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The basis of this comprehensive care plan is a 47-year-old Mexican man, initials F. H., who was transferred to UNC Hospital in Chapel Hill on 10/05/04 with acute renal failure. On 10/04/04 he went to Good Hope Hospital in Angiers, NC where he presented with hemoptysis, oliguria, fatigue, and bodyaches. Mr. H emigrated from Mexico illegally on 10/03/04 and spent several hours crossing the Arizona desert before journeying across the United States to meet with a family friend who lives in Angiers. Within one day of his arrival, Mr. H complained of feeling very bad and his contact here in the US promptly took him to the hospital for treatment. When the patient was brought to Memorial Hospital in Chapel Hill, his chief complaints were a sore throat, aching all over, and shortness of breath for one week; he was also acutely confused according to his physicians. It was documented that he denied use of tobacco, alcohol, and illicit drugs; it was further noted that Mr. H spoke Spanish only. Given the circumstances of his recent arrival, the patient’s past medical history was unknown, but he was diagnosed with acute renal failure based on his lab values, specifically BUN and Cr levels, his urinary retention, and the results of a renal biopsy (performed on 10/12/04). The patient’s BUN was still very high at 59 MG/DL on 10/20/04, but it had improved from an initial value of 200 MG/DL. Mr. H’s Cr was at 10.1 MG/DL on 10/20/04, which is also very high and a direct consequence of his renal failure. His red blood cell count, hemoglobin, and hematocrit were all low; this was expected given his kidney malfunction (Campbell, 2003). The patient also presented with azotemia, acidosis, and pulmonary edema. Acid-fast bacillus (AFB) smears were all negative, however, ruling out a bacillus infection; the pulmonary edema was When I received the patient assignment, I researched his history and noted his lab values (see Appendix A) as well as the medical interventions taken to aid the patient’s recuperation. The recent biopsy indicated pigment nephropathy in accordance with rhabdomyolysis, a condition in which the muscle is broken down and myoglobin collects in the kidneys (Russell, 2000). The patient also underwent the placement of temporary catheters, initially in his femoral veins (bilaterally) and subsequently in his right subclavian vein so that he could receive hemodialysis (HD) treatments intended to rid his body of accumulating nitrogenous wastes. Mr. H’s physicians ordered IV placements for him, although he was no longer receiving IV therapy when I met him. The IV sites led to the development of phlebitis bilaterally. To treat this, Keflex was prescribed and drug The dates of care for this patient were 10/19-20/04 on 3 West, nephrology. The first day of clinicals was four hours long; this was fortuitous as it allowed me to gauge the patient’s needs and his particular concerns regarding treatment. I can speak Spanish to a limited degree, but my comprehension of the language is greater than my speaking ability. With limited skills, I discovered that the patient considered himself a Catholic though he did not attend church regularly. That day proved especially helpful as I met Mr. H’s only acquaintance in NC; for the remainder of this report, that friend will be referred to as J, in order to protect the patient’s identity in respect to HIPAA. He too spoke Spanish, but English as well. Having J present enabled me to allay some of the patient’s concerns regarding length of stay and the HD treatments, and helped me gather more information on what could be done to alleviate Mr. H’s boredom during his hospital visit. As it turned out, the patient did not watch much TV, he did not read for pleasure, nor did he care much for music. J also confirmed that Mr. H did not have family in the US and that the patient’s parents back in Mexico did not understand the specifics of their son’s illness. This was a consequence of different dialects of Spanish according to J who had phoned the patient’s family with little success, as he did not comprehend their particular language. J also explained that he himself was unable to visit the patient regularly because he worked long hours every day and lived about an hour and a half away from Chapel Hill. As it turned out, Mr. H was the godfather to J’s nephew and although not related by blood, the godparent role in Mexican families is binding. This person is intended to care for a godchild should that child’s parents die leaving the him/her an orphan. Additional notes on the patient included the following: he was on a renal diet, but spoke of not having much of an appetite lately; he mentioned muscle soreness of his calves and I noticed that he had nonpitting edema of both ankles; the bottoms of his feet were healing from blisters; he did not have shoes or clothes available in the hospital; and he was able to bathe and ambulate independently and was collecting his urine in a urinal for intake and output (I &O) measurements. Also, although there were medical notes indicating that Mr. H was married, he told me that he was not, but both his parents were still alive. The patient did not have any medical insurance. Finally, given Mr. H’s age, he would fall under generativity versus stagnation according to Erikson’s developmental tasks Mr. H’s needs were many. As a new immigrant