Ascites Is A Special Case In The Medical Geriatric Ward Nursing Essay

Ascites Is A Special Case In The Medical Geriatric Ward Nursing Essay Background I think ascites is a special case in this Medical Geriatric ward, because I saw this only one case of ascites in this four weeks practicum. And it is my first time that care patient with ascites. Therefore, I interest and choose this case for studying the nursing care of ascites. In this total patient care study, I will talk about the information and relevant clinical data about this case, the pathophysiology of ascites, the nursing assessment, care plan within patient hospitalize period 20-21/09/2010, plan for future management, and what I learn from this case. Case presentation Patient X is 72-year-old male. He lives in old age home, chair bound for activities of daily living. He is dependent Comprehensive Social Security Assistance, exsmoker and exdrinker. He was admission to Accident Emergency at 20/09/2010. He complained that increased abdominal distension for 2 days, poor appetite, shortness of breath. Physcial condition: conscious, SaO2 95% under room air, afebrile, chest clear, no ankle edema. His primary diagnosis is cirrhosis and gross ascites. He has chronic renal impairment, diabetes mellitus, alcoholic cirrhosis of liver, and chronic ascites. Last time admitted from 05-07/09/2010 for ascites, therapeutic abdominal tap was done and 1.3L ascites fluid was removed. Ascites is an accumulation of extracellular fluid in the peritoneal cavity abnormally. It is the most common major complication of portal hypertension following liver cirrhosis. Blocking the blood flow through the liver sinusoids to hepatic veins and vena cava lead to increased pressure in the portal venous system. It results in plasma leaks out directly from the liver capsule and the congested portal vein into the peritoneal cavity. In addition, hepatocellular damage reduces the livers ability to synthesize normal amounts of albumin, which may deteriorate by leakage of protein in ascites. The evidence of hypoalbuminemia shows in the blood test that the albumin was 24g/L, which is a low level. Adlosterone cannot activate by liver to stimulate the kidneys to retain sodium and water due to hepatocellular damage. Thus, sodium and water are still retention, and the volume of peritoneal cavity fluid grows continue. In this case, the medical management can be performed to patient X should be paracentesis or abdominal tap. This procedure involves using a thin needle to pull ascites fluid from the abdomen (George Longstreth, 2009). Large-volume paracentensis repeated done in combination with Albumin administered intravenously, which can avoid a sudden drop in blood flow in the arteries and to replace each liter of removed ascitic fluid. The physician prescribed IV administration of Albumin 40g after tapping and 30g. 10500ml milk like in color of ascites fluid was removed. If ascites is recurrent, therapeutic abdominal tap may need to be done every two weeks or more frequently, and need to remove up to 10 liters ascites fluid (Cirrhosis Ascites). Ascitic fluid analysis also done before for provides a sample of fluid for analysis, which help for determine the underlying cause of the ascites. No malignant cell was found. An abdominal x-ray and ultrasonography study was done to comfier the presence of ascites. It may locate fluid in the peritoneal cavity. The result did not show dilated bowel. A low sodium and protein diet with restriction of fluids 1L per day. Edema in the form of ascites brings about shallow breathing and impaired gas exchange, as a result of respiratory compromise. We need to Promote and maintain an effective breathing pattern, Arterial blood gas analysis and pulse oximetry monitor every four hours were ordered. Potassium- sparing diuretic Frusemide tablet 40mg twice a day was prescribed. Nursing assessment In abdominal assessment, inspect for skin integrity (pigmentation, lesions, scars, veins, and umbilicus, etc), contour (flat, rounded, etc), distension, respiratory movement, visible peristalsis, and pulsations. Then to auscultation of the abdomen, warmed the stethoscope and the hands, light pressure act on the stethoscope is sufficient to detect bowel sounds and bruits. Then perform percussion of the abdomen; abdominal percussion is aimed at detecting fluid in the ascites, gaseous distension, and masses within the abdomen. Percuss lightly on abdomen according to auscultation site at each abdominal guardant. The sound will be dull if the ascites is presence. Measure the abdominal girth circumference. Assess the amount of distress leaded by the ascites that ask the patient whether the fluid is interfering with sleeping, eating, and breathing (Head-To-Toe Assessment (R. Abdomen), 2008). Nursing diagnosis Excess fluid volume and deficient fluid volume related to fluid shifts secondary