meet the body’s ability to respond to it. The development of dyspnea happens when there is a divergence between the central respiratory motor activity and the incoming afferent information from the airway receptors and also the lungs and the chest wall formation (Periyakoil 2006). Therefore the respiratory effort increases when the central motor command to the respiratory muscles have to be increase meaning that when there is an increase in mechanical work load or the muscles are weakened there is an increase in the work of breathing (Periyakoil 2006).

The experience of shortness of breath is the definition of dyspnoea, and the person involved may or may not be suffering (Hallenbeck 2003). The cause of dyspnea is that there is a CO2 build-up and there is also a deprivation in oxygen. A persons having carbon dioxide elevation can stimulate dyspnea much more than a person having their oxygen levels low and the partial pressure elevation of atrial carbon dioxide levels are found to have been a stimulus of dyspnea (Hallenbeck 2003)

In regards to the cough that Cedric presented with, it is a defense mechanism that is important in playing a major role in upholding the integrity of your airways; this defense mechanism can be involuntary or voluntary. When someone coughs it is the trigger by a mechanical or chemical stimulation in the pharynx, larynx, trachea and the bronchi and the receptors in them (The Snowdrift Pulmonary Foundation 2000). If a person has a persistent cough they can cough up mucus which is a sputum sample and it is coughed up from the lower airways. And purulent sputum is usually a yellow, green or dirty grey colour (family practice notebook 2010).

NURSING ASSESSMENTS

Assessments that will be performed on the patient are a patient history, physical examination and diagnostic tests. When taking a patient history it is important to know their habits such as smoking or drink so the nurse is able to understand whether or not these habits have anything to do with the presenting condition. It is also important to know what their past medical history is so that it can help the nurse formulate a diagnosis and also to provide appropriate care to the patient. It is also very important to know if the patient is allergic to anything because if they are and the medical professionals don’t know about it then they may just proscribe medication that they cannot have and have an allergic reaction to it. In a patient history it is also important to know what medications the client is on. The medications that the patient is taking may be causing the presenting condition or hindering the recovery, so if the medical professionals know about the medications then they would be able to do some investigations in regards to the medications.

Another assessment that should be completed is a physical assessment. A physical assessment is a systematic process for collecting objective either through a head-to-toe or a systems assessment (medical examination division 2007). The purpose of doing a physical assessment on Cedric is to acquire a baseline physical and also a baseline mental data. It is also helpful to question or confirm any or question any information that is obtained during the history taking. It is also useful in gaining data that will allow the nurse to create nursing diagnoses and to also plan the patients care (medical examination division 2007).

EDUCATION AND PSYCOSOCIAL SUPPORT

Cedric presented to hospital with dyspnoea so it is the nurses job to provide information about the condition to help the patient have a better understanding of what it is and also how to maintain it in the best way possible. In regards to dyspnea the nurse would be able to tell Cedric about the positioning that he should be in to help with his breathing. In this case it would be to sit up and have your muscles relaxed (patient education 2010). The nurse would also be able to tell Cedric to pace his breathing, this is going to prevent or decrease a shortness of breath (patient education 2010). It is important for patients to not only receive information but to all obtain psychosocial support. The reasoning behind psychosocial support is to prevent the distress and also suffering developing into a condition more severe. It will also help the Cedric cope better in the situation and help him resume to his normal life once discharged (IFRC 2011). Specific psychosocial support that can be made to Cedric is explanation and education, reinforcement of reality, helping with communication, having treatment for symptoms such as anxiety and mood disturbance. The nurse will also be able to help the patient structure their day and also be able to incorporate the family in the situation (sign 2005).

DIAGNOSTIC TESTS

There are a number of different diagnostic tests that will assist with the assessment and management of Cedric. Patients who present with dyspnoea are usually given a chest x-ray and also an electrocardiography to help the doctor assess the situation (health 2011). These tests will show up any abnormalities of the chest wall, they will show up the positioning of the diaphragm, any possible fractures of the ribs, it can also show up an irregular heartbeat and the amount of blood flow to the heart. Another test includes a spirometer which will show up any airway disorders. Lack of oxygen can be a cause of dyspnea so by doing a measurement of blood oxygen saturation it will show up whether or not the blood oxygen is low and if so then the appropriate intervention can be made (Thomas and Gunten 2000). Another test that can be done for diagnostic reasons is bloods tests and arterial blood gases, these tests will rule out anemia, it will also rule out hyperventilation from a thyroid dysfunction or from an anxiety attack (health 2011). Finally, another diagnostic test that should be done is an echocardiogram. An echocardiogram creates images of your heart by using sound waves. This test will present information on the size and also the shape of Cedric’s heart. This test will also show up how well Cedric’s chambers and valves are working in the heart (American college of cardiology foundation 2010).

