“Up to 65 per cent of Australians are likely to experience or witness an event which threatens their life or safety” (19). Quite often trauma victims can recover by their own. However, with others it may have a negative reaction to a traumatic event which can then lead to an illness called Acute Stress Disorder (ASD) (16). This disorder is associated with mental and physical conditions combined thus causing reductions in a person’s quality of life and as a consequence includes economic burdens (12). (3) Due to the result of all the accumulating evidence, Diagnostic and Statistical Manual – fifth edition (DSM-5) has marked and modified goals and criteria for ASD. Under new criteria, ASD diagnosis will no longer predict chronic Post-traumatic Stress Disorder (PTSD). It will help to identify more severely affected survivors of trauma prior a diagnosis of PTSD can be made. Furthermore, the acuity people will perhaps get benefit from earlier interventions and short-term rehabilitation programs that are the great help in the recovery process. Early rehabilitation interventions, including self-care strategy, thought control strategy, and cognitive behavior therapy (CBT) would speed up recovery and prevent chronic longer term problems. Besides that, family members, clinicians, and social support networks play an important role in support mechanism for recovery process. Inaddition, some potential barriers are also discussed in predicting of new problems and relapse which may occur in order to manage them.

Potential recovery

According to (2) DSM-5 in 2013, ASD was relocated in Trauma- and Stressor-Related Disorders. ASD is a psychological and physical shock which usually appears in response to a traumatic event in a person’s life. The acutely traumatized person can be directly exposed to or be the witness of a traumatic events such as serious accident (21%), physical assault (19%), rape or witnessing a mass shooting (50%) or natural disaster (10%)(19). (9) Symptoms of ASD occur immediately right after the trauma, and it lasts for more than 2 days and less than 1 month (4). The victim usually suffers from anxiety, distress, intense fear, helplessness, avoidance behaviours or re-experience the event (16). (15) It has been recorded that 15% to 45% of children and adolescents directly experience to at least one traumatic event. There is no statistics of how many distressed people can fully recover due to these traumas; however in many studies it has been confirmed that ASD patients can have a full recovery under appropriate treatments. This study strongly emphasis on ASD rehabilitation rather than attempting to predict subsequent PTSD. Due to ASD timeframe is short, many victims are usually been ignored. Particularly, children and adolescent are in high risk of developing PTSD which leads to long-term psychological sequel in their life and causes a burden on health care systems. Therefore, (15) highlighted that recognizing ASD symptoms is an important step in toward enhancing intervention in the right time and speed up the recovery process. Additionally, with a formal diagnosis, it will allow highly distressed people to claim compensations from the health care service and payment for recovery treatment (4). In order to get appropriate diagnosis and early intervention, physicians play a critical role for assessments and monitoring all physical and psychological symptoms.

Recovery process

Whenever a referral from a physician has been made, the traumatized patients will go through a rehabilitation process. This process needs self-care strategy, thought control strategy, and CBT to support patients’ recovery and to decrease the future incidence of PTSD. (7) With self-care strategies, it focuses on personal strengths and their own judgment. Whether any kind of psychotherapies are provided to traumatic people, they should rely on their own recovery ability first. Without their own effort, all the supports will become ineffective. Traumatic patients, then, will receive reassurance and support, such as simple information and advices on self-care to overcome the normal recovery process. However, if the person cannot scope with these extremely severe events, and express a prolonged distress, or interfere with daily activities, they will need to be referral to another level of psychotherapy.

Currently, it has been found that thought control strategy is an acceptable strategy for managing trauma related distress in the short term rehabilitation. Use of thought control strategy will aim to reduce the

emotional distress

by sharing the traumatic stories in the unforgettable period of time (14). There are four components (worry, distraction, social element and re-appraisal) which are the most commonly used to focus on helping the patient to normalize reactions to trauma (22). The first being Worry/Stress, it is best trying to get the patient to not concentrate on the stressful thought itself. Encouraging the patient to try and replace worry or stress with other day to day concerns that may hold a more minor bearing. The second is distraction. Finding a healthy distraction could be simple as think about things that provide a positive feeling or immerse the patient in an activity that is pleasurable. This will stop the patient concentrating on the traumatic event and allow them to go about a daily routine. The third would be social elements that could help. This could be asking or speaking with friends about their thoughts and how they have dealt with such events in their lives. Asking about what worked for them or what may have helped them avoid concentrating on the stressful event. This would be discussed fully so that the patient could reflect and understand how this could apply to their situation. The fourth is re-appraisal, trying and interpreting their feelings and understanding why these things are affecting them emotionally and rationalize their reactions to these feelings. From here they should challenge the validity of their emotions and feelings in order to control positive or negative feelings.

