Theory of Culture Care Diversity and Universality - Essay Example

?Include rational and references, use APA format while citing references What additional information do you think is needed? List them in bullet format: (5%) Vital signs Volume, quality, quantity of diarrhea Contents and names of herbal medication Any hx of back pain, unusual changes or pain Patient diet History of smoking (smoking has protective effect but NOT encouraged) Hx of previous colonoscopy Previous abdominal pain If any bleeding from other sites Any epigastric pain Recent fever Jaundice LMP Platelets problems How often and for how long is she taking ASA 2. What are your differential diagnoses? Give at least 10 of them, with the most likely ones list first. For each diagnosis, you need to explain why you think this diagnosis is relevant; what data support the diagnosis; what data against it, what additional information or lab/diagnostic tests you will need to rule in or rule out each of the differential diagnosis. (20%) 1) The first differential diagnosis is ulcerative colitis. The data that supports this diagnosis includes bloody diarrhea, anemia, weight loss, insidious onset, arthritis (painful knee joints), rash (erythema nodosum), abdominal pain, and tachycardia/palpitations. Also, the peak age is between 14 and 40. Furthermore, the mother has hx of stomach problems (usually family hx), and the presence of white blood cells in stool indicates an inflammatory disease, which is possibly ulcerative colitis. The lab/diagnostic tests I will need to rule in or out ulcerative colitis are Esr, in which the CRP sedimentation rate is elevated (and is expected to be elevated); CDC - anemia/leukocytosis; hypokalemia; sigmoidoscopy if inflammation is present; x-ray of knee; and rheumatoid factors/pANCA. An endoscopy and biopsy can also be used, which would allow an entire view of the colon using a thin, flexible lighted tube with an attached camera. During the procedure, small samples of tissue (biopsy) can also be taken for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis. A standard x-ray of the abdominal area may be done to rule out toxic mega colon or a perforation if these conditions are suspected because of severe symptoms. Finally, a CT scan of the abdomen or pelvis may be performed if there is a suspected complication from ulcerative colitis or inflammation of the small intestine that might suggest Crohn’s disease. A CT scan may also reveal how much of the colon is inflamed. 2) The second differential diagnosis is Crohn’s Disease. The data that supports this diagnosis includes bloody diarrhea, weight loss, fatigue, insidious onset, arthritis (painful knee joints), rash (erythema nodosum), fever, and abdominal pain or tenderness. Also, the onset age is between 15 and 25; males are more likely to develop the disease than females, and people are put more at risk if there is family history of the disease. The lab/diagnostic tests I will need to rule in or out Crohn’s Disease are CT scan, to look for thickening of the colon; CBC, for anemia; pANCA, as ASCA in Crohn’s may differentiate from UC; biopsy; and an IBD serology 7 panel. 3) The third differential diagnosis is infectious colitis/diarrhea/gastroenteritis. The data that supports this diagnosis includes bloody diarrhea, weight loss, anorexia, dehydration, pale skin, abdominal pain or cramps, fever, elevated WBC in stool, anemia, and hyperactive bowel sounds. This disorder is common in all ages, but especially in individuals who have a long history of stomach problems or have tender arthritis. The lab/diagnostic tests I will need to rule in or out infectious colitis/diarrhea/gastroenteritis are testing stools for WBC/leukocytosis; Ova + parasite to exclude amebiasis; toxin assay to rule out c diff; cultures to rule out salmonella, shigella, e.coli and campylobacter; and urinalysis, BUN, specific gravity, and electrolytes. 4) The fourth differential diagnosis is Ischemic colitis. The data that supports this diagnosis includes bloody diarrhea, abdominal pain LLQ tenderness, elevated WBC, and anemia. Ischemic colitis usually occurs in older people. The lab/diagnostic tests I will need to rule in or out Ischemic colitis are chem. 7, which usually has low HC03; ABG (elevated lactate); x-ray of abdominal area; CT scan of abdomen, which would show thickening; and a colonoscopy. 5) The fifth differential diagnosis is diverticulitis. The data that supports this diagnosis includes bloody diarrhea, elevated WBC, LLQ abdominal pain, tenderness, or rebound tenderness, anorexia, and diarrhea or constipation. Individuals can have a long history of signs and symptoms or have no fever. Diverticulitis is more common in individuals over the age of 40. It may be that age-related changes, such as a decrease in strength and elasticity of the bowel wall, could contribute to diverticulitis. The lab/diagnostic tests I will need to rule in or out diverticulitis are CT scan to determine inflammation; sederate elevated; CBS leukocytosis; barium enema to dx diverticulitis; and a colonoscopy. 6) The sixth differential diagnosis is colon cancer. The data that supports this diagnosis includes bloody stools, change in bowel habits, fatigue, weakness, weight loss, anemia, and abdominal pain. Individuals that develop colon cancer are usually older than 45 years of age. A family history of colon cancer is often unknown, though there is a first degree relative mother with a “bad stomach.” Joint pain is usually not associated with colon cancer. The lab/diagnostic tests I will need to rule in or out colon cancer are DRE for mass/guiac; colonoscopy; CBC - anemia; LFTS will be elevated; and CT scan. 7) The seventh differential diagnosis is irritable bowel syndrome. The data that supports this diagnosis includes alternating diarrhea and constipation, and bilateral lower quadrant abdominal pain or distention. Individuals that are more at risk are females in their late 20s, who have a history of depression and are often stressed. Females are more likely to develop irritable bowel syndrome than males. There is low incidence of bloody diarrhea and are usually mucous stools, no significant weight loss, and no evidence of fever. The lab/diagnostic tests I will need to rule in or out irritable bowel syndrome are CBC, which will be normal; sedimentation, which will be normal; and stool for ova + parasites. 