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Obesity in Woodbury Iowa
Obesity in Woodbury Iowa is a significant public health concern. The prevalence of obesity in in Woodbury County Iowa is 38.3 % among the females. In Iowa State, the prevalence of obesity among the females is 35.9% while the prevalence of obesity among the females at the federal level is 36.1%.
Therefore, the prevalence of obesity among the females in Woodbury County exceeds the Iowa state and the national statistics. 37.5 % of the men in Woodbury County, Iowa, are obese. At the state and the national levels, 36.3% and 33.8% of men are obese respectively (Centre for Disease Pprevention and Control, 2015). Similarly, the prevalence of obesity among the men in Woodbury County, Iowa, supersedes both the state and the national prevalence rates.
Obesity in Woodbury Iowa
Contributing Factors
Obesity is affected by both the race and age. In Iowa, the prevalence of obesity is highest among the Hispanics and Non-Hispanic blacks and lowest among the Non-Hispanic whites. Obesity increases with age and is mostly affects adults aged 60 years and above and is lowest among the adults aged 20 to 39 years of age. The level of education impacts on obesity as well (Office Of Disease Prevention and Promotion , 2018 ).
Obesity reduces with the increase in the level of education. Education increases the level of awareness on the factors associated with obesity as the preventive measures. Obese patients who have a diploma or a degree have shown increased life expectancy. The positive impact of education on obesity is uniform across all age groups.
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The level of income impacts obesity as well. Higher levels of income are associated with reduction in the prevalence, the severity and the effects of obesity. Higher levels income impact on the access to healthcare services. Families that can afford insurance policies or out of pocket payments access healthcare services for managing obesity. Therefore, the prevalence of obesity among such individuals is reduced, as compared to individuals in lower socio-economic class.
Individuals with low income cannot afford the foods that are nutrient intensive. Generally, the foods that are sugar and fat intensive are cheap in the United States markets. Sugar and fats are predisposing factors to obesity. Culture affects obesity. Culture dictates the type of foods that the members of the particular culture dependent on as food. Culture also affects health seeking behavior (ODPP, 2018).
Culture impacts on the perception of the specific cultural group on the engagement in physical activities that significantly affect obesity. Healthcare policies determine the impact of obesity to any community. Healthcare policies determine the access by the respective members of the community to healthcare services regarding the management of obesity.
Healthcare politicizes on financing healthcare determine the access to care for obese to the individuals who cannot afford the care. Healthcare policies also affect the availability of resources and facilities for managing obesity. The county’s and the national policies in managing healthcare community services such facilities for physical exercises and educational resources and personnel are key to implement obesity management strategies (Galloway-Gilliam, 2013).
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Obesity in Woodbury Iowa
Interventions
One of the programs that have been undertaken in my state to prevent obesity is early childhood care. Statistics indicate that on average, children spend most of their time per week under non-parental care.
The State of Iowa in partnerships with the Center for Disease Control and Prevention (CDC) have drawn up programs on adequate diet, performance of physical activities and reduction in care time. The state government supports the programs in schools and children care centers through funding, provisions of evidence based recommendation for early child care to prevent obesity (Benson at al., 2013).
The programs support the breastfeeding mothers and the availability of nutrient rich diet to the children that prevents obesity. The hospitals within my community have initiated hospital strategies aimed at reducing obesity. The initiative targets the hospital employees and the patient under the care. The initiatives encourage healthy food and beverage choices, physical activities within the hospitals environment and support for lactating mothers.
The hospitals also partner with the community to increase healthy living behaviors for the community members. The hospitals provide education on obesity prevention and management using the locally available resources.
Obesity in Woodbury Iowa
Scope and Role of Nursing and Public Health Nursingon Obesity in Woodbury Iowa
Nurses have a role in encouraging patients to maintain healthy diet. Nurses possess the knowledge on the foods that contribute towards obesity and that prevent the occurrence of obesity. Nurses spend a significant amount of time with admitted patients. Additionally, nurses interact with patient at the community level in offering primary healthcare services. Nurses educate patients on physical activities as part of the measures to prevent obesity as a public health issue.
Physical exercises reduce the amount of fats that accumulate in the body. Nurses educate on the type, the duration and the intensity of the physical exercises that are appropriate for each of the patients presenting with or at risk of obesity. Nurses conduct assessments of patients who present with obesity. Nurses provide care to a patient in clinical setting. Assessment is the initial step of the nursing process (Schofield et al., 2011).
