Abstract

This is a case study analysis that was performed following a certain patient’s hospitalization. The purpose of this case study analysis is to encourage the reader to critically think and identify certain pathophysiological processes, medications, clinical manifestations, abnormal assessment data, and abnormal laboratory values. The purpose of identifying the abnormalities is to critically deliberate what this means to the patient in question and why it matters. What diagnostic tests should physicians use? What do abnormal results mean? Does the patient require a new medication? Does the patient require a transfer to a higher level of care? By explanation and identification of deviations, clinicians can better serve other patients in their treatment. This case study will also prove that all pieces of the care plan are as equally important as the next and that the healthcare teams, especially nurses, must use their critical thinking skills and assessments skills to make sound and safe decisions for the patients.

Keywords:



Vital signs, signs, symptoms, clinical manifestations, decline, medications

Case Study Analysis of Patient’s Evolving Health Status

The patient is a 56-year-old Hispanic female presented to the emergency department with a stated complaint of back pain exacerbating over the past three days. The patient reported a fever, chills, myalgias,


dysuria, urinary frequency, and swelling in the left foot and leg. The patient had recently discharged from the same hospital a few days prior to this admission date and diagnosed with multiple compression fractures and was status post kyphoplasty.

Medical history includes diabetes mellitus type two, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, and multiple spinal compression fractures. Past surgical history includes vertebroplasty and hysterectomy. The social history of the patient is that she is married and lives at home with her husband. She has five children and is on disability for the compression fractures. The patient denies any history of alcohol abuse but reports the previous usage of cocaine and marijuana. The patient underwent admission to a medical-surgical unit and was alert and oriented times four and cognitively intact until the evening of day four of admission. The patient became confused and began to decline neurologically and respiratory wise. The patient was transferred to the intensive care unit on the afternoon of day five on BiPAP and was subsequently intubated on day six of admission.

Pathophysiology

The patient has a past medical history of diabetes mellitus type two, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and multiple spinal compression fractures. Diabetes mellitus is an endocrine disease process related to how blood glucose is absorbed and controlled in the body. In a working pancreas, beta cells secrete insulin when there is a rise in blood glucose (this is usually at the point where the body is eating). Insulin is released from the pancreatic beta cells and enables glucose to move back into the cells, decreasing the amount of free glucose in the bloodstream. In a patient with diabetes mellitus type two, beta cells release insulin. However, the tissues that absorb glucose become desensitized so that nearly as much glucose that is released into the bloodstream is not absorbed. The body gets adjusted to chronically having an increased amount of insulin, also known as hyperinsulinemia. Medications and clinical manifestations will be discussed in a later section of this case study analysis.

This patient also had a history of chronic obstructive pulmonary disease. In particular, emphysema. Chronic obstructive pulmonary disease is a respiratory disorder related to expiration. A patient that has chronic obstructive pulmonary disease is able to get air and oxygen in. However, the process of exhalation is impaired. In emphysema, there is a breakdown and thinning of the alveolar walls and therefore, impairs gas exchange. Since the walls are thin, they are not as flexible and cannot inflate or recoil properly and effectively holding the carbon dioxide in the lungs. Generally, patients with chronic obstructive pulmonary disease have both chronic bronchitis and emphysema, but the patient’s medical record stipulates emphysema. When a patient has more carbon dioxide in the lungs than there is supposed to be, it can cause the patient to have the blood’s pH become acidic and can cause problems related to arterial blood gases and effective breathing.

Atrial fibrillation is a condition of the heart that instead of the heart’s atrium contracting and relaxing, they tremble and shake. When the atrium shakes, it cannot pass blood effectively into the ventricles to disperse or become oxygenated. The blood then pools in the bottom of the atrium and when there is a contraction that empties out the atrium, it will send the blood out. Typically, the pulse will have to be a heart rate of greater than 100; that is not always the case. Since the blood is pooling, it is becoming stagnant and can form a thrombus. Atrial fibrillation causes an increased risk of cerebrovascular accident. Most likely, it is a stroke that is ischemic.

Hypertension is chronically elevated high blood pressure. It is divided into two categories:  primary and secondary. For primary hypertensive patients, the blood pressure is chronically elevated for unknown reasons. Secondary hypertension is a byproduct or spinoff of a disease process that is affecting the blood pressure i.e. chronic kidney disease. For the patient in the case study, she was diagnosed with primary hypertension. Hypertension is dependent on three factors:  cardiac output, stroke volume, and total peripheral resistance. Cardiac output is the quantified volume that exits the heart. Cardiac output, along with heart rate, determines the stroke volume. Stroke volume is the blood volume expelled with systole contraction, as dictated by the heart rate and cardiac output. Total peripheral resistance is how much resistance to pressure there is from ventricular pumping. If hypertension is left untreated, it will create damage not only to the vessels in which the pressure is weakening the vessel walls but to the organs the blood within the vessels is producing nutrients and oxygen to.

