Education Category: Health
Ages: 4-8, 8-12, 12-16

1.Case description

Name:                          S. Ugali

Birthdate and place:    15-07-1942

Medical history:           HIV, inadequate therapy discipline

Marital status:              Widow, one son whom he has no contact with

Career:                        Owner of a fruit stand

Cause of admission:    Severe pneumonia

Religion:                     Kululu Tribe

Mr. Ugali was admitted to the general public ward on the 23th of September in Coptic hospital. Mr. Ugali is 68 years old. He was admitted due to a severe pneumonia. He had trouble breathing and almost collapsed. People who found him on the street brought him to Coptic hospital. Mr. Ugali is HIV positive, but refuses to take in his HIV suppressive medication. Mr. Ugali has his origin in the Kululu tribe, he was raised with the opinion that medicine don’t work. He believes in homeopathic and herbal medicine.  Therefore mr. Ugali refuses to take his HIV medication. This is probably the reason that the pneumonia developed. Mr. Ugali’s wife has passed away 7 years ago. He only has a son of 23 years old, with whom he has no contact. He has no health insurance, therefore he needs to pay the costs of his own hospitalization. Mr Ugali lives in a small village near Nairobi in a small self made home. To provide for money he sells fruits on the streets.

2.Eleven health patterns of Gordon

1. Perceived health and conservation

Mr. Ugali is admitted to the hospital due to a pneumonia, probably caused by the HIV infection.

He does not believe in the power of suppressive HIV medication and refuses to take the medication. Since a early ages he has learned that homeopathic and herbal medication help against illnesses. 

Mr. Ugali does not smoke, drink and doesn’t use drugs. Mr. Ugali has no health insurance, this means that he needs to pay the hospital bill by himself.

2. Nutrition and metabolism

Mr. Ugali has a pneumonia. This is probably caused by the HIV infection.  Due to the pneumonia the appetite decreased and he has lost weight. It’s hard sometimes for mr. Ugali to get enough oxygen, because of the secretions that are formed in his lungs. Therefore he gets oxygen.

Due to the HIV infection the immune system of mr Ugali is weakened, because he can’t get out of bed the risk of him getting decubitus is increased. Though the weakened immune system his own body won’t be able to heal the skin by itself.

3. Execration

Mr. Ugali passes urine and stool well. The urine has a good color and doesn’t smell, the feces has a good color and structure. Mr. Ugali coughs up a lot of secretions. This has a green color.

4. Activity

Due to the pneumonia everything cost him lots of energy, it’s hard for mr. Ugali to remain practicing his daily activities, such as personal hygiene, walking around and doing physical exercises. It takes lots of energy to cough up his secretions, sometimes he even uses his accessory respiratory muscles.

5. Sleep and rest

Nevertheless the pneumonia mr. Ugali gets enough sleep during the night and day, he is able to rest a lot. He wakes up sometimes during the time because of the coughing, but he still gets enough rest.

6. Perception and cognition

Mr. Ugali doesn’t feel very sick. He thinks the pneumonia can be cured with herbal and homeopathic medicine. He thinks the pneumonia has developed by the cold wetter that passed by a few days ago. He can’t relate the HIV infection to the pneumonia and the risks it brings.

7. Self-perception

He has the feeling that since he is in the hospital he isn’t able to make his own choices. He has the feeling the doctor forces a certain treatment on him. When you look at mr. Ugali you see on his faces that he is in pain, because of the pneumonia. Mr Ugali won’t tell the nurses that he is in pain. Since he was young he was told to never complain and accept the things God offers. He should be happy to still be alive, because it always could be worse.

8. Roles and relationships

Mr. Ugali is a widow, he lost his wife 7 years ago. He has one son of 23 years old, but does not have any contact with him. They do not have any contact because of family circumstance. Mr Ugali would love to have contact with his son again, because he misses him a lot. Besides this he has no other social support system. He has a fruit stand, but since he is in the hospital he cannot earn any money. There is no one who can take over the business.

9. Sexuality and reproduction

Mr Ugali was infected with HIV by cheating on his wife and having unprotected sex with another women.