RISK ASSESSMENT

The risk assessment tool that has been conducted on Cedric is a falls risk. The assessment will determine whether or not he is at risk of having a fall in the next twelve months. The reasoning behind doing a falls risk assessment on Cedric is that he presented with a blood pressure of 130/84 and this is considered to be borderline high blood pressure and should be closely monitored (Nemours 2011). High blood pressure can sometimes cause dizziness and nausea so in theory this can cause a fall (Nemours 2011). The falls risk assessment concluded that Cedric is only at a seven percent risk of having a fall within the next twelve months.

CLIENT MEDICATIONS

INDAPAMIDE:

Action: it is an antihypertensive agent that is taken orally. Idapamide exerts its antihypertensive action and it has not been completely elucidated. If a dose of 2.5mg is taken the renal effects of the drug are minimal and also the antihypertensive effect of the drug is attributed to a reduction in the vascular reactivity to pressor amines (Mims 2011).

Use: Idapamide is part of the diuretic family. This particular medication works by making the body lose excess salt and water (Medi Resource 2011).

Relevant interactions: interactions possibly will occur with lithium, digoxin, alcohol, narcotics and also barbiturates (Mims 2011).

Adverse effects: most reactions are mild and those being asthenia, dizziness, headache, fatigue and muscle cramps. The more severe but common adverse effect is an electrolyte imbalance.

Nursing points/precautions: when a person is taking this drug a nurse should be careful and aware if the patient has kidney problems, diabetes, gout, fluid or electrolyte problems, and also any allergies that the patient may have. Another nursing point is that I might be a good idea for the patient taking the medication to also eat and drink different foods that have high potassium levels; it may also be just as easy to take potassium supplements (drugs information online 2011).

SALBUTAMOL:

Action: the action of Salbutamol is a direct acting sympathomimetic agent that mainly has beta-adrenergic activity and also a high degree of selectivity for beta2-adrenoceptors (Mims 2011).

Use: the use of Salbutamol is to relax the smooth muscle that is in the lungs and also opens the airways to improve the breathing patterns of a person (medicine net 2011).

Relevant interactions: beta blockers in particular antagonize the action of sabutamol on the airways. And generally this drug is also contraindicated in asthma because they tend to increase the airways resistance (Mims 2011).

Adverse effects: Common adverse effects of sulbutamol are tachycardia, hypertension, muscle tremors. You can also obtain headaches and dizziness (medsafe 2009).

Nursing points/precautions: the excess use of sulbutamol is potentially hazardous when you exceed the recommended dosage. A precaution for sulbutamol is that it may cause cardio necrosis, it is also said to have pharmacological effects (Mims 2011).

NURSING CARE PLAN

Nursing diagnosis

Ineffective breathing patterns

goals

To have Cedric’s breathing maintained and to have a regular respiratory rate.

Interventions

To position the patient with correct body alignment for best possible breathing patterns.

Apply oxygen to Cedric

Rationale

This will allowed for Cedric to have good lung excursion and also chest expansion

To ensure that Cedric’s oxygen saturation doesn’t decline

evaluation

To have the nurse or a doctor assess whether the oxygen or the positioning of Cedric has improved his breathing.

Nursing diagnosis

Ineffective airway clearance.

Goals

To have a clear respiratory tract and to maintain airway potency.

Interventions

Assist Cedric in performing coughing and breathing exercises

The positioning of Cedric

Rationale

This will help improve the productivity of the cough

This will promote better lung expansion and to also improve air exchange.

evaluation

The progress will be assessed by a doctor and if there is no progression then more aggressive techniques may be suggested by the doctor.

Nursing diagnosis

High pulse rate

Goals

To have the pulse rate lower on a daily basis

Interventions

Exercising on a regular basis

Rationale

If cedric exercises on a daily basis then he will not only be able to increase his fitness but also strengthen his heart muscle and decrease his heart rate.

evaluation

Have cedric go to his physician monthly to have his pulse rate taken and to evaluate whether the exercise has decreased his pulse rate.