Acute metabolic encephalopathy is an imbalance of chemicals in the brain. Most commonly, it is a change in a patient’s mentation. For this patient, her encephalopathy was related to an elevated ammonia level. Metabolic encephalopathy can be caused by a number of different ailments. For example, elevated ammonia, medications, other neurologic disorders, and hypoxemia. Also, in this patient’s case, the patient’s respiratory system had become compromised and later had to placed on BiPAP and then intubated.

Concept map

Chronic Obstructive Pulmonary Disease

Nursing diagnoses

-Ineffective airway clearance

-Impaired gas exchange

-Ineffective breathing pattern

What is it?

COPD is an obstructive breathing disease that makes it harder to people to exhale normally.

Clinical Manifestations and lab values

-Coughing mucus greater than three months over two years

-Arterial blood gas abnormalities

-Difficulty breathing

-Pursed lip breathing

-Chest tightness, especially when coughing

-bluish colored lips

-lower oxygen saturation percentages

Treatment and Management

-Albuterol inhalation nebulizers

-intravenous corticosteroids

-corticosteroid inhalation breathing treatments

-Ambulation

-Incentive spirometer

Clinical manifestations

For the patient in the case study, the patient had clinical manifestations that progressively started to decline in health status. For the morning assessment, the patient was alert but not oriented to person, place, time or situation (when stated in the report the patient was alert and oriented times four up until day four of admission). The patient was also confused, restless, agitated, and increasing in hostility and becoming combative with the staff. The patient had bilateral lower lobe fine crackles and expiratory wheezes and had a 91-92% oxygen saturation on four liters nasal cannula. The patient was also using accessory muscles and had sternal retractions. The patient was experiencing tachycardia in the 120s.  The patient’s lower extremities were graded at 2+ pitting edema. The patient had a yellow generalized skin appearance and was warm and wet from sweating.

For a patient that was previously alert and oriented times four and cognitively intact until day four of admission to become confused, erratic, and unable to answer any questions is a steep decline in mentation. As it would later come about, the patient was in acute metabolic encephalopathy that ran parallel with acute hypercapnic respiratory failure. The confusion, combative actions were caused by an elevated ammonia level. Ammonia levels are between 11 and 32 and the patient’s levels were 85. The patient had to a drug called Lactulose in an enema form in order to get to ammonia level down. The impaired liver function also caused the yellow generalized appearance for the patient.

The patient was reading sinus tachycardia in the 120s on her telemetry monitor. This is a compensatory mechanism for increased respiratory effort. In addition, the patient’s confusion, restlessness, and agitation also played a factor in the patient’s elevated heart rate. The blood pressure was also elevated.

The patient had a previous medical history of chronic obstructive pulmonary disease and yet her respiratory system started to decline. The patient developed bilateral lower lobe crackles and expiratory wheezing. Since the patient’s gas exchange was already compromised from her history of chronic obstructive pulmonary disease; the crackles were evident by the patient’s inability to release carbon dioxide properly so more than likely (not confirmed at the time information was gathered to write the case study) the patient may have had atelectasis. The expiratory wheezing was trying to get the carbon dioxide out of the lungs. The use of accessory muscles and sternal retractions were present as the patient’s body was forcefully trying to compensate and let go of the carbon dioxide. The patient was also on four liters nasal cannula to get the patient to have a 91-92% oxygen saturation rate. Usually, in a patient that has chronic obstructive pulmonary disease, it is unwise to administer more than three or four liters of oxygen because it can cause them to become further hypercapnic.

One of the last clinical manifestations the patient had was 2+ pitting edema on the lower extremities. This is due to the blood pressure being increased. The patient remained in the 140s-150s systolic. The blood pressure is a hydrostatic pressure that will force blood outward. When the heart contracts, it sends blood for dispersion to other parts of the body. To adequately perfuse organs and digits, the blood much reaches the tissues and provide the oxygen and nutrients required to remain healthy. When the blood pressure is elevated for a long time, usually years, the pushing pressure becomes too much and will develop edema, or swelling, in the extremities. For this patient, the edema was graded at a 2+ which is substantial. This patient may have had a hypotonic osmolality and was fluid overloaded, which would further the cause of having edema. Coincidentally, the patient also had low serum albumin.

Labs

Ammonia is the result of protein breakdown. In patients with a working liver, the broken-down proteins (the ammonia) is sent to the liver to breakdown even further. When the liver function is impaired, the ammonia cannot reach the liver and therefore, ammonia levels remain in the blood and rise. Ammonia levels are known to affect the brain and cause hepatic encephalopathy. The patient reported no previous history of hepatic insufficiency or problems and the ammonia level went unchecked until just before the patient was transferred to the intensive care unit where the level was 85 on a range of 11-32. This would explain why the patient was alert and oriented times four and cognitively complete until the evening of day four when the patient started to become confused. The patient’s ammonia levels increased to a critical range.