to the US, he dealt with a new home, a new language, separation from his family and what was familiar, a new job, the stress of providing for himself and finding a permanent place to live. Acute illness further compounded all of these challenges. Ultimately, however, the patient’s needs could be separated into the psychosocial and physiological realms. Some possible diagnoses related to his psychosocial wants were “anxiety, fear, fatigue, hopelessness, powerlessness, altered family processes, risk for loneliness, impaired social interaction, knowledge deficit, relocation stress syndrome, acute confusion, and potential for enhanced spiritual well-being” while those related to physiological needs were “self-care deficit syndrome, fluid volume excess, altered nutrition: less than body requirements, risk for impaired skin integrity, and urinary retention”. Cultural deprivation was also a concern for this patient although it is not explicitly listed as a nursing diagnosis according to NANDA (Rodgers, 2004). Mr. H was in a precarious position when I first met him. Although he had been in the hospital for two weeks, he was just starting to show signs of recovery. I feared, however, that his physical well-being might be thwarted if his psychological health was not addressed. I did not ask the patient point-blank if he was depressed, but I sensed that he was lonely with no one to speak to, as the nurses on the unit did not speak much Spanish. When I began to ask him questions, he opened up to me and spoke at great length about his family back home, how he was employed while in Mexico (he used to make dyes and materials for tennis shoes), and what his level of education was (4th grade). From what I gathered, Mr. H’s physical needs were being met. The HD was working at lowering his BUN and Cr levels. His muscle soreness was dissipating day by day. His phlebitis was being treated with an antiinfective and his upper arm mobility was getting better. His I & O was recorded daily to estimate his kidney function. He was able to sleep at night, even though he was in a strange place, and he was eating at every meal although he stated that he did not like the hospital food To this end, the most pressing nursing diagnoses for Mr. H were first, urinary retention as evidenced by oliguria and azotemia (as illustrated with high BUN and Cr lab values) related to acute renal failure and rhabdomyolysis. Secondly, Mr. H suffered from powerlessness as evidenced by a self-imposed confinement to his hospital room and a subdued affect related to a complete cultural transition over a short period of time, the acute onset of a serious illness, the inability to converse in English or Spanish with most of the healthcare staff, and a deficit of knowledge related to the HD Mr. H’s experienced altered urinary elimination that could potentially lead to a lifelong need of HD and his self-concept was undergoing change as a result of his physical incapacitation and the foreign environment to which he was restricted until his discharge. To address the physical component of his care, long-term goals were formulated as such: the patient will comply with HD therapy as scheduled upon discharge, and the patient will demonstrate care for a catheter site established for dialysis. In the interim, the patient would maintain daily dietary requirements by eating at least 90% of every meal, and Mr. H would exhibit greater knowledge of ARF by answering questions about why he needed the catheter, how HD helped rid the body of wastes, and the potential causes of ARF (Campbell, 2003). This expanded knowledge was expected to encourage patient compliance with routine dialysis upon discharge by emphasizing self-efficacy and Planned interventions to meet these goals and outcomes would entail coordination with a social worker in or near Angiers to locate a HD center where Mr. H could receive weekly treatment despite his lack of insurance, and teaching the patient how to cover his temporary catheter properly in anticipation of doing so when he was discharged. During his stay at the hospital, proper nutrition was available, but did little good if the patient did not eat enough at each meal. To achieve the first short-term outcome, I thought that the patient should have more control over what items he ate and that a Mexican food choice should be included on the daily menu. I called dietary services to request a menu printed in Spanish and one that reflected typical Mexican foods that would be more appealing to the patient. I asked that future menus also be made available in Spanish. A menu was tubed up and later that morning, Mr. H and I went over the menu offerings as he selected his food choices for the following day. That afternoon, I reported that Mr. H ate all his lunch except for a bun (he preferred toasted, sliced bread). The success of this intervention could be measured by examining the patient’s food tray after each meal and consulting with Mr. H as to how he liked or The second outcome was achieved by teaching Mr. H about kidney failure and HD because he had indirectly indicated his partial knowledge on each topic the first day that I met him. He asked me when he would be discharged and I replied that it would depend on his BUN and Cr levels improving, explaining that these values correlated to his kidney function by ridding the body of wastes. He said nothing, but looked