Lucille's Liver Failure Nursing 480 Visual Report • Brittany Cole • 10.14.2016
Meet Lucille Bluth... Lucille is a 60-year-old Caucasian female who has recently been diagnosed with cirrhosis of the liver. Lucille is married to her husband, George, and has four children, Gob, Michael, Lindsey, and Buster. She also has two grandchildren, George Michael and Maeby. Lucille does not work, she lives in a high-rise condo in Newport Beach, CA with her 33-year-old son, Buster, whom she helps to take care of because of his developmental delays. Her husband is in prison for using the family company, The Bluth Company, for embezzlement and consumer fraud. The rest of the family lives near by, and she sees them everyday.
Lucille has a family history of alcoholism and hypertension. She drinks 5-10 vodka martini’s daily, yet is still very active in her community, the Balboa Yacht Club, and the family business. She attends water aerobics five times a week, and meets with family members daily. Lucille does not show affection towards her family, and is often very critical of them. Lucille is shocked by her diagnosis, and is in denial. She has a PPO through The Bluth Company.
Lucille recently went to the doctor because she noticed that she had become extremely fatigued, gained a lot of weight in a short amount of time, had vomiting/nausea episodes, and had increasingly painful abdominal pain. The physician asked Lucille about her drinking habits, and after running several labs, determined that she has cirrhosis of the liver. Lucille’s family is in the developmental stage of the aging family. Their tasks focus on adjusting to retirement, grandparent roles, and Lucille living alone (Kaakinen et al., 2015).
The Disease: Cirrhosis ➔
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Cirrhosis is the extensive and irreversible scarring of the liver caused by chronic inflammation and necrosis of the liver cells. The most common cause of cirrhosis in the United States is chronic alcoholism. Alcohol toxins have a direct effect on the hepatocytes causing inflammation in the liver. As the liver enlarges, the cells begin to degenerate, the liver becomes more fatty, and begins to scar. As Lucille continues to drink, the liver damage progresses. However, if she were to stop drinking before scarring occurs, the inflammation and fatty infiltration are reversible. As alcohol abuse continues, the scar tissue begins to spread throughout the liver causing cellular necrosis and liver failure. Classic signs and symptoms of cirrhosis are: jaundice, fatigue, significant change in weight, GI symptoms, and abdominal pain. Labs are drawn to assess AST and ALT levels.
(Ignatavicius & Workman, 2016)
(L. Bluth, personal communication, October 10, 2016)
The Family: George Bluth - Her Husband: George is 65-years-old and was recently arrested for using The Bluth Company for embezzlement and consumer fraud. On the day of his arrest, he left the company to his wife, Lucille. She then turned the company over to Michael, who had be working for his father for many years. George is now focused on getting acquitted for his crimes. Gob Bluth - Her Son: Gob is a 37-year-old magician who can’t keep a steady job. Gob is constantly in and out of work and is always trying to get money from The Bluth Company to support his lifestyle. He lives on the family yacht, but often tries to spend the night at Michael’s house because the rest of the family resides there. Michael Bluth - Her Son: Michael is 35-years-old and was recently appointed the CEO of the Bluth Company. Although he is the middle child, he is viewed as the head of the family while George Sr. is in prison. In addition to his work responsibilities, he is raising his son, George-Michael, by himself as his wife died many years ago. Michael is constantly at odds with the rest of his family, because they continue to use The Bluth Company as a personal piggy bank. Lindsay Bluth Funke - Her Daughter: Lindsay is Michael’s twin, and is also 35-years-old. She is married to Tobias Funke and together they have a daughter, Maeby. Lindsay is unemployed, but uses her free time to host and array of charitable events. Lindsay enjoys the finer things in life and often uses the company money to go on shopping sprees.
The Family: Buster Bluth - Her Son: Buster is 33-years-old and still lives at home with his mother because of his developmental delays. While he is well educated in the fields of archeology, cartography, and ancient agrarian business, he still requires assistance with everyday activities, and is overly dependant on his mother. Tobias Funke - Her Son In Law: Tobias is 37-years-old and married to Lindsay Bluth. Tobias recently lost his license to practice as a psychologist after performing CPR on a man who was sleeping and is now an aspiring actor. Tobias has not been able to find a job, which has put additional strain on his relationship with his wife and in-laws. In lieu of a job, Tobias has grown accustom to using The Bluth Company as a source of money. George Michael Bluth - Her Grandson: George Michael is the 15-year-old son of Michael Bluth. George Michael is shy and socially awkward, but receives outstanding grades in school. He recently starting dating his classmate, Ann, which has helped boost his confidence. George Michael loves his family despite their flaws and would do anything any family member asked of him. George Michael was recently promoted to manager of the family owned banana stand. Maeby Funke - Her Granddaughter: Maeby is a 15-year-old rebel. She loves to break the rules and push the limits. While she does not receive good grades in school, her charming personality allowed her to con her way into a job editing movie scripts at Universal Studios, unbeknownst to her family.