The arterial blood gases demonstrate the body’s management of oxygen, carbon dioxide, and sodium bicarbonate. They are drawn by a respiratory therapist and analyze the patient’s pH, partial pressure carbon dioxide (PaCO

₂

), and the sodium bicarbonate (HCO

₃

)

_.



In this case, the patient’s pH was 7.30, PaCO

₂

86,


HCO

₃

41.8. The pH reveals how much hydrogen ion is in the bloodstream. If the hydrogen ion is increased, the pH is low and the blood is acidic. If the hydrogen ions are not as present, the pH is elevated and the blood is basic. Any levels outside of 7.35-7.45 can be detrimental to health, depending on severity. PaCO

₂

is a respiratory management compensatory mechanism to help balance out sodium bicarbonate and can retain carbon dioxide or expel it, depending on the patient’s condition. For this particular patient, the patient’s breathing was altered and the respiratory system could not compensate for the holding of carbon dioxide in the lungs. HCO

₃

is a compensatory mechanism for the renal system (kidneys). For the renal system to become involved in a compensating manner, the patient’s pH and PaCO

₂

failed to achieve compensation. It takes days to weeks for the HCO

₃

to increase. When analyzing the patient’s arterial blood gases, they are all out of range. However, though some values are critical, it is not bad for a patient with chronic obstructive pulmonary disease. Patients with this disease typically have altered blood gases due to alveoli damage and/or chronic mucus production. The body is trying to keep up its stamina for its difficulty in expelling air.

Glucose is the energy that human cells use for fuel (other than oxygen). Glucose is simply sugar and when a person eats, the blood glucose increases from the glucose in the food. Glucose is then distributed to other parts of connective tissue for absorption. Insulin helps to sensitive receptors in the connective tissue to absorption glucose. Though a patient that has diabetes mellitus type two, their receptors become desensitized to the glucose, despite the insulin and therefore, blood glucose will stay elevated. For this patient, up until day five, her blood glucose had remained between 200-240. A normal blood glucose is between 70 and 110. When a patient has elevated blood glucose, it can increase cardiac, respiratory, and infection treatment difficult because the blood is viscous from the glucose, it moves slower than characteristic.

Albumin is a plasma protein that is responsible for sustaining the osmotic vascular pressure. Osmotic pressure is a towing pressure to maintain a working intravascular fluid balance. Therefore, if the albumin is low, the patient will experience edema. Edema is swelling. For this patient, the patient was experiencing lower extremity edema with an albumin level of 2.5. Albumin levels are affected by hepatic function and if the liver function tests are altered, that will reflect in the albumin levels.

Liver function tests such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are enzymes that are mostly found in the liver and detect hepatic impairment and injury. These enzymes appear if there has been found to have an injury to the hepatocytes. Injury can occur from a genetic standpoint or an external effect (i.e. alcohol). The patient’s ALTs were 111 on a range of 13-56 and the ASTs were 112 on a 15-37 range. Chronic alcoholism will cause injury to the liver cells and will increase liver function tests. These tests are diagnostic and should be paired with a typical basic metabolic panel. The husband later admitted to the physician that he did not think she was alcoholic because she only drinks two beers a night, every night, for the past twenty years.

Medications

Ipratropium is an inhalation bronchodilator used to expand the bronchioles to allow air passage in and out easier. Surprisingly, only 2% of this drug is absorbed by the body if used via inhalation. There is greater absorption if used via aerosol. This patient had Ipratropium nebulizers scheduled every four hours at 500mg per treatment total. However, do not use Ipratropium more than 12 times in a 24-hour period due to this establishing a pattern that this medication does not work. Nurses must teach their patients to provide good oral hygiene after a treatment followed by notifying the nurse if the patient is experiencing any rapid heart rate increase and nervousness.

Lactulose is an osmotic laxative used to stimulate people to have a bowel movement followed by a significant period of constipation. Lactulose also binds to ammonia and excretes it through the stool, effectively lowering the ammonia levels. Lactulose can be given orally and rectally. Rectal lactulose is usually administered in an intensive care unit because if the patient requires rectal lactulose, they are too sick to be on a medical-surgical unit. For the patient in this case study, lactulose was administered through a 300mL enema to get the ammonia level to decrease. As for nursing implications, pay attention to how many bowel movements the patient is having and if the bowel movements are becoming more and more diarrhea-like. This could lead to possible electrolyte depletion and abnormal values.

Metformin is a biguanide that controls blood glucose production from the liver. Metformin also decreases glucose reuptake in the intestines and does not cause hypoglycemia. It does not cause hypoglycemia because its mechanism of action is not in the pancreas, it is in the liver. Patients taking Metformin should be cautious that this medication can cause diarrhea and nausea within the first two weeks of starting the drug. Patients should also be taught to check blood glucose before meals and at bedtime to see how effective metformin is and report this to their doctor. Patients should notify their physicians and healthcare team that they are currently taking Metformin prior to having a scan performed with intravenous contrast, as it can lead to nephrotoxicity and lactic acidosis. The case study patient was on Metformin, oral 500mg twice a day.

