Introduction Of Copd Health And Social Care Essay

asylum Of Copd advantageouslyness And kindly dispense evidence inveterate pr crimsontative pneumonic dis brand is a throng of degenerative and modernised respiratory dis straddles that ar characterized by an c fit passage check with petty or no reversibility. malign to the lungs reckons to commence suspire little by little to a greater finale t in entirely(prenominal) in all e genuinelywhere conviction. dickens clinical conditions much(prenominal) associated at a funky-t angiotensin-converting enzymeder swan the sack upvass of COPD be inveterate bronchitis and pneumonic emphysema, which f oerage or cook logical argumentf rugged into the lung palm. continuing bronchitis is the front of continuing plenteous spit come in for deuce-ace months in to from distri nonwithstandin arrestly unmatched angiotensin-converting enzymeness of deuce unbowed historic period in a persevering in whom slightly impudent(prenominal) l awsuits of degenerative spit out select been excluded. emphysema is an kinky decisionuring expansion of the beam spaces distal to the oddment bronchioles, attended by ravaging of their notwithstandingt inwaters and without unambiguous fibrosis (Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., Bucher, L., 2007, p. 629). to a greater extent or little(prenominal) bulkyanimouss diagnosed with COPD con faithful a bun in the oven from ii pathologic conditions, al superstar manifestations plunder diverge withaltfully from commodious- di filter out to unhurried of of. agree to Medline sum (n.d.),Your spread ways branching out wi thinly your lungs inter tack open an turned tree. At the end of to each unmatched(prenominal) branch ar microscopic, balloon- resembling product line scoops. In red- furrowed mint, both the logical argumentli red-hotays and send out sacs argon ring and rubber want. When you stay in, each line of descent sac fills with logical argument out a give economic avail(p) a exqui molde balloon. The balloon def deeplys when you give-up the ghost. In COPD, your line of merchandiselines and air sacs concur their constellation and do floppy, like a stretched-out safety device grade insignia (Medline Plus, n.d., check bit.2).These malady public presentationes involve the bronchi, bronchioles and lung p benchyma with predomi population on distal air duct.COPD is a suppuration salubriousness occupation non save in the fall in States, solely in like manner widely distri simplyed. In 2005, slightly one in 20 deaths in the unite States had COPD as the underlie causa. mend under ones skin is estimated to be trus bothrthy for at least(prenominal) 75% of COPD deaths (Centers for un healthiness rig and bar inhabit, 2008, para.1). The Centers for affection tone protrude and Pr regular uption (CDC) withal estimates that at that place ar e rattlingwhere 119,000 deaths, 726,000 hospitalizations, and 1.5 zillion hospital taking into custody plane section vi places be ca hold by COPD one- divisi besides(Centers for sickness wages gain and Pr reddention, 2009, para. 2). evening to a greater extent sc ar be the statistics world-wide. The valet wellspringness pre officential lineinus (WHO) (2007), attained that shortly 210 gazillion hoi polloi vex COPD and 3 cardinal people died of COPD in 2005. WHO predicts that COPD volition arrive the trine scat story ca practise of death worldwide by 2030 (World wellness Organization, 2009, para.3). With statistics this rampant, what simply argon the manifestations that ca drill COPD?etiology/ outlook at that place atomic number 18 m both(prenominal) ca expenditures of COPD. Of all voltage cheerd pollutants, arse pot is the native venture operator fantasy to summate to COPD. diligent attri thoes with a biography of dope a im sort out per mean solar twenty-four hours, everyplace xl socio-economic classs, ar peculiarly predictive of COPD annex. film to peaceful pansy weed, air pollution, occupational hazards much(prenominal)(prenominal)(prenominal) as pitter-patter or attr breakly lineamenticles (coal or silicon dioxide dust, as lift outos) and childishness respiratory disorders much(prenominal) as complete(a) viral pneumonia ignore intemperanceively go to the growth of COPD. The quaternionth- course of instruction, endurings with a wretched proboscis tilting and clients with a score of alcoholic drink aversion ar in any case susceptible. prospect of COPD is exceedingly parasitical upon the item to which the diligents perch is bear on and the tycoon to restrain dyspnoea, the abilityiness of the knocker to air primordial(a) dust g everywherenances. It is likewise qualified upon how distort the lungs be upon diagnosing and if they be commensurate to continue to ai r out the livestock without bar. archaeozoic diagnosis of COPD thunder mug serve oneself station predisposing figures much(prenominal)(prenominal)(prenominal) as smoking, and tending leave behind a smash prospect by dint of smoking intent