10. Stress processing

Mr Ugali can’t cope with the fact that he is HIV positive. He constantly tells it is a minor disease. He is not able to undermine the fact that HIV is a dangerous disease if isn’t treated probably.

11. Values and religion

Mr Ugali is raised as a member of the Kululu tribe. Due to his values he doesn’t believe the power of medication. He believes that God has a reason for everything also for the fact that he is HIV positive.

(Hesselink, 2011)

3.Complexity score

When mr. Ugali was adimitted in Coptic hospital his status was evaluated due to the complexity score card. His status is now stable, but can change easily. Mr. Ugali refuses to take his HIV medication and the inhalers for the pneumonia. Therefore his situation can suddenly get worsen. This means that a nurse needs to check on mr. Ugali regularly. When his situation change the nurse needs to be able to give immediately care.  This means that the complication pneumonia due to the HIV infection can aggravate.

Mr. Ugali will get treatment from the doctor, the nurse and the physiotherapist. The physiotherapist will exercise with mr. Ugali to prevent decubitus  and gives him breathing exercise.

Mr. Ugali has an tube in his arm and gets oxygen because of the Pneumonia. Due to the pneumonia Mr. Ugali isn’t able to breathe properly. This is also the reason that he needs help to take care of his personal hygiene, mobilizing, dressing, using the toilet and moving around. This costs him lost of energy and to be able to save this energy to recover from the pneumonia the nurse needs to help him.

Due to the fact that mr. Ugali refuses to take his HIV medication, because in his believe the HIV medication given by the hospital don’t work only the homeopathic and herbal medicine. This is the reason mr. Ugali needs extra attention.  The nurse needs to find a way to let mr. Ugali know that the HIV medication is necessary otherwise the disease will get worse. Mr Ugali feels like he isn’t able to make his own choice and the doctor is forcing the treatment on him. Mr Ugali feels like they don’t listen to his values and standards.

The HIV infection is the reason why mr. Ugali has the pneumonia.  Due to the fact that mr. Ugali does not take his HIV medication mr Ugali got the pneumonia. Only mr. Ugali things the bad wetter a few days ago is the reason for the pneumonia. He is not able to see the link between the HIV infection and the pneumonia.

This is the reason why mr. Ugali score high in almost every item of the complexity score card. His total score is 23 points, this means that mr. Ugali is high complexity. The high complexity starts at 18 points and ends at 32 points. This means that mr. Ugali isn’t very high complex, but more average complex.

4.Sorting of health patterns

(Hesselink, 2011)

1. Accountability and prioritization of (potential) nursing problems

The health patterns are divided in functional and dysfunctional.  When we observe as a nurse that the health situation of mr. Ugali is a normal situation or when mr. Ugali feels that the health situation matches his own health aspects, values and standards the health situation is placed as functional. When the nurse observe a health situation that isn’t a normal situation for mr. Ugali or he feels that the health situation does not matches with his own health aspects, values and standards the health situation is placed as dysfunctional.  For example the fact that mr. Ugali refuses to take his medication is dysfunctional. But the fact that he does not take his medication, because his religion says that only herbal and homeopathic medicine work is functional. The reason that this is functional is,  is because these are his values and standards. Values and standards can’t placed as dysfunctional.

The onion diagram makes clear how cultures express them self. The culture is divided in four layers, called the symbols, the heroes, the rituals and the values. The symbols are the superficial layer and the values of a culture are the most deep layer of the culture. This means that symbols can chance and can taken over by another culture. The values of a culture will never chance and every new born in the specific culture will be raised with the same values. The fact that mr. Ugali is refusing to take his HIV medication is, because his father told him since a young age that only herbal and homeopathic medicine will work. This is an value of the Kululu tribe and is the reason why mr. Ugali choose to not follow the HIV treatment, but to cure himself with the herbal and homeopathic medicine. (Hofstede, 2005)The culture of Mr. Ugali is based on the G-group. This is a group that is very group related and collective (meaning the community is more important that the individual).  If mr. Ugali decide to take the HIV medication prescribed by the doctor, he will go against the values of his culture and the community. This makes him an outsider of his culture and possible his culture will go against him. (Shadid, 2007)

