Government Policies to Reduce Obesity

/in /by


Aaron Lukse

Obesity is a major issue facing the United States. Over the past two decades the percent of Americans who are considered overweight has increased dramatically. This phenomenon is not only taking place in adults but there has been a significant increase in juvenile obesity as well (Oliver 2005). There have been various steps taken toward combating the increasing obesity rate. Some of the proposals included taxes on food, setting specific guidelines for lunches in schools, getting rid of various sodas and junk from school cafeterias and set limits on various food advertisements (Oliver 2005).

One area that has gained much momentum over the years has been the idea of calorie labeling. In many ways these laws are sound and prudent public health policy initiatives because it promotes the populations health and well being (Gostin 2000). These laws might seem as though that the government is trying to regulate private behavior, however many times over the history the government has intervened in private habits. Historically some of the prior government intervention in the private affairs include in the case of alcohol, illegal drugs, tobacco, and sexuality (Kersh 2002).

Many believe that there are “triggers” that make the government intervene in private affairs. These triggers include social disapproval, medical science, self help, the demon user, demon industry, mass movement, and interest group action. In the case of obesity many researches believe that these triggers have been tripped and that is the reason for the various government interventions (Kersh 2002).

In many ways the move towards calorie labeling creates a certain type of citizen involvement and participation (Morone 2003). This restores the power to the people to have more control of their decisions and food choices. Many people underestimate the amount of calories in fast food and therefore are not aware of how much calories they are consuming on a daily basis. When calories are labeled this would make people aware of exactly how much calorie are in various fast foods. Having these labels would positively influence their decision making process.

Also, just having the calorie label by itself may not be enough. Those calories should be further broken down to let the consumer know how much of the food has other nutrients. For example, the label could indicate the percentage of proteins, carbohydrates and sugar. Another solution is to incorporate the nutrition values and the calorie labeling and create a simple red, yellow and green food label indicator.

Green label would indicate that the food has low calories and high nutritional value. A yellow label next to the food would suggest moderate calories and moderate nutritional value. A red label would indicate that the food is in high calories and low nutritional value. This would a very simple and straightforward method because people would instantly know whether a food is good, bad or neutral in calories and nutritional values by a simple glance.

At the individual level food labeling creates deterrence to eat high calorie food and persuade people to make healthier choices (Gostin 2000). This would be an effective intervention because there’s the possibility that the society might move towards stigmatizing people that continues to eat unhealthily foods even after reading the label. (Bayer 2006). Also, this would force many of the corporations to abandon high calorie foods for low calorie foods which are much healthier.

In the same way that smoking has been stigmatized by public health officials and anti tobacco activists, eating at a fast food restaurants despite the fact there’s a clear warning about calories could be stigmatized as well. Stigmatization of smoking may have been a factor in reduction of smoking (Bayer 2006). The same type intervention could be used to stigmatize obesity. This stigmatization could cause isolation and even severe embarrassment to people that would eat at fast food restaurants that have calorie labeling (Bayer 2006).

Also, having the calorie label could create fear in the heart of consumers that if they eat a high calorie food that it might lead to various chronic diseases (Aranowitz 2009). The calorie labeling in many ways would be a type of early prevention of various diseases (McGinnis 2002). M.J. Roseneau in 1910, made a strong argument that in public health fear is an important tool because it makes the public think about the future thereat of chronic disease (Avery 2004).

There are other programs in addition to the calorie labeling that could be implemented. In the same way there are additional taxes imposed on cigarettes to make it expensive to buy, the same could be done with fast food. Additional taxes could be added to fast foods over a certain calorie threshold. In the same way there are additional taxes on fast foods with high calories, the foods that are healthy could have zero taxes such as on fruits and vegetables (Yach 2003).

In many ways the raising of fast food prices will force many people to buy healthier food which could be much cheaper. Also, in the same way there are labels outside the cartons of cigarettes, there could be labels placed outside of fast food cartons. These warning labels would tell the consumer that eating high calorie food may cause obesity and even chronic diseases (Yach 2003).

Also, another intervention in addition to calorie labeling at the restaurant would be to have the calorie labels during advertisement of the food product. In the same way that many of the drug companies are required to provide the various side effects of the drug at the end of the commercial, all fast food companies should provide the total calories of the products being advertised (Yach 2003). Another great program to implement would be counter advertising. Many of the commercials on television for various fast foods hide their calorie content. With counter advertising the government or various non profit organizations can tell the truth about the contents in various fast foods.

One of main ways to reduce obesity is to have communities play a main role in health interventions (Schlesinger 1997). These local communities can create various educational types of programs to reduce obesity. Also, the local community might be a better indicator of how much to spend in terms of healthcare interventions (Savedoff 2007). Local neighborhood groups can create programs to encourage physical activity. This can be done by building various parks, gyms, basketball and other recreational activity centers. Many people that are physically active are more aware of their eating habits would consume low calorie and healthier foods.

Many of these communities can increase the availability of healthier foods and beverages. They can pass local ordinances which would indicate that the local food and grocery store should carry certain percentage of healthy foods. Also, the local groups can regulate the types of beverages that are in schools and recreational areas. The communities might also make these healthier foods affordable so that more people would have access to it. Also, these local groups can create ways for local farmers to bring in fresh fruits and healthier foods to the neighborhoods.

Also, communities can implement ordnances that prohibit the advertisement of less healthy foods and promote the advertisement of healthier food from local farmers. Also, local groups can encourage various physical activities such as walking, biking and running.

Community level programs could have different impact depending on whether the program is implemented at a neighborhood that is economically disadvantaged compared to one that is better off both in terms of health and finance. One of the main reasons the member of economically disadvantaged neighborhoods might have a different outcome with the same intervention is due to social capital (Shortt 2004). Social capital is characteristic of a group which creates mutual trust and reciprocity. In many ways people from disadvantaged backgrounds lack the trust in the system as well in their community.

Also, in many ways a lot of the interventions could have negative consequence on socially disadvantaged neighborhoods. For example, one of the interventions that were suggested was to raise the prices of the fast foods. Raising the price of food would adversely affect the people in these neighborhoods. Many of these neighborhoods lack quality supermarkets that carry healthier food. They would be forced to pay more without access to other healthier alternatives that a wealthier neighborhood. There is also the possibility of income inequality in many disadvantaged neighborhoods. This creates a lack of financial resources to buy healthier food. Some of the ways to overcome these shortcomings are to provide incentives for large supermarkets to be built in disadvantaged areas. Also, the various communities should improve the availability and geographic proximity of supermarkets to disadvantaged the population.

References

  1. J Eric Oliver, and Taeku Lee. 2005. “Public Opinion and the Politics of Obesity in America” Journal of Health Politics, Policy and Law 30(5): 923-54.
  2. Lawrence O. Gostin, 2000 “Public Health Law in a New Century: Part I, Law as a Tool to Advance the Community’s Health” Journal of the American Medical Association 283(21): 2837-2841; “Part II: Public Health Powers and Limits” 283(22): 2979-2984; “Part III: Public Health Regulation: A Systematic Evaluation” 283(23): 3118-3122.
  3. Rogan Kersh and James Morone, 2002. “The Politics of Obesity: Seven Steps to Government Action” Health Affairs 21(6): 142-53
  4. James Morone and Elizabeth Kilbreth, 2003. “Power to the People? Restoring Citizen Participation” Journal of Health Politics, Policy and Law 28(2-3): 271-88.
  5. Ronald Bayer and Jennifer Stuber, 2006. “Tobacco, Stigma and Public Health: Rethinking the Relations” American Journal of Public Health 96(1): 47-50
  6. Robert Aranowitz, 2009, “The Converged Experience of Risk and Disease” The Milbank Quarterly 87(2): 417-42
  7. J Michael McGinnis, Pamela Williams-Russo and James R. Knickman, 2002. “The Case for More Active Policy Attention to Health Promotion” Health Affairs 21(2): 78-93.
  8. George Avery, 2004. “Bioterrorism, Fear, and Public Health Reform: Matching a Policy Solution to the Wrong Window” Public Administration Review 64(3): 275-88.
  9. D. Yach, C. Hawkes, J Epping-Jordan, S. Galbraith, 2003. “The World Health Organization’s Framework Convention on Tobacco Control: Implications for Global Epidemics of Food-Related Deaths and Disease” Journal of Public Health Policy 24(3-4): 274-90.
  10. Mark Schlesinger, 1997. “Paradigms Lost: The Persisting Search for Community in U.S. Health Policy” Journal of Health Politics, Policy and Law 22(4): 937-58.
  11. William Savedoff, 2007. “What Should A Country Spend on Health Care?” Health Affairs 26(4): 962-70
  12. S.E.D. Shortt, 2004. “Making Sense of Social Capital, Health and Policy” Health Policy 70(1): 11-22.

Occupational Therapy Reflective Essay

/in /by

  • Bianca Haw

“I’m an occupational therapist, an obscure profession if there ever was one.


We are few and far between, maybe because we have


chosen to

serve people with disabilities

.


All disabilities.


Not a glamorous endeavour, nor a lucrative one.


