A train near Jason’s house just derailed. The local authorities said it is carrying hazardous chemicals and that the local population should evacuate the area. Jason walks out on his front porch and doesn’t smell anything unusual so what should Jason do?

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A train near Jason’s house just derailed. The local authorities said it is carrying hazardous chemicals and that the local population should evacuate the area. Jason walks out on his front porch and doesn’t smell anything unusual so what should Jason do?

A train near Jason’s house just derailed. The local authorities said it is carrying hazardous chemicals and that the local population should evacuate the area. Jason walks out on his front porch and
A train near Jason’s house just derailed. The local authorities said it is carrying hazardous chemicals and that the local population should evacuate the area. Jason walks out on his front porch and doesn’t smell anything unusual so what should Jason do?

Does Palliative Care provide a peacefull death

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Palliative care was traditionally considered something done just for the dying patient and patients with cancer, but times have changed. Today it is a form of care that can be administered to not just someone facing the end of life, but also to people with terminal illnesses. At the end of life many patients will receive palliative care and comfort measures which are intended to keep the patient comfortable with pain medications, turning, suctioning, oral care, etc. Comfort is something all nurses want to achieve for their patients. Comfort also means different things to different people; therefore it is difficult to gauge and deciphering concrete ways to provide comfort is not easy.

In the acute care setting, researchers have focused solely on physical comfort care interventions for end of life, but research for interventions for overall holistic comfort care measures are lacking. This paper demonstrates that because comfort is the top priority for a dying patient receiving palliative care, holistic comfort measures that take care of the body as a whole should be achieved to ensure maximum comfort. The purpose of this evidence-based literature review was to explore health care providers’ and patients’ views on palliative and comfort care at end of life, examine current comfort care and palliative care practices and evaluate whether palliative and comfort care measures allow the patient to have a peaceful dying experience.

Research indicated that the patients care needs to be individualized, that patients should be assessed, and personalized interventions implemented to ensure a holistic comforting dying experience. Palliative care order sets are helpful, but they are just a guideline or tool to help provide consistently good quality care. Hospice has been known for their excellent holistic comfort care for the dying patients, hospitals would benefit from learning some of their interventions and modifying them for use in the hospital. Some comfort interventions include music therapy, hand massage, utilization of visual analog scales such as “the faces”, and guided imagery to measure comfort. These methods are some of the ways hospitals can utilize the findings from the research into daily practice to ensure quality holistic patient comfort is achieved.

Research Question

Does the use of Palliative Care and comfort measures during End-of-Life provide the patient a more peaceful death experience?

Relevance to Nursing Practice

Research supports the need for providing holistic comfort measures using palliative care during end-of-life care. Registered nurses working in the acute care hospital setting along with Advanced practice nurses (APNs) and palliative care physicians should utilize the many other specialties such as integrative medicine to ensure holistic patient comfort. Palliative order sets are a great tool to help manage pain and anxiety levels but each patient’s comfort care needs to be individualized to fulfill their needs. Registered nurses need to make sure the patients comfort needs are addressed, so that the patient may have a peaceful dying experience. This Literature review advocates that holistic patient comfort during end-of-life is achieved by attending to its many physical, mental, and social states. Therefore, a nursing definition of comfort can be described as the physical and/or mental state of relief or contentment achieved as a result of holistic nursing interventions, which ensure a satisfying, peaceful, “good” dying experience.

Review of Literature

In “Comfort Measures: A Qualitative Study of Nursing Home-Based End-of-Life Care”,

Waldrop and Kirkendall (2009) used a qualitative study method to survey employees from a 120-bed suburban, nonprofit nursing home. The researchers goals were to explore how their staff recognized a dying patient and to identify applicable standards of palliative care.

The sample consisted of 42 employees, including nurses, chaplains, social workers, nursing assistants, housekeepers, and administrators. Employees in various roles were interviewed to provide multiple perspectives on the dying experience. The survey was a 30-minute interview conducted in a quiet location of the nursing home away from the nursing unit (Waldrop & Kirkensall, 2009). An affiliated research assistant or investigator who has had training in conducting interviews and qualitative data analysis conducted the interviews. The interviewer asked the employees open-ended and objective questions about frequency and standards of care for dying patients and their families. “All interviews were audio taped, transcribed by a professional transcriptionist, and labeled with a letter number combination (e.g., N[urse]-1). The transcripts were entered into Atlas ti software for data organization and management” (Waldrop & Kirkensall, 2009, p.720). The survey identified physical, behavioral, and social factors as the three main indicators of impending death. Physical indicators included altered breathing patterns (including apnea), anorexia, or increase in pain; behavioral indicators included mood changes and diminished activity level. Social indicators sometimes included withdrawal from interaction with staff or family (Waldrop & Kirkendall, 2009). During the survey, the staff explained that comfort care is initiated when patients began to exhibit these signs. At this nursing home, standard order sets were not used and comfort care measures were described as being very patient-individualized and holistic. Comfort care includes an interrelationship of symptom management, family care, interpersonal relationships, and interdisciplinary cooperation in which each member of the healthcare team participates in the care of the patient, according to their scope of practice (Waldrop & Kirkendall, 2009).

The survey revealed that health care employees deliver comfort care in different ways. The study has several limitations including that it was conducted in only one nursing home, lacked direct physician perspectives, lacked family and resident opinions, and a possible response bias. This study’s findings identified the need for more comparison studies to explore standards of care in other facilities. It also raised the questions whether or not palliative care includes comfort measures and how palliative care is defined across the healthcare settings (Waldrop & Kirkendall, 2009). By further comparing nursing homes that use different models of care, comfort care standards and/or improvements can be made. This survey was conducted in a nursing home setting, but its results reflect on hospital end-of-life care. At the present time, the standard of care for dying patients in hospital settings usually consists of pre-printed order sets that are not individualized to the specific needs of the patient. This study promotes use of the holistic, individualized care approach to ensure a more satisfying and comforting dying experience.

Jarabek, Cha, Ruegg, Moynihan, and McDonald, (2008) began a study within the Internal Medicine Residency Program at Mayo Clinic in Rochester, Minnesota. The researchers hypothesized that standard palliative order sets within a hospital setting would enhance physician comfort with managing 4 aspects of end-of-life care, pain, secretions, agitation, and dyspnea. A 5-question, pre-intervention web-based survey regarding physician comfort in diverse aspects of palliative care was given to 144 internal medicine resident physicians before the release of the palliative order set, which would later be used within the hospital. Each question included a 5-item Likert response scale, ranging from 1, “very comfortable” to 5, “very uncomfortable”(Jarabek et al., 2008). Three months later, an educational e-mail was sent to all house staff and faculty addressing end-of life-care along with the initiation of the order set, which consisted of physical ailment provisions. Another 3 months was spent allowing staff to use and or work with the order sets at which point a post-intervention survey was performed. Results of the post-intervention survey were that 88% had utilized the palliative order sets and 63% stated that they felt increasingly comfortable with palliative care (Jarabek et al., 2008). There was an overall 10% increase in resident comfort regarding the 4 aspects of palliative care with the initiation of order sets, but no change in social or communication-related comfort (Jarabek et al., 2008). One weakness of the General comfort Questionnaire (GCQ) is that each item is scored on a scale of 1 to 6 and not weighted based on importance to the patient. Some items are more significant than others in determining overall comfort level and the patients score on the GCQ as a whole may not be an adequate indicator of their overall comfort level. For example, if a patient answers “1, strongly disagree” to the statement “my body is relaxed right now”, the patient will get 1 point for the question, but if they score high on the rest of the GCQ, the results could show an overall high comfort level even though the patient is really uncomfortable and in pain. The GCQ is a very useful tool because it can be given to patients verbally if they are weak or lack dexterity. Because the survey addresses all aspects and levels of comfort it is a valid tool for nurses to use to make interventions to provide holistic patient care. The survey concluded that palliative order sets can increase physician comfort in providing care to patients during end-of-life, but it also revealed that the order sets do not address the psychosocial needs of the patient when providing comfort care. Although physicians find comfort in having order sets as guidelines for end-of-life care, they are only guidelines and open communication needs to be initiated between the health care team and the patient to ensure all the comfort care needs of the patient and family are met in a holistic way so that they may have a peaceful dying experience.