Assessment, as part of the nursing process, involves collection of data about the patient thorough history taking, physical examination, and clinical tests. Nurses take history of patients on their diet, performance of physical activities, and the impact of obesity on every individual patient during the clinical visits. The nurse also conduct laboratory tests including lipid profile tests in order to assess the risks of development of cardiovascular disease as a complication of obesity. Part of the nurses’ assessment focuses on vital signs such as blood pressure measurements.
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Expansion of the Scope of Obesity in Woodbury Iowa
One of the ways to increase the scope of community health nursing interventions in addressing obesity is through partnerships. Community partnerships involve creation of community based networks. The collaboration with the population level partners allows the nurses and public health professionals to gauge the factors that contribute to obesity the community level.
The aim of the partnerships should be to do community specific assessments on the prevalence, causes, and impacts of obesity on the local community (Betancourt, Green, Carrillo, & Firempong, 2016). Further, the aims of the local community partnerships should be to recommend, initiate and implement strategies that are suitable for the local community , based on the population specific needs identified during the assessment.
Policy development is another way of increasing the scope of the nurses’ and public health professionals’ roles in combating obesity. Nurses and public health professionals are key stakeholders in managing obesity, as a public health issue. The professional input is critical in developing policies that are specific to the local community population.
The professionals collaborate with the department of health, which is responsible for drafting policies for public healthcare such as obesity ((Betancourt et al., 2016). The public health issues should be alignments with the national statistics on obesity, ways of preventing obesity and the federal government’s regulation in combating public health problems.
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References
Benson, G. A., Sidebottom, A., VanWormer, J. J., Boucher, J. L., Stephens, C., & Krikava, J. (2013). HeartBeat connections: A rural community of solution for cardiovascular health. Journal of the American Board of Family Medicine, 26(3), 299–310.
Betancourt, J. R., Green, A. R., Carrillo, J. E., & Owusu Ananeh-Firempong, I. I. (2016). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public health reports.
Schofield, R., Ganann, R., Brooks, S., McGugan, J., Bona, K. D., Betker, C., Dilworth, K., … Watson, C. (2011). Community health nursing vision for 2020: Shaping the future. Western Journal of Nursing Research, 33(8),1047–1068.
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Children Health Insurance
Medicaid and the Children Health Insurance Program (CHIP) Health Care Policy
1-What legislation introduced Medicaid, and what are the funding sources for the program?
2-What are some of the changes, including CHIP, that have occurred to the Medicaid program since its inception?
3-What are the demographics of the majority of people covered by Medicaid, and how many people in the United States are covered by Medicaid?
4-Evaluate the changes that have occurred to Medicaid with the inception of the Patient Protection and Affordable Care Act. What are the current changes in Medicaid based on current legislation?
5-Assess social and cultural changes and their impact on developing new health policies to make Medicaid and CHIP more effective.
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Medicaid was established in 1965 in conjunction with Medicare as part of the Social Security Act. Medicare is a health-insurance program for retirees, disabled employees, and their spouses and dependents that is funded and administered by the federal government (United Health, 2021).
Medicaid, on the other hand, is a combined federal-state program in which states and territories receive federal financial assistance in providing health and long-term care to federally designated low-income families and individuals (United Health, 2021).
Prior to the passage of Medicaid, states received limited federal reimbursements for health care services paid on behalf of public assistance beneficiaries. In 1960, Congress approved open-ended federal matching funds to states for impoverished elderly people’s health care. Still, the breadth of the health-care services that states financed for low-income individuals and families varied significantly (United Health, 2021).
The original law provided states the option of obtaining federal funds to assist in providing health care coverage to children from low-income families, their caregiver relatives, the blind, and the handicapped (United Health, 2021). Medicaid was created to give low-income individuals and families more access to mainstream health care. States would receive funds from the federal government to cover half or more of their expenses in providing services to beneficiaries.
At the same time, the program was designed to offer states a lot of flexibility in how they structure their medical aid programs. States that choose to participate in the program were obligated to provide a baseline range of health care to those receiving public assistance (United Health, 2021).
They were also authorized to provide extra services at their discretion, such as serving medically needy people who did not get government aid. The federal government has consistently strengthened the rules and regulations governing state Medicaid programs.
