COMMUNITY NURSING APPROACH : CHILDREN AGREGTATES

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Community health needs may be assessed using a variety of methods. Regardless of the assessment method used, data must be collected. Data collection in community health requires the exercise of sound professional judgment, effective communication techniques, and special investigative skills. Four important methods are discussed here: surveys, descriptive epidemiologic studies, community forums or town meetings, and focus groups.


Assessment method, focus groups, is similar to the community forum or town hall meeting in that it is designed to obtain grassroots opinion. However, it has some differences. First, only a small group of participants, usually 5 to 15 people (Polit & Beck, 2007), is present. The members chosen for the group are homogeneous with respect to specific demographic variables. For example, a focus group may consist of female community health nurses, young women in their first pregnancy, or retired businessmen. Leadership skills are used in conjunction with the small group process to promote a supportive atmosphere and to accomplish set goals. The interviewer guides the discussion according to a predetermined set of questions or topics. Major advantages of focus groups are their efficiency and low cost, similar to the community forum or town hall meeting format. A focus group can be organized to be representative of an aggregate, to capture community interest groups, or to sample for diversity among different population groups. One example is a research study involving Hmong youths and adults. Eight focus groups were held to determine perceptions of healthy diet and exercise among parents and children (Pham, Harrison, & Kagawa-Singer, 2007). Whatever the purpose, however, some people may be uncomfortable expressing their views in a group situation (Polit & Beck, 2007).
MODEL OF ASSESSMENT FOR AGREGTATES CHILDREN

Healthy children are a vital resource to ensure the future well-being of nations. They are the parents, workers, leaders, and decision makers of tomorrow, and their health and safety depend on today’s decisions and actions. Their futures lie in the hands of those people responsible for their wellbeing, including the community health nurse. The well-being of children has been a subject of great concern globally. Its importance has been emphasized through development of numerous laws and services, yet the needs of many children continue to go unmet. Many young children often go to bed hungry; some infants and toddlers do not receive even the most basic immunizations before they reach school age. Accidents and injuries are a leading cause of death; preventable communicable diseases increase mortality among the very young.

Global History of Children’s Health Care
Only recently in the history of the world have children been considered valuable assets, even in countries where there are now well-developed programs of infant health promotion and protection, infant and child day care services, and strict educational expectations for all children. Cultural practices that are fostered by political forces prevent many countries from improving the health of infants and young children.
The health of children in one country can affect that of children in other countries, including the United States. Major natural disasters place whole populations at risk, especially the very young and the very old. Examples include the severe acute respiratory syndrome (SARS) epidemic in 2003; the 2004 earthquake and tsunami that affected families from Sri Lanka, India, Indonesia, and Somalia to Thailand; and the Chinese earthquake of 2008

NATIONAL PERSPECTIVE ON INFANTS, TODDLERS, AND PRESCHOOLERS
The infant (birth to 1 year), toddler (ages 1 and 2 years), and preschooler populations (ages 3 and 4 years) are generally healthy, and most of them have a usual source of health care (96%). For children age 4 and younger, 87% were reported by their parents to be in excellent or very good health. The major causes of death among the 1- to 4-year-old population are unintentional injuries (motor vehicle crashes, falls, drowning, fires, and burns), followed by birth defects and cancer. Assault (homicide) and diseases of the heart are also among the five leading causes of death for this age group.

Accidents and Injuries
Toddlers and preschoolers are vulnerable to many types of accidents and unintentional injuries, such as those caused by unsafe toys, falls, burns or scalding, drowning, motor vehicle crashes, and poisonings. These injuries may result in death or significant disability. The loss of children’s lives resulting from all injuries combined represents a staggering number of years of productive life lost to society.

Suffocation is the leading cause of death in infant, are related to either prone sleeping position, wedging between the wall and mattress, soft bedding or sleeping surface obstructing the nose and mouth, head entrapment, hanging, and “overlaying by another person”. 

Infants and toddlers are at risk of falling when they are not adequately supervised. Falls are a leading cause of nonfatal injuries and hospitalizations for infants, toddlers, and preschoolers. Falls from stairs, a bed, or other furniture can cause permanent injury or death. As the infant grows and learns to walk, frequent falls are common and continuous supervision and childproofing the home are essential activities. Pointing out to parents the potential dangers related to falls and teaching them about effective preventive measures they can take (e.g., window guards, dangers of infant walkers) are viable means of preventing serious injuries. Young children are curious, and their explorations can lead to injuries from other sources (e.g., burns, drowning, poisoning).

Burn injuries can affect children of all ages.  Spilled hot liquids or foods cause most scald burns for 6 month olds to 2 year olds. Bath water that is too hot can also cause serious scalding injuries. Scalding is the most common cause of burns requiring hospitalization in toddlers. Infants are often burned by touching a parent’s cigarette or by reaching for a cup of hot coffee or the handle of a pot on the stove. A crawling or toddling child can pull an iron cord causing the iron to topple on him, resulting in a burn or injury. Electrocution can result from inserting a finger or toy into an electrical outlet. Young children playing with lighters and matches often cause house fires; proper installation and maintenance of smoke alarms help to prevent deaths and injuries. Cigarette lighters and matches are fascinating to young children. Toddlers or preschoolers may be able to start a flame, injuring or killing themselves or others. The sound of a smoke alarm may frighten young children, and it is important for community health nurses to instruct parents not only to teach their young children about fire prevention, but also to be aware of the sound of the alarm and know what actions to take when they hear it.

Injuries and deaths from motor vehicle crashes continue to be a major safety problem. Poisoning is a constant safety concern for young children, and toddlers are most often at risk. Poisoning is one of the leading causes of injury-related hospitalization in this age group.

Childproofing the home to eliminate major sources of poisoning is the best way to keep children safe. This includes keeping plants out of a child’s reach or eliminating them from the home until the child is older, locking up household chemicals (e.g., toilet bowl cleaner, bleach, mouthwash, oven and drain cleaners, pesticides, gasoline, paint thinner, hair products) and storing them out of a child’s sight and reach, using childproof medication containers, and storing all medicines in a locked box with a key that is kept out of reach.

Child Maltreatment
Child abuse is the maltreatment of children, which may include any or all of the following: physical abuse, emotional abuse, neglect (physical, medical, or educational), and sexual abuse (including sexual exploitation and child pornography). The problem is often difficult to detect and is underreported. One example of an often-overlooked form of abuse is shaken baby syndrome. Shaken baby syndrome, suspected in infants or toddlers who exhibit traumatic brain injuries caused by violent shaking or impact, is characterized by a triad of symptoms: retinal hemorrhage, subdural hemorrhage, and/or subdural hemorrhage with few signs of external trauma. 
 
 
Child abuse is seldom the result of any single factor, but rather a combination of chaotic environments, stressful situations, and parents who have difficulty coping with problems and stress. Risk factors for child maltreatment are found in four areas:

1.    Parent or caregiver behaviors
2.    Family characteristics
3.    Child factors
4.    Environment

Parental factors may include personality characteristics that include an external locus of control and poor self-esteem, along with problems with impulse control and antisocial behavior. Depression and anxiety may also play a role, and about one third of parents who had a childhood history of abuse or neglect will go on to maltreat their children. Substance abuse is a factor in roughly one-third to two-thirds of child abuse and neglect cases. Alcohol and drug abuse often lead to neglect, as parents use money meant for household expenses on substances. Little knowledge of normal child development can result in unrealistic expectations. Holding negative attitudes toward their children, viewing them as property, exhibiting harsh parenting styles and verbal aggression, not knowing how to handle children’s behaviors, and being easily frustrated are parental characteristics that have also been associated with risk of child maltreatment. Young parental age is also a factor, although this may be because it is also associated with poverty, lower levels of social support, and higher levels of stress.

Family characteristics that include domestic violence and marital conflict, financial stress and unemployment, and social isolation may lead to increased risk of child maltreatment. Children living with single parents (most often mothers) are at higher risk of physical and sexual abuse, as well as neglect; they are also more likely to live in poverty. Single parents have the sole caretaker burden and experience more stress than parents who have joint responsibilities.  Families at high risk for child abuse may be those that are either chronically troubled or temporarily stressed.

Children with difficult temperaments or behavior problems, or whose parents perceive them to have problems, could be at greater risk of abuse or neglect, but some research has noted that these child characteristics are probably less significant than negative parental attitudes.