to portal hypertension, hypoalbuminemia. It is a combination of volume problem for patient with ascites. The expected outcomes of this care plan are that a normal balance of fluid in the peritoneal cavity will be maintained as evidenced by normal serum albumin levels, without of hypovolemia, decreased abdominal girth, and normal blood pressure measurement. Electrolyte or acid- base are balance. For nursing intervention, monitor the intake and output of patient daily, and record the IO chart. Output should be equal to or exceed intake. Strictly restrict the patients fluid intake. If possible, administer medication with meals, so mealtime fluids can be used for taking medications. Assess the patients dietary intake and habits that may lead to fluid retention. Limit high sodium intake, because it can lead to increased water retention. Administer albumin and diuretics as physician prescribed. Aspirin and nonsteroidal anti-inflammatory drugs may inhibit prostaglandin synthesis and impair sodium excretion by the kidney. Thus, it needs to avoid administering them. Weight the client and measure the patients abdominal girth daily. Closely monitor the patient after paracentesis procedure. To ensure the client has tolerated the procedure well, check the vital signs frequently. Check the dressing carefully to ensure that there are no losing excessive amounts of fluid. Use a pouch to co llect leaking fluid if necessary. Ineffective breathing pattern related to increased intra-abdominal pressure on the diaphragm. The expected outcomes of this care plan are that the patient express relief of feelings of faulty breathing pattern as a result of no shortness of breath and the presence of normal respiratory excursion. Patient has a normal respiratory rate, compared with baseline. (Lynda juall carpenito-moyet) For nursing intervention, position the client in a high-Fowler position with an arm supported with pillows. It can facilitate breathing and relieves the pressure acting on diaphragm. Monitor the clients respiratory status (crackles and increased respirations) for the development of atelectasis or pneumonia to identifies fluid in lungs. Encourage the patient to deep breathe and cough. Use an incentive spirometer to maintain and monitor the respiratory function. If the cough does not loosen to expectorate reparatory secretion, patient can receive ultrasound treatment For improving gas exchange, administer oxygen and blood products as ordered. Teach the patient some breathing techniques, such as pursed-lip breathing to overcome poor breathing patterns (Lynda juall carpenito-moyet). To evaluation the outcome, treatments of ascites enable the client to breath with minimal difficulty. Imbalanced nutrition: less than body requirements related to increased pressure on stomach and intestines, feeling of fullness, poor appetite. The expected outcomes of this care plan are that patient X has appetite and he can keep or increase body weight to an ideal weight and consume sufficient nutrients. Identify deficiencies in daily intake. For nursing intervention, measure the body weight daily to monitors the weight gain or loss. Monitor hemoglobin, hematocrit, albumin, total protein values for monitoring the intake of nutrients, presence of anemia, and colloidal osmotic pressure. Offer and encourage oral hygiene before meals, because poor oral hygiene may cause bad odor and taste, which can reduce appetite. Encourage the patient to rest before meals due to fatigue may decrease appetite and ability to eat. (Lynda juall carpenito-moyet) Provide small, frequent meals for patient instead of few large ones, because even distribution of intake can help to prevent feeling full and ensures enough nutritional intake. Determine food preferences and selected low or no protein and low salt (no more than 1500 mg/day of sodium). If possible, encourage the patients relative to bring permitted foods from home. Prevent constipation to reduce abdominal pressure and fullness. Administer Lactulose liquid 20mal three times a day as physi cian ordered. Plan for management after discharge, patient x should back to the old age home and have follow up by community geriatric assessment service. Recommend short the follow up clinically admission if symptomatic ascites occur. Refer PCU home care nurse for visiting and symptom assessment, and admission clinically for symptom management. Learning points After this total patient care study, I have learnt that more understand the cause and care of ascites. And know that to provide a holistic care not only physical nursing care, but also we need to care the patient mental, social, finical condition, and discharge planning Make sure patient can have a complete care after discharge. Word count: 1452 Black, J. M. Hawks, J. H. (2009). Medical-Surgical nursing: Clinical management for positive outcomes. Missouri: Saunders. George F. Longstreth MD http://www.healthline.com/adamcontent/ascites#ixzz11s5PVSzi Head-To-Toe Assessment (R. Abdomen) (Head-To-Toe Assessment (R. Abdomen), 2008) (Cirrhosis Ascites). http://www.healthcentral.com/ency/408/guides/000075_11.html

