Advances in medical technology and modern medicine ensure that life expectancy is extended and the natural course of death is altered. Although modern medicine and technological advances have not reached the point of curing chronic diseases, they prolong life by offering secondary support to patients such as respiratory support and nutrition (Akdeniz et al., 2021). Death is an inevitability for all people but some patients at the end of life experience difficulties and suffering. Close family members also experience a range of mental, psychological, and other problems. As one the primary caregivers, family members are often distraught when one of their own is diagnosed with a fatal condition and may on behalf of the patient seek life-sustaining interventions to prolong the life of one of their own. Further, a patient can, on their initiative, insist on life-sustaining interventions. Whether sought by the patient, family member, or physician, decisions on life-sustaining interventions are morally, emotionally, and ethically challenging.
From an ethical viewpoint, decisions on life-sustaining interventions should be made by the patient. However, in most instances, a patient is usually not in the right frame of mind to make such decisions. In such cases, it is the prerogative of a family member, proxy, or physician to decide on whether to prolong the patients life by keeping them on life-support. Family members who have to make such decisions on behalf of their loved ones can feel lost and unable to decide especially when they have different views on life-sustaining interventions (Akdeniz et al., 2021). Others may want everything done to ensure they extend the patients life as much as possible but be unable to make the decision and thus expect a physician to decide for them. In such circumstances, the physician faces an ethical dilemma because they have to balance the wishes of the family members with the goals of alleviating suffering for the patient and provision of comfort until death.
Stakeholders and Contextual Factors
Various stakeholders hold different views on life-sustaining interventions by patients or doctors. For instance, religious authorities oppose life-sustaining interventions if they would not provide qualitative benefits to a patient. Instead, they advocate for pain relief for dying patients and letting nature take its natural course. Every religion accepts death as an integral step in the life cycle and has structures, laws, and prayers that guide the artificial shortening or prolonging of a patients life (Vermeulen & Krabbe, 2018). Christianity unequivocally opposes euthanasia and physician-assisted suicide. However, Christians can accept life-sustaining interventions if such interventions lead to the patients qualitative improvement. If there is no qualitative improvement, Christians should let the natural course of events take place. According to the Catholic Church, patients can forgo life-sustaining interventions that only minimally prolong life without hope of spiritual or physical benefit.
Additionally, various cultures globally perceive the end of life differently, and depending on their view they may favor prolonging a patients life or letting nature take its course. Western nations where healthcare systems are more advanced and life expectancy is higher favor extending a patients life while in the developing world, letting nature take its course is often preferred. Thus, the improvement of healthcare systems and an increasing life expectancy demand an exploration of all health interventions. In the medical profession, professional identity is perceived as an important part of personal identity and a prerequisite for professional identity (Kristoffersen, 2021). In this regard, due to the complexities of life-sustaining interventions and the subjective nature of the decisions, deciding whether to put a patient on life-support is impacted by the physicians personal identity. Thus, where one physical may feel obligated to put a patient on life-support, another physician may oppose such a decision on personal grounds.
Analysis Moral Theories and Ethical Principles
Moral theories assist physicians to reflect and make ethical decisions but while they may help make ethical decisions, they are not predictive. Some of the most common moral theories are utilitarian theory, Kantian theory, rights theory, and virtue theory. According to the utilitarian theory, the point of an ethical decision is to maximize the amount of happiness with each decision (Grace, 2018). Thus, if the pain of one individual can lead to several lives being saved, the physicians decision must lead to maximum utility. For life-sustaining intervention, the patient or physician must consider the well-being and welfare of family members and friends before deciding on an intervention. The Kantian theory emphasizes the consequences of actions. Thus, a decision is righteous if it leads to the desired consequences. This theory also stresses the wrongfulness of using the human body as an instrument and emphasizes that the righteousness of an action depends on its maxim. Thus, a decision to extend life-sustaining intervention will be considered righteous if its maxim is righteous.
The virtual theory posits that the virtuous act in any situation constitutes what a virtuous individual would do in such circumstances. Thus, doing what a good person would do constitutes an ethical action. The core intent of medicine is to improve patients lives. Working as a physician requires plenty of skills and care for the patients welfare. Thus, good physicians offer the best care to the best of their abilities and skills. According to rights theory, patients have rights as one of their intrinsic features (Grace, 2018). These rights must be recognized and respected by caregivers. Thus, in deciding on life-sustaining interventions, a patients rights must be considered.
In addition to the moral theories, the four principles of nonmaleficence, beneficence, autonomy, and justice offer a framework for deciding medical ethical and moral dilemmas. The principle of fair access implies that patients should have access to all healthcare resources no matter what. On the other hand, autonomy means that patients can be able to make independent decisions and have their confidential information protected. Beneficence denotes the moral duty that physicians have to ensure that they provide the best care possible for their patients (Beauchamp & Childress, 2019). Finally, nonmaleficence is a direct translation of the Hippocratic injunction to not harm. These four principles capture essential elements of any decision that medical practitioners will be required to make throughout their careers. They provide a framework for moral deliberations and justify moral medical decisions. Thus, in deciding on a particular life-sustaining intervention, a medical professional must understand and follow the four ethical principles such that the ultimate decision reflects nonmaleficence, beneficence, autonomy, and justice.
Physicians often make decisions about prolonging a patients life. These decisions involve more than selecting the appropriate life-sustaining intervention. Consequently, ethics is an inseparable part of medicine because doctors are ethically obligated to provide care that benefits the patient, mitigate, avoid, or reduce harm to a patient, and honor the wishes and preferences of a patient. Thus, a physician is duty-bound to these obligations which often leads to ethical dilemmas. When faced with an ethical dilemma due to the thin line physicians have to walk to fulfill a patients needs and be ethical, ethical theories and principles act as a point of reference. For example, when deciding on a life-sustaining intervention, a physician will follow one of the four ethical theories and the four ethical principles. Depending on the choice of an ethical theory, a physician may decline or accept a request by a patient or their family members to put them on life support.
Conclusion
As medical technology and modern medicine advance, doctors have several options available to sustain human life despite not adding any qualitative value. The decision to recommend life-sustaining interventions is challenging and follows serious moral and ethical reasoning by the physician or the patient. When a physician, due to the inability of family members and the patient, is expected to decide on a life-sustaining intervention for a patient, they could apply the utilitarian theory, Kantian theory, rights theory, and virtue theory to help in decision making. The utilitarian theory posits that an ethical decision yields maximum benefit for the maximum number of people. The Kantian theory emphasizes the maxims, the rights theory underscores the legal rights of a patient, and the virtual theory argues that an ethical decision resembles one that would be made by a good person. In addition to the ethical theories, the ethical principles of nonmaleficence, beneficence, autonomy, and justice provide medical practitioners with a framework for ethical decision-making.
There are many different types of heart surgery, aimed at reaching specific medical goals and helping patients. Any medical intervention concerning the heart is inherently dangerous, as people are extremely dependent on its function to survive. However, it sometimes becomes necessary for medical professionals to operate on it. One such procedure is the coronary bypass surgery, or CABG. Heart attacks occur when the blood vessels of the heart are unable to transfer the necessary blood around ( Coronary bypass surgery, 2020). Cholesterol deposits in the arteries, or a smaller artery diameter can both lead to cases of artery blockage. In case of such an occurrence, it becomes necessary to redirect the blood flow from a blocked area, and provide a new pathway for the blood ( Coronary bypass surgery, 2020). Open heart surgery is performed in order to achieve this effect, where another blood vessel is taken from an arm or a leg, and transplanted to the necessary area. While the process does not cure the initial cause of a heart attack, it can save a persons life and alleviate heavier symptoms, such as pain or breathing problems. Compared other types of treatment for heart attacks, the coronary bypass surgery is only a temporary measure, requiring further intervention in the future. With the advancement of medicine and technology, it becomes possible to improve the quality of the surgery, along with the survival rate of the patients. With the development of medical tech, such as the currently present heart-lung machine, it will be possible to make the procedure much less damaging, dangerous and invasive for the patients( Coronary bypass surgery: Past, present, and future, 2021). The improvement in these areas can guarantee lesser rate of subsequent heart attacks, potential infections and other side effects.