And I say serve because we deem that in helping we see weakness,


while in serving

we see wholeness

.


We’ve opted for wholeness nearly a century ago


and have been at odds with the system ever since.


We don’t fix people, you see: with them,


we simply try to find a way to

meaning

,

balance

,


and

justice.


I chose occupational therapy because it blends

science

and

humanism

,

intellectual rigour

and

compassion

.


”


— Rachel Thibeault (from

Occupational Therapists without Borders

)



1

Occupational Therapy First Year Portfolio Task

A year ago, I was in my final year at high school and studying for finals. Now, I am a first year Occupational Therapy (OT) student at the University of Witwatersrand who is getting ready for her end of year exams, scary stuff! But I can’t complain when I think back on how much I’ve learned this past year and how it has impacted me when I think about my future. At the core of it, this year has taught me that OT is not what I thought it was. Yes, I had an idea of what an OT does in terms of activities but I was not aware of what it would take to get to the same point as the OT’s who I had observed during my time job shadowing in my matric year.

I’ve learned a lot during this first year and I now have a deeper understanding of the career path that I am pursuing- what it will demand from me, how it will influence the lives of others through me, the scope of OT and what I need to know to not only be good as an OT, but to be a great OT. It has me anxious about the mountainous path looming ahead and passionate to reach the finish line all at the same time. In talking about the mountains that I see rising ahead of me, I thought that I would reflect on the mountains that I have already crossed and how they impacted my grasp of OT and how it helped me to link the theory to the clinical uses. The first mountain was Problem Based Learning (PBL) which actually grounded me in order to prepare me for the much larger mountain: Fieldwork.

One of the first lectures that we had was on PBL’s, problem based learning. And to say that I took the concept for granted and wrote PBL’s off as time-wasters would be correct. So when I realised just how helpful and beneficial PBL groups could be, I was all in. PBL’s have taught me the importance of working as a group, time-management, designation of tasks, following certain steps in order to reach a set goal and understanding different concepts from a first-look evaluation and then comparing this to theory or researched constructs.

6

This form of methodology can be defined as a teaching and learning strategy where students learn about a subject through the experience of problem solving.

6

During this process students learn about thinking strategies and gain knowledge and insight into the topic. PBL teaches us to think critically rather than to draw superficial conclusions. Our first problem in PBL prepared me for what OT is, the background into OT and the professional environments of an OT.

PBL taught me that occupations are daily activities that reflect cultural values, provide structure to living, make appropriate use of an individual’s time and give meaning to their lives.

8

Occupation could also be said to be ‘ordinary and familiar’,

4

thus it is the

nature

of the occupation that gives it purpose and meaning.

4

Even Occupational Therapy was better explained to me once I had combined my new knowledge with that of our textbook: Occupational Therapy can be accomplished through the teaching, facilitation and maintenance of skills, the encouragement of engagement in “purposeful activity”

2

and in “occupation”

2

so that a person can reach his/her optimal level of function”.

3

OT is both an art and a science which uses occupation as both a means and an end in therapy, both in individual and group therapies, to enable people, families and communities in a wide range of settings.

7

This is a lot more in-depth and complicated than I ever suspected it could be. I think that I was under the impression that occupation meant ‘work’ like so many others believe. And even in knowing and understanding this, I still battle to explain it to people. I even have a friend who calls OT’s glorified housewives who love to garden!

One thing that has become clear to me, studying our Problems in PBL, sitting through our Psychology and Sociology classes and studying OT this past year- OT is very holistic. Never is a patient defined by their symptoms and OT’s tend to study every aspect of a person’s life before drawing conclusions or beginning therapy. The word ‘holistic’ has come to mean many things to me this year, but none more than that a person’s characteristics are“intimately interconnected and explicable only by reference to the whole”.

9

Once I had gained the theoretical knowledge about OT, I was more than ready to start with the fieldwork part of the year. I was placed at Thambo Memorial Hospital in Boksburg for four mornings over three weeks. The patient that I was assigned to was diagnosed with

deep partial thickness burns with an amputated lower left arm from the elbow

. But aside from my patient I was able to observe my Fourth Year with her other patients, was able to ask her questions and even assist in certain assessments, treatments and activities. This was a completely different experience to the one that I had had when I job shadowed at the same hospital a year before. As an outsider and someone who is not aware of what OT truly meant, I merely saw the assessment of different patients at a superficial level and only really understood the treatment as games or activities that would keep the patient busy so that they did not notice that they were making use of the injured or problem area. Thankfully I now understand OT better and can see certain aspects of therapy and theory coming out in the actions of the OT’s and their patients. Being able to see therapy performed from this view and being able to interact and speak with other OT’s on a more professional level has helped to cement my plan to become an OT.

During my time at the hospital I was lucky enough to observe most of the steps in the OT process. The OT process is defined in the Practise Framework as the collaboration of the OT and the patient through the steps of evaluation, intervention and outcomes in order to achieve health and participation in life through the engagement in occupation .

5

The

evaluation

step consists of the

occupational profile

and the

analysis of occupational performance

which help the OT determine what the patient hopes to gain during therapy, what they need to accomplish, what the patient can do and what are the barriers or supports to their health and participation in therapy. In this, I was able to speak with and fill out forms for two separate patients and also assist in the assessment of a third patient. With the occupational profile, the patient is very much the centre and all the questions are focused around them so that the appropriate goals for the end of therapy can be set.


Intervention

has three parts to it:

intervention plan

,

intervention implementation

and

intervention review

. The plan is developed by both the OT and the patient to guide the therapy with the use of theory. Outcomes or goals are also decided upon during this stage. Implementation is the actions of the OT which will revolve around therapy as well as the support and encouragement needed to see an improved occupational performance.

7

Implementation is direct towards the goals set and the OT is required to monitor and develop the patient at all times

5

so that the activities are appropriate and can be adapted if they are not performing in the intended way. Finally, review is simply reflecting on the implementation and assessing the progress towards the set goals.


Outcome

is the determination of success at reaching the desired goals. The results of this step will be used in planning further therapy if it is needed. This step is one of the hardest to observe in my opinion and is also very subjective. A patient may feel that he is fine and does not need any more therapy while the OT may see him as dysfunctional. To be dysfunctional is not saying that there is something socially wrong with a person or that they are overtly damaged, this is something that I have come to learn this year. Dysfunction, defined within an OT’s perspective is “when a person cannot do or is at risk for not being able to partake in occupational participation and performance”.

10

In terms of my assigned patient I was unfortunately able to witness the barriers between her and my Fourth Year who was her OT which resulted in her unwillingness to participate in therapy, added to that was her de-motivation and also the selection of an inappropriate activity during therapy. My patient was French speaking and thus the OT could not effectively fill out her necessary forms, could not adequately communicate with her and had to get this information from the patient’s husband. And so the patient, who the OT thought, enjoyed cooking and cleaning chose an activity of making milkshakes. Once I spoke to the patient (since I know some French) it became clear that she does not enjoy milkshakes and only cooked and cleaned because it was culturally expected of her as a wife. This brings into play the

therapeutic relationship

. The therapeutic alliance between the patient and the OT develops over time

11

and requires the OT to be able to communicate in an effective way such that these details are made known. Because of what happened to my Fourth Year with her miscommunication with her patient, I now understand the importance of our Dictionary assignments- to be able to communicate with any patient, no matter how rudimentary it is. Also, the selection of activities is imperative, especially for patients who are de-motivated which often occurs with burns patients or amputees. The loss of a limb or partial limb is a huge thing to deal with both physically and emotionally and burns patients are often de-motivated due to the pain of movement. Choosing the correct activity during therapy of these patients can determine whether there will be any progress in that session or not and also whether the patient will continue to be de-motivated or could possibly start to find reasons/purposes to want the therapy to succeed. This can also be accomplished through the

therapeutic use of self

to be able to use yourself, as an OT professional, to read the situation and adapt it,

11

whether it is during evaluation or during the intervention steps. Culture also needs to be considered when referring to patients. An OT need to take their patient’s culture into consideration and respect it. While culture may not define a person, it does indeed impact on their lives and ways of living.

12

Thus, my patient may only cook and clean because she is a wife but it is her responsibility in the home so she will need to rehabilitate to a point where she can continue with her tasks, but it may not be a good idea to use these tasks as activities since she sees them as work rather than leisure tasks.

Overall, I would definitely say that this year has been a success. My knowledge of OT and the profession has increased and I am even more certain that I want to be doing this as a career. The importance of the OT process is further defined by role of an OT which is categorised through the use of self, the therapeutic relationship, proper communication and compounded with a firm foundation of knowledge and attained skills. To reiterate what Rachel Thibeault said, “we see wholeness… We don’t fix people, you see: with them we simply try to find a way to

meaning

,

balance

, and

justice

.”

1

Occupational Therapy is about the patient, it is not about us save for what we can do for others… So the goal is to learn, make mistakes, learn from them, observe and experience as much as possible so that we can do everything possible to help them.