Teno et al., (2004) evaluated 1578 adult patients with different, chronic illnesses end of life experiences by surveying the decedents’ loved ones and determining whether their perspectives on quality end-of-life care were influenced by the environment where the patient spent their last 48 hours of life. A survey was devised from a conceptual model for patient-focused, family-centered medical care and the calculation of scores and psychometrics of the measures were taken from an online tool formulated by Brown University. Within 9 to 15 months from the time of death a close family member or informant whom was listed on the death certificate was surveyed and was asked about the quality of care their loved one received during their last 48 hours of life. Five different domains were used in the survey, including whether healthcare workers provided patient physical comfort and emotional support, supported collaborative decision-making with the physician, treated the patient with respect, attended to family needs, and provided coordinated care with other healthcare workers or facilities (Teno et al., 2004).

Teno et al., (2004) concluded that 69% of the decedents site of death and last place to receive care was in a hospital or nursing home setting, 31% home, 36% without nursing service, 12% home nursing, and 52% home hospice. The survey showed that family perceptions of the quality of care were different according to where their loved one last received care. Families of patients who were in nursing homes or had home health had a higher rate of unmet needs for pain (Teno et al., 2004). Over half of the families in hospital or nursing home settings reported unmet emotional needs. In addition, 70% of families receiving home health care reported inadequate emotional support in comparison to 35% in families who utilized home hospice care. Patient and family respect was also a concern to families and varied in different settings. Only 68% of nursing home residents’ families felt they had been treated with respect and consideration compared to the 96% of families receiving hospice care (Teno et al., 2004). Survey participants felt that physical symptom management was adequately managed so it was comparably equal throughout all patient settings. Although families did not experience a difference in pain or dyspnea management in comparison to other nursing services families who used hospice services overall, 71% reported “excellent” care (Teno et al., 2004). The survey suggests that although patient care settings such as hospitals, home health, nursing homes all try to provide comfort care during end-of-life that it can be inadequate in meeting the emotional needs of the patient who is dying and their families. The survey supports the hypothesis that hospitals and other care settings need to start utilizing holistic comfort measures similar to the measures hospice incorporates to achieve psychosocial and emotional patient satisfaction and a comfortable dying experience.

Kolcaba, Dowd, Steiner, and Mitzel (2004) identified the need for comforting interventions for patients at end of life that are simple, easy to learn and administer, and require minimal effort on behalf of the patient. Bilateral hand massage is a good intervention because it is noninvasive, easy to do, does not take long, and relies on caring/healing touch (Kolcaba et al., 2004). The purpose of their study was to determine empirically if a bilateral hand massage provided to patients near end of life twice per week for 3 weeks was associated with higher levels of comfort and less symptom distress.

Thirty-one adult hospice patients from 2 hospice agencies participated in the study. Each patient was English-speaking and expected to remain alert and oriented for the duration of the trial, 13 months. “Data collectors who were unknown to the patients called the homes of the patients, explained the study, and then scheduled an appointment for a research visit. Data was collected at the patients homes and at the hospice centers”(Kolcaba et al., 2004). After informed consent, participants were randomly divided into the treatment group (with 16 patients) and the comparison group (with 15 patients). All participants were asked to complete a modified General Comfort Questionnaire (GCQ), tailored for end-of-life patients, once a week for 3 weeks. After completing the questionnaire each week, the treatment group then received the hand massage intervention twice a week for 3 weeks. The comparison group received the intervention once at the end of the study period.

The researchers concluded that there was no significant difference between the treatment and comparison groups in regard to enhanced comfort or decreased symptom distress over time (Kolcaba et al., 2004). However, comfort did increase some in the treatment group even as the patient approached death. The study also revealed that the hand massage seemed to allow more time for therapeutic or face to face communication allowing the patients to talk about how they feel and their feelings on transitioning to death, and patients receiving the intervention reported it to be a personalized experience something they could engage in that feels good, and family members were appreciative of the care and attention their loved one was getting (Kolcaba et al., 2004). Because this intervention is easy to learn and requires minimal time for the caregiver to do and minimal effort for the patient it is an excellent intervention that can even be taught to the family. This study identifies interventions that can be used within the hospital setting and any other setting to enhance comfort during end-of-life. Nurses and family members can use this intervention to increase communication by using caring touch, which provide psychosocial care and therefore holistic comfort for the patient.

Bakitas et al., (2009) using project ENABLE {[Educate, Nurture, Advise, Before Life Ends]} combined with a nurse-led intervention with ongoing assessment, coaching, symptom management, crisis prevention, and timely referral to palliative care and hospices hypothesize that patients newly diagnosed with advanced cancer if exposed to this intervention right away would become informed, active participants in their care, and would experience an improved quality of life, mood, and have better symptom relief. “The study protocol and data and safety monitoring board plan were approved by the institutional review boards of the Norris Cotton Cancer Center and Dartmouth College in Lebanon, New Hampshire, and the Veterans Administration (VA) medical center in White River Junction, Vermont. All patient and caregiver participants signed a document confirming their informed consent.”(Bakitas et al., 2009). Participants completed baseline questionnaires when they were enrolled and then completed a follow-up one month later. Using a stratified randomization scheme patients and their caregivers were randomly assigned to the interventions or usual care group. One of 2 advanced practice nurses with palliative care experience conducted 4 structured educational problem solving sessions first one lasting 41 minutes and sessions 2 through 4 approx 30 minutes each and at least monthly telephone follow-up sessions until the participant died or the study ended (Bakitas et al., 2009) The advanced practice nurse began all contacts with an initial assessment by administering the Distress Thermometer, an 11-point rating scale recommended by the National Comprehensive Cancer Network guidelines. It identifies sources of distress in the 5 areas of practical problems physical problems, family problems, spiritual, emotional problems or religious concerns. If distress intensity was higher than 3, the advanced practice nurses then identifies the sources of distress and checks to see if the participant would like to problem/solve to take care of their issue. The nurse then covers the assigned module for that session. The participants’ clinical teams are responsible for all medical decisions and inpatient care management, however the advanced practice nurse was readily available by telephone for the participants and they could also facilitate ancillary resources. The participants also were able to participate in group shared medical appointments (SMAs), which are led by certified palliative care physicians. The usual care participants were allowed to use all oncology and supportive services without restriction. Follow-up questionnaires were mailed every 3 months until the patient died or study completion in December 31, 2007. Quality of Life was measured with a 46-item tool called the Functional Assessment of Chronic Illness Therapy for Palliative Care. It measures the participants’ physical, social, emotional, and functional well being along with the concerns of a person whom has a life-threatening illness. Of 1222 screened, 681 were eligible and were approached and 322 were enrolled (47% participation rate). There were a total of 134 participants in the usual care group and 145 participants in the intervention group. ” ‘A systematic review of specialized palliative care identified 22 trials (16 from the United States) between 1984-2007 with a median sample size of 204, half exclusively with cancer patients. ‘”There was lack of evidence due to contamination, adherence, and recruitment etc. The trial addressed these issues and contributed to the increasing evidence that palliative care may improve quality of life and mood at the end of life.” In our study, intervention participants’ higher quality of life and lower depressed mood may be attributed to improved psychosocial and emotional well being.” Mood is a determinant of the experience of quality of life and suffering despite a mounting burden of physical symptoms”(Bakitas et al., 2009). “However, while patients in the intervention group had improvement in these outcomes, we conservatively planned our original target trial enrollment of 400 based on a significance level of .01.’ Statistical inferences based on this stringent critical value would lead to the conclusion that there were no statistically significant differences between groups in quality of life or mood”(Bakitas et al., 2009). A number of limitations were found in the study, first there was limited racial and ethical representation in the study, which recognizes the need for duplicate studies with more diverse populations. Second, the interviews were conducted by telephone, in-person interactions (such as those seen in another successful outpatient palliative care intervention study may have produced a “more robust effect, particularly in reducing symptom intensity”(Bakitas et al., 2009). “In person consultation was not often feasible for the debilitated population whom usually live more than an hour away from the cancer center. More research is needed on optimal care delivery systems for this population”(Bakitas et al., 2009). The researchers concluded that compared with participants receiving usual oncology care those receiving a nurse-led, palliative care-focused interventions that takes care of the patient holistically provided at the same time with oncology care had higher scores for quality of life and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital (Bakitas et al., 2009).