Hob Osterlunds essay is permeated with many ideas and thoughts revolving around two tragic fates of patients. Inevitably, nurses are witnesses and participants in such tragedies from time to time because it is impossible to treat patients mechanically and detachedly. The complexity of the authors position is that she is experiencing two entirely different tragedies and situations simultaneously. A woman dying of cancer and clinging to life and a young drug addict who has gone insane should seem to evoke opposite emotions. However, they all intertwine in the same hospital, cling to each other with one similar symptom baldness, and cause a general feeling of bitterness and sand slipping from under their feet.
The author begins with the physical manifestation of the disease baldness and room numbers. Such descriptions appear impersonal, often becoming the norm in the medical community. She starts with the eye of a nurse who sees many patients through the lens of their illnesses and the numbers on the hospital ward door (Osterlund, 2016). However, the author expands this view for the reader, giving more detailed medical information and more personal information. This way, the nurse gets to know and connects with her patients. At first, they are just room number and disease, but in the process of long-term care and communication, a nurse cannot help but get to know her patients better and get to know them personally.
This essay conveys a sense of the commonality of human grief. All people can share feelings with others, despite different circumstances. In the face of adversity, tragedy, and death, every person feels the same, no matter how he tries to behave. In the end, a dying patient asks her husband to sit with a deranged young man (Osterlund, 2016). Maybe partly because she wants her husband to care for someone who will outlive her, or perhaps because personal grief makes people more sensitive to someone elses tragedy.
Reference
Osterlund, H. (2016). Bald Places. In Editor B. Doyle (Ed.), A Sense of Wonder: The Worlds Best Writers on the Sacred. Orbis Books.
Inpatient services refer to the activity of care provided to people who require twenty-four-hour monitoring in a medical facility or other appropriately outfitted healthcare centers. It is a consequence of underlying medical or psychiatric conditions, with medical professionals following a medication regimen predicated on need documentation. Good examples include patients needing sophisticated operations and certain regular procedures (Martins et al., 2020). Casualties in gruesome accidents and who happened to have escaped with their lives fit categorically as those who require specialized surgeries. Even if it does not necessitate a cesarean section, childbirth falls under inpatient services. Acute ailments or medical conditions that require close observation, such as admitted cancer patients, need inpatient services.
On the other hand, outpatient services refer to a structured, nonresidential treatment regimen delivered in routinely timetabled appointments to patients who do not require a higher level of care. Those who need ongoing services after completing a somewhat more rigorous treatment program undergo outpatient services. Minor procedures, especially those that use minimally intrusive approaches, are becoming increasingly popular in outpatient settings and blood tests are examples of lab testing. Physical examinations performed regularly, consultations, and follow-ups with specialists also fall under outpatient services. Level I, Outpatient Treatment, is the American Society of Addiction Medicine (ASAM) Treatment Level relating to substance use disorder services.
In an inpatient setting, the patient being admitted requires a few, if not all, of their needs taken care of. Being under the care of doctors, nurses, and other healthcare professionals, recovery on most occasions is boosted. Surgeries, both routine and complex, childbirth and rehabilitation services best fit under this setting. Key personnel in the inpatient setting include but are not limited to laboratory technicians, pharmacists, nurses, and cardio-therapists. Well-being and preventative measures, such as counseling and cutting weight initiatives, are examples of outpatient services. Prognosis, such as lab testing and magnetic resonance imaging (MRI) scans, are examples of diagnostic services. Surgical actions and chemotherapy are examples of treatment options. Drug and alcohol treatment, as well as physical therapy, are examples of rehabilitation. Key personnel in outpatient settings are majorly all-rounded physicians and nurses.
With healthcare advice being easily accessible, telehealth and conferencing on video are gaining traction as less costly alternatives to enhance public health services. Telehealth norms amplified dramatically through COVID-19 as a strategy for restraining virus transmission. It is especially useful for those in rural, metropolitan, or remote areas who need frequent access to healthcare experts who reside many miles away. Through teleconsultation with the professional, additional healthcare professionals, clinical nurse specialists, midwives, health workers, and nurses typically offer head-on medical assistance to patients to guarantee the necessary treatments are undertaken (Jung et al., 2022). These healthcare specialists can fashion customized treatment regimens to hinder unneeded admissions and appointments. When combined with statistical insights and predictive technology, they can more accurately forestall a patients issues from worsening.
Virtual assistance solutions as a trend will carry on to occur across the care field, from eHealth sessions to remote hospitalization and home-based treatment. In February 2020, telehealth accounted for less than 1% of Medicare principal care visits (Jung et al., 2022). Due to the pandemic, the number had climbed to 43% by April. This upward trend seems to be lasting since both medical providers and patients embrace a different digital orientation. It will be vital for firms to align their online plans with their customers changing needs, expansion objectives, and financing systems. It is not a cure-all but a natural progression in better-assisting doctors and patients while also enhancing communication.
Whereas the patients appreciate the comfort and accessibility of digital interactions, they still value personalized treatment. Personalized care is essential for an ideal healthcare involvement, as per a 2020 assessment of healthcare patients, whether the care provided was virtual or had professionals in attendance. Patients trust that professionals must take the time to listen, establish apprehension, and converse commendably. Professionals must link improvement determinations to agendas that yield quantifiable outcomes to be effective.
With fast-tracking innovations due to rapid technological advancement, much has been simplified in healthcare. Switching to technology will result in a higher standard of treatment throughout the board. Using digital healthcare amenities makes it tranquil to create cutting-edge digital platforms, enhance operational effectiveness by taking a holistic perspective on patient care, and improve automated administrative and clinical activities. Collaboration is made easier, and HIMSS (Healthcare Information and Management Systems Society) scores are improved. Increased ability to innovate and eventually lead to better patient outcomes.
With the rising cost of healthcare, technology comes in handy to save costs in the long run. With the governments help, major public hospitals in the country need to be incorporated with technological equipment to easily provide medical services to their patients. Lastly, protection against cyberattacks has been a top challenge for many leaders in the healthcare administration (Lee, 2021). With hackers getting more strategic and smarter by the day, administrators in medical facilities need to rise to the task and hire top-tier cybersecurity experts who will ensure sensitive data and systems are guarded tightly.
The difficult work of ambulance doctors is also complicated by citizens unable to define the appropriateness of their call to the service. In critical situations, this can have fatal consequences for some patients. The work offers academic sources that have studied this problem.
Gardner GJ. The use and abuse of the emergency ambulance service: some of the factors affecting the decision whether to call an emergency ambulance. Emergency Medicine Journal. 1990 Jun 1;7(2):81-89.
Problem
When an emergency arises, under the pressure of panic, it is difficult for people to determine whether it is appropriate to call an ambulance or not.
Intervention
After entering the hospital, patients and doctors were interviewed to find out how correctly the patients determined their condition.
Comparison
The public awareness of the circumstances in which immediate medical assistance can reduce service load.
Outcome
Patients poorly know ambulance work only 62% correctly identified their conditions to calling for help.
Kirkby HM, Roberts LM. Inappropriate 999 calls: an online pilot survey. Emergency Medicine Journal. 2012 Feb 1;29(2):141-146.
Problem
Inappropriate calls can cause death or severe complications in a patient to whom doctors did not have time to arrive due to unavailability.
Intervention
Researchers have created an online questionnaire to see if people understand situations in which to call an ambulance. According to the number of points respondents received for interpreting scenarios, the level of understanding of the relevance of calls was determined.
Comparison
Compared to the first resource, such a survey showed that the primary source of inappropriate calls is panic.
Outcome
In situations where the help of doctors is definitely needed, most respondents would call for help. However, in 2 out of 7 cases, the study identifies a problem when there is no need for specialists, but calls are received.
Edwards MJ, Bassett G, Sinden L, Fothergill RT. Frequent callers to the ambulance service: patient profiling and impact of case management on patient utilisation of the ambulance service. Emergency Medicine Journal. 2015 May 1;32(5):392-396.
Problem
There are a certain number of patients who often and without a significant reason, apply to an ambulance. It interferes with the correct work of the ambulance and drains out limited resources.
Intervention
A group of patients, who often called an ambulance, was identified. Researchers highlighted factors that helped reduce the number of calls from this group of patients.
Comparison
The main focus here is on those who make constant calls, not on single ones.
Outcome
Competent management of a group of complex patients and prior intervention, such as regular observation by a doctor, helps to decrease the load on the ambulance service.