If these self-care strategy and thought control strategy still have not worked well for recovery, CBT would be the next step of treatment in rehabilitation. (12) CBT will be given in five therapy sessions this comprising prolonged exposure (PE) and cognitive restructuring (CR). (12) found that these sessions provide brief forms of treatment in reducing acute symptoms of ASD in the initial month after trauma exposure. (8) PE focuses in emotional processing of thoughts. It helps interrupt and reserve recovery process by blocking cognitive and behavioral avoidance. This is accomplished through in vivo and imaginal expose. Vivo exposure involves repeatedly activities and situations that are avoided because of trauma. Overtime, the patient can reduce distressing emotion and fear. Then, they can cope effectively through these distresses. Imaginal exposure is related to repeatedly describe the event aloud in details, then recording. After that, they listen to their record in order to help them to realize their coping skill.

Following initial assessment, patients were informed that they would



be reassessed after 6 weeks

Support mechanism

Besides psychotherapy in rehabilitation process and early supportive care structure being delivered is an important step which supports the recovery process. Its result last long in reductions of ASD symptoms. Supportive care deliverers are family members, physician or social support network will help the traumatic patient go though the acute phase. (17on) In most cases, family members usually ask for advices on how to help their love in stressful situation. This will let the family to be able to utilize a communal experience in order to enhance the therapeutic growths. The use of positive family members has also been shown effectively assisted their traumatic member to manage their stressful conditions. They provide support, love and reinforce coping strategy with the trauma. The individual does not feel isolated, but also they feel warm and being caring. The individual, therefore, can describe what happened and how they response though this hard time.

However in some cases family sometimes is not enough to support traumatic patients. If the trauma patients and their family feel unable to cope with this traumatic event, they can seek professional help from a physician such as an Australian Psychological Society (APS) psychologist. An APS psychologist will help the severe distress people to understand and manage the symptoms associated with the trauma. An APS psychologist would develop effective coping strategies for affected individual as well as their family to support the recovery process (18). If not, traumatic people also seek help from social support network such as Beyondblue, Sane or Mental Health organizations. Beyondblue is a support service designed to support, give advice and create actions. Whatever the situation is, Beyondblue always listens to their distress stories and share their misfortune. Beyondblue members can really help patients come to terms with their illness and help them to move forward (23). Similarly, The Australian Centre for Posttraumatic Mental Health is a not-for-profit organization which its aim to reduce the impact of trauma causing to the victims. They connect the capability of individual’s family with their organizations within the community. Therefore, they can understand about the traumatic victims, then, help them to prevent and recover from the adverse mental health effects of trauma.

Barrier : wrong diagnosis, overwhelm with treatment, comorbid psychiatric disorders

Due to a shorten timeframe of ASD, there appear some barriers which prevent the recovery process such as late diagnosis, overwhelmed treatments. Besides that some will subsequently develop comorbid psychiatric disorders. In case of traumatic events happen, the victims are late identified. Then, they will receive some simple advices how to overcome that situations. They are supposed to recover on their own. However, there are still significant people who cannot go through this recovery process by themselves. They need help from physicians to be assessed in order to receive a formal diagnosis. This process somehow is taken time which lead to a late diagnosis. If this is too late for appropriate treatment of stress disorder, it will develop further into PTSD. Furthermore, without this proper diagnosis, traumatic patients will not get the benefit from standard rehabilitation treatments (4). This problem can be predicted by the role of physicians who can manage clinical judgments in order to give their patient an early diagnosis.

For those patients who have received treatments within hours or days after an acute trauma incident, they sometime do not response well to treatment plan due to overwhelm of different interventions. They will present a psychosocial and environment difficulties related to problems such as agitation, emotional pain, and dissociation. Quickly treatment but also slowly explanation and monitoring the response from patients will enhance effective support to recovery process. With patients that respond positively and appear to be recovered from ASD, they sometimes sudden relapse when new event happen to their life. They suffer from fear about safety for themselves as well as their family. The relapse can be recognized by close family members who help the patients to report it to physician in order to get continual treatment (17).

Treatment of ASD is usually focused on its specific symptoms. However, some subsequently develop with ASD might be appear such as depression, withdrawal, shame or drug and alcohol abuse, and even suicidal behavior (17). The comorbid psychiatric disorders occur due to the inability scoping with that such traumatic events. These occurssing will significantly affect the recovery process; therefore, it is a requirement for careful attention in both pharmacologically and psychotherapeutically. The patient at high risk of suicide or drug and alcohol abuse should be highlighted during initial assessment. It is necessary to evaluate this potential harm which gets into the treatment pathway and the recovery process.

Conclusions

In conclusion, (4) the criteria set for ASD in DSM-V will allow identifying the people who had negative reaction to a traumatic event. Because of the short duration, it is necessary to assess severe traumatic people as quickly as possible. Then, they can receive an appropriate diagnosis in order to get benefit from rehabilitation treatments. Having an early treatment will move towards healing and recovery process. Moreover, as a result of suffering both physical and psychological conditions, these fragile people require a high level of support from family member, physicians as well as social support network to be back to normal life.

Infection disease acquired in hospitals have changed during the past decades, Gram-negative pathogens were predominantly responsible. However serious infections were brought under control with the discovery of penicillin, but as resistance to antibiotics spread new and dangerous superbug strains emerged. The main infective threat on the increase in micro-organisms that is resistant to many antibiotics is Methicillin-resistant Staphylococcus aureus (MRSA), (Abb, 2004). Aims of this essay:

The Background and significance of MRSA infection.