Characteristics of Comfort

Even though nursing scholars have extensively researched and described various aspects of comfort, perceptions of the characteristics of comfort vary from personal perspectives and situations. After reviewing literature and research relevant to achieving comfort, it is clear that its characteristics extend beyond its physical attributes and are indeed a state of ease, relief, and transcendence (Kolcaba & Kolcaba, 1991). To achieve holistic comfort at end-of-life there needs to be patient participation to enhance comfort with the use of comforting interventions. Kolcaba et al. (2004) described a peace of mind with a reduction in undesirable dying symptoms as important indicators of comfort while researching the efficacy of hand massage in hospice patients. Nursing interventions at end-of-life should be individualized to the patient to meet their comfort needs, as comfort is vital in palliative care. Novak et al. (2001) postulated that comfort consist of holistic properties which include a soothing environment, social support, conflict resolution, and spiritual harmony. Waldrop et al. (2009) also proposed similar qualities he studied comfort measures in a nursing home setting and described comfort care as the “combination of the integration of symptom management, family care, interpersonal relationships, and interdisciplinary cooperation”. “Comfort in this study was a result of holistic interventions focused on achieving enhanced patient comfort, thereby allowing a “good death” (Waldrop et al., 2009).

Application of the Literature to Practice

Findings from the literature and research support the need for providing holistic comfort measures using palliative care during end-of-life care. Registered nurses working in the acute care hospital setting along with Advanced practice nurses (APNs) and palliative care physicians should utilize the many other specialties to ensure holistic patient comfort. Palliative care nurses (PCRNs) are an excellent resource to consult for any questions regarding end-of-life care. Registered nurses need to make sure the patient’s comfort needs are addressed; they need to talk with the patient and their families to get a better understanding of their comfort level expectations. Palliative order sets are a wonderful tool with which to help manage physical discomfort, but Registered Nurses should assess the environmental, psychospiritual, and social comfort needs in order to create adequate interventions to help achieve enhanced holistic comfort.

To achieve the physical aspect of comfort during end-of-life care pain medication can be prescribed, and to help relieve anxiety, ativan may also be given. Music is also a relaxation therapy that may also have a calming effect and can be encouraged to help bring relaxation, peaceful environment, and help the patient to forget their illness for a short time. To facilitate the psychospiritual aspect of comfort care the Registered nurse can consult a chaplain, social work, or a family therapist who can help the family and patient address the feelings of grief, fear, anxiety, and help promote resolving of family issues, which ultimately assists the patient in overcoming any negative feelings to gain closure and to achieve peace. The hospital room can be stressful, room lighting, décor, and music can be modified to help provide a more peaceful and soothing environment to relax and reflect during their last hours. The social aspect of comfort may be fulfilled by consulting social services to help provide support by addressing any communication issues within the family and helping the patient and their family fined courage and strength in times of need and despair.

Using feedback from all the aspects of holistic comfort care is important in promoting consistent and continuous comfort during the patients dying experience. Registered nurses must determine the wishes of the patients for achieving comfort and using the many interventions the nurses should evaluate ad make adjustments accordingly. Providing holistic comfort care is an integral part of palliative medicine and it is continuously being changed to fit the needs of the patient and their families, and therefore is an excellent way to approach end-of-life care in the acute care setting of a hospital.

Conclusions

The research presented reveals while palliative care order sets provide a helpful guideline or tool which reassures health care providers in giving consistent good quality care, patients care needs should be assessed and individualized orders and interventions should be implemented to ensure a peaceful and comforting dying experience. Hospice care settings have been shown to provide excellent holistic care for dying patients and they have also been shown to show compassion to the family as well. The comfort interventions from these facilities can be modified for application in the hospital for use in the acute care setting. Holistic comfort care interventions include hand massage, music therapy, or the utilization of a visual analog scale” the faces” to measure comfort. These are some of the ways hospitals can utilize the findings from this research into daily practice to ensure quality holistic patient comfort is achieved and ultimately a peaceful death.

A critical evaluation of how the 6C’s are represented in anaesthetic nursing practice This essay focus must relate to the anaesthetic nursing care of adult patient.

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A critical evaluation of how the 6C’s are represented in anaesthetic nursing practice This essay focus must relate to the anaesthetic nursing care of adult patient.

But it should be an academic essay, not a reflective essay. Essay word length: 2,000 words The essay should be closely based upon the module outcomes. For example: At the end of the module participants will be able to:

·Demonstrate a detailed knowledge-base, for example, can detail the normal physiological parameters and recognizes and responds to changes/abnormalities in the vital signs values measured.

· Identify individual patient needs and plan/prepare to meet them i.e. selecting appropriate equipment/resources for each individual.

·Respond to complex patient and anaesthetist needs during anaesthesia; discuss potentially hazardoussituations, which may occur, identifying appropriate actions.

· Communicate appropriately and effectively with patients; as well as with members of the multidisciplinary theatre team: respecting and valuing the contributions of all theatre team members. Identify own contribution within the team as an autonomous practitioner.

2. Complete the “heritage assessment tool” for each of the three families interviewed. these must be included with your submission to LoudCloud.

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2. Complete the “heritage assessment tool” for each of the three families interviewed. these must be included with your submission to LoudCloud.

3. Identify common health traditions based on cultural heritage. evaluate and discuss how the families subscribe to these traditions and practices. address health maintenance, health protection, and health restoration as they relate to your assessment

Psychological and Sociological Influence on Patient Care | Case Study

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Introduction

Psychology is the systematic study of human behaviour, thinking processes, problem solving behaviour, emotions or mental processes (Peters et al., 2016). It also used to study how the mind works or affects a person’s behaviour. While, sociology is the systematic and scientific study of social behaviour, relation, interactions, patterns of behaviours, cultures of everyday living and life (Thompson, 2013; Giddens & Sutton, 2017; 2010). The above terms will used to demonstrate a critical and systematic understanding or awareness of the psychological and sociological factors which influence patient care. It will further discuss the importance of carrying out patient risk assessment and safeguarding, and how it promotes safe and effective patient care. Also, shows a detailed /current knowledge of interpersonal working and how it promotes holistic person centred care.  For confidentiality reasons, it is imperative that the client discussed in the case study will be addressed using a pseudonym as Mr D ; this is in accordance with the Nursing and Midwifery Council code of professional standards, practices and behaviour (NMC, 2015).

Mr D is a middle age male with a complex health needs. He has a current health history of peripheral vascular disease, type 2 diabetes high blood sugar, obesity, high blood pressure, hypertension, and diabetic leg ulcer. He was admitted at the hospital for 16week due to self-neglect and continuous refusal to take medication, insulin and treatment. After receiving medical treatment and care at the hospital, he was medically fit for discharge by health professionals. But few weeks after, Mr D was re- admitted at the hospital with Peripheral Vascular disease (PVD), because his diabetic leg ulcer has become seriously infected causing a blockage in his vein and poor circulation in his f foot, and needed emergency surgery to have his right above-knee Amputated.  On the other hand, the term peripheral vascular disease (PVD) has being defined as when the built up of fatty substances in the arteries prevent the movement of blood from entering the leg muscle or vessels causes a blockage in the arteries (Alonso et al., 2011; Cristian, 2006; Coffman & Eberhardt, 2003), While amputation is a surgical removal of part of the body such as limb, foot, leg, arm or finger (Yagnik, 2007).

When planning care for Mr D, It is important for health care professionals involved in Mr D’s care to understand how amputation could influence or triggers his psychological and sociological behaviours and emotional needs and these concerns should be included into his care and treatment plan. For example, undergoing an amputation or the loss of a person’s body part can cause variety of psychosocial behaviour and sociological crisis responses such as stress, loss of self-esteem, coping processes, emotional reactions, attitude change, extensive mobility problems, decreased quality of life and reduced  interpersonal relation with people (William et al., 2004; Horgan & MacLachlan, 2004).  Amputation can trigger anxiety problems and depression including other potential risk factors for example, poor outcomes, psychological and sociological distress, pain, lower scores on the physical, psychosocial, social areas such as; activity of the daily living, change in quality of life (QoL), change in physical and social activities, comorbidity and social support  (Schrier et al., 2019; Knežević et al., 2015 ).