Conclusion
These sources reveal several aspects of inappropriate ambulance calls. The main problem is the inability of people to determine the situation in which to contact an ambulance. For its solution, it is necessary to increase citizens knowledge of ambulance work.
References
Gardner GJ. The use and abuse of the emergency ambulance service: some of the factors affecting the decision whether to call an emergency ambulance. Emergency Medicine Journal. 1990; 7(2):81-89.
Kirkby HM, Roberts LM. Inappropriate 999 calls: an online pilot survey. Emergency Medicine Journal. 2012; 29(2):141-146.
Edwards MJ, Bassett G, Sinden L, Fothergill RT. Frequent callers to the ambulance service: patient profiling and impact of case management on patient utilisation of the ambulance service. Emergency Medicine Journal. 2015; 32(5):392-396.
Advanced practice nurses (APNs) represent a significant group of professionals who possess specific responsibilities, have rigid regulations for their activities, and need to comply with various rules regarding the certification and prescriptive authority. APNs need to acquire a minimum of a Masters level of education and support their skills through continuous learning in the area of their expertise. The regulatory organizations that command the area of APNs in the state of New Jersey are the Division of Consumer Affairs and the Board of Nursing. One of the crucial aspects of advanced nurses practice is a controlled substance prescription, which also requires specific criteria fulfillment. In such a way, APNs need to conduct six hours of continuing education related to CDS. It is also crucial to comply with the regulation of signing a joint protocol with a collaborating physician to obtain prescriptive authority.
The nursing field occupies an essential place in the healthcare industry and has its regulations and guidelines to perform high-quality services. Advanced Practice Nurses (APNs) represent a group of professionals who carry substantial duties and have a critical responsibility for the treatment of and effective care of patients. New Jersey State Nurses Association (2006) defines APNs as registered nurses with masters level nursing education (at minimum) who provide expert clinical care in a variety of settings (para. 1). Thus, APNs have a vital role and are obligated to perform at the highest level. This paper aims to investigate the requirements for Advanced Practice Nurses in New Jersey and their implications.
First, it is significant to review the necessary aspects that APNs in New Jersey have to follow for prescriptive practice. According to the New Jersey Division of Consumer Affairs (2015), APNs possess a prescriptive authority and are requested to have a joint protocol with a licensed physician before advocating any medical devices or medication. Consequently, expert nurse practitioners in NJ have the power for prescriptive activities but have to comply with additional regulations. Moreover, when the nurses apply for prescriptive authority, they are required to have a continuing professional education certificate obtained five years before the application date (New Jersey Division of Consumer Affairs, 2015). In such a way, APNs need to fulfill rigid guidelines to acquire a possibility for prescriptive practice.
The next crucial point is the regulatory organizations that have authority over APNs in New Jersey. All APNs exist under the banner of the Division of Consumer Affairs and have to be certified by the Board of Nursing (BON) (Nursing Licensure, n. d.). Hence, those are the official bodies that control the practice of advanced nurses. Moreover, APNs and healthcare institutions need to comply with the required certifications. In NJ, APNs receive their certificates from the BON that can accept authorizations issued by agencies accredited through the American Board of Nursing Specialists or the National Commission for Certifying Agencies (Nursing Licensure, n. d). Therefore, APNs are required to hold a registered nurse license and the certification issued or accepted by the BON within the state.
Besides specific regulations APNs need to comply with to possess a prescribing authority, there are numerous guidelines and requirements for other aspects of their practice. First, it is crucial to understand the point of education and continuous learning for advanced nurses. All APNs are required to complete a graduate education program with a minimum of 39 hours in pharmacology and six contact hours of controlled dangerous substance (CDS) related pharmacology (Drake & Torre, n. d.). In such a way, there are particular essential fields, in which nurses, applying for advanced practice, need to have expertise. Additionally, APNs need to acquire at least 30 contact hours of continuing education related to their specialty, and the BON does not identify that those hours need to be pharmacology-related (Drake & Torre, n. d.). Consequently, there is a significant emphasis on continuing knowledge among APNs to ensure their professionalism and the ability to follow new developments within their area.
The paragraphs above mention the necessity of obtaining a joint protocol with a collaborating physician before moving to the prescription stage. This agreement represents an ongoing process consistent with agreed-upon parameters of their respective practice in the form of a written contract between APN and a physician (Drake & Torre, n. d., p. 2). Thus, advanced nurses need to have collaboration arrangements with doctors and have to comply with it carefully, remembering about physicians involvement in prescribing medications. The joint protocol needs to include particular elements to be valid. Hence it should incorporate the information about the nature of the practice, record-keeping methodology, patient population, medication categories, specific points for recording, and rules for consultations (Drake & Torre, n. d.). APNs are obligated to ensure the legitimacy and rationality of this agreement. Moreover, a discussed protocol needs to be reviewed and signed again at least annually by both parties involved (Drake & Torre, n. d.). It is vital to update it to reflect possible modifications in functions or skills.
Another critical point regarding APNs performance and operations concerns the guidelines of the Center for Disease Control and Prevention (CDC). Advanced practice nurses need to apply for prescribing CDS, and after they possess an authority to do this according to the protocol (Drake & Torre, n. d.). As mentioned earlier, each APN is required to obtain six hours of continuing education related to CDS. Moreover, before starting the registration to acquire the Federal Drug enforcement agency number, APNs have to have CDS prescription ability in the state of New Jersey (Drake & Torre, n. d.). Revisioning of the joint protocol is essential for this point as well to decide the necessity of collaboration. The BON can check compliance with all regulations through random audits upon license renewal (Drake & Torre, n. d., p. 3). Consequently, the area of prescribing controlled dangerous substances is a sensitive field within the nurses practice and needs careful attention.
There are also other significant aspects related to the prescription of CDS. First, APNs need to make sure whether a patient already had treatment with a specified drug or pharmaceutical substitute (New Jersey Division of Consumer Affairs, n. d.). A particular system in which the professionals can access medication history exists. The New Jersey Prescription Monitoring Program (NJPMP) can help APNs to observe the medical record (New Jersey Division of Consumer Affairs, n. d.). Therefore, APNs need to carefully turn to the issue of prescribing CDS and take each case separately. The CDC suggests that practitioners should be cautious with the dosage of CDS and avoid increasing the dose or have a precise justification for this move (New Jersey Division of Consumer Affairs, n. d.). The professionals need to follow those guidelines to achieve the best treatment results and avoid potential dangers.
The point of prescribing the medication or medical devices and following existing requirements is an essential topic for APNs. The paragraphs above mention the necessity of collaboration with a physician through signing a joint-protocol. It is also crucial to remember that APNs can have the prescriptive authority within the state of New Jersey, where they got their certification required by the BON. One can say that the presence of those regulations might limit the power possessed by APNs, although they aim to eliminate the risks and ensure the safety of patients. The curious point is that all individual APNs have their prescription blank pads printed on special paper, as required by the NJ statute (The Society of Psychiatric Advanced Practice Nurses, n. d.). It is a significant request because it helps to avoid alterations in the medications or doses.
Thus, possessing a prescriptive authority with specific limitations is a serious responsibility for practitioners. Additionally, every APN must remember that in the case of prescribing controlled dangerous substances, only one medication of this type can be in one prescription (The Society of Psychiatric Advanced Practice Nurses, n. d.). There are numerous details concerning collaborative practice with physicians, as well. For instance, besides carefully designing joint protocols, the parties involved should develop specific guidelines defining roles and responsibilities (The Society of Psychiatric Advanced Practice Nurses, n. d.). As a result, clear standards and instructions shape the abilities of APNs within the area of expertise. All the established regulations and legislation related to the medication prescription and APNs power within this field are vital for the professionals, and any violation might have adverse consequences. In conclusion, APNs in New Jersey have to comply with strict regulations, possess a particular level of education, obtain specialized certifications, and be engaged in continuous learning.
An interview is an integral part of the assessment to determine the effective intervention for improvement of patients mental health. A counselor needs to have many skills and ideas in both psychology and related sciences to build rapport with a client, understand the features of his or her condition, and determine the course of treatment. However, the interview is the essential step in the process of assisting clients with mental or physiological concerns, since, at this stage, a professional receives all the information for further analysis.
