The Human Papilloma Virus and Cervical Cancer in Ghana

The Human Papilloma Virus and Cervical Cancer in Ghana CONTENTS INTRODUCTION HUMAN PAPILLOMA VIRUS Causes Risk factors Prevention Vaccination Screening CERVICAL CANCER Signs and symptoms INTRODUCTION Sexually Transmitted Infections (STIs) are infections that one can acquire from having sexual contact with an infected person. There are over 20 STIs which have been identified including HIV/AIDS, chlamydia, pelvic inflammatory disease, trichomoniasis, syphilis, gonorrhoea, HPV and genital herpes1. According to WHO, more than a million people acquire a sexually transmitted infection a day2. STIs require treatment but there are some such as HIV/AIDS which are incurable and deadly but can be managed to prolong life. Majority of STIs are asymptomatic2 but the infection can still be passed on to partners3. If there are symptoms, they include bumps, sores or warts near the mouth, penis, vagina, or anus, swelling near the penis, skin rash, painful urinations, weight loss, night sweats, aches, pains, fever, chills, jaundice, vaginal or penal discharge and severe itching near genitals4. Infections are spread predominantly, as suggested by its name, through sexual contact, including vaginal, oral, anal sex or even genital touching3. Some ways of protecting one’s self against STIs are; Abstinence from sexual activities Condom usage during sex Limiting the number of sexual partners one has. The more the number of partners one has, the higher the chances of catching an STI. Practicing monogamy. This means a couple should have sex with only each other Careful choice of sex partners. Dont have sex with someone whom you suspect may have an STI. Getting checked for STIs so that the infection is not passed on to others Knowing the signs and symptoms of STIs and looking for them in one’s self and their sex partners. Learning more about STIs to better protect one’s self.4 STIs are classified under bacterial, viral, and parasitic/fungal infections. For the purpose of this paper, the viral group shall be taken into consideration. In general, viral infections involve many different parts of the body at the same time5. Viral infections include; Human Papilloma Virus (HPV): The human papilloma virus (HPV) is the most common viral infection. There are about 40 types of HPV that are transmitted sexually through oral, anal or vaginal sex. Genital Herpes: Genital Herpes is caused by the Herpes Simplex Virus. It is in the same family of viruses that cause cold sores around the mouth. Hepatitis B Virus: Hepatitis B or Hep B, affects the liver. It is not to be mistaken with Hepatitis A or C, which are other forms of liver disease. Hepatitis B is easily transmitted not only through sexual activities, but by sharing items like razors, needles and toothbrushes. Human Immunodeficiency Virus (HIV): Human Immunodeficiency virus or HIV/AIDS attacks the body’s immune system, leaving infected individuals unable to fight off other illness. It is transmitted through sexual activities, but also spread by sharing items like razors, needles and toothbrushes. Cervical cancer occurs when there is an abnormal proliferation of cervical cells. These cells gradually develop pre-cancerous changes before turning into cancers. It is one of the most common cancers in women across the world. When pre-cancerous cell changes are detected early, using a method called the pap test, they can be successfully treated to prevent cancers from developing6. Cervical cancers are classified into squamous cell carcinoma and adenocarcinoma. The focus of this paper is to describe the relationship between one of the viral STIs, the Human Papilloma Virus, and cervical cancer in Ghana. HUMAN PAPILLOMA VIRUS Human papilloma viruses, commonly referred to as HPVs, are aetiological agents of cervical intraepithelial neoplasia and cervical cancer7. In humans, HPV is the most common sexually transmitted virus. It affects about 50% of sexually active people at some point in their lives8. Often, being infected is asymptomatic and the infection may go away without medical treatment. HPV is spread through contact with infected genital skin, mucous membranes and body fluids, and can be transmitted through vaginal, anal and oral intercourse. HPV lives in the epithelial cells of the body hence it usually affects the surface of the skin, vagina, vulva, anus, cervix, penis head, mouth and throat. Over 100 HPV types have been identified and each is referred to by a number9. HPV can be classified into a high-risk or low-risk strains. Not all of the sexually transmitted types cause serious health problems. High-risk HPV strains are known to cause about 70% of cervical cancers8. These are majorly types 16 and 18, but they also include types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82. Low-risk HPV strains rarely cause cancers but instead cause warts on skin surfaces. Of the total number of virus types found, about 60 cause warts on hands and feet (A papilloma is a benign tumour derived from epithelium ­). There are about 40 types of HPV that are transmitted through sex. CAUSES HPV infection is caused when the virus enters your body through a cut or abrasion in the epidermis of the skin. The virus is transferred primarily