Critically Review Epidemiology of MRSA.

Explore MRSA Screening/programmes in both hospital and community.

Critically analyse Ethical implications of introducing MRSA Screening.

MRSA was first discovered in 1961, during the time in the UK when almost all people were having significant health care through the National Health Service. MRSA was first recognised as a source of infection which then became a major nosacomial pathogen transmission within the hospital and in the community. Infections due to Staphylococcus aureas are a growing clinical and a public health problem globally, and the incident of patient infection and colonisation of MRSA continues to rise in the UK health-care system. Delano et al (2000) described MRSA as a major nosacomial pathogen, with transmission within hospitals, transmissions between different hospitals, hospitals within the same country and even intercontinental spread of endemic strains. However certain strains could be found worldwide and only few strains were responsible for a large part of MRSA infections, (Boyce et al, 2005). Germany saw the proportion of MRSA to S. aureus in clinical specimen rise from 8 % in 1995 to 30 % in 2003 – a higher increase than in nearly all other European countries, (Robinson and Enright, 2004).

Community-associated MRSA (CA-MRSA) infections have turned out to be the most troubling pathogen. Its increase in the community has reported infections among healthy children and adults. But little remains unknown about how patterns of colonisation with MRSA in the community have changed, (Health Protection Agency, (HPA), 2004). An epidemiology report stated that each year around 1 in 10 NHS patients contract a healthcare associated infection (HAI) in the UK (Department of Health, 2003). In Scotland, HAIs were recorded as a major factor in an estimated 457 deaths each year and a contributory factor in a further 1,372 deaths 3% of all deaths, DoH (2003). Therefore the economic burden of HAI to the hospital sector was substantial, with the annual cost to the NHS estimated to be £186 million in Scotland (Walker, 2001) and in excess of £1 billion in England and Wales Plowman et al, (1999). MRSA has been is identified by (Boyce et al, 2005) as the major cause of hospital associated infections, causing skin and soft tissue infections, pneumonia, bloodstream infections, and bone and joint infections in both children and adults. The Health protection Agency verify that once acquired, MRSA has the potential to cause multiple infections, for cardiac surgery patients, sternal wound infection can lead to mediastinitis, infection of the heart valves or endocarditis. The lethal MRSA strain known as USA600 which causes bloodstream infections has been known to be five times more lethal than any other strains. Research conducted by Henry Ford Hospital study claims that this strain has some resistance to the potent antibiotic drug vancomycin used to treat MRSA, and its unique characteristics have been linked to high mortality rate. However, Chastre and Trouillet, (1995) argues that all MRSA strains have significant mortality risk, with this strain it is unclear whether other factors such as older age, diseases or the spread of infection contributed to poor outcomes. The latter adds that MRSA colonisation and infection is now considered endemic within hospitals in the UK, with critical care and regional units being recognized as high-risk areas. (Coello et al, 1997) is in agreement stating that intensive care patients are known to have a higher risk of developing MRSA infection than medical patients. This could be due to their association with the frequent use of broad-spectrum antibiotics or the increased transmission risk because of frequent contact with many personnel (Haley et al, 2002). Risk factors include: previous hospitalization; underlying disease, surgical wounds; intravascular lines; recent antibiotics (leading to potential suppression of the immune system); and pressure ulcers (Ayliffe et al,1998).

Managing these patients proves to be very difficult and costly due to problems associated with treating systemic MRSA infections, its propensity to spread and colonize debilitated patients, and its asymptomatic carriage in the nose and throats of staff and patients, (Ayliffe et al, 1998). Treating systemic MRSA infection needs extensive antibiotic therapy; the need for the patient to be nursed in isolation; an extended length of stay and a severely unwell patient who is then further compromised. The risk of death in patients with RSA is three times greater than other hospital-acquired infections (Romero-Vivas et al, 1995). As well as increasing morbidity and mortality, MRSA infection is expensive. Costs can be divided into those related directly to the effects of the infection, such as extended length of stay, pharmacological intervention and other aspects of management, and expenses related to the cost of controlling the infection. Then major threat facing the UK health care system is the MRSA transmission in the community among individuals who had not been in hospital previously, or had had any contact with a person who had been in hospital or care homes, previously would have explained how they contracted the bug. With the increase of community acquired MRSA (CA-MRSA) this would prove to be a huge problem, because some infected people will inevitable be hospitalised themselves, or visit relatives and friends who are in hospitals. Therefore an increment in outbreaks of new types of MRSA strain, (Boyce et al, 2007). Barr et al (2007) claims that the community strains are different from the hospital strains, he believes that the community strains have evolved independently and so they present a whole new series of problems for control and treatment. The aim of this write up is to discuss MRSA screening; how screening patients can prevent the spread of MRSA; the prevalence and incidence of MRSA in the UK, a critical epidemiology of MRSA will be discussed with the inclusion of ethical implications on screening.