The settings for the interview, in general, can be located anywhere, for example, a hospital or private office of a therapist. However, some conditions can positively affect the progress of communication and the establishment of trusting relationships. It is preferable that the room has warm, calm colors, and good natural lighting, but not too bright. These features will help the client feel more relaxed on a subconscious level. In addition, the room in which communication takes place should be isolated from external sounds, phone calls, as well as unexpected visitors as the noise distracts the counselor and the client, as well as creates a feeling of insecurity. Such conditions will be most convenient for communication and, most likely, will help a client to feel trust for his or her counselor.
Moreover, the arrangement of clients and a therapist also has a significant impact on the interview process. Too close proximity will make a client feel uncomfortable due to penetration into his or her personal space. At the same time, a large distance will create a feeling of disinterest. In addition, various barriers between clients and the counselor also impede free communication as they create an environment. For this reason, the optimal arrangement of clients and the counselor is chair or sodas located face to face. This position assists in maintaining eye contact and open communication.
Building rapport is one of the critical action for interviewing clients, since psychologist can understand and evaluate their concerns only in the environment and conditions which help people to disclose themselves. Balkin and Juhnke (2017) note, The mere fact that a client will sit down with a complete stranger and begin to disclose highly personal information is worthy of respect for the courage and risk that accompanies this scenario (133). For this reason, the consultant needs to be very careful during the first sessions with clients to create an environment of trust for them. In this process, skills such as listening without judgment, asking questions, and empathy are necessary.
Lack of judgment is crucial as a person who wants to open up and often even a slight expression of dissatisfaction, such as a look, can cause closing of his or her feelings again. Communicating questions are also important, since they help a client tell inconvenient information without looking for a reason for its disclosure. Empathy also makes clients feel that their thoughts and feelings are not unique and common, so the psychologist needs to show the same emotions when appropriate, such as being angry or showing sympathy. Thus, soon the trusting relationship between the client and the counselor will help to proceed to a discussion of more private and harmful experiences.
The primary skills for conducting an interview are listening, empathizing, and responding appropriately. Listening is a key skill as clients words always carry valuable information that can demonstrate his or her concerns. However, the reaction to the clients stories is also significant, as it encourages the person to further dialogue. For example, the counselor must maintain eye contact and respond with nods while the client speaks, he or she can also interpret her or his words, ask clarifying questions or directly answer or explain some of the speakers concerns. Empathy is also part of the reaction, which can be expressed in words and other manifestations. For this reason, the ability to respond appropriately, not to interrupt, and encourage further communication is a key skill of a mental health professional
However, interviewing is just one of the first steps in determining treatment for a patient. The next step is case conceptualization that involves such actions as evaluating client concerns, organizing observations and evaluations, and selecting a theoretical interpretation for determining diagnosis and treatment (Schwitzer & Rubin, 2015). Case conceptualization ultimately gives the consultant a clear idea of the clients concerns and the factors that cause and keep them, which allows him or her provide an effective plan of interventions. Therefore, case conceptualization is a crucial part of the process of determining the diagnosis and its features and choosing a treatment regimen for the client.
In conclusion, the role of the interview and the proper implementation of all its steps is vital for mental health professionals as it is the first stage in providing help for people. The communication and professional skills of counselors or psychologists help them build trusting relationships with clients and help them disclose their feelings. At the same time, scientific knowledge and professional experience make it possible to assess the clients concerns adequately and offer them the most appropriate treatment option. However, the first step is always to collect information, and interviewing is the most effective way to obtain it.
References
Balkin, R. S., & Juhnke, G. A. (2017). Assessment in counseling practice and applications. Oxford: Oxford University Press.
Schwitzer, A. M., & Rubin, L. C. (2015). Diagnosis and treatment planning skills: A popular culture casebook approach (2nd ed.). Sage Publications, Inc.
Disordered intestinal absorption is not a single condition but rather it involves many conditions that have many causes and therefore various clinical presentations. Therefore, there is no uniform management, instead a management strategy tailored for individual cases. This essay aims to review, yet comprehensively, malabsorption syndrome about types, pathophysiology, diagnosis, consequences, and treatment.
Introduction
Disordered intestinal absorption is not a single condition but rather it involves many conditions that have many causes and therefore various clinical presentations. Defective absorption affects large sized molecules (macromolecules) as proteins, fats and carbohydrates, or small sized ones (micro molecules) as minerals and vitamins, or both. The underlying defect is disturbance in intra-luminal absorption, terminal absorption (at the brush border of the small intestine), or defective transport across the intestinal epithelium (Scott, 1975). Any of the previous conditions is associated with defective absorption of one nutrient or more and is termed malabsorption syndrome. As the term signals a patho-physiological condition rather than provide an aetiological perception; therefore, malabsorption is not an ideal definitive clinical diagnosis (Binder, 2005).
Diarrhoea is the most prevalent symptom, which may be fatty diarrhoea (steatorrhoea) with excretion of 6% or more of the daily fat dietary intake. Secondary systemic disorders may occur as pernicious anaemia, which may result because of absent intrinsic factor needed for vitamin B12 absorption (Binder, 2005). Depending on the underlying disturbance, bone diseases (osteomalacia or osteoporosis) and or hypoproteinaemia may result (Scott, 1975).
Definition, and classification of malabsorption syndrome
Definition of malabsorption syndrome
Greenson (2005) defined malabsorption syndrome as any type or degree of small intestine dysfunction affecting the physical absorption of a substance normally absorbed from or retained in the small intestine. Montalto and others (2008) defined malabsorption syndrome as a disorder of mal-digestion and or malabsorption extending beyond the compensating mechanisms of the small intestines that result in manifestations of nutrients deficiency.
Classification of malabsorption syndrome
In 1960, Adlersberg suggested classifying malabsorption syndrome into a primary and a secondary types. The primary type includes coeliac disease and tropical sprue. The primary type is genetically transmitted or environmentally determined. Alternatively, environmental factors interact with genetic predisposition to excite or lessen the disorders manifestations. Adlersberg (1960) inferred that such a distinction between the primary and secondary type is important as diseases producing the secondary type (infective as Whipples disease, or anatomical as short bowel syndrome) should be investigated and treated whenever possible.
Shaffer, Thomson, and others (2000), agreed with Scott (1975) that a classification based on the possible causes of malabsorption would be helpful in management and raise clinical suspicion indices as to the diagnosis and management. They classified malabsorption syndrome in two broad categories, disorders of digestion, and disorders of absorption. Digestion disorders may result from defective mixing action of the stomach as in cases of partial gastrectomy.
Further, they may result because of pancreatic insufficiency (secondary to cystic fibrosis, inflammation or tumours), or because of bile salt deficiency as with liver diseases, biliary disease or ileal resection. Defective absorption may result from loss of absorptive surface whether surgical, mucosal damage, inflammation (as in Crohns disease) or infections and infestations. Isolated biochemical abnormalities as disaccharidase deficiency can produce a type of malabsorption syndrome determined by the underlying deficiency.
Montalto and others (2008) recognized the difficulty in having a uniformly agreed upon classification of malabsorption syndromes is because of the complicated nature of the absorption process, which occurs and is influenced by many organs, and the effect of many diseases on the absorption mechanisms.
Causes of malabsorption syndrome
Causes of malabsorption syndromes are many. Table (1) [see appendix 1] summarizes the different aetiologies of malabsorption syndromes based on the classification suggested by Shaffer, Thomson et al (2000).
Diseases of the small intestine
Scott (1975), Shaffer, Thomson, and others (2000) pointed the main small intestinal disorders that cause malabsorption is short bowel syndrome, stagnant (blind) loop syndrome, tropical sprue. Bacterial infection (Whipples disease), parasitic infestations, and small bowel infiltration by amyloidosis, or lymphoma are other causes pointed by the authors.
Parrish (2005) provided a coherent and systematic review on short bowel syndrome focusing on how to capitalize on the remaining bowel part. The syndromes definition is defective small intestine absorptive capacity because of decreased length or decreased functional length of the bowel. The causes differ in frequency between adults and children; in adults, surgical resection as a treatment for obesity or tumour resection, and vascular accidents (embolism and or thrombosis of the mesenteric vessels) are the commonest causes. In children, the commonest causes are necrotizing enterocolitis, narrowing of the intestinal lumen by volvulus, hernia, and intussusceptions. Other causes in both age groups include Crohns disease, radiation enteritis, trauma, and abdominal tumours (Parrish, 2005).