The environment can play a part, along with parental, family, and child factors, in determining risk for child abuse and neglect. Parents who maltreat their children have reported more loneliness, greater isolation, and lower levels of social support. Social isolation may indicate a lack of positive role models to help them better understand parenting and the consequences of child maltreatment. Unemployment, poverty, and neighborhood factors such as crime, violence, and substance use play a part in the stress placed on families. Strong, significant relationships have been found between unemployment, poverty, and child maltreatment, especially child neglect.

Communicable Diseases

Infants, toddlers, and preschool-aged children experience a high frequency of acute illnesses, more than any other age group. Common types of acute conditions seen from birth to age 5 include fever, respiratory infections (including ear infections, colds, influenza), conjunctivitis (pink eye), and gastrointestinal problems. Communicable diseases are prevalent in these age groups, as very young children are building an immune system and are just beginning to come in contact with a greater number of people outside their families. 

Public health nurses should inform parents of the dangers and suggest safer interventions that  may help alleviate symptoms, such as use of a bulb syringe and saline nose drops, a cool-mist humidifier, or petroleum jelly under the nose.

Bronchiolitis is the most common type of lower respiratory infection among infants. It is the leading cause of hospitalization in this age group. The majority of hospitalizations for bronchiolitis are for infants 6 months and younger.  As with older children and adults, air pollution may make infants and children under age 5 more susceptible to bronchitis and other respiratory illnesses. Preschool-age children are thought to be especially “vulnerable to air pollution- induced illnesses”. Public health nurses can inform families who live in areas where air pollution is significant to take the necessary precautions.

Vaccines are one of the greatest achievements of public health. Example the vaccine-preventable diseases of mumps, pertussis, tetanus, and diphtheria, hepatitis A and B, Haemophilus influenzae type B (HiB), and varicella. Public health nurses and other health professionals are encouraged to provide parents of very young children with meaningful stories of preventable deaths due to these diseases, and to “defend our beliefs . . . more strongly” rather than relying solely on dispassionate facts and figure.

Chronic Diseases
Infants and young children can be afflicted with chronic diseases that affect their quality  of life. For instance, the most common chronic disease in early childhood is dental caries, which is five times more common than asthma. 

Asthma symptoms may begin in infants and toddlers. Asthma is considered by some to be the most common chronic disease of childhood. Public health nurses can assist families in finding appropriate health care providers and encourage proper administration of asthma medications and treatments. They can also teach families to reduce the presence of asthma triggers in their homes.

Autism is a developmental spectrum disorder that is often first noticed in toddlers. Parents become aware that the child’s communication and interaction with others is different, and that the child may also display obsessive and narrow interests. What causes autism is unclear, but some theories suggest faulty early neural patterning and overgrowth as a possible explanation. Families may need to be referred to early educational intervention programs and social services agencies for assistance.

Sickle cell anemia, an inherited blood disorder. The characteristic chronic and severe anemia is common in young children with this condition, and it can affect memory, learning, and behavior. When both parents have the genetic mutation, the newborn will be afflicted with the disease. Those with the sickle cell trait have no symptoms of the disease, but can pass it on to their offspring. In many states, routine newborn screening for sickle cell anemia is offered. Because sickle cell anemia can lead to splenic sequestration (or pooling of blood in the spleen), many children have either nonfunctioning spleens or have had them surgically removed. Risk of infection is always a concern when this occurs before age 5. Public health nurses working with populations at risk for this disease can educate and refer families for diagnosis and treatment.

The incidence of food allergies is increasing in the population. Infants with close family members who have atopic diseases are at risk for development of allergies. Prolonged breast-feeding for 1 year is recommended for these infants, or the use of hypoallergenic infant formula, and delayed introduction of solid foods is also important: i.e., dairy foods after age 1, eggs after age 2, nuts and fish after age 3. Fortunately, once allergies are diagnosed, they can be managed through dietary changes and by avoidance of allergy producing foods. Parents need to be educated, so that they can consistently read food labels and alert family members to the young child’s allergy so that inappropriate foods are avoided. Other chronic illnesses can have a profound effect on child and family.

Poor Nutrition and Dental Hygiene
Other health problems found in the birth to preschool age group include nutritional problems (underfeeding or overfeeding, overeating, and inappropriate food choices) and poor dental health. Nutritional and dental health needs are great during this period of rapid growth. Many factors contribute to early nutritional and dental problems. A healthy start is foundational to well-being later in life. Nutrition is basic in strengthening this foundation. 

Public health nurses can encourage pregnant women to consider the benefits of breast-feeding their infants carefully, and provide education and interventions to assist them with the most common barriers: concern about insufficient supply of breast milk, problems with the baby latching onto the breast, painful nipples, and scheduling problems. The community health nurse can join with labor and delivery nurses and lactation consultants in promoting breast-feeding among mothers in the community. Nurses can lobby local hospitals to educate new mothers about the benefits of breast-feeding and stop the routine distribution of free samples of infant formula. Overfeeding of an infant can lead to childhood obesity and becomes a risk factor for heart disease, hypertension, and diabetes.  The most common sources of energy and nutrients for infants and toddlers are breast milk, formula, and milk. For toddlers, juices and fruit-flavored juice drinks are the next two sources of nutrition. Fortified foods (e.g., grain-based foods with added vitamin A, folate, and iron) become increasingly more significant in diets of toddlers, as do supplements (multivitamins). 
 
Dieticians recommend feeding older infants and toddlers a “wide variety of fruits, vegetables, and whole grains, as well as food naturally rich in iron”.  Public health nurses can encourage parents to continue to introduce new healthy foods to their toddlers and not give up or give in too soon. Home visiting programs that promote fruit and vegetable consumption in preschoolers have been shown to be effective in increasing the number of servings for both children and parents. Young children’s diets, often unreasonably high in sugar, increase the incidence of dental caries in this population group. The combination of sugar, bacteria that cause dental disease, and the composition of the teeth determines the severity of dental caries.

HEALTH SERVICES FOR INFANTS,TODDLERS, AND PRESCHOOLERS
A variety of programs that directly or indirectly serve the health needs of very young children may be found in most communities. Community health nurses play a major and vital role in delivering these services. In community health, programs fall into three categories, which approximate the three priorities of public health nursing practice: prevention, protection, and promotion.
Preventive Health Programs
Neighborhood community centers found in urban and rural settings provide families with parenting education, health and safety education, immunizations, various screening programs, and family planning services. In some areas, nurse run clinics are established at local schools or community centers to assist in outreach services to the community. Community health nurses, in collaboration with an interdisciplinary team, are often the primary care providers in these programs. The major goals are to keep communities healthy by focusing on primary and secondary prevention services. Three examples of preventive health programs for infants and young children are immunization programs, parent training programs, and quality day care services.
Immunization Programs
Health departments, community clinics, and private health care providers continue to offer immunizations against the major childhood infectious diseases—measles, mumps, rubella, varicella, polio, diphtheria, tetanus, pertussis, Hepatitis A and B, and HiB—some of which can cause permanent disability and even death. Pneumococcal, meningococcal, and influenza vaccines are also recommended, as is the vaccine for rotavirus. Many of these diseases no longer plague infants and children, and newer vaccines offer even greater promise of health. Pneumococcal conjugate vaccine has been associated with reductions in the incidence of otitis media and insertion of pressure-equalizing tubes in children under age 5, resulting in reduced expense for antibiotic prescriptions and ambulatory medical visits.

Parent Training Programs
Parent education and training programs have been useful in providing parents with the tools needed to deal with the stresses and challenges of parenting effectively. A meta-analysis of 77 program evaluations revealed that effective programs consist of teaching parents to use time-out rather than corporal punishment as a means of discipline; promoting consistency in discipline; encouraging emotional communication skills and positive parent–child interaction; and requiring that parents practice these skills during classroom sessions.
Quality Day Care and Preschool Programs
Quality child care provides a significant avenue for preventing illness and injury among young children.  Quality preschool program attendance can provide children with language and pre-academic skills that may lead to better learning outcomes in kindergarten. Head Start, a federally funded program that offers early childhood education to low-income children between ages 3 and 5, has consistently demonstrated significant improvements in preschoolers’ social-emotional and cognitive development, and those attending Head Start do better on several developmental measures than children who did not attend Head Start. Head Start children are also more likely to receive dental and health screenings, to have up-to-date immunization coverage, to have better school attendance, and to be less likely to be held back in school.  Community health nurses can influence the quality of day care and preschool programs through active educational efforts, monitoring of health and safety standards, and working to improve the state’s role in passing stronger licensing laws.

Health Protection Programs
Health protection programs for infants and young children are designed to protect them from illness and injury. Ultimately, these programs may even protect their lives.