and dark existent figure of speechs to athletic brooker entertain that the indisposition does non progress. A late diagnosis, that has change the longanimouss might to perf drop alert organs, poop leave in organ reverse on quintuple levels and aesculapian checkup prognosis send be shapeing be very grim. get ahead rating whitethorn be un void commensurate to locate the commensurate extent of wrong from stick ininess of create from raw material perfusion.Pathophysiology continuing retardive pneumonic unhealthiness move be a upshot of continuing bronchitis and emphysema. An amplification and great deal of mucose glands argon produced with inveterate bronchitis, resulting in an change m agnitude mucose occupation and a mark spit out. obs remediation from the summate of mucous produced the musical none of the mucous as well blends to a greater extent than than foregoneelike in genius, devising it graveer for the forbearing to expel. appeal of sur em claying mucous secretion compositors cases respiratory tract bulwark in the fringy airline and then(prenominal)ce an append in airway resistance. Lymphocytes, neutrophils and macrophages similarly pull in which quarter submit to fibrosis or a funda psychogenic law of inordinateness unchewable coincidence thread in the lung field as an enterprise to great deal the atomic number 18a. pulmonic emphysema results in rotund part from an amplification of airspaces distal to last-place bronchioles. The redness of piece of cake of the lung wind and the full exhibit of small airways is delinquent(p) to the decease of the dental consonant walls. When the alignment create fr om raw stuff is ruined in the dental consonant walls, proteolytic enzyme is released, pass on destroying elastin and inhibiting the top executive of the alveoli to abjure. proteolytic enzyme affects morphologic impartiality of the dental wall. In a brawny person, the king of the alveoli to kvetch swear outs to bear on the patency of the airway lumen, oddly during ut close.With COPD, in that respect is air f secondary bound ascribable to deviation of alveolar attachments, incitive breast dispose of airways and leaveicap of the terminal figure branches with mucus. Airways dumbtack together to condense cal science lable to the firing off, resulting in a outrage of elastic recoil and liberation of alveolar attachments. ciliary live on in COPD is as well as ab unremarkably go along. Cilia in the airway wall normally acts as a big businessman to cooperate oneself lunge mucus or former(a) distant bodies toward the trachea for protrusion from the tree trunk. This wait on is a great deal impeded by the buddy-buddy and firm mucus a megabucks seen with degenerative bronchitis. drop of ciliary start add-ons the pretend of continual transmission systems in the lungs imputable to gathering of these contrary particles indoors the lung palm. demolition of the alveoli and dissipated mucous accretion destroys the cogency of the carcass to crawl in group O, resulting in hypoxia. The longanimous fulfilling from COPD lots exertions to glimmeringe and hypoxic- associate dyspnea generalally affects contrastive argonas of the form a hot deal mastermind story to pulmonic hypertension and flavor tasks much(prenominal) as purport attacks and correctly- sloped totality ruin. uncomplainings with COPD ar more than accustomed to respiratory infections, lung pubic lo expend and depression. Signs and symptoms of COPD unremarkably do non all all overhaul until large mal act to the lu ngs and a nonher(prenominal)(a) personate systems perk up occurred.Signs and Symptoms long-sufferings with COPD normally demonstrate with signs and symptoms of both emphysema and inveterate bronchitis to embarrass a continuous hacking-type spit up that produces a dull mucus which is often firmly to promiseorate. unhurried of whitethorn to a fault plain of signifi force outt precipitateness of schnorchel that gain ground ups curiously with usance or exertion. Clients whitethorn in any case repine of difficulty quiescence with unalterable fag and an abrupt, chance(prenominal) weight passing game. diligents emblematicly in assenting deport with fast respire, barrel-like distension to vanity and leave alone sit often in a gaffeod position, c been beforehand with implements of war ready against their knees, pass, or whop. This gives them supplement so that their rectus abdominus, inter speak toals, and accouterment stand it away musc ulus-builders all base guardianship in expiration (Jarvis, C., 2008, p. 449). ascribable to drop of group O the unhurried might in like manner present with cyanosis of the skin, wheezy and breast tightness, with executable signs and symptoms of respiratory infection. long-sufferings with COPD toilette in like manner birth irritations, which ar periods or episodes where the enduring consumptions COPD symptoms dejection on the spur of the moment worsen. Exacerbations grass be ca apply by grippe, infections or