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Running head: PORTFOLIO II
Nursing 308P
Portfolio II
Sara Voigtritter
Jennifer Lillibridge
December 15, 2011
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PORTFOLIO II
Normal Aging Process
There is no normal aging process. One way of defining aging is as “a total process
that begins at conception” (Meiner, 2011, p. 15). The course of aging varies for
individuals based on their unique “genetic, social, psychologic, and economic factors
intertwined in their lives” (Meiner, 2011, p.15). Some universal themes are present,
however, in all aging individuals. Biologic theories of aging vary, but they all contain
explanations of the facts that: all aging people suffer “deleterious effects” that lead in
time to a decrease in the older adult’s ability to function, age-related changes are
“progressive” occurring as part of a continuum, and these changes affect all members of
the aging members of society at some point as time goes on (Meiner, 2011, p. 16).
The most frequent chronic conditions that affect older adults (aged greater than 65
years) are “arthritis, hypertension and heart disease” (Meiner, 2011, p. 149). The major
causes of death for adults aged 65 years or greater are: “heart disease, cancer, stroke,
chronic lower respiratory disease, diabetes mellitus, accidents, pneumonia, and
influenza” (Meiner, 2011, p. 149).
Older adults are confronted with a myriad of hardships as they attempt to navigate
the aging process. In addition to the natural aging process, there are many other factors,
which can influence, negatively or positively, the aging experience of older adults. Some
of those factors include: health maintenance, environment, current health financing,
lifestyle changes, end of life issues, bioethical issues, and community support systems.
Factors that Influence the Aging Process
According to Meiner (2011), older adults have a high incidence rate of ineffective
health maintenance behaviors. One such example is that “22% to 27% of older women
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and 18% to 37% of older men do not engage in regular exercise” (Meiner, 2011, p. 135).
Other examples of ineffective health maintenance behaviors include not eating
healthfully and not adhering to prescription medication regimens.
Environmental factors that can affect the aging process include: “geographic area,
housing, perceived criminal victimization, and community resources” (Meiner, 2011, p.
116). Meiner (2011) found that socioeconomic status is the greatest indicator of illness
and death in older people. A more thorough assessment of environmental factors is
therefore indicated in older adults to identify areas of need, and correctly link patients to
available resources (Meiner, 2011).
Currently, older people can begin receiving Social Security earnings at age 62,
however if benefits begin before age 65, monthly payments are reduced. Beginning in
2003, the age at which patients receive full benefits will be gradually increased to age 67
years. Very poor older adults may also rely on Social Security to fill the gap that is left by
pension plans affected by forced early retirement or market failings. Many older adults do
not understand current Medicare rules and benefits. These patients should be instructed to
call the Social Security Administration for help navigating the system (Meiner, 2011).
One of the many lifestyle changes that can affect patients over the age of 65 years
is losing the ability to drive. Due to natural processes of aging patients may experience at
least one of the following symptoms: “loss of hearing acuity, loss of visual acuity, limited
mobility and increased reaction time, medications, drowsiness, and dementia or mental
impairment” (Meiner, 2011, p.99). For many older adults, driving is one of the last
freedoms they possess, and the loss of the ability to drive is a difficult pill to swallow.
Another difficult lifestyle change can be age-related sexual difficulty. Despite the
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perception many people may have of sexless grandparents, many older adults are still
very interested in sexual activity. Teaching patients about normal age-related changes and
assistive devices available to help older people facilitate sexual encounters can help
patients resume sexual activity. (Meiner, 2011)
End of life issues are especially important to aging patients. Care of dying patients
requires strong professional and ethical conduct. Nurses are not allowed to assist patients
with suicide, however, it can become ethically blurry when removing a patient from lifesupport. Meiner (2011) encourages nurses to approach such situations with a check of
whether or not the situation “feels right” (p. 44). What nurses do have an obligation to
perform, in regards to dying patients, is “to provide comprehensive and compassionate
end-of life care which includes the promotion of comfort and the relief of pain, and at
times, foregoing life-sustaining treatments” (Meiner, 2011, p.44).
Bioethical issues in aging include: “euthanasia, patient competency and decisionmaking capabilities, guardianship issues, DNR orders and policies, patient refusal of
treatment, informed consent, use of feeding tubes, and use of restraints” (Meiner, 2011, p.