Safety and Injury Protection
Accident and injury control programs serve a critical role in protecting the lives of children. Efforts to prevent motor vehicle crashes, a major cause of death, may include driver education programs, better highway construction, improved motor vehicle design and safety features, and continuing research into the causes of various types of crashes. Programs that provide training, education, and child safety seats have been shown to improve child safety seat use.

Protection from Child Abuse and Neglect
Services to protect children from abuse are not as well developed or effective as safety and injury prevention programs, an observation accounted for by a variety of factors. Most child abuse occurs in the home, so only the most blatant situations become evident to outsiders. Community health nurses and physicians who see injured children may find parents’ explanations plausible and may not suspect or want to believe that abuse might be responsible.  Most professionals adopt the levels of prevention model to describe child abuse and neglect prevention efforts.
Primary Prevention
Primary prevention measures include the use of public service announcements that promote positive parenting, family support groups, and public awareness campaigns about child maltreatment and how to report it, along with establishing community education to enhance the general well-being of children and their families.
Secondary Prevention
Services are designed to identify and assist high-risk families to prevent abuse or neglect. High-risk families are those families that exhibit the symptoms of potentially abusive or neglectful behavior or that are under the types of stress associated with abuse or neglect. These can include families living in poverty, exhibiting substance abuse or mental health problems, and parents or children with disabilities.
Tertiary Prevention
Intervention and treatment services are designed to assist a family in which abuse or neglect has already occurred, so that further abuse or neglect may be prevented and the consequences
of abuse or neglect may be minimized. Often, families are referred to mental health counselors for “intensive family preservation services” to improve family communication and functioning. The effectiveness of local programs depends, in large measure, on the willingness of community health professionals to increase their awareness and work as a team to detect, report, and develop interventions for the perpetrators and victims of abuse and neglect. Ongoing education of health care providers is recommended to increase awareness of changing child abuse patterns, new reporting laws, and resources available to families.

ROLE OF THE COMMUNITY HEALTH NURSE
Community health nurses face the challenge of continually assessing each population’s current health problems, as well as determining available and needed services. The role of community health nurses include providing interventions to serve young children’s health needs, such as educational interventions for the young child that include nutrition teaching to provide information and encourage parents to act responsibly on behalf of their children to assist in healthy habit formation for a lifetime. Other interventions involve encouraging age-appropriate immunizations or cessation of smoking during pregnancy, and PHNs may employ persuasive tactics to move clients toward more positive health behaviors. With reporting and intervening in child abuse, nurses practice a form of coercion to protect children from threats to their health.

NURSING PERSPECTIVE FOR SEXUALITY DISORDERS

6:20 PM Add Comment
    Sexuality broadly refers to all aspects of being sexual and is one dimension of the personality .

It include more than the act of intercourse and is an integral part of life. it is evident in the person’s appearance and in beliefs, behaviors, and relationships with others. Four aspect of sexuality are as follows:
 

  1.     Genetic identity, which is a person’s chromosomal gender
  2.     Gender identify, which is s person’s perception of his or her own maleness or femaleness
  3.    Gender role, which is the cultural role attributes of one’s gender, such as expectations regarding behavior, cognitions, occupations, values, and emotional response
Sexual orientation, which is the gender to which one is romantically attracted. Accepting a  broad concept of sexuality allows nurse to explore ways in which people are sexual being and understand more fully their feeling, beliefs, and actions, Nurses are often called on to intervene in the sexual concerns of patients when providing holistic patient care. Therefore it is important to develop skill and competence in addressing sexual issues by increasing awareness through education.
Self-awareness of the nurse
The nurse’s level of self-awareness is a critical component of discussions with patient regarding sexual issues .the first step in developing self-awareness involves clarification of values regarding human sexuality .

Cognitive dissonance:
The first phase of growth in developing sexual self-awareness is cognitive dissonance, which arises when two opposing beliefs exits at the same time E.g. nurses grow up learning what society
Family and friends believe about sexual issues.

Anxiety:
Most people think that anxiety is a negative emotion. However a mild level of anxiety can be positive because it can promote an awareness of danger, give extra energy, or stimulate professional growth by creating enough discomfort to initiate some type of action. In this second
Phase, the nurse realizes that uncertainty , questions ,and problems regarding sexuality are normal ,the nurse begins to understand that everyone is capable of a variety of sexual feeling and behaviors and that anyone can have a sexual dysfunction or question sexual identify

Anger:
Anger generally arises after anxiety ,fear ,and shock subside, it is generally self-directed or directed  toward the patient or society.th nurse begins to recognize that issues associated with sex or sexuality are emotional and sometimes highly volatile, rape , abortion, birth control, equal rights. child abuse , pornography, and religious issues all are related to sexuality and give rise to controversy and debate. This  realization often breeds anger and contempt in the nurse , E.g. The nurse may become angry at a colleague or a friend who makes judgmental remarks about pro-life or pro-choice activities,
Action:
The final step in the growth experience is the action phase. Several  behaviors emerge during this final phase of the growth experience ;data inquiry , choosing values ,and prizing values
Data inquiry occurs when the nurse seeks out additional information about sexual issues. Once  the information is obtained, the nurse may discuss and deciding what to believe ,and the nurse will eventually make some choice about a value position.

Assessment
Any basic health history must include question about sexual history . A nurse who is comfortable discussing sexuality conveys the message that it is normal to talk about sexual health in a health assessment interview, if nurse can be composed and professional ,they can ask questions about patient’s sexual  health naturally .the patient can then discuss sexual matters openly and without embarrassment
The time and number of question needed to discuss a problem very depending on the patient .often just a few questions during an interview will obtain the relevant information. Examples of questions nurse may ask related to a patient’s sexual health include the following;
  1. tell me what you understand about ( menstruation, intercourse, sexual changes with aging, menopause)
  2. since you have been diagnosed what questions have you had regarding your sexuality?
  3. are there any changes you have noticed in your sexual patterns since becoming ill?
  4. have you noticed any differences or problem in your sexual responses since taking this medication?
  5. often people have question about (masturbation, sexual frequency, safe sex, alternate position)
  6. sometimes it is uncomfortable to talk about sexual issues with your partner how is this for you and you partner?
Behaviors;
There are many modes of sexual expression. In a classic work, Kinsey (1953) suggested that most people are not exclusively heterosexual or homosexual. His  studies indicated that  substantial percentage of men and women had experience both heterosexual and homosexual activity.
Heterosexuality;
Heterosexuality can be defined as sexual attraction to members of the opposite sex, it is the predominant sexual orientation among people in American society the coupling of a man and a woman in a sexual partnership has both legal and religious sanctions, such as  it influences the culture ,values, and norms of contemporary American life.
Homosexuality;
Homosexuality can be defined as sexual attraction to members of the same sex. The term gay is used to refer to both male and female homosexual. However  some use the term to refer only to male homosexuals and use the term lesbian to refer to female homosexuals
Bisexuality;
Bisexuality is defined as a sexual orientation or attraction to both men and women .bisexuality can be view from different perspectives .someone believe that it is a distinct sexual orientation
Insert  in the behavior and characteristic of bisexual men has increased in light of the acquired immunodeficiency syndrome epidemic and the need to design effective preventive interventions for HIV infection.
Transexualism ;
The term transsexual simply implies going from one sex to another transsexual is a condition in which one has a profound discomfort with his or her own sex and a strong and persistent identification with the opposite gender. a transsexual is an individual with a gender identity disorder.

Selected nursing diagnoses
  1. ineffective sexual pattern related to conflicting sexual feeling ,as evidenced by verbalization of confuse and happiness
  2. risk for self-directed violence related to sexual identity confusion, as evidenced by suicide attempt.
The sexual response cycle;
In addiction to modes of sexual expression or sexual orientation ,the physiological and psychological response to sexual stimulation also can be described the four stages of the sexual response cycle are desire, excitement , orgasm, and resolution.
The most common problem for women are;
  1. lack of orgasm
  2. vaginism
The most  common problem for men are;
  1. erectile dysfunction
  2. ejaculatory disorders
Stages of the sexual response cycle;
Stage1;desire;
sexual fantasies and desire for sexual activity
Stage2;Excitement,
subjective sense of sexual pleasure along with physiological changes ,including penile erection in the male and vaginal lubrication in the female
Stage3;orgasm,
peaking of sexual pleasure and the release of sexual tension accompanied by rhythmic contraction of the perineal muscles and pelvic reproductive organs
Stage4;resolution,
sense of genital relaxation, muscular relaxation, and well-being

predisposing factor;
biological ; biological factors are initially responsible for the development of gender, that is whether a person is genetically male or female
psychoanalytical; freud saw sexuality as one of the key forces of human life. In  three essays of the theory of sexuality he proposed that sexuality began before puberty and that sexuality during infancy was central to personality development. He also believed that a person’s choice of sexual expression depended on a mix of heredity, biology, and social factor
behavioral;for the behaviorist sexual reaction are the observable response to Evert, measurable stimuli, behaviorists are not concerned with the instraphycic process of early childhood and adolescence; rather, they view sexual behavior as a measureable physiological and psychological response to a learned stimulus or reinforcement event.