Diarrhoea and steatorrhoea are cardinal symptoms, in addition, manifestations caused by increased gastric secretions and intestinal motility changes are usually present. In addition, osmotic drag of water and electrolytes to the small bowel lumen worsens diarrhoea. Changes in GIT motility in the form of increased transit rate, and decreased gastric emptying rate result in a degree of stagnation of intestinal contents, which is a risk factor to increased growth of small intestinal (Parrish, 2005).
Tropical sprue is characterised by persistent and prolonged diarrhoea, it is endemic in many Asian countries, some Caribbean islands, and parts of South America; therefore called travellers diarrhoea. This suggests environmental factors present in endemic areas; American soldiers serving in Vietnam suffered the disease, which calls for high suspicion index for military and other Servicemen cases appearing in Afghanistan and other endemic areas (Khokhar, 2004).
In his retrospective descriptive study on chronic diarrhoea patients is conducted in Islamabad (Pakistan) between 1994 and 2003. Khokhar (2004) inferred the disease aetiology is still unknown but a pleomorphic virus similar to orthomyxovirus and corona virus was identified in some adult and children cases. All patients in the series reviewed showed megaloblastic anaemia because of B12 and Folic acid deficiency. Treatment is mainly by tetracycline, folic acid supplementation, and fluid and electrolyte replacement during the acute phase (Khokhar, 2004).
Whipples disease (intestinal lipodystrophy) is a rare disease affecting mainly middle-aged men, caused by Tropheryma whippelii, and the main characteristic is chronic diarrhoea and arthritis. The organism may be present in the environment evidenced by morphological relationship to actinomycetes; and isolation of the organisms DNA in the gastric juice of 10 % and the saliva of 30% of healthy individuals. Currently, there is not enough data available on specific antibodies against the organism isolated from patient. Treatment is by tetracyclines for long periods up to two years (Dutly and Altwegg, 2001).
Coeliac disease
Coeliac disease is a chronic inflammatory disorder affecting the small intestine (the jejunum more than the ileum) and has genetic predisposition (Scott, 1975). Torres and colleagues (2007) reviewed the recent concepts in coeliac disease focusing on pathogenesis, prevalence, and diagnosis and inferred the chronic inflammatory process is T-cell mediated which results in the autoimmune characteristics of the disease.
The main disease characteristic is the bodys immune response to ingested wheat gluten and related proteins of rye and barley. This response is the cause of the chronic inflammatory process that results in atrophy of intestinal villi, and hyperplasia of the intestinal crypts. The disease affects children and adults and is the commonest small bowel disease caused by food allergy in humans, the disease prevalence in North America and Europe ranges from one in 100 to one in 300.
Green and Cellier (2007) stated the disease develops only if the individual has one of two or more alternative forms (alleles) of HLA (Human Leukocyte Antigen) gene. These alleles occupy the same position locus on paired chromosomes and control the same inherited characteristic (HLA-DQ2, and HLA-DQ8).
Epidemiological studies suggest that environmental factors play an important role in developing coeliac disease traits. These factors are the protective effect of breast-feeding, and the timing of introducing gluten contained food to weaning (at four month age carries a high risk, while at seven months carries a marginal risk). Second, Rotavirus gastrointestinal infections increase the risk to develop coeliac disease traits early in life (Green and Cellier, 2007).
Gluten ingestion triggers coeliac disease traits; the alcohol-soluble gliadin is the main component of gluten protein that forms the main toxic bulk. The undigested molecules of gliadin make amino acids fractions resistant to enzymatic degradation by gastric, pancreatic, and small intestinal brush borders protease enzymes. Thus, these chains remain in the small bowels lumen to cross the epithelial barrier on increased intestinal permeability as when infection by Rotavirus occur to interact with antigen-presenting cells in the lamina propria resulting in immune reaction and consequently the chronic inflammatory process (Green and Cellier, 2007).
The clinical picture of coeliac disease vary with age, in infants and young children the presenting symptom is usually diarrhoea, abdominal distension, vomiting, anorexia, and failure to thrive are common complaints at this age group. In older children and adolescents, extra-intestinal manifestations are more common as short stature, and anaemia. In adults, females are more commonly affected than males (2-3 to 1) with dominating symptoms of iron deficiency anaemia and osteoporosis (Green and Cellier, 2007).
Torres and colleagues (2007) pointed to the changing pattern of clinical presentation of the disease in adults as diarrhoea, and abdominal discomfort becoming more common. Besides, iron deficiency anaemia and osteoporosis manifestations are becoming common presentations in silent cases without diarrhoea.
Diagnosis of coeliac disease needs duodenal biopsy that displays intra-epithelial lymphocytosis, villous atrophy, and crypt hyperplasia. Indications for serological tests are persistent unexplained abdominal discomfort with or without malabsorption symptoms or irritable bowel syndrome. The most sensitive antibody tests for diagnosis are the immunoglobulin A (IgA) class (Green and Cellier, 2007).
Pancreatic diseases causing malabsorption
Exocrine pancreatic insufficiency may result from chronic pancreatitis, pancreatic tumours, resection, or genetically determined cystic fibrosis (Scott, 1975). Cystic fibrosis is caused by a recessive gene on autosomal chromosome 7, estimated to be present in 4% of individuals. This gene controls movements of water and electrolytes across the cell wall; therefore, faulty gene results in increased electrolytes and decreased water entering the cell, subsequently secretions become thicker to obstruct secretory glands ducts.
Turnpenny and Ellard (2007) stated that 85% of cystic fibrosis patients have pancreatic ducts blocked by the thick secretions resulting in obstruction of pancreatic enzymes release with subsequent malabsorption and steatorrhoea. Besides steatorrhoea, diabetes may or may not be present, with occasional abdominal pain, and duodenal biopsy may be normal. Picture of complications like pseudo cyst formation and or biliary obstruction may be present. Lundh test (low trypsin on feeding a standard meal) is positive. Treatment includes pancreatic extract, and low fat and high protein diet (Diakowska and others, 2006).
Pathophysiology
There are three phases of absorption in the small intestine. First is the luminal phase during which hydrolysis and breaking down of carbohydrates, proteins, and fat ingested occur, this phase depends on pancreatic and biliary enzymes. Second is the mucosal phase, during which final hydrolysis of dietary food elements occur, and absorbing the hydrolysed molecules by intestinal mucosal cells processing them in preparation for cellular transfer and export. Third is the transport phase where the absorbed nutrients are transferred to blood and lymph circulation. Both second and third phases depend mainly on the functional and anatomical integrity of the intestinal mucosa (Sedlack and Viggiano, 2008).
About minerals and vitamins, Sedlack and Viggiano (2008) stated that absorption of iron, calcium, magnesium, and water-soluble vitamins occurs in the duodenum and jejunum. Fat-soluble vitamins (A, K, D, E, and B12) absorption occurs in the ileum, taking in consideration the jejunum cannot adapt to absorb fat-soluble vitamins whereas the ileum can adapt to absorb minerals and vitamins.
Dietary carbohydrates are mainly in the form of starch, disaccharides, and glucose and can only be absorbed in the small intestine as monosaccharides. This mandates primary digestion by pancreatic amylase enzyme and disaccharidases enzymes secreted by the small intestine brush border. Lactose (milk disaccharide) needs digestion by lactase enzyme secreted by the small intestine brush border. Dietary proteins are in the form of polypeptides and need massive hydrolysis to smaller sized units (dipeptides or tripeptides) a process called proteolysis. This process is aided by pepsin enzyme secreted from the stomach (chief cells) as pepsinogen.
Proteolysis also needs trypsinogen and other peptidases enzyme secreted from the exocrine pancreas (acinar cells). Enterokinase enzyme secreted by the small intestine brush border activates these pro-enzymes to pepsin, and trypsin. Thus, enterokinase deficiency results in hypoproteinaemia. Dietary fat is commonly available in food as triglycerides acted upon by pancreatic lipase to produce fatty acids and glycerol. Transformation of these simpler products to chylomicrons occurs by the intestinal mucosal cells before being absorbed into the circulation through lymphatic circulation (Binder, 2005).
There are three different mechanisms for diarrhoea in malabsorption syndrome, Sedlack and Viggiano (2008) explained these mechanisms as follows. Osmotic diarrhoea where water-soluble molecules are not absorbed and retained in the small intestinal lumen; thus, increasing the inside osmotic pressure. This results in stool volume less than a litre per day with increased osmolar gap but diarrhoea stops on fasting.