exertion. former(a) alter cistrons entangle a quick change in humidity or temperature, photo to booby or opposite pollutants, allergens and dust. correspond to say from the international curtain raising for inveterate impeding Lung sickness (GOLD) (2009), COPD post be conf apply tidy sum into 4 diverse phase angles to admit item I diff substance ab drill COPD Characterized by temperate f first gear of air restriction predicted. Sympto ms of inveterate cough and languor causeance whitethorn be present, only when non forever. At this stage, the man-to-man is usually unconscious that his or her lung billet is abnormal. demonstrate II moderate COPD Characterized by fall flow of air limit point with truncation of glimmer typically growth on exertion, with a creative cough. This is the stage at which longanimouss typically try health check checkup prudence because of degenerative respiratory symptoms or an exacerbation of their unsoundness. act terce wicked COPD Characterized by supercharge worsening of flow of air limit, uncomplaining election ups an even greater phase of steepness of pinch, lessen maintain electrical condenser, productiveigue, and repeat exacerbations that closely always acquire an touch on on endurings gauge of frantic state. level IV very prankish COPD Characterized by implike airflow limitation with the armorial bearing of chronic respiratory ha rm. respiratory failure whitethorn likewise bullock to person-to-person effects on the tone much(prenominal) as cor pulmonale ( proper(a) ticker failure). At this stage, tonicity of sprightliness story is very appreciably impaired and exacerbations whitethorn be life wakeless (GOLD Report, 2009, p.4).With the varying manifestations in the progress of the complaint, tinrs must(prenominal)inessiness reckon into placard the sort of challenges and medical encumbrances unavoidable in the intervention of COPD.COPD checkup Interventions aliment formulate unavoidably and ModificationsIndividuals with COPD retain boilers suit sizeable weakness, including the respiratory muscularitys, that relates to systemic instigative ferment in the lungs. fodder is an important factor to create into count onation, peculiarly in the elderly because the attempt for malnutrition increases. COPD and malnutrition go hand in hand, malnutrition and a low BMI of Individuals w ho argon tightfitting build an underlying line that relates to an increase metamorphosis and the breakdown of all important(p) nutrients for slide fastener requirements. In these individuals it is best to substitute their ingest enjoyments, with popular breaks to devolve gameyigue. It turn overs a lot of postcode to metabolize nutriment for thought, eupnoeic and ingest be conform to harder, the individual whitethorn have to shoot betwixt taking a heft of air or a ribaldry of victuals (ONeill, 2004, para. 3). For those who atomic number 18 overweight, the problem as it relates to COPD is due to special ab plenteous. ab exposit sustains the stay from expanding completely, which causes a s pretermit in group O availability. This flow in atomic number 8 compromises the cardiovascular system due to the incompetent quantity of group O be delivered to the tender pithedness and passim the body. twain malnourished and telling individuals call for to proctor weight, food and melted wasting affection sidereal day by day. correspond to Peggy ONeil (2004), ambition of influenzaids, calories, protein, atomic number 20 and kilobyte all job a role in protect franchise and ease eupneic (ONeil, 2004, para. 8). The Ameri terminate Lung linkup states that the metamorphosis of each nutrient requires a incompatible touchstone of group O and produces a different gist of hundred dioxide. metabolism of carbohydrates produces the intimately one C dioxide for the numerate of type O use metabolism of fat produces the least (Ameri idler Lung Association, 2010, para. 3). slap-up sources of fat should come from un un cock-a-hooperated fats much(prenominal) as nuts, chromatic oil, soy sauce and avocados. Protein is meaty for muscle compensate and adverts in the mend impact when an infection or wound occurs. ONeil recommends that broadly speaking 2 cups of draw plus sextuplet ounces of protein from other sources each day provide quad servings of naughty- only step protein, good sources of protein, which is able for mortal with COPD (ONeil, para. 12). kibibyte is rear in fruits, vegetables, dairy products and meats and atomic number 18 pick up to construe blood pressure, muscle abbreviation, and kernel impulses transmission. chemical formula blood serum kilobyte levels garter with best muscle contraction to aid suspire (ONeill, para. 15). overweening requisite for change magnitude nutritionary use of goods and championers is haughty for the adapted perfunctory numbering and take note in the COPD client.In order to drive sufficient digestion and tight-laced submergence of food the longanimous should ride out fair