From this end of the mountain range, I can only see the obstacles blocking the destination from my sight. And yet I am not feeling deterred. Rather, I am excited to see what the mountains will contain and what I can learn from them. The next mountain that I see is end of year exams… So I think that I am going to do this one mountain at a time and never forget what I have learned and discovered on the way so that I am prepared for every challenge that approaches me.

Works Cited


1

Gerber,AK. OT Without Borders.

“I’m an occupational therapist…

(accessed 30 September 2014).


2

Hersch, G. I., Lamport, N. K., & Coffey, M.S.

Activity Analysis: Application to Occupation

, 5

th

ed.: SLACK Incorporated; 2005


3

Thorner, S. The Essential Skills of an Occupational Therapist.

British Journal of Occupational Therapy

1991; 6(64).


4

Curtin, M., Molineux, M., & Supyk- Mellson, J.

Occupational Therapy and Physical Dysfunction: Enabling Occupation

, 6

th

ed.: Elsevier: Churchill Livingstone; 2010.


5

American Occupational Therapy Association. (2008). Occupational Therapy Practise Framework: Domain and Process (2

nd

Edition). American Journal of Occupational Therapy, 62, 625-683


6

Devan, D., Casteleijn, D..

Problem Based Learning 2014

. Lecture presented at Khanya Building, Wits Education Campus; 2014.


7

Schell B., Gillen G. & Scaffa M. .Willard and Spackman’s Occupational Therapy. 12th ed. Baltimore MD. Lippincott, Williams & Wilkins; 2013


8

Jay J.

Occupation & Activity

. Lecture presented at Khanya Building, Wits Education Campus; 2014.


9

Oxforddictionaries.com. holistic

: definition of holistic in Oxford dictionary (British & World English)

[Internet]. 2014 [cited 1 October 2014]. Available from:

http://www.oxforddictionaries.com/definition/english/holistic


10

Smith R.

Intro to Occupational Dysfunction

. Lecture presented at Khanya Building, Wits Education Campus; 2014.


11

Devan D.

Occupational Therapy Process: PBL Post Problem Tut

. Lecture presented at Khanya Building, Wits Education Campus; 2014.


12

Smith R.

Cultural Diversity

. Lecture presented at Khanya Building, Wits Education Campus; 2014.

Benefits of needle exchange program

/in /by

Benefits of needle exchange program

Please see attached guideline and instruction for completing this assignment
1- definition of a proposal: use this to understand the definition of a proposal
2: Sample log part 1: use this as a guide for writing the Reflective journals
3: Sample of a proposal: This is an example for how the project should be written.PLEASE FOLLOW THIS SAMPLE STEP BY STEP. THE PARAGRAPH WRITTEN IN COLOR ARE FEEDBACK FROM THE PROFESSOR.
4: Project guideline.

Promoting Good Health Primary Care

/in /by

Health professionals, particularly those working in primary care, have an important part to play in promoting good health. Therefore it is the intention of this essay to explain the theoretical base that underpins the nurse’s health promotion practice. Reference will be made specifically to promoting good nutritional intake and healthy lives for children. The essay will identify how evidence-based research concerning the subject of health promotion can be used to inform the practice of the nurse. The essay will highlight the priority given to the promotion of healthy eating by use of examining current government guidelines and healthcare strategies.

This part of the essay will examine potential definitions of health. Health is not just about physical health but also about mental and social well-being. It may be most effective when meeting basic needs, accessing relevant information and relying on family or community support (Bury 2005). The World Health Organisation (WHO) defines health promotion as “the process of enabling people to increase control over, and to improve their health” (WHO 1998). The growth of interest and activity in health promotion over recent years must also attempt to develop some methods of prevention to ill-health (Downie et al. 2000). Factors surrounding the nutritional health of children has many elements; some of which include their genetic make-up, environmental influences and the stage of development of the child (Holden and MacDonald 2000). Erikson’s (1968) established the psychosocial theory of development which took into consideration the effect of external aspects, parents and society on personality development from childhood to adulthood (Erikson 1968). According to Erikson’s (1968) theory every person must pass through a series of eight inter-related stages of their life cycle. Stage number four is school-age child where children are learning and developing new skills and it is also a very social stage of development (Erikson 1968). Social issues will be discussed in more depth later in this essay.

According to the Scottish Government “nurses and midwives play a dynamic and vital role in improving health and delivering health services to the people of Scotland” (Scottish Government 2001). Therefore in terms of promoting the health of children through healthy nutrition, nurses are encouraged to educate children through visits to schools, attending youth groups, giving advice to new parents and offering advice at clinics and so on. The school nurse works in cooperation with the school to produce an environment that promotes healthy living as well as looking after the needs of individual children (School Nurse 2010). Health education is important for preparing the social, practical and emotional knowledge of children and providing them with social skills. It also helps to protect and promote the health of children through an environment and culture which is safe, healthy and beneficial to learning (Department of Health 2004). Holden and MacDonald (2000) identified that nutritional education is essential to enable children to make informed choices about food and understand the relationship between diet and health. Nurses are often available to give advice and guidance on good diet and nutrition and regularly give health talks at school assemblies. The next part of the essay will look at some of the legislation surrounding health promotion for children.

School meals in Scotland have undergone a transformation over the past few years due to the Hungry for Success Initiative which introduced nutritional guidelines for school lunches (Fife Council 2010). The Schools Health Promotion and Nutrition Scotland Act (2007) encourages the Hungry for Success programme and requires all local authorities to ensure that food and drink provided in schools comply with the nutritional requirements specified in the regulations. This act places health promotion at the centre of school activities. It encourages local authorities to provide school pupils with healthy drinks and snacks either free of charge or at a reduced cost. It also requires local authorities to promote school meals and to also reduce the stigma attached for pupils having free school meals. Another project that was initiated was the Hygiene, Healthy Eating and Activity in Primary Schools Initiative (HHEAPS) (Food Standards Agency 2009). This was devised for schools to raise children’s awareness of food hygiene, healthy eating and physical activity and the main concept was to link the three together, providing children with a basic understanding of how colds and flu viruses spread, how they can feel mentally and physically better about themselves, as well as enjoy fun activities with their peers. The importance of health promotion in schools is a key part of the role of the school nurse and often concentrates on exercise and healthy eating which can include fighting obesity and perhaps even eating disorders (School Nurse 2010).

The Scottish Government (in partnership with Learning Teaching Scotland and NHS Health Scotland), have produced a leaflet called Healthy at Schools: Healthy for Life which acts as a guide for parents to explain why schools are promoting health (Scottish Government 2009), so as to keep parents involved. Pupils are giving the opportunity to take part in a physical activity or sport and they learn about health in many different subjects. The social, mental, emotional and physical health of school pupils are the responsibility of all teaching and non-teaching staff in schools. Good nutrition has a positive influence on child development and any health promotion involvement that focus on children and young people can be the basis for a healthy lifestyle that may be continued into adulthood (Licence 2004). Therefore the priority of health promotion and nutrition education is directed mainly at changing diet and lifestyles, with the aim of reducing chronic diseases (Webb 2002). According to The Scottish Government (2008), 20% of primary one school children are classed as overweight, some even categorised as being obese. Childhood obesity can lead to childhood diabetes, early puberty in girls and can lead to some types of cancers and heart disease later in life (Kozier 2008). It is therefore vital to begin health promotion in children as early as possible, to allow them to make their own choices about their health as they become older.

Having examined some of the policies surrounding health promotion, it is now appropriate to examine the role of the nurse as a health promoter in greater depth. The nurse’s role in health promotion and health education involves taking into account all of the processes involved from assessing, planning, implementing and evaluating, as these are all essential elements of a health promotion programme (Whitehead 2002). According to Kemm and Close (1995), health promotion is an activity that intends to prevent disease or promote health. One of the key aspects of health promotion is attitude and to suggest ways to change attitude and its associated behaviour is of the main objectives in health promotion (Downie et al. 2000). It is vital to adopt the most important approach to health promotion and Ewles and Simnett (2005) suggest five approaches to health promotion: medical, behavioural change, educational, empowerment and social change. In terms of health promotion for children the educational approach and the behavioural change can be linked together as school education programmes can help pupils to learn the skills of healthy living thus aiming to change their attitudes and behaviour with the hope of them adopting a healthier lifestyle (Ewles and Simnett 2005).

To provide structure for health promotion, several health promotion models have been developed. One of the better known and most popular one is Tannahill’s model of health promotion (1995) which describes health promotion as three interlinked circles that include health education, health prevention and health protection. As the circles overlap they form the seven components of health, and number five on the list – positive health education – is aimed at changing behaviour and encouraging beneficial use of leisure time as in exercise and fitness (Downie et al. 2000). Changing behaviour could be done by either educating parents in positive health or by showing the consequences of poor health. Health education is described as an activity aimed at informing people about the prevention of disease, and according to Naidoo and Wills (2000) health prevention can be divided into three categories. Primary prevention is aimed at prevention of the start of the disease, secondary is aimed at preventing the development of the disease and tertiary is aimed to reduce any further suffering for those who are already ill (Naidoo and Wills 2000). The Ottawa Charter for Health Promotion (WHO 1986) outlines the key principles for health promotion which include strengthening individual’s personal skills and capacities, empowerment and because society is forever changing, be able to create a healthy working and living environment.