Epidemiology of MRSA

MRSA is an epidemiological problem, which can have its source in the community and health care settings, the epidemiology, of MRSA in relation to agent, host, environment, web of causation and its natural history. The National Audit Office 2004 report shows that figures collected from the DoH’s own mandatory reporting system had indicated 8% increase in MRSA incidences between 2000-2004. The 2004 report figures almost reaching 20.000 infected patients. Therefore this made the rate of infection in England the worst amongst Europe, (Cuevas et al 2004). However other sources quoted the UK infection rate as being 30,000 hospital acquired infection per year, (Morton et al 2003), which they quote as infection representative of a 9& infection rate. The latter continue to claim that 5000 will die, but it is important to make the distinction that the authors did not suggest that 5000 will die, they will do so as a result of the MRSA infection.

MRSA is a skin bacterium that is resistant to many antibiotics. It can colonise the skin, however colonisation itself does not cause illness, (Timbury et al, 2002). Colonisation in vulnerable patients may precede infection that may be severe and life threatening. A high percent of 20-30%.of population may carry MRSA a Gram positive bacterium as their normal skin organisms, (Cooper et al, 2003). The latter, further state that the infections MRSA cause, are not considered more serious than those caused by Meticillin sensitive can be more difficult to treat. MRSA is a virulent bacterium that can cause serious infections of the skin. It can be introduced into the body through broken skin, insertion of a device or an invasive procedure. Once within the body it can cause a range of illnesses from relatively minor localised skin and wound infections, such as boils, to systemic life threatening infections such as endocarditis, pneumonia and bacteraemia (Cooper et al, 2003. Meticillin is an antibiotic previously used to treat infections; however it is now replaced by Flucoxacillin from the same group of antibiotics. Flucloxacillin is known to be very effective antibiotics for many common infections including those caused by MRSA. However there is an increasing emergency of strains of MRSA that have developed resistance to antibiotics such as Flucloxacillin.

MRSA has developed resistance by mutation of the penicillin binding site in the bacterial cell wass so that the antibiotic no longer attach itself to its target, making such strains resistant to all penicillin’s and cephalosporin antibiotics. Unfortunately MRSA also often acquires resistance to other antibiotics making it multi-resistant. Treating infections caused by resistant bacteria require the use of more complex antibiotics, some of which can only be administered intravenously. It is important that the use of these antibiotics is reserved for more serious infections; resistance can emerge during therapy, especially if prolonged,

The prevalence of MRSA transmissions has steadily increased in hospitals and in care homes in the UK and Globally. The centres for disease control (CDC) in the United States, claims that’s in the mid 19890s MRSA was mainly limited to relatively large urban medical centres and the rates where smaller with the prevalence rates of 50% to 10%. However by the 90s rates among the community hospitals increased to 20%, (Klevens et al, 2007).

Because no systemic, population-based surveillance of community isolates of MRSA, the true prevalence of MRSA cannot determined. However one study found that up to 40% of MRSA infections in adults were acquired before admission to hospital. However published reports on MRSA colonisation and infection among study participates who lack traditional risk factors indicate that community prevalence rates are rising., ( ). The incidence of community-associated MRSA has risen dramatically in the UK, particularly among children. ( ), suggest that there varying evidence suggesting there appears to be different MRSA strain found in the children within the community setting. The epidemiologic features described appear to show a major departure from features typically associated with MRSA colonization or infection. Young children tend to have higher colonisation rates, probably because of their frequent contact with respiratory secretions, ( ). Although Streptococcus pneumonia colonization has been inversely associated with MRSA colonization in unvaccinated children, this and other risk factors for MRSA carriage have not been assessed following widespread use of the heptavalent pneumococcal conjugate vaccine (PCV7), ( ). Colonisation may be transient or persistent and can last for years, ( ).

( ), MRSA infection presents a serious epidemiological problem because not only are new strains appearing but also a number of nasocomial MRSA infections are known to have their source in the community setting, which causes the route of transmission to remain a mystery. ( ), claims that the CA-MRSA are unlike the hospital strains which typically are resistant to multiple antibiotics, but the community strains have tended to be susceptible to other antibiotics classes and often are resistant only to beta-lactam antibiotics. It appears that the origins of community acquired strains are subject to debate, some suggesting they are feral descendants of hospital isolates (Alvina, 2008). If these are isolate then they must have undergone considerable change, because they possess distinctive PFGE patterns and have lost hesitance to multiple antibiotics.

Screening

Screenings is a way to identify health issues, those at risk or are already affected by, a disease or its complications. Dr Angela E Raffle , a Consultant in Public Health , suggested that they are types of screening that can do more harm than good however, to be screened is to people who think or feel they are healthy to find if they have certain health problems or risk factors they did not know about before. However an opportunity for education for health arise, screening can be used as tool to mobilise community group or individual action one the individual has their screening results it is up to each individual on how to change his or her health behaviour or even encourage to maintain positive behaviours. Therefore screening can be used in a way which helps to motivate and support people to develop skills and to make decisions, collectively or individually, which are right for them. Used in this way screening becomes an effective health promotion.