Mr. Ugali is insecure about the medication, because of his culture he does not deal with the insecurity. Everything that is different for mr. Ugali is dangerous. He relays on his religion that helps him accept his insecurity. His religion will help him heal from the HIV and pneumonia. (Hofstede, 2005)

Kenya is a very masculine country, this means that men should be assertive and dominated over women. Men are not allowed to cry are show their emotions. This is the reason why mr. Ugali won’t say to the nurses that he is in pain. If he says he is in pain he will fail as a men. The fact that mr. Ugali doesn’t complain, has also to do with his religion and culture. He is brought up with the values that he is not able to complain, he needs to be happy with the fact that he is alive and that God has an reason for everything. (Hofstede, 2005) Since I was young I have learned to tell when I am in pain. I am brought up with the value that men are also allowed to shown that they are in pain and that they are allowed to shown their emotions. I think this is a good thing. I believe when mr. Ugali tells to the nurse when he is in pain or talk about his feelings his hospital stay will be a lot more comfortable. I believe that when mr. Ugali shares his feelings towards the HIV medication to the nurse, it will be possible for the nurse and the doctor to make a treatment that will make mr. Ugali happy and is not going against his values. I think when you involve mr Ugali in the treatment he will be following the treatment eventually.

Trough dividing the health patterns in functional and dysfunctional the nursing problems are established. The nursing problems will be prioritized by the pyramid of Maslow. The pyramid from Maslow is divided in five stadiums, called from bottom to top, physical needs, needs for safety and security, needs for social contact, needs of appreciation and recognition and self-development. The pyramid of Maslow says that you first need to accomplish the lower needs before you can accomplish the higher needs. This means that you first need to accomplish your physical needs before you can start working on your needs for safety and security or others.

In case of mr Ugali he first needs to get help with his personal hygiene before the nurse can reduces his  lack of knowledge. (Hesselink, 2011)

With the pyramid of Maslow the nursing problems of mr. Ugali are prioritized into the following list

1. Inadequate therapy discipline
2. Acute pain
3. Shortage of self-care: personal hygiene, dressing, toilet
4. disturbed gas exchange
5. Reduced mobility 
6. Lack of knowledge
7. Powerlessness
8. Inadequate coping
9. Risk of decubitus 
10. Risk of infection
11. Risk of loneliness

The decision to put inadequate therapy discipline on number one is, because that is the reason mr. Ugali is admitted to the hospital. Probably if he had taken his HIV medication he wouldn’t have the pneumonia. The disturbed gas exchange and reduced mobility are placed high in the priority, because of the stadium needs of physical in the pyramid of Maslow. The reason Lack of knowledge and inadequate coping is placed above the risk of decubitus and infection is, because the lack of knowledge cost that mr. Ugali does not see the danger in HIV and the importance in taken medication. If he would understand the importance of taken the HIV medication and the inhalers form the pneumonia the risk of him getting decubitus or infection will go away. This is the same for the nursing problems powerlessness and inadequate coping. Mr Ugali is already trying to get in contact with his son again, because he misses his son a lot. This is the reason why the nursing problem risk of loneliness is placed last. (Hesselink, 2011)

2.Nursing Diagnoses

2.1Inadequate therapy discipline

Problem:         Inadequate therapy discipline

                        ‘The insufficient adherence to the prescribed treatment’

Etiology:          The religion of mr. Ugali

Symptoms:      Refusing to take the HIV medication and refusing the pneumonia treatment. Thinking of it being a minor disease. Mr. Ugali does not believe in the power of the HIV medication he only believes in the power of herbal and homeopathic medication. He believe that God has an reason for him getting HIV.

SMART Learning goal

Within a week Mr. Ugali takes his medication so he can be treated for the HIV-virus and pneumonia, taking into account the values and believes of mr. Ugali. This appears from the observations from the nurses.

