Planning Care for an Adult Patient
Urologic cancers and specifically bladder cancer, are becoming increasingly commonplace medical occurrences and the following essay will offer insights into the hospitalization process of a bladder cancer patient. According to (Marchese, 2006), bladder cancer is a muscle invasive disease that requires cystectomy and urinary diversion to improve the chances of cure. The surgical alteration of a urinary system presents the possibility of complications such as emboli, pneumonia, and infections. Further, as elaborated by (Perimonis and Kaliopanou 2004; Kane 2000a; Kane 2000b) the possibility of altered body image, changed sexual function, and incontinence is increased. The teaching needs of a bladder cancer patient are pretty significant, and thus, communication is a key element to help build and nurture the therapeutic nurse-patient relationship. This essay now seeks to address the communication and nursing care needs of such a patient and how a nursing practitioner facilitates these processes.
Application of Peplau’s Interpersonal Relations Theory to a Bladder Cancer Patient
Peplau’s theory of interpersonal relations provides a theoretical framework through which nurses can plan, assess and offer interventions that provide optimal outcomes for patients. As suggested by (Peplau, 1992), a nurse is a complex individual who can be deemed to be the total of nursing training, past experiences, and unique personality traits.
In using this communication theory on a bladder cancer patient, the basic understanding that the patient too is unique and knowledgeable within their frame of reference. Peplau’s theory involves a series of steps all aimed at addressing the communication needs of the patient and these include:
Orientation: The orientation phase involved the meeting of the patient, getting acquainted and making them understand that you would be the caretaker for the period that they would be hospitalized. This is an important phase since first impressions always matter and it is important to aim to impact the patient positively during this phase. This process proved important in my experiences as it marks the transition from of a nurse in the patients eyes from stranger to a resource person and counsel/helper for the patient. It is at this stage that the nurse answers the patients questions and vice versa and marks the stage in which the patients accepts there is a lot they can learn from the nurse.
Identification: In this application phase f the communication theory the patient has an idea of how the health care system works. The trust level with the nurse is still in the initial stages, and the patient will accept interactions with the nurse albeit gradually (Axelrod 2016). The patient can express the problem areas and the work they need to be done. In this stage through communication and interaction the nurse and the patient can formulate an activity plan, discussions on nutrition and an explanation of neo bladder care can also occur here.
Exploitation: As the name suggests, at this stage the patient can take advantage of opportunities provided by the nurse and the relationship they share with the health practitioner is one of mutual benefit. Through the enhanced communication already existent at this stage, the patients vacillated between self-directedness and dependence.
Resolution: At this stage most of the goals of the patients have been met and promptly. At this point in time, the patient displayed a high of self-reliance and decreased reliance on the urologic nurse (High et al. 2000). The patient is also now able to take part in support groups for bladder cancer and continence diversion patients.
Barriers to Communication about the Bladder Cancer Patient
The anxiety and anger issues presented communication barriers at the patient briefing with the urological nurse when a surgery date was being scheduled. The patients anger mainly stemmed from fear and uncertainty as to how this surgery would impair his career and sexual function. These fears were very valid since the recovery time required for the anticipated surgery can be quite substantial (Hojat et al. 2004). During the pre-surgery period, the patient appeared confused as to what exactly the surgery entailed. The medical jargon and complex surgical procedures had to be packaged into visual aids that showed the organs and how they would be affected by the surgery. The visual aids used showed an anatomical representation of the prostate, bladder, and the seminal vesicles. Also, the grief and knowledge lacuna that accompanied the cancer diagnosis presented a communication barrier as the patient had already made up his mind that his fate was sealed. A lot of demystifying had to be done by the urological nurse as well as the lead oncologist.
Communication techniques that employed the use of practical and visual aids proved to be very active with the bladder cancer patient since they deconstructed the medical jargon into an easily comprehensible language with the use of pictures and practical demonstrations. As well, techniques that involved participative discussions and active listening skills were useful in facilitating effective communication.