They are various types of screening which include: Whole-body computerised tomography (CT) screening (a sophisticated kind of x-ray), the implied promise is that it can either find disease and lead to better outcome because of early recognition, or it can give important reassurance that you are healthy. Whole-body magnetic resonance imaging (MRI) screening, although there is no radiation dose, the usefulness of this as a screening procedure is completely unproven.

There are good public health reasons for screening certain populations, or sub-populations. However, one need to think carefully about the role of screening and whether the time, energy and money involved are justified, and the fact that screening can intrude into people’s lives and invade their privacy. However MRSA screening is for the benefit of both the individuals and the rest of the population in hospital or out in the community. Early identification of patient with MRSA and subsequent prevention of patient to patient spread through infection control measures is believed to be important interventions to control MRSA. Experts and policy makers, nationally and internationally recommend universal MRSA admission screening. However no controlled trails have tested the hypothesis that rapid screening may improve patient outcome by decreasing MRSA cross transmission and increasing the adequacy of pre-operative prophylaxis. DoH operational guidance (July 2008) states that all elective admissions must be screened by April 2009 and that all admission including emergencies admissions.

In view of high levels of MRSA prevalence in the UK health care system, from April 2009 the Doh implemented the MRSA screening on all patients electively admitted to the hospitals. The requirement extended to emergency admissions. The stringent measures introduced by the DoH to reduce the burden of infection associated with MRSA, with success numbers of MRSA bloodstream infections appear to be falling by more than half from 2003 to 2008, Muller (2008). However the overall numbers of healthcare associated infections reported to the English health Protection Agency rose substantially, raising question about the focus on MRSA argued, (Donalds 2006). Before April 2009 most NHS trusts screened patients for MRSA when they were considered to be at high risk of MRSA colonisation or infection. However the mandatory MRSA screening policy extends the range of individuals screened to include people at low risk of MRSA colonisation or infection, such as patients without serious comorbidity admitted for hernia repair or arthroscopy. The policy runs contrary to current UK guidelines for the control of MRSA, which emphasise selective screening, (Muller, 2009) and to US guidelines, which do not support legislation to mandate MRSA screening, Bonita et al (2000). In the UK, hospital admission is the main risk factor for acquiring MRSA, and invasive medical procedures (particularly placement of a central venous catheter) are the biggest risk factor for MRSA bloodstream infections, (Pugliese and Favero, 2004). This is clearly a matter of debate, research claims that more infected people are found in the community and some do not appear to have had any contact with the hospital, the statement above needs more evidence to back it up. The evidence supporting screening even in high risk groups is largely derived from uncontrolled studies. A large controlled study in a Swiss surgical unit reported no benefit from screening on admission. The Department of Health’s impact assessment of universal MRSA screening assumes that everyone screened has an equal risk of infection.

Preadmission screening was extended to all patients who were due to have surgery. Long-term patients, whose inpatient stay was on either the intensive care unit or the ward, were routinely screened. Previously, day case cardiology cases had been excluded from preadmission screening because of the short time these patients stayed in the hospital. The screening comprised skin swabs from the nose, axilla and groin. Increased efforts were employed to ensure that all patients were screened before their admission. Screening was undertaken at the outpatient appointment in the preadmission clinic, via the GP surgery or in the local hospital in the case of inpatient transfers. Before this initiative, all patients had been routinely screened, but this was performed on admission instead of before admission. This led to a situation whereby patients were operated on and moved through several departments before their MRSA status was detected. Referring hospitals were also asked to screen those who required transfer for surgery. If MRSA was detected, or if the status was unknown, the patient was admitted directly into a side-room and nursed in isolation until cleared of MRSA, the negative result was known. The MRSA screening tests have false positives leading to the isolation of patients who are non MRSA positives carriers as well as false negatives missing some carriers. For modelling purposes agar culture of bacteria from swabs was considered to identify MRSA with a sensitivity of 68% and a 6% incidence of false-positive tests. Enrichment broth culture was considered to identify MRSA with a sensitivity of 98% and a 6% incidence of false-positive tests. Real-time PCR was considered to identify MRSA with a sensitivity of 92% and a 9% incidence of false-positive tests.

Patients colonised or infected with MRSA should whenever possible be placed in a private room, or housed with other patients who have MRSA, (British Society for Antimicrobial Chemotherapy). The effectiveness of this widely accepted policy has not been proven in randomised trials, (Grundmann et al 2006. However in a systemic review, Cooper and co-workers, (Coopers et al, 2004), concluded that patient isolation, when combined with other control measures could reduce the spread of MRSA. Guidelines recommend that healthcare workers wear gloves when caring for MRSA-positive patients and that gowns be worn when substantial contact with patients or their environment will occur, (Coia et al, 2006). Nonetheless, Pittet et al, (1999) suggest that effectiveness of the use of gloves and gowns to care for patients with MRSA has not been established in randomised trails, although epidemiological studies support their use. Boyce et al (2002) claims, that as part of major nursing based procedures, hand washing has a vital part to play. They go on to claim that is is probably regarded as the gold standard, because all the articles on the subject they reviewed suggested hand washing. The lack of evidence of an effect associated with specific measures should not be mistaken for lack of effect, (Cooper el 2004). It can obviously be argued , that this is largely be due to the fact that although there have been a number of trails on the subject ethical and practical difficulties involved has proved far from easy to get a good evidence base in this area (Muto et al, 2003).