45). These issues are often discussed in hospital ethics committees, which do not have
legal authority, but instead serve to help patients, patient representatives and healthcare
providers consider each other’s points of view. Nurses are recommended to make up at
least one third of such committees. It is important to note that such committees are in
place to facilitate the decision making process, not make decisions. (Meiner, 2011)
Community support systems exist in every community. Studies have found that
older adults with large social networks can better survive the myriad of challenges poor
health and major life events can throw at them. Support systems as simple as local
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churches and as complex as Meals on Wheels can help older adults adapt to life. Other
area agencies that can help include: “recreational opportunities, chores services, legal
assistance, transportation, information, and referrals” (Meiner, 2011, p. 124). Another
resource available is the conservator should the older adult no longer be able to handle
his or her own finances. Conservators may be voluntarily selected or selected by the court
depending on the status of the older person.
Sickle Cell Anemia
Sickle Cell anemia is a chronic genetic illness that affects one in every 600
African Americans (McKinney, James, Murray & Ashwill, 2009, p. 1284). When a child is
born with sickle cell anemia, his or her body produces sickle hemoglobin (HbS) instead of
normal circular hemoglobin when exposed to certain factors. It is characterized by chronic
hemolytic anemia, ischemic tissue injury, and pain. It is a chronic disease that is life-long in
duration, but begins at birth. (McKinney et al., 2009)
Pathophysiology
A normal red blood cell is a “smooth, biconcave disk” which changes shape as needed to
navigate the myriad of shapes that the circulation, from the smallest capillaries to the largest
arteries and veins. In sickle cell anemia, due to “low oxygen concentration, acidosis, or
dehydration” (McKinney et al., 2009, p.1283) the patient’s red blood cells become sickleshaped and are no longer able to flex and bend as needed to navigate circulation. The cells
cluster together and occlude the patient’s small vasculature. These occlusions in the small
vasculature most frequently affect the lungs, spleen, and brain. They also cause tissue
ischemia, infarcts (including strokes), and organ damage to the eyes, heart, genitourinary
system, hands, feet, and joints. The cells resume their normal shape when they are properly
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oxygenated again, however if the sickling occurs repeatedly, the blood cells can be damaged
beyond repair. (McKinney et al., 2009)
Signs and symptoms
Sickle cell disease signs and symptoms result from the sequestration of normal and
sickled red blood cells in the vasculature. Common manifestations are “ chronic hemolytic
anemia, pallor, jaundice, fatigue, cholelithiasis, delayed growth and puberty, avascular
necrosis of the hips and shoulders, renal dysfunction, and retinopathy” ((McKinney et al.,
2009, p. 1284). It is also characterized by acute exacerbations called “sickle cell crisis” in
which “infection, dehydration, hypoxia, trauma, or general stress” can cause a crisis episode
(McKinney et al., 2009, p.1284). These crisis episodes are “vaso-occlusive, acute
sequestration, or aplastic” (McKinney et al., 2009, p. 1284).
Appropriate lab work
Laboratory tests that confirm a diagnosis of sickle cell disease include: “CBC count, r
focusing, hemoglobin electrophoresis, and high-performance liquid chromatography”
(McKinney et al., 2009, p.1284). Because of the constant breaking down of red blood cells
that occurs in sickle cell disease patients, the children affected have increased reticulocyte
counts as their bodies try to compensate for the continuous loss of cells. The diagnosis can
also be made in utero using chorionic villus sampling or amniocentesis. (McKinney et al.,
2009)
Treatment and Medications
Treatment of the hospitalized sickle cell anemia patient depends on the kind of crisis the
child or infant is experiencing. For vaso-occlusive crisis treatment includes: analgesia (oral
or intravenous), fluids (oral or intravenous), oxygen (if hypoxic), incentive spirometry,
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frequent assessment of pain, and rest. If the episode causes a cerebrovascular accident
(CVA), rehabilitation and red blood cell transfusions are indicated. For acute sequestration
crisis, in which blood pools in the spleen, emergency reperfusion treatment with crystalloid
and colloid intravenous fluids is indicated and transfusion of blood may be required if the
problem is recurrent. If acute sequestration recurs frequently, removal of the spleen may be
indicated. Lastly, aplastic crisis requires treatment by red blood cell transfusions. (McKinney
et al., 2009)
Home care of infants and children with sickle cell anemia include: ensuring adequate
fluid intake, expecting urinary frequency, providing adequate rest, avoiding cold and extreme
heat, avoiding prolonged sun exposure, avoiding infection, daily body temperature
monitoring, daily penicillin, avoiding use of aspirin, using caution when travelling, and
immediately notifying a physician if the infant or child shows signs of infection. (McKinney
et al., 2009)
Two Nursing Goals and Interventions
First nursing goal: the child and family will explain the rationale behind the current
treatment regimen and vocalize feeling comfortable implementing it in the home setting.