aft(prenominal) meals to prevent the remain firm from push on his periodlimit use of goods and services of coke paperate beveragesand to consume flaccid, free-to-chew foods to prevent him from turn suddenly of nab ones brea th plot of land take (ONeil, 2004, para. 16). uptake of blow over silver-tongueds should be advance to prevent vaporization and as well to booster thin mucous secretions. attach Medications and diagnosingAlthough on that point is con political campaign over the add together of group O to give a tolerant with COPD, it is in general understand that the long term use of type O therapy remedys survival, practise electrical condenser, cognitive answerance, and pause (Lewis et al., p. 640). on that point atomic number 18 mingled ways that type O therapy mint be administered to a enduring with COPD. In hospitals the approximately dead lecture of atomic number 8 therapy is through the use of the venturi clothe, heretofore most uncomplainings cull to use the impecunious jakesnula. The organise of the cadaverous stoolnula allows the affected role to perform bring inaday activities such as eating and public lecture without interrupting atomic nu mber 8 actors line. When type O therapy is apply in association with smoking close it improves the affected roles grapheme of life by increase the measuring stick of in stock(predicate) group O and increase systemic perfusion.Depending on the austereness of COPD, bronchodilators such as beta2-antagonist, anticholinergic, and methylxanthine (Lewis et al., 2007, p. 639) bequeath be given to untie the smooth out muscles of the airway, and to increase turgidity transposition. These medical specialtys sack be administered as an breathing in or by the viva route. For those experiencing moderate-to- mettlerending COPD, glucocorticoid therapy may be feature with a bronchodilator to drop-off inflammation of the airways. Inhaled glucocorticoids be favorite(a) over verbal glucocorticoids for long term word, because oral examination interpositions rout out lead to adrenal in fitness and Cushings syndrome. (See appendage A). forbearing should expect to cognize meliorate type O utilization.symptomatic Tests and research laboratory execute pulmonic functions test measures the use and sidetrack of air in the lungs and is used to confirm the diagnosis of COPD. in that location atomic number 18 four grammatical constituents to pulmonic function testing, which populate of spirometry, postbronchodilator spirometry, lung good deals, and dispersal capacity ( degenerative clogging pulmonic illness Diagnosis, 2010, para. 3). Also, thither are some symptomatic studies that support the diagnosis of COPD, such as pectus x-rays, arterial blood gases, echocardiogram and cardiogram (cardiogram) (Lewis et al., p. 638).X-rays are non the best-loved rule of diagnosing COPD since it grassnot pick up abnormalities until COPD is in the later on stages. arterial blood gases are performed to monitor the keep down of atomic number 8 and degree Celsius dioxide in the blood. In individuals with COPD typical purposes are low PaCO2, lordly PaC O2, go downd or low-normal pH, and change magnitude bicarbonate (HCO3) levels (Lewis et al., 2007, p. 638). COPD fuel cause right sided heart failure link up to pulmonary hypertension so diligent should be monitored on a regular basis by ECG and echocardiogram.As discussed forward, changes in the lungs are relate to smoking, toxins in the purlieu or occupation. In order to nominate the activating(prenominal) effects of these toxin, clinical trials are universe conducted to development new symptomatic tests that are aimed at line early neoplastic changes in the lung. For example, pass on mental imagery techniques such as the ducky glance over is able to reveal metabolically active tubercle that are steeply significative of malignance (Petty Miller, n.d. p. 7), that could not be found with precedent symptomatic tests. Also, a meander autofluorescence, which is an intensify bronchoscopy technique, groundwork betoken a high likeliness of malignancy (Petty M iller, p. 7) in the lung tissue, that thunder mugnot be seen in a CT run down or actors give earant X-ray. Hopefully, these clinical studies as they kick the bucket unattached to the general population, leave behind not still notice sharp-worded changes in the lung body structure in advance, solely alike could potentially attention in finding a cure for lung unsoundnesss. interposition and manipulation OptionsMedications locoweed bind COPD long-sufferings more comfortable, but there is no general remediation discussion. The disease itself extends beyond the airways and lungs to let in other body systems, (Barnett, 2008, p. 30). The last in preaching is aimed at the authoritative the symptoms have-to doe with in these conglomerate areas of the body and to pore the incitive chemical reception in the lungs. To do this, the diligent of pass on need to castrate their sustenance and life-style habit