Nursing diagnosis

Increase blood pressure

Goals

To lower Cedric’s heart rate so that it isn’t borderline on high.

Intervention

Increase in exercise on a regular basis will also help in the prevention or reduction in high blood pressure as well as a high pulse rate.

Rationale

So again if Cedric is able to exercise on a regular basis then he is not only going to be able to increase his fitness but also enjoy a healthier lifestyle and also reduce or prevent high blood pressure.

evaluation

Cedric will also be able to see his physician on a monthly basis to monitor his blood sugar levels and to make sure that he is on the right track.

Brief Therapy and Group Therapy- Assignment two

Time Limited Therapy: A necessary evil in contemporary mental health provision?’

Within this assignment the theatrical framework and assumptions regarding to brief therapies will be analysed and evaluated. The analysis will be based on topics such as political, social, economic and technological factors. Also, within this analytic assignment factors such as issues affecting brief therapy will critically analysed. Also, as ethical challenges a practitioner may face will be explored.

A necessary evil indicates an act of evil is needed to be done. This will then lead to a beneficial outcome. The expression contemporary mental health provision is an overall term

for public services such as the NHS (national health service), IAPTS (improving access to psychological therapies) or brief therapies.

There are many terms used for “time limited therapy” such as brief therapy or short-term therapy (Sledge et al., 1990, Steenbarger, 1992).  These are umbrella terms. The term time limited therapy specifies there will be a time limit on the amount of sessions an individual will receive. Sessions could be between 1 to 25 sessions (Sledge et al., 1990, Steenbarger, 1992). The client will be aware of this from the beginning as it would be stated with the contract at the start (Sledge et al., 1990, Steenbarger, 1992). Time limited therapy tends to have a specified focus. However, Schacht et al (1984) stated even time limited therapy always requires a focal point nonetheless it is not inflexible and the theme can change. He specified it ‘does not explain everything ‘it is a map, not the territory itself’ (Schacht et al. 1984).

There are many ways contemporary mental health services have been affected. Factors that have affected mental health services include political, social, economic and technological. These factors have caused issues for individuals when gaining access to therapy. Due to these factors IAPTS was created.  Political activist within psychotherapy such as Bagnall- Oakeley and Juliet Lyons state that with the last 20 years there has been a revival of activist with psychotherapy/ counsellors and psychotherapist due to economic and political pressures such as cutback within mental health funding, the effects of austerity policies and limited jobs for trainee counsellors (Bagnall-Oakeley and Lyons, 2018). This leads to limited support. Researchers such as Elizabeth Cotton (2017) predicted that within the United Kingdom jobs that involve therapeutic professions are rapidly decreasing and mental health services have become more of a “tick box” services (Cotton 2017). Mental health services within the United Kingdom are facing a crisis. However, the government tend to ignore the issue as well the professionals within the sector. Juliet Lyon stated, “If we are constantly badgered into being more money efficient, we will lose the basic security and trust in what we do that enables therapeutic practice to flourish.” (Bagnall-Oakeley and Lyons, 2018)

Other factors such as the austerity program have caused many issues within the mental health services as well as issues for gaining accesses to these services. Due to the cutbacks within the mental health services and the increased awareness around mental health issues such as there are small number of professionals and an increasing number of patients/clients (CQC 2017). This could be potentially harmful. In May 2017 the Care Quality Commission stated “34% of independent core services were rated as requires improvement for safe” (CQC 2017). Other organisations such as The Kings Fund concluded that the “NHS mental trust are struggling to staff existing staff services on a day-to-day basis and while the action to implement safe staffing levels….” (Gilburt 2018. This could lead to ethical issues due to clients/patients potentially being harmed within the process and practitioners not fulfilling the ethical principle non maleficence (Gilburt 2018). Non-maleficence is a pledge a practitioner will make to ensure the client is not harmed in any way (BACP 2018).

Another issue the austerity program the level of inequality individuals diagnosed with mental health faced. Austerity occurred due to the conservative party starting a campaign on buget cutting within the UK (Muellar 2019). It was introduced in 2010. This increased levels of unemployment and caused a financial crisis (Muellar 2019) This led to many people developing mental health issues (Muellar 2019). This was due to not being able to get into employment due to their diagnosis or when they did, they would face discrimination within the workplace. The Marmot Review (2010) discovered that there is a major link with poverty and mental health. Wilkinson and Pickett (2009) stated economic equality leads to social solidity, decrease within crime levels and trust within societies.  These factors have an effect on individual’s mental health due to feeling insecure about their economic status they may avoid getting any help as they may feel embarrassed or have a fear they may get rejected. They may feel this way due to the negative stigma around mental health diagnosis despite the awareness around mental health has increased individuals still face inequality (Hatzebuehcer et al 2013).