Interventions include determining the family and child’s understanding of sickle cell anemia
and their current treatment, providing further information or clarification as needed. Include
sample temperature logs; ensure family can vocalize potential side effects of medications,
and that the family is able to vocalize the home care instructions included above. (McKinney
et al., 2009)
Second nursing goal: the hospitalized child or infant with sickle cell disease will report
lower pain scores on the age-appropriate pain assessment tool. Interventions include:
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monitoring pain hourly using an age appropriate pain assessment tool, administering
analgesia as needed to provide pain relief, increase oral or intravenous fluids, administer red
blood cells as ordered, and use non-pharmacologic pain relief measures such as play and
distraction. (McKinney et al., 2009)
Potential Psychosocial Effects of Hospitalization on Children
The hospitalized child’s reaction to illness is affected by the child’s developmental level.
A toddler will react differently to hospitalization than a school-aged child, for instance, but
one of the more effective ways to manage anxiety in the hospital setting is to prepare the
child or family at a developmentally appropriate level for what will occur during the
hospitalization. This paper will focus on the toddler’s reaction to hospitalization. (McKinney
et al., 2009)
In the toddler, the nurse can let the parents know that their child may regress in behaviors
and development while in the hospital, to expect the child to throw temper tantrums if
frustrated, and that the child may become more dependent and cling to parents more than
they do at home. For instance, a potty-trained child may need to wear diapers while in the
hospital or begin wetting the bed. As much as possible, following the same schedule as at
home and keeping as many routines in place as possible will help the toddler to cope. Parents
should be allowed to be involved in the toddler’s care, including staying in the child’s room
if possible. The nurse should provide a safe environment for acting out and tantrums,
anticipating them if the child is frustrated. If it is safe, the child should be allowed to be
mobile and be independent as much as possible. Some examples of this include allowing the
child to feed his or her self or dress his or her self. The nurse should anticipate providing
physical comfort after procedures or if the parents need to leave for a time. Also, the nurse
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should approach the child with a positive attitude at all times, as the child may exhibit
negative behaviors. (McKinney et al., 2009)
Cultural influences may be involved as well. In African American culture, for example,
pain is considered to be unavoidable and expected in life, and illness may be considered a
punishment from God. Because health is considered a gift from God, while illness is
considered to be a measure of separation from God, spiritual care is very important to many
African American families. Because of this belief that God is in control of the illness,
families may not seek care as quickly, instead choosing to increase their spiritual connection
first. African American families tend to make decisions together rather than as individuals, so
involvement of many family members can help them to make difficult care decisions. Also,
African American families tend to have less access to healthcare, so early social services
involvement is crucial to ensure that families with children who have chronic illness get
access to the health services they need. (Wilson, 2011)
Gestational Diabetes
Gestational diabetes mellitus (GDM) is a condition that affects 3% to 9% of all
pregnancies and is the cause of 90% of pregnancies involving diabetes (Lowdermilk, Perry,
Cashion & Alden, 2012). It occurs more frequently in Hispanic, Native American, Asian and
African American women, and women who develop gestational diabetes are at an increased
risk of developing diabetes mellitus later in life (Lowdermilk et al., 2012, p. 701). Risk
factors include: maternal age over 25 years, previous macrosomic infant, previous
unexplained intrauterine fetal demise, prior diagnosis of gestational diabetes mellitus in
pregnancy, immediate family history of diabetes mellitus or gestational diabetes, obesity, and
fasting glucose greater than 140 mg/dl (Lowdermilk et al., 2012).
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Pathophysiology
Gestational diabetes is characterized by glucose intolerance that occurs after the first
trimester of pregnancy. The body’s need for insulin rises during pregnancy and the pancreas
is not able to meet the demand for insulin required to adequately metabolize glucose. Maybe
controlled with diet alone or a combination of diet and insulin. Because gestational diabetes
does not occur until the second trimester of pregnancy, a diagnosis of gestational diabetes
does not usually increase risk for major congenital anomalies. However, if gestational
diabetes is poorly controlled it can lead to fetal macrosomia and neonatal hypoglycemia.
(McKinney et al., 2009)
Signs and Symptoms and Appropriate Lab Work
The classic symptoms of diabetes mellitus are polyphagia, polydipsia, and polyuria,
which are all hard to differentiate from the normal progress of pregnancy. Gestational
diabetes is therefore diagnosed after a screening test performed at 24 to 28 weeks gestation
(Lowdermilk et al., 2012). All women should be screened at the first prenatal visit for a
fasting glucose of greater than 140 mg/dl or a random blood glucose level of over 200 mg/dl.