Respect, Empathy, and Dignity In a Medical Context
According to (Dickert and Kass 2009), making patients feel respected as persons and valued is a multi-faceted process that goes beyond recognition of autonomy. Further studies suggest that patients who feel respected by their healthcare providers have significantly improved clinical outcomes and greater levels of satisfaction. Given acute/chronic illnesses it is argued that patients incapacitation may hinder their ability to communicate effectively, but that does not tarnish their desire to be treated respectfully.
(Rankin, Kramer, and Miller, 2005) suggested that empathy is an emotional reaction that is not dependent on the cognitive understanding of why a person is suffering but rather facilitates understanding and action. According to (Hojat et al.) the emphasis of modern medical education on the doctors/nurse’s emotional detachment, clinical neutrality, and affective distance could be contributing greatly to the decline in empathy in many health care providers. It is advisable for physicians to self-assess and measure empathy that is extant in the context of the physician-patient relationship (Lillo et al. 2009).
Modern healthcare is continuously faced challenges and has among other things been described as reductionist, inhumane, interventionist and paternalistic. Moreover, it is constantly threatened by organizational and resource crisis as well as a communicational crisis involving the physician and patient and a lack of general trust between the two. One prominent term in the debate on the autonomy of patients is dignity. Assessed against the Ethical Theory by Immanuel Kant, dignity appears to be related to a person’s autonomy. Further, this is because dignity closely linked to one of Immanuel Kant’s more famous assertions contained in the categorical imperative that stated that ”One should act so as to treat humanity, whether in their person or another, as an end and never only as a means.
Dignity largely entails the addressing of each patient in their unique distinctiveness. However a cautionary approach should be used (Logstrup, 1997) and a certain distance to the patient should be maintained. Dignity should be applied to all patients irrespective of their incompetence, unconsciousness and incapacitation and medical professionalism should see to it that this is practicable.
(2) Nursing Care
According to (Barbra and Susan 2014), the nursing process is an organized sequence of solution oriented steps aimed at identifying and managing the health problems of patients.
This section will now focus on the nursing care needs of a patient; Ramat diagnosed with Acute Lymphocytic Leukemia (A.L.L). This is a type of cancer that originates predominantly from immaturely formed white blood cells in the bone marrow. It is a cancer of the blood cells characterized by the overproduction and accumulation of cancerous white blood cells referred to as lymphoblasts. It is important to note that Acute Lymphocytic Leukemia is also referred to as Acute Lymphoblastic Leukemia.
Roper, Logan and Tierney’s Activities of Living Model
This model was first published in 1980 as the Elements of Nursing Model. According to (Safarino, 1990) this model incorporates a life span approach that considers the characteristics of a person on prior development, current development and projected future development of the person. In addition to the life span approach, the model also uses an independence v dependence continuum. It further incorporates a set of 12 Activities of Living (AL’s), which are representations of activities undertaken by people whether they are sick or well. These elements together are what is termed as model of living. The model of nursing is considered to be in use when the model of living is used in conjunction with the nursing practice.
Components of the Activities of Living Model
Roper, Logan and Tierney’s Activities of Living Model contain five major components which are: (A) The Activities of Living, (B) Life Span Continuum, (C) The Dependence/ Independence Continuum, (D) The Factors Influencing the Activities of Living and (E) Individuality in Living.
(A) The Activities of Living (AL’s)
According to (Roper, Logan and Tierney 1990) it is imperative that a model of living describes in detail what living means/ entails. The twelve AL’s referred to by this model are Maintenance of a safe environment, Breathing, Communicating, Mobilizing, Eating and Drinking, Eliminating, Personal Cleansing and Dressing, Maintaining Body Temperature, Working and Playing, Sleeping, Expressing Sexuality and Dying.
(B) Life Span Continuum
This is the second component of the activities model, and it is many concerned with the continuum from birth to death. This is included in the model because each living human being has a lifespan that begins at conception and ends at death. (Roper et al. 1990), suggested that each experiences continuous change, growth and development in the course of their lifespan.