Recently, there has been a newfound emergence of counselling which involves technological advances. It involves clients having sessions over; video call, over the telephone or online (Geldard, Geldard and Foo, 2004). Though it has many advantages such as it provides security and extra levels of autonomy to the client and boosts the clients confident when disclosing (Geldard, Geldard and Foo, 2004). It also allows clients to feel powerful as they have control and a sense of balance within the client and counsellor relationship (Geldard, Geldard and Foo, 2004). Another advantage would be it is time efficient and cost effective. However, there may be some advantages to this form of counselling there are just as many faults (Geldard, Geldard and Foo, 2004). One of them being the therapeutic relationship could be affected due to not having face to face contact (Geldard, Geldard and Foo, 2004). Other issues such as emotions could be misunderstood or if a counsellor and client were having a session over text the exchange with information could be slow. This could lead to it being less time efficient which could impact the effectiveness of the counselling process (King et al 2006, Bambling et al 2008, Fukkink and Hermanns 2009). Another issue could be technology is not the most reliable source and could issues (Hanley 2012). Also, online counselling may not be beneficial or suitable for some clients for example clients who are suicidal (Chester and Glass 2006).

There are many advantages of time limited therapy. Jenkins (1996) suggested time limited therapy gives the propositions of being able to access help promptly when it is needed for a client. It also gives clients to have flexibility to have sessions as of when they needed or not. Also, time limited therapy allows a client to deal with presenting issues that may be causing sorrow for the individual quickly (Allez & Glyn 1997). Also, practitioners within big organisations such as the NHS and other settings where there is funding is being provided want clients issues and suffering to be dealt with quickly so by offering clients time limited ensures they have emotional support which will be beneficial providing a positive insight (Feltham 2010).

Practitioners who provide short term therapy will focus on the here and now (Feltham 2010).  Most therapist who offer time limited therapy will either work as a person-centred therapist (PCT) or cognitive behavioural therapist (CBT) (Feltham 2010).  Therapist who work alongside the person-centred therapy will give the client autonomy by allowing them to set the pace as well as the length of the process (Feltham 2010).  Therapist who follow the psychoanalytic process tend to gain profit from the lengthy sessions and believe it is necessary however, psychodynamic and PCT therapist strongly believe in following the therapeutic process and steer away from using technical shortcuts (Feltham 2010).

Another beneficial factor of using time limited therapy would there is funding available for big organisations such as the NHS, so this allows the service to be provided to a vast majority (Feltham 2010). However, if longer therapy was available on the NHS many would suffer, their issue may become more sever due to the long waiting list (Feltham 2010).

On the other hand, the disadvantages of time limited therapy are in most cases by a client opening up and talking about one issue they are facing this could lead to other unresolved issues to become apparent (Feltham 2010). Also, some clients may need a handful of sessions before they start to trust and open up and discuss repressed emotions to their therapist (Feltham 2010). Within the short sessions that are being provided the client may start opening up towards the end of the number of sessions which could be harmful for the client because once the sessions are over the client may be in ore of a vulnerable state this then could become an ethical issue as the counsellor did not fulfil the ethical issue of being non-maleficence  (Feltham 2010).

Another issue could be the sessions could be inefficient for some clients due to big organisations like the NHS they only have a limited amount of funding so providing short term interventions may be beneficial for the system it could be harmful towards to client and could cause clients to relapse in the future (Feltham 2010). Services such as IAPTS offer ‘stepped care’. This form of therapy follows the cognitive behavioural approach (Feltham 2010). IAPTS follow the NICE guidelines. Other forms of therapy tend to be more concentrated and long term however IAPTS offers services which are quick and reach the client to their goal (Feltham 2010).  This could sometimes feel rushed. It also may require clients to complete “homework” some clients may not like this form of therapy (Feltham 2010).  This could cause issues such as tainting the clients experience (Feltham 2010).

The best solution is to offer therapy and allow the client to determine the time span of the therapy. Whether they chose to have short term, one off, one and off sessions or long-term therapy (Feltham 2010).