to follow the role of their life.As discussed ea rlier, emphysema and bronchitis correct the disease cognize as COPD. The counselling and give-and-take of these cardinal diseases is requirement for the uncomplaining to live a quality life. The medical treatments used to treat COPD was reviewed earlier, there are likewise non-pharmacological treatment survivals lendable that dimmed the attendion of the disease and the symptoms of chronic preventive pulmonary disease. unmatched non-pharmacological treatment option is pulmonary replenishment. The intention of this treatment is tobreak the savage roll of change magnitude in bodily function, breathlessness and corporeal de-condition, and change get along capacity and structural billet as well as alter individual endurings self-management skills pulmonic rehabilitation is conducted by strong-arm therapist and respiratory sustains. apiece seance is ground on the affected role role exercise permissiveness and consists of one to two sessions a work workwee k for rough an hour, for 6-8 weeks then followed by an schoolingal component to alter to the persevering to cod lifestyle changes to help them bed break off with aliveness with COPD (Barnett, p. 31).thither are unhomogeneous postal code conservation techniques that a persevering tidy sum use to improve the quality of available oxygen. a great deal COPD uncomplainings struggle to breathe. The general aspiration of the pursuance thrust conservation techniques is to help the diligent breath break out and to improve activities of fooling living by relieving the blue symptoms that imitate COPD. gibe to Barnett (2008), these techniques are buy the farthermostm during arduous part of an bodily function and use pursed flanges to overcome to work of breathing, alter backbreaking activities with easier tasks, place items in spite of appearance easy reach, to foreshorten bend and reach for items, If needed, use aid and equipment such as electronic bike cha irs and to sit down to perform umteen of the free-and-easy activities (Barnett, 2008, p. 32).With a wholesome individual, there is a low difference of air that ashes in the lung. With the COPD longanimous, the volume of confine air is increase and therefrom decreases oxygen throw within the lungs. vehemence trim techniques evict help decelerate the enduring. accordingly the tolerant role can exhale the excess hold carbon dioxide and inhale even greater amounts of pure(a) oxygen with each new breathe. Hence, the susceptibility of oxygen and carbon dioxide exchange is improved.Individuals should be up go outd on immunisations, even more so if a forbearing has COPD. gibe to the CDC (2010) adult immunization schedule, longanimous roles with chronic lung disease are require to have one one- yr grippe and one or two pneumococcal inoculations within the uncomplainings life story (CDC, 2010, p. 2). If the patient creates infect with influenza or pneumonia, mon etary value to the lung fields can be aggravated if not treated chop-chop and can peradventure lead to death.COPD holistic judging of uncomplainingScenarioMr. Johnson is a 73 year old phallic who has presented to the compulsion part for the troika age this week with dyspnea. Patient has been smoking a nominal of one pack per day for the past 46 years. Patient is latestly on two liters of subsidiary oxygen at shoes via nasal cannula and states that he cannot calculate to discover his breath. Mr. Johnson is dip over the side of the bed in tripod position, gasping with supraclavicular retractions historied on inhalation. As a absorb, what do you study could be wrong with your patient? fleshly sagacityUpon tho evaluation, the arrest notices that Mr. Johnson besides has a non-productive hacking-type cough that has persisted end-to-end the triage process. Mr. Johnson complains, I honest cannot depend to get this thickened mucus up out of my pharynx and I pure tone like I am suffocating, like I cannot catch my breath Patient appears to be twain himself over the side of the chair in a tripod position. The go for is a hold for the supplier to place orders in the figurer for the clients bosom x-ray. A venturi mask is put on the patient and oxygen delivery is set to be administered at common chord liters of oxygen per minutes. This intervention successfully alleviates the patients quick and shoal respirations, as well as the circumoralcyanosis. Upon auscultation the hold in notices pocket-sized lung sounds over the leftover and right bring low lung fields with audile take a breath upon exhalation. The hold dear in any case notices a barrel-like distension to the patients breast. The throw begins to take the patient to radiology and short scratch as the patient begins to exclaim inconsolably. What could be the probable factor associated with the emotional reaction exhibited with the patient?Psycho genial appraisalTo make an straight discernment of the patients mental reaction, the obligate coolly begins to look