Women who are negative at the first screening and at low risk for developing gestational
diabetes should not be screened again. This includes normal-weight women under 25 years of
age who do not have a family history of diabetes, are not in a high risk ethnic or racial group,
who do not have a family history of diabetes, and no history of abnormal glucose tolerance.
(Lowdermilk et al., 2012)
All other women should be screened with a glucola screening in which the woman
ingests 50 grams of oral glucose and a fasting blood glucose test is performed an hour later.
If the blood glucose level is 130 to 140 mg/dl, the test should be followed with a100 gram
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glucose tolerance test followed by a blood tests at one, two and three hours post glucose
consumption. If two or more values are greater than or equal to 130 to 140 mg/dl the woman
is considered to have gestational diabetes. (Lowdermilk et al., 2012)
Treatments and Medications
Treatment of gestational diabetes consists of diet, exercise, blood glucose monitoring,
and, if necessary, insulin or glyburide. Only 20% of women with gestational diabetes require
insulin to manage blood sugar levels in addition to dietary compliance. Most women are
controlled with diet and exercise alone. Glyburide can be taken before meals instead of
insulin to manage postprandial blood sugar peaks. (Lowdermilk et al., 2012)
If glucose levels are well controlled, limited antepartum fetal surveillance is indicated.
Women who have hypertension, prior intrauterine fetal death or suspected macrosomia may
need non-stress testing biweekly starting at 32 weeks gestation. Careful monitoring of fetal
growth for macrosomia is indicated as the fetus nears full term due to the increased risk.
(Lowdermilk et al., 2012)
Blood glucose levels are monitored hourly during labor and delivery to decrease
incidence of fetal hypoglycemia, which occurs more frequently if maternal levels are not
within the optimum range of 80-120 mg/dl. If necessary, fast-acting insulin may be
administered during labor, however this can usually be accomplished by not using dextrose
intravenous fluids in women with gestational diabetes. If the mother has pre-ecclampsia or
macrosomia, cesarean section delivery may be necessary. (Lowdermilk et al., 2012)
After delivery, most women with gestational diabetes have normal glucose levels. If
women have had gestational diabetes, their risk for developing diabetes mellitus is increased
35 to 60% and their risk of developing gestational diabetes in subsequent pregnancy is 35 to
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75% (Lowdermilk et al., 2012, p.704). Fasting glucose levels should therefore be checked
yearly in women who have had gestational diabetes to ensure glucose tolerance remains
normal. (Lowdermilk et al., 2012)
Two Nursing Diagnoses and Interventions
Risk for ineffective health maintenance related to knowledge deficit of ways to maintain
normal blood glucose levels. Interventions: demonstrate and ensure client can competently
use her home glucose monitor, develop a plan for meeting dietary recommendations that
takes into account the client’s lifestyle and food preferences, ensure client can identify signs
and symptoms of hypo and hyperglycemia, ensure client can verbalize actions to take for
symptoms of hypo or hyperglycemia, and ensure client understands scheduled appointments
and need for fetal monitoring after 32 weeks. (McKinney et al., 2009)
Risk for fetal injury related to elevated maternal glucose levels. Interventions: Assess
women’s current diabetic control by asking about home glucose monitoring levels and
looking at current lab values for glucose, monitor fundal height to assess for possible fetal
excessive growth, assess fetal movement and heart rate, and ensure that client understands
and keeps scheduled appointments for fetal monitoring and non-stress tests after 32 weeks.
(Lowdermilk et al., 2012)
Fetal Surveillance During a High Risk Pregnancy
Approximately 500,000 pregnancies a year are designated as high risk. In high-risk the life of
the fetus or the mother is compromised because of a disorder related to pregnancy or that is
preexisting and contributes to risk during pregnancy. Causes of high-risk pregnancy can be
biophysical, psychosocial, sociodemographic, or environmental. Examples of biophysical
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causes include nutritional status, genetic factors, and medical disorders. Psychosocial factors
include smoking, caffeine, alcohol, drugs, and psychologic status. Sociodemographic factors
include low income, lack of prenatal care, age, parity, residence, and ethnicity.