Grapes of Wrath and Migration Experience Essay

The novel, â€Å"The Grapes of Wrath† by John Steinbeck, takes you on a chronicle of one family’s migration, from Oklahoma to California as a result of exodus. The family is forced to migrate west in search of a livelihood during the great depression of the 1930’s. The structure of the chapters in this book alternate between narrating the journey of the Joad family with descriptions of the westward movement of migrant farmers in the 1930s as they flee drought and industry. Steinbeck, a native of California, draws from first hand experiences to guide the reader not only along the journey of one family in particular, the Joad’s but, to also expose the desperate conditions of migrant farming-families faced during the great depression in America. The Joad family was a part of a migration of people called â€Å"okies† which were farmers from the southwest that migrated westward in search of opportunity. The Okies were farmers whose topsoil blew away due to dust storms and were forced to migrate along Route 66 to California in search of work. The Okies were resented for migrating in large numbers to areas in the West where work was already hard to find and the sudden multitude of workers caused wages to be lowered. The Joad’s reside in Oklahoma, referred to as the â€Å"Dust Bowl† of the U. S . because of its lack of rain. The Joads’ were sharecroppers evicted from their homes because they failed to pay the bank their loan payments to the Shawnee Land and Cattle Company. The entire area was being evicted by the land owners, forcing sharecroppers’ to leave all that they have ever know and cared for behind in search of a sustained life elsewhere. The novel opens up by introducing the main characters and painting a picture of a dried up withering Oklahoma farming region. Released from an Oklahoma state prison after serving four years of a manslaughter conviction, Tom Joad makes his way back to his family’s farm amid the desolation of the Dust Bowl. He meets Jim Casy, a former preacher and the man who baptized Tom as a child. Tom gives the old preacher a drink from his flask of liquor, and Casy tells Tom how he decided to stop preaching. He admits that he had a habit of taking girls â€Å"out in the grass† after prayer meetings and tells Tom that he was conflicted for some time, not knowing how to reconcile his sexual appetite with his responsibility for these young women’s souls. Eventually, however, he came to the decision that â€Å"there ain’t no sin and there ain’t no virtue. There’s just stuff people do. It’s all part of the same thing. † No longer convinced that human pleasures run counter to a divine plan, Casy believes that the human spirit is the Holy Spirit. Jim accompanies Tom to his family’s farm; when they find it deserted, fronted by withered crops, they find Muley in that house. Muley is an old family friend that stayed behinde while his family leaves for California to tend to his rightful land. He explains haltingly that a large company has bought all the land in the area and evicted the tenant farmers in order to cut labor costs. The three men proceed forward traveling to Tom’s Uncle John’s house, where they find the Joads preparing for a long trip to California in search of work. The entire family has gone to work picking cotton in hopes of earning enough money to buy a car and make the journey to California. Large California landowners have poster announcement for employment throughout western Oklahoma, and Ma and Pa Joad have decided to move their family their; evicted from their farm by the bank that owned it, they feel as though they have no choice. Once Tom has been reunited with his family, in the following chapters, the narrator assumes the voice of generic tenant farmers, expressing what their possessions and memories of their homes mean to them. The farmers are forced to pawn most of their belongings, both to raise money for the trip and simply because they cannot take them on the road. Steinbeck makes it apparent during this section of the novel that he believes that the economic system makes everyone a victim—rich and poor, privileged and disenfranchised. All are caught â€Å"in something larger than themselves. † This is used to give reference to the bigger picture of society and how situations dictate undesired behavior. In a sense it was a way of taking some hatred off the people hired to kick people off their lands because these people too lost their livelihood. When the time comes to leave, Muley Graves bids the family good-bye, but Grampa suddenly wants to stay. He claims that he aims to live off the land like Muley