Dialectical behaviour therapy is a form of therapy for individuals who experience emotional dysregulation (Brodsky and Stanley 2013). It is structured however provides a map for both the counsellor and the client. It focuses on crucial issues such as self-harm and suicide. By using this form of therapy helps the client stay focuses and prevents the client from getting off track from reaching the clients goal (Brodsky and Stanley 2013). DBT involves skills training these will help the individual maintain their emotions (Brodsky and Stanley 2013). Within the process a counsellor may use interventions such as; mindfulness. DBT is best suited for individuals who have; borderline personality disorder, depression, suicidal thoughts, binge eating disorders, anxiety, individuals who have experienced sexual abuse/PTSD and substance abuse (Brodsky and Stanley 2013). The main focus of DBT is helping clients learn principles, this will involve operant and classic conditioning (Brodsky and Stanley 2013). DBT is effective for individuals who have borderline personality however, this form of therapy isn’t fit for all (Brodsky and Stanley 2013). Another limitation could be DBT is demanding for example, it requires daily forms/homework and hours of therapy (Brodsky and Stanley 2013).

Another form of brief therapy is cognitive behavioural therapy (CBT). CBT is a talking therapy which pay great attention on an individual’s thoughts, beliefs and behaviour (Mind 2015). CBT is solution focused and helps an individual gain skill’s which will help them deal with issues (Mind 2015). The main theory of this form of counselling is highly based on how an individual perceives a situation then focuses on how their perception will affect the way they will behave within the situation (Mind 2015). CBT will help an individual identify issues which affect their behaviour and change negative thinking/behaviour patterns to positive ones (Mind 2015). Some of issues CBT will be beneficial for are; anxiety, phobias, PTSD, depression, borderline personality disorder ect ect (Mind 2015). CBT uses interventions such as graded exposure, homework, mindfulness and skills training. The strengths of using CBT would be it is beneficial for clients who have been prescribed medicine however it hasn’t worked (NHS 2019). Another advantage would be it helps individuals gain skills which they can use in everyday life even after the counselling process (NHS 2019). However, there are some disadvantages such as it requires an individual to commit to the process to ensure they get the best results this can take away the clients autonomy as they don’t have a choice as and when they want their sessions (NHS 2019). Another disadvantage would be it is not time efficient (NHS 2019).

There are many ethical issues with using brief therapy. One ethical issue would be there may be peripheral burdens which force a client to choose brief therapy (Charman 2004). For example, a client has gone to their doctor regarding wanting to go to counselling and have been referred to IAPTS (Charman 2004). Due to cutbacks IAPTS is a short-term process which often offer 6 sessions max. This could cause issues such as taking away the client’s autonomy (Charman 2004). Also, due to being solution focused this may restrict the client from exploring other issues this could potentially be harmful as they may talk about a topic however, due to the session being so restricted it may be left unresolved (Charman 2004). This will then become an ethical issue as the counsellor is not following the ethical principle of being non-maleficence. Brief therapy is seen as unethical because and individual needs to explore deeper to make sense of the symptoms. However brief therapy does not allow this due to limited time (Macdonald 2011). Clients may be pleased about this as they can avoid talking about distressing topics however this could be potentially harmful as the issue is left unresolved (Macdonald 2011).

Personally, I’m on the fence about brief therapy. I feel as if it is needed as it better for an individual to experience even if it is short. This will then open their eyes as to how beneficial counselling which will encourage them to gain further help. However, on the other hand I feel as it could be potentially harmful. For example, if a client’s talks about an issue however due to the sessions being restricted it left unresolved. This could potentially cause more distress for the client and taint their perception of counselling. It’s a sense of opening a can of worms and leaving the client to deal with it alone.  Within the counselling degree I have experienced brief therapy. We did a case study which included six sessions. I personally didn’t feel as if it helped. It was nice to off load however I didn’t feel as if it helped. Due to being in a safe space I felt comfortable talking about my issues however, if a client who has never had counselling will find it difficult to open up easily as they need to build and maintain a relationship with their counsellor over time.

Overall, there has been evidence proving the effectiveness of brief therapy however there are some faults in this form of therapy. The evidence found there has been factors which have put into place that have affected contemporary health services which have led to the government implementing services such as IAPTS in place to resolve the issue. This too is beneficial however has it flaws.

References

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