Dahlgren and Whitehead (1991) established the Determinants of Health model which explained how health is shaped by a variety of factors either positively or negatively. Economic, social and environmental conditions can determine the health of people and populations and also included in this model are the essential changes in the circumstances of daily life. Such factors can decide whether or not a person is in the right position, either physically, socially or personally to meet their requirements, succeed and be able to cope with changes in their situations (Local Government 2010).

In terms of social issues, it is vital to highlight that promoting good health amongst children is virtually impossible unless parents are also targeted. Since parents and carers make most decisions regarding what a child eats, perhaps whether they can go out to play and whether they can join organised sporting activities, it is important that parents also have appropriate information on how to keep their child healthy (NHS Scotland 2010). Healthy families are better equipped to deal with challenges such as illness as they have developed effective coping strategies. Midwives can begin the process by giving targeted information to expectant parents on initiatives such as breast feeding, childhood immunisations and different activities to nurture happy, healthy babies. Some of these activities may include toddler swimming lessons or attending baby rhyme time classes (Netmums East of Scotland 2010). Nurses could then reinforce this by providing further information and advice during clinics, nursery classes and through school-based drop-in advice services (Advice Guide 2010).

Nurses can use their role as a liaison between health and education by working in partnership with members of the teaching profession to promote good health to young children. This might be by providing training for school-based staff to support children with healthcare needs such as asthma or diabetes or working with physical education teachers to encourage all children to take part in sports and other activities (The Scottish Government 2003). It is important that nurses show children why good nutritional intake is so important, by focusing on how it will not only prevent future illnesses, but it will help them to feel better and be more alert and active. It is also important to include how environmental issues such as poor housing, poor income and low levels of education can all affect the health of children (The Scottish Government 2003). Children can only follow through by choosing the healthy options they have been taught if they understand the importance of why they should choose a healthy diet (Frey and Barrett 2006). Fast food chains can also target children, and although many of them offer healthy choices, it is vital that children and parents understand the consequences of always choosing the unhealthy options, such as fatty foods potentially leading to heart disease, or sugary drinks leading to tooth decay (Food Standards Agency 2005). It might be possible to use educational aids such as pictures and videos to highlight to slightly older children and their parents of what could happen if they continually choose unhealthy foods (Brown and Ogden 2004).

Nurse’s who work with children and young people also have an important role in identifying children who may be at risk of malnutrition. It is important for nurses to be able to recognise health problems that may be related to poor nutrition, for example, tiredness, slow growth, delayed puberty, pale skin and poor hair condition. The Royal College of Nursing (2006) suggests that basic screening of a child’s nutritional status contributes significantly to identifying children at risk (RCN 2003). The Scottish Intercollegiate Guidelines Network (SIGN) have specific guidelines developed on evidence based clinical practice for the National Health Service (NHS) and they suggest that children whose families live in a deprived area should be considered as an increased risk of developing tooth decay (SIGN 2005). Parents and carers should receive oral hygiene education from the local dental team and health professionals should ensure that oral health messages are relevant and applicable to lifestyles and communities (SIGN 2005).

Nurses need to take into account the ‘social world’ of their patients and to understand their social situations. Factors within the social and maternal environment can influence health and development (Bromley and Cunningham-Burley 2010). The nurses role is to recognise the relationship between social issues and health and to be aware of cultural differences with regards to nutrition (Food Standards Agency 2002). According to Save the Children Scotland (2009) 240,000 children in Scotland live in poverty; that is one in four young people in families that struggle to get by every day. Families on low incomes find it hard to provide the basic necessities like decent, healthy food so therefore poverty affects the way that people eat (Save the Children Scotland 2009). Circumstances and the environment determine whether families are healthy or not. Genetics, relationships, education levels and income all have a huge impact on health (Anon. 2010). The nurse’s role in health promotion also includes health psychology which is the understanding of psychological influences on how people stay healthy. Health care professionals deal with problems identified by behaviours, attitudes, diet, exercise and so on (Ogden 2003). Some socially excluded families may not have the communication skills to identify and utilise what is available in terms of health promotion and disadvantaged families may have difficulty in taking up healthy options. Parent’s perceptions of healthy eating and exercising need to change and parent’s need to be more aware of the outcomes of an unhealthy diet. Children follow in their parent’s footsteps and do what they are brought up to think is correct.

According to Nursing and Midwifery Council (2008), nurses are bound by and must adhere to the NMC Code of Conduct which states that it is the nurse’s duty to care for their patients and they must try and do what they think is best for them (NMC 2008). Nurses need to make people more aware of their role in promoting health and well-being of children and young people. Nurses need to work together with other health professionals including social care and local councils to change families attitudes and behaviours (Moyse 2009). Overall families are resilient and resourceful but they may need extra support and outside help to adapt successfully. Families cannot be forced to change but nurses can give them enough information and offer support to help them to change. Families need to believe that they can change and that changes will be good for them and that they will benefit from changing their lifestyles. Nurses need to influence the health of communities and problem areas. The Scottish Government published a paper which provided a framework to support a programme which could help to deliver a policy for health improvement (The Scottish Government 2003). The main objectives in this paper for health improvement are that by 2010 -2012 life expectancy for people living in all areas of Scotland should be improved and it is also expected that inequalities between the most deprived and most comfortable groups should be reduced (Scottish Government 2003).

In conclusion, this essay has examined some of the issues surrounding health promotion in children, focusing specifically on nutritional intake. It has firstly explained the knowledge base that underpins the nurses health promotion practice. The essay has looked at some of the legislation and government policies surrounding health promotion, and then also looked at the role of the nurse as a health promoter, and how a nurse must take into account social and educational issues when attempting to implement any health promotion initiative. The essay looked at a health promotion model and one component of this was discussed in more detail. Having examined current government guidelines and healthcare strategies, the essay then looked at guidelines that were developed on evidence based clinical research. Nurse’s should try to encourage people to take responsibility for their health and to make them more aware of the long term affects an unhealthy diet can have on younger children. Bad nutrition affects skin, hair, nails and teeth. The essay has also discussed factors within the social and maternal environment which can influence health and development. It has also looked at why nurses must work together effectively with other health professionals to change family attitudes and behaviours. This essay has also discussed why people struggle to change, the effect of social class and health inequalities. Throughout completion of this essay it has become apparent that health promotion of children and young people is a vital part of the role of the nurse and the nurse can influence health improvement through health promotion.

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Stroke Brain Symptoms

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Stroke

Information on Stroke

What is a stroke?

A stroke is a medical condition very much like a heart attack, but it occurs in the brain. The blood vessels in the brain can become clogged or occluded from different sources. An ischemic stroke can be due to a clot or embolism of the vessel; or atherosclerosis, hardening of the arteries by a fatty deposit known as plaque, can be the culprit. A stroke can also be caused by a hemorrhage from a ruptured vessel which can be due to an aneurysm or high blood pressure. When any of these conditions occur, the brain does not receive enough oxygen; and the brain cells die.

Since each area of the brain controls a different body function, the effects of a stroke on the body can vary greatly. Depending on which part of the brain is affected, one can experience permanent residual conditions such as paralysis, aphasia (inability to speak), dysphasia (difficulty with speech), seizures, dysphagia (difficulty swallowing), and dysarthria (slow or garbled speech). A stroke can cause slurred speech and can have an impact on the swallowing mechanism which can lead to aspiration pneumonia. A diet of thickened liquids can be a helpful prevention tool.

How do I know that I’m having a stroke?

The warning signs of a stroke include:

  • Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body.
  • Sudden confusion, trouble speaking or understanding.
  • Sudden trouble seeing in one or both eyes.
  • Sudden dizziness, loss of balance or coordination or trouble walking.
  • Sudden severe headache with no known cause.

If you or a loved one experiences any of these symptoms, call 911 immediately and seek treatment at the nearest hospital. A clot-busting medication called tissue plasminogen activator (tPA) is available that can break up or dissolve this clot and prevent permanent damage; however, treatment must begin within three hours from the onset of symptoms. Rapid treatment dramatically improves your chance of recovery. While tPA is a safe treatment for a stroke due to a clot, it cannot be given if the stroke is due to hemorrhage. This would increase the bleeding and cause even more damage.

You will notice that each of these warning signs for a stroke are of sudden onset. The symptoms of a stroke occur rapidly.

Occasionally, these symptoms can occur and last for only a few minutes. It is important to take these symptoms seriously since they are a mechanism for the body to warn us of possible impending doom. These symptoms may be a sign of a TIA or a “mini-stroke”, which can be a warning sign of an even larger stroke. A TIA does not cause permanent damage like a full-blown stroke does. Once a stroke has occurred, the brain tissue cannot regenerate itself; and the damage cannot be reversed.

How is a stroke diagnosed?