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Children Health Insurance
Many changes in federal Medicaid legislation have occurred during the last four decades, including substantial changes in eligibility, benefits, payment arrangements, and other administrative issues (Smith, Kennedy, Knipper, & O’Brien, 2005). These developments, when paired with state judgments about the scope of their programs, have resulted in Medicaid expanding well beyond its original focus on providing mostly acute care services.
Furthermore, Medicaid has surpassed private insurance as the primary source of funding for long-term care for persons with disabilities (Smith, Kennedy, Knipper, & O’Brien, 2005). Despite several revisions in federal legislation, the essential basis of the federal-state partnership in the program has remained relatively same. The Supplemental Security Income (SSI) program was established in 1972 (Smith, Kennedy, Knipper, & O’Brien, 2005).
This nationally financed income support program for persons with disabilities replaces the previous federal-state cash assistance programs for the elderly, blind, and handicapped. SSI and Medicaid eligibility were intertwined. Many obligatory and voluntary eligibility categories were expanded in the 1980s, with a particular focus on extending Medicaid coverage to low-income pregnant women and children who did not receive public assistance payments (Smith, Kennedy, Knipper, & O’Brien, 2005).
States were obligated to contribute increased Disproportionate Share Hospital payments to hospitals that cater to a significant number of Medicaid recipients and other low-income people under the Omnibus Budget Reconciliation Act of 1981. The Personal Responsibility and Work Opportunity Act of 1996 broke the historical relationship between Medicaid eligibility and the financial assistance program for Aid to Families with Dependent Children.
For low-income households, a new obligatory Medicaid eligibility group was formed; Medicaid eligibility was no longer automatically linked to receipt of public assistance cash payments (Smith, Kennedy, Knipper, & O’Brien, 2005). The Children’s Health Insurance Program (CHIP) was enacted into law in 1997 and provides states with federal matching money to offer health care to children whose families’ earnings are too high to qualify for Medicaid but too low to buy private insurance.
Through their CHIP programs, all states have greatly increased children’s coverage, with virtually every state providing coverage for children up to a minimum of 200 percent of the Federal Poverty Level (Smith, Kennedy, Knipper, & O’Brien, 2005). The federal Medicaid statute has been amended several times since it was enacted. Federal mandates have grown, particularly in the field of low-income children’s programs.
The creation of 51 extremely diverse Medicaid programs has come from the mix of Medicaid mandates and alternatives. These programs function under broad national principles but are influenced by state judgments regarding who is eligible and what they are eligible to receive (Smith, Kennedy, Knipper, & O’Brien, 2005).
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The sources of funding for Medicaid include Federal Medical Assistance Percentage (FMAP), through Enhanced Matching Rates, Disproportionate Share Hospital payments (DSH) and State Financing of the Non-Federal Share (Rudowitz & Snyder, 2015). The federal government guarantees states matching payments for eligible Medicaid expenditures; states are promised at least $1 in federal money for every $1 spent on the program by the state.
As economic conditions change, FMAP, which is an open-ended funding system, permits federal funding to flow to states depending on real costs and requirements (Rudowitz & Snyder, 2015). Medicaid offers a greater matching rate for certain services or populations in some cases, the most famous example being the ACA Medicaid expansion enhanced match rate. The federal government will cover 100 percent of Medicaid expenditures for newly eligible people in states that expand (Rudowitz & Snyder, 2015).
DSH hospital payments are another source of funding for hospitals that treat a lot of Medicaid and low-income uninsured patients. These DSH payments have been critical to the financial viability of safety net hospitals in several states (Rudowitz & Snyder, 2015). Lastly, States have a lot of flexibility when it comes to deciding how to support the non-federal portion of Medicaid spending.
State general fund appropriations are the major source of money for the non-federal portion. The utilization of alternative monies by governments has risen modestly but consistently over the last decade. This is most likely due to states’ growing dependence on provider taxes and fees to fund the state portion of Medicaid (Rudowitz & Snyder, 2015).
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Children Health Insurance
Pregnant women with low income, children from low-income families, children in foster care, individuals with disabilities, seniors with low income, and parents or caregivers with low income are all served by Medicaid programs(Lee & Jarosz, 2017). States can also opt to include additional categories, such as low-income adults who may or may not have children, in their eligibility. In 2015, the ACS recorded about 66.4 million participants nationwide, accounting for 91.7 percent of the 72.4 million reported by the Centers for Medicare and Medicaid Services in mid-2015 (Lee & Jarosz, 2017).
