Case Study Rehabilitation Backup Final

Introduction

This assignment aims to discuss a Pacifc Islander’s health history and

illness. I will use the Marjory Gordon’s health assessment tool for the

interview assessment and formulate a Nursing Care Plan using this. A

discharge plan will also be develop for the client needs and a discussion

regarding an alternative therapy for the client’s condition will be examined.

I will also list the clients medication regime and identify six medications in

detail regarding the dosage, side effects and rationale. Two of these six

medications will be thoroughly analysed and emphasised to the client and

clients family for educational purposes. Finally I will reflect on this

assignment using Schon’s reflection-in-Action and Reflection-on-Action

tool.

In this assignment I have used pseudonyms to replace the identification of

the client’s details to ensure his privacy and protection. I will refer to him

as Mr Jack throughout the assignment. I have also incorporated old and

new literature/references as I found it difficult to find current literature for

Pacific purposes as you will see in this assignment. This literature is

currently still used and referred to by other theorists and writers.

Patient Medical Profile:

Mr Jack is a 68 year old male of Samoan descent admitted to a

rehabilitation ward for a recent hemiarthroplasty surgical placement of his

left hip. Mr Jack is well known to the medical services as he has had

previous admissions in the past regarding his medical conditions.

of 31Student ID: 20600910

Mr Jack presented as fatigue, with shortness of breath (SOB). His balance

was notably poor due to his recent surgical hemiarthroplasty on his left hip

and recent experiences of vertebrobasilar, transient ischemic attacks (TIA).

Prior to this admission Mr Jack was able to mobile himself independently

without the necessity of a walking device. However due to his current

condition he is utilising a walking frame with the assistance of a belt and

two nurses. Mr Jack complains of dizziness and pain on his left hip due to

his recent surgery.

Previous Medical History:

Mr Jack has a history of polycytharmia rubra vera, hypertension, previous

cerebrovascular accident (CVA), recurrent vertebrobasilar transient

ischemic attacks (TIA’s), gout, a Type 1 aortic dissection in 1999 repaired

with graft and a vascular ulcer on the left shin. Mr Jack has had previous

multiple infarcts in the posterior circulation of the brain, had cervical spine

degenerative disease, bilateral cataracts, mild renal impairment, and has

experienced muscular neck pain in the past.

Medical Diagnosis on Admission:

Fracture left neck of femur (#L NOF) – hemiarthroplasty.

Positive blood culture – likely contaminant.


Marjory Gordon Health Assessment

Health Perception and Health Management Pattern:

Mr Jack prefers to use Samoan traditional medicines and methods for

health purposes rather than Western medicines as he feels these contribute

to his tiredness. However, Mr Jack will take Western medication if doctor

has prescribed this to him. He states throughout his life he has always

taken Samoan herbal medicines as he feels this helps with ‘cleansing his

system’ and makes his body feel stronger. Mr Jack started smoking at the

age of 15 years and has recently stopped smoking in the last three months.

Mr Jack does not drink alcohol anymore. He no longer drinks alcohol

although in the but he was a regular consume of this substance perhaps 3-4

times a fortnight. He visits his local GP for follow-up of his blood pressure

regularly due to his wifes encouragement for a health check-up. Mr Jack

has had 4-5 colds in the last year. up. Mr Jack feels his current admission

was precipitated due to the dizziness he experiences when standing or

doing a physical activity. He has had previous admissions to the hospital

for myocardial infarct and transient ischemic attacks. He knows he is not

to over exert himself but tends to forget about his medical condition stating

“the mind is willing but the body is weak”. He would like to leave the

rehabilitation ward and gain his independence around his mobility again.

Nutritional/Metabolic Pattern:

Mr Jack enjoys his traditional Samoan meals such as taro, green bananas,

vegetables, fruit. He eats at least three main meals a day, breakfast, lunch

and dinner, and would usually have a snack in between if feeling hungry.


He enjoys drinking 4-5 hot beverages during the day. Mr Jack prefers to

drink water rather then fizzy drinks. His fluid intake is approximately

1500mls-2000mls daily. Mr Jack weighed in at 112kg on admission and

currently weighs 108kgs with a notable weight loss of 4kgs. He has no

difficulty swallowing, is on a normal diet of food with his preference and

thin fluids. Mr Jack usually has no problems with skin integrity, however

reported a shin ulcer which was slow to heal a few years ago. He has no

dental problems, all teeth intact.