In order to help determine the cause of a suspected stroke, a physician will most often order an x-ray called a CAT scan. Another test that can give a much more detailed view of the brain is Magnetic Resonance Imaging study or MRI. Patients that have a pacemaker or any type of metallic implant are not candidates for an MRI due to the high-powered magnetic field required for this test. Also, patients that are claustrophobic may not be able to tolerate the confined space of an MRI, Another beneficial procedure offered is a Magnetic Resonance Angiogram of the brain which can detect an area of abnormality minutes after the blood flow to an area has ceased. A conventional MRI may not detect a stroke until up to 6 hours after it has started, and a CAT scan sometimes cannot detect it until it is 12 to 24 hours old.

What can I do to prevent a stroke?

There are many things that can be done to prevent or lower your risk a stroke. They include a healthy exercise program, a diet high in fruits, vegetables and fiber and low in fat and salt, and avoidance of alcohol and tobacco products. Consistent control of chronic conditions such as atrial fibrillation of the heart which cause the blood to pool and clot in the atria, diabetes, hypertension, and obesity, and to undergo regular physical exams and monitoring of blood cholesterol levels all help to reduce your risk for stroke.

Medication therapy is another way to reduce your risk of stroke. Anticoagulant or antiplatelet medications such as Aspirin, Plavix, and Coumadin and Heparin may be prescribed by a physician for stroke prevention or treatment. These medications thin the blood and help to prevent clot formation which can travel to the brain and cause a stroke.

Now that I have had a stroke, is there an effective treatment?

Unfortunately, the permanent damage that can occur from a stroke cannot be reversed; however, the prevention program detailed above can reduce your risk of having a second stroke. A rigorous therapy and rehabilitative program may be extremely beneficial in learning activities of daily living and regaining some control of your life. Often, patients learn how to bathe and dress themselves independently. Family and caregivers can play a huge role in this process and work with their loved one to build muscle strength. A supportive, patient and encouraging environment can work wonders in helping to avoid the depressive symptoms that often occur after a stroke. A new-found or renewed interest in a hobby such as playing a musical instrument can also be a beneficial therapy for a stroke victim.

Retrieved March 11, 2008 from the American Stroke Association.org website: http://www.StrokeAssociation.org

Retrieved March 11, 2008 from the Safe-Stroke Awareness for Everyone website: http://www.StrokeSafe.org

Retrieved March 11, 2008 from the National Stroke Association website: http://www.Stroke.org

Retrieved March 11, 2008 from the MedicineNet.com website: http://www.MedicineNet.com

The Drug Problem in America Today

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This essay will be as a conveyor of America’s current drug problem and the paraphrasing of studies undertook by credible sources which revolve around the issue and to showcase the extent and true depth in how prevalent drugs are in the modern times for America ranging from the importation of substances, the synthetic opioid epidemic, and the rising numbers in overdose rates in the last five years.

The Main Factors at Play



The rates in which American’s are dying of overdoses are steadily increasing to the point of being categorized as a national crisis, with the amount of 42,000 Americans dying from overdoes in 2016 alone. (Claire Felter “The U.S. opioid epidemic” 2) With an ever changing society overdoses deaths are increasing with a rate that is triple of what is was in 2002 from 1.0% a person per 1000 to a 2.0% per 1000 (Christopher M Jones. ”Drug and Alcohol Dependence” 1) the current research articles state that the main culprits in the rise in drug related deaths come from a combination of our current healthcare system in using opioids and synthetic opioids to treat pain coupled with a constant supply of heroin which has risen substantially since 1990 and with the recently added synthetic opioid fentanyl (2) the American drug problem is over time steadily increasing as the rates of overdose deaths increase as doctors over prescribe opioids while drug traffickers mix fentanyl into heroin to lower price and increase potency. (Leslie Cooley Dismukes “How did we get here? Fentanyl and Heroin trafficking trends” 4)

History of Opioids.

Opioids have been prevalent in societies ever since the cultivation of the poppy plant in 3400 BC by the Sumerians in Mesopotamia.  In the late 1700’s the British were using  opium to get China addicted to open up the Chinese markets to trade for even the British knew of it’s addictive qualities. Once we as people were able to extract morphine from the poppy plant in 1803 it became widely used for medical purposes as an analgesic opioid. (5 “Opioids and the Treatment of Chronic Pain.) The acceptance of using opioids for treating chronic pain was perceived as the best method by medical professionals but was also understood the nature in the longer an opioid is taken for pain the stronger the addiction to the opioid becomes.  For most of the 19th century opioids were regarded with precaution and having strict national and international regulations place onto opioids in medicine and its overall distribution. (5) It was not until the 1990’s when things started to switch to an increasing usage of opioids for pain management and it was due to an increasing demand from the non-medical usage side of pain killers the numbers of first time opioid drug abusers rising from 628,000 in 1990 to 2.4 million in 2004 that gave a spike in the overall overdose death statistics. (5)  An increase of 120 percent in the span of 14 years, peeking the interest of law enforcement and health agencies to labeling such as an drug epidemic.

Regions affected.

The major impact of damage done to America from illicit drugs is in the north east of America and the South East from the direct relation to its area to Mexico and Columbia. While North Carolina being at the center of it, with a statistics of 4 of the 25 American cities where opioid abuse epidemic is the worst from the use of fentanyl and prescription painkillers such as oxytocin and hydrocodone. (4) The external suppliers from Mexico and Columbia traffickers can easily transport to this area with hidden compartment vehicles and the other various transport routes into North Carolina and the South East. It plays into the other regions as well and the deaths from drugs are from misuse and overuse coupled only with an increasing supply from traffickers and internal factors pertaining to the over prescribing from physicians. In the United States 80% of the yearly total of people who overdose are non-Hispanic white Americans with 20% being Non-Hispanic black and Hispanic. (2)  The impact to the public health from illicit drugs is the loss of labor work force contribution, foster care intake numbers spike, and increase in HIV, hepatitis C, and various diseases from shared instruments for transmitting the drug into the system.(2)

Combating the Opioid Crisis.

Illicit drug abuse has caught the eyes and attention of the national level taking in funding and new tactics to combat overseas trafficking such as the Merida Initiative which the United States gave Mexico 3 billion dollars to fund counter narcotics and work with China in the labeling of over 100 synthetic illicit drugs as controlled substances and ceasing production of four fentanyl variations to curb the supply into the United States.(2) While also taking efforts to focus on internal affairs such as controlling the overuse of scripts given out and outreach programs to help addicted users to lower the impact of the modern illicit drug crisis in America. The government has been enacting more funding for state grants for purpose of planned rehabilitation and the usage of programs to reduce transmission of diseases by educating on the harms of needles and sharing of instruments. (2)   Funding more public programs to educate the general public such as the wellness campaigns for tobacco did to show the dangers of smoking they want to promote programs that teach about synthetic opioids while also providing a grounded foundation to lay a framework down for prevention. To educate the public more on synthetic and natural opioids and the addiction associated with them. States have taken to asking for funding from the national level to help curb their drug issues with money for local law enforcements. Law enforcements want to create partnerships with communities and nonprofit groups to help take down the issues and provide a support system for the community. (4)

Economic cost of the crisis.

The true cost of the illicit drug crisis is estimated to be around $50,779 per user(1) and with a total cost of 33.1 billion for the entirety of the heroin disorder in America, that does not include painkillers and synthetic opioids. (1) From the incarceration, housing, and, feeding coupled with treatment plans and rehab bring a huge cost to society. With a projected path if the numbers keep increasing at the rate they do now for heroin users and studied growth seen over the past three years the projected numbers of total cost are to be of 51.2 billion dollars (1) and with the overdose rates rising as well the study accounts for the cost of lost labor for the user if they have died between the ages of 18-25.(1) Most of the numbers to determine cost derive from lost labor and the amount lost during incarceration with attempts to lower drug abuser numbers and to combat the trafficking and supplying of opioids and synthetic opioids in the efforts to lower the overall cost to society for the negative impact that the modern drug problem brings on America. The substantial magnitude of the heroin disorder and the undocumented cost of synthetic opioids cause a great debt to society and bring more awareness to the real dangers addiction poses to America and the public health and the health of our economy.

Scale of the Epidemic

The scale of the epidemic is of a national scale increasing fivefold since the 1990’s. while the studies attest to the epidemic of being more deadly than 9/11 and the Iraq Wars combined of U.S. Military troops. (2) While pain was seen as being undertreated medically doctors prescribed more and there was the company manufacturing the opioids pressuring doctors to prescribe with health care providers describing moments of aggressive marketing and told to avoid alternatives to pain management such as acupuncture and physical therapy.  (2) Patients would also put on pressure and request opioids over any other form of treatment. Over time the outside supply of drugs from external drug cartels and trafficking and mixing with the internal production and supplying of synthetic opioids the growth rate of first time users becoming addicted jumped in a short time and goes on at the current moment with studies showcases the sharp rise from 2015 with overdose deaths ranging to 33,091 in 2015 and a year later it was 42,249 in 2016 with a steady and quick increase from 20102 to 2016.(2 U.S. opioid overdose deaths “CFR Editoral”) It has become a national prevalent epidemic with every angle used to try to combat and reduce the problem before it becomes too large to handle. For the development of the modern illicit drug issue did not begin until we have a surplus of opioids for the public to access and use beginning with the legal distribution of pain killers for pain management. (2) Twenty five American cities are hugely affected by the oversupply of easily attainable opioids and creating a multiple of negative factors such as lost labor force, socioeconomic cost, and property crime.(4) If efforts cannot curb the issue at hand it will based on research studies only slowly increase each following year increasing overall American cost and American overdose deaths.