confused at the explanation. I then judged that more teaching was needed. As part of a teaching plan, I put together a notebook of written material for the patient that described HD in Spanish. I also used the NIH website to refresh my understanding of HD and its use for ameliorating kidney dysfunction (National Kidney and Urologic Diseases Information Clearinghouse, 2002). I presented the notebook to Mr. H on 10/20/04 in the morning around 0900. He proceeded to flip through it all morning before setting it down around 1200. Before leaving him that day, I asked him several questions regarding what he had read and if he understood the reason for the catheter and HD. He was able to answer why he had the catheter and what factors could relate to ARF. He was still uncertain as to what exactly HD did for his body, so we discussed that topic a bit By providing written material pertinent to the patient’s treatment and making it available to read at his leisure, I anticipated him taking more interest in his medical condition. After setting a foundation of additional knowledge and perhaps motivation to learn more, I began to work on the long-term goals that I’d established for Mr. H, being the self-care of his catheter site. I asked the dialysis team and my clinical instructor for help with this endeavor. The dialysis team was consulted briefly for instructions on covering a temporary catheter so that the patient could shower. He had spoken of only washing himself limb by limb since being admitted to the hospital when I asked him if he had showered that day (10/19/04). My instructor and the team told me to use a plastic of some sort secured with tape to keep the catheter site dry and clean while Mr. H showered. I made a request for Saran Wrap from the hospital kitchen and obtained a roll of plastic tape used to secure catheters. I proceeded to demonstrate to Mr. H how he should cover his site completely each time he wanted to shower. Phlebitis left his arms sore and reduced his range of motion so I cut several strips of tape and stuck them to the shower rod. Evaluation of this demonstration was yet to be seen when I left the patient. It was unknown at that time whether or not the patient would undergo HD after discharge, the date of which was also unknown. Despite these questions, the demonstration was pertinent to Mr. H’s long-term care by providing a short-term lesson on self-efficacy/ self-care that would promote confidence on his part that might translate into better management of his health should he need HD outside the hospital (Tsay, In addition to the interventions aimed at Mr. H’s physical healing, I also attempted to alter the patient’s sense of powerlessness. Given the circumstances, I foresaw an opportunity for long-term growth. I hoped to help the patient feel empowered by the deepening of his current spirituality. Although such an intercession might be perceived as one specifically aligned with a value- belief diagnosis, I felt compelled to include this aspect in the patient’s care because I believed that an enhanced spirituality would greatly add to the patient’s sense of control over his current situation. I wished that the patient would explore his understanding of what was happening to him and why according to his faith. Although “the nursing and health care literature makes it clear that spirituality and religion are not synonymous”, I inferred from Mr. H that his Catholic beliefs were linked directly to his spirituality (Dossey, 2005). As someone who grew up in the Catholic Church, I knew that many Catholics believe that all suffering here on earth is rewarded in life after death. A return to his faith, potentially could offer some worth to his current struggle. In a paradoxical way, Mr. H could regain a feeling of control and power via the acceptance of his current illness in a broader context that his In developing the intervention for this long-term goal, I called the hospital Chaplain. He arranged a visit by a Spanish-speaking Catholic priest from the nearby church St. Thomas More. I envisioned an initial visit that would have a snowball effect, with subsequent visits that would also relieve Mr. H’s loneliness. As mentioned before, the nurses on 3 West spoke little Spanish and the patient’s affect was apathetic and seemingly depressed, likely conditions of his physical illness and the extended hospital stay (Strandmark, 2004). Along with the long-term goal outlined above, short-term outcomes were prepared for this patient. The patient would express an interest in his treatment by reading the written material provided. Also, the patient would leave his room more frequently after acquainting himself with the unit floor plan and his room number. Overall, the following interventions were enlisted to reaffirm autonomy as “The patient’s illness alone can compromise self-determination… [which] can be a result of the institutional environment, the presence of worry, anxiety, and the patient’s lack of knowledge or inability to speak for himself” (Nordgren, 2001). Nordgren also wrote of the strong link between the The interventions planned to help Mr. H meet the listed outcomes consisted of keeping the patient busy with simple tasks and activities while in the hospital, enabling him to contact his family in Mexico to relay news of his illness, and accompanying the patient on walks to the hospital garden and around the 