Elimination Pattern:

Mr Jack would pass urine at least five times daily, in the morning,

throughout the day and before he goes to bed. He would usually have at

least one to two bowel motions throughout the day.

Activity/Exercise Plan:

Mr Jack exercises at home in his garage. He has a set of weights and bike

machine which he utilises for a period of 15-20 min three to four times a

week. He enjoys walking around his neighbourhood for at least 15 min if

he has not used these machines. Mr Jack tries to stay as active as possible

by doing chores around the house whether it be gardening, fixing the car or

hanging the washing. He is quite aware of his health status and tries to

maintain as active as possible. At times Mr Jack experiences dizziness,

shortness of breath (SOB) or tires when attempting these activities so

would rest a while before resuming them again. He can independently


feed, dress, shower, groom, toilet himself with the assistance of a mobility

device. Pulse rate = 72. Respiratory rate = 15.

Sleep/Rest Pattern:

Mr Jack gets at least seven to eight hours of sleep at night and would

occasionally have two naps in the day depending on how tired he feels

during the day or if the weather is too hot. Sometimes Mr Jack would rest

immediately if he starts to feel slightly dizzy or gets headaches, these

symptoms usually occur when doing a physical activity.

Cognitive/Perceptual Pattern.

Mr Jack’s first language is Samoan. English is his second language. He

feels confident in speaking both languages and clearly had no problem in

this area. Mr Jack understood the reason for his admission and was

orientated to date, time and place.

Self Perception/Self Concept Pattern:

Prior to admission Mr Jack felt well and healthy, there were times he

experienced feelings of fatigue, tiredness and dizziness at home, but related

these feelings to undertaking too much exercise or chores around the

house. He states he tries to not be a burden to his wife and family in

regards to seeing following-up appointments with his local doctor as he

feels like a burden to them. While in hospital, he knows he is not ‘100%

right’ but tries hard to gather his strength back in order to go home and be

with his fanau (family). Mr Jack states at times he is aware that his


medical condition and his health tends to ‘get him down’ but when his

family arrive to visit him in hospital he suppresses his feelings and assures

them ‘he’s okay’. Mr Jack tries to give his family the impression that

‘everything will be okay’ but he knows he needs to look after himself as

much as possible for the sake of his grandchildren.

Role Relationship Pattern:

Mr Jack is the father of three children and grandfather of four

grandchildren. His wife and children visit him once or twice daily at the

hospital. He describes his family as very close and when there is a

fa’alavelave (problem) in the family, they seek his advice. He states he

comes from a supportive family who all have an input and try to manage

his health, from his diet to his daily exercises. Mr Jack is very comfortable

with his supportive family but till worries about his health condition.

Sexuality/Reproductive Pattern:

He has a strong loving supportive relationship with his wife and is seen as

the role model to the whole fanau. He enjoys spending time with his

family and grandchildren and quality time alone with his wife at home.

Coping/Stress Tolerance Pattern:

Mr Jack copes with stress by trying to keep himself occupied with

activities. He prefers to go for walks and attempting to forget the situation.

He knows he needs to avoid stress and tries to avoid difficult situations.


Mr Jack will often take ‘time out’ and have some quiet time by himself

when he feels upset.

Value Belief Pattern:

Mr Jack is a very religious and spiritual man. He attends a Samoan

Methodist church religiously every Sunday when he is feeling well and is

also a great supporter of the congregation’s activities. Mr Jack and his

family have evening prayers each evening home.


Nursing Care PlanDate Nursing Diagnosis

Client Problem and Cause

Client Centred Objective

Nursing Intervention Rationale Evaluation

07/03/08 Impaired Gas exchange related to transient ischemic attacks and myocardial infarction

Mr Jack will state he has not experienced difficulty in breathing each 8 hourly shift.

Monitor respiratory rate/depth use of accessory muscles and areas of cyanosis.

Auscultate breath sounds, noting presence/absence, and adventitious sounds.

Monitor vital signs, note changes in cardiac rhythm.

Investigate reports of chest pain and increasing fatigue. Observe for signs of increased fever, or cough.

Indicators of adequacy of respiratory function or degree of compromise and therapy needs/effectiveness (Carpenito-Moyett, 2005).

Development of atelectasis and stasis of secretions can impair gas exchange (Carpenito-Moyett, 2005). .

Compensatory changes in vital signs and development of dysrhythmias reflect effects of hypoxia on cardiovascular system (Carpenito-Moyett, 2005).