Propofol is a lipid emulsified sedative drug used in the intensive care unit and the operating room. Propofol’s purpose is to sedate the patient and often times can make them forget. Propofol is only administered through an intravenous line and the patient has to be on a cardiac monitor. Nurses should be careful when drawing labs on the same extremity the Propofol is infusing on, as it can affect the complete blood count and basic metabolic panel labs. Nurses should also be careful in their administration of Propofol, as too much of the drug can cause hypotension. Nurses are not to intravenous push Propofol but can titrate as directed by the ordering physician. For initiating Propofol, 2-2.5mg/kg initiation rate. After the patient is proven to be sedated, the drip can be titrated. The patient here was intubated on day six of admission and Propofol was used for sedation.

Methylprednisolone is an intermediate-acting corticosteroid used to strengthen lung capabilities for patients with asthma and/or chronic obstructive pulmonary disease. It can be administered oral, intravenous, and intramuscular. Patients and nurses should be aware to not stop any type of corticosteroids abruptly, as this can cause an adrenal crisis. Patients should be tapered off of steroids for the prevention of adrenal crisis. Corticosteroids also increase bone demineralization. For this patient, the corticosteroids she was taking at home contributed to the spinal compression fractures she complained of. The patient’s dosage started off at 125mg oral of this medication and would start to taper off the steroids on day seven.

Diagnostic tools

The patient ended up receiving a computed tomography (CT) scan of the brain that showed no acute intracranial process. This was done early in the morning of day five of admission to rule out a cerebrovascular accident. A CT scan is a relatively cheaper option (as compared to a magnetic resonance imager) that can note vascular and structural changes in the brain. As for this patient, the CT scan could not determine the cause of the patient’s confusion. Later on, a basic metabolic profile came back with ammonia level elevated.

The patient, later on, received a chest x-ray. An x-ray can be a portable machine used to view the body on a flat plane rather than 3D. The patient’s chest x-ray demonstrated that the patient’s heart was slightly enlarged and fluid overloaded.

Medical and nursing care plans

The medical care plan included medications, diagnostic tests, insertion of invasive lines and airways, and laboratory workups. For medications, the physicians ordered Precedex for agitation, scheduled Solumedrol 60mg every eight hours, Propofol for sedation, and ipratropium nebulizing treatments. Diagnostics are a daily chest x-ray and an echocardiogram. An arterial line was inserted into the left radial artery and the patient was intubated with an endotracheal tube after failing to wean off of BiPAP and became the respiratory effort doubled worse than before the patient was in the intensive care unit. Laboratories include daily arterial blood gases, complete blood counts, basic metabolic panels with ammonia. Venous thromboembolism prophylaxis includes sequential compression devices and heparin subcutaneous injections.

For nursing diagnoses:  ineffective airway clearance related to damaged vessel walls as evidenced by desaturation of oxygen levels and increased respiratory effort. Ineffective breathing pattern related to the inability to properly exchange blood gases as evidenced by a desaturation in oxygen and partially compensating arterial blood gases.

Conclusion

Ultimately, this patient survived her decline in health status and was able to recover well after being downgraded from the intensive care unit four days after admission to a higher level of care. This case study was intended to introduce all aspects of the patient care plan and all the variables that contribute to the patient and the outcome. All parts of the care plan are equally important and it is the job of the healthcare team to become as knowledgeable as possible, in order to treat patients timely and accurately.

BIBLIOGRAPHY

• Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016).
  
  Nurses pocket guide: Diagnoses, prioritized interventions, and rationales
  
  . Philadelphia: F.A. Davis Company.
• McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2019).
  
  Pathophysiology: The biologic basis for disease in adults and children
  
  . St. Louis, MO: Elsevier.
• Pagana, K. D., Pagana, T. J., & Pagana, T. N. (2015).
  
  Mosbys Diagnostic and Laboratory Test Reference
  
  . St. Louis, MO: Mosby.
• Vallerand, A. H., Deglin, J. H., & Sanoski, C. A. (2017).
  
  Daviss drug guide for nurses
  
  . Philadelphia: F.A. Davis Company.

The Role of a Nurse

The role of the nurse has developed massively from the times of Florence Nightingale to the modern 21st century. Florence Nightingale became an extremely famous heroine after her great efforts during the Crimean war. She fought to get all the wounded bandages, fresh bedding, food and cleaning supplies. Nightingale showed empathy and sympathised with the wounded and dying soldiers, she took the time to comfort and take concern for them. She was also able to manage others who worked around her, directing what could be done, such as assisting with letter writing and helping to wash or dress the men that were incapable. These are all factors that are now necessary skills for a nurse. (M.L.Lobo, Cited in J.B.George pg.43, 2002) Nightingales main priority was to secure and protect the environment that her patients were in. This consisted of keeping them clean and in a condition where infection could be minimised. These main features have been taken on board and have developed a vast amount to provide the most effective and safe practice of health care to date. This essay will aim to talk about the role of the nurse through the 4 principles of the

NMC code

(2015) and also express the importance of the 6 Cs of nursing whilst integrating them and linking each one to the NMC code. It aims to express the importance of communication, commitment, confidentiality, team work , fundamentals of care and professionalism.