Precipitating stressors
physical illness and injury;
Physical illness may alter sexuality nurse often care for patients with sexual dysfunctions quality or altered sexuality patterns, they need to discuss and therapeutically intervene in patient’ responses to these change.
psychiatric illness
Psychiatric illness affects a person’s sexuality as well as the  sexual behavior and satisfaction of the person’s partner although having a psychotic illness such as schizophrenia does not imply sexual dysfunction. The patient may not be able to understand or control sexual thoughts o impulse for example a patient may openly masturbate on an inpatient unit or inappropriately touch othees.

medication
Some medication contribute to sexual dysfunction ,and nurse need to be knowledge about the medication they administer, the index of medication that can create sexual side effect continues to grow ,these medications, which may include antihypertensives, antihistamines etc. often the medication itself or the dosage can be changed to correct the problem. Abuse  of alcohol or no therapeutic drugs also may have a debilitating effect on sexuality.
HIV/AIDS
Fear of contracting a sexually transmitted disease (STD) may create change in sexual behavior ,the most frightening STD is acquired immune deficiency syndrome(AIDS).HIV is a leading worldwide health problem despite the attempts by health care  professionals to educate society about safe sex practice. These  practice include the following;
  1. using condoms
  2. reducing the number of sexual partner
  3. promoting sexual behavior that decrease the exchange of body fluids
  4. the aging process
In the past researchers suggested that sexual activity decreased with aging. More  recent studies indicate that pattern of sexual activity remain stable over  middle and late adulthood years with only a small decline in later life .one important variable affecting  sexuality in older adults is the lack of knowledge about the normal change that occur with the aging process. Psychological  factors, such as self-esteem, also can influence sexual activity in older adults. older adults may be less inclined to be sexually active if they believe the physical change that occur with aging make them unattractive.
appraisal of stressor
Feeling of oneself as a sexual being change throughout the life cycle and they are influenced by a person’s appraisal of the stressful situation. Sexual l identity cannot be separated from self-concept or body image
coping resources
it is important for the nurse to assess the patient’s coping resource because these can have a significant impact on sexual health. resource may include the person’s knowledge about sexuality, positive sexual experience the patient has had in the past
coping mechanisms
Coping mechanism related to sexual response may be adaptive or maladaptive ,depending on how and why they are being used. Fantasy is a coping mechanism used to enhance sexual experience, men and women may escape to erotic fantasies with unknown loves during sex with their spouse .although many people fear that fantasies about people other than their sexual partner indicate that they are unsatisfied or unattached to their partner /this is typically not the case. fantasies are often a creative way to increase sexual excitement and enjoyment and do not usually indicate dissatisfaction with a current partner ,however excessive fantasy can be maladaptive when used as a replacement for actual sexual expression or yhe development f intimate relationships with others.






                    

NURSING CARE FOR PATIENTS WITH PNEUMONIA

2:16 AM Add Comment
Pneumonia is one of important disease that occur to the patient with so many factors. There is include of medical surgical nursing that necessary for appropriate nursing treatment. Now days pneumonia that divide become several types need different treatment that as nurses we have to know the based knowledge about it to prevent pneumonia before and to help the healing process. 

The definition of pneumonia
Pneumonia is an acute inflammation of the lung parenchyma caused by a microbial organism.
The  etiology of pneumonia
Normal defense mechanism, normally, the airway distal to the larynx is sterile becouse of protective defense mechanisms.these mechanisns include the following : filtration of air, warning and humadification of inspired air, epligotis closure over the trachea, cough reflex, mucociliary escalator mechanism, secretion of immunoglobulin A and alveolar macrophages.

Factor predisposing to pneumonia. Pneumonia is more likely to result when defense mechanism become incompetent or at overwhelmed by the virulence or quantity of infectious agents.Decreased consciousness depresses the cough and epligottal reflexes, which may allow aspiration of oropharyngeal contents into the lungs. 

Tracheal intubation interferes  with the normal cough reflex and the mucociliary escalator mechanism. It also bypasses the upper airways, in which filtration and humidification of air normally take place. The mucociliary mechanism is impaired by air pollution, cigarette smoking, viral upper respiratory infections (Urls), andnormal changes of aging. In cases of malnutrition, the function of lymphocytes and  and polymorphonuclear (PMN)  leukocites are altered. 

Diseases such as leukimia,alcoholism and dibetes mellitus are assotiated with an increased frequency og gram-negative bacili in the oropharynx.(gram negative bacili are not normal flora in the respiratory tract). Altered oropharyngeal flora can also occur secondary to antibiotic therapy given for an infection elsewhere in the body.The factors presdiposing to pneumonia are:

  1. Aging
  2. Air pollution
  3. Altered consciousness:alcoholism,head injury,seizures,anesthesia, drug overdose, stroke
  4. Altered oropharyngeal flora secondary to antibiotics
  5. Bed rest and prolonged immobility
  6. Chronic disseases: chronic lung disease, diabetes mellitus,heart disease,cancer, end-stage renal disease
  7. Debiliting illness
  8. Human immunodeficiancy virus (HIV) infection
  9. Immunosupressive drugs (corticosteroids, ancer chemotherapy,immunosuprressive therapy after organ transplant)
  10. Inhalation or apiration of noxious substances
  11. Intestinal and gastric feeding via nasogatric or nasoinstestinal tubes
  12. Malnutrition
  13. Smoking
  14. Tracheal intubation (endotraceal intubation,tacheostomy)
  15. Upper respiratory tract infection
  16. Acquistion of organism.organism that cause pneumonia reach the lung by three methods:
  17. Aspiration from the naopharynx or oropharynx.many of the organism that cause pneumonia are normal inhabitans of the pharynx in healthy adults
  18. Inhalation of microbes presentin the air.Examples include mycoplasma pneumoniae and fungal pneumonias
  19. Hematogenous spread from a primary infection elsewhere in the body. An example is staphylococcus aureus.
Types of pneumonia

Pneumonia can be couse by bacteria,viruses,mycoplasma fungi,parasites and chemicals.Althought pneumonia can be classified according to the causative organism, a clinically effective way is to classify pneumonia as comunity-acquired or hopspital-acquired pneumonia.classifying pneumonia is important becouse of differences in the likely causative organism and the selection of appropriate antibiotics.
Organisms associated with pneumonia
Community-acquired pneumonia
  1. Streptococcus pneumoniae
  2. Mycoplasma pneumoniae
  3. Haemophilus influenzae
  4. Respiratory virusses
  5. Chlamydia pneumophila
  6. Oral anaerobes
  7. Moraxella catarrhalis
  8. Staphylococcus auereus
  9. Nocardia
  10. Enteric aerobic gram-negative bacteria (e.g klebsiella)
  11. Fungi
  12. Mycobacterium tuberculosis
Hospital-acquired pneumonia
  1. Pseudomonas aeruginosa
  2. Enterobacter
  3. Escherichia coli
  4. Proteus
  5. Klebsiella
  6. Straphylococcus aureus
  7. Sterptococcus pneumonia
  8. Oral anaerobes
Community acquired pneumonia (CAP) is defined as a lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization.Smoking is an inportant risk factor. The causative organism is identified in CAP include S.pneumoniae (35%). H.influenza (10%) and atypical organism (e.g. legionella,mycoplasma,chlamydia viruses).

Once the patients is diagnosed with CAP, there are three step approach is recomended in initiating therapy
Assesment of the ability to treat the patient at home (e.g evaluate comorbidities,hemodynamic stability).

Calculation of the pneumonia PORT (pneumonia patient outcomes research team) severity index (PSI) with recomendations for home care and clinical judgment. This scale, produced by the agency for healthcare research and quality (AHRQ) is based on multiple factors and the score indicates the patients risk class
Clinician judgment in the final decision to treat, either as an outpatient in the hospital.