Reflective of developing acute chest syndrome (i.e., chest pain, dyspnea, fever, and leukocytosis), which increases the workload of the heart and oxygen demand (Carpenito-Moyett, 2005).

Mr Jack did not experience shortness of breath and stated there were no difficulties in his breathing.

07/03/08 Pain related to hemiarthroplasty surgical placement on left hip

Mr Jack will verbalize adequate relief of pain or ability to cope with pain each 8 hourly shift.

Monitor signs and symptoms associated with pain, eg BP, heart rate, temperature, colour and moisture of skin, restlessness, and ability to focus.

Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating the pain (Gulanick & Myers, 2006)

Mr Jack did not experience any pain and was able to manage moderate pain through non-medical alternatives eg massage..


Respond immediately to complaint of pain.

Offer analgesics as charted by doctor if pain continues.

Encourage non-pharmacological methods to reduce pain. Eg: breathing exercises, massage, back rubs, repositioning, or distraction techniques, tv, listening to music, Samoan radio station.

In the midst of painful experiences a patient’s perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship. nurse in evaluating pain (Gulanick & Myers, 2006).

Pain medications are absorbed and metabolized differently by patients, so their effectiveness must be evaluated from patient to patient (Gulanick & Myers, 2006).

Breathing techniques reduces anxiety and massage decreases muscle tension can promoting comfort (Gulanick & Myers, 2006).

07/03/08 Potential for infection related to surgical hemiarthroplasty procedure on left hip

Mr Jack’s surgical wound on left hip will remain infection free each 8 hourly shift.

Utilize good hand washing technique.

Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). Use of

Mr Jack’s wound has remained free from infection each 8 hourly shift. Nil evidence of sluff, pus, foul smell, swelling of skin observed.


Inspect and record signs of, injured site, swelling, increased pain, or purulent drainage in surges.

Assess for temperature every two hourly

Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).

disposable gloves does not reduce the need for hand washing (Ralph & Taylor, 2006).

Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture (Ralph & Taylor, 2006).

Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicaemia (Ralph & Taylor, 2006).

Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI) (Ralph & Taylor, 2006).

07/03/08 Risk for falls related to lower impaired balance.

Mr Jack will remain fall and injury free each 8 hourly shift.

Keep bedside rails up in bed in low position.

Ensure client uses a transfer

This prevents patient from falling out of the bed when resting (Comer, 2005).

Staff member will be able to assist

Mr Jack has remained injury free each 8 hourly shift. He has not had any falls or sustained injuries.


safety belt and a nurse present at all times when ambulating with walking frame.

Ensure there are no obstacles in the path of Mr Jack when he is ambulating. Eg . shoes, bags.

Ensure client’s necessary objects are within reaching distance. Eg. Hospital trolley close to bed, with spectacles, tissues, drink, meals.

the client if he/she is feeling dizzy or unsteady at any time during ambulation. Thus providing and promoting a safe environment and making the client feel safe too (Comer, 2005).

Promotes a safe environment and prevents client from tripping over obstacles (Comer, 2005).

Prevents client from reaching over too far for an item and falling during the attempt (Comer, 2005).


Discharge Plan:

Patient Name:Sam Jack NHI: ABC0123Address: 68 Disney World Pl DOB: 16/03/1941

New WorldPALACE

Telephone: (04) 911-1111 Admission Date: 07/03/2008GP: Dr Local Discharge Date: 21/03/2008Consultant: Dr Magoo Discharge Destination: Home

Diagnosis/ Reason for Adm:

Fracture left neck of femur (#L NOF) – hemiarthroplasty.

Positive blood culture – likely contaminant.

Mobility:

After several assessments with the Physio Therapist and Occupational

Therapist it has been determined in order for Mr Jack to maintain his

independence he will need to use a walking frame, a walking stick and a

hand reacher to mobilise with. Mr Jack has been encouraged and taught

how to use these devices and displays the confidence and determination to

use these devices when needed.

Current Supports

Mr Jack lives at home with his wife, one independent son and one

dependent daughter who attends college. They are all aware of his current

condition and have all been involved with his current care whilst in

hospital. A meeting was held with the Multi Disciplinary Team (MDT)

and the family prior to Mr Jack’s discharge and the family will continue to

support their father in regards to encouraging Mr Jack’s independence with

his mobility. The family are aware of their father’s needs and have been


informed that a referral has been made to the Orthopaedics Department and

Mr Jack’s local GP for follow-up of his mobility and treatment.