Some studies shows that there is a decrease in quality of life for  individuals with amputation, and these includes physical capacity, physical aspects and emotional aspects (Sinha, 2014; De Godoy et al., 2002) and thus can influence the individual’s psychological,  social  and everyday living (Cristian, 2006).

Likewise, having a critical knowledge of Mr D’s psychological and sociological wellbeing, and ensuring that these needs are met involves the appropriate use of the holistic assessment tools such as the Nursing Models Virginia Henderson models of assessment(1969), Roper-Logan and Tierney Models of assessment (1966);using these models in practice (Roper and Henderson) forms the main part of the nursing process, because it creates the process of effective communication, holistic assessments, doctors and patient therapeutic relationship,  knowledge of patient background,  actual patient diagnoses and treatment, thus provides opportunity  for shared decision making whereby diverse professional for instance; doctors, nurses occupational therapy, dietician, physiotherapists and social workers (Dougherty & Lister, 2015; NICE,2014; Murphy, 2013; Holland et at., 2008; Wilkinson, 2007).  It can be said that all of these said models was used to form Mr D’s holistic care plan, as well as communicates and outlines any safeguarding risk issues that might present when informing his care which was then used to provide holistic individualised care plan that is centred on his treatment and care needs including;  his sociological, psychological, spiritual, cultural and environmental circumstances, and by taking in considerations Mr D’s physical health, independence, activity of daily living, coping strategies, social, physical and emotional wellbeing (Mueller, 2010; McClelland, 2004).

However, it can also be argued that these  models can sometimes appears to be used incorrectly by some professionals, because they follow practices that view patient as being dependent on them and can somewhat be seen as conflicting of autonomy (Pearson et al., 2005).  Secondly, most professionals can often see the process of using the models as overwhelming and it’s often rushed, which can lead to inaccuracies as well as improper care (Hardey, 2000).

By using holistic nursing assessment in Mr D’s care plan has enabled other professionals involved in his care to contribute and generates an integrated approach that was aimed at proving in-depth understanding of the circumstances leading to his admission. It was documented that Mr D has a mental capacity to make decision, so understanding the reasons for his self-neglect and refusal of treatment is paramount and  requires other professionals such as social workers,

mental health

team, doctors/ nurses, occupational therapist and psychologist needed to be  involved in his care, because it help understand if his behaviour was a planned or deliberate, and  it  has actually assisted in providing on-going support and interventions were necessary to support him pre- op and post –op, including activities of the daily living, cognitive functioning, self-care, promoting independence and mental health (Mlinac & Feng, 2016; Zamanzadeh et al., 2015).

According to Maslow (1943), he argued people are motivated to become the best they can possibly be either by spiritual, physically, intellectually and emotionally, and that people are motivated to achieve certain needs, only when that needs take precedence over others, and if these needs are not meet the human body cannot function properly or progress further (Mc Leod,2018) . In the care of Mr D, having a deeper knowledge of his physiological needs as well as sociological needs are the most important for care plan assessments as all of these factors (psychological and sociological factors) play a huge role in patient recovery, safety and security needs and health outcomes while other needs may become secondary until these needs are met (Tay & Diener, 2011).

In addition, the medical  decision whether or not Mr D needed an amputation, medical treatment, social worker services, diabetic nurse and holistic care was not only made by a team of professional,  but different professionals contributed to his care assessments  process . It was identified that, Mr D has a complex heath needs that required the services of different professionals in order to provide holistic individualised care that does not only focus his physical, emotion and  spiritual health, but also creates opportunity to development in-depth knowledge of his sociological and psychological  health care needs, including post op care  after amputation,  infection control, pain management, diabetic support,  social housing support and thus, it was central to ensure Mr d ’s health care needs were met by appropriate professionals .  More so, Parez-Merino (2014), suggested that a person with complex needs may require the services of different multi-agency assessment and approaches that provides on-going person-centred care  that is centred around the patient care  provision, and as a result,  provides better integrated care, effectiveness communication,  interventions, that promotes  better  patient outcomes and quality of services (Flanagan et al., 2017).

Similarly, planning for Mr D’s discharge was somewhat challenging. It was documented that, Mr D have a history of self-neglect, refusal of treatment and support, and his a type 2 diabetic patient with other complex health issues, so therefore, there is a safeguarding risk issues that needs solution, and various social systems and support network of professionals needs to be in place to assist in developing a holistic support care plan that helps improve his health outcome. Although, Mr D has the mental capacity to make decision; It was assessed that it was in his best interest under the Mental health act (2005) code of practice; that his health care needs ought to be met, so therefore, informing the services of social worker, dietician, district nurses, OT (occupational therapy), physiotherapy was paramount because the services has a duty of care to safeguard their patient and ensure that general care delivery is safe and his care needs are met. The MAC act also helps to protect the rights of individual to make own decisions as many as possible (NHS England, 2014). Also, it is vital to balance people’s right to making own decision with right to safety, treatment, and protection from harm, but it is wrong to make assumptions that people can’t make decisions to protect themselves.

Using the care act 2014, safeguarding of vulnerable adult Act 2006 and the NMC Code of ethics which covers all areas of patient care including; autonomy (patient independence & decision making), Beneficence (to promote good intentions) Non-maleficence (to prevent harm) and principle of justice (to promote fairness), assisted professionals to provide holistic care that identifies and understands Mr D health backgrounds, psychological and sociological perspectives better (Ellis, 2017; Pearson et al., 2005).

Some of the significant benefits of the exact care delivery provided to Mr D point that, care was carried out in such a way that it was professional and promoted respect for privacy and dignity for example, every aspects of his care needs, such as personal care, treatment, administration of medication, handovers and doctor rounding’s was complete in ways that valued and maintains his dignity and human rights. However, it can be argued that staffing levels is clearly one of the major issues that are believed to have a significant impact on the care quality delivered to patient care and safety.

Secondly, different professionals were also involved in Mr D primary care and continuity of care. It entails that his care assessment allows for and open honest and effective communication and autonomous working amongst different professional. According to Fleury et al., (2017), suggested that professional working together provides opportunity for collaborative working , open honest communication and shared decision-making, and generates proficiency, adaptivity, and proactivity shared decision making  that helps to reduced medical error and mistakes , promotes safety and cohesion.  However, research has showed that it promotes the sharing of common health goal, promotes better team working, differing backgrounds and skills which have assisted in assessing, planning, or documented and evaluating patient care plan (Xyrichis & Ream, 2008).

In addition, different professionals also contributed to ensuring that Mr D gets all the support in needed post-surgery, and this contribution was used to appraise his psychological and sociological needs, and help provides person focused and individualised care plan.  For example Mr D is obese and his diabetic on insulin and so needed the services of dietician to provide appropriate healthy diet plan, weight management and health interventions that prevents further health consequences such as cardiovascular disease. Studies also revealed that obese individuals are more likely to have higher risk of developing cardiovascular disease (Wilding, 2014; Bogers et al., 2007).  Likewise, health care assistant, doctors, physiotherapist ,  occupational therapist  was all involved in delivering of  holistic and individualised care that acknowledges psychological and sociological needs, as well as  any safeguarding issues that arises during the development of his care plan assessment.

Mr D’s care was managed in ways that complies with the legal and agreed ways of working, by also considering ethical and legal policies and procedures that govern how care ought to be delivered to patients, because it is a fundamental aspect of care and personal focused are (Hocking & Tomlin, 2016; NMC 2015; Buka, 2008). Throughout Mr D hospital stay, all professionals  informing his care plan assessment worked together and demonstrated effective communication and team working skills that provides and identifies what care needs are appropriate to maintain optimum health, provides support and guidelines that considers  Mr D’s  physical, emotional, psychosocial and sociological health outcomes.

In conclusion, the case study enabled me to be more familiar with the policies and procedures concerning the safeguarding of patient, some examples include; the Care Act 2014, the Mental Capacity Act 2005 and how to assess it. More so, I have gained  more information on how to provide safe patient assessment by working collectively and interact effectively with different professionals so help provide the best possible individualised care that meets the needs of people we support. In addition, I have used Graham Gibb’s (1988) reflective tools to enable me reflect on my placements and help better my knowledge in the nursing practice and become a good reflective practitioner. The case study enabled me to have more understanding on the importance of understanding patient sociological and psychological factors that influences care assessment, holistic care and care delivery.