Hospital-acquired,ventilator-associated, and health care-associated pneumonia. Hospital-acquired pneumonia(HAP) is pneumonia occuring 48 hours or longer after hospital admission and not incubating at the time hospitalization.ventilator associated pneumonia (VAP) refers to pneumonia that occurs more than 48 to 72 hours after endotracheal intubation.Health care-associated pneumonia (HCAP) includes any patient with a new onset pneumonia who :
  1. Was hospitalized  in an acute care hospital for 2 or more days within 90 days of the infection.
  2. Resided in a long-term care facility
  3. Received recent intravenous antibiotics therapy,chemotherapy,or wound care within the past 30 days of the current infection.
  4. Attended a hospital or hemodialysis clinic.
Fungal pneumonia : Fungi may also be a cause of pneumonia
 
Aspiration pneumonia : refers to the sequelae occuring from abnormal entry of secretions or substances in to the lower airway. It usually follows aspiration of material from the mouth or stomach in to the tracea and subsequently the lungs. The person who has aspiration pneumonia usually has a history of loss of conciousness, the gag and cough reflexes are depressed , and aspiration is more likely to occur.Another risk factor is tube feedings. The dependent portions of the lung are most often affected, primarily the superior segments of the lower lobes and posterior segments of the upper lobes, which are dependent in the supine position.

Opportunisitic pneumonia.certain patients with altered immune response are highly susceptible to respiratory infections.individuals considered at risk include:
  1. Those who have severe protein-calorie malnutrition
  2. Those who have immune deficiencies
  3. Those who have received transplants and been treated with immunosupressive drugs
  4. Patient who are being treated with radiation therapy,cheotherapy drugs, and corticosteroids.
Pneumocytis jiroveci is an ooportunistic pathogen, this fungus rarely causes pneumonia  in the healthy individual.pneumocystis jiroveci pneumonia (PCP) has been identified as the most common acquired immunodeficiency syndrome (AIDS).

Clinical manisfestations are insidious and include fever , tachypnea , tachcardia , dyspnea , nonproductive cough and hypoxemia.
The pathofisiology of pneumonia
Pneumococcal pneumonia is the most common cause of bacterial pneumonia and is caused by the streptococcus pneumoniae organism.S.pneumoniae, also called pneumococcus can infect the upper respiratory tract, the blood and the nervous system. The organism is generally found in the nose and throat.When it invades  the lung,pneumonia can occur. 

The pathophysiology related to this type of pneumonia, there are four characteristic stages of the disease process:

Congestion, after the pneumococcus organism reach the alveoli, there is an outpouring of fluid in to the alveoli. The organisms multiply in the serous fluid, and the infection is spread.The pneumococci damage the host by their overwhelming growth and by interfering with lung function.

Red hepatization. There is massive dilation of the capillaries, and alveoli are filled with organisms,neutrophils, red blood cells (RBCs) and fibrin. The lung appears red and granular, similar to the liver, whic is why the process is called hepatization.

Gray hepatization.Blood flow decreases, and leukocytes and fibrin consolidate in the affected part of the lung
Resolution, complete resolution and healing occur if there are no complications. The exudatw becomes lysed and is processed by the macropages. The normal lung tissue is restored, and the persons gas exchange ability return to normal.
Pathways of Pathopysiologic course of pneumococcal pneumonia
Aspiration of S. pneumonia
V
V
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Release of bacterial endotoxin
V
V
V
V 
Inflammatory response(attraction of neutrophils, release of inflammatory mediators, accumulation of fibrinous  exudates, red blood cells and bacteria)
V
V
V
Red hepatization and consolidation of lung parenchyma
(leukocyte infiltration by neutrophils and macrophages),
V
V
V
Gray hepatization and deposition of fibrin on pleural surface, phagocytosis in alveoli
V
V
Resolution of infection, macropages in alveoli ingest and remove degenerated neutrophils, fibrin and bacteria.
The clinical manisfestation of pneumonia
The symptoms of pneumonia include fever, shaking chills, shortness of breath, cough productive of purulent sputum(rust-colored sputum can be seen in pneumococcal pneumonia, and pleuritic chest pain).

Pneumonia may also manifest a typically with a more gradual onset, a dry cough, and extrapulmonary manisfestation such as headache , myalgias , fatigue, sore throat, nausea, vomiting and diarrhea. On physical examination, crackles are often heard. This presentation of manisfestations is classically produced by M.pneumoniae but can also caused by legionella and C.pneumoniae.

The initial manisfestation of viral pneumonia are highly variable. Viruses also causes pneumonia that is usually characterized by an atypical presentation with chills, fever, dry, nonproductive cough, and extrapulmonary symptomps. Viral pneumonia is also found in association with systemic viral diseases such as measles, varicella-zoster and herpes simplex.
The complication of pneumonia
The complications may include the following :
Pleurisy (inflammation of the pleura) is relatively common.
Pleural effusion (transudate fluid in the pleural space) can occur. It develops in 40% of hospitalized patients with pneumococcal pneumonia. Usually the effusion is sterile and is reabsorbed in 1to 2 weeks, occasionally, effusions require aspiration by menas of thoracentesis.

Atelectasis(collapsed, airless alveoli) of one or part of one lobe may occur. These areas usually clear with effective coughing and deep breathing.

Bacteremia (bacterial infection in the blood ) occurs in 30% of patients with pneumococcal pneumonia and is associated with a 20 % mortality rate. The Rate can go as high as 60% in elderly patients.

Lung abcess is not common complication of pneumonia. It is seen with pneumonia caused by S.aureus and gran negative pneumonias .

Emphyema (accumulation of purulent exudates in the pleural cavity)is relatively infrequent (occurs in <5% of cases) but requires antibiotic therapy and drainage of the exudates by a chest tube or open surgical drainage.
Pericarditis result from spread of the infecting organism from an infected pleura or via a hematogenous route to the pericardium (fibroserous sac around the hearth).

Meningitis can be caused  by S.pneumoniae. The patient with pneumonia who is disoriented ,confused, or somnolent should have a lumbar puncture to evaluate the possibility of meningitis.

Endocarditis, can develop when the organisms attack the endocardium and the valves of the heart. 

 The management of pneumonia
Diagnostic
  1. History  and physical examination
  2. Chest X-ray
  3. Gram stain of sputum
  4. Sputum culture and sensitivity testing (if drug-resistant pathogen or organism not covered by empiric therapy)
  5. Pulse oximetry or ABGs (if indicated)
  6. Complete blood count, differential and routine blood chemistries (if indicated)
  7. Blood  cultures (if indicated)
  8. Collaborative therapy :
  9. Appropriate antibiotic therapy
  10. Increased fluid intake
  11. Limited activity and rest
  12. Antypiretics
  13. Analgesics
  14. Oxygen therapy (if indicated)
  15. Chest X-ray often shows a typical pattern characteristic of the infecting organism and is invaluable in the diagnosis of pneumonia. Lobar or segmental consolidation suggest a bacterial cause, usually S.pneumoniae. Caviatary shadows suggest the presence of a necrotizing infection with destruction of lung tissue commonly caused by S.aureus, gram negative bacteria and M. tuberculosis. Pleural effusions, which can occur in up 30% of patients with CAP, can also be seen in X-ray.
  16. Sputum gram stain and cultures are not always obtainable. The interpretation of a gram stain is not standardized, and atypical pathogens are missed. however, obtaining a lower respiratory tract sputum specimen for culture is recommended before initiating antibiotics therapy in the hospitalized patient.
  17. Pulse oximetry  is measured routinely and can reveal oxygen desaturation, arterial blood gases (ABGs) may be obtained and can reveal hypoxemia.
Collaborative care
  1. Pneumococcal vaccine, is indicated with individual that are considered at risk who :
  2. Has chronic illnesses such as lung and hearth disease and diabetes mellitus
  3. Is recovering from a severe illness
  4. Is more 65 years old of age
  5. Is in long term care facility.
  6. Drug therapy
  7. The main problem with the use of antibiotics in pneumonia are the development of multidrug-resistant (MDR) organism and the patient’s hypersensitivity or allergic reaction to certain antibiotics.   
  8. Most cases of CAP in otherwise healthy adults to do not require hospitalization. The oral antibiotics therapy administered is frequently empiric treatment with broad-spectrum antibiotics. The ampiric antibiotics regimen needs to be adapted to the local patterns of antibiotics resistance.   
  9. When using empiric therapy, it is important to recognize  the nonresponding patient. Therapy may require modification based on the patient’s sputum culture results or clinical response.Clinical response is evaluated by factors such as a change in fever,sputum purulence,leukocytosis, oxygenation, and chest X-ray patterns.
  10. Nutritional therapy
  11. Fluid intake of at least 3 L/day is important in the supportive treatment of pneumonia. If the patient has hearth failure, fluid intake must be individualized. If oral intake can not be maintained, intravenous (IV) administration of fluids and electrolytes may be necessary for the for the acutely ill patient.
  12. Weight loss often occurs in patients with pneumonia because of increased metabolic needs and difficulty eating due to shortness of breath and pleuritic pain. Therefore it is important to provide nutritional intake to meet the needs of the patient. Small,frequent meals are better tolerated by the dypneic patient.
The nursing process


Nursing  assessment
Subjective  and objective data that should be obtained from a patient with pneumonia are preseated  
subjective data
Important health information.