Personal Cares

Mr Jack is able to attend to his oral cares independently (brushing teeth,

washing face,. combing hair). The Occupational Therapist has provided

Mr Jack with a shower stool to assist him in the shower, he has been

advised to use the hand reacher in the shower to assist him when bending.

He also uses this device when putting on shoes and socks to prevent him

from bending and falling. Mr Jack appears very confident when using the

devices provided for him when attending to his personal cares.

Management of Daily tasks

Mr Jack and his family have been informed about conserving his energy

when undertaking daily tasks at home or in the community. Mr Jack is

aware he is not overexert himself in case he starts to have dizzy spells

related to his TIA condition. Mr Jack and his family have been encouraged

to reinforce the use of the devices he has been given to make daily

activities easier for him. His wife has stated she will assist with domestic

tasks and all meals. However declined ALL assistance with regards to

management of daily tasks and this was to ensure Mr Jack would maintain

mobility, movement and interaction with/on family occasions. Mr Jack

expressed to his family he will only need their assistance when requested

as he would like to maintain his independence. Mr Jack does not drive.

Mrs Jack has stated she will drive him to the necessary venues in regards to

paying bills, outings and attending church.


Communication skills.

Mr Jack has no difficulty in interpreting and understanding conversation.

He speaks in both Samoan and English and does not need an interpreter in

this area. Mr Jack wears spectacles when reading however, states he has

difficulty in reading now and finds it hard to concentrate for a long period..

Mr Jacks wife assists in this area by reading out loud to him.

Cognition

Mr Jack is orientated to date, time, place and person. He has insight into

his admission and understands the underlying cause of his admission. He

remembers what happened prior to admission and stated he “felt dizzy and

fell down”. Mr Jack has difficulty in concentration when trying to focus on

something for example reading. He states his vision is a blurry at times

although he wears prescribed spectacles for reading. Concentrating on

reading is the only difficulty he has in regards to his cognitive status. Mr

Jack had eye surgery for a bilateral cataracts several years ago. A referral

has been made by the eye specialist to the Outpatients Eye Department for

follow-up of his vision.

Management of Health:

Medications on discharge:

Paracetamol 1gm PO qid (Pain relief)

Aspirin EC 100mg PO mane (Pain relief and prevention of

Ischemic strokes)

Dipyridamole 150mg PO bd (Coronary vasodialator)

Allopurinol 100mg PO mane (Prevents gout)


Felopindine 2.5mg PO mane (Antihypertensive drug)

Bendrofluazide 2.5mg PO mane (Prevents Oedema)

Hydroxyurea 500mg PO mane (Prevents growth of cancer cells)

Laxsol 2 tablets PO bd (Prevents constipation)

Lactulose 20ml PO bd (Prevents constipation)

Codeine phosphate 60mg PO qid (relieves inflammation )

Cyclizine 50mg PO PRN (max daily 150mg. ) (treatment of nausea,

vomiting and dizziness).

Prior to discharge Mr and Mrs Jack were spoken to by the House Surgeon

in regards to the medication regime and the complications that would occur

if Mr Jack was to become non-compliant. Education regarding his

hypertensive condition was especially emphasised as Mr Jack has had a

long history of hypertension and transient ischemic attacks. As this

admission was precipitated by a fall due to Mr Jack feeling ‘dizzy’ it was

stressed to him and his wife that he remain compliant with his medication.

Mr Jack has no known allergies or drug reactions to the prescribed

medications.

Mr Jack’s surgical wound on his left leg remains infection free. Surges

were removed eight days prior to discharge. Nil evidence of drainage,

discharge, sluff, pus or bleeding from wound on left hip on discharge. Mr

Jack has been prescribed with codeine, paracetamol and aspirin to assist

with management of pain. Laxsol and Lactulose have also been prescribed

for management of bowel elimination for prevention of constipation. Mr

Jack is able to mobilise self to the toilet with little assistance.


Eating/Drinking

A referral has been made to the dietician for management of his dietary

intake. Although Mr Jack continues to be on a normal diet it is important

his retains an adequate healthy diet for his wellbeing. Mr Jack needs to

know that fatty foods found in traditional meals can contribute to his

cardiovascular condition (Turley, Tobias, Lawes, Stefanogiannis, Hoorn,

Ni Mhurchu, & Anthony, 2006).. Thin fluids.