2.2Shortage of self-care: personal hygiene, dressing, toilet

Problem:         Shortage of self-care: personal hygiene, dressing, toilet

‘Not able to maintain the self-care activities, because of a disturbed function of the body’

Etiology:          The pneumonia

Symptoms:      Lack of energy. The weakened immune system needs all the energy to fight against the pneumonia. The fact that mr. Ugali refuses to take his HIV medication and the pneumonia treatment

SMART learning goal

After two weeks mr. Ugali is able to take care of his own personal health, he is able to wash and dress himself and going to the toilet on his own. This appears from the observations from the nurses

2.3Acute pain

Problem: Acute pain

                        Label: A strong unpleasant feeling that can take one second till six months

Etiology: The pneumonia and HIV

 Symptoms: The coughing hurts mr. Ugali a lot, you can see it on his face

SMART learning goal

After a week the acute pain is in control and mr. Ugali is expressing his pain to the nurses so they can give him adequate pain medication, this appears from the observations from the nurses

2.4Reduced mobility

Problem:         Reduced mobility

                        ‘An restriction in your movement, without being immobile’

Etiology:          HIV

Symptoms:      Weakened immune system,  lack of energy, bedridden and coughing through the pneumonia

SMART learning goal

After a week mr Ugali is able to mobilize by himself to reduces the risk of decubitus, this appears from the observations from the nurses.

2.5Inadequate coping

Problem:         Inadequate coping

                        ‘Not able to handle inner or environmental stress normal’

Etiology:          The religion of mr. Ugali

Symptoms:      He believes that God has a reason for everything also for the fact that he is HIV positive, He constantly tells it is a minor disease. He is not able to undermine the fact that HIV is a dangerous disease if isn’t treated probably. Mr. Ugali doesn’t feel very sick. He thinks the pneumonia can be cured with herbal and homeopathic medicine. He thinks the pneumonia developed by the cold wetter that passed by a few days ago.

SMART learning goal

Within two weeks mr. Ugali is able to cope with the fact that he is HIV positive due to more

Knowledge, this appears from the observations from the nurses.

3.Interventions

3.1Inadequate therapy discipline

NIC

Interventions

• Education
• Setting goals with mr. Ugali
• Taking into account the values and standard of mr. Ugali

Activities

• Witch factors holding mr. Ugali back for not taking the medication
• Improve self-convidence. Let mr. Ugali take about his feelings and values towards the treatment. Accept mr. Ugali as the way he is. Give only the care that mr. Ugali needs and prevent that mr. Ugali feels that he is being pressured
• Educated mr. Ugali about HIV, pneumonia and the treatment
• As a nurse take in consideration to be able to chance the behavior of mr. Ugali takes time
• Discus with the doctor and mr. Ugali about an alternative treatment. This will give mr. Ugali the feeling that they take his values in consideration.  (Carpenito-moyet., 2008)

3.2Shortage of self-care: personal hygiene, dressing, toilet

NIC

Interventions

• Helping mr. Ugali with personal hygiene
• Helping mr. Ugali with dressing
• Helping mr. Ugali with going to the toilet

Activities

• Take in consideration that mr. Ugali needs all his energy to recover from the pneumonia
• Ask mr. Ugali what he is able to do by himself, with the personal hygiene and dressing. Support mr. Ugali at the things he is not able to do by himself
• If you notice that mr. Ugali has no energy to do anything, discuss this with him and take over the hole care
• Make sure that mr. Ugali has privacy during the personal hygiene, dressing and going to the toilet
• If mr. Ugali is not able to walk to the toilet give him a bath pan (Carpenito-moyet., 2008)

3.3Acute pain

NIC

Interventions

• Adequate pain medication
• Emotional supporting
• Education

Activities

• Educate mr. Ugali about pain medication. Take in consideration the fact that mr. Ugali is raised with the fact that he is not allowed to show any emotion.
• Take notice of the pain. Appoint to mr. Ugali that you can see on his face that he is in pain.
• Discuss with mr. Ugali if he wants to take pain medication or consider and herbal or homeopathic option as painkiller
• Ask mr. Ugali is there is something that will take his mind of the pain. This can maybe prevent taking painkillers. This makes sure that you take the values of mr. Ugali in consideration. (Carpenito-moyet., 2008)