8) The eighth differential diagnosis is toxic mega colon. The data that supports this diagnosis includes abdominal pain and tenderness, dehydration, and anal rash. There is no evidence of a fever and weight loss is not common. Toxic mega colon is usually caused by chronic constipation. The lab/diagnostic tests I will need to rule in or out toxic mega colon are abdominal x-rays; blood electrolytes; and a complete blood count. 9) The ninth differential diagnosis is hemorrhoids. The data that supports this diagnosis includes bloody stools, constipation, or chronic diarrhea. It is common in adults, and the son is 2 years old. Weight loss and joint pain are not common symptoms. The lab/diagnostic tests I will need to rule in or out hemorrhoids are stool for guiac/DRE and a colonoscopy. 10) The tenth differential diagnosis is HUS (hemolytic-uremic syndrome). The data that supports this diagnosis includes diarrhea, blood in the stools, weakness, and anemia. A medical emergency usually leads to a kidney injury in a short period of time. The lab/diagnostic tests I will need to rule in or out hemolytic-uremic syndrome are blood clotting tests (PT and PTT); a comprehensive metabolic panel, which may show increased levels of BUN and creatinine; a complete blood count (CBC), which may show increased white blood cell count and decreased red blood cell count; platelet count is usually reduced; urinalysis may reveal blood and protein in the urine; urine protein test can be used to show the amount of protein in the urine; and stool culture may be positive for a certain type of e. coli bacteria or other bacteria. 2. Final diagnoses/problems with ICD 9 code, list all you have (10%) Final diagnoses: diarrhea ICD Code 787.91 most likely ulcerative colitis ICD Code 556.9 Problems: Hypokalemia 276.8; Anemia unspecified ICD 285.9; Dehydration ICD 276.51; and Depression ICD 296.33. 3. List nursing diagnoses (10%) Fluid volumes deficit r/t excessive loss of body fluid; diarrhea r/t malabsorption, inflammation or bowel irritation or stress; fatigue; depression; and knowledge deficit. 4. Management plan (35%) A. Medical management (15%) MEDICATIONS Medications that may be used to decrease the number of attacks (Wall C.G., 2009) include 5-aminosalicylates, such as mesalamine or sulfazine, which can help control moderate symptoms; Immunomodulators, such as azathioprine and 6-mercaptopurine; Corticosteroids (prednisone and methylprednisolone) taken by mouth during a flare-up or as a rectal suppository, foam, or enema; and Infliximab (Remicade) or other biological treatments, if you do not respond to other medications. Probiotics are "good bacteria" that may improve colon health. Some studies show probiotics can reduce ulcerative colitis symptoms. Good bacteria from eating active yogurt cultures. Omega-3 fatty acids are found in cold-water fish and some studies show they may reduce symptoms of inflammatory bowel disease. Studies also show omega-3 fatty acids may be valuable when combined with certain medications used to treat ulcerative colitis. All opiod and ant cholinergic agents should be discontinued. Correct anemia transfusions may be needed if there is a significant loss of hematocrit < 25-28%. Electrolyte imbalance should be corrected as needed. Abdominal x-rays should be administer and repeat abdominal exams and evaluations. Anal excoriations need to be treated, and proper hygiene needs to be implemented to avoid further skin breakdown. SURGERY Surgery to remove the colon will cure ulcerative colitis and removes the threat of colon cancer. Surgery is usually recommended for patients who have colitis that does not respond to complete medical therapy or changes in the lining of the colon that are thought to be precancerous, serious complications such as rupture (perforation) of the colon, severe bleeding (hemorrhage), or toxic mega colon. B. Teaching and counseling (10%) DIET AND NUTRITION Certain types of foods may worsen diarrhea and gas symptoms, especially during times of active disease. Diet suggestions include eating small amounts of food throughout the day, drinking plenty of water, avoiding high-fiber foods, avoiding fatty, greasy or fried foods and sauces, and limiting milk products if you are lactose intolerant. Furthermore, individuals should be taught about immunosuppression with corticosteroid use and the importance of signs and symptoms of disease, and when to seek treatment. Since they may have remission and exacerbations, the individual should have regular close follow ups to evaluate exacerbations and improvements. STRESS management Stressful events in your life, such as moving, or losing a job or a loved one, can cause digestive problems. Alternative medicine education Most individuals with inflammatory bowel diseases, like ulcerative colitis or Cohn’s disease, have implemented some type of alternative or complementary therapy. Side effects and ineffectiveness of conventional therapies are among the reasons for looking to alternative care. The Food and Drug Administration typically do not control these therapies. Manufacturers can claim that their therapies are safe and effective, but do not make attempts to offer proof of their safety and effectiveness. Even natural herbs can have side effects and cause dangerous interactions. C. Health promotion/maintenances (10%) Referral to crohn’s and colitis foundation; emotional support; yearly flu shot; yearly dental visit to promote oral health; periodic blood testing - a baseline set of tests before IBD therapy and after is helpful to determine medication-associated abnormalities and benefits. Colonoscopies every 1 to 2 years - these are key in the management of UC—determining the severity and extent of disease, monitoring the effectiveness of therapy, checking for postoperative recurrence, and screening for colorectal cancer. Blood pressure screening; depression screening - continued screening and appropriate medical treatments are necessary; ophthalmologic screening; pap smears; and regular monthly breast self examinations should be encouraged and performed. 