Bluth Family Culture “Culture refers to the behaviors and beliefs that characterize a particular group of people, society, or nation” (Denham et al., 2015, p. 143). The Bluth family values wealth, fashion, how they are perceived by others, social status, and where the live. Their love of money drove them to use the profits from the Bluth Company as their personal piggy bank so they could continue to (L. Bluth, personal communication, October 10, 2016) appear wealthy, when in fact they were broke. The family is very judgemental amongst themselves and toward others. They place an emphasis on looking perfect 100% of the time. Lucille is notorious for calling out any imperfections in family members. Lucille refuses to do any chores and views herself as being above performing physical labor. Instead, she pays a housekeeper who she treats with little respect. This attitude of superiority (G. Bluth, personal communication, was passed down to both Lindsay and Gob, but Michael is willing to work hard for success. October 10, 2016) The Bluth family values their membership to the Balboa Yacht Club, especially Lucille, who feels her social status will be lost if she is not an active, participating member, making weekly appearances. The family’s cultural values prove challenging when coping with Lucille’s new diagnosis. (L. Bluth, personal communication, October 10, 2016)
Bluth Family Religion “Religion generally refers to an organized system of beliefs and practices shared by a group. The shared values and beliefs center on a divine entity� (Denham et al., 2015, p. 417). Most members of the Bluth family do not prescribe to a religion, and consider themselves atheists. They do not attend church, or believe in any divine entities. While in prision, George Bluth experimented with converting to Judaism as a source of coping, but after being threatened by other inmates, gave up his search for a higher power. George Michael Bluth recently began dating Ann, who is a devout Christian. George Michael has begun to attend church, Bible studies, and prayer meetings with Ann, and is using his new found faith to cope with his grandfather being in prison, and his grandmother's new diagnosis. George Michael does not try to convert his family members, and is well received by his family. Lucille is also an atheist. She is currently in denial about her diagnosis and sees no need to believe in a divine power. Instead, she continues to use alcohol to cope. The rest of the family are still processing the new diagnosis, and are using one another to cope and processes their feelings about their mother’s diagnosis. (M. Funke, personal communication, October 10, 2016)
Strengths: ➔ ➔ ➔
Unconditional family support Open communication between family members The family has a history of staging interventions to help one another
Challenges: ➔ ➔ ➔ ➔ ➔ ➔ ➔ ➔
No community support No friends outside the family for support The family is in the public eye Financial instability Unwilling to make financial sacrifices to cover medical bills Lucille does not want to stop drinking despite her diagnosis The family is very judgemental of each other, which could make coping more difficult The entire family struggles with addiction
Communication: The Bluth family has an aggressive style of communication. Aggressive communicators, “express their feelings and opinions and advocate for their needs in a way that violates the rights of others. Thus, aggressive communicators are verbally abusive” (University of Kentucky, n.d.). This type of communication is detrimental, especially when coping with a new diagnosis of cirrhosis. Lucille’s comments about her disease tend to criticize, blame, or attack others, and she does not listen well to what her family member have to say about her drinking habits. If this pattern of communication continues, Lucille could end up becoming isolated from her family (University of Kentucky, n.d.). The Bluth family also uses a lot of nonverbal communication through eye contact and facial gestures. However, in their own way, these forms of nonverbal communication show love. The family does not hug, kiss, or show any physical affection.