Past health history:lung cancer , GOPD diabetes mellitus,chronic debilitating disease, malnutrition ,altered consciousness, AIDS , exposure to chemical toxins,dust,or allergens.

Medication: use of antibiotics , corticosteroids , chemotherapy or any other immunosuppressants.

Surgery or other treatment: recent abdominal or thoracic surgery splenectomy,endotracheal intubation,or any surgery with general anesthesia :tube feeding.
Functional health patterns.
Health perception-health management:cigarette smoking,alcoholism,recent upper respiratory tract infection,malaise.

Nutritional-metabolic : anorexia , nausea , vomiting , chills.

Activity-exercise : prolonged bed rest or immobility , fatigue , weakness , dyspnea , cough , nasal congestion
Cognitive-perceptual: pain with breathing , chest pain , sore throat , headache , abdominal pain , muscle aches.
Objective data
General;  fever ,restlessness or lethargy;spling of affected area.

Respiratory: tachypnea , pharyngitis , asymmetric chest movements or retraction, decrease excursion , nasal flaring , use of accessory muscles , grunting , crackles , friction rub on auscultation , dullness on percussion over consolidated areas , increased tactile fremitus on palpation , pink , rusty, purulent, green, yellow or white sputum .

Cardiovascular tachycardia.

Neurologic changes in mantal status,ranging from confusion to delirium.

Possible finding leukocytosis abnormal ABGs with or normal PaCO2 , PaCO2,and pH initially,and later PaO2, PaCO2 and pH ,positive sputum gram stain and culture,patchy or diffuse infiltrates abscesses,pleural effusion or pneumothorax on chest x-ray.


Nursing diagnoses.
Nursing diagnoses for patient with pneumonia may include but are not limited to: Nursing diagnosis ineffective breathing pattern related to inflammation and pain as evidenced by dyspnea,tachypnea,nasal flaring,altered chest excursion.
Patient goal  demonstrates an effective respiratory rate,rhythm,and depth of respirations.
Outcome(NOC)    
  1. Respiratory status: ventilation
  2. Respiratory rate
  3. Respiratory rhythm
  4. Ease of breathing
  5. Symmetrical chest expansion
Measurement scale
1=severely compromised
2=substantially compromised
3=moderately compromised
4=mildly compromised
5=not compromised   
DO :
  1.  Ventilation assistance
  2. Monitor respiratory and oxygenation status to determine change in status
  3. Position to minimize respiratory effort to reduce oxygen needs
  4. Encourages slow deep breathing ,turning and coughing to promote effective breathing pattern
  5. Monitor for respiratory muscle fatigue to provide additional support if needed
  6. Initiate and maintain supplemental oxygen to improve respiratory status
  7. Administer medications that promote airway patency and gas exchange
                                                                                                                                                             Nursing diagnosis ineffective airway clearance related to retained secretion and excessive mucus as evidenced by ineffective cough.adventitious breath sounds dyspnea.

Patient goal
  1. Demonstrates effective coughing and increase air exchange
  2. Experiences normal breath sounds
Outcome (NOC)   
  1. Respiratory status: airway patency
  2. Respiratory rate
  3. Ease of breathing
  4. Moves sputum out of airway
Measurement scale
1=severely compromised
2=substantially compromised
3=moderately compromised
4=middly compromised
5=not compromised     Airway management
DO
  1. Auscultate breath sounds, nothing areas of decreased/absent ventilation, and presence of adventitious sounds to obtain ongoing data on patient’s response to therapy
  2. Remove secretions by encouraging coughing or by suctioning to clear airway
  3. Regulate fluid intake to optimize fluid balance and liquety secretions.
  4. Cough enhancement
  5. Assist patient to a sitting position with head slightly flexed, shoulders reflaxed, and knees flexed to improve respiratory status
  6. Instruct patient to inhale deeply several times, to exhale slowly, and to cough at the end of exhalation to promote effective coughing
  7. Encourage use of incentive spirometry to aid in lung expansion and prevent atelectasis.
The conclusion are :
  1. Pneumonia is an acute inflammation of the lung parenchyma caused by a microbial organism.
  2. The factors presdiposing to pneumonia are: Aging,Air pollution,Altered consciousness:alcoholism,head injury,seizures,anesthesia, drug overdose, stroke,Altered oropharyngeal flora secondary to antibiotics,Bed rest and prolonged immobility,Chronic disseases: chronic lung disease, diabetes mellitus,heart disease,cancer, end-stage renal disease,Debiliting illness,Human immunodeficiancy virus (HIV) infection,Immunosupressive drugs (corticosteroids, ancer chemotherapy,immunosuprressive therapy after organ transplant),Inhalation or apiration of noxious substances,Intestinal and gastric feeding via nasogatric or nasoinstestinal tubes,Malnutrition,Smoking,Tracheal intubation (endotraceal intubation,tacheostomy),Upper respiratory tract infection.
  3. The symptoms of pneumonia include fever, shaking chills, shortness of breath, cough productive of purulent sputum(rust-colored sputum can be seen in pneumococcal pneumonia, and pleuritic chest pain).
SUGGESTION
  1. Learning about pneumonia the basic ones is the importance one material that should be understand by nurse to take solution if find patient with problem pneumonia. Need more sources to write this paper better.
BIBLIOGRAFI
  1. Lewis,Brien,Dikse, et al.2007. Medical Surgical Nursing 7th edition assessment and management clinical problems international edition. US. Evolve
  2. Greganti Andrew,Marshall R Runge et al.2005. Netters internal medicine. New Jersey. Icon learning system-teterboro

NURSING MANAGEMENT : Patient Care Delivery System

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One important function of the professional nurse at the first line management position of nursing service department is organizing the activities of the staff into a workable pattern to meet patient needs. She/he should establish effective relationships between the activities to be performed, the workers to perform them.
Assignment
Assignment refers to “a written delegation of duties to care for a group of patients by trained personnel assigned to the unit.”

Purposes of assignment: 

  • To delegate the work to be done to the nursing personnel.
  • To gain the cooperation of the nursing personnel by knowing and accepting the acceptance of the work to bedone.
Principles of personnel assignment: 
  1. Made by the head nurse or nurse in charge for each individual nurse.Based on :
  2. Nursing needs of each patient and approximate time required to care for him.
  3. The capabilities, skill level, previous experience and the interest of the staff members.
  4. Job description.
  5. Planned weekly, and revised daily if necessary to assure continuity of care.
  6. Take into account all the direct , indirect and unit activities
  7. Consider the geographical location of the unit and the assigned duties to save nurse’s time and effort.
  8. Must be balanced among nursing staff.
  9. Never to assign the same task to more than one nurse
Characteristics of effective assignment:

  • Definite and easily understood.
  • Simple.
  • Clear.
  • Signed.
  • Written.
  • Posted in advance.
Process of organizing patient care

  • Planning:Is a process of developing a course of action for meeting the needs of patient. In planning, the head nurse decides what should be done, when, how, where, by whom and to whom
  • Assigning:Assignment of patient and nursing activities are written in the assignment sheet by the head nurse/nurse in charge, based on the principles of assignment

Methods of patient care delivery

I. The traditional methods

  • Case method.
  • Functional method.
  • Team method.
  • Modular nursing.
  • Primary nursing method.