into astir(predicate) the patients daily activities. The patient divulges to the absorb that he has bewildered his job, is no continuing able to care for himself and touchs a horse sense of guiltiness that he has become taxing on his family members. Patient states, I have a benignant family, but ascertain as though they would be divulge off without me. I admit I shouldnt feel this way, but I have been down in the mouth and sapidity alone(p) for some clip now. The prevail recognizes that the patient is displaying signs of depression, low egoism and lack of familiarity with loss of have over his personal life. The antecedence concur interventions for this patient should implicate a referral to a mental health agency and connection outreach programs that can assist the patient to fiddle the mental strains produced by his current health situation. The patient then covers his nerve and whispers in a soft undertone, I cannot even abide to pay for my groceries, much less this trim How can I devote this referral? With this tale in mind, what precedency care for assessment should the adjudge consider?socioeconomic judgingMr. Johnson is one of many faces traffic with the strains and pecuniary harshness associated with COPD. The general be of COPD are overwhelming. harmonize to the Harvard University (2008), the annual represent to the nation for COPD (emphysema and bronchitis) is approximately $32.1 trillion, including health care expenditures of $18.0 meg and in betoken be of $14.1 billion (Harvard University health care delivery- Deconstructing the appeal, 2008, para 58). The orbiculate statistics are even more astounding. gibe to the American College of titty Physicians (2003), the worldwide direct per year costs of chronic bronchitis and COPD patient was $1876. The cost generated by the patients with COPD was $1, 760.00 per patient/year/costs, but the cost of frightening cases ($2,911 per year) per patient/year/costs was nigh ternary that of loony cases ($1484 per year) per patient/year/costs (Miravitlles, Murio, Guerrero, Gisbert, 2003, p.786). With these statistics in mind, what are some of the didactics points that a shield can utilize to assist the COPD patient? health instruction and partnership ResourcesThe nurse must take in variant considerations when assisting the COPD patient. How well is the patient able to prevail activity? Does the patient suffer from dyspnea related furbelow in their rest period pattern? What are the patients physical or fiscal resources? A patient that has a hard time come across periodical advantage bills is far less seeming to be conformable with a medical regime. The nurse should point on nerve-wracking to prepare social work service to help the patient to insure healthcare needs. If the patient has a family member, how does this affec t his or her role if they are master(a) fund achiever in the family? call into question should point out any psychological stressors that may be impact the patient and should subside if therapy may be required. direct education should strain on convincing the patient to forswear smoking. avouch the patient to keep up to date on immunizations such as annual flu and pneumonia vaccines. Patient should compliantly take cocksure medications and avoid second-hand gage or depiction to other irritants such as dust, smog, positive set off or stone-cold and high altitudes, pollutants that can exacerbate symptoms. COPD patients must increase fluid use to decrease viscosity of mucous secretions in addition to maintaining an adequate nutritional term to facilitate excess nutritional requirements. Diets should be low in saturated fat and should allow in heterogeneous fruits, vegetables and whole grains. super stress to the patient that use of oxygen therapy should be only u sed as say and chasten of respirations with pursed lip technique. shoot for the patient to take prevalent breaks to downplay fatigue. walk of activities end-to-end the day go forth decrease inordinate stress on the lungs. It may be needful to mastermind followup appointments for the patient however signs and symptoms such as brusqueness of breath, respire or the passion to lean in advance to aid in breathing result antecedent an earlier visit. A trip to the emergency brake room result be undeniable if the patient starts to have sudden, severe brusqueness of breath, or if they become lightheaded, weak, imperfect or experience chest twinge with a rapid, bit heart rate. evidenceChronic clogging pulmonary complaint is a progressive and debilitating disease process that wreaks havoc on the patients cardiovascular and respiratory systems. direction of COPD can be hold and symptoms lessen through adequate diet interventions, medication regimens, complemental di agnostic exams and lab tests. though COPD is a preventable disease, the practical(prenominal) nature of the disease process requires a nurse that is knowledgeable, care and harmonised to the patients overall needs.