(L. Bluth, personal communication, October 10, 2016)
Chronic Illness Theoretical Framework & The Bluth’s: The chronic illness framework is a multifaceted approach for assessing a family dealing with chronic illness. This framework has three parts to it; the illness type, the time phases of the illness, and family functioning within the confines of the illness. Within the illness type, the nurse should assess the onset of the disease - was acute? Chronic? Etc. The nurse should also assess the predicted course of the disease and how the family member will be incapacitated. Within the time phases, the nurse should assess how the family responds with day-to-day management, and long term management. Finally, the nurse should determine the family strengths and vulnerabilities, and any extra demands the diagnosis will put on the family to help them cope (Kaakinen et al., 2015). When applying this framework to Lucille’s new diagnosis of cirrhosis we find the following: ➔ Illness type: Cirrhosis ◆ Progressive Chronic: In this stage, the Bluth’s must make gradual changes in their roles to adapt to Lucille’s new diagnosis. The Bluth’s will most likely experience fatigue as the disease progresses, and Lucille requires more medical attention. Additionally, they may experience exhaustion from Lucille’s unwillingness to change her drinking habits. ➔ TIme Phases of Cirrhosis ◆ The family is in the initial/crisis time phase as they have just learned of Lucille’s Diagnosis. In this phase, the family is experiencing extreme stress and should Focus on building relationships with the medical staff, and learning more information about the disease. However, most importantly, the family (especially Lucille) should begin to accept the diagnosis and the impending lifestyle change. ➔ Family Functioning ◆ Each family member should be assessed individually to see how their role(s) are being affected. With George in prison, Lucille is the head of the household. However, Michael has begun to take on these leadership roles after being appointed CEO of The Bluth Company. With Lucille’s illness, he will continue to lead the family, and will experience added the stress of making the family financially stable as Lucille’s Medical bills put further strain on the family. Lucille will feel a loss of control as she has been the “go-between” between Michael and George Sr.. Lengthy hospital stays and alcohol rehabilitation will decrease the amount of time she spends with her family. Additionally, she is currently in denial, placing more strain of the family to encourage her to seek help for her drinking problem.
Based on the findings from the Chronic Illness Framework assessment, it is clear that the Lucille is struggling with accepting her diagnosis. Additionally, the family is undergoing fatigue from the extreme stress of the new diagnosis. Finally, the Bluth’s do not have any community resources to help them with these drastic changes. Facilitate Acceptance/Rehabilitation
ID Family Stressors & Ways to Cope
Provide Community Resources
Studies have shown that, “alcoholic liver disease patients experience a struggle to preserve their identity as a significant individual” (Mikkelsen et al., 2015). The role of the nurse in this situation is trifold: to strengthen the patient's identity by acknowledging their struggles, worries, and fears, to help the patient maintain self-control by providing community resources to assist them with their daily struggle, and to be a safety net for the patient in case they relapse or begin to struggle with acceptance and sobriety. Nurses should approach care with a sympathetic attitude, and act proactively when the patient begins to withdraw from alcohol (Mikkelsen et al., 2015).
Caregiver involvement has been shown to improve patient outcomes. However, “informal caregiving has also been shown to cause significant economic and health burdens for the caregivers” (Rakoski et al., 2011). As a nurse, it is important to recognize the increased burden the patient will be on the family. The nurse should identify family stressors by asking each member, “in the last few weeks, what problems have you experienced, or do you see as most significant” (Mikkelsen et al., 2015)? The nurse should then ask the family member to appraise the problem using a variety of questions (what information do you have? What resources do you need? etc.). Finally, the nurse should ask the family member what they believe needs to happen to deal with the problem (Mikkelsen et al., 2015). The nurse should allow ample time for each family member to answer, and use the information to help the family cope as a unit as they adapt to their new roles.
Some of the main barriers to controlling chronic disease are lack of support for self management and lack of family support causing failure to adhere to treatment (CDC, 2015). To break down these barriers, the nurse should provide informal counseling and social support, advocate for individuals and communities, educate the patient about available community resources, help the patient navigate the healthcare system to reduce stress, create community-clinical linkages to help create a comprehensive team to care for the patient, assess how well the patient is self-managing the disease, and support individual, family, and community goal setting by the patient and their family (CDC, 2015).