and continues to protest loudly until the Joads lace his coffee with sleeping medicine. Once the old man is asleep, the family loads him onto the truck and begins the long journey west. When the families leave the farms, the land if left vacant, and is worked by people with no connection to the land. This is used to drive home a theme of man and his relationship to the land as a symbol of ownership. Such a separation between work and life causes men to lose wonder for their work and for the land. As the Joads make their way down highway 66, it is described as being backed-up and filled with broken down poor farmers getting ripped off by auto repair shops selling parts. Steinbeck suggests that the hardships the families face stem from more than harsh weather conditions or simple misfortune. Human beings, acting with calculated greed, are responsible for much of their sorrow. Such selfishness separates people from one another, disabling the kind of unity and brotherhood that Casy deems holy. It creates an ugly animosity that pits man against man, as is clear in Chapter 12, when a gas station attendant suggests that California is becoming overcrowded with migrants†. Steinbeck uses Pa Joad to embody the desire to be connected with the land, this is displayed by his willingness to stay back from his family to tend and live off his native soils. Conversely Jim Casy represents the focus of the family and it’s the most important aspect is to stay together. Ma Joad also represents the glu holding the family together and the backbone of the family unit. The family reaches Oklahoma City, while here they suffer the loss of their dog, and Grandpa Joad, and are forced to give them informal funerals due to a lack of money. After suffering such a major loss, the family picks up new passenger the Wilson’s a family they met broke- down on the side of the road. A few days down the road the family gets told by a car salesman that implications of open jobs in California are false. This brings a large sense of worry among the family because there survival depends on the opportunities waiting in California. At this point of the novel the many amilies traveling along the road have come together as one family creating a sense of comfort and belonging. The people have created rules and enforcement of law; this is a drastic change in identity and life. They are no longer farmers but migrant men. The family reaches California, marking a major shift in the journey. Once in California, the family is warned by Ma that the family is falling apart, as a result of the passing Grandma and the separation from the Wilson’s. Coming after two sets of dire warnings from ruined migrant workers, Granma’s death bodes especially ill for the Joads. They now seem fated to live out the cautionary tales of the men they have met in Chapters 16 and 18, who now seem like predictors of the future. Before the Joads even set foot on its soil, California proves to be a land of vicious hostility rather than of opportunity. The unwelcoming attitudes of the police officers and border guards seem to testify to the harsh reception that awaits the family. Once in California the family is forced to move north by authority, which do not take a liking for the okies. The family reaches a camp where they stay for a little while. This camp was a squatter settlement of okies with no food or work to speak of. This is an unsettling feeling for the Joads and a sense of anguish settles over the family. A man come into the came looking for people to work, but he does not have the proper papers and will not disclose the wages to the workers. This creates skepticism by for the okies and a scuffle breaks out. Which results in Jim Casy taking the blame for Tom knocking out a police officer. The men take Jim Casy away and the Joads flee in search of safety and work. The family finds work in a peach orchard where they get paid 5 cents a basket. That evening, Al goes looking for girls, and Tom, curious about the trouble on the roadside, goes to investigate. Guards turn him away at the orchard gate, but Tom sneaks under the gate and starts down the road. He comes upon a tent and discovers that one of the men inside is Jim Casy. Jim tells Tom about his experience in prison and reports that he now works to organize the migrant farmers. He explains that the owner of the peach orchards cut wages to two-and-a-half cents a box, so the men went on strike. Now the owner has hired a new group of men in hopes of breaking the strike. Casy predicts that by tomorrow, even the strike-breakers will be making only two-and-a-half cents per box. Tom and Casy see flashlight beams, and two policemen approach them, recognizing Casy as the workers’ leader and referring to him as a communist. As Casy protests that the men are only helping to starve children, one of them crushes his skull with a pick handle. Tom