Lactase deficiency, sorbitol rich foods (a sugar used in diabetic sweet diet) and excessive use of antacids cause this type of diarrhoea. In secretory diarrhoea, there is abnormal water and electrolyte transport through the intestine, in other words, the intestine secretes rather than absorbs. In this case, the stool volume is more than a litre per day, and is more like extracellular fluid in osmolarity and composition.
Diarrhoea does not stop on fasting, and the condition occurs on exposure to bacterial toxins, steatorrhoea, over use of laxatives, and hormone-secreting tumours as Zollinger-Ellison syndrome. The problem in exudative diarrhoea (third mechanism) is abnormal permeability of intestinal mucous membrane to allow transfer of serum proteins, mucous or blood into the intestine lumen. It occurs in invasive bacterial infections (as shigellosis), inflammatory, ulcerative or infiltrative bowel disease. Motility GIT disorders may take a rapid transit form as in short bowel syndrome where diarrhoea is because of malabsorption, or take a delayed (slow) transit form, where diarrhoea is because of bacterial overgrowth as in stagnant loop syndrome (Sedlack and Viggiano, 2008).
Diagnosis
A road map to diagnosis of malabsorption syndrome is shown in appendix two figures two (initial assessment) and three (further assessment) (Schiller, 2004).
Based on the request of the Chairman of the British Societys clinical services committee, Thomas and colleagues (2003) published the second edition of guidelines to investigate a case of chronic diarrhoea. Based on these guidelines, initial evaluation includes history of present illness, diarrhoea of more than three months, accompanied by weight loss, mainly continuous or nocturnal, and large volume of stools are suggestive of organic disease. Positive family history may raise suspicion on coeliac disease or inflammatory bowel disease. Medical history may suggest short bowel syndrome, pancreatic disease, a systemic disease, or a drug induced diarrhoea.
Thorough examination is useful in diagnosis and assessment, dry tongue and skin point to dehydration, oedema point to hypoproteinaemia. Associated iron deficiency anaemia suggests proximal small intestine malabsorption, examining the stools for blood or occult blood is a wise practice in these cases. Associate metabolic bone disease, osteoporosis or osteomalacia, points to defects in calcium and protein absorption that is proximal bowel malabsorption. Hyper-pigmentation points to the possibility of Whipple disease, coeliac disease, or eosinophilic gastroenteritis. Associated arthritis commonly points to Whipples disease or ulcerative colitis.
Initial investigations include complete blood picture, ESR, C-reactive protein, liver function tests, blood urea, serum electrolytes, folate, serum iron, and Schilling test for vitamin B12 malabsorption. Although these tests have a high specificity; yet, they have low sensitivity as an indication for organic disease. Although infectious diarrhoea is uncommon in immuno-competent patient, yet stool culture and microscopic examination should be done.
Qualitative faecal fat stain and quantitative faecal fat determination are needed to diagnose steatorrhoea. Specific stool tests as faecal elastase (for pancreatic enzymes), stool osmolality and measuring the osmotic gap help to distinguish the diarrhoea mechanism. Stool analysis for fat, blood, and markers of inflammation (as lactoferrin) are helpful tests to assess the cause of diarrhoea. Serological tests as antiendomysium antibodies help to diagnose coeliac disease (Thomas and colleagues, 2003).
Further evaluation includes mainly distal duodenal biopsy may show Howell-Jolly bodies in cases of coeliac disease (interpreted with other findings as there are many causes for differential diagnosis). Small bowel imaging (barium follow through) reserved to cases where distal duodenal biopsy is negative. Non-invasive techniques as Technetium hexa-methyl-propylene amine labelled leukocyte scanning is helpful to diagnose inflammatory disease especially Crohns disease (Thomas and colleagues, 2003).
Nutritional consequences of malabsorption syndrome
Malabsorption is a serious condition to all age groups; however, it is of special importance in young age groups as infants and children are growing, the associated nutritional deficiencies may cause enduring growth and development (both physical and mental) disabilities. Dehydration that warrants fluid therapy is common in all age groups; however, cases of hypoproteinaemia with oedema may be an exception.
Electrolyte and vitamin deficiencies need special care for diagnosis and replacement treatment. Remote consequences of malabsorption may affect all body systems, chronic inflammation of the GIT mucosa because of the disease, or associated vitamin deficiency aggravates the condition. Anaemia specially iron deficiency and megaloblastic are common occurrences. Abnormal bleeding tendency because of vitamin K deficiency may also occur.
Osteoporosis and osteomalacia are also common because of calcium, magnesium, vitamin D, and protein malabsorption, calcium deficiency gives rise to tetany. Amenorrhoea, impotence, and infertility may occur because of nutritional deficiencies. Hyperparathyroidism resulting from calcium and vitamin D deficiency may also occur. Nervous system disorder may occur with peripheral neuritis secondary to vitamin deficiency is the commonest. Skin affection occurs in the form of hyperkeratosis secondary to vitamin A, zinc, essential fatty acid deficiencies, petechiae and purpuric rash secondary to vitamin K deficiency occurs (Semrad and Powell, 2008).
Prognosis and treatment
In mild cases, the main treatment objective is to maintain hydration and nutrition through symptom control using antidiarrheal agents as bismuth subsalicylate. In moderate to severe cases or cases associated with other clinical manifestations as fever, anaemia, blood or fat in the stools, or dehydration or changes in serum electrolytes, treatment strategy focuses on replacement therapy, and specific cause therapy (Scott, 1975).
Non-specific treatment is targeted to dietary modification, where it is advisable to have smaller and more frequent meals. Limit gas producing food, straw use, and chewing gums. Limiting spices, and fibres in meals, lactose, gluten rich foods (in coeliac disease), and fats in steatorrhoea are advisable measures. However, vitamin and mineral supplements are advisable early (Jeejeebhoy, 2002). Intravenous nutrition indications are dehydration, electrolytes disturbances, emergency conditions (as bleeding, toxaemia, or postoperative). Oral nutrition is the preferred route to maximize the calorie content from fats and carbohydrates, and maximize the protein content, taking in consideration not to worsen the diarrhoea (Sedlack, and Viggiano, 2008).
Every effort should be made to reach an aetiological diagnosis; effective specific treatment depends of knowing the cause of malabsorption. Antibiotics are advisable in infective cases or case of bacterial overgrowth (short bowel, and stagnant loop). Pancreatic enzymes preparation in pancreatic malabsorption, cholestyramine is useful in cases of malabsorption secondary to bile acid malabsorption. Specific antidiarrheal medications are useful if the mechanism of diarrhoea is identified, an example is clonidine in secretory diarrhoea (Shaffer, and Thomson, 2000)
Prognosis of malabsorption depends on patient factors as age, associated diseases (AIDS, Addisons disease, diabetes), and management factors. Prolonged untreated deficiencies or acute disturbance of electrolytes may seriously affect the disease outcome. Although malabsorption syndrome has high morbidity; yet except cystic fibrosis, it has a low mortality. Another factor is the slowly progressive course and late onset of some disorders, which may delay the treatment. Patient education is of great importance in determining the prognosis, as the treatment may be for long period, dietary supplements and restriction may continue for life; therefore, patient understanding and cooperation is an important factor in prognosis (Semrad, and Powell, 2008).
Conclusion
Malabsorption syndrome is a challenging condition because of the various causes, the patho-physiological mechanisms, and the complex differential diagnosis. Tailoring management strategy based on individual case presentation is the best approach for proper diagnosis and efficient treatment.
References
Adlersberg, D., 1960. Classification of Malabsorption Syndrome: Introductory Remarks. American Journal of Clinical Nutrition, (8), 166.
Binder, H. J. 2005. 275: Disorders of Absorption. In Kasper, D., L., Braunwald, E., Fauci, A., Hauser, S., Longo, D., L., and Jameson, J., L. (editors). Harrisons Principles of Internal Medicine. 16th edition. New York: McGraw-Hill Medical Publishing Division. 3113-3120.
Diakowska, D., Diakowski, W., Knsat, W., Grabowski, K., et al, 2006. Abnormal Metabolism of Cholesterol Fractions in Chronic Pancreatitis and Results after Surgical Treatment. Adv Clin Exp Med, 15 (4), 631-636.