Night time Needs

A urinal has been provided for Mr Jack for night time purposes.

Occupational Therapist has encouraged Mr Jack to toilet before retiring to

bed at night to ensure bladder is empty.

Therapy alternative for Client and Fanau (Family).

Throughout the assessment of this client I have identified one non-medical

therapy which could benefit the client and family in regards to

rehabilitation of the client’s surgical fracture on the left hip. This method

is called the fofo (massage). A Samoan traditional technique which is well

known for its therapeutic healing, not only for the physical being of the

individual, but also for the spiritual being (A. Fanueli. Personal

Communication, March 30, 2008). There are many types of traditional

fofo’s (Samoan massages) used in the Samoan community. There is the

fofo vai (massage with traditional herbs/leaves), fofo itu (massage used for

people who are spiritually possessed) and fofo gau (massage for the

manipulation of bones, and for pain therapy) to name a few.


During the assessment of Mr Jack he stated he preferred using Samoan

traditional methods rather than Western medical treatment for his health.

Mr Jack felt the Western medications he was prescribed contributed to the

symptoms he was exhibiting, such as dizzy spells, feeling tired and at times

nauseous. Therefore was not surprised to see why he was experiencing

most of these symptoms after being informed about the side effects from

the medications. However Mr Jack did verbalise he will continue using

both Western and Samoan traditional methods after discharge.

Rationale

In this instance I would advocate the fofo gau to Mr Jack and his fanau.

This traditional alternative assist’s with alleviation of muscle pain, spasms,

dislocations, manipulation of bone fractures, body alignment and blood

circulation (A. Fanueli. Personal Communication, March 30, 2008).

As a young female of Samoan descent I am very familiar with this

procedure of the fofo gau. I come from a family line of Taulasea’s

(traditional healers) and observe this practice through my father whose

patients visit him daily for all sorts of conditions related to body pain,

muscle pain and fractures. Like Western methodologies, the Samoan

Taulasea assesses a client prior to commencement of treatment for the fofo

gau (A. Fanueli. Personal Communication, March 30, 2008). The Taulasea

will need to obtain a history from the patient and the patient’s fanau to

determine their mobility before their incident. The Taulasea will ask if the

patient had sought Western therapies such as recent surgery, enquire about

current medications he/she is on, how long they have had their condition


and what other traditional methods they have sought. After the assessment,

the Taulasea will decide whether they are able to continue with the fofo

gau, sometimes prior to the commencement of this procedure a prayer is

offered either by the Taulasea or patient. Samoans see health in a holistic

manner. Macphersons (1990) states that health is believed to be achieved

through balance of the three worlds, the natural world, the social world and

the spiritual world.

I feel this traditional alternative will suit Mr Jack’s needs as his preference

is traditional therapies and he continues to experience mild to moderate

pain on his left hip. The fofo gau soothes tight, tense or overworked

muscles, increases energy levels, improves circulation of blood and

lymphatic fluid, softens skin where scar tissue has formed, prepares healthy

muscle for demanding activity and aids recovery from the activity (A.

Fanueli. Personal Communication, March 30, 2008). There is no price

attached to this procedure as Samoans do things out of ‘love and kindness’

for their people. This method is also a treatment Mr Jack and his family

will be familiar and comfortable with.

Medication Regime

Medication: Felodipine

Action: Antihypertensive drug.

Dosage: 2.5mg PO mane (per orally in morning)

Side effects: Headache, fatigue, drowsiness, dizziness.


Rational: Mr Jack has a history of hypertension. Felodipine is used to

treat high blood pressure. It relaxes the blood vessels so the

heart does not have to pump as hard (Skidmore-Roth, 2006).

Medication: Dipyridamole

Action: Coronary vasodialator

Dosage: 150mg PO bd

Side effects: Dizziness, stomach pain, headache, diarrhea, vomiting,

nausea.

Rational: Dipyridamole is used in conjunction with other drugs such

as Aspirin to prevent excessive blood clotting. It reduces

the risk of death after a heart attack and prevents another

heart attack or TIA’s (Skidmore-Roth, 2005)..

Medication: Codeine Phosphate

Action: Acts by suppressing the cough centre in the brain.

Dosage: 60mg PO qid

Side effects: Lightheadedness, dizziness, sedation, nausea and vomiting..