(C) The Dependence/Independence Continuum
This component is mainly concerned with the stages of a lifespan where one cannot for a variety of reasons perform certain activities of living independently. About nursing, stages of this lifespan may refer to old age or when one is incapacitated by sickness and is dependent on others to enable most of their daily activities and needs especially personal cleansing and dressing, eating, eliminating, etc.
(D) The Factors Influencing the Activities of Living
It was further noted by (Roper et al. 1990), that though each performs activities of living at the various stages of their lifespan, the major distinction is that they all do it differently. Some factors influence how this activity of living are carried out. Physical factors such as urological problems like bladder cancer can affect processes of eliminating such as urination. Psychological factors that entail cognitive and emotional well-being could influence things such as communication because they are related to one’s mood, self-confidence, and intelligence quotient. Socio-cultural factors are largely influenced by ones socialization, religion, culture and could influence one’s mode and manner of personal dressing and cleaning. Environmental factors determine ones exposure to pollution, allergens, sanitation and these entire have a direct bearing on an individual’s lifespan.
(E) Individuality in Living
The process of living and carrying out the activities of living is a highly individualized process and consequently is done uniquely and largely determined by an individual’s personality. A persons Individuality in living is often demonstrated by their attitude and beliefs towards AL’s, their general knowledge range on AL’s and the how, when and where the person carries out these AL’s.
Problems Identified from the Acute Lymphocytic Leukemia (ALL) Patient
In this section, it is instructive to note that the problems identified in the Acute Lymphocytic Patient, were identified with the help of the Roper, Logan and Tierney’s Activities of Living Model. ALL patients are susceptible to a wide variety of conditions such as shortness of breath, fatigue, dizziness, anemia and palpitations but for this essay, the focus will be on two problems: Fever (pyrexia) and Susceptibility to Easy Bruising and bleeding.
According to the U.S National Library of Medicine, fever is one of the most common symptoms of ALL. The high occurrence of fevers in ALL patients could be attributed to the increased susceptibility ti infections due to degraded and compromised white blood cell capabilities.
Easy Bruising and Bleeding
Patients suffering from ALL have increased predisposition to bleeding through nose bleeds, abnormal periods, thrombocytopenia; They also have a high likelihood of getting bruised easily and developing pressure ulcers/sores.
Nursing Care for the Problems Identified.
According to an ALL Clinical Presentation by (Seiter, 2015), fever is one of the more common symptoms of ALL and patients may have fever without evidence of any other infection. However, it is highly advisable for health practitioners to assume that the fevers are as a result of infection since most ALL related infections are fatalistic if not aggressively and promptly treated. According to (High et al. 2008), fever in medical contexts is defined in a number of ways: i)A singer oral temperature that exceeds 100°F or (37.8°C), ii) Repeated Oral Temperatures > 99°F >(37.2°C) iii) Increase in temperatures > 2°F or > 1.1°C over the baseline temperature. Further according to (Hojat et al.2001 ) a single temperature reading of more than 100°F or (37.8°C) is both a sensitive and a specific predictor of an infection with the predictive value of 55% positive. The temperatures of older adult patients receiving long-term care is often measured orally although there is an increased body of evidence that rectal measurements of temperature are more accurate than axillary and oral methods. As well research now indicated that use of electronic techniques to measure temperature is better than the standard mercury thermometer.
According to Nancy Munro (2014), fevers almost always indicate disruptions to the body’s defence mechanisms and the challenge is to figure out if the underlying case is infectious or non-infectious. For instance, drugs are a non-infectious cause of fever and drugs such as thyroxines which stimulate heat production, phenothiazines which alter thermo regulation and vasoconstrictors which limit the dissipation of heat.