According to the Center for Medicaid and CHIP Services, there were 74 million Medicaid and CHIP members as of March 2017, with almost 36 million of them enrolled in CHIP or children enrolled in Medicaid. Children and teens account for over half of all persons covered by means-tested public health insurance (Lee & Jarosz, 2017). Nearly 11 percent of adults are 65 and older, many of whom are low-income and rely on Medicaid to supplement Medicare.
Adults who are disabled or institutionalized make up another 14%, while women who have given birth in the last year make up just under 2%. More than seven out of ten people in means-tested health insurance plans belong to these vulnerable categories (Lee & Jarosz, 2017). Only 12% of those left work full-time or part-time.
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Genetic Counseling
With the increase in knowledge around genetic issues, it is important that all healthcare providers are prepared to have thorough genetic-based discussions now with their patients. In this assignment, you will synthesize your knowledge into a client case with a real or potential genetic health-related illness. • Use the Surgeon General’s Family History Tool at http://www.hhs.gov/familyhistory/portrait/index.html to complete this assignment.
Directions:
Write a 1,000 word paper addressing a client case that might benefit from the process of genetic counseling.
-Describe the reason for the genetic counseling based on the findings from your completion of the history tool.
-Discuss the possible reactions the patient may have to your counseling and how to avoid negative reactions.
Imagine this assignment as if you are giving this counseling to a patient. Discuss the following:
Health.
Prevention
Scr: eening
Diagnostics
Prognostics
Selection of treatment
Monitoring of treatment effectiveness
Genetic Counseling
Genetic Counseling: Introduction
Diabetes mellitus is considered a lifetime condition which inhibits the body’s capability to regulate metabolic glucose levels. Basically, it is divided into two categories that are; diabetes mellitus type 1 and type 2. Symptoms of type 1 occur after the destruction and damage of cells found within the pancreas leading to a deficit in the production of insulin. In diabetes mellitus type 2, insulin is produced, but it is either not enough or not effective at all (Hivert, Vassy, & Meigs, 2014). As an integral pillar of managing patients suffering from diabetes mellitus, genetic counseling is an aspect that should not be overlooked.
Reasons for Genetic Counseling
The patient is a 37-year-old African American male. The patient’s father passed away three years ago when he overdosed anti-diabetic medication. The patient’s mother was diagnosed with diabetes mellitus three years ago and has developed a diabetic foot complication. The client weighs 120.0 kilograms and his height is 1.4 meters. Diabetes mellitus is a disorder that has been associated with familial inheritance.
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The genetic factors responsible for causing diabetes mellitus are believed to be located from HLA regions within chromosome 6p21 (Hivert, Vassy, & Meigs, 2014). The protein sequences are inheritable factors. According to the family’s history, the patient is at risk of developing diabetes mellitus. A significant reason for genetic counseling is to create awareness. Through genetic counseling, the patient is expected to appreciate the fact that the condition can run across generations (Kaveeshwar & Cornwall, 2014).
Possible Reactions from the Patient
During the process of counseling, a patient’s reaction is either positive or negative. Positive feedback from the patient acts as a trajectory method to determine the cooperation of the client. The cooperation from the patient is determined by the patient’s mood and response (Anstee, Targher, & Day, 2013). In order to avoid negative reactions, a health worker is expected to first assess the patient’s mental well-being. For example, a depressed patient is most likely to respond negatively during genetic counseling (Anstee et al., 2013).
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The genetic counselor is expected to approach the client in a professional manner to avoid unnecessary predicament. Establishing rapport allays anxiety. In addition, the patient should be given time to present any ideas that might be necessary for the discussion. Appreciating any effort made by the patient to ask questions is also critical in managing negative feedback from the client.
Health
The ability of an individual to manage and adapt to mental, physical, psychological and spiritual well-being constitutes the health aspect of the individual (Anstee et al., 2013). A chronic illness like diabetes mellitus negatively affects the psychological status of any patient. Therefore, while providing counseling, mental, physical, psychological and spiritual well-being of the patient should be continuously assessed.
Prevention
The prevention of the occurrence and diabetes mellitus and the associated complications of diabetes will be undertaken in three stages including; primary, secondary and tertiary preventive measures. During primary prevention, the patient is educated on self-management and administration of insulin (American Diabetes Association, 2014). Secondary prevention is crucial for the patient diagnosed with diabetes mellitus.
Insulin administration and a change of lifestyle are two key pillars in improving the quality of life for diabetic patients. Dietary modification and engaging in physical activity for a specific period of time a day are crucial for prevention of complications arising from diabetes mellitus.