The NMC code (2015) have set out 4 main categories that describes everything a nurse should be able to do and what a nurse needs to abide by. These categories are; prioritise people, practice effectively, preserve safety and promote professionalism and trust. The first  section to be focused on is Within prioritise people of the NMC Code (2015) it states “treat people as individuals and uphold their dignity” this statement explores the importance of being non-prejudice when working within the nursing profession. Prejudice is defined as “preconceived opinion that is not based on reason or actual experience” (M.Waite, 2012) this is creating a judgement on someone from visual appearances and body language before you get to know a person. Prejudging someone, gives an overall first impression of a person. These are solely controlled by the nonverbal communication that happens when we first come in contact with someone. Therefore, the impressions we make are based on how a person looks, smells and sounds.  This is not always a positive impression. For example, if a new school teacher were to arrive to school in clothes that were creased, and their hair was not fixed, then we would assume that the teacher is incapable of teaching and is as disorganised as their appearance. However, these impressions can change; if the teacher were to perform extremely well and happened to be an outstanding teacher, then our first impressions are completely forgotten as they have over ruled them. Hence why a person should never judge a book by its cover. (Six degrees, 2018). However, regardless of the person, their background or what they have done, nurses and doctors take an oath to treat and care for all patients that come through the health service and prejudice is not even thought of.

Prioritising people also consists of upholding the patient’s dignity. This is key in the profession. Upholding dignity allows for the patient to feel comfortable and respected. Patients are extremely vulnerable in times of care and are exposed to situations that may be distressing for them. Nurses must be mindful of a patient’s morale in these circumstances. In cases where patients need to undress and get into a hospital gown, a nurse must ensure that they have their own private space, even if that means it’s closing the curtain from other patients around them. It consists of listening to a patient’s point of view and understanding how they feel. Its concentrating solely on them and giving them the person centred care that they deserve. There are ten elements of dignity that have been previously described by Dr Hicks in her book “Dignity, its essential role it plays in resolving conflict” that are beneficial in a health care profession. The most important that are relevant to nursing include; the acceptance of every persons individuality and identity, being understanding- taking into account what others are feeling at a distressing time, safety- ensuring that people are to feel at ease, fairness- treating all patients equally and lastly the most important is allowing the patient to have independence- this is to encourage people to have autonomy and to reiterate how they always have a say as to what happens during their care experience; it enables empowerment. (D.Hicks, 2011)

The Fundamentals of care was set out to improve the quality of care for adults. It is now the basis of nursing. The NMC have defined the fundamentals of care as “The fundamentals of care include, but are not limited to, nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions… making sure you provide help to those who are not able to feed themselves or drink fluid unaided.” (NMC, 2015). The fundamentals of care aim to treat patients with dignity and respect but also ensuring that people’s physical, social and psychological needs are assessed and managed. Consent must be gained before carrying out any needs, such as assisting with feeding, brushing teeth, bed baths, assisting with toilet needs etc. This is the use of beneficence, acting in a way that is beneficial for the patient. Although the fundamentals of care are set out to promote care and have a benefit for the health, it can also have a negative impact on the patient. It is taking away the patients independence, patients are made to feel as though they are incapable of doing daily tasks that they carried out prior to coming into hospital. An example of this is on a cardiac ward; after having a heart attack and even though you are now stable and mobile, you cannot leave your bed area and therefore are made to go to toilet into a disposable bedpan, when in reality they could have gone to the toilet. One study found that 12% of patients aged 70 and over had noticed a decline in their ability to carry out essential tasks independently such as bathing dressing, using the toilet, eating and moving around, between their arrival to hospital and discharge (K.E.Covinsky et al, 2003). It also makes patients very reliant on nurses, they then feel that they can’t carry out tasks without a nurse and because they are so used to nurses assisting them with their care, they become more dependent and less mobile. In terms of mobility, being bed bound for weeks on end in hospital can cause muscles to break down in the body. Evidence has proven how longer stays in hospital can lead to worse health outcomes. Older patients can lose mobility rapidly when not kept active. Monitors recent review had shown how for healthy older adults, 10 days of bed rest can lead to 14% reduction in leg and hip muscle strength. With a further 12% reduction in aerobic capacity (Monitor, 2015 cited on National Audit Office p.14). This expresses how nurses should encourage patients to walk around on regular intervals if they are able and it is safe to do so to decrease the chances of having muscle loss and to ensure that they are able to go back to their own homes rather than to other care facilities.