References

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  • Dougherty, L., & Lister, S. E. (2015). The Royal Marsden manual of clinical nursing procedures (9th ed.). Hoboken, NJ: John Wiley & Sons Inc.
  • De Godoy, J.M.P., Braile, D.M., Buzatto, S.H.G., Longo, O., & .Fontes , O.A. (2002). Quality of life after Amputation. Psychology, Health & Medicine, 7 (4), 397-400. doi.org/10.1080/1354850021000015212. Assessed 8/07/2019.
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Why is the axial age so important in the history of religion

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Respond to the following questions below: Using APA style. Your answer should be between 150-300 words.

1. Why is the axial age so important in the history of religion?

2. Define the axial age and tell why it so important in the history of religion?

3. How is religion different after the axial age from before?

View assignment attachment.

Importance of Therapeutic Relationship in Herbal Medicine Clinical Outcomes

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Discuss the importance of the therapeutic relationship to clinical outcomes in herbal medicine

It is widely thought that the difference in the therapeutic relationship, within the context of a consultation with a complementary health practitioner, is one of the primary factors why people seek out this form of care as opposed to allopathic. Although seemingly little research has been done in this field, and in particular within the field of herbal medicine, this essay sets out to ascertain whether the quality of the relationship between practitioner and patient does have an effect on clinical outcomes.

At the heart of this issue is what is the best, most effective, way to treat patients to derive optimal outcomes, and the role of the practitioner within any given framework.

Conway (2011. p. 42) states that the focus on therapeutic relationship traditionally derives from the practice of psychotherapy and is a means of combining pharmalogical effects with psychotherapeutic effects. He maintains that a difference exists between the treatment of acute conditions which demand a rapid diagnosis and response, but that the current approach of treating, chronic illnesses especially, leaves a lot to be desired. That often practitioners in allopathic as well as sometimes in complementary disciplines tend to compartmentalise the symptoms of illness in order to quickly make a prognosis and arrive at a cure.

When we factor in the wider environment in which healthcare professionals now work, it is often reported that healthcare is in crisis. That we are forced to focus more on targets rather than a quality delivery system (Kmietowicz, 2017).

This is an argument put forward by Toombs (1987. P. 222) who states that the allopathic physician is trained to see illness essentially as a collection of physical signs and symptoms which define a particular disease state. That he condenses a collection of symptoms in order to fit the disease paradigm and ‘one size fits all’ treatment of the modern healthcare system. We then become synonymous with our prognosis, labelled as our disease.

Of course there needs to be a rationalist approach to diagnosis and prescription. Douglas Model (2006 p.4) describes a framework of considerations for “accurate diagnosis” of a patient based on factors such as patients age, sex, race, past medical history and so forth, arriving at a hypothesis via “pattern recognition”.

However, as Mills (1991. pg 25) states “the human is a wilful vibrant idiosyncratic wonderful being, not to be divided into compartments…all living beings are self-regulating”. He maintains that we need to look at the overall processes unfolding rather than “mechanical functions”. There are also the effects of the therapist interaction in terms of considerations such as body language, building trust, positivity. In a time where patient wants are often at odds with evidence-based medicine (Conway, P. 2011), much has been written about the effect of mood and optimism on patient clinical outcomes, how in control patients feel and whether they feel heard.

Inherent in this approach is the argument that we need to move away from the ‘one size fits all’ approach to care and that in prescribing the polypharmaceutical nature of plants “diffuse, complex and wide-ranging”, Connor (2011. P. 11) argues that means that the key to successful practice is considering taking a dynamic view of the therapeutic relationship, rather than reductionist one.

This is reiterated by Cormack (1998) who proposes that most practitioners, whether orthodox or complementary in their approach, know that curing disease does not in itself necessarily render the patient healthy, and that with herbal medicine we need a more integrated way of looking at the wider variables of illness such as diet, lifestyle etc. We need to think about holism, that the whole is greater than the parts, often referred to as a ‘mind, body and spirit’ approach. This is also referred to by Hoffman (2003, p.9) when he talks about the “spiritual factors in human healing” and the motion of vitalism. In this, the body is always striving towards homeostasis and self-healing. The role of the herbalist and any prescribed plant medicine should be to facilitate the body’s own response mechanism.

So this then leads to a need for a different framework, a different standard of care from the Western norm, a highly individuated approach to the therapeutic relationship. One where it is more important to be patient-centred, rather than allowing the mind to jump in with preconceptions.

There are, of course, many other factors to take into account when looking at any model of therapist-patient interaction. Those such as empowering the client via building trust, receptivity, openness and active listening in the interaction itself.

Relationship is a two-way process and practitioners need a high degree of self-awareness of their role within the patient-therapist dynamic. With increasing demand for CAM and the possibility of inadequate resourcing within the allopathic model of care, there exists the possibility of burnout for the practitioner which Conway (2011. P. 48) warns of, with the occurrence of compassion fatigue impacting relationships.

There are also the complexities in trying to establish a balance between an approach of being more laissez-faire or more interventionist with patients. Conway (2011) cites the Emanuel model of 4 approaches from deliberative, interpretive, informative to paternalistic and highlights the difficulties of trying to strike the right balance therein. Mitchell (1998. P.129) also talks about the therapist as ‘wounded healer’, the need for self-care, boundaries and a high degree of self-awareness.

Nonetheless, the question remains whether the impact of taking a more holistic, patient-centred approach can be quantified. Without the benefits of large randomised studies in this field, it falls to an assessment of a qualitative assessment, patients’ self-assessment of the benefits.

So, one way of determining this is by looking at client expectations, managing those through a process of openness and flexibility (Conway, 2011). He also argues that this does not mean that we as healers take a passive role in the therapeutic relationship, that we can be “critical and radical, challenging and aiding the patient to develop a deeper and more vital sense of self” (2011. p.162).

Ultimately as herbalists we need to bring a multiplicity of skills to the table. We need to be able to engender a subtly nuanced patient-therapist relationship where we seek to place the patient at the heart of what we do. To neither be determined to be ‘right’ nor, conversely, too passive in empowering the patient to achieve better outcomes.

Word count: 1052

Bibliography

  • Conway, P. (2011) The Consultation in Phytotherapy. Elsevier Limited.
  • Hoffman, D. (2003) Medical Herbalism, Healing Arts Press
  • Mills, S (1991) The Essential Book of Herbal Medicine. 2

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  • Mitchell, A, Cormack, M. (1998) The Therapeutic Relationship in Complementary Health Care. Churchill Livingstone.
  • Model, D, (2006) Making Sense of Clinical Examination of the Adult Patient. Hodder Education

References

  • Kmietowicz, Z & Gareth Iacobucci, G. Government fails to assuage doctors’ concerns over NHS crisis BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j153 (Published 10 January 2017)
  • Toombs,K.S. (1987) The Meaning of Illness; A Phenomenological Approach to the Patient-Physician Relationship  pg 222  2011 jmp.oxfordjournals.org

Suicide as a Public Health Emergency

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Introduction

Suicide, which is now the tenth leading cause of death in the United States, is a rapidly escalating public health emergency. (Puntil, York, Limandri, Greene, Arauz, & Hobbs, 2013). The suicide rate in the U.S. has increased by 33% over the past 20 years, yet attention to this growing health concern and funding for its research is significantly lower than for other leading causes of death and even many of those causes which are responsible for far fewer deaths than suicide (Godlasky & Dastagir, 2018). In Tennessee, the statistics are even more staggering. With a suicide rate 20% higher than the national average, it is the ninth leading cause of death in the state (Status of Suicide in Tennessee, 2019). On average, Tennessee loses three of its citizens each day to suicide, and the state recorded 1,163 suicide deaths in 2017 (Status of Suicide in Tennessee, 2019). As a psychiatric-mental health nurse practitioner student and a citizen of the state of Tennessee, this topic is of great significance and concern to me and is one that I will likely face throughout my career as a mental health care provider.