Screening
The process of screening involves coming up with a strategy to identify a condition which might have not manifested with signs and symptoms. The patient will be screened based on the presenting symptoms. The patient will be assessed on the level of blood glucose, the urinary functioning, the amount of water and food taken. The objective of the assessment is to identify the symptoms such as increased thirst, hunger, and the rate of urination.
The level of glycosylated hemoglobin is also part of the screening process in diabetes mellitus case. In the case scenario encountered, screening other family members is significant (American Diabetes Association, 2014). The unrecognized clinical manifestations among the siblings are identified through screening. In order to prepare in advance on dealing with the complications of diabetes mellitus, the process of screening is required.
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Diagnostics
Diagnosis is the process of coming up with the exact condition that the patient presents with. A patient is diagnosed with diabetes mellitus if the random blood glucose is 11.0 mili-moles per liter in cases with hyperglycemia, or oral glucose tolerance test of 11.0 mili-moles per liter or a fasting blood glucose level of 7.0 mill moles per liter. The management approaches for diabetes include self-insulin administration, physical activities, nutritional aspects and a general change in lifestyle (American Diabetes Association, 2014).
Prognostics
Aggressive management of the symptoms of diabetes mellitus includes prevention of complication like diabetes ketoacidosis. Control of the blood sugar results into control of micro-vascular complications of diabetes mellitus. Further, research studies have shown that the control of the level of glycosylated hemoglobin is associated with a reduction in the number of cases of mortality among diabetes mellitus patients. In order to prevent uncertainties, the patient needs to be advised to regularly administer insulin and monitor the glucose levels (Scirica, Bhatt, Braunwald, Steg, Davidson, Hirshberg, & Cavender, 2013).
The Selection of Treatment
Selecting the method of treatment will depend on the blood sugar levels of the patient. Other than insulin, other diabetic drugs like glibenclamide and metformin are prescribed based on the severity of presenting symptoms (American Diabetes Association, 2014). Administration of the drugs is preferred only in cases where the recommended lifestyle change fails to correct the blood sugar levels and associated symptoms. Furthermore, the dosage of drugs administered depends on the level of sugars present in circulation.
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Monitoring of Treatment Effectiveness
Monitoring involves making keen and observant follow up on the patient’s adherence to lifestyle modification, medication, participation in physical exercises and nutritional modification. The client will be educated and instructed to measure the glucose level by use of glucometer on a daily basis. The reduction of sugars in the blood will imply that the client positively responds to drugs, and other management approaches.
The medication dosage will be adjusted according to the level of glucose levels (American Diabetes Association, 2014). For example, an increase in the blood glucose level above 7.9 mili-moles per liter requires the use of high potency anti-diabetic medications.
In conclusion, diabetes mellitus is a lifelong condition which needs proper and well-structured management. A collaborative approach among the health workers, the patient and family members is necessary. As part of management on counseling, effective familial history is necessary.
The patient’s reaction expected during counseling is either of positive or negative feedback. The condition requires the combination of genetically oriented measures. The level of blood sugar in diabetes mellitus determines the screening, diagnosis, prognosis, treatment selection and measurement of treatment effectiveness.
Anstee, Q. M., Targher, G., & Day, C. P. (2013). Progression of NAFLD to diabetes mellitus, cardiovascular disease or cirrhosis. Nature Reviews Gastroenterology & Hepatology, 10(6), 330.
Hivert, M. F., Vassy, J. L., & Meigs, J. B. (2014). Susceptibility to type 2 diabetes mellitus—from genes to prevention. Nature Reviews Endocrinology, 10(4), 198.
Kaveeshwar, S. A., & Cornwall, J. (2014). The current state of diabetes mellitus in India. The Australasian medical journal, 7(1), 45.
Scirica, B. M., Bhatt, D. L., Braunwald, E., Steg, P. G., Davidson, J., Hirshberg, B., & Cavender, M. A. (2013). Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. New England Journal of Medicine, 369(14), 1317-1326.
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Neonatal Resuscitation
Introduction
Is there a thing that is as defenseless and precious as a baby who is newly born? I agree with the fact that thousands of babies in the United States are premature before their small bodies can sustain life. The normal time needed for a fetus to be fully developed in to a normal baby is usually thirty six to forty weeks. Premature infants therefore, are those born before the thirty sixth week.