by skin-to-skin contact. Genital HPV infections are contracted through sexual intercourse, anal sex and other skin-to-skin contact in the genital region. Some HPV infections that result in oral or upper respiratory lesions are contracted through oral sex. It is possible for a mother with an HPV infection to pass on the virus to her infant during delivery. This exposure may cause HPV infection in the babys genitals or upper respiratory system3. RISK FACTORS The following are some risk factors inherent in HPV: Prevalence of genital HPV is directly related to the number of lifetime sexual partners, recent changes in sexual partners, marital status, age at which one first had sex, illiteracy, oral contraceptive use, alcoholism, hormonal and dietary factors and immune suppression,(domfeh et al) Age at first sexual intercourse: the age of a person at the time which they first had sex could be an indicator for the number of sexual partners they have in their lifetime. Number of sexual partners. The greater the number of sexual partners one has, the more likely they are to contract a genital HPV infection. Having sex with a partner who has had multiple sex partners also increases the risk. Weakened immune systems. People who have weakened immune systems are at greater risk of HPV infections. Immune systems can be weakened by HIV/AIDS or by immune system-suppressing drugs used after organ transplants. PREVENTION The best way to prevent getting an HPV infection is to avoid direct contact with the virus, which is transmitted by skin-to-skin contact. It is difficult to avoid skin-to-contact with our loved ones in our relationships. Also, in most cases of HPV infection, there are no visible signs for us to know in order to avoid direct skin contact with infected individuals. Correct and consistent condom use is associated with reduced HPV transmission between sexual partners but areas not covered by condoms can still pass on the virus when they come into contact partner’s skin. Regular pap tests, which can detect precancerous changes in the cervix that may lead to cancer are recommended. SCREENING AND VACCINATION CERVICAL CANCER Most cases of cervical cancer are caused by two specific varieties of genital HPV: Types 16 and 18. Once HPV enters an epithelial cell, the virus begins to make the proteins it encodes. Two of the proteins made by high-risk HPVs (E6 and E7) interfere with cell functions that normally prevent excessive growth, helping the cell to grow in an uncontrolled manner and to avoid cell death. Often, infected cells are recognized by the immune system and eliminated. Sometimes, however, the infected cells are not destroyed, and a persistent infection results. As the persistently infected cells continue to grow, they may develop mutations in cellular genes that promote even more abnormal cell growth, leading to the formation of an area of precancerous cells and, eventually, a cancerous tumour. Other factors may increase the risk that an infection with a high-risk HPV type will persist and possibly progress into cancer. These include: Smoking or chewing tobacco (for increased risk of oropharyngeal cancer) Having a weakened immune system Increased parity (for increased risk of cervical cancer) Long-term oral contraceptive use (for increased risk of cervical cancer) Poor oral hygiene (for increased risk of oropharyngeal cancer) Chronic inflammation10 It can take 15 to 20 years for cervical cancer to develop in women with normal immune systems. It takes only about 5 to 10 years in women with weakened immune systems, such as those with untreated HIV infection 9 IN GHANA In Ghana, cervical cancer constitutes about 57.8% of all gynaecological cancers. It is the second most common cancer in women with an estimated incidence of 26.4 per 100,000. It is also the second most common cancer in women aged 15 to 44 years in Ghana. Every year, 3,038 women are diagnosed with cervical cancer and 2,006 die from it in Ghana (Edwin, 2010; Nkyekyer, 2000; WHO, 2010) The Pap smear and VIA have been observed to have challenges with regards to sensitivity and specificity even though the Pap smear is the gold standard for screening in Ghana. A study conducted at the Ridge Hospital in 2013, 201 women were sampled to be used to determine the prevalence of HPV and the associated risk factors. 1

Nursing Process Essay

The client is a 70 year old, Caucasian male who is a retired siding salesman from Riverside, IA, who has an extensive history with Paralysis agitans (Parkinson’s disease). The client was first admitted to the long term care facility in December 2012. The client explained that he came to be at this facility after â€Å"already being in two places like this†. He was removed/discharged from the last long-term care facility for being what he called â€Å"disruptive†. The client described the staff at the last facility as not very kind to the residents. There was an incident where the drugs that were prescribed to the client made him hallucinate and he became unruly with the staff and was restrained and taken to the hospital for evaluation. He was then transferred to this long term care facility. Wanting to gather the client’s health history, an interview was scheduled. In starting the interview with the client, he was