Conclusion

The current American drug problem is a prevalent widespread one being fed by multiple factors whether they be external or internal. Coming from the three main illicit drugs of heroin, synthetic opioids and natural opioids a range of trafficking from Colombia and Mexico with an over prescribing of over the counter pain killers has led to an increase in socioeconomic cost and the sharp rise in the last five years of overdose deaths and related diseases such as HIV and hepatitis C that come with the association of sharing of syringes and of other instruments to transmit drugs into the system. Today the drug epidemic is seen as a national health crisis and is being combated with state funding, community outreach programs, and tighter regulations on medical scripts. With all the awareness and growing concern over the rising rates studies projected a hopeful outcome if it gets under control of seeing the next few years a decline in first time addicted users and overall drug overdose related deaths pertaining to opioids.


References:

(1)   Ruixuan Jiang, Inyoung Lee, Todd A. Lee, A. Simon Pickard “The societal cost of heroin use disorder in the United States.” https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0177323

(2)   Christopher M. Owens “Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid Pain relievers – United States, 2002–2004 and 2008–2010” https://www.sciencedirect.com/science/article/pii/S0376871613000197?via%3Dihub

(3)    James M. Lindsay

“The U.S. Opioid Epidemic”

https://www.cfr.org/backgrounder/us-opioid-epidemic

(4)

Leslie Cooley Dismukes

“How Did We Get Here? Heroin and Fentanyl Trafficking Trends”

http://www.ncmedicaljournal.com/content/79/3/181.full

(5)

R. A. Rudd


N., Aleshire


R., Matthew Gladden

, J.E. Zibbell

“Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014”


https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.13776

Health Promotion in Nursing Care

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Health Promotion in Nursing Care

How is health promotion defined? The process of empowering people to make healthy lifestyle choices and motivating them to become better self-managers. Examples of health preferment approaches include education and counseling agendas that end

Case Study (Nursing)-thickness thermal burn

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Case Study (Nursing)-thickness thermal burn

Case Study (Nursing)-thickness thermal burn

Diagnosis And Forms Of Management Of Delirium Nursing Essay

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Delirium is a very common medical condition marked by changes in clinical and mental status. This is one of the most frequent reasons psychiatrists are consulted throughout he world. The referrals come from a variety of sources ranging from ICU to primary care, medical, surgical and orthopedic wards.

Delirium occurs in 15% to 60% of nursing home patients, 14% to 56% of inpatients, and up to 60% to 87% of patients in the intensive care unit (ICU).1-2

It occurs more commonly (up to 30%) in elderly individuals causing significant morbidity and increased mortality in this patient group 3, 4. It has got serious repercussions in terms of residual morbidity and loss of quality of life amog the sufferers. The cost of the treatment of the acute episode and its sequelae are huge to the serice provider.It is believed that delirium in elder people is a marker for future dementia and early death5.

The problem is that it is often unrecogised especially amongst individuals who do not get behavioral disturbance. Even after recognition it is often treated insufficienly.Delirium may be prevented in up to one third of older patients1.

It is therefore important to revisit and review the management of delirium according to current evidence.

Diagnosis

The diagnosis of delirium is often difficult due to the variety of behavioral and cognitive symptoms it can present with and the fact that all of its signs can fluctuate within seconds.

Delirium is characterized by

Fluctuating disturbance of consciousness- manifesting as problems in concentration and attention.

Perceptual disturbance like illusions or hallucinations. Which can develop or recover quickly.

Disturbed psychomotor behaviour,

Disturbed sleep-wake schedule.

Presentation

Delirium may present in one of the following ways

Hypoactive – This is characterized by reduced motor activity and lethargy. The diagnosis is often missed.

Hyperactive- This is manifested as patient being overactive may be agitated and displaying inappropriate behaviour. The patient is loud, resistive, hyper vigilant, and often problematic

Mixed subtype- which is the most common type8 can have symptoms of both at different times.

Aetiology

The etiology of delirium is usually multifactorial. Condition like old age, co incident medical illnesses and preexisting cognitive impairment can precipitate or aggravate the signs and symptoms of delirium. Almost any illness can give rise to delirium in the susceptible person.

For example illnesses related to:

Cardiological conditions like myocardial infarction, heart failure.

Respiratory conditions like pulmonary embolus or hypoxic conditions.

Neurological conditions like stroke or subdural hematoma.

Electrolyte imbalance.

Drugs particularly those with anticholinergic side effects like tricyclic antidepressants, antiparkinsonian drugs9 or steroids and benzodiazepines.

Alcohol withdrawal.

Urinary retention, fecal impaction

Infection

Severe pain

Post operative stage.

Differential diagnosis

Usual conditions that can complicate the presentation, diagnosis and management of delirium are

Dementia.

Affective disorders like depression or manic state.

Schizophrenia.

Non convulsive seizure

Temporal lobe epilepsy

Assessment

History: A good and thorough history is the cornerstone of diagnosis. It is often necessary to get a collateral story from relatives and ward staff. Among other things one needs to know-

Onset and course of symptoms

Previous intellectual and functional level like daily living skills

List of medications both prescribed and non-prescribed drugs including recent additions or omissions.

Alcohol intake history

Similar episodes having symptoms of delirium.

Sensory deficits – use of hearing aid, glasses etc.

Co- morbid illness

Assessment tools: There are some standardised tools used to assist in diagnosis like-Mini Mental State Examination (MMSE)6 or Confusion Assessment Method (CAM) screening instrument7.

Examination

A full physical examination is essential focusing especially on the consciousness level, evidence of alcohol abuse or withdrawal, possible sources of infection, neurological examination (including assessment of speech) and rectal examination – if impaction is suspected.

Investigations

The base line investigations which are essential in order to identify the underlying cause of delirium are full blood count, urea and electrolytes, liver function tests, blood glucose, blood cultures, urinalysis, chest X-ray, ECG. Depending upon history and examination some other investigations may be indicated like:

CT head – if an intracranial lesion or head injury is suspected.

Serum Calcium level

Serum B12 and folate level

Arterial blood gases to check for metabolic alkalosis

Treatment

The overall approach is to treat the cause which is deemed to have given rise to the delirium and to provide a structured and predictable environment in which the medical illness can be treated adequately

Treating the cause

The offending illness should be aggressively diagnosed and treated adequately. Pneumonia and UTI are the usual causes in terms of infection. They should be treated by appropriate antibiotics.

Metabolic causes and electrolyte disturbances should be diagnosed and treated promptly.

Removing offending medication

Medications that alter the dopamine/acetylcholine balance within the CNS are usually the culprits. In the pathophysiology of delirium it has been postulated that cerebral anoxia and dopamine excess has a role to play in production of the cognitive symptoms of delirium10.

Commonly medications that have been found to cause such symptoms are opiate analgesics, benzodiazepines, tricyclic antidepressants, steroid, antipsychotics, digoxin and anticholinergic drugs like oxybutynin and antiparkinsonian drugs.

One needs to carefully evaluate which of them can be safely withdrawn or reduced in dose. Ideally, benzodiazepine use should be completely avoided.

Non -pharmacological interventions-

Management should also address the symptomatic relief of the syndrome. This may include

Use of supplementary oxygen to keep oxygen saturation above 95%. This is essential to support higher cortical functions and to meet the increased metabolic demand.

Ensuring proper hydration by improving oral fluid intake or IV fluid if necessary.

Maintaining nutrition

Maintain/ restore normal sleep pattern.

Prevent constipation

There are some common concerns faced by the nursing staff while managing the care of a person with delirium. Some of these concerns may be addressed on the following principles.

Physical restraint should be avoided as much as possible and is to be used only to ensure safety of the patient11.

Wandering: Patients at risk of wandering should be nursed in a reasonably closed and safe environment. It is often possible to distract the wandering patient. Relatives may help in suggesting alternatives means of distractions that may be more meaningful for the patient. If this does not work the least restrictive option should be used which should be in the best interests of the patient

Agitation The cause for agitation needs to be identified and treated. Usual causes of agitation are pain, thirst, need for voiding, retention of urine etc. Catheterization should be avoided if possible because of risk of injury to urethra by pulling on it in agitated patient.

Environmental Management

The patient with delirium is unable to manage a complex environment and adjust to the rapid changes going around them and respond adequately to multiple sensory stimuli in a balanced way. Therefore the plan should be to modify the environment for them.

The patient should preferably be nursed in a quite single room with appropriate lighting to avoid the possibility of misperception. Regular and repeated reminders of the time and place help to improve the patient’s orientation. Family members and friends should be encourageed to visit which may help to calm the patient

Sensory impairment should be appropriately dealt with by providing hearing aids and glasses if the person needs them. There should be consistence in nursing staff. The approach should be gentle. Unnecessary distractions are to be minimized like television, bleep, mobile phones and public address systems.