These effects seem to be more prominent in ambulatory

than in non ambulatory patients, and some of these adverse

reactions may be alleviated if the patient lies down.

Rational: A drug made from opium or morphine that is used to relieve

pain and to prevent coughing and diarrhea (Skidmore-Roth,

2006)..


Medication: Allopurinol

Action: (Prevents gout)

Dosage: 100mg PO mane

Side effects: Skin rash, pain or bleeding when urinating; fever, sore

throat, headache. bruising, severe tingling, numbness, pain,

muscle weakness; unusual weakness; fever, chills, body

aches, flu symptoms;

Rational: Allopurinol reduces the production of uric acid in the body.

Uric acid buildup can lead to gout or kidney stones.

Allopurinol is used to treat gout or kidney stones, and to

decrease levels of uric acid in people who are receiving

cancer treatment (Skidmore-Roth, 2005)..

Medication: Hydroxyurea

Action: Prevents growth of cancer cells


Side effects: Nausea, vomiting, diarrhoea, loss of appetite, rash, itchiness,

constipation, or drowsiness.

Rational: Is used to treat cell disease or certain types of cancer.

Hydroxyurea is used for treating cancers of the blood, skin,

ovary and head and neck. Hydroxyurea is also used to

decrease the painful episodes associated with sickle cell

disease. Hydroxyurea does not cure sickle cell disease, but


may help to control the symptoms when used on a regular

basis (Skidmore-Roth, 2006).

Medication: Aspirin EC

Action: (Pain relief and prevention of Ischemic strokes)


Side effects: Upset stomach, heartburn, drowsiness; headache, severe

nausea, vomiting.

Rational: Aspirin is used to treat mild to moderate pain, and also to

reduce fever or inflammation. Aspirin is sometimes used to

treat or prevent heart attacks, strokes, and chest pain

(angina). Aspirin should be used for cardiovascular

conditions only under the supervision of a doctor

(Skidmore-Roth, 2006)..

Pharmacokinetics of Felodipine

Felodipine is completely absorbed from the gastrointestinal tract after oral

administration. Felodipine is extensively metabolized by the liver. After

72 hours, approximately 70% of a given dose is excreted as metabolites in

the urine and 10% is secreted in the faeces. Less than 0.5% of a dose is

recovered unchanged in the urine..

Pharmacodynamics of Felodipine

The acute effect of felodipine is a reduction in total peripheral resistance

which leads to a decrease in blood pressure associated with a modest reflex

increase in heart rate. This reflex increase in heart rate frequently occurs


during the first week of therapy and generally attenuates over time. Heart

rate increases of 5 to 10 beats/minute may be seen during chronic

administration. The effect on the heart rate is inhibited by beta-blocking

agents. Following administration of Felodipine a reduction in blood

pressure generally occurs within 2 to 5 hours. During chronic

administration, substantial blood pressure control lasts for approximately

24 hours; reductions in diastolic blood pressure levels were 40 to 60% of

those at peak plasma levels. The antihypertensive effect is dose-dependent

and correlates with the plasma concentration of Felodipine. Felodipine in

therapeutic doses has no effect on the intrinsic system of the heart (Burton,

Shaw, Schentag, & Evans, 2005)..

Pharmacokinetics of Codeine

Codeine is readily absorbed from the gastrointestinal tract. It is rapidly

distributed from the intravascular spaces to the various body tissues, with

preferential uptake by the liver, spleen and kidney. Codeine crosses the

blood-brain barrier, and is found in foetal tissue and breast milk. The

plasma concentration does not correlate with brain concentration or relief

of pain; however, codeine is not bound to plasma proteins and does not

accumulate in body tissues.The plasma half-life is about 2.9 hours. The

elimination of codeine is primarily via the kidneys, and about 90% of an

oral dose is excreted by the kidneys within 24 hours of dosing (Burton,

Shaw, Schentag, & Evans, 2005)..

.

Pharmacodynamics of Codeine


Codeine binds with stereospecific receptors at many sites within the central

nervous system to alter processes affecting both the perception of pain and

the emotional response to pain. Precise sites and mechanisms of action

have not been fully determined. It has been proposed that there are

multiple subtypes of opioid receptors, each mediating various therapeutic

and/or side effects of opioid drugs. Codeine has a very low affinity for

opioid receptors and the analgesic effect of codeine may be due to its

conversion to morphine (Tozer & Rowland, 2006).