5. Discussion of cultural, ethical and socioeconomic issues that might influence on care of Maria (10%) For the Latinos who have emigrated from another country, they may have assumptions about medical professionals and services based on incidences in their home country that may affect health-seeking behaviors. In Mexico, the poor have limited access to proper health care. Some Mexican immigrants may wonder how they could access care in the U.S. if they couldn’t access it in their own country. Patients are not used to getting attention for their medical needs in their home country. When they come here and receive medical attention, they become interested and engaged but the system still confuses them. Mexico’s poor are likely to see a pharmacist or faith healer when they have ailments. Pharmacists may recommend over-the-counter medications, some of which are prescription-only in the U.S.  Patients often expect slow delivery of service. They have a lack of confidence that providers will really help, especially if the patient is poor. For this reason, patients may feel less confident about U.S. providers who are Latino. Physicians in Mexico are revered: “What is said is done, no questions asked.” Questions are not asked for fear of insulting the provider. This includes questions about the patient’s prognosis. Patients from Mexico and many underdeveloped countries are accustomed to providers who wear white coats. American providers who dress casually may have to prove themselves more. There are exceptions to this. Economic barriers: Uninsured and underinsured Latino patients are in survival mode. Maintaining the most basic needs, such as affording food and paying for housing, take over their everyday lives. Most of these people are close to becoming homeless and some are already homeless. As such, preventive care is viewed as a luxury, something that only the rich can afford. This attitude is only strengthened by previous experiences in Latin American countries, where treatment was almost nonexistent due to a major lack of financial resources. For most individuals, healthcare in Latin America was unaffordable and unattainable, and most experience the same problem in the U.S. Lack of Health Insurance Coverage: Latinos in the United States are without health insurance. Even though there are a large amount of preventive services available at free or reduced costs, patients and providers do not always know about these services. Moreover, the individuals without health insurance may not see the point in being screened for a disease that they cannot afford to treat. Legal Status There are undocumented patients who are worried that hospital personnel or DSHS will call INS. Once in a while, fake ID numbers will be used or people will share ID numbers so that they can avoid risking deportation. Patients who have been referred by other medical facilities may be less worried of being reported. Health Literacy Health literacy is the ability to obtain, process, and understand basic health information and services to make correct health decisions and is vital to promote healthy individuals and communities. Health literacy is incredibly low among the more vulnerable individuals of our communities—those with lower education levels, racial/ethnic minorities, the uninsured and publicly insured, and the elderly (U.S. Department of Health and Human Services, 2008). Language Non-English speaking Latinas are significantly less likely to access preventive services (Schueler et al., 2008). Language ability is also related to acculturation (Schueler et al., 2008).  When services are not provided by a Spanish-speaking provider, or with interpreter services, Latinos may not comprehend the reason behind the test.  They may also feel apart from the experience. Providers who speak Spanish, but not experienced enough for decent communication with the patient, may believe that they are successfully conversing when they actually are not and their patients may not feel comfortable asking for clarification. Public health campaigns that are centered on preventive services may not offer translation services for Spanish speakers. However, campaigns in Spanish are increasing as the Latino population continues to increase throughout the United States. 6. Nursing theory: what nursing theory you think should be used to guide the care of Maria, why? (10%) Leininger’s theory is suitable for the range of this case study because it involves the notion of care as vital to nursing and sets out to comprehend individuals in regard to their “lifeways, cultural values and beliefs, symbols, material and nonmaterial forms, and living contexts.” I have selected Leininger’s Theory of Culture Care Diversity and Universality for this case for its concentration on the human care phenomenon, as Leininger defines care as the essence of nursing. It is culturally based care that prompts greater health outcomes, overall well-being, and the means to cope with illness and death (Leininger & McFarland, 2002). This theory concedes that individuals should be at the centre of care, which is something that I have always upheld as the essence of nursing. My project goals reflect the theory’s focal point of nursing, most importantly regarding the individual within their context. As an extension of this belief, the Sunrise Model provides a practical tool to use within my project to categorize the themes that surfaced from the analysis of the literature. Read More