Ethical Implications

The Department of Health’s impact assessment does not mention the consequences of the mandatory screening policy on patient isolation, even though its best practice advice is that patients with MRSA colonisation or infection should be isolated if possible, Wyllie et al (2005). As well as adversely affecting the patient, isolation may affect control of other infections because it reduces the availability of isolation rooms. Thus MRSA screening of low risk patients is of uncertain benefit and may do harm. The issue of consenting to a screening test and the subsequent management of a patient found to be MRSA colonised is primarily an ethical one. There is no published literature referring specifically to the ethics of screening for MRSA and principles were, therefore, extrapolated from work on other conditions Krantz et al (2004). Ethical considerations include the right of the individual to make an informed choice, the balance of benefit over harm and general fairness. The objective of MRSA screening is to protect all vulnerable individuals within the hospital, rather than simply preventing infection in the individual being screened. A comprehensive ethical model must include the concerns of both the individual and public health, and consider all groups affected: those offered screening, other patients susceptible to MRSA infection, staff and policy makers. The concept of justice or general fairness demands that all patients are treated in the same manner, irrespective of their social or economic status. Selection for screening and subsequent MRSA colonisation management should not be influenced by these factors, and provision of patient information should recognise variations in levels of understanding.

The balance of benefit and harm associated with MRSA screening is most complex for those being offered screening. The actual MRSA screening test, be it carriage assessment or swabbing, is extremely low risk in terms of direct harm. However, those offered screening may become anxious regarding their test result or, alternatively, could be reassured by the efforts of the hospital to limit MRSA transmission. Those patients subsequently found to not be colonised should also be reassured by this fact. Patients colonised with MRSA may feel stigmatised and reactions to the use of contact precautions or isolation can vary. Concerns expressed in the literature include the possibility that patients in single-bed rooms or isolation: receive poorer quality care as a result of limited contact with healthcare staff,

experience restrictions in accessing other hospital areas and receive less stimulation. In addition, the patient’s subsequent placement in the community could be hampered by MRSA colonised status. However, the privacy of a single room can be viewed positively by patients (Dent & Dent, (2005).

When the patient is at risk of infection, for example due to an imminent surgical procedure, knowledge of their MRSA colonisation status allows measures to be taken to reduce their risk of developing an infection. This may delay the patient’s admission or procedure, while decolonisation is carried out. For individuals at high risk of becoming colonised with MRSA the screening of others does not cause harm but is beneficial, once actions are taken to minimise spread. For staff and policy makers the balance is between the benefits of preventing MRSA infection and reducing its overall prevalence, and the negative aspects of a resource intense screening strategy. The principle of autonomy implies that the individual has the right to refuse treatment. For MRSA screening, there is a conflict between allowing the individual the right to choose to not be screened and the rights of vulnerable others. A patient refusing to be screened can be managed as if testing MRSA positive, but will be subject to some negative factors associated with MRSA colonisation. It is important that both patients and staff understand the reasons for MRSA screening, including the uncertainties surrounding any screening process. Good quality information can reduce the anxiety generated by a screening test and fulfil the requirement for informed consent. The manner in which such information is imparted and the quality of care given to those requiring isolation are important and may influence an individual’s willingness to participate in screening. The legal consequences of any litigation following acquisition of MRSA infection in hospital could be altered by knowledge of whether the patient was or was not colonised at the time of admission. Studies in England and Scotland have suggested that up to 1 in 4 hospitals MRSA bacteraemia cases are diagnosed within 48 hours, indicating that the individual had been incubating MRSA on admission (Ferguson et al (2005).

Conclusion

Clinical effectiveness assessment identified a large body of literature on MRSA. However most publications reported on observational studies, infection outbreaks or routine information collection and, as a result, the literature base was considered methodologically weak. The following findings were used to support cost effectiveness analyses: • the incidence of MRSA colonisation amongst patients admitted to acute inpatient care in the UK is not known. Given the restricted data, the results of an ongoing study screening patients admitted to a UK district general hospital and citing an MRSA prevalence of 7% were selected for the economic model. However, several factors such as nurse-to patient ratios and low hand-hygiene-compliance rates could have made detection of a difference in transmission rates difficult during the trial periods. Health-care workers who are nasal carriers can serve as sources of MRSA transmission, although they are not nearly as important a reservoir as are colonised or infected Patients. Because nasal colonisation of health-care workers can be transient, recovery of an outbreak or endemic strain from a health-care worker on one occasion does not provide convincing proof that they have transmitted the organism to patients, ( ).

