Advocating For Options And Resolution In The Life Nursing Essay
The human body is both fascinating and frustrating in its complexity with intricate connections of countless cellular structures that work in tandem to sustain life. These structures, not visible to the unaided eye, carry out specialized functions that have the capacity to exert a profound effect on an individual. Control over such phenomena is only even in its beginning with the advances in medical technology over the last century. Parallel in its complexity, but on a significantly larger (and more visible) scale, are all the external factors contributing to the aging process. Health, safety, family dynamics, socioeconomics, ethics, and law might present as separate disciplines, but just as individual cells appear as one body, each issue above contributes to the well being of one individual. Cells exert the internal forces of change on the body while these larger issues exert the external forces that help or harm. Pressure from every direction is inevitable, especially as age and injury are accrued, but intervention and assistance is available to increase and maintain a desired quality of life.
Nurses are instrumental in the untangling and reorganization of the external forces that shape their patients. As the patient advocate, the nurse cares for the patient by providing a large scope of human and physical resources that have the objective of relieving stress within the patient, allowing them to resume life as usual.
For one patient, Susan Smith, internal health conditions are significant, however such external forces as money, access to health care, mental state, culture, shelter, attitude, and education affect the ability of the nurse to provide effective health care. It is impossible for this patient to achieve a total recovery unless the nurse begins interventions to correct external issues as well as the internal-they are strongly related and one will not recover fully without the other.
Patient Susan Smith has several conditions affecting her quality of life. She has a history of chronic illness and has suffered a recent crisis in which she sustained burn injuries and mild smoke inhalation. Jett (2010) explains, "the person may...regress because of an illness or...crisis, but these events can be a potential stimulus for growth and a return to moving along the wellness continuum" (p. 3). This "health crisis," as it seems, does not have to be the end of health for Smith, but it can infact be an opportunity for her to achieve better health than she had previously experienced. In addition to treating Smith's acute burns and the pain associated, new attention to her old diagnoses which include CAD, insulin dependent DM, significant hearing loss, osteoarthritis of the hips, hands, and knees, spinal stenosis, dry macular degeneration and a history of breast cancer, is one way the nurse can begin the process of moving this patient back up the wellness continuum.
During hospitalization exists a great opportunity for the nurse to closely assess and evaluate the patient. The process begins by using a framework, such as Maslow's Heirarchy of Human Needs (Jett, 2010). The framework begins by meeting the needs most essential to life such as air, water, pain, and mobility and progresses to higher levels of "self actualization and transcendence" (Jett, 2010, p. 6). The ultimate goal is to reach the highest level of the hierarchy, but it is a gradual climb, and the nurse and patient must progress through each level before moving to another.
For Smith, to meet her most basic needs, the nurse must monitor for and treat any acute or breakthrough pain or infection associated with her burn wounds, and assess and evaluate her respiratory status, as smoke inhalation can be damaging. "Cells are destroyed and the bronchial cilia are rendered inactive" in the lung tissue which leaves them susceptible to "bronchial congestion and infection" (LeMone, 2008, p. 494). After these immediate needs are met the nurse must assess her current chronic conditions.
For Smith, it is of significance to have tight control of glucose levels during her acute stress in-hospital, but the nurse will also assess her history and ability to function with her diabetes and other chronic conditions on a regular day at home. These conditions may be complicated by Smith's sensory deficits. Significant hearing loss and dry macular degeneration are factors that make communicating, understanding instruction, and performing activities of daily living a challenge. In an assessment of Smith, the nurse finds that she has difficulty carrying out instruction. This could be the result of both hearing loss and sight; however, her family reports that she seems confused, suggesting a shift in cognitive function. According to Touhy (2010), "an older person with a change in cognitive function needs a thorough assessment to identify the presence of specific pathological conditions" (p. 318). For the nurse to do this, several resources such as the Geriatric Depression Scale or the Minimental State Examination may be necessary (Touhy 2010). It is vital to differentiate a sensory deficit from a change in cognitive function so as to treat most effectively. Smith's chronic conditions may be causing her additional pain in her back, hips, hands knees, which will make movement and taking care of herself more difficult. It is important to determine how she copes at home, with the care and treatment of her own illness. Since she is likely to be on many medications (polypharmacy) an important assessment is to find out exactly what drugs she takes, and how she takes them to rule out "misuse or misunderstandings" (Jett, 2010, p. 229).
With these collective conditions the patient is at a deficit to function of her own accord, as they impede her from meeting her own most basic needs. She must be treated to improve these
conditions and advance on Maslow's Hierarchy of Needs first, and progress to coping with external forces and decision making.