flies into a rage and wields the pick handle on Casy’s murderer, killing him before receiving a blow to his own head. He manages to run away and makes it back to his family. In the morning, when they discover his wounds and hear his story, Tom offers to leave so as not to bring any trouble to them. Ma, however, insists that he stay. They leave the peach farm and head off to find work picking cotton. Tom hides in a culvert close to the plantation—his crushed nose and bruised face would bring suspicion upon him—and the family sneaks food to him. Word gets out that Tom is a murder and is forced to leave his family. Before he leave he has a hear to heart with his mother, he speaks of Jim Casy and his way of spirituality for the greater good. As Tom leaves his family to fight for social justice, he completes the transformation that began several chapters earlier. Initially lacking the patience and energy to consider the future at all, he marches off to lead the struggle toward making that future a kinder and gentler one. The Joads are left to work on the farm but, then there is a six day flood that wipes away the families cars and settlement. This forces the family to set off on foot for higher ground. Al decides to stay with the Wainwrights and Agnes. Traveling on foot, the remaining Joads spot a barn and head toward it. There, they find a dying man and small boy. The boy tells them that his father has not eaten for six days, having given all available food to his son. The man’s health has deteriorated to such an extent that he cannot digest solid food; he needs soup or milk. Ma looks to Rose of Sharon, and the girl at once understands her unstated thoughts. Rose of Sharon asks everyone to leave the barn and, once alone, she approaches the starving man. Despite his protests, she holds him close and suckles him. This is the closing of the book, which for me is an amazing ending. It was symbol of family and the fight for the greater good of the common people. Analysis In the Grapes of Wrath, we are taken along side a family of okies, who are forced to migrate west. Through this journey we can use the insights of the suffering the migrants went though to better understand the immigrant experience. Throughout history outsiders have driven people off their native land. They fall victim to the physical and environmental forces that drive them off the land. Immigrants or in this case migrant workers are labeled as trash and are used as capital gain and cheap labor. This is due a lack of options and the people are forced to work for unfair pay and to be treated unjust. The Dust bowl was an ecological and human disaster in the Southwestern Great Plains regions of the United States in the 1930’s. The areas affected were Oklahoma, Texas, New Mexico, and Colorado. The poor handling of the land and years of drought caused this great disaster (Jones â€Å"History†). During this time the â€Å"Okies†Ã¢â‚¬â€œa name given to the migrants that traveled from Oklahoma, Texas, Kansas, or anywhere in the Southwest or the northern plains to California–encountered many hardships. These hardships are brilliantly shown in John Steinbeck’s The Grapes of Wrath. Scholars agree, â€Å"The most important fact about the dust storms was not scientific but human: their tragic effect upon people seeking livelihood on the stricken Midwestern farms† (French 4). Steinbeck believed society was inhumane to the Okies and through his novel we can account for how the Okies were treated. By looking at Steinbeck’s own personal background and information from historical commentaries we are better able to grasp his reasoning for writing the novel because he understood what it was like to grow up as a farmer, and an outsider. More importantly, however, we are able to share in his compassion for the Okies. To fully understand Steinbeck’s reasoning for writing the novel it is important to look at his family and where he grew up. John Ernst Steinbeck was born on February 27, 1902, in Salinas California. His parents were middle-class people who played many roles in the community and cultural life. His father worked as a manager of a flourmill, and his mother taught in a one-room rural school (Swisher 13). Steinbeck’s compassion for the Okies is clearly seen in passages like, this: â€Å"The Okies are resourceful, and intelligent Americans who have gone through the hell of the drought, have seen their lands wither and die and the topsoil blow away: and this, to a man who has owned his land, is a curious and terrible pain† (French 56). The encounters Steinbeck had with the Okies inspired him to write The Grapes of Wrath (Swisher 20). The Okies were not only exposed to greed but also to the terrible feeling of an empty, deprived stomach. Steinbeck remarks, â€Å"And in the South he [a homeless, hungry man] saw the golden oranges hanging on trees, the little golden oranges on