II. The advanced method
Case managemen

CASE METHOD
It is the oldest patient care delivery method. In this method one professional nurse assumes total responsibility of providing complete care for one or more patients (16) while she is on duty. This method is used frequently in intensive care units and in teaching nursing students
Advantages
  1. High degree of autonomy
  2. Lines of responsibility and accountability are clear
  3. Patient receives holistic, unfragmented care
Disadvantages
  1. Each RN may have a different approach to care
  2. Not costeffective
  3. Lack of RN availability
FUNCTIONAL METHOD
  1. Emerged during 1950s due to shortage of nurses.This method focuses on getting the greatest amount of tasks in the least time. In this method, the nursing care is divided into tasks and each staff member is assigning to perform one or two tasks for all patients in the unit according to the level of skill required for performance as follows:
    • Registered professional nurses:
    • Responsible for administering medication to all unit patients, another for changing dressings and administering ordered treatments (such as postural drainage or warm compresses) for all patients.
  2. Technical nurses:Responsible for taking vital signs and recording intake and output for all patients in the unit, while another might be giving baths to all bedridden patients.
  3. Nurse aides:Responsible for making beds for all ambulatory patients and assisting mobility impaired patients to move in bed or walk in the hall.
  4. Unit clerk:Responsible for answering telephone, delivering messages, recording admissions and discharges, etc
Advantages
  1. Care is provided economically and efficiently
  2. Minimum number of RNs required so it is efficient when there is a shortage in the staff or there is limited number of professional nurses
  3. Tasks are completed quickly
  4. Useful in emergency situations.
Disadvantages
  1. Care may be fragmented
  2. Patient may be confused with many care providers
  3. Caregivers feel unchallenged
  4. Lack of communication among the different persons who care for the patient.
  5. Neglecting the humanity of the patient and the individual needsof the patient will be lost in an effort to get the work done

TEAM METHOD
The concept of team nursing was introduced in the early 1950s. It is a method of nursing assignment that binds professional, technical and nurse aides into small teams. This method allows for efficient utilization of technical and/or nurses aide through the direct supervision, guidance, and teaching of professional nurses.

One registered nurse in the team is appointed by the head nurse to serve as a team leader. The team members commonly consist of at least one professional nurse, one technical nurse, nursing students and nursing aides.  All team members may receive reports about their patients’ care needs from the team leader or team member on previous shift. 

The team leader usually assigns
  1. Professional nurse to care for the most seriously ill patients, to ensure informed observation and skilled interventions.
  2. Often, the team leader assigns the technical nurse to bath, feed, and move and change dressings for patients.
  3. Aides are assigned to make beds, assist ambulatory patients with bathing and grooming, testing urine and performing simple nursing care procedures.
  4. Team leader usually administers medications and monitors parenteral fluid therapy for all patients assigned to the team.
  5. Without team planning and communication through the team conferences, team nursing may become in reality just a variation of the functional method
  6. The team leader usually assigns
  7. Professional nurse to care for the most seriously ill patients, to ensure informed observation and skilled interventions.
  8. Often, the team leader assigns the technical nurse to bath, feed, and move and change dressings for patients.
  9. Aides are assigned to make beds, assist ambulatory patients with bathing and grooming, testing urine and performing simple nursing care procedures.
  10. Team leader usually administers medications and monitors parenteral fluid therapy for all patients assigned to the team.
  11. Without team planning and communication through the team conferences, team nursing may become in reality just a variation of the functional method
Advantages
  1. High quality, comprehensive care with a high proportion of ancillary staff
  2. Team members participate in decision making and contribute their own expertise
Disadvantages
  1. Continuity suffers if daily team assignments vary Team leader must have good leadership skills
  2. Patient Care Delivery System Insufficient time for planning and communication

PRIMARY NURSING METHOD

This method is the best in an agency with an all professional nurse staff. It is: A comprehensive, continuous and coordinated nursing process for meeting the total needs of each patient. 

Basic concepts in primary nursing 

Patient assessment by a primary nurse, who plans the care to be given by secondary or associate nurse when the primary nurse is off duty. The 24 hours responsibility for care is put into practice through the primary nurse’s written directive on a preplanne communication assignment. Patient Care Delivery System Complete communication of care given in the nursing staff daily reporting method. Discharge planning including teaching, family involvement and appropriate reference.

The head nurse:

  • Assigns primary nurse to patients by matching the skills of the nurse to the needs of the patients.
  • Ensures proper scheduling for all shifts so that if primary nurse is off the unit an associate nurse is available for care.
  • Guides, counsels and evaluates care given.
  • May also assign herself to patients either as a primary nurse or associate nurse. 
1. Primary nurse:
Functions of primary nurse include performing the following:
  • Conducting an admission (initial) assessment.
  • Developing, planning, implementing, and revising the nursing care plan.
  • Directing care in her absence.
  • Collaborating with physicians and families.
  • Making referrals.
  • Teaching health concepts.
  • Making discharge plans.
2. Associate nurse:
  • Associate nurse may be professional or technical nurse.
  • She carries out the nursing care planned by the primary nurse when she is not on duty
  • Technical nurse:
  • Carry out the nursing tasks assigned by the primary or associate nurses in giving the care.
  • Nurse aides:
  • Their activities are focusing away from direct contact with the patient and can be utilized as messengers and transporters.
  • Ward clerk:Responsible for the non nursing functions of administrative dutie
  • Technical nurse:
  • Carry out the nursing tasks assigned by the primary or associate nurses in giving the care.
  • Nurse aides:
  • Their activities are focusing away from direct contact with the patient and can be utilized as messengers and transporters.
  • Ward clerk:Responsible for the non nursing functions of administrative dutie
Advantages
  • High quality, holistic patient care
  • Establish rapport with patient
  • RN feels challenged and rewarded
Disadvantages
  • Primary nurse must be able to practice with a high degree of responsibility and autonomy RN must accept 24hour responsibility
  • More RNs needed; not cost effective
Advantages
  • High quality, holistic patient care
  • Establish rapport with patient
  • RN feels challenged and rewarded
Disadvantages
  • Primary nurse must be able to practice with a high degree of responsibility and autonomy RN must accept 24hour responsibility
  • More RNs needed; not cost effective

NURSING CARE FOR PATIENTS CHRONIC KIDNEY FAILURE (CKD)

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Chronic kidney damage is defined as structural abnormalities of the kidney that can lead to decreased kidney function.

The level of glomerular filtration rate (GFR) is accepted as the best measure of overall kidney function in health and disease. Pathologic studies show that substantial kidney damage can be sustained without decreased GFR (National Kidney Foundation,2009). 

Albuminuria is widely accepted as a marker of glomerular damage, and excretion of even small amounts of albumin (microalbuminuria) is the earliest manifestation of diabetic kidney disease. In addition to its importance as a marker of kidney damage, albuminuria is also an important prognostic factor for the progression of kidney disease and development of cardiovascular disease.

Other examples of markers of kidney damage in chronic kidney disease include abnormalities in the urine sediment and abnormalities on imaging studies of the kidney. High blood pressure was not defined as a marker of kidney damage because high blood pressure has other causes. The relationship between high blood pressure and kidney disease is complex, as high blood pressure is both a cause and a consequence of kidney disease.

As a rule, kidney failure due to chronic kidney disease is preceded by a stage of variable length during which GFR is decreased. GFR is affectedby a number of factors in addition to kidney disease, not all individuals with decreased GFR have CRD. 

Mild reduction in GFR was defined as CRD only in the presence of kidney damage. However, because of the risk of complications, moderate to severe reduction in GFR and kidney failure (ESRD) were defined as chronic kidney disease, irrespective of the presence of kidney damage. Other than kidney disease, the most important factor affecting GFR is age. 

After approximately age 20 to 30 years, the normal mean value for GFR declines with age in both men and women, with a mean decrease of approximately 1 ml/min/1.73 m2 per year. Therefore, mild reduction in GFR may be normal at the extremes of age and, in the absence of kidney damage, is not considered to be CRD. GFR is slightly lower in young women than in young men and this difference appears to persist at older ages2 (Coresh J, Astor CB, Greene T, Eknoyan G, Leyeu SA, 2003).

ETIOLOGY
Currently, chronic kidney disease (CKD) is a common syndrome in clinical practice, which will gradually develop to end stage renal disease (ESRD) without proper treatment. These days, with the increasingly high proportion of the secondary kidney disease, over 50% cases with CKD are due to diabetes and hypertension in developed countries (Reutens et al., 2011; Wang et al., 2011), except for a lot of cases of CKD which are caused by recurrent urinary tract infection (UTI). 

Phimosis, with high incidence in young male patients, without proper treatment, may lead to recurrent UTI, adherent foreskin, and even urethral stricture (Sandler et al., 2008). Therefore, it can be inferred that through inducing chronic UTI phimosis disease may indirectly cause chronic renal failure.