Safety & Ethics
Safety is a concern for Smith because she is widowed, lives alone, has no close relatives, is being treated for multiple diseases, has sensory deficits and decreased mobility, continues to drive despite recent car accidents, and is exhibiting possible signs of confusion. It is important to consider the patient's desire to remain in the home, but should then include an assessment of the home environment itself to determine how it can be adapted for the patient if necessary. A primary safety concern with this patient is that she lives alone. Her nearest family is six hours away and she is adamant about remaining in her own home, so a solution that allows her to remain home, but with access to immediate care in case of an emergency is optimal. Another concern is that she still has her license and has a need to travel to and from doctor's appointments.
Several solutions exist but the best possible option is to prepare the home so it is accessible to the patient, which has the benefit of satisfying the patient's desire to remain home alone, yet function fully and safely. Programs such as "Home Safe Home Assessment Program" offered by Bloomington Hospital, may offer a way to evaluate the patient in the home and make adjustments accordingly (Bloomington 2010). A disadvantage however might be the costs associated because insurance may, or may not cover these costs. To be able to notify someone in case of an emergency, an alarm system that the patient wears might also be implemented.
She still has the option of relocating to an assisted living facility, or obtaining an in-home health aid, but this is not what the patient wants. If she can be accommodated safely, it is best to keep her home and self-sufficient opposed to forcing her to lose her home or independence. An adjustment she will likely have to accommodate however, is to public transportation, or a caregiver who will shop for groceries and take her to appointments. After two accidents it is unsafe for Smith to drive, and her injuries and confused mental status may also prevent her from doing so.
The financial status of Smith is problematic because she is limited to a single fixed income, only has a tenth grade education, and has many health problems that would make it difficult to work. Recent home fire damage, insurance costs, plus health care costs associated with hospital stays and medication will greatly exceed her income. Money for food, clothing, and shelter (if she has no current home due to fire damage) will be inadequate, complicating her conditions further.
Because Smith is on a fixed income, she likely qualifies for Medicare and Medicaid, which will cover many of her health care costs. However, other outstanding costs will still exist. She will still need to be able to afford the basic necessities of life such as food and shelter to maintain safety and security. The nurse may not be able to directly assist the patient in arranging financial compensation, but what the nurse can do is initiate the role of a case manager to follow the patient through her care until her needs are met (Jett, 2010, p. 361). As described in Jett, (2010) this care manager will be "a resource person whom the client can seek for advice and counsel and for brokering (negotiating, arranging) the flow of services" (p. 361) This will allow the client to have the best access to community resources and aid available. An example of such resources is the TRICARE health insurance program. As a widow of a WWII vet, Smith qualifies for this specific insurance, which may assist her in her expenses.
It is not indicated how much the family is able to care for the patient except to say that the nearest children are six hours away and they call or visit on occasion. Ideally the family is able to act as a support for an ill parent, but with such distance between them other interventions may be necessary. The children and the patient disagree on the course of action for her future care and see the only possibilities for her future in an assisted living facility, or home health. There needs to be conversation and understanding between the children and their mother about all the possible alternatives. The nurse should attempt to communicate to the family that in a home that is safe, quality of life is going to be optimal and cost efficient. However, the nurse might also encourage the patient to consider a employing a caregiver who comes on occasion or as needed to make sure that she is safe and well cared for in the home, and able to shop for groceries and go to appointments. Compromise from both parties may be the best action for this situation to ensure the health of the patient. To open discussion it may be beneficial for a third party, such as a social worker to collaborate with the nurse and family to discuss a timeline for care and possible options (Nicoll, 2006).
Patient Susan Smith, with her extensive list of health problems and additional external factors is an ideal candidate for the use of the interdisciplinary team. As the nurse, advocating that each physician, social worker, case manager, physical therapist, occupational therapist, pharmacist, and family member be well informed and involved in patient care is key. "To be effective, the team must have an ongoing , collaborative practice that incorporates shared goals, care-planning, role-blending, and shared leadership according to Nicoll (2006)" (p. 65). With not just high quality nursing care, but care in every discipline the patient can move beyond the first level of Maslow's Heirarchy of Needs and surpass her level of health prior to her crisis. That is the ultimate goal. No nurse alone has all of the necessary resources to solve the problems of her patients, but the nurse does know who to find to fill missing roles. Being relentless in pursuit of care for the patient is the nurse who will stretch her abilities as far as she can to achieve a goal for her patient.
Implications of employing an interdisciplinary team in this case have positive outcomes. Each detailed and unique aspect of this patient and family's overall health, social, and mental status is more closely addressed. Without such interventions, care of the patient might slide to undesirable quality and preferences of care options might be limited. Exercising use of each member of the interdisciplinary team however, provides the patient health and well-being from all angles. Chronic conditions and treatment are managed appropriately, and performance of activities of daily living maintains client independence and health. Most importantly, allowing the patient to remain in her own safe home, and with a caregiver who assists her as needed, benefits not only the patient, but the children who want to know their mother is safe.
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