The NMC Code (2015) second category for nurses to adhere to is “Practice effectively”. One of the points expressed is to “communicate clearly”. Communication amongst all nursing is one of the most important roles that a nurse has. Communication is usually taken for granted and is dismissed to the point where people believe that it is not important. But, in a nursing role, a nurse has to be able to communicate efficiently and effectively with both patients and other members of staff. There are two forms of communication; verbal and non-verbal. (S.Kraszewski & A. McEwen, 2010) Verbal communication is the use of speech or written information in order to express opinions and beliefs or simply for a conversation. The way in which we speak with tone of voice and with pitch is all based around the individual patients. If a patient were to be slightly deaf, then a nurse would understandably be using a higher volume of speech and also using a slow pace to give the patient time to understand what it is that they are actually saying. However, if the patient were to be of a well hearing health then a nurse would use a mediocre tone of voice and perhaps use a faster pace as the patient will understand more clearly. Verbal communication is the most common form. However, non-verbal communication also pays an important role. Non-verbal communication is the use of body language, eye contact and facial expression. This is useful in situations where the use of speech isn’t always appropriate. For example, in cases where a patient has been given a short time frame to live, a nurse may have broken the news and have used a healthy silence to allow the patient to digest the information that has been given. But, maintaining an open body stance and having soft eyes in this situation, allows the patient to recognise that they are there to talk to and ask questions when they feel they can (Nursing times, 2018). Albeit, there are many strengths and weaknesses to both forms of communication. Verbal communication can ensure that a point has gotten across to the patients and that they understand fully everything that has been explained to them. It also allows for a nurse to gain consent, they are able to discuss with a patient the procedure of their care and the patient is then able to decline or consent. This also brings out a sense of autonomy in the patients as they feel in control of their health care; they have a say as to what goes on, such as when they wish to wash, whether they want to go ahead with extensive surgery, to even when they wish to get out of bed. Effective communication also makes a patient feel valued. It shows how you are willing to listen and attempt to understand how they are feeling. This will build a report with a patient which makes them more trusting and they take on board what you have to say. Verbal communication can also have weaknesses. These can include language barriers. Visual and hearing impairments are a form of language barriers. The loss of hearing makes it difficult to understand what a person is saying. You would need to be able to speak sign language and studies have shown how only a minority of health professionals can communicate using sign language. It was reported in 2013 that 46% of reported deaf respondents have communicated with health professionals with the use of pen and paper. Having to write things down in order to have a conversation. 23% have reported they currently communicate using spoken English and the use of lip reading; stating that they would prefer not to. (Research into the health of death people, 2013). This research is only based on the presence of 553 deaf people within the UK. This can suggest how it is not a true representative of the whole deaf community worldwide. 553 deaf people is a small amount compared to the thousands that are present in the UK. This is stating that it only gives a slight insight into the difficulties faced by deaf people within the NHS; it cannot be said that all deaf people feel this certain way. Also, the study was carried out 6 years ago, therefore, it is slightly out of date. There is a possibility that there has been an increased awareness into the struggles that the deaf community face and changes could have been made over recent years to improve the experience these people face during health visits. It is important for a nurse to be aware of all these barriers when in their role.

Team work is also necessary when working within a nursing role. Teams have all different levels of experience and knowledge within the NHS and this has to be recognised and understood to enable the delivery of care to be most effective. The main function of a team during healthcare is to provide a good quality of care. The Harding committee (DHSS 1981, cited in S.Kraszewski & A. McEwen, 2010. pg.76-77) stated that a team has to have four certain key elements in order to function. These are; an overall common objective that is to be accepted by all staff within the team, an understanding of their personal roles, skills and how they function- taking into consideration about their own responsibilities and lastly having mutual respect for all other team members and their role. If a team was able to express and act upon these key elements, then the care delivered would be of a high standard. Even though, the definition is outdated coming from 1981, it is extremely relevant in modern day nursing as the principles of a team remains the same and the emphasis on teamworking is still at a high. However, the Harding committee failed to acknowledge the strength that communication has within a team. Under ‘practice effectively’ of the NMC code (2015) it states “work-co-operatively” and one sub-point says that a nurse must maintain effective communication with colleagues which links with another sub-point of sharing information to identify and reduce risk. Having effective communication whilst in a team can enhance the quality of care given.

The third category of the NMC code (2015) is to “Preserve Safety”. This is essential in nursing care both for the nurse themselves and for patients. This means that nurses have to recognise and notice their capabilities, to work within their own skill set and competence to prevent any harm. It is encouraging that nurses ask for help from suitably qualified staff, this not only increases the quality of care, but also improves and develops the skill sets of the nurse.  It also states how nurses should “always offer help if an emergency arises in your practice setting or anywhere else”. This form of commitment can be shown to the profession itself. If a shift was over and an emergency arises a nurse would not just clock off and leave, they would step in and help to resolve the situation and provide their services when needed. Nurses have a commitment to personal excellence. This is carrying out frequent evaluations of one’s self to further develop the professional care that is being given. It allows for nurses to critically evaluate themselves to make changes or improvements, writing up reflections in order to say what has been done well and what they would do differently. This is showing commitment to the job, making changes to improve and develop further to enhance not only yourself but the patient’s well-being. Commitment to the job can also be shown towards colleagues. Complimenting colleagues on what they have done well and help assist them on what they are still learning. Show care and compassion to other employers as well as patients. (J.R.Ellis&C.L.Hartley, 2004)

4 Promote Professionalism and trust

Confidentiality

Care

Courage

Empathy

RCN 8 principles

Reference List

• M.Waite (2012)
  
  Paperback Oxford English Dictionary,
  
  Seventh edition. Oxford University Press. Oxford.
• D.Hicks (2011)
  
  Dignity: The essential role it plays in resolving conflict.
  