asked if he would be comfortable with being asked some questions and was informed that he did not have to answer any questions that he was uncomfortable with. Due to the client’s paralysis agitans and his muscle weakness he is primarily in a wheelchair. The client was asked if there was anything that he needed before starting and if he would prefer the door be closed or the curtain be drawn for privacy, he stated that wasn’t necessary. It was observed that the client had tremors in his right hand and arm. A few minutes after sitting down, the client asked for help moving his hand that was resting on the bed to the arm of his wheelchair; in doing this it seemed to help calm the tremors. When speaking with the client, he is of sound mind and has a sense of humor. This indicates that the client’s paralysis agitans has not affected the area in the right hemisphere of the brain that controls personality. The client noted that he was in respectable physical health until 1996. He then explained that in the spring of 1996, while he was running he suffered from a TIA (Transient Ischemic Attack). The client sought out professional answers from 5 specialists and was diagnosed with Paralysis agitans. The client conveyed this was a concern he had because his father also had Paralysis agitans. The client describes that the Paralysis agitans has  progressively become worse over the past 18 years. It was observed that his speech was slow and monotonous. The client spoke in a low and discreet volume. A lack of facial expressions was also noticed. The client can walk with the assistance of a walker but is generally in a wheelchair. Name of Drug Dosage Route Time Related to Carbidopa-Levo 25 100 tab Orally TID Paralysis agitans Comtan 200 mg tablet Orally TID Paralysis agitans Seroquel XR 50 mg tablet Orally In the afternoon Nonorganic psychosis He is prescribed 3 tablets to be taken orally 3 times a day Carbidopa-Levodopa 25-100 (25 mg of Carbidopa and 100 mg of Levodopa) for paralysis agitans. He is also prescribed 200 mg of Comtan to be taken orally 3 times a day for paralysis agitans. These drugs raise the level of dopamine in the brain. A side effect of having elevated levels of dopamine in the brain is psychosis. The client is also given 50 mg of Seroquel XR orally in the afternoon to alleviate his nonorganic psychosis. It is documented in the client’s chart that there are symptoms of sleep apnea. When asked, the client stated that he was unaware of having that condition. The client does not use a continuous positive airway pressure (CPAP) machine  while sleeping at night. When talking more in depth about sleep patterns and concerns the client stated that he gets approximately 8 hours a sleep a night, this is without any help from sleep aids. When speaking of his bedtime rituals he said that he does have two beers, back to back, at night right before bedtime, while watching television. He does not have difficulty falling asleep but did claim that he sometimes has a hard time staying asleep at night. When questioned about taking occasional naps throughout the day he stated â€Å"depends on if I’ve been up all night†. The client then explained that it is the noise level at the long term care facility that keeps him awake. When inquiring about the client’s family he stated that he has been married for 48 years and has two children, a son who is 44 years old and a daughter that is 39 years old. The client also has seven grandchildren. When asked what he likes to do in his spare time he replied that he loves spending time with his wife and children. He stated that before coming to this long term care facility he enjoyed playing card and gambling. He now plays computer games for fun, when his wife is there to help him. The client explained that he has a â€Å"little bit† of high blood pressure and it was noted in his chart that he is given an 81MG Aspirin daily for atrial fibrillation. Aspirin 81 mg Orally o.d. A-fib Acetaminophen 325 mg Orally Every 6 hour Pain He has no history of heart surgeries or surgeries of any kind. The client reported that he has never had rheumatic fever. When asked about blood clots, the client responded that he believes that his TIA in 1996 was a result of arterial emboli. The client claims that sometimes he has numbness in his legs and his hamstrings tighten up and it can be painful. He stated that he will ask for his prescribed 650 MG of acetaminophen for the pain. When speaking about everyday stresses with the client, he stated that he doesn’t have a lot of stress but gets irritated when that staff turn on the lights every morning at 6:30 am. When asked if there was anything that he does when he notices that he is stressed, the client mentioned that when he was younger he would travel to Vedic City in Iowa and practice with the Maharishi meditating. He says that meditating has been very helpful in his adult life. The client also mentioned that he liked to follow the Maharishi lifestyle and eat only organic foods but it is not possible to follow that when residing at a long term care facility. Other things that he does to distress are look at his pictures that he has on his shelf in his room. The one that helps him the most is a black and white picture of him in a small airplane with