3.4Reduced mobility

NIC

Interventions

• Therapy
• Exercise
• Education about movement

Activities

• Prevent that mr. Ugali lies the hole day in bed in the same position. If mr. Ugali has no energy to get out of bed makes sure that he chance his position every two hours to prevent decubitus
• Start slowly with exercising, begin with putting mr. Ugali in a chair for 15 minutes three times a day.
• When he is able to sit for more than 15 minutes in a chair let mr. Ugali walk by himself to the toilet and back to his bed.
• When he is able to walk the small distance you can let mr. Ugali walk in the hallway. Existent this further and further. Untill mr. Ugali is able to mobilize by himself
• Consult the physiotherapist
• With every exsercise you do with mr. Ugali take in consideration that he needs all the energy to fight against the pneumonia, because of his weakened immune system (Carpenito-moyet., 2008)

3.5Inadequate coping

NIC

Interventions

• Improving adequate coping
• Emotional support
• Listen

Activities

• Determent the existing capacity of coping with the situation, listen to mr. Ugali how he is feeling and what his feelings are towards the treatment, the HIV and pneumonia
• Stimulate mr. Ugali to evaluate his own behavior
• Talk about the values and standards of mr. Ugali, let him know that you consider them
• Learn mr. Ugali more about the treatment and HIV. Learn him about the danger if he does not take the HIV medication.
• Talk about his religion with mr. Ugali, this is the own thing that makes him secure. (Carpenito-moyet., 2008)

4.Accountability the intervention with evidence based practice

4.1Step 1: Make from the clinical problem a question that can be answered

Thought searching for scientific articles the intervention of how to improve inadequate therapy discipline. This means that mr. Ugali will eventually take his HIV medication through the intervention. To accountability this intervention at least two scientific articles will be used. To be able to find the articles there need to be draw up an Three part question. This means that the problem and the intervention are specific and put in the question.

Problem: Mr Ugali is 68 years old, he refused to take his HIV medication, because of his religion.

Intervention: Improve the coping skills of mr. Ugali

Outcome: Mr. Ugali will take his HIV medication

With the above three part question the problem can be translated in an answerable question, called:

Question: Will improving the copings skills of Mr. ugali who is 68 years old and refusing to take his HIV medication because of his religion, make sure that mr., Ugali has an adequate therapy discipline?

To come to this three way question there needs to be taken in consideration the ethical and legal aspects. Mr. Ugali has no health insurance this means that he needs to pay everything by himself. With finding scientific articles we need to make sure that the interventions does not cost a lot of money for mr. Ugali. Mr. Ugali refuses to take him medication, because of his religion. By searching for the right intervention for mr. Ugali we need to take his values and standards in consideration. It is very important that the healthcare profession respects his religion and that mr. Ugali gets the feeling that they listen to him. If we don’t listen to his believes the chances that mr. Ugali will take his medication is low. By answering the question with scientific articles we need to make sure that we search specifically for copings skills in religion.

Mr ugali has the right to refuse treatment. It is the duty of the healthcare profession to explain to mr. Ugali the consequences that come with refusing treatment and the risk he takes. If mr. Ugali still refuses treatment the healthcare profession legally needs to respect the decision of mr. Ugali. This means that the nurses of doctors cannot force treatments on mr. Ugali. This is way it is important to make sure that improving coping skills will make sure that mr. will have an adequate therapy discipline. Mr. Ugali has the right to receive full information about the treatment that is given to him. The information must be real and understandable for the patient. This means that the nurses and doctors needs to inform mr. Ugali. This will help him understand more about his treatment, this is something that is very important to mr. Ugali.

Mr. Ugali needs to be respected by the healthcare profession this means that the healthcare profession needs to take his values and standards in consideration. If the healthcare profession does not do that according to the law they discriminate mr. Ugali. (Draft of the national patients right charter, 2012)

4.2Step 2: Efficiency searching for scientific articles

For searching for scientific articles there are inclusion and exclusion criteria’s begin used. This means that only the articles that fulfill the inclusion criteria’s can be used.