Dutly, F., and Altwegg, M., 2001. Whipples Disease and Tropheryma whippelii . Clinical Microbiology Reviews, 14 (3), 561-583.
Green, P. H. R. and Cellier, C., 2007. Celiac Disease. N Engl J Med, 357 (17), 1731-1743.
Greenson, J. K., 2005. The Surgical Pathology of Malabsorption. Web.
Montalto, M., Santoro, L., DOnofrio, D., Curigliano, V. et al, 2008. Classification of malabsorption syndrome. Dig Dis, 26(2), 104-111.
Parrish, C. R., 2005. The Clinicians Guide to Short Bowel Syndrome. Practical Gastroenterology, 29 (9), 67-106.
Scott, Ronald, B. [Sir] (Editor), 1975. Prices Textbook of the Practice of Medicine. 11th edition. London: Oxford University Press.
Sedlack, E., and Viggiano, T., 2008. Chapter 7: Gastroenterology and Hepatology, Part 1. In Habermann, T. M., and Ghosh, A. K., ed. Mayo Clinic Internal Medicine Concise Textbook. Rochester, MN: Mayo Clinic Scientific Press and Informa Healthcare USA, INC. 228-231.
Semrad, C.E., and Powell, D., W, 2008. Chapter 143: Approach to the Patient with Diarrhea and Malabsorption. In Goldman, L., and Ausiello, D., ed. Cecil Textbook of Medicine. 23. Philadelphia, PA: Saunders. 1046-1062.
Shaffer, E., A., Thomson, A., B., Astra Inc. Staff, and Staff of the Canadian Association of Gastroenterology, 2000. First Principles of Gastroenterology: The Basis of Disease and an Approach to Management. Chapter 7: Section 9. Ottawa: Canadian Public Health Association.
Thomas, P. D., Forbes, A., Green, J., Howdle, P., Long, R. et al, 2003. Guidelines for the investigation of chronic diarrhoea, 2nd edition. Gut, (52 [Suppl V]), v1-v15.
Torres, M. I., Casado, M. A. L., and Rios, A., 2007. New aspects in celiac disease. World J Gastroenterol, 13 (8), 1156-1161.
Turnpenny, P., and Ellard, S., 2007. Emerys Elements of Medical Genetics. Section B. London: Elsevier/Churchill Livingstone.
Being a nurse manager is a very complex job. It involves organizing people with varying personalities, skills, and education to give high-quality and safe patient care (Yoder-Wise, 2011). A nurse manager is responsible for financial management, patient outcomes, and resource utilization. Therefore, a good and efficient nurse manager should provide the necessary leadership that will ensure that the care given at the hospitals is in accordance with the organizations policy (Whitehead, Weise & Tappen, 2010). This paper will examine the qualities of Nicole Harrison, a Nurse Manager in the Intensive Care Unit of MD Anderson Cancer Center.
Nicole Harrison has been an employee of Texas University Hospital since 2005 (FindTheBest, 2012). Currently, she enjoys an annual salary of $151200. She had been in the nursing profession for quite some time and has enjoyed working in four other hospitals before finally landing at this hospital in 2005. Nicole was employed by the University of Texas MD Anderson Cancer Center agency as a nurse but eventually rose up the ranks to the current position. She has been working as a nurse for 20 years acting in various capacities in different hospitals. She believes that her current work is the best and hopes to spend the remaining professional years at this place.
Nicole is a level four nurse, with all the certifications needed. She currently holds a masters degree in nursing. Nicole is pursuing a Ph. D in nursing at the hospitals university (FindTheBest, 2012). She is therefore an expert nurse with a lot of experience. She is also a fully registered nurse and a licensed Vocational Nurse approved to operate anywhere in the United States. All these educational qualifications coupled with her work experience have helped her attain the current position as a Nurse Manager (Whitehead et al, 2010).
The Intensive Care Unit MD Anderson Cancer Centers roles include the provision of anesthesia care, life support, and pain management for patients that require intensive care at this hospital (The University of Texas, 2013). The care provided to the patients at this level is very detailed. A team of care experts and nurses work together to ensure the needed care is effectively administered to patients. As a nurse manager in the intensive care unit of the hospital, Nicole plays a major role in ensuring that all operations in the unit run effectively (The University of Texas Medical School, 2006). The numbers of nurses that work under her supervision are 200. The hospital has 52 intensive care unit beds where the nurses operate in shifts to ensure 24 hours daycare is offered to the patients (The University of Texas Medical School, 2006). This means that the amount of responsibility dedicated to her by the hospital is a lot (The University of Texas, 2013). Therefore, she ensures the units performance is kept at par with other units with the aim of achieving the hospitals mission.
She believes in several leadership philosophies that have helped her perform her duties effectively. She says that for an individual to be a leader, the person must possess integrity, be empathetic, consistent and fair (Harwood, 2012). She accords her success as a nursing leader to the above principles and her ability to understand diverse perspectives in the field of health care. She also observes the ethics required in the nursing profession. She has involved herself in community service on many occasions. This presents her as a leader who has a sense of service (Harwood, 2012).
Nicole believes that nursing to her is not just a profession. It is a calling as she notes down. She recognizes Faye Glenn Abdellah born on March 13, 1919. She was a great theorist and an exemplary leader in the field of nursing (Nursing Theory, 2011).
Being a nurse is a challenging role in society. It is a noble profession. It offers an opportunity to meet people from different aspects of life (Denver Health, 2010). Through nursing, Nicole has been able to interact with so many people and understand the different aspects of humanity. Through nursing leadership, Nicole also developed personal responsibility, confidence that has helped her accomplish so many things in her life. Above all leadership in nursing also carries a package of negative aspects. The long hours needed at the workplace leaves an individual with limited personal and family time (Whitehead et al, 2010). These may result in stress due to lack of rest and a feeling of being overworked. The only thing that keeps Nicole going is the level of appreciation she gets from the hospital and the community at large. Nursing can only be fully realized when practiced as an art and at the same time as a science. The social aspect of nursing should not be neglected.
When a new nurse is to be assigned to the department, Nicole looks at various aspects apart from the educational qualifications. The history of the nurse to be hired is put into consideration. For instance, the individual should be a top performer with minimal patient death (Denver Health, 2010). The new nurse is also interviewed for patient satisfaction rates and the number of innovations the individual has initiated at workplace. A nurse in this department must possess very high standards of professionalism and be willing to spend most of their personal time with the patients.
Nicole believes in herself as a competent nursing leader. She is in the process of attaining the highest levels of education in the nursing field. Moreover, since she is in one of the best cancer medical centers in the world, she is not planning to look for a job elsewhere. She believes that she will be among the top leadership of the hospital with time due to her stunning performance as a nursing head.
From Nicoles interview, it can be observed that she is an exemplary nursing leader that any fresh nursing graduate should emulate. A good leadership style involves a well-balanced approach to individual values and the requirements the organization one is working for needs (Denver Health, 2010). A good leader must be visionary, this will enable professional attainment of the organizations goals. Passion is also an important aspect of good leadership. A nurse leader should show her passion for the nursing job. This will ensure that other nurses are inspired to follow the leaders direction and hence enhance the hospitals efficiency (Denver Health, 2010). Another important aspect of good leadership is integrity. One should be honest and use his/her knowledge in such a way that maturity is demonstrated. A leader nurse should always stick to the code of ethics; this ensures that moral leadership is realized. If a leader puts in mind all this then the leadership style will be the best; leadership by example (Denver Health, 2010).
Prof. Phillip Backer, a nursing theorist who visualized nursing from a fluids point of view, can illustrate the kind of leadership that is necessary for nursing (Nursing Theory, 2011). He believes that life is a continuous journey on the sea and illness is fluid. This paradox is built on the patient as the most important goal in the nursing field. He came up with the guide of nursing in the form of the Ten Commandments. These rules if observed by any nursing leader then the outcome of the nursing practice will always be positive and satisfactory (Nursing Theory, 2011). The rules in this case simply describe what is required of a nurse while in practice.