Change of environment like inter or intra ward transfer should be avoided12.

Mobilizing the patient early is helpful in minimizing recovery time and may assist in rehabilitation of muscle strength after critical illness.

The patient must be kept safe by limiting dangerous objects around the patient ensuring that they don’t fall whilst mobilsing

Psychological intervention:

Patient with delirium are likely to talk in a confused and rambling way. One should not collude with the contents of what they are saying. It is better to tactfully disagreeing or change the topic. Any delusional content in the speech shouldn’t be disputed directly.

Pharmacological management

The main aim of drug treatment in delirium is to treat behavioural disturbance like agitation and hallucination that can be distressing or dangerous to the patient and to minimize risk of harm to others. It is often a matter of striking a balance between effective management of symptoms of delirium and troublesome adverse effects of the medication.

Drugs mainly used in the treatment of delirium are benzodiazepine and antipsychotics. Their use should be kept to a minimum. It is best to use one drug only at a time, starting at a low dose and if necessary increasing the dose after a few hours.

In terms of antipsychotics haloperidol has been the most widely used medication so far and has been the gold standard in treatment of delirium. Haloperidol can be administered by intravenous, intramuscular or oral routes.

Regarding use of second generation antipsychotics they have been extensively used in treatment of delirium all over the world but robust evidence in terms of well designed and conducted double blind placebo controlled trials is lacking. One of the first atypical antipsychotic agents approved for use in USA in delirium was risperidone. A double-blind trial comparing risperidone with haloperidol demonstrated equivalence in efficacy and response rates15. But another large scale study failed to replicate such advantage of risperidone over haoperidol16, Olanzapine was also found to be beneficial in treatment of delirium. In a study done in Canada in critical care setting olanzapine was found to be as efficacious as haloperidol and had less extrapyramidal side effects and sedation17.

Quetiapine has not been studied extensively in treatment of delirium but there has been a few case series and open-labelled trials which showed good results18

A systematic review done by Campbell et al in 2009 looked at studies published between January1966 to October 200813. This included randomized, controlled trials comparing typical and second generation antipsychotics either to each other or placebo. This review concluded that there was no superiority for second-generation antipsychotics over haloperidol in managing delirium. Another review done by Peritogiannis et al looked at studies done between1997 to 2008 indicated that atypical antipsychotics were well tolerated in terms of troublesome side effects such as extra pyramidal side effects and were effective and safe in symptomatic treatment of delirium but the evidence was inconclusive.

Currently there is little evidence to support the use of second-generation antipsychotics over haloperidol in managing delirium.

Haloperidol is the most frequently used and best studied antipsychotic medication for delirium. This may be due to its few anticholinergic side effects, few active metabolites, and small likelihood of causing sedation.

It is used at a small dose of 0.5 mg. orally which can be given up to two hourly. A maximum dosage of 5 mg (orally or IM) in 24 hours is a generally acceptable but more amount may be required depending on the severity of distress and, severity of the psychotic symptoms.

Sedation should only be used in situations where behavioral management is not effective or quick control is desirable. If sedatives are prescribed, it should be reviewed regularly and discontinued as soon as possible. The aim should be to taper off any sedatives within 24 – 48 hours.

Benzodiazepines have a unique role in treatment of it is very useful in short term in treating agitation and aggression. On the other hand it can aggravate the symptoms of delirium particularly in patients with dementia. They are not as effective as antipsychotics when used as a single drug. In combination with anipsychotics tey have been used to good effect

Benzodiazepines are the preferred treatment for delirium associated with seizures or withdrawal from alcohol (delirium tremens), where it should be used in a reducing dose.

Lorazepam is the preferred drug in this group due to its rapid onset and shorter duration of action, whether used orally and intramuscularly.

Other pharmacological interventions have been used elsewhere in different circumstances with varying degrees of success. Intravenous flumazenil, has been used successfully in a small number of patient based on the theory of GABA antagonism, temporarily19.

Anticholine esterase drugs have also been used in treatment of delirium with varying grades of success more so in cases of delirium like symptoms in Lewy body dementia.

Disruption of the sleep-wake cycle may be a vital element in development of postoperative delirium. On this basis melatonin (being important in maintaining normal sleep) has been used with good effect to treat postoperative delirium20.

Prevention

There has been a lot of interest in preventing delirium in high-risk populations such as post operative elderly patients by managing postoperative pain. But the effectiveness of this approach has not been well established. However it did have a beneficial effect on the duration and severity of this disorder21

Managing the patients after discharge

It should be ensured that the delirium has been properly investigated and treated before discharge. Discharge should be planned in consultation with other professionals involved in caring for the patient, both in hospital and in the community.

Follow up

Delirium is a commonly followed by dementia or may be a precursor of severe illness and co morbidity. It is therefore often necessary to refer the patient to a Geriatrician, or a Psychiatrist of Old Age.

Discussion Of Management For Hip Replacement Surgery Patients Nursing Essay

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According to the Scottish Arthroplasty Project’s annual report (2009), 6312 total hip replacement operations were carried out in 2007/08. (Scottish Arthroplasty Project, 2009).

This essay will discuss and justify the management required for patients who undergo total hip replacement surgery, during the first 72 hours post operatively. It will include information on the current evidence base for post operative care, using guidelines and policies and will show how early post operative management will allow the patient to fulfil their activities of daily living. It will also show how the patient can return to normal by using the Roper, Logan and Tierney model of nursing care. Preventing post operative complications is the most important goal in the post operative stage. A major element of the nurse’s role in the post operative period is to diagnose, monitor and intervene in rapidly changing situations so complications do not arise.

Hip replacement surgery is commonly carried out when patients suffer from chronic pain, immobility and deformity. These symptoms are mainly caused by osteo-arthritic changes in the joint, and affect all activities of daily living (Temple, 2004). The procedure is normally carried out under general anaesthetic (being ‘put to sleep’) or by spinal (epidural) anaesthetic. It is done by completely removing the old hip joint and replacing it with prosthetic parts (NHS, 2010).

Osteoarthritis is a disease that affects joints in the body and is characterized by damage to the surface of the joint. When a joint develops osteoarthritis, the articular cartilage which is found on the ends of bones, gradually roughens and becomes thin. The bone underneath thickens and becomes more rough (University of Dundee, 2009). The bone at the edge of the joint grows outwards forming osteophytes or bony spurs. This new bony tissue could be the body’s attempt to repair the damage to the cartilage. Friction against the osteophytes generates particles of articular cartilage which are shed into the joint. These particles are then taken into the synovium and trigger an inflammatory response. Irritation due to the release of inflammatory enzymes causes extra fluid to be formed which leads to joint swelling. In severe osteoarthritis, the cartilage can become so thin that it no longer covers the thickened bone ends. The bone ends touch, rub against each other, and start to wear away. The loss of cartilage, the wearing of bone and the bony overgrowth at the edges can alter the shape of the joint, forcing the bones out of their normal alignment, causing deformity and pain (Arthritis Research UK, 2010). The cause of osteoarthritis is unknown but there are several risk factors which include gender, age, obesity and genetic influences (Waugh and Grant, 2006).

Post operative care is defined as the care that is given between 24 hours and 30 days after surgery (Hutton and Cooper, 2002). Post operative care is essential to ensure the patient fully recovers from the surgery and is able to return to normal capacity as soon as possible, without complications. Kontoyannis (2008) suggests that the “post operative period is very important for monitoring the patient to prevent immediate and long term complications.”

Kozier et al (2008) states that “nursing during the post operative phase is especially important for the patient’s recovery”.

Post operative care can be divided into three main categories – assessment, monitoring and management. According to the Scottish Intercollegiate Guidelines Network (SIGN) “regular assessment, selective monitoring and timely documentation are key to post operative care” (SIGN, 2004).

The first post operative assessment should take place immediately when the patient comes back from operating theatre. As soon as the patient returns to the ward, the nurse makes a very quick assessment of the patient’s condition. Criteria for assessment include respiratory, circulatory, neurological, dressing, patient comfort and safety (Long et al 1993).

This assessment means that a baseline can be determined, the nurse can then record any changes in the patient’s condition from when they left the operating theatre and any problems can be identified quickly. The nurse has the responsibility to inform the doctor of any information about the patient’s condition when the first post operative assessment is being carried out. The Nursing and Midwifery Council (NMC) Code of Conduct states that nurses must “share information with your colleagues” so that they can “protect and promote health and well-being of those in your care” (NMC, 2007).

During the first post operative assessment, after the nurse has received a hand over from the theatre nurse, the patient will arrive back at the ward with an intravenous infusion. They might also have a PCA (patient controlled analgesia) and drain (Pudner, 2005). The nurse will monitor the patient’s vital signs, drain site and assess for pain.

Monitoring allows the gathering of information so that trends may be determined. This means that any worsening or progression in the patient’s condition can be recognised. Monitoring is essential to determine if the patient is responding to the treatment. The normal monitoring regime for any post operative patient includes: temperature, pulse rate, blood pressure, respiratory rate and oxygen saturation levels. These observations should be recorded and documented at 30 minute intervals, progressing to 4 hourly for the duration of the patients stay in hospital, unless the patient’s condition dictates otherwise.