The criteria’s are:

• Only PUBMED is being used. This is an reliable site to search for scientific articles
• The articles are searched with the highest prove with the pyramid of prove. In this pyramid the randomized control articles are the most valid articles.
• The articles are not allowed to be older than 5 years
• The articles needs to be in English
• The articles is free and fully available in pubmed, because of the small amount of time the articles need to be available immediately.
• The artikels that are searched are about about improving copings kills will improve adequate therapy discipline
• There needs to be find at least two scientific articles about improving copings kills will improve adequate therapy discipline
• The searching words that are used needs to come from the three way question

4.3Step 3: Assessment of the scientific articles on methodological quality and apply in practice

To assess the articles the question list of Hunnick is being used. This is an list of 44 questions that can be answered with yes or no. When the most questions are answered with yes the article is valid and can be used for answering the thee way question. If the most answers are being answered with no the article can’t be used.

Both articles have been assess by the hunnick list. The articles are valid and can be used for the research.  The article (Finocchario-Kessler, 2011) scored 42 points out of 50 and the article (Michaud, 2010) scored 38 out of 44. In the annex you can find the filled in hunnick forms for both articles

4.4Step 4: Apply the results (available evidence) that has been found through searching in practice

There has been found two articles that answer the question: Will improving the copings skills of Mr. ugali who is 68 years old and refusing to take his HIV medication because of his religion, make sure that mr., Ugali has an adequate therapy discipline?

The article from Finoccahario-kessler et. al. is an randomized control trail and did research to the patients autonomy and influence of religion/spiritually believes on the adherence of HIV treatment. They tested different kinds of interventions to improve the adequate therapy discipline. It is very important that an patient with HIV takes his drugs, because this reduces the resistants of the HIV virus against the HIV drugs and prevent transmitting to other people. (Finocchario-Kessler, 2011)

The article explains that when an patient with HIV has an high autonomy and the right coping skills to deal with the HIV, the therapy adherence is higher. It is also very important that the patient gets a lot of support from family and friends, Self-effiency and social support created high adherence to HIV medication. The article says that the negative religious believes, practice and copings skills are associated with poor HIV medication adherence. Patients with high believes in God and things that it is an punishment from god or that they get HIV with an purpose and that no drug can help them are more likely to have an poor adherence. On the other hand the believe in God also helps patients with HIV in terms of their psychological well being. It is very important to learn more about religious believes in comparison with HIV treatment. (Finocchario-Kessler, 2011)

The article makes clear that it is important to reach out to spiritual and religious groups and churches to help to improve the patients coping skills and therapy adherence. They need to reduces the stigma on HIV in their community. Almost everyone in Kenya goes to church, so if they would take about HIV in church it will help.  (Finocchario-Kessler, 2011)

The article from Michaud at el an qualitive study also did research to HIV adherence in combination with adequate psychological adjustment and effective coping skills. They do not give any numbers but trough interviewing the participants they found out that when the patient with HIV knows what HIV is and knows the importance of the risks when not taking medication the adherence is higher. Also the fact that the patient get social support and has accepted the fact that he is HIV positive the HIV adherence is higher. When the patient has good copings skills the adherence is also higher. (Michaud, 2010)

These two articles describe that the right coping skills will improve HIV treatment adherence. This means that the intervention of improving mr. Ugali’s coping skills will improve his HIV adherence.

4.5Step 5: Frequently evaluate the process and results

Evaluation can be done by monitoring the HIV treatment adherence. This needs to be done on an daily basses. If the nurse finds out that the adherence is poor the coping skills of Mr. Ugali needs to be improved. There is not a specific scale that can be used to measure the HIV adherence. Every day the nurse, the doctor and mr. Ugali needs to evaluate the process together.

The nurse needs to talk to mr. Ugali about HIV and his copings skills. The nurse needs to explain to mr. Ugali what HIV is and the risk of not taking his HIV medication. She needs to find out what the real reason is way he is nog taking his HIV medication. The nurse needs to ask mr. Ugali how he is feeling and what he is thinking about HIV and the treatment. The nurse can give mr. Ugali other coping strategies without going against his values and standards. In this way the nurse can concluded if improving the coping skills of mr. Ugali will improve his adherence to HIV medication.

If this does not work they need to find another way to improve his adequate therapy discipline. Maybe they can ask someone of his religion to talk to him about the impotency and get more social support.