Nursing Interventions
References CDC. (2015). Addressing chronic disease through community health workers: A policy and systems level approach. Retrieved from http://www.cdc.gov/dhdsp/docs/chw_brief.pdf Denham, S., Eggenberger, S., Young, P. & Krumwiede, N. (2015) Family-Focused nursing care. F.A.Davis: Philadelphia, PA. Ignatavicius, D. D., Workman, M. L., Blair, M., Rebar, C. R., & Winkelman, C. (2016). Medical-surgical nursing: Patient-centered collaborative care (8th ed.). Elsevier: Saint Louis, MO. Kaakinen, J., Duff-Gedaly, V., Hanson, S. & Coelho, D. (2015) Family health Care nursing: Theory, practice and research (5th ed.). F.A. Davis: Philadelphia, PA. Mikkelsen, M. R., Hendriksen, C., Schiødt, F. V., & Rydahl-Hansen, S. (2015, October). Coping and rehabilitation in alcoholic liver disease patients after hepatic encephalopathy - in interaction with professionals and relatives. Journal of Clinical Nursing, 24(23-24), 3627-3637. doi:10.1111/jocn.13006 Rakoski, M. O., Mccammon, R. J., Piette, J. D., Iwashyna, T. J., Marrero, J. A., Lok, A. S., Volk, M. L. (2011, December). Burden of cirrhosis on older Americans and their families: Analysis of the health and retirement study. Hepatology, 55(1), 184-191. doi:10.1002/hep.24616 University of Kentucky. (n.d.). The four basic styles of communication. Retrieved from https://www.uky.edu/hr/sites/www.uky.edu.hr/files/wellness/images/Conf14_FourCommStyles.pdf
Images (In order of appearance) (Untitled image of the Bluth Family). Retrieved from: http://www.bluthfamily.com/images/bluthfamily.jpg (Untitled image of Lucille Bluth). Retrieved from: http://vignette4.wikia.nocookie.net/arresteddevelopment/images/8/88/S4_Lucille_(01).jpg/revision/latest?cb=20130502032638 (Untitled image of Liver). Retrieved from: http://www.mayoclinic.org/~/media/kcms/gbs/patient%20consumer/images/2013/11/15/17/37/an00758_%20ds00097_%20ds00373_%20ds0039 8_%20ds00411_%20ds00455_%20ds00785_%20my00349_im00967_r7_normcirrhosisthu_jpg.jpg (Untitled image of Lucille Bluth). Retrieved from: http://www.oystermag.com/sites/default/files/imagecache/article-image-650x580/images/enhanced-buzz-21337-1288122815-21.jpg (Untitled image of George Bluth). Retrieved from: http://media.tumblr.com/0ecc791c7c4a906bb0dd55cf27552968/tumblr_inline_mo8s3d7fDY1qz4rgp.jpg (Untitled image of Gob Bluth). Retrieved from: https://i.ytimg.com/vi/4m5VrMWRBbw/maxresdefault.jpg (Untitled image of Michael Bluth). Retrieved from: http://www.animaatjes.nl/films-en-series/series/arrested-development/animaatjes-arrested-development-2639152.jpg (Untitled image of Lindsay Bluth). Retrieved from: http://watchesinmovies.info/img/f2/arrested-portia.jpg (Untitled image of Buster Bluth). Retrieved from: http://www.billboard.com/files/media/arrested-development-buster-650-430.jpg
(Untitled image of Tobias Funke)). Retrieved from: http://vignette2.wikia.nocookie.net/arresteddevelopment/images/a/ab/Arrested-development_(6).jpg/revision/latest?cb=20130521213519 (Untitled image of George Michael Bluth). Retrieved from: http://vignette2.wikia.nocookie.net/arresteddevelopment/images/1/1f/1x10_Pier_Pressure_(31).png/revision/latest?cb=20120229061138 (Untitled image of Maeby Funke). Retrieved from: https://img.buzzfeed.com/buzzfeed-static/static/2016-05/29/13/asset/buzzfeed-prod-web07/sub-buzz-12340-1464543011-1.jpg (Untitled image of Lucille Bluth). Retrieved from: https://uproxx.files.wordpress.com/2015/09/belt-buckle.png?w=650 (Untitled image of Lucille Bluth). Retrieved from: http://67.media.tumblr.com/tumblr_ldggc68svd1qefwl8o1_500.png (Untitled image of Gob Bluth). Retrieved from: http://media-cache-ec0.pinimg.com/236x/57/8f/7e/578f7e919acb436e85213dc521f6b5ab.jpg (Untitled image of Maeby Funke and Michael Bluth). Retrieved from: https://img.buzzfeed.com/buzzfeed-static/static/2015-08/10/10/enhanced/webdr08/enhanced-1596-1439218308-9.jpg (Untitled image of George Bluth). Retrieved from: http://vignette2.wikia.nocookie.net/arresteddevelopment/images/f/f1/1x09_Storming_the_Castle_(25).png/revision/latest?cb=20120219184146 (Untitled image of Lucille Bluth). Retrieved from: http://66.media.tumblr.com/521011b2d0c244be604a1afea8c3c01f/tumblr_mnn0oxdvv21qcm16uo1_500.jpg
(Untitled image of Lucille Bluth). Retrieved from: http://vignette3.wikia.nocookie.net/arresteddevelo pment/images/7/7a/3x11_Family_Ties_(10).png/rev ision/latest?cb=20130323215833 (Untitled image of Lucille Bluth and Michael Bluth). Retrieved from: https://s-media-cache-ak0.pinimg.com/236x/81/14 /ed/8114ed28f83b03ae018c1a18dc8dda2e.jpg (Untitled image of the Bluth Family). Retrieved from: http://assets.bwbx.io/images/users/iqjWHBFdfxIU/ iN_b7YqSduXY/v1/-1x-1.jpg (Untitled image of the Bluth Family). Retrieved from: http://www.dvd.net.au/movies/a/11443-1.jpg