How to Manage Fever
Nursing care interventions that can be used to treat fever include the use of physical cooling mechanisms. According to the Oxford Journal: External Cooling in the Management of Fever (2016), the use of cool liquids applied to the skin can be useful in helping abate febrile conditions. The use of isopropyl alcohol is however now discouraged despite its wide use in early medical practice following increased cased of alcohol poisoning. Oral thermometers were mostly used in Mr. Ramat’s case, and some actions took to abate febrile situations. In Mr. Ramats case, for fever cooling methods that entailed the use of a cooling mattress were used. This was given research on safe non-steroidal and non-alcohol cooling methods. The use of combined evaporation and convection methods entails the use of a continuous spray of finely atomized water under high pressure combined with either hot warm and cool air and cooling done using a mattress at 20° are very effective (Weiner 1980; Khogali 1983).
Non-steroidal anti-inflammatory drugs have also proven effective in controlling fever. The downside of using this drugs to treat fever is that they have in some instances been known to cause renal dysfunction. Etiologic diagnosis is critical when the fever is determined to be caused by an infection, for instance, the case study of a leukemia patient where blood cultures isolated staphylococci prompting the health practitioners to begin penicillin therapy (Raab et al. 2016).According to the Blood Journal (2016), febrile episodes resulting after a blood transfusion to a leukemia patient and which abate after 18-24 hours rarely warrant cause for alarm.
Nursing Care To Control/Prevent Bruising and Bleeding In A.L.L Patient
Patients with A.L.L have increased susceptibility to bruising and bleeding. Further, A.L.L often causes gum bleeding and mouth sores and mare, therefore, complicate processes such Activities of Living such as oral hygiene and eating/drinking. As suggested by Losapio (RN) in Nursing Care Plan for a Patient With Acute Myelocytic Leukemia, a nurse should work closely with a leukemia patient’s dietician to avoid preparing foods as that may further aggravate the oral mucosa such as spicy foods, acidic foods as well as very hot and cold foods. Invasive procedures should be kept to a maximum to limit patient discomfort due to the tendency to bleed easily (Kane 2000a). Oral hygiene for A.L.L patient Mr. Ramat was done with the use of a soft bristle toothbrush to avoid triggering mouth bleeding and laceration of internal mouth sores.
Ramat’s hospital attire was made of soft and specially made materials as were his
beddings to avoid exerting unnecessary friction which will lead to skin bruising.
Leukemia patients are also more susceptible to pressure ulcers. Debra Wood of the Lahey Medical and Hospital Centre advises that to minimize the occurrence of pressure sores; the certain things should be done. Ramat’s position was therefore changed every two hours if as per Wood’s recommendation for a bedridden patient. It was also important to ensure Ramat achieved and maintained good body alignment (Kane 2000b). In Ramat’s case, this involved placing him in positions that were only 30 degrees towards one side or the other and we avoided positions that exerted pressure squarely on the hip. Nurses should also monitor the bleeding of A.L.L patients as this could lead to further complications such as anaemia. Bleeding was monitored through abdominal assessment, checking for bleeding of skin and oral mucosa among other things. This monitoring was done every four hours as per Wood’s guidelines.
The fact of living life administering patient care instills a great deal of insight that is useful for personal and professional development. On a personal, it forces one to reflect and be thankful for being in a prime position to impact society positively. Care giving is a noble action, and being able to facilitate the processes which alleviate the pain and suffering of patients is very fulfilling (Logstrup 2007). The little strides of seeing a patient who couldn’t walk begin to walk or open their eyes after a bout of unconsciousness yields indescribable joy. As a person, it fosters a sense of responsibility since it reminds a heath practitioner that they need to be accountable for their actions since this will be a key determinant in someone’s well being. It also breeds passion for the job and consequently a sense of commitment towards the job at hand.
On a professional level real time experiences in a health facility improve one’s professionalism. This is because more experienced health practitioners can offer useful tips and lessons since they assume the roles of mentors and this is important for novice health practitioners (Marchese 2006). It also sharpens one’s resolve to humanity since Medicare oft evokes compassion, empathy, patience among other virtues and tenets that make one a better healthcare practitioner but most importantly a better person.
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