However, according to the present medical literature, phimosis is rarely mentioned as the cause of ESRD. We here present a case in which a patient with phimosis-induced chronic pyelonephritis finally developed ESRD, after which a literature review was presented.

Major risk factors for development and progression of CKD include diabetes, hypertension, older age, and being African American. Nearly 45% of incident kidney failure is attributed to diabetes and another 20% is attributed to chronic hypertension.5 Other less common but important causes include primary glomerulonephritis, lupus, and polycystic kidney disease.

More than 10 million Americans are diabetic and 40 to 50 million American adults have hypertension, constituting an enormous at-risk population for kidney disease. Notably, diabetes and hypertension are also important risk factors for cardiovascular disease and, to some extent, influence the high incidence of cardiovascular disease in the CKD population. 



PATHOLOGY
At that time most of the nephron renal failure (including glomerular and tubular) intact while others allegedly damaged (intact nephron hypothesis). 

Intact nephron-nephron hypertrophy and increased production volume filtration with reabsorption even in a state of decline in GFR / power filter. This adaptive method allows the kidneys to function until ¾ of nephron-nephron broken. Load dilarut material should be larger than can be reabsorbed result in osmotic diuresis with polyuria and thirst.

Furthermore, as the number of nephrons are damaged multiply oliguric arise with retention of waste products. The point at which the onset of symptoms the patient becomes more pronounced and appear typical symptoms of kidney failure when some kidney function has been lost 80% - 90%. At this level of renal function creatinine clearance of such values down to 15 ml / min or lower it. 

Decreased renal function, the end product of protein metabolism (which is normally excreted into the urine) accumulate in the blood. Uremia occur and affect every system of the body. The more waste products pile 8then the symptoms will be more severe. Many symptoms of uremia improved after dialysis. (Brunner & Suddarth, 2001: 1448).
www.icchealth.com
Classification Chronic renal failure is divided into 3 stages:
  1. Stage 1:decreased renal reserve, on the stage of normal serum creatinine levels
  2. and asymptomatic patients.
  3. Stage 2: renal insufficiency, which lebihb than 75% of the network has been
  4. broken, Blood Urea Nitrogen (BUN) increased, and increased serum creatinine.
  5. Stage 3: end-stage renal failure or uremia.
 

This classification is based on estimated GFR, and recognises five stages of kidney disease, as follows:
  • Stage 1: Normal GFR; GFR >90 mL/min/1.73 m2 with other evidence of chronic kidney damage
  • Stage 2: Mild impairment; GFR 60-89 mL/min/1.73 m2 with other evidence of chronic kidney damage
  • Stage 3: Moderate impairment; GFR 30-59 mL/min/1.73 m2
  • Stage 4: Severe impairment: GFR 15-29 mL/min/1.73 m2
  • Stage 5: Established renal failure (ERF): GFR < mL/min/1.73 m2 or on dialysis (For CKD Stage 5 we have adopted the term established renal failure instead of end-stage renal disease or end-stage renal failure, as this is the term used in the National Service Framework for Renal Services).

CLINICAL MANIFESTATION
Clinical manifestations according to (Smeltzer, 2001: 1449) are: hypertension, (due to fluid retention and sodium from sisyem activity of renin - angiotensin - aldosterone), congestive heart failure and pulmonary edema (due to excessive fluid) and pericarditis (due iriotasi the pericardial layers by toxic, pruritis, anorexia, nausea, vomiting, and hiccups, twitching, seizures, changes in level of consciousness, inability to concentrate).
Clinical manifestations according Suyono (2001) are as follows:
Cardiovascular disorders Hypertension, chest pain, and shortness of breath due to pericarditis, effusi perikardiac and heart failure due to fluid retention, heart rhythm disturbances and edema.

Pulmonary disorder, Shallow breathing, KUSSMAUL, cough with thick sputum and ripple, noise Crekels.
Gastrointestinal disorders,Anorexia, nausea, and fomitus related to protein metabolism in the colon, gastrointestinal tract bleeding, ulceration and bleeding mouth, ammonia breath odor.

Musculoskeletal disorders
Resiles leg syndrome (sore on his leg that is always driven), burning feet syndrome (tingling and burning, especially feet), tremor, myopathy (muscle weakness and hypertrophy - limb muscles.
Integumentary disorders skin pale from anemia and straw - brass due to accumulation urokrom, itching - itching caused by toxic, thin and brittle nails.
Disorders endokrin
Sexual Disorders: libido and erectile decreased fertility, menstrual disorders and aminore. Glucose metabolic disorders, metabolic disorders of fat and vitamin D.

Disorders of fluid electrolyte and acid and alkaline balance
usually salt and water retention but can also occur loss of sodium and dehydration, acidosis, hyperkalemia, hipomagnesemia, hypocalcemia.

Hematological System, anemia caused by reduced production of eritopoetin, so that the stimulus eritopoesis marrow - bone marrow decreased, haemolysis due to reduced life span of erythrocytes in uremia toxic atmosphere, may also occur malfunctioning of thrombosis and thrombocytopenia.

NURSING MANAGEMENT
Nursing management of patients with CKD is divided into three, namely:
Conservative
  1.  Do blood and urine examination
  2. Observation of fluid balance
  3. Observe for edema
  4. Restrict incoming fluid
Dialysis
  1. Peritoneal dialysis
  2. Usually done in the case - the case of emergency.While dialysis can be done anywhere that is not acute CAPD (Continues Peritonial Ambulatory Dialysis)
  3. Hemodialysis : That is dialysis done through invasive action in the vein using a machine. At first hemodiliasis done through the femoral region, but to simplify it done. 
  4. AV fistule: combining venous and arterial
Double lumen:
  1. directly on the heart area (vascularization to the heart)
  2. Operations
  3. Intake stone
  4. Kidney transplant

NURSING DIAGNOSIS
  1. Exess fluid volume
  2. Imbalance nutrition: less than body requirements
  3. Risk for infection
Exess fluid volume
OUTCOME
  1. Kidney function: after 3x24 hours patient will have intake in output balance after 24 hour
  2. No increasing of weight gain in abnornal (edema)
  3. Normal blood pressure 120/80mmHg
  4. No fatigue
  5. No malaise
INTERVENTION AND RATIONALES
  1. Monitor respiratory pattern for symptom of respiratory difficulty ( dyspnea, tachypnea, and shortness of breath ) that are indicators of fluid excess
  2. Weight patient daily and monitor trends to evaluate intervention
  3. Monitor intake and output to determine effect of treatment on kidney function
  4. Provide appropriate diet to help control edema and hypertention
  5. Instruct the patient and/or caregivers on measures instituted to treat the hypovolemia ( daily weight, fluid restriction) to help monitor and control fluid overload and related hypertention
Imbalance nutrition: less than body requirements
OUTCOMES
  1. After 3x 24 hours patient will have balance nutrition with criteria result
  2. Increase nutrition intake
  3. Food intake become 1 portion of diet
  4. Increase energy
  5. No nausea again
INTERVENTION AND RATIONALES
  1. Monitor for nausea and vomiting to intervene as necessary
  2. Monitor trends in weight loss and gain to detect changes in status
  3. Monitor albumin, total protein, hemoglobin, and hematocrit levels as indicators of nutritional status and response to treatments
  4. Monitor caloric and nutrient intake to detect changes
  5. Provid oral care before meals to prevent stomatitis, remove bad taste, and increase patient appetite
  6. Refer for diet teaching and planning to ensure adequate intake within prescribed diet restriction
  7. Provide needed nourishment within limits of prescribed diet to detect changes
Risk for infection
OUTCOMES
  1. After 3x24 hours patient will not experience infection with criteria result:
  2. The client is free from signs and symptoms of infection
  3. Demonstrated ability to prevent infection
  4. The number of leukocytes within normal limits
  5. Demonstrate healthy behavior
INTERVENTION AND RATIONALES
  1. Maintain aseptic technique in patients who are at risk to prevent sign and symptom of infection
  2. Colaboration with doctor to take antibiotics as prescribed / to prevent infection
  3. Teach the patient and family the signs and symptoms of infection and teach how to avoid infection/increase cooperation with patient and family
  4. Monitor granulocyte count, WBC/the sign of infection
REFERENCES
National Kidney Foundation. K/DOQI Clinical Practise Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification. Am J Kidney Dis 2002; 39 [suppl1]:1-266.
Joint Speciality Committee - Royal College of Physicians, The Renal Association
(2006) Chronic Kidney Disease in Adults, UK guidelines for Identification, Management and Referral.
K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002;39(2 Suppl 2):S1-246.