3rd floor. While trying to accomplish the planned interventions, I sought collaborative help from a social worker assigned to the patient’s Med B service, a Spanish interpreter named Maria, volunteer services, and Mr. H’s physicians. The social worker visited the patient so that Mr. H could speak with his family. She had access to a long distance code that was necessary for the call to Mexico to be placed. He declined the opportunity as he was able to speak with his family the night before; I was not aware of this as it occurred after I left Mr. H and his friend J, who made the call for the patient. Although the social worker and I explained that the additional call would be free, Mr. H turned down the offer because he Likewise, the interpreter was called for her services. I wanted Mr. H to feel comfortable and to have the chance to ask me questions or raise concerns, but he spoke to the interpreter for only few minutes and told us that he did not have any pressing issues to discuss. Although my Spanish could be classified as intermediate, I wanted the patient to have access to someone completely fluent in case he had worries that had not been treated (Cotton, 2005). In an attempt to keep the patient busy, I noticed that Mr. H was receiving newspapers, but in English. I discovered that volunteer services was given Spanish newspapers weekly, so I obtained a couple of recent publications for Mr. H in order to keep up on current events. It was at this time that I also became aware of Mr. H’s need for reading glasses. I mentioned this to his doctor who noted that the patient might be referred to an ophthalmologist on an outpatient basis. In the interlude, Mr. H read small print items from a distance, and he did leaf through the newspapers I brought. While speaking with Mr. H’s doctor, I asked if whirlpool therapy would help with the soreness in his calves. She replied that it might and that she would discuss it further with the other healthcare providers, however, she also noted that the soreness was likely due to the rhabdomyolysis and that the During my visit to the unit on the 19th and 20th, I walked with the patient along the third floor and down to the main entrance of the hospital and to the small garden just off the information desk. I wanted to get Mr. H outside for a short time; I did not know when he’d last been outdoors. As it was, he had no shoes, so I brought him a pair of grip socks. He responded well to the moderate activity, and appeared energetic and revived after sitting outside for twenty minutes. A medical school student on rotation had told the patient that he should get out of his room occasionally to walk and Mr. H took the advice to heart. I saw him several times after my assignment walking the halls of the third floor. Overall reflection of Mr. H led me to several conclusions. For one, I came to a deeper appreciation of what it’s like to be a stranger in a foreign land who must rely on health care workers who might not speak my native language. Mr. H had been in the hospital for two weeks prior to our meeting. Before our encounter, he luckily had the services of doctors and medical school students who spoke Spanish. They were able to convey the gravity of his illness and help him understand the therapies they imposed for his ultimate benefit. Mr. H was well looked after, but his emotional needs were not fully addressed largely due to the language barrier. I felt incredibly rewarded with the opportunity to introduce small elements of change to positively affect Mr. H’s mental and emotional requirements. As a nursing student, I had two days to serve the patient, but I also hoped to leave Mr. H with a network of resources that could be employed in the following days and weeks. I feel that I was able to impart to him a more solid foundation for progressive healing holistically. Burks, K. J. (1997). Intentional action. Journal of Advanced Nursing, 34(5), 668-675. Campbell, D. (2003). How acute renal failure puts the brakes on kidney function. Cotton, C. E., Tolman, E. E., Mack, J. C. (2005). A Su Salud! New Haven: Yale Dossey, B. M., Keegan, L., Guzzetta, C.E. (2005). Holistic Nursing a Handbook for Practice (Fourth ed.). Sudbury: Jones and Bartlett. Hetherington, E. M., Parke, R. D. (2003). Child Psychology: A contemporary viewpoint (Fifth edition ed.). New York: McGraw Hill. National Kidney and Urologic Diseases Information Clearinghouse. (2002). Your kidneys and how they work (los rinones y su funcionamiento). Retrieved 10/19, 2004, from http://kidney.niddk.nih.gov/spanish/index.asp Nordgren, S., Fridlund, B. (2001). Patients' perceptions of self-determination as expressed in the context of care. Journal of Advanced Nursing, 35(1), 117-125. Rodgers, S. G. (2004). List of health patterns and nursing diagnoses (personal Russell, T. A. (2000). Acute renal failure related to rhabdomyolysis: pathophysiology, diagnosis, and collaborative management. Nephrology Nursing Journal, 27(6), 567. Strandmark, M. K. (2004). Ill health is powerlessness: a phenomenological study about worthlessness, limitations and suffering. Scandanavian Journal of Caring Science, 18, 135-144. Tsay, S. L., Healstead, M. (2002). Self-care self-efficacy, depression, and quality of life among patients receiving hemodialysis in Taiwan. International Journal of Nursing Studies, 39, 245-251.

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