The actions of an opioid analgesic may therefore depend upon its binding

affinity for each type of receptor and whether it acts as a full agonist or a

partial agonist or is inactive at each type of receptor. At least two of these

types of receptors mediate analgesia (Tozer & Rowland, 2006).

Patient and Family Education for Felopidine

The role of the nurse is to promote, educate and advocate for the client.

This also includes medications being prescribed to patients. It is important

to ensure that not only the client is informed about what to expect from the

medications but also the fanau understand the effects of the medications

(Bastable, 2002).

In the case of Mr Jack, he has a well known medical history of

hypertension, myocardial infarction and transient ischemic attacks. In the

role of a nurse it is essential to emphasise the importance and compliance

of this drug in regards to Mr Jacks health. I will provide information in

handouts explaining to the client and fanau in layman’s terms that


Felodipine alone or in combination with other drugs is effective for the

management of hypertension and angina and reinforce this by mentioning

pacific people are at greater risk with this disease (Shotter, 2004). I will

reassure Mr Jack and his family that Felodipine has neutral effects on the

hearts morbidity and mortality and therefore is safe to use to treat

hypertension and/or angina.

Knowing Mr Jack has a preference for using traditional medicine I will

educate him to take medication exactly as directed, without food. This

could allow Mr Jack to take his traditional medicine maybe with his food

or after, leaving both Western and Samoan medicinal therapies open. Mr

Jack and his fanau will need to know he is to avoid concurrent grapefruit

juice and alcohol which may cause hypotension (low blood pressure). The

family and client will also need to know the drugs dosage is not to be

altered and taken as prescribed, swallowed whole and not crushed or

chewed (Skidmore-Roth, 2006).. Expected side effects in this discussion

will include headaches; nausea, vomiting, constipation or drowsiness. I

will also advise Mr Jack and family members to report signs or symptoms

of, chest pain, palpitations; persistent headaches, vomiting, constipation,

peripheral or facial swelling; a weight gain five pounds within a week; or

difficulty of breathing.

Patient and Fanau Education for Codeine

Codeine handouts will be given to the client and fanau for educating

purposes regarding this drug. I will inform the family and client that

Codeine may cause constipation which is problematic in patients with


unstable angina, and after myocardial infarction. As with Felodipine I will

emphasise to use the drug exactly as directed and not to increase dosage or

frequency. Emphasis around the physical and psychological dependency of

this drug will be mentioned as codeine is prescribed to alleviate pain which

makes it easy for a person to develop a codeine addiction, because he/she

may think codeine is the only way to cope with their pain (Skidmore-Roth,

2006).

The client and fanau will be informed Mr Jack is not to use alcohol or over

the counter (OTC) medications especially sedatives, tranquilizers,

antihistamines, or pain medications without consulting his doctor. He will

be educated around daily fluid intake and maintaining adequate hydration

of 2-3ltr a day as this drug can cause constipation. Increasing exercise,

fluids, fruit, or fiber may help with this constipation.

As Mr Jack already experiences dizziness he and fanau will need to know

that Codeine’s side effects are dizziness, drowsiness, confusion, agitation,

impaired coordination, or blurred vision. Mr Jack is to use caution when

climbing stairs, or changing position e.g. rising from sitting or lying to

standing, or when engaging in tasks. Other side effects which occur with

this medication is nausea or vomiting, a loss of appetite. Encouraging

frequent mouth care, small, frequent meals, sucking lozenges, or chewing

gum may help with this. Mr Jack and fanau will be informed to report

signs or symptoms of confusion, insomnia (lack of sleep), excessive

nervousness, excessive sedation or drowsiness, or shakiness; stomach

upset; respiratory difficulty or shortness of breath; facial flushing, rapid


heartbeat, or palpitations; urinary difficulty; unusual muscle weakness; or

vision changes.

Schon’s Reflection tool: Reflection-in-Action and Reflection on Action.

Donald Schon a writer on reflection has influenced training development

and conceptions in many professions. Schon characterises reflection in two

main stages, reflection-in-action and reflection-on-action (Redman, 2004).

This model is sometimes described as ‘thinking on our feet’ and seen as an

automatic activity that occurs subconsciously in practice at an everyday

level.

Reflection-in-Action

Jasper (2003) states reflection-in-action is perceived by some people to be

intuitive and an ‘unconscious’ process, and therefore not really reflective

activity that we use deliberately. My reflection-in-action at the time of

undertaking this assignmen was quite simple, My initial goal and approach

towards this assignment was to gather the required information, retrieve a

signed consent form from a patient during my clinicals, formulate a nursing

care plan then the rest of the work will follow through. However, this was

not the case after reflection-on-action.