  Yale University Press. London.
• K.E.Covinsky et al (2003) ‘Loss of independence in activities of daily living in older adults hospitalised with medical illnesses’, Journal of the American Geriatric Society, 51 (4), April 2003.
• M.L.Lobo cited in J.B.George. pg.43 (2002)
  
  Nursing Theories the base for Professional Nursing Practice
  
  , fifth edition.Pearson Education LTD. New Jersey.
• S.Kraszewski & A. McEwen (2010)
  
  Communication skills for adult nurses.
  
  Open University Press. Berkshire, England.
• Nursing Times (2018) Available [online]
  https://www.nursingtimes.net/clinical-archive/assessment-skills/communication-skills-3-non-verbal-communication/7022784.article
  
  Accessed [20/12/2018]
• NMC Code (2015) Available [online]
  https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
  
  Accessed [12/12/2018]
• Communication in health and social care (2010) Available [online]
  https://resources.collins.co.uk/free/BTECHSCunit1.pdf
  
  Accessed [18/12/2018]
• Royal College of Nursing (2016) Available [online]
  https://rcni.com/hosted-content/rcn/first-steps/why-communication-important
  
  accessed [28/12/2018]
• Six Degrees (2018) Available [online]

  The Psychology of First Impressions

  Accessed [01/01/2019]

• Research into the health of deaf people (2013) Available [online]
  https://signhealth.org.uk/wp-content/uploads/2014/03/SignHealth-Deaf-Health-Survey-Report.pdf
  
  Accessed [01/01/2019]
• Monitor (2015) cited on National Audit Office p.14 (2016) Available [online]
  https://www.nao.org.uk/wp-content/uploads/2015/12/Discharging-older-patients-from-hospital.pdf
  
  Accessed [02/01/2019]

Introduction.

When we think of drug addicts and abuse we normally think of people who take the common street drugs such as cocaine, crack, heroine, or other illegal drugs. However most people don’t realize or take seriously the growing number of abusers of prescription drugs currently in our country. There is a common misconception that just because a doctor prescribes a certain drug that that is somehow safer and different than using the so-called street drugs. After all, you are being given a prescription to take the drug by your physician, and it is not illegal or a crime. However, we must realize that addiction isn’t limited to just illicit drugs on the street, but often doctor prescribed medications as well.

Prescription drugs have improved and saved countless numbers of lives over the years as many new breakthroughs have been achieved in science and medicine in treating a variety of known diseases. “However, using these drugs without the supervision of a physician or for purposes different from their intended use can lead to serious adverse consequences, including death from overdose and physical addiction. Because many prescription drugs are often opiate based, when abused, these drugs can be as addictive and dangerous as illegal drugs.” 1) (Pat Moore Foundation | Prescription Drug Abuse, 2009).

According to (M.D ,Volkow, 2005), director at the National Institute on Drug Abuse, 2) “an estimated 48 million people (ages 12 and older), have used prescription drugs for non-medical reasons, which represents approximately 20 percent of the U.S. population.”

Additionally, 3) “in 2000, about 43 percent of hospital emergency admissions for drug overdoses (nearly 500,000 people) happened because of misused prescription drugs, and in “2006 alone, 700,000 emergency room visits were attributed to prescription drug overdoses.” 4) (Thibodeau, 2009).

This type of drug abuse is increasing at an alarming rate because of their widespread availability, including online pharmacies which have made it much easier for anyone regardless of age to acquire drugs without a prescription. (Prescription Drug Abuse Information | Drug Rehab Programs, 2009). 3)

“One of the most common and primary methods of obtaining prescription drugs by addicts is by doctor shopping according to the Drug Enforcement Administration (DEA).”5) This method refers to a person who continually searches out different doctors to prescribe the same medications in order to feed their addictions. I think most of us either know or have known individuals or even family members who have resorted to this type of behavior in order to get prescription drugs for this purpose.