his flight instructor standing on the wing. The client use to pilot planes when he was younger. When the client was asked if he was religious and he explained that he is Methodist but hasn’t been to church in about 5 years. He did state that he does pray occasionally. The client stated that is not afraid of dying but he is afraid of falling. He then joked that maybe it’s not so much the falling but maybe it’s the landing. When assessing the client’s vitals it was noted that he has slightly elevated blood pressure of 129/84 and could be cause for concern of pre-hypertension. Metoprolol tartrate 25 mg Orally BID Hypertension It is noted in his chart that the client is given a 25 mg tablet of metoprolol tartrate orally twice a day for hypertension. His respirations were within normal range at 18 respirations per minute. SaO2 was at 86%. The client’s temperature was taken orally and was 97.6  °F. The client is 6 feet and 1 inch tall and weighs 257 lbs. The client has a BMI of 33.9. The client received a vaccination for influenza on 10/16/13. The clients chart states that he requires assistance with many daily activities. He is dependent on help with dressing, and bathing. When asked, the client stated that it is challenging to get dressed and undressed due to the stiffness in his arms and legs. The client is on a regular diet and states that he  doesn’t have any difficulty swallowing foods and doesn’t require help with feeding. When asked about appetite he said that sometimes he doesn’t have much of an appetite but he believes that is due to the medications that he is taking. The client explains that he is not aware of having any food allergies. He also stated that after eating he does not experience sensations of nausea/vomiting, but does encounter heartburn/indigestion occasionally, which he takes 30 ml an antacid suspension. He is also given one multivitamin orally daily for supplement. Antacid Suspension 30 ml Orally Every 6 hours Supplement heartburn Multivitamin 1 tablet Orally o.d. Supplement When the client was asked about dentures he stated that he does not have dentures even though dentures were noted in his chart. He states he needs aid in transferring from bed to a chair and with toileting. When asked about the character of his stools he explained that both consistency and color were normal. The client also stated that he does not need the help of laxatives. Noted in the client’s chart he is given a 100 mg capsule of Docusate sodium orally 2 times a day to help with constipation. Docusate sodium 100 mg capsule Orally BID Constipation The client does not have any history of kidney or bladder disease. He claims that the frequency, amount and color of his urine are normal. He also claims that he does not have any difficulty voiding and there is no pain or burning while urinating. According to the CNA, the client is able to stand,  holding the hand rails, while urinating. It is noted in the clients care plan that he is urinary incontinent which is related to impaired mobility and PRN straight catheter needed for intermittent retention secondary to BPH. The client is given one 0.4 mg of Tamsulosin HCL orally a day for BPH (benign prostatic hyperplasia). Tamsulosin HCL 0.4 mh Orally o.d. BPH The client needs assistance with bathing as well. The client also has a DNR order. Parkinson’s disease (paralysis agitans) is a progressive disorder of the nervous system that affects ones mobility. According to Hubert and VanMeter, Parkinson’s disease is a â€Å"dysfunction of the extrapyramidal motor system that occurs because of progressive degenerative changes in the basal nuclei, principally in the substantia nigra.†(UMMC, 2012) The substantia nigra is the primary area of the brain that is affected by Parkinson’s disease (PD). (UMMC, 2012) The substantia nigra is comprised of a specific set of neurons that send chemical signals, called dopamine. Dopamine then travels to the striatum, responsible for balance, control of movements, and walking, by means of long fibers called axons. (Okun, 2013) These regular body movements are controlled by the activity of dopamine on these axons. With PD the neurons in the substantia nigra break down and die causing the loss of dopamine, which in turn causes the nerve cells in the striatum to trigger excessively. The excessive firing of neurons makes it impossible for one to control their movements, a sign of Parkinson’s disease. (Okun, 2013) According to the Parkinson’s disease Foundation (2014): As many as one million Americans live with Parkinson’s disease, which is more than the combined number of people diagnosed with multiple sclerosis, muscular dystrophy and Lou Gehrig’s disease. Also approximately 60,000 Americans are diagnosed with Parkinson’s disease each year, and this number does not reflect the thousands of cases that go undetected. An estimated  seven to 10 million people worldwide are living with Parkinson’s disease. Incidence of Parkinson’s increases with age, but an estimated four percent of people with PD are diagnosed before the age of 50 and men are one and a half times more likely to have Parkinson’s than women. (p 1) Since PD is a progressively degenerative disease the signs and symptoms change over time and vary from person to person. A widely