Reflection-on-Action

Schon’s speaks of reflection-on-action as planned intervention to support

learning from an experience. What I have learnt from this assignment as I

reflect back on my ‘laid back’ plan on how to manage this assignment, is to

be more prepared when dealing with a client’s life.


I have learnt it takes more than time to assess, plan, implement and

evaluate a patient’s needs. Comer (2005) mention the nursing process is an

organised, systematic and deliberate approach to nursing with the aim of

improving standards in nursing care. It uses a systematic, holistic, problem

solving approach in partnership with the patient and their family. I have

learnt that nursing entails not only just the health or medical problem of

why a client is admitted to hospital, but it evolves a whole holistic style of

nursing where what the nurse assesses and finds, can affect not only the

patient, but the patient’s family. Being culturally aware of patients needs

and traditional background is a necessity. I have learnt communication is

the ‘key’ to establishing a rapport with the client. As a student nurse I have

found nursing a patient is like nursing the family or community as

extended family of a patient would be involved in their care too. I feel it is

important to constantly communicate and liaise with medical staff and

family for the sole purpose of maintaining the patients health and

wellbeing.

Conclusion

In this assignment I have learnt the nursing process is a problem-solving

technique. It is a organised method to help nurses logically approach

situations that may lead to problems. It allows the nurse to consider more

possibilities without jumping too quickly to a conclusion. Using the

Nursing Process I have been able to complete a health assessment for a

client, obtain a medical history from the client, educate the client and

family in regards to the clients health and ensure essential follow-up was


maintained after discharge for the client. On completion of this assignment

I feel privileged to have had participated with a pacific client and their

family. I am more aware of what I can contribute as a Student Nurse to my

community because of the knowledge I hold in regards to health

maintenance. Because of the nursing process I feel confident and know I

can make a difference when dealing with Pacific People and their health as

a third year pacific nursing student.


Reference List.

Bastable, B. S. (2002). Nurse as Educator: Principles of Teaching and

Learning for Nursing Practice. UK: Jones.

Burton, E. M., Shaw, M. L., Schentag, J. J., & Evans, E. W., (2005).

Applied Pharmacokinetics & Pharmacodynamics: Principles of

Therapeutic Drug Monitoring. Philadelphia: Mosby

Carpenito-Moyet, J. L. (2005). Nursing care plans & documentation:

Nursing diagnosis and collaborative problems. (4th ed).

Philadelphia: Lippincott.

Comer, S. (2005). Delmar’s critical care nursing plans (2nd ed). USA:

Thomson.

Gulanick, M. & Myers, L. J. (2006). Nursing care plans: Nursing

diagnosis and interventions. (6th ed.). USA: Mosby.

Jasper, M. (2003). Beginning reflective practice: Foundations in nursing

and healthcare. Cheltenham: Nelson Thornes.

Macpherson, C. & Macpherson, L. (1990). Samoan medical belief and

practice. Auckland: University Press.


Reference List

Parsons, D. F. C. (1995). Healing practices in the South Pacific. USA:

Institute for Polynesian Studies.

Redmond, B. (2004). Reflection ion action: Developing reflective practice

in health and social science. USA: Library of Congress.

Skidmore-Roth, L. (2006). 2007: Mosby’s nursing drug reference.

Missouri: Mosby.

Shotter, C. (2004). The role of nurses in managing patients with heart

failure. Nursing times, 101(9), 36-37.

Skidmore-Roth, L. (2005). 2006: Mosby’s nursing drug reference.

Missouri: Mosby.

Sparks, S. & Taylor, M. C. (2006). Nursing diagnosis: Reference manual.

(6th ed). USA: Lippincott.

Tozer, T. & Rowland, M (2006). Introduction to pharmacokinetics and

pharmacodynamics: The quantitative basis of drug therapy.

Philadelphia: Mosby.


Reference List

Turley, L.M., Tobias, M., Lawes, M. M. C., Stefanogiannis, N., Hoorn, V.

S., Ni Mhurchu, C., & Anthony, R. (2006). Cardiovascular

mortality attributable to high blood cholesterol in New

Zealand. Australian and New Zealand Journal of Public

Health, 30,(3), 252-257.


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