Suicide Prevention Policy

A policy related to the topic of suicide prevention in the state of Tennessee is the TN Suicide Mortality Review and Prevention Act of 2018 (S.B. 1949/H.B. 1961, Public Chapter 1005). The purpose of this policy is to identify contributing factors to suicide deaths in the state of Tennessee and develop state changes for prevention strategies to reduce the number of suicide deaths in the state. The policy addresses the need to establish a statewide program in accordance with recommendations from the U.S. Surgeon General to investigate all suicide deaths through mortality reviews conducted by a review and prevention team. The bill calls for the composition of the team to include the commissioner of health or their designee, the commissioner of mental health and substance abuse services or their designee, the executive director of the Tennessee Suicide Prevention Network, a physician and a nurse with training in suicide prevention, the chief medical examiner or their designee, the chair of the Health and Welfare Committee of the Senate or their designee, and the chair of the Health Committee of the House of Representatives or their designee (S.B. 1949/H.B. 1961, Public Chapter 1005). The policy outlines that the team shall hold quarterly meetings to review suicide deaths and identify trends, risk factors, response deficits, barriers to safety for persons at risk for suicide, and define strategies for prevention. Additionally, the team shall undertake the statistical studies of suicide patterns and mortality rates for the state and provide annual reports to the governor and general assembly concerning their activities and recommendations for law or policy changes that would promote the prevention of suicide deaths. Finally, the policy authorizes the team to inspect the hospital and outpatient records, laboratory data, police investigation data, and medical examiner data of persons who died by suicide to aid in their investigations (S.B. 1949/H.B. 1961, Public Chapter 1005).


Position

My position on this topic is that the state should formulate and implement state-level suicide prevention research and planning, and that adequate federal and state funding should be given to such efforts. As such, this position is in support of the TN Suicide Mortality Review and Prevention Act of 2018. According to the American Foundation for Suicide Prevention, suicide is preventable. The AFSP states that through research, prevention strategies can be identified and implemented, thus saving lives (Tietjen & Jobes, 2019). The AFSP notes that when Congress prioritizes funding for research on public health issues like heart disease, cancer, and diabetes, the mortality of these diseases decreases in relation to the research funding they receive. Suicide mortalities resulting from mental health issues, the AFSP posits, can be decreased as well if Congress prioritizes funding for research into preventative and treatment measures (Tietjen & Jobes, 2019). Tennessee Governor Bill Lee has proposed a $1.1 million investment to expand the state’s partnership with the Tennessee Suicide Prevention Network to establish a new outreach model and focus on evidence-based practice interventions (Cook, 2019).


Opposition

Some policy makers oppose provisions for funding of this and other mental health research and suicide prevention programs on the basis of cost and perceived lack of value or benefit of such programs. According to the CDC, while some states do receive funding for their suicide prevention programs, such support is not guaranteed, and most mandate that these planning groups come without funding, or funding comes with specific requirements that may affect participation on the committees or shift the driving force and control away from the issue’s advocates (Lubell, Harber Singer, & Gonzalez, n.d.). Budget cuts for mental health services in Tennessee resulted in a 10.1% decrease in funding between 2009 and 2011 (State Mental Health Cuts, 2011). According to The National Alliance on Mental Illness, the budget for the largest payers of behavioral health services in the U.S., Medicare and Medicaid, continues to be slashed, and funding for the Substance Abuse and Mental Health Services Administration’s Mental Health and Substance Abuse Treatment Programs has been reduced by approximately $600 million (Howard, 2018). Policy makers in opposition of mental health funding often cite savings to states and communities by cutting Medicaid funding. However, NAMI argues that rather than saving money, these cuts simply shift the financial responsibility to emergency rooms, community hospitals, and law enforcement agencies (State Mental Health Cuts, 2011). While some policy makers oppose the proposed $150 million a year that the American Foundation for Suicide Prevention advocates for to pay for suicide research, the cost of suicides and suicide attempts far exceeds that number at a price tag of $93.5 billion a year (Godlasky & Dastagir, 2018).

Some experts posit that the lack of support for funding of state suicide prevention programs is a result of the stigma associated with mental illness and suicide. According to Godlasky and Dastagir, stigma is associated with fear, and suicide reflects one of our most primal fears – fear of death (Godlasky & Dastagir, 2018). Because of discomfort associated with emotion-driven misconceptions about mental illness and suicide, it may be that suicide prevention efforts do not get the attention or support they need because people choose not to think of mental illness and suicide in the same capacity they think of deaths related to other illnesses such as cancer and heart disease.


Conclusion

In conclusion, our state is facing a mental health crisis of completed suicides which affects over 1,000 citizens each year, and thousands more suicide attempts. As these numbers continue to rapidly climb, there is a call to action to address this public health emergency. Research and implementation of prevention programs are the keys to reducing suicide deaths in the state. It is imperative that the state answers this call to action by implementing the guidelines of the TN Suicide Mortality Review and Prevention Act of 2018 and that adequate funding for this legislation is provided in an effort to protect its citizens from preventable suicide deaths.


References

More than a Sugar Rush: The Impact of Globalisation on Type 2 Diabetes in Malaysia

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Over the last several decades, globalisation has generated unprecedented changes across society. These changes are particularly profound in developing nations, in which marked epidemiological changes in built environment, physical activity and diet have impacted morbidity and mortality patterns (Basch, Samuel, & Ethan, 2013; Noor, 2002). This change in disease pattern has seen noncommunicable diseases, such as Type 2 Diabetes (T2D), rather than infectious diseases become a significant public health concern (Noor, 2002). Type 2 Diabetes is a chronic disease, in which gradual insulin resistance results in ineffective management of blood glucose levels and consequent overproduction of insulin by the pancreas (Diabetes Australia, 2019; World Health Organisation, 2016b). As the disease progresses, insulin producing cells are reduced and the pancreas is no longer able produce sufficient insulin and is associated with several deleterious complications, including heart attack, stroke, kidney failure, leg amputation, vision loss and nerve damage (Diabetes Australia, 2019; World Health Organisation. 2016b).

Once considered a disease of excess, T2D prevalence has risen rapidly across low- and middle-income countries and T2D now affects more people in developing nations, than people in developed nations, placing a tremendous financial burden of countries such as Malaysia (Basch et al., 2013; Unnikrishnan, Pradeepa, Joshi, & Mohan, 2017; World Health Organisation. 2016b). Given the direct (e.g., medical) and indirect (e.g., quality of life) costs of T2D, it is important for public health practitioners, policy makers and individuals to better understand the impact of globalisation on T2D in Malaysia in order to develop a strong and effective response (Basch et al., 2013; World Health Organisation. 2016b).

Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 1980, with 60% of world cases occurring in Asia (Hu, 2011; World Health Organisation. 2016b). In Malaysia, the prevalence of T2D continues to rise, with known cases increasing from 4.3% in 1996 to 9.8% in 2016 (Tee & Yap, 2017; World Health Organisation. 2016b). However, the true burden of disease is likely to be far greater, with the reported prevalence of total cases (i.e., known and undiagnosed) increasing from 8.9% to 17.5% across the same period (Tee & Yap, 2017). Moreover, Wan Nazaimoon et al. (2013) reported a false-negative frequency of 5.8% when diagnosis was based solely on a fasting plasma glucose test, highlighting the importance of accurate diagnostic measures.

In contrast to the Caucasians, Asians develop T2D at a younger age, at lower degrees of overweight/obesity (a known risk factor for T2D) and tend to progress from pre-diabetes to T2D at a faster rate (Hu, 2011; Unnikrishnan et al., 2017). It is of no surprise then, that the greatest increase in prevalence in Malaysia has occurred in the younger age groups; 5.9% and 8.9% for 20-24-year-olds and 25-29-year-olds, respectively (Tee & Yap, 2017). In terms of gender differences, the prevalence of diagnosed cases of T2D is greater among Malaysian men (10.2%), compared to women (9.5%), despite a higher prevalence of overweight (38.3%) and obesity (15.3%) among Malaysian women compared to men (36.2% and 10.3% respectively; World Health Organisation, 2016a). Given Malaysia’s multiethnic population, understanding potential differences between different ethnicities is an important factor in intervention development. By ethnicity, the overall T2D prevalence was highest among Indians (22.1%), followed by Malays (14.6%) and Chinese (12%; Tee & Yap, 2017). In terms of location, the urban-rural gap has continued narrow with total case prevalence rates of 17.7% and 16.7% reported in 2015 for urban and rural dwellers, respectively (Tee & Yap, 2017; Unnikrishnan et al., 2017; Zaini, 2000).