Respiratory assessment is paramount to the post operative care of a patient. The nurse must observe the rate of and depth of the respirations. Pain increases the rate and depth; therefore if the patient is short of breath, a pain assessment should be carried out (Heath, 2004).

The nurse should also assess cardiovascular activity. They should note and seek further advice if the patient is hypertensive, tachycardic or bleeding.

From these observations, it can be determined if the patient is suffering from shock associated with pain or excessive blood loss.

Other monitoring requirements that post operative hip replacement patients receive would be pain assessment and observations on the operated leg, for example, colour, movement and sensation. This is to check for circulatory and nerve damage (Temple, 2004). This neurovascular assessment should be carried out and documented at 30 minute intervals, progressing to 4 hourly for at least 24 hours after surgery (Pudner, 2005).

The level of consciousness can be assessed by asking the patient to respond to questions and commands. If the patient cannot communicate clearly or is finding it difficult to concord with commands, the doctor should be informed immediately. Low levels of consciousness might indicate that the patient is suffering from shock or they have not recovered from anaesthetic (Long et al, 1993). The assessment tool used for measuring consciousness is AVPU (Alert, Verbal, Painful, Unresponsive). This is used to determine whther the patient is alert and fully conscious or only responds to verbal, painful stimuli or is fully unresponsive (SIGN, 2004).

The nurse should assess the operation site quickly, without causing pain and observe the dressing. In the immediate post operative period, the nurse is responsible for observing the wound site at frequent intervals. If it is expected that fluid may collect in the hip area, a drain will be inserted to let the fluid escape (Long et al, 1993). If there is a drain present, the type and quantity of fluid should be observed and documented. If drainage from the wound is excessive the operation site would need to be examined. Chrintz et al (1989) states that in wounds that heal by first intention, the dressing can ideally be removed after 24-48 hours and need not be replaced. Kozier et al (2008) also say that the dressing should be left for “at least 24 hours” but only if there is no signs of excessive bleeding or drainage. However, Pudner (2005) maintains that the dressing is “usually taken down after 24 hours to leave the primary dressing exposed”. Wilson (1995) proposes that “repeated exposure of the wound within 48 hours of surgery increases the risk of the patient developing a wound infection”.

Whilst the nurse is involved in monitoring physiological changes, maintaining dignity and comfort of patients is also an integral aspect of caring for any patient. The NMC Code of Professional Conduct states that as a nurse “you must treat people as individuals and respect their dignity” (NMC, 2007). Patient comfort and safety is imperative for the recovery from the operation and healing of the wound. To prevent unnecessary pain, it is important that the patient is comfortable and that they are positioned appropriately, using pillows between the legs so as not to dislocate the new hip joint. Providing comfort to the patient eases their physiological and psychological distress and pain. Comfort strategies include; hydration and elimination, nutrition, effective analgesia, personal hygiene, listening and being there for the patient/family, effective communication and treating the patient as an individual. Patients and their carers feel empowered and cared for, which improves the nurse-patient relationship (Manley and Bellman, 2000). Assessing pain is essential for providing comfort for the patient.

Pain assessment should be carried out whenever the vital signs are being monitored. It is essential that the nurse assesses the site, nature and severity of the patient’s pain in order to choose the most suitable treatment.

To assess pain, there are several tools that can be used. The most common being a numerical rating scale. The patient can score their pain on a scale of 1 to 10, 10 being the worse pain they can imagine (Manley and Bellman, 2000). When assessing pain, it is important to listen to what the patient is saying. A study by Seers (1987) showed that nurses persistently record the patients pain score to be significantly lower than the patient’s own assessment.

Opioid analgesics are the most commonly used analgesic for routine post operative pain relief. Examples of opioid analgesics include morphine, diamorphine and pethidine. The main side effects of opioid analgesics are respiratory depression, reduced gastrointestinal motility and nausea. The nurse needs to continually reassess respiratory rate, nausea and bowel movement when the patient is using opioids (Manley and Bellman, 2000). If the patient is experiencing nausea and/or vomiting, then an anti-emetic (anti sickness) drug such as metoclopramide can be prescribed.

It is also very important to prevent potential infection. To prevent the potential for infection, it is important to follow hand hygiene policies and to use aseptic technique whenever there is a dressing change or when touching the skin around the operation site (Pudner, 2005). This breaks the chain of infection at the mode of transmission so therefore the infective agent should not be able to reach the site of entry and the patient should not acquire an infection.

There is also the potential for pressure area sores to develop and this must be assessed as the patient’s mobility will be reduced. A tool such as the waterlow scoring system helps to identify patients who are at a risk of developing pressure sores and the nurse will be able to monitor and intervene as required. The nurse has to encourage the patient to mobilise so as to prevent the potential pressure sores developing (Pudner, 2005).

When assessing the patient, the Roper, Logan and Tierney model of nursing care is commonly used. This model of care is based on what is perceived to be the 12 activities of daily living, which are related to basic human needs; maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal hygiene, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying.

To maintain a safe environment for the post operative hip replacement patient it is important to prevent dislocation of the hip prosthesis. This is done by ensuring that the patient does not flex the hip at an angle of 90° or more, ensuring that the patient uses a high toilet seat whilst in hospital and has one for discharge, that they do not cross their legs and encouraging mobilisation to strengthen muscles around the joint.

To prevent dislocation of the new hip joint, an abduction wedge or gutter splint should be used between the legs for the first 24 hours and at night until the patient is discharged to stop the patient crossing their legs (Pudner, 2005).

Nurses need to assess the patient for fluid balance, especially if they are on an intravenous infusion. Intravenous infusions are normally prescribed for patients after oral fluids have been withheld due to surgery. Fluid balance records should be documented every hour for patients who have a urinary catheter and/or a drain in situ. When the patient’s catheter is removed, they are encouraged to pass urine. This is important because the surgery has been carried out on the lower limbs and it shows that the body has recovered from the anaesthetic and there has been no damage to the urinary system nerves during surgery. Anaesthetic may affect the bladder tone and consequently makes micturition difficult.

Adequate sleep and rest aid recovery from surgery. Sleep disturbance and deprivation can be caused by pain, difficulty obtaining a comfortable position, siting of intravenous infusions or drains and being in a strange environment.

Possible complications that could arise from total hip replacement surgery include; dislocation of the hip joint, excessive wound drainage, thromboembolism, infection, pressure ulcer development, hetertopic ossification (formation of bone in the periprosthetic space), deep vein thrombosis (due to decrease in mobility), necrosis (bone death caused by lack of blood supply) and loosening of the prosthesis (Smeltzer et al, 2004). The nurse should be aware of the possible complications that could arise from this type of surgery and should follow guidelines on how to deal with these should they occur. Hip replacement patients are at an increased risk of developing deep vein thrombosis due to the bed rest and blood pooling in the lower legs after surgery. Early rehabilitation of exercise and movement of the legs helps prevent deep vein thrombosis occurring and is recommended for all patients (Smeltzer et al, 2004).

Patients who have suffered from immobility which was caused by osteoarthritic changes in their hip joint may have suffered from social exclusion. This is turn means that their self esteem is altered as they have not been able to socialise with their peers. The nurse can ask the patient if they would like social work to be involved in their discharge and social work can then help the patient return in their socialisation within the community.

Health promotion is also a vital part of post operative management for patients. Patients need to be educated on what is best for their new hip joint in terms of exercise, diet and lifestyle choices before they are discharged from the hospital. Education about changing their lifestyle is important to prevent any other problems that may occur later on. Nurses can give patients smoking cessation advice and can help with exercise, by referring the patient to physiotherapy if required. Dietary advice can be given to the patient and if the need demands, referral to dietician may be appropriate. This includes dietary information and advice for patients who are overweight, as this can result in more severe osteoarthritic changes due to excess weight on the hip joint.

Much nursing research in the past 20 years has stressed the importance of patient education as an element of health promotion. The involvement of patients in the management of their care is desirable to their recovery. Promoting health post operatively is not only about providing information. Health promotion must be perceived as an element of health care in which nurses seek to enable the patient to take control over their own lives and health through processes of education.

Normally patients who undergo hip replacement surgery are discharged home after 3 – 5 days (NHS, 2010). The nurse has to ensure that the patient is discharged home with correct medication, including pain relief and previous medication and that the patient has received a discharge letter which they should give to their GP.

To conclude, using the current evidence base from Scottish Intercollegiate Guidelines Network (SIGN, 2004), and use of current NHS policies and guidelines, post operative care is essential to healing from the operation and gives the patient the best possible chance from recovering fully. Continually monitoring the patient post operatively gives the nurse useful information about how the patient is progressing or deteriorating and can then act accordingly, following specific national guidelines.

Following the information and standards set by bodies such as the Nursing and Midwifery Council and SIGN gives the nurse the evidence base for which they should be using when caring for patients who have undergone total hip replacement surgery. Well informed nurses use this best practice to give patients the best possible care and can prevent potential problems and complications if following them correctly.