Introduction

According to (D’Amico, 2011), health assessment to be a patient means the systematic way of collecting client’s data, with an aim of determining his/her current health status, the health risk they may be exposed to, and identifying the health practice activities to be done to improve the patient’s health status. It can also refer to the intentional and interactive process by which nurses critically collect, and analyses and digests the relevant collected information form the patient to judge their the status of their health. In this essay, I shall present a health history assessment on an old aged patient and therefore there will be the need to make use of Comprehensive Health Assessment (CAH), which is a clinical practice relevant for the elderly patients. (Agedcare, 2013), states that the elderly are exposed to more sensitive medical and social issues in terms of the care requirements, therefore requires Comprehensive Health Assessment, that ensures skilled staff that will ensure care to the patient. My patient was elderly Ms. Pamela Jackson, and therefore, for the assessment, I was interested in demographic data, the patient’s perception on health, past medical history, both for the patient and the lineage family, and some other information about the patient.

Demographic Data

The demographic data in an assessment include the birth year, the gender, country they come from and if there are, many ethnic groups then which one does the patient belong. Ms. P.K was 86 years old by last year when I assessed her. She is currently living in New York but she was born in South Carolina. Pamela lives in third floor, on a story building but used an elevator, in a one-bedroomed house, and her children supports her financial, while for social security and Medicare she receives form the government.

Perception of Health

World Health Organization (WHO) (2014) defines health as the state of being mentally, physical, and socially well and it is not merely the idea of not having any disease. In this case, the elderly usually do not feel comfortable as they feel lonely, with nobody with them to help them go through. The patient describes the pain that she goes through when the chest pain begins and hopes that things could have been different if she were healthy. The patient loves other activities, and normally still strong when she feels healthy. She could go to the farm, walk her dog around and after these activities she could relax. Pamela usually feels that the chest pains and these illnesses normally takes this fun away from her, and usually feel bad about it. She occasionally feels that she is already old and therefore, she does not deserve to suffer that way instead she can die. Feeling of social disconnectedness from the other family members who she cannot visit normally, however, sometime they make feel healthy and loved. Therefore, Pamela says that nowadays she loves her life and has a change of perception towards being healthy.

Past Medical History

In 1964, she had some surgical procedures done on her, the first one involved, total abdominal hysterectomy that included the removal of uterus including the cervix, this surgery is done for women through their vaginas when they are faced with conditions such endometrial hyperplasia, uterine prolapse, or cervical dysplasia. This was highly relevant for Pamela because she was suffering from dysplasia. Five years later, she had another surgery, bunionectomy. This type of surgery helps in the removal of bunion, which is an enlargement experienced at the joint base of a big toe and it is normally comprised of the soft tissue and the bone. Pamela was experiencing irritation on her legs by then, and she had no fitting shoe, therefore had go through with surgery (Bunionectomy, 2000).

The same year that she had bunionectomy, is the same year that she was diagnosed with hypertension, and this was the time her problems started. She was administered some drugs that currently she remember which ones, but she can think about is that she stopped using them after 3 months because they had a side effect on her body, as they were causing drowsiness to her. Some years later, she was diagnosed with peptic ulcer disease, but for this she was administered specific drugs, and that is, cimetidine that helped her resolve the problem within 4 months’ time. Pamela does not have history of other illnesses such as heart disease, lung disease, nor cancer.

She had allergies when she was administered penicillin back in 1965; the drugs caused rashes on her body and hives. Therefore, she is normally advised not to use penicillin or to be used on her by any other medical specialist. She also have a social history of using alcohol, she has two beers every weekend with some wines when having dinner. She had no prescription for illegal drug use, as she never used tobacco related drugs.

Family Medical History

Pamela did not have the chance to grow up in the care of her mother as she died at the age of 40, leaving Pamela very young, that her aunt decided to take of her until she grew old. The cause of death for her mother was kidney failure. Her father is also deceased, and the cause of his death was a heart attack, that stroke him and he was gone. Pamela has been feeling that alone as her husband died too, he suffered from pneumonia and seizures. The old woman does not have any sisters, but was blessed with four daughters who are all well, but the son also died and was suffering from pneumonia. Her family therefore has a history of hypertension but no diabetes or cancer. Her family members do not have any habit of alcohol use or smokers only use alcohol during occasions.

Review of Systems

Starting from the top of her body to the bottom, she was interviewed on how she feels about every part. The standard body energy of the body should good, the weight stable at 160 Ibs, and the standard height 5’8”2. Given the age of the patient, her eyesight began to be blurry and this required her to wear reading glasses, but she has no diplopia or any other eye pain. The age Pamela makes her earing capabilities reduced, and therefore, for so many years, she has been experiencing hearing loss, hence she has to use hearing aid. Nose: she has no history of tonsillectomy, and has been wearing full set of dentures for many years and it has been working well for her, she has had no obstruction. She has no history of pleurisy, asthma, or coughing in her respiratory systems.