Risk for T2D is determined by several, often interrelated genetic and metabolic factors (World Health Organisation. 2016b). Encouragingly, although not without significant complexity, the majority of risk factors for T2D are behavioural and thus, highly modifiable (Popkin, 2006; Unnikrishnan et al., 2017). Both unhealthy dietary practices and overweight and obesity are independent risk factors for T2D (Basch et al., 2013; Hu, 2011). Specifically, excessive caloric intake and a diet high in refined grains, animal fats, processed foods, added sugar and low in fibre is associated with increased T2D risk (Hu, 2011; Popkin, 2006; Unnikrishnan et al., 2017).

Unsurprisingly, these same dietary characteristics contribute to overweight (i.e., BMI 25 – 29.9 kg/m2) and obesity (i.e., BMI 30 kg/m2; Basch et al., 2013; Chee Cheong et al., 2019). Once considered a public health concern of the West, overweight and obesity has reached epidemic proportions in developing nations and account for 44% of T2D cases globally (Basch et al., 2013). Indeed, Malaysia has the highest rate of overweight and obesity in South East Asia and alarming prevalence rates of 37.3% (overweight) and 12.9% (obesity), both of which are higher among women (Chong Tzyy Jiann & Lee, 2018; World Health Organisation. 2016a). In higher income countries overweight and obesity are more prevalent among rural and low SES populations, while in low-middle income nations, including Malaysia, the opposite has been observed (Popkin, Adair, & Ng, 2012). However, as with T2D prevalence rates, the gap between rural and urban populations is narrowing (Popkin et al., 2012; Unnikrishnan et al., 2017).

Overweight and obesity typically result from an energy imbalance, in which gradual but persistent weight gain occurs (Noor, 2002). In combination with excessive calorie intake, physical inactivity is a major contributing factor to overweight and obesity (Noor, 2002). Moreover, physical inactivity independently increases the risk of T2D across all ethnic groups in Malaysia (Tee & Yap, 2017; Unnikrishnan et al., 2017; World Health Organisation. 2016a). Likewise, cigarette smoking is an independent risk factor for T2D, with smokers experiencing a 45% increased risk than non-smokers (Hu, 2011; World Health Organisation. 2016b). This is of particular concern in developing countries, including Malaysia, where approximately 60% of males are regular smokers (Hu, 2011).

In contrast to high income nations, in Malaysia, T2D is most common among more affluent, urban populations (Basch et al., 2013; Unnikrishnan et al., 2017). While this mitigates some of the barriers to improvement (i.e., sufficient medical care and preventative measures) often experienced by individuals with reduced economic or social capital, as a developing nation, even the more affluent, urban populations remain at a distinct disadvantage. For example, despite the increasing prevalence of T2D, Malaysia does not have an operational policy or action plan to prevent or reduce the number of new T2D cases among adults or children, a population in which T2D cases is also rising (Basch et al., 2013; World Health Organisation, 2016a). Moreover, the increasing prevalence of T2D and the associated risk factors among the poor will likely have serious implications for health inequalities (i.e., state capacity for the delivery of health services, as well as accessibility and affordability of adequate health care for individuals; Basch et al., 2013; Unnikrishnan et al., 2017).

Globalisation, that is the freer movement of capital, technology, goods and services, has had marked and rapid impact on developing nations, including Malaysia (Popkin, 2006; Popkin et al., 2012). While there have been numerous enhancements to quality of living, the rapid modernisation that has occurred in Malaysia has also generated profound changes in built environment (i.e., urbanisation), physical activity and diet (Hu, 2011; Noor, 2002; Popkin, 2006; Popkin et al., 2012). The impact of these changes is reflected in the increasing prevalence of T2D and associated risk factors, specifically, overweight and obesity and physical inactivity (Chee Cheong et al., 2019; Delvarani, Ghazali, & Othman, 2013; Noor, 2002; Zaini, 2000).

Research has shown that built environment (i.e., environments modified by humans) influences the development of T2D (Unnikrishnan et al., 2017). Specifically, the rapid urbanisation that has occurred in Malaysia over the last several decades has led to a multitude of demographic changes associated with increased risk of T2D (Fournier et al., 2016; Popkin et al., 2012; Zaini, 2000). Interestingly, these changes are not inherently nor exclusively detrimental and have, in many cases, led to a better standard of living, improved quality of life (Zaini, 2000). For example, urbanisation is associated with better transportation systems, improved availability food (i.e., modern supermarkets), and increased access to information and technology (e.g., mass media, television etc.; Noor, 2002; Popkin, 2016; Unnikrishnan et al., 2017). However, urbanisation has also led to increased consumption of food outside the home (82% of urban dwellers), greater availability and consumption of energy-dense, nutritionally poor foods and reduced physical activity (Delvarani et al., 2013; Noor, 2002; Unnikrishnan et al., 2017). Furthermore, a reduction in average household size (

M

= 5.2 persons in 1980,

M

= 4.3 persons in 2010) and income growth have created a new middle class, with increased purchasing power and a greater ability to participate in a consumption economy (Fournier et al., 2016; Noor, 2002).

Occupational and lifestyle changes associated with urbanization have also led to a reduction in physical activity (Noor, 2002). Prior to modernization, levels of physical activity were high in developing nations where the majority of individuals engaged in unmechanised occupational activities (Unnikrishnan et al., 2017). However, industrial changes associated with globalisation have led to an increase in less physically demanding occupations, causing a significant decline in overall physical activity levels (Unnikrishnan et al., 2017). Furthermore, recreational physical activity levels tend to be low in developing nations; this has certainly been observed in Malaysia, with inadequate levels of physical activity for reported for both adults and children (Tee & Yap, 2017; Unnikrishnan et al., 2017). Moreover, improved transportation systems, increased car ownership and greater time spent in sedentary activities (occupational and leisure) also contribute to the maintenance of an obesogenic environment (Noor, 2002; Unnikrishnan et al., 2017).

Similarly, dietary changes associated with globalisation promote an obesogenic environment (Basch et al., 2013). Indeed, as a consequence of globalisation, there is increasing adoption of the so called “Western diet” which typically includes increased consumption of animal-source foods, high intake of refined carbohydrates and added sugars (i.e., energy-dense foods) and decreased fibre intake (Hu, 2011; Popkin et al., 2012). This nutrition transition is advanced through food imports, the increasing presence of transnational food corporations (e.g., Coca-Cola, McDonalds, Kentucky Fried Chicken etc.) and changes in local food production (i.e., convergence with transnational production practices; Noor, 2002; Popkin, 2006; Popkin et al., 2012).

Specifically, Malaysia has high consumption of sugar-sweetened beverages ([SSB] e.g., soda) and fast-food (Noor, 2002). For example, the National School-based Nutrition Survey (2012), 82.5% of adolescents reported consuming fast-food at least once per week, 7% consumed more than three cups of SSBs per day and a staggering 96.3% had insufficient intake of fruits and vegetables (Chee Cheong et al., 2019). Similar consumption patterns have been reported for adults (Tee & Yap, 2017). Moreover, it has been reported that Malaysians generally consume fast-food as a snack, in addition to standard meals (Chee Cheong et al., 2019). This is likely to exacerbate the resultant risk of unhealthy diet on T2D.

Independently and in combination, urbanisation, insufficient physical activity and unhealthy dietary patterns promote and maintain an obesogenic environment and T2D (World Health Organisation. 2016b). Diet and lifestyle modification are highly effective in the prevention of T2D (Hu, 2011). To best support individual behavioural change, a combination of regulation (e.g., taxes) and capacity-building (e.g., knowledge) strategies is required.

In terms of regulation, several developed nations have successfully implemented so called “sugar taxes” designed to reduce the purchase and consumption of unhealthy food and drinks (Goryakin, Monsivais, & Suhrcke, 2017; Popkin et al., 2012; World Health Organisation. 2016b). Moreover, New York City restricted SSBs to 16oz and France imposed bans unlimited SSBs refills (Goryakin et al., 2017). Given the high level of consumption of SSBs in Malaysia and their association with T2D, similar policies could be of benefit to the Malaysian population (Goryakin et al., 2017). Indeed, Malaysia has only recently removed its sugar subsidy, with little reported change in consumption; a sugar tax may produce the desired outcome (FMT Reporters, 2017). Brand recognition and aggressive marketing by transnational corporations play a significant role in consumer purchasing behaviour (Abdullah & Asngari, 2011; Hu, 2011). As such, greater regulation of advertising and marketing of unhealthy food and beverages, as well as cigarettes, may be useful in T2D prevention.