Environmental factors include exposures to infection, radiation, chemicals, therapeutic drugs,
illicit drugs, pollutants, stress, and diet. If these factors indicate the pregnancy is high risk,
further monitoring is advised, including fetal monitoring, non-stress testing, contraction
stress testing, and biophysical profiles. (Lowdermilk et al., 2012)
Fetal Monitoring
Indications for electronic fetal monitoring include maternal diabetes mellitus, chronic
hypertension, hypertension in pregnancy, intrautrerine growth restriction, sickle cell disease,
maternal cyanotic heart disease, fetal postmaturity, history of previous stillbirth, decreased
fetal movement, isoimmunization, hyperthyroidism, collagen disease, and chronic renal
disease. It is performed in the third trimester to determine the fitness of the intrauterine
environment. Nurses provide clinical teaching and education to help women cope with and
comply with fetal testing if it is indicated for their pregnancy. Nurses may also perform
nonstress tests, contraction stress tests, and biophysical profiles, in addition to the initial
assessments and interventions if indicated by suboptimal results. (Lowdermilk et al., 2012)
Nonstress Testing
Nonstress testing is easy and quick to perform, non-invasive, inexpensive, and has no
contraindications. It is less sensitive than contraction stress testing at detecting fetal
compromise. Inconvenience associated with nonstress testing includes the need for twiceweekly testing and high rate of false-positives. During the testing, the client is seated in a
semi-Fowler position and the fetal heart rate is recorded with a Doppler transducer while a
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tocodynamometer records uterine contractions or fetal movements. If fetal movement is not
evident on the tracing, the client may be given a handheld event marker that notes the
movement on the tracing. All of the fetus’s heart accelerations should be concurrent with
fetal movement. The test takes approximately 30 minutes to complete. If the fetus is asleep,
vibroacoustic stimulation may be applied to wake it up. The results will show that the fetus is
reactive or non-reactive. If the fetus does not meet criteria for being reactive within 40
minutes, a contraction stress test or biophysical profile is indicated. (Lowdermilk et al., 2012)
Contraction Stress Testing
Contraction stress testing allows for earlier warning of fetal compromise with fewer
false-positives than nonstress testing, but it is more expensive, takes more time, and can be
more invasive if oxytocin stimulation is needed. If is used infrequently due to these
disadvantages. Contraindications for contraction stress testing are: placenta previa, preterm
labor, vasa previa, cervical incompetence, multiple gestation, and previous classic cesarean
incision. (Lowdermilk et al., 2012)
As in nonstress testing, the woman sits in a semi-Fowler position, but in contraction
stress testing there is a slight lateral tilt to aide in uterine perfusion. The fetus is monitored
with a ultrasound transducer and a tocodynamometer while the mother’s contractions are
stimulated using nipple stimulation or oxytocin stimulation. The mother performs nipple
stimulation on herself for ten minutes on one nipple. If contractions are not induced in that
time oxytocin may be used to stimulate contractions. An intravenous infusion is started and
dilute oxytocin is given to the mother at 0.5 milliliters a minute. The dose is doubled every
20 minutes until uterine contractions lasting 40 to 60 seconds are induced within a 10-minute
period. (Lowdermilk et al., 2012)
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The test results either show negative, positive, equivocal, suspicious or unsatisfactory
results. If no late decelerations are observed, the test is negative. If repetitive late
decelerations occur, the test is positive. Negative tests are repeated in a week. Hospitalization
for further close monitoring or birth is indicated after a positive contraction stress test.
(Lowdermilk et al., 2012)
Biophysical Profile
Biophysical profiling is performed using an ultrasound. The test includes the amniotic
fluid volume, fetal breathing movements, fetal movements, and fetal tone. It also includes
fetal heart rate reactivity by non-stress test. The fetal heart rate, fetal breathing movements,
fetal movement, and fetal tone indicate the functioning status of the central nervous system.
The amniotic fluid volume indicates how well the placenta is functioning. The entire
biophysical profile is an indicator of the fetus’s health. The nursing role in the biophysical
profile is generally to counsel and educate the expectant woman about the test. (Lowdermilk
et al., 2012)
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References
Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2012). Maternity & women's health care.
(10 ed.). St. Louis: Mosby, Inc.
Meiner, S. E. (2011). Gerontologic nursing. (4th ed.). St. Louis, MO: Elsevier.
McKinney, E. S., James, S. R., Murray, S. S., & Ashwill, J. W. (2009). Maternal-child nursing.
(3rd ed.). St. Louis, MO: Saunders.
Wilson, L. (2011). Cultural Competency: Beyond the Vital Signs. Delivering Holistic Care to
African Americans. Nursing Clinics Of North America, 46(Culturally Competent Care),
219-232. doi:10.1016/j.cnur.2011.02.007