Infants born before the twenty sixth gestation week have anatomically underdeveloped lungs and, they cannot physiologically support ventilation. I appreciate that there has been giant leaps forward within the last decades which has enabled us all but the most premature and smallest infants.
Currently, analyzing the Millennium Development Goals on Neonatal resuscitation in the developing world indicates that there is an impressive progress in child health. However, there is barely any notable achievement as far as neonatal health is concerned. Neonatal deaths’ proportion (death within the initial twenty eight days) is anticipated to increase as a result of the reduction in postneonatal deaths burden.
The World Health Statistics shows that the health-related MDGs indicate that approximately thirty seven percent of the under-five mortality is usually within the neonatal period. Most deaths occur during the first week (early neonatal period). More than one million neonates lose their life within the first twenty four hours as a result of poor quality care, globally and annually.
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Continuum of Care
The key principle in developing strategies aimed at addressing (NHC) Neonatal Health Care revolves within the continuum of care. Throughout the lifecycle, including childhood, childbirth, pregnancy and adolescence, the care need to be offered as a seamless continuum spanning the health center, community and home, globally and locally (Atkins and Murphy, 1994, 50). Therefore, decreasing child mortality depends entirely on managing neonatal mortality or otherwise, tackling Neonatal Health Care.
Personal Experience
I am a RRT (Registered Respiratory Therapist) and have worked in NICU (Neonatal Intensive Care Unit). Additionally, I have visited many other units as part of the duties as a Respiratory Care nurse. I have experienced the procedures and tests, the angst and waiting as well as the sensitive roller coaster of emotions that both parents and child endure. In case the infant is developed adequately and is strong enough for survival, there is anxiety concerning the quality of life for the child and the family that has to cater for the child’s specific needs.
Is the cost measurable in terms of real dollars and emotionally? Mezirow (1990) argues the mortality and morbidity rates in particularly low birth weight children is remarkably high; it is in fact, so high that the sole ethical choice is to leave them die a painless and natural death. Infants that are born before the twenty fourth gestation week need not be resuscitated for financial, medical and ethical reasons.
Medical ethic principles are justice, beneficence, non-maleficence and respect for autonomy. These principles act as the guideline for health care professionals when dealing with all their patients. There is no exception. Respect for autonomy recognizes “the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act” (Lim et al, 2000, 492).
In the case of neonates, the biological parents have the responsibility of making the child’s health care decisions, as far as ethics in medicine is concerned. The non-maleficence principle implies that healthcare professionals should not create needless injury or harm intentionally to the patient, either with omission or commission acts. All procedures ad tests should have their benefits weighed. Beneficence can be defined as “the duty of health care providers to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient”.
In respect to the justice principle, each patient should be given what is rightfully theirs. Equal persons should be given equal treatment (Speck, 1985, 93). Moreover, patients need to be treated with honesty and dignity, and together with their families, the healthcare community’s total disclosure is necessary so that they are able to make informed decisions. Even if, a health care professional does not agree with the decision made, it is necessary to treat the patient with dignity; the choice should be respected.
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My Critical Experience
From my many years of practice as a nurse, I choose this critical experience since it was tremendously emotional and had a profound impact on me until today. Douglas was delivered at twenty five weeks of gestation with a weight of five hundred and fifty grams. He was born spontaneously preterm in vertex presentation. His primigravida single mother, Annette, had pre-eclampsia which led to the preterm birth.
Annette was given a dose of steroids thereby delivering Douglas within the next hour. Using antenatal steroids is considered as critical intervention in anticipation of prematurity which improves preterm babies outcome (Teasdale, 2000, 581).
At birth, Douglas’ condition was critical and therefore, the need for resuscitation. As mentioned earlier, surfactant treatment is administered to preterm infants having respiratory distress since they lack a protein referred to as surfactant which prevents the lung’s small air sacs from collapsing. Douglas was therefore given surfactant treatment together with a breathing mechanical ventilator aid so that his lungs could remain expanded.
The boy’s condition improved, and he was successfully transferred to CPAP (Continuous Positive Airway Pressure). This was aimed at delivering pressurized air to his lings via small tubes in the nose to help in breathing. Douglas developed bleeding in the brain (intracranial bleed) of grade III on the second day. Intracranial bleed is prevalent during the first 3 days of life and an ultrasound examination diagnoses it. Mild intracranial bleeds resolve themselves and no of few lasting problems (Miles, 1989, 71).