By 1960, she was admitted of hematemesis and melena, which means vomiting of blood and discharge of black stool with blood (Wilson, 1990). Her endoscopy showed some evidence of gastritis and therefore received units of packed cells; this helped make her stool brown. Pamela has had a history of cystitis, E Coli, but was treated using Bactrim. She had five pregnancies, with four successful and one miscarriage had her menopause at the age of 50. In terms of neuromuscular part, she experienced osteoarthritis on the shoulder, hips, and all of her knees for at least 20 years. Pamela did not have histories of anxiety and emotional distress, depression, no blood clotting.

Developmental Considerations

According to (Hoffman, 2001), development is a component in the healthcare across all the lifespan; therefore this gives advantage to the healthcare professionals to take care of their clients. Erickson states that in each stage of development there are different tasks that should be considered and this ensure that an individual experiences a normalized psychological development. The eight stages, given that Pamela is over 65 in age, she belongs to Ego Integrity vs. Despair.

In terms of physical development, there is increased vulnerability to diseases, and this led to the patient experiencing many illnesses such as chest pain and aching joints all over. The elderly normally experience changes such as integumentary including sagging, wrinkling; musculoskeletal changes including loss of elasticity in the joints; metabolic rate declines and other changes that normally reduce the pride and ego of the elderly. Therefore, they sometimes feel disadvantaged by their age.

The patient had retired long ago and therefore has the challenge of feeling despair, as he lived in a room alone, with the physical challenges she could move around as she used to when she was young. There is reduced income for the client as she had retired. Lastly Pamela has lived for; long and therefore have gone through sad period when the family members dies and live her still alive.

Cultural Considerations

The patient is an American belonging to the Caucasian ethnic group. She has lived in the United States whole her life without any histories of migration to other countries. She resides in New York and fluent English speaker. She loves to watch movies and listen to some old school music in order to avoid having more heart attacks due to her status. She is a retired nurse, with low-income sources and depends on the government for social security and Medicare, and a Christian who does not have a lot of cultural consideration and therefore, gives an easy time to the healthcare professionals.

Psychosocial Considerations

Pamela understands her situation but the best thing is that she lives with one of her daughters to help her go through the experiences. However, the patient is a very active personality; this is despite the fact that she has the arthritic symptoms. She acknowledges and already accepts the heart attack she normally have, but sometimes this makes her very anxious as she keeps on wondering the moment it will strike her again.

Physical Assessment

Due to her combination of chest pains and the heart attacks, I would critically assess her heart functioning and the lungs too. There should be a careful monitoring of the increasing chest pains and heart attack, this may be a proof of myocardial infarction and therefore should be admitted for more checkups. The patient’s cholesterol should also be monitored and therefore should be advised to have enough physical exercises but light ones, to ensure free-flowing blood circulation. Some medications such as HMG Co-reductase should be administered to reduce the cholesterol level in the body.

Need Priorities for the Patient

There are many elderly person in the world who are faced with such challenges of heart attack and have chest pain as they continue to grow older. To prioritize the needs, there should be assessment and screenings of the heart functions of these persons, and some education that is related to the hypertension in old age and how they can go through the matter. The only difficult part here is the news that some types of food that they will have to avoid, such as the fatty foods. They should be eating mostly vegetables with reduced sugary contents and some exercises.

Collaborative Recourses

The first collaborative resource for the patient would be church, where she could meet other friends and family and feel loved and cared for. Therefore, she will not have to feel lonely in the house and alone too. The next resource is the family members like her daughter and grandchildren coming over to give her a visit at the home. Doing some, exercises can be another resource helping her to increase the heart beat and circulation of blood.

Reflection

The interview took place in the room of the interviewee, I ensured that her daughter was not around so that we could have free environment for her to disclose everything to me. I first assured her of confidence with the information and that it would help to improve the healthcare of the elderly as she is. The tension between us reduced the more I was asking questions, therefore we could communicate freely.

During my time with Pamela, it helped learn how important health assessment was to the patients, mostly to the delicate elderly, who usually feel exclude in most societies. I learned the health risks that the elderly go through and can now have recommendations on how to solve their problems. Some of the barriers I had were the problem of lack of confidence with the information, in a way the interviewee at times did not provide all the information relevant for this assessment. However, the more question she developed the confidence and was able to open up.

References

Agedcare. (2013, October).

Comprehensive health assessment of the Older Person

. Retrieved from Department of Health:

http://health.vic.gov.au/agedcare/publications/assess/downloads/cha_summary.pdf

Bunionectomy

. (2000). Retrieved from Encyclopedia of Surgery:

http://www.surgeryencyclopedia.com/A-Ce/Bunionectomy.html

D’Amico, D. a. (2011). Cilinical Pocket Guide for Health an Physical Assessment .

Nursing Author Donita D’Amico

, 36-38.

Hoffman. (2001, January).

AGE-SPECIFIC COMPETENCY

. Retrieved from EIRCKSON’S DEVELOPMENTAL TASKS:

http://www.au.af.mil/au/awc/awcgate/army/erickson_stages.htm

Wilson, D. (1990).

Hematemesis, Melena, and Hematochezia

. Retrieved from NCBI:

http://www.ncbi.nlm.nih.gov/books/NBK411/