used clinical rating scale is the Hoehn and Yahr scale (HY); this helps to identify signs and symptoms in the various stages of Parkinson’s disease. (MGH, 2005) Early stages, like HY’s stage one, of Parkinson’s disease the symptoms are usually mild and appear unilateral. There may be changes in facial expressions, posture and locomotion; these symptoms are usually untimely and bothersome but not disabling. As the disease progresses, into stage two of the HY scale, it may begin to affect ambulation and be noticeable bilaterally with minimal disability. (MGH, 2005) As symptoms worsen, as in stage three of the HY scale, there is considerable slowing of body movements, early impairment of equilibrium with walking and standing and generalized dysfunction that is moderately severe. The Hoehn and Yahr scale’s stage four explains that signs and symptoms are severe but the person can still walk to a limited extent. (MGH, 2005) Rigidity and bradykinesia become factors in mobility. In stage five the person is unable to walk or stand so is bedridden or confined to a wheelchair. This stage is referred to as the â€Å"cachectic stage †. Constant nursing care is required in stage five (Costa and Quelhas, 2009). There are many complications that are associated with PD; one can be difficulty swallowing (dysphagia), likely due to the loss of control of muscles in the throat. (UMMC, 2012) Drooling can occur since saliva may accrue in the mouth due to dysphagia. Difficulty swallowing can also lead to malnourishment, but also poses a risk for aspiration pneumonia (Leopold and Kagel, 1997). Constipation can be another complication as to the slowing of the digestive tract. Parkinson’s disease can also cause urinary retention and urinary incontinence. Dementia and difficulty thinking comes in later stages of PD. (University of Maryland Medical Center, 2012) Depression is very common in patients with Parkinson’s. The disease process itself causes changes in chemicals in the brain that affect mood and well-being. Anxiety is also very common and may be present along with depression (University of Maryland Medical Center, 2012). Sleep problems  and sleeping disorders are also associated with PD, with this comes fatigue. Some patients may experience feeling light headed when standing due to the drop in blood pressure (orthostatic hypotension). Pain can also be another symptom related to Parkinson’s disease (Okun, 2013). There is not yet a cure for Parkinson’s disease but there are treatments that can help alleviate the symptoms. The most commonly used is drug therapy. Medications can help with difficulty with movement, walking and controlling tremors by increasing the brains amount of dopamine. (University of Maryland Medical Center, 2012) The most common and most effective Parkinson’s disease drug is Levodopa. This is a natural chemical that passes into your brain and is converted to dopamine (Okun, 2013). There is also surgical procedures available, deep brain stimulation. With this procedure the surgeon implants electrodes into a specific location in the patient’s brain. A gen erator is implanted in the patient’s chest, which is attached to the electrodes. This generator sends electrical impulses to the patient’s brain, which may lessen the symptoms of Parkinson’s disease. (University of Maryland Medical Center, 2012) Other ways that help control the effects of PD is a healthy diet. Constipation is a complication associated with PD, so a diet that is balanced with whole grains, fruits and vegetables helps to manage this complication. Balance, coordination, flexibility and muscle strength deteriorate with PD so, exercise is encouraged. Exercise also helps with decreasing anxiety and depression. The client exhibits many of the discussed signs and symptoms of Parkinson’s disease. The client experiences resting tremors, bradykinesia, mask like face (hypomimic), slowed speech and is in a wheelchair. He scores very poorly according to the Hoehn and Yahr scale. The client is on medications to help diminish the signs and symptoms of Parkinson’s disease. Impaired physical mobility level 3, related to bradykinesia, ak inesia, neuromuscular impairment motor weakness, pain and tremors. (Berman & Snyder, 2012) Evidenced by lack of decisive movement within physical environment, including movement in bed, transfers, and ambulation. Limited range of motion (ROM). Decreased muscle stamina, strength and control. Limitation in independent, purposeful physical movement of the body and impairment unilaterally on the right side. Due to the muscular and neuromuscular weakness related to Parkinson’s disease, evidenced by it being difficult for the patient to ambulate. The client has a defect of extrapyramidal tract, in the basal ganglia, with loss of the neurotransmitter dopamine. (Berman & Snyder, 2012) Classic triad of symptoms: tremor, rigidity, bradykinesia (Jarvis, 2012). Tremors associated with paralysis agitans make it difficult maneuver. Tremors cease with voluntary movement and during sleep (VanMeter and Hubert, 2014). Immobility is an expected human response to Parkinson’s disease. The client’s immobility puts him at risk for thrombophlebitis, skin breakdown, pneumonia and depression. Immobility impedes circulation and diminishes the