More severe bleeds cause the brain ventricles to expand rapidly, causing brain pressure which brings about permanent brain damage. The results are neuro developmental delay or cerebral palsy. Douglas also had PDA (Patent Ductus Arteriosus), a common heart problem in premature babies. This however did not need treatment as it was small.
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Irrespective of the boy’s critical condition during the first week in life, there was an improvement in his general condition. Naso-gastric tube feeds started being used, and intravenous fluids stopped (Shields-Poe and Pinelli, 1997, 32). While still an inpatient at the hospital, Annette visited Douglas for 2 days during which she was updated of his critical condition. Annette did not bond with her son comfortably, although the nurses encouraged her to.
She gave excuses so that she could not express milk and therefore Douglas was fed with donor breast milk. On the 3rd day, she was discharged, and she visited only once every week. However, she called nurses most of the times to enquire about his progress. Annette’s behavior was brought to the attention of a social worker, and it was reviewed. When I was delegated to look after Douglas, I met the mother once during which I spoke with her and encouraged her to hold and touch the baby which she did.
On the 22nd day after birth, the CPAP was working for Douglas; he could tolerate the feeds and was adding weight. For the six days I took care of him, his general condition was satisfactory. Annette called at nights to check on Douglas’ condition. I informed her he was stable with a 30 grams weight gain. She was enthralled and promised to come the following day.
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On my seventh night duty, on the twenty eight days after birth, I was surprised to meet Douglas re-intubated and on Nitric oxide high frequency mode ventilator. Douglas has developed PPHN (Persistent Pulmonary Hypertension), stopped breathing and was cyanotic. According to Wood (2009), preterm PPHN is linked to high risk adverse neurodevelopmental and health outcomes. To date, it is among the most complicated conditions experienced in NICU.
His critical condition made him be supported using various intravenous infusions, among them morphine to manage pain. Annette had visited at day time and cuddled her baby. She also has a social talk with the in-charge nurse and she was to come during the evening and stay overnight with her son. Unfortunately, Douglas succumbed to cyanotic attack after she left. She was updated of this on her way back to the hospital. On arrival, Annette and the friend she had come with were confused to see the extreme technical situation surrounding the boy.
I offered a drink and a chair to Annette. The serving consultant counseled her and recommended the life support to be withdrawn since Douglas IVH was at grade IV. Annette was unable to decide on the care withdrawal. She begged to leave and come back with her mother the following morning to discuss the situation further and come up with a decision. She immediately left.
At NICU, 4 nurses are delegated with the responsibility of receiving admissions from the theatre and labor ward and taking care of sick babies. We were 3 three nurses that night as a result of staff shortage. An emergency came from the clinical nurse manager from the labor room. One of the nurses rushed to the labor room and brought back twenty eight weeks preterm Mark who was intubated. He required medications and infusions and since his condition was grave, attention was focused to him.
After Mark settled, I was beside Douglas when I realized that his heart rate had gone down to 120 per minute from the usual 160 per minute. The consultant agreed with me that nothing more could be done. The morphine infusion had to be increased to manage pain (Reid, 1993, 307). I called Annette as they were driving home with the friend to inform her of the development. She confirmed that she would come back the following with her mother as earlier agreed.
I touched Douglas’s hand soothingly and wished Annette was there to console and hold him. Suddenly, the nurse attending to Mark called out for drugs as Mark had developed cardiac arrest. We worked to resuscitate Mark but I could see that Douglas was also going in to an arrest since there was continuous drop in the heart rate. Mark was the priority at the moment but I wished I could go over to Douglas and console him.
His monitor stopped indicating vital signs. Mark died shortly after Douglas. We did all we could have done to save the two lives but as with hundreds of other babies, we were unsuccessful. The social worker had to follow Annette to provide further care.
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The Care of Premature Newborns
“Good ethics begin with compelling facts” is a guiding principle when dealing with ethical care for premature newborns. So as to make a profound decision, the first thing is the qualified obstetrician to assess and gather all the necessary information utilizing all the available resources. Consequently, the parents need to be informed in a way that they can understand (respect for autonomy).
“It should be emphasized that there is some uncertainty with any predictive process, because every infant is unique. The prognosis for the fetus may change after birth, when a more accurate assessment of the gestational age and actual condition can be made” (Daly et al, 2004, 2).After the fetal weight and gestational age are determined; the parents should be presented with the facts and counseled on the child’s possible outcomes.