I believe I will eventually make a great nurse. Currently, I am almost through with the educational requirements needed for a professional nurse. Five years from now, I expect to be a leader in any capacity as a nurse. The skills and passion I possess will enable me to attain that goal (Denver Health, 2010). I am planning to get into the job market as a nurse as soon as possible and start implementing the policies that I think are the best for patients. I believe this will help me build a professional code of conduct that is acceptable. I will use all the necessary talent and skills that I have at my disposal to enable me to attain that goal. Therefore, any individual who wishes to join the nursing fraternity should be prepared to handle the prevailing dynamics that accompany the day-to-day activities of a nurse.
References
Denver Health. (2010). Special Nursing Annual Report: 150 Years of Level One Care for All. Web.
FindTheBest. (2012) Nicole P Harrison Dir, Clinical Nursing Nursing Administration. Web.
Over the last decade, there have been several advances in anesthetic and surgical techniques which have greatly impacted the work of postoperative care. These improved areas have seen many patients recover very quickly with minimal effects from an anesthetic state (Monda & Oesterling: 717). New and improved suturing materials have become available and thus have enabled more operative surgery to be performed (718). Because these techniques facilitate quicker recovery, the patients stay in hospital has remained quite short and the number of patients going through surgical wards has increased spontaneously hence drastically expanding the role of postoperative nursing care.
However, challenges still exist among patients who have undergone radical prostatectomy and ones who have had a transurethral resection. This is because there are variables that enter treatment decision making such as age, accompanying comorbidities, and patient preference, and significant other demands and opinions (Merrill & Potosky: 1603). Furthermore, prostatectomy may result in serious side effects on the patient, hence treatment and care that seem equal based on disease response and survival may not be significant since most patients have been found to mostly suffer from localized prostate cancer.
On the other hand, transurethral resection of the prostate (benign prostate hyperplasia) has become a common urological condition among aging males (1604). Studies have revealed that at least half of men above 50 years of age have some degree of prostatic enlargement even though the cause is unknown (Parker & Tong: 7). When the enlargement of the prostate occurs to the point where urine outflow is obstructed, transurethral resection of the prostate is one of the most commonly preferred treatments (12).
Radical prostatectomy
In most cases, radical prostatectomy is performed when there is a complete lack of evidence of metastases (Walsh & Worthington: 54). If such a scenario occurs, two types of radical prostatectomies are performed namely: retropubic approach or perineal approach. In the retropubic approach, an incision is made in the lower abdomen and there is a possibility that the surgeon may avoid removal of the nerves controlling erections and bladder muscles (54).
If this happens, there is a likelihood of lowering the impotence risk as well as incontinence that is a common feature of many of such similar surgeries (55). However, it should be noted that this does not eliminate the possibility of such complications occurring. On the other hand, a radical perineal prostatectomy involves doing an incision in the skin between the scrotum and anus (Religio & Larson: 259). It is noted that in this type of surgery, it is not possible to do nerve-sparing surgery through the approach and again it does not support the removal of lymph nodes (260). In some cases, however, a surgeon may remove some lymph nodes by doing a small incision in the abdomen through the use of a laparoscope (261).
The period for the surgeries may take in between two to six hours, but the perineal approach normally takes a shorter time as compared to the retropubic approach (Religo & Larson: 262). However, both types of surgeries may lead to an approximate hospital stay of three days and about 4 weeks of absence from work (Wilson: 343). During the operation, the management of fluid is normally maintained through administering crystalloid and colloid solutions (Wilson: 344).
After the operation, the patient is moved to the recovery ward where the nurse assesses the patients respiratory status and ensures that the patient is going through normal respiratory functions (Wilson: 345). Some of the identified causes of airwaves are 1. obstruction as a result of collection of mucus in the throat, vomit aspiration; laryngospasm attributed to intubation and anesthetic irritation; bronchospasm attributed to any other respiratory disease experienced by the patient earlier, and if the patient inhale gastric juices during surgery (347)
Postoperative care following a radical prostatectomy usually involves the management and care of the ureteral injury, bladder injury, and urine leak from an anastomotic site (Walsh & Worthington: 71). Rectal injury has been detected in some cases as well; it has been proved that successful laparoscopic two-layer rectal wall repair can be achieved when the injury is detected earlier during the intraoperative session (73). However, if this fails, some extra operative interventions will be needed.
After the surgery, the nurses continue to observe and assess the patients condition closely. It is crucial to maintain the patients airways together with ensuring the patient is well oxygenated and thus if necessary, the working suction to be made available at all times; and administration of oxygen for the early period of post-operation to be needed until the patient appears to have good skin color (Walsh & Worthington: 74). Sometimes specific suctions may have been provided by the surgeon in the patients notes and thus should be followed to the latter and the wound sites and drainage are observed for excessive blood loss (Wilson: 349)
The extraperitoneal approach to radical prostatectomy is necessary since it reduces the intra-abdominal complications such as ileus, avoidance of peritoneal space in patients with a history of previous abdominal surgery, and limitation of postoperative urine leak to the extraperitoneal space (Walsh & Worthington: 74). This approach calls for the first step which entails helping the patient manage their urinary incontinence i.e. it involves an assessment to identify characteristics and contributing factors of the urinary incontinence (74).
In this case, a patient profile will be identified through the number and amount of incontinent and incontinent episodes, precipitating events, urgency and leakage, and a number of pads used (74-75). In most cases, an indwelling catheter is being inserted into a patients bladder immediately after the surgery, especially when the patient is still asleep to ensure he or she urinates easily (Wilson: 350). This will ensure the pressure on the operative area is reduced and at the same time allow the nurse to measure the output of the urine (Wilson: 350).
Transurethral resection
Transurethral resection requires the intervention of nurses that primarily involve the management and prevention of the resultant complications. When the most dangerous complication, commonly known as transurethral resection (TURP) syndrome occurs, it normally causes severe dilutional hyponatremia as hypervolemia (Parker & Tong: 7).
Transurethral resection of the prostate involves the insertion of a resectoscope along the urethra by the use of a loop that has been electrically energized to excise hyperplastic lobes of the prostate (Beetstra & Gabrielson: 163). After the surgery, the patient is expected to be retained as an inpatient, where the nurse begins his or her duty by first completing an initial assessment and monitor for the signs of urinary compromise (Monda & Oesterling: 720; Beetstra & Gabrielson: 165).
The nursing interventions entail monitoring the urinary catheter for any signs of patency as well as blood loss, often conducted after every 1 to 2 hours as recommended by the American Urological Association (Monda & Oesterling: 723). Such signs of excessive blood loss being monitored are rapid pulse and decreasing blood pressure and input Vs output after every one or two hours (724). After the check is done, the output can be calculated by subtracting the total amount of irrigation solution infused from the total amount of urine output that is emptied from the bag (730). In case blood clots supersede the catheter drainage, irrigation may be performed and if the anomaly persists, continuous bladder irrigation, commonly known as CBI infusion, may be performed (Schover: 11; Monda & Oesterling: 726).
The removal of the urinary catheter is normally done after 3 days and the nurse continues to monitor the urinary output in a span of two to four hours, and subsequently encouraging the patient to take between two to 3 L of fluids per day. This is meant to relieve the patient of dysuria and eliminate hematuria (Monda & Oesterling: 732; Beetstra J & Gabrielson; 166).
Occasionally, discomfort may occur as a result of irrigation, bladder distention, or bladder spasm, thus prompting the physician to recommend the use of smooth muscle relaxants e.g. opium suppositories (Beetstra J & Gabrielson: 166). Combining this with the minimization of the catheter manipulation and an additional rest normally provide a good start for the patients comfort (167). Since the discomfort is largely attributed to the irrigation of the meatal resulting from the movement of the catheter, it is important to reduce the pressure through frequent rotation of the bladder with such equipment as Velcro holder (Monda, J. & Oesterling: 734)
Conclusion
Radical prostatectomy is a very important treatment for non-metastatic prostate cancer. However, the operation can be lengthy and may come with additional side effects due to the incisions on the surrounding tissues and glands (Monda & Oesterling: 136).
Nurses, therefore, play an integral part in the postoperative care of such patients as they recover from the effect. At the same time, caring for the TRUP patients need skilled medical and nursing care after the surgery to ensure the patients experience the least amount of pain as they recover. In both cases, patient education will form an integral part of the care process since this will not only facilitate quicker recovery but will form a crucial step in the transition to home care (Monda & Oesterling: 137). Primarily, this calls for a clear knowledge of the appropriate treatment techniques to ensure a positive outcome of the whole nursing process.
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