In addition to regulation policies, public health strategies that empower individuals to make healthful choices may be beneficial (Delvarani et al., 2013; Hu, 2011). For example, creating spaces within the urban environment for exercise and maintaining safe walking/cycling paths could increase physical activity levels and reduce overweight/obesity and menu/front of package labelling may promote healthier food choices (Goryakin et al., 2017). Furthermore, nutrition education programs, as seen in Finland and South Korea, may be of benefit in addition to standard “food pyramid distribution” to support and maintain significant shifts in diet (Popkin, 2006). For example, nutrition education in schools could instruct students in food selection and preparation. Finally, it is important for these strategies to be underscored by the development of a strong knowledge base of T2D and the associated risk factors if healthful choices are to be maintained (World Health Organisation. 2016b).

Like many other developing nations, Malaysia is in the grips of a T2D epidemic (Basch et al., 2013). Globalisation has had an unprecedented impact on the built environment, level of physical activity and diet of Malaysians, creating an obesogenic environment that that led to increasing T2D prevalence (Basch et al., 2013). Diet and lifestyle modification are an effective means of preventing T2D, however, strategies that systematically address the impact of globalisation on T2D in Malaysia (i.e., the causes of causes) are required to produce effective and lasting change (World Health Organisation. 2016b).


References

Geriatric Nursing

/in /by

Introduction

This paper will try to show different ways for geriatric care that are useful to a LPN

who encounters aging people in daily life. Because they are complex, older people

always deserve personal attention. Nurses address physical, psycho social, cultural and

family concerns as well as promoting health and emphasizing successful aging.

Life expectancy is rising at rates which call for the proper preparation of nurses to take

good care of the rapidly increasing number of the aged.

It is important to distinguish changes involved with normal aging from changes

attributable to pathophysiology. Alterations in the structure and function of multiple

body system may affect an older person appearance, mobility and ability to fight off

infections. Geriatric medications need to be managed so as to avoid too much use of

medicine since this group receives a lot of medication if poor care is taken. Multiple

medications can cause a variety of drug interaction in older people. Primary drug reaction

occurs when one drug causes one side effect, secondary drug reaction occurs when one

medication reacts with another. This is brought about by polypharmacy. Old people

should be treated in ways that are of benefit and do no harm or as little harm as possible

Principle of assessment: data regarding biomedical, functional, psychological and social

issues are obtained to help in planning and implementation of individual health care.

A pressure ulcer is a lesion caused by unrelieved external pressure resulting from

occlusion of the blood flow, tissue ischemia and cell death. Pressure ulcers are often

viewed as a complication of an acute or chronic illness. The presence of ulcers may also

be evidence of poor nursing care. Although pressure ulceration can be prevented, it may

also occur despite optimal nursing care and advanced technologies. In order to provide

effective nursing care for the older adult with pressure ulcers, the nurse must approach

patient care within a holistic frame work. This framework should include an integration

of good assessment, use of research-based intervention and methodical intervention of

patience outcomes. Some specific issues of prevention, assessment and treatment of adult

with pressure ulcers are, aging skin: The older people have an aged skin and due to

exposure to the sun the skin wrinkles, epidermis thins, blood vessels recede, dermal-

epidermal ridges flatten and the skin appears thin and fragile. The age related changes

may lead to ulceration. The skin which is our largest organ can help in viewing the

overall functioning of the entire body. All clinicians working with older people at risk for

or suffering from pressure ulcers must be mindful of these varying relationship in using

the cutaneous “window” of person to plan and implement individualized, comprehensive

care.

Summary

Ulcers have different stages. Stage one ulcers are characterized by non-blancherble

erythema of intact skin. It is important to note that stage one pressure ulcers are difficult

to identify in darkly pigmented people and are usually indicated by discoloration,

warmth, endyma, indurations and hardness. Stage two ulcers are partial lesions

extending into the epidermis and the dermis. Stage three ulcers are defined as the full

thickness skin loss. Stage four is characterized by extensive tissue damage which extends

to the muscle, bone or the underlying structures.

Through a holistic assessment and evaluation a nurse can build a plan of care for those

patients who suffer from pressure injury. When treating an ulcer wound treatment should

focus on wound healing. For a chronic, non healing ulcer, comfort should be a top

priority. For pressure injury careful positioning padding to reduce the risk of pressure

ulceration is important. Wound healing occurs only if the patience is physiologically able

to provide needed substrate; wound cleanliness, moist and infection free and the cause of

injury is removed. For older people it takes longer to heal and so extra care should be

taken. When normal interventions fail to heal a pressure ulcer, surgical intervention

may be the best option. If the paitent is not mobile you have to frequently turn the paitent

to prevent the sore/ulcer getting any worse .

Cardiovascular disease affects the heart and the blood vessels. The disease is caused

by disruption in the blood circulation secondary to decreased vessel. Cardiovascular

disease is common in 50% of the population over the age of 65, and accounts for 40% of

deaths in this group. Because of the changes associated with normal aging and some of

the unique aspects of reporting and presenting in old adults, underestimation of the

seriousness, cardiac disease often occurs. This can lead to misdiagnosis, under treatment,

and even death. There are different kind of heart disease: Atherosclerosis and

arteriosclerosis. Arteriosclerosis is a disease of the arteries, characterized by abnormal

thickening and hardening of vessel walls, it also leads to atherosclerosis. Due to advance

in age the disease easily finds its way to old people and so it should be carefully

diagnosed and proper treatment given. When diagnosing look out for cases of fainting,

continuous chest pain, nausea, shortness of breath, rapid heart rate, rapid weight gain,

pain in the abdomen, swelling of legs among others. Then address the issue of

hypertension, high blood cholesterol, diabetes, obesity and overweight, smoking, and

hereditary issues. Treatment includes medication and physical exercises.

The following age related changes may occur in the respiratory system of an old

person: diminished muscle strength in the diaphragm and thorax, stiffer chest wall,

decreased elastic recoil, decreased elasticity in the alveoli reduced surface area, with

diminished capacity for gas exchange, decreased vital capacity, and drier mucous

membrane leading to more difficulty in mucous excretion. Tests should be carried out by

doing x-ray coupled with physical examination. The following are possible diseases in

old people; bronchitis, asthma, pneumonia, tuberculosis, and chronic obstructive

pulmonary disease. Some of this disease leads to cardiovascular disease due to effect on

the lungs by air pollution. Nurse should draw a plan for treatment which includes

working with other specialties like heart experts.

Diabetes melitus is a metabolic disorder with two major types, type one and type two.

Their end result is hyperglycemia. Type one is caused by lack of insulin production by

beta cells. Type two is the most common and is caused by deficiency or inadequacy of

insulin receptors in cells. Treatment goals are to symptoms and maintain as normal blood

glucose as possible without inducing hypoglycemia to decrease the risk of long term

complications. Nurse should emphasize nutrition and exercise which are vital for victims.

For older people monitoring for complications which can lead to lower extremity

amputation, hypertension, myocardial infarction, stroke, vision loss, or nephropathy

should be carried out especially in type 2 diabetic patient.

Conclusion

Changes in structure and function of the nervous system occur with normal aging and

can result in changes in mobility, balance, coordination, sensation, comprehension,

cognitive performance or behaviour. These changes reflect a slowing of neurological

response as fewer neurons are available to provide sensory and motor messages to and

from the central nervous system. The common terms for dizziness include vertigo, pre-

syncope and disequilibrium.

Stroke is also known as brain attack It is created by interruption of blood supply to

some areas of the brain. This interruption can occur as a result of an occlusion or

hemorrhage. Occlusion leads to ischemic stroke, categorized as thrombic and embolic.

Thrombic stroke occurs in vesicles when oxygenated blood fails to flow to the occlusion

site. Embolic stroke occurs when clots form everywhere