The most common types of drugs that are often abused are central nervous system depressants such as benzodiazepines or tranquilizers, frequently prescribed for anxiety and sleeping disorders, opioids and narcotics for pain relief, and stimulants such as those given for attention deficit hyperactivity disorder, (ADHD), narcolepsy, and obesity. 6) (Prescription Drug Abuse Chart – Drugs of Abuse and Related Topics – NIDA, 2009)

“For example, U.S. prescriptions for stimulants (including those taken for ADHD) increased from around 5 million in 1991 to almost 35 million in 2007. Prescriptions for opioid painkillers such as oxycodone (OxyContin) and hydrocodone (Vicodin) increased from 40 million in 1991 to 180 million in 2007.” 7) (Mayo Clinic, 2008).

I feel the reasons for this significant increase in prescription drug abuse is simple. We live in a society today that tells you a pill can cure and solve all of your problems no matter what they are. All we have to do is turn on the television and see the constant bombardment of advertisements for the latest prescription drugs on the market. As a result, the pharmaceutical industry is making billions of dollars off of people and is certainly not going to complain, thus encouraging and driving the epidemic even more. Furthermore, these drugs are relatively easy to obtain and are socially acceptable by the vast majority of the public compared to illegal drugs.

In just the past several years, we have seen the emergence and proliferation of many “pain clinics” throughout the United States. Although not all are bad, some of these facilities as stated by 8) (Silverman & Brown, MD, 2009), “are often non-physician owned and operate just inside the law. The physicians who practice in these facilities are rarely accredited through board certification processes, and many take no insurance and advertise confidential, cash only services. Some even advertise armed guards in the waiting rooms. With no oversight, these facilities serve as a source for a continuous supply of controlled substances to often times addicted and sometimes naïve people. It is not uncommon to find patients of these facilities receiving tens of thousands of milligrams of opioid medications each month.”

With these types of programs and clinics operating and encouraging such drug abuse, I feel that the people who really need these medications are often the ones who suffer, such as individuals with painful terminal diseases and illnesses like cancer. I experienced this first-hand with my mother several years ago when she was diagnosed with terminal lung cancer that had metastasized to her bones, and helplessly watched her suffer from pain. While she was undergoing radiation treatments at a cancer clinic, her doctor there stated that she should use Advil to help with her pain and that the government was cracking down on schedule drugs that were prescribed. My response to this is, if cancer patients can’t get the necessary pain medications they desperately need, yet addicts can get all they want, then there is something very wrong with this country we live in and our health care system.

Conclusion.

What is important to recognize and become aware of about prescription drug abuse is that it is much the same as other forms of illegal drug abuse such as cocaine or heroin, and no one is immune. It can be just as dangerous and deadly as other illicit drugs, and affects individuals of all ages, races, gender, and socio-economic backgrounds. It can also destroy families, jobs, and homes as well as having fatal health consequences. In fact, use of prescription drugs now causes more deaths than heroin and cocaine combined, according to the U.S. Drug Enforcement Administration.” 9) (Treatment Solutions Network, 2009).

Furthermore, with the recent tragic and untimely deaths of celebrities such as Michael Jackson, Anna Nicole Smith, and Heath Ledger related to prescription drug abuse, I feel this problem is finally being brought to the forefront and exposed, bringing a much needed awareness to the dangers and consequences of abusing prescription drugs.

References:

1) Pat Moore Foundation | Prescription Drug Abuse. (n.d.). . Retrieved December 6, 2009, from http://www.patmoorefoundation.com/prescription-drug-abuse

2 M.D ,Volkow, N. (2005). NIDA – Research Report Series – Prescription Drugs: Abuse and Addiction. Retrieved December 6, 2009, from http://www.drugabuse.gov/ResearchReports/Prescription/Prescription.html

3) Prescription Drug Abuse Information | Drug Rehab Programs. (2009). . Retrieved December 6, 2009, from http://www.prescription-drug-abuse.org/

4) Thibodeau, D. (2009, October 20). Prescription drug abuse now tops illegal drug use | GoDanRiver. Retrieved December 7, 2009, from http://www2.godanriver.com/gdr/news/local/danville_news/article/prescription_drug_abuse_now_tops_illegal_drug_use/14771/

5) Drug Addiction – Doctor Shopping – Chronic Pain Medication Addiction. (2009). . Retrieved December 6, 2009, from http://www.drug-addiction.com/doctor_shopping.htm

6) Prescription Drug Abuse Chart – Drugs of Abuse and Related Topics – NIDA. (2009). . Retrieved December 6, 2009, from http://www.nida.nih.gov/DrugPages/PrescripDrugsChart.html

7) Mayo Clinic. (2008). Prescription drug abuse – MSN Health & Fitness – Addiction|Quit Smoking. Retrieved December 6, 2009, from http://health.msn.com/health-topics/addiction/articlepage.aspx?cp-documentid=100211994

8) Silverman, MD, S. M., & Brown, MD, L. (2009). Prescription Drug Abuse: In the US and Florida. Retrieved December 7, 2009, from

http://www.hgexperts.com/article.asp?id=6649

9) Treatment Solutions Network. (2009). Prescription Drug Abuse and Addiction. Retrieved December 6, 2009, from

http://www.treatmentsolutionsnetwork.com/prescription-drug-abuse.html