supply of nutrients to specific areas. As a result, skin breakdown and formation of pressure (decubitus) ulcer can occur (Berman and Snyder, 2012). Immobility also promotes clot formation. Self-care deficits related to neuromuscular impairment, immobility, decreased strength, and loss of muscle control and lack of coordination, ridgity and tremors. Self-care deficits, dressing, hygiene and toileting, evidenced by tremors and motor disturbance. The client lacks the ability to cleanse his body, comb his hair, brush his teeth and do skin care. . The client is also unable to dress himself satisfactory. He does not have the capability to fasten his clothes. The patient is assisted with ADL’s. Patient is incapable to bathe, dress or brush teeth without aid. Patient occasionally needs assistance with feeding. Assistance is also required with toileting. Aid is needed with ADL’s because of the lack of coordination and for safety. This nursing diagnosis is important because it ensures hygiene, improves quality of life, and promotes dignity, self-worth, independence and freedom. Risk for falls related to decreased mobility, a nd unsteady gait secondary to sedentary lifestyle and Parkinson’s disease. Patient uses a wheelchair and ambulates with a walker. Patients gait is impaired due to Parkinson’s disease. Festination, or a propulsive gait (short, shuffled steps with increasing acceleration), occurs as postural reflexes are impaired, leading to falls (VanMeter and Hubert, 2014). Falls also result in psychological implications for the patient with a decrease in self-confidence and a fear of further falls. This contributes to a decrease in mobility and culminates in a significant reduction in quality of life (Jarvis, 2012). Impaired bowel elimination/constipation related to medication, physical disability and decreased activity. Evidenced by the client not passing stools daily. Medications prescribed to patient for Parkinson’s disease attribute to constipation. The patients experience with immobility is also a  contributing factor for constipation. This nursing diagnosis is important because it allows nursing staff to monitor the patient’s bowel movements and avoid fecal impaction. Imbalanced nutrition less than body requirements related to tremors, slowing the process of eating, difficulty chewing and swallowing. Evidenced by the client occasionally needing assistance with eating. Pressure sores develop more quickly in patients with a nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or a rehabilitative program. The goal is to optimize the client’s nutritional status. Impaired verbal communication related to decreased speech volume, decreased ability to speak, stiff facial muscles, delayed speech, and inability to move facial muscles. Evidenced by lack of expression on the client’s face, client’s hindered speech. Loss of dopamine can affect the facial muscles, making them stiff and slow and resulting in a characteristic lack of expression. Speech impairment is referred to as dysarthria and is often characterized as weak, slow, or uncoordinated speaking that can affect volume and pitch. Difficulty speaking and writing because of tremors, hypophonia, and â€Å"freeze† incidents. This is an expected consequence of Parkinson’s disease. Nursing Care Plan- Alteration in impaired physical mobility- Parkinson’s disease Related to: Goals Intervention Bradykinsia Client will use a walker to go to breakfast in the mornings and not need assistance with transfers. Client will be able to perform all active ROM by 3 months Examine current mobility and observation of an increase in damage. Do exercise program to increase muscle strength. Perform passive or active assistive ROM exercises and muscle stretching exercises to all appendages. To promote increased venous return, prevent stiffness, and maintain muscle strength and endurance. Without movement, the collagen tissues at the joint become ankylosed (permanently immobile) (Berman & Synder, 2012) Akinesia Client will gain power of voluntary movements. Joint contractures will not occur. Assess the possibility of deep brain stimulation. Refer to physical therapy. When the muscle fibers are not able to shorten and lengthen, eventually a contracture forms, limiting joint mobility (Berman & Synder, 2012) Tremors Client’s tremors will decrease. Encourage deep breathing, imagery techniques and meditation. Encourage holding an object in hand Suggest holding the arm of the chair. Stimulating the brain by concentrating on breathing may cease tremors. (www.theparkinsonhub.com) Pain Client will not experience pain >4 on a scale of 0-10 Before activity observe for and, if possible, treat pain. Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain. Administer pain medication per physician orders. Encourage/assist to reposition frequently to position of comfort. Pain limits mobility and is often exacerbated by movement. (www.ptnow.org) Nursing Care Plan- Alteration in Skin Integrity, Impaired: Risk for – Pressure Sores; Pressure Ulcers, Bed Sores; Decubitus Care Related to: Goal Interventions Rationale Neuromuscular impairment Client will be free of any pressure ulcers for length of long term stay. Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain or any other signs of infection. Pay special attention to high risk areas and ask client questions to determine whether he is experiencing loss of sensation. Apply barrier cream to peri area/ buttocks as needed. Use ROHO cushion on wheelchair. Checking skin once a day will ensure that skin stays intact. (Jarvis, 2012) Immobility Client will be able to express s/s of impaired skin. Teach skin and wound assessment and ways to monitor for s/s of infection, complications and healing. Use prophylactic antipressure devices as appropriate Early assessment and interventions may help complications from developing. To prevent tissue breakdown. (Jarvis, 2012) Nursing Care Plan- Self Care Deficits Related to: Goal Intervention Rationale Immobility Client will assist with bathing, grooming, dressing, oral care and eating daily. Assist client with bathing, grooming, dressing, oral care and eating daily. Use high back wheelchair. The effectiveness of the bowel or bladder program will be enhanced if the natural and personal patterns of the patient are respected. Loss of muscle control and lack of coordination Client will improve muscle control and coordination in all extremities for the length of long term stay. Client will walk to dining room and in hallways- 5 mins a day 5 days a week. Use consistent routines and allow adequate time for patient to complete tasks. Assist client with ambulation. This helps patient organize and carry out self-care skills. Tremors Client will be able to assist with dressing. Provide appropriate assistive devices for dressing as assessed by nurse and occupational therapist. Encourage use of clothing one size larger. Teach and support the client during the client’s activities Apply extensions on breaks with ball grips The use of a button hook or of loop and pile closures on clothes may make it possible for a patient to continue independence in this self-care activity. Ensures easier dressing and comfort. Grips will be easier to grasp with tremors. Neuromuscular impairment Client will be clean, dressed, well groomed daily to promote dignity and psychosocial well-being. Assist with shower as needed. Assist with daily hygiene, grooming, dressing, oral care, and eating as needed. This promotes dignity and psychosocial well-being. Nursing Care Plan- Falls, risk for Related to: Goal Intervention Rationale Decreased muscle tone Client will express an understanding of the factors involved in possible injury. Educate the client about what makes them at risk for falls. Bed should be in lowest position. Provide assistance to transfer as needed. Reinforce the need for call light. If the client is educated and shows an understanding of the factors involved with falls, they are less likely to fall. Prevent fall. Nursing Care Plan- Impaired Bowel elimination/constipation Related to: Goal Intervention Rationale Inactivity, immobility Client will have soft formed stool every other day that are passed without difficulty. Encourage physical activity and regular exercise. Adjust toileting times to meet client’s needs. Report changes in skin integrity forum during daily care Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate defecation. low-fiber diet Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake. Initiate supplemental high-protein feedings as appropriate. Change in mealtime, type of food, disruption of usual schedule, and anxiety can lead to constipation. Proper nutrition is required to maintain adequate energy level. Diminished muscle tone Encourage isometric abdominal and gluteal exercise Apply skin moisturizers/barrier creams as needed To strengthen muscles needed for evacuation unless contraindicated. (http://www.gutsense.org) Medications Encourage liquid intake of 2000 to 3000 ml per day To optimize hydration status and prevent hardening of stool (VanMeter & Hubert, 2014) My thinking about my resident has definitely changed since the initial day when I conducted a health history assessment on him. I knew that first day that I was going to appreciate getting to know this resident because of how smoothly the conversation flowed. This resident had some amazing stories to tell. I absolutely adore that fact that he and his wife have been married for 48 years. I enjoyed listening to him remember what life was like before being diagnosed with Parkinson’s disease, it appeared to lighten his spirit. I feel very fortunate to have been given the opportunity to care for such a genuine soul. My whole clinical experience was a positive one. I realized that if I lacked the knowledge about a particular task to ask for help. I liked the fact that clinicals was hands on and that I gained experience in a long term health care facility. Another thing that this clinical rotation  taught me was that it takes an exceptional type of person to go into geriatric nursing. Probably the number one thing that I’m going to take away from this clinical experience is the total importance of dignity. I too will be old someday and I applied the golden rule to this experience. I treated others as I want to someday, and hopefully, will be treated. What a fantastic learning experience. References: Berman, A., & Snyder, S. (2012). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice. Upper Saddle River: Pearson Education. Coleman, J., (September 1, 2013) Meditation & Mitigating Parkinson’s Symptoms. Retrieved from http://www.theparkinsonhub.com/your-quality-of-life/article/meditation–mitigating-parkinsons-symptoms.html Costa, M. & Quelhas, R. (2009). Anxiety, Depression, and Quality of Life in Parkinson’s Disease. The Journal of Neuropsychiatry and Clinical Neurosciences 2009; 21:413-419. Jarvis, C. (2012). Physical Examination & Health Assessment. St. Louis: Elsevier Kegelmeyer, D., (July 1, 2013) Functional Limitation Reporting (FLR) Under Medicare: Tests and Measures for High-Volume Conditions. Retrieved from http://www.ptnow.org/FunctionalLimitationReporting/TestsMeasures/Default.aspx Leopold N., Kagel M. (1997). Pharyngo-esophageal dysphagia in Parkinson’s disease. Dysphagia 1997; 12:11–18 Massachusetts General H ospital (MGH) (May, 2005) Hoehn and Yahr Staging of Parkinson’s Disease, Unified Parkinson Disease Rating Scale (UPDRS), and Schwab and England Activities of Daily Living. Massachusetts General Hospital. Retrieved March 2, 2014, from http://neurosurgery.mgh.harvard.edu/functional/pdstages.htm#HoehnandYahr Okun, M. (2013). Parkinson’s Treatment: 10 Secrets to a Happier Life. CreateSpace Independent Publishing Michael S. Okun M.D. Parkinson’s disease Foundation (2014, March) Understanding Parkinson’s. Parkinson’s Disease Foundation. Retrieved March 2, 2014, from http://www.pdf.org/en/understanding_pd University of Maryland Medical Center (2012, September) Parkinson’s disease. University of Maryland Medical Center. Retrieved March 2, 2014, from http://umm.edu/health/medical/reports/articles/parkinsons-disease#ixzz2upFLCggw VanMeter, K. C., & Hubert, R. J. (2014). Gould’s Pathophysiology for the Health Professions. St. Louis: Elsevier.

New Orleans’ economy is very dependant on the tourism and lodging industry

New Orleans' economy is very dependant on the tourism and lodging industry. In the past couple of years this industry in New Orleans has declined. In 1996 the city hosted 12 million tourists and conventioneers and they spent close to $4 billion. The average daily room rate was $105. The September 11 attacks had a huge affect on the tourism industry. Although the economy in New Orleans is rising, the number of tourist each year has dropped dramatically. This past year New Orleans hosted an estimated 7.995 million visitors. This is approximately the same number as they hosted in 1991, meaning the increase in visitors throughout the nineties has been abolished. On the positive side, these 8 million visitors spent an approximate $4.5 billion on hotel rooms, food, drinks, entertainment, and shopping. This figure is actually higher than that spent by the 12 million visitors in 1996. This $4.5 billion created 2.9 billion in revenue and helped support more than 138,000 are jobs. New Orleans has done a great job in compensating for the decline in the tourism industry. Because of the lack of visitors they have simply made it more expensive for the guests they do receive. The current average daily room rate for New Orleans' hotels is about $170. Average airfare from Denver to New Orleans is $400. Even though these prices are so high, the great thing about New Orleans is that no matter what day of the year visitors can always find free events. All of this contributes to what should be a very profitable 2004.

Fiction Analysis of aP and the Lesson Essay examples

The theme of desire has been portrayed in many novels and stories. Perhaps the most well-known depiction of desire can be found in the Bible. In the Book of Genesis, a snake tempts Adam and Eve to eat the forbidden fruit of the Tree of Knowledge after he convinces them that they will gain God’s knowledge of good and evil and be protected from death. Despite God’s word to not eat of the fruit, Adam and Eve did so anyway. Surely, this story portrays temptation; however, beyond the theme of temptation lays the theme of desire. Knowing it was wrong, Adam and Eve ate the fruit because they had the desire for what the snake promised them. Similarly, Toni Cade Bambara and John Updike also display the theme of desire in their short stories. In†¦show more content†¦The setting is very important in both stories in that it defines not only the plot, but the characters themselves. Sylvia and Sammy are products of their environments. Being in an unpleasant environment would definitely put any individual on edge. Because both characters are unhappy with their surroundings, both are quite cynical. Aside from comparing one customer to a witch, Sammy also refers to others as â€Å"sheep† and points out â€Å"house-slaves in pin curlers† (Updike 3). Sylvia is also cynical in the way she talks of Miss Moore. At a point, Sylvia states that she is a â€Å"nappy-head[ed] bitch†, which in no means is a proper way for anyone, let alone a child, to speak (Bambara 1). Despite being so cynical, the reader finds that both characters have another side as well. When faced with desire, Sylvia’s and Sammy’s mannerism changes. The reader sees Sylvia in a whole new way when she sets eyes on the fiberglass sailboat. In fact, Sylvia’s entire persona changes. Not only is she dumbfounded by the price of the sailboat, but she is awestruck by its greatness. 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