It is imperative that the health care team and physician address the process of decision making as a team, together with the parents. Moreover, the parent’s belief system and desires as well as the child’s needs should be kept at the forefront. The Journal Pediatrics have categorized the treatment decisions and summarized them on prognosis basis as:
1. In case there is a high likelihood of early death and survival would encompass high risk of morbidity that is unacceptably severe: intensive care not indicated.
2. In case there is a likelihood of survival and the risk of inadmissibly severe morbidity is small: indicate intensive care.
3. In cases that fall within the mentioned categories and there is uncertain prognosis and likely extraordinarily poor, and survival encompasses diminished child’s quality of life, parental desires determine the approach for treatment. (Carkhuff, 1996, 211).
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During the last few decades, there has been an improvement in the prognosis for tremendously premature infants. However, many of the exceptionally small and extremely premature infants die or possess a morbidity rate that is unacceptably high. In this population, the medical complications are usually profound and complicated. Some complications result from the birth event and others are congenital defects. Majority of the morbidities are linked to immature lung development.
Fetuses produce surfactant, an essential proper lung function protein, at the age of thirty two weeks. Surfactant deficiency is treated by medical science by refining and producing porcine and bovine surfactant. However, this is usually not as effective compared to native surfactant. There is the instantaneous complication of reduced delivery of oxygen to the brain, organs and blood. Besides this, the long term complication is anoxia, brain injury as a result of inadequate oxygen supply to the brain. High morbidity rates attract the greatest categories of complications.
Majority of the morbidities bring about profound and severe disabilities, and cause early demise (Murphy et al, 2003, 227). The mortality rate of neonates in this group is relatively high, and the severe to moderate morbidity rate is more than fifty percent. It is worth noting that the statistics for very small and very premature neonates indicate a one hundred percent mortality rate. These children possess physical limitations and abnormalities that they have to bear with for their entire lives and which their families need to provide care. The outstanding care is extremely expensive and emotionally exhausting.
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Reflect on the cost of offering care to late preterm vs a term infant. Late preterm have far much less complications as well as complicated medical needs as opposed to Extremely Low Birth Weight (ELBW) neonates, and yet the cost of caring for them during their 1st year of life is astoundingly vast. The cost for taking care of a premature infant who is late term is three times more the cost for term infants.
Extremely Low Birth Weight neonates’ cost is six times a term infant’s cost, if the infant survives. At a national level, the cost for ELBW’s care is staggering. United States spends 5.8 billion dollars annually (Raeside, 2000, 98). This represents forty seven percent of all infant hospitalization costs and twenty seven of all pediatric stays. 65, 600 dollars is the average cost, where the least viable consume most of the resources.
The figures refer to the initial hospital stay costs. This is the first care as far as caring for children with profound or severe disabilities are concerned. Is this burden fair to the society? These are some of the prevailing questions in the light of the discussion on medicine socialization and healthcare coverage. What is the belief of the society on the value of life? Can a baby’s existence be replaced with the dollar value?
Considering that resources are infinite, should they be used on the few neonates and leave the majority to share the smaller percentage? (Schmieding, 1999, 636). What if it is my child is among those that require disproportionate resources and care to survive? What if my child is among those being given a normal care level since there are few providers as majority of the providers are focused on ELBW who need the highest care level? The answer to these questions will vary depending on the role of a person; a parent, health care consumer or a provider.
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Figure 1: Grave Neonatal Morbidities in < 750 g Birth Weight Infants in the National Institute of Child Health and Human Development Neonatal Centers, 1995-1996
Condition
Frequency of Morbidities (%)
Range
Respiratory Distress Syndrome
78
54-97
Oxygen required at twenty eight days after birth
81
64-92
Chronic Lung Disease
52
8-86
Necrotizing Enterocolitis
14
9-38
Septicemia
48
30-64
Grade 3 intraventricular hemorrhage
13
6-29
Grade 4 intraventricular hemorrhage
13
3-26
Periventricular Leukomalacia
7
2-30
Growth failure
100
92-100
This data is for infants who are alive at twenty days (Cotton, 2001, 515).
Conclusion
Preterm neonates require extensive care to ensure their survival. Major challenges that make this goal ineffective include inadequate nurses and medication. More than often, care has to shift to neonates who require immediate attention. It is sue to these reasons that neonate mortality is still high although there has been an improvement in child care as per the MDGs. It takes a lot of courage to work as a nurse and especially when emphatic with the mother to the neonate infant.
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