the dark green trees; and guards with shotguns patrolling the lines so a man might not pick an orange for a thin child, oranges to be dumped if the price was low† (318). In conclusion Steinbeck wants his readers to feel the pain of the Okies. They were discriminated against because of a circumstance (The Dust bowl) they had no control over. Steinbeck can relate to this inhumane treatment because he too had suffered teasing and hatred based solely on his physical characteristics. Nature handed the Okies and Steinbeck a bad hand and he wanted society to grasp the reality of human unkindness. Steinbeck writes, † If you [land owners] could separate causes (hunger in a stomach, hunger in a single soul, hunger for joy and security) from results (growing labor unity, striking at new taxes, widening government), if you could know that Paine, Marx, Jefferson, Lenin, were results, not causes, you might survive. But that you can not know. For the quality of owning freezes you forever into I, and cuts you off forever from the we† (Steinbeck 206). So we can use Steinbeck’s life experiences and historical references to use the Joads journey west to better understand the immigrant experience.

How can we remove causes of hunger today Essay - 764 Words

Q. How can we remove the causes of hunger in the world today? At the end of World War II public officials and scientists from all over the world predicted that, with advances in modern technology, it would be possible by the end of the century to end poverty, famine, and endemic hunger in the world. Today these optimistic projections have been replaced by hopelessness and resignation as perhaps one-fifth of the worlds peoples live in absolute poverty with incomes of less than $700 a year. The United Nations estimates that around 830 million people in the world do not have adequate access to food. An estimated 24,000 people die from hunger or hunger related causes, three-fourths of which are children under the age of five. Moreover,†¦show more content†¦Sadly much of these produce is wasted each year. In the US and Europe alone, farmers burn large amounts of excess crops and kill animals to raise the price of the produce, while it would have been a lot cheaper to sell the produce in cheaper price and make profit in quantities. Food exploitation due to corruption is another major cause of hunger, especially in the developing countries. Around three-quarters of the developing countries that report child malnutrition are busy exporting food to the developed countries. For example, during the much-publicized famine in the1980s, Ethiopia was exporting green beans to Europe. In the year 1999, the Indian government had 10 million tons of surplus food grains, which increased to 60 million by the year 2000. Most of the produce was left in the granaries to rot in the hope of being exported. It also stopped buying grain from its own farmers, leaving them destitute. 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The Police Force Essay examples - 1835 Words

Throughout history the police force has severely changed, with the first forms of policing appearing in the Anglo-Saxon period in England; where the king would provide protection to the civilians for a tax (Mawby, 1999). Centuries later and the principles of protecting the people are generally the same. However, in recent times crimes and perpetrators are becoming more sophisticated; the need for higher abilities to control and manage these complicated situations is becoming more prevalent. It can be seen that the entry requirements into the police force are also dramatically increasing over the decades. This paper aims to critically assess the effectiveness of higher education requirements by outlining the advantages and disadvantages†¦show more content†¦Further studies will need to be looked at to gain a better knowledge of the current demographic of this debate. In Australia the first national level study relating to a university education for upper level police managers began in 1986 (Trofymowych, 2008). It entailed the survey of 529 higher ranking police officers nationwide; and their view on tertiary education being a requirement into police services. In the review, â€Å"Characteristics and Educational Needs of Upper-Level Managers in the Australian Police Forces†, 86 per cent supported the need for tertiary education for higher ranking police officers, whilst only a small margin believed that a university education would not help police officers to operate better (Rohl and Barnsley, 1995). It was recommended that a national university degree be deployed and that it should be a requirement to join the police force. A key point outlined in the survey was that â€Å"You can make an academic out of a policeman, but you cannot make a policeman out of an academic† (Rawson, 1986:140). 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