Effect of an ERAS protocol and laparoscopic surgery on patient safety

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Evidence Based Practice and Applied Nursing Research


Evidence Table


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Zhu, Y., Xiang, J., Liu, W., Cao, Q., & Zhou, W. (2018). Laparoscopy Combined with Enhanced Recovery Pathway in Ileocecal Resection for Crohn’s Disease: A Randomized Study.

Gastroenterology Research & Practice

, 1–7.


https://doi.org/10.1155/2018/9648674


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The purpose of this article is to study the use of minimally invasive laparoscopic surgery coupled with an ERAS protocol and its effect on patient safety and short-term postoperative outcomes in patients with Crohn’s disease undergoing elective ileocecal resection (Zhu, 2018).


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The author cites 23 articles that show the benefits of a laparoscopic versus open approach for colon resection as well as the benefits of using an ERAS protocol versus conventional perioperative care. In spite of the wealth of information available regarding the benefits of the laparoscopic surgical approach over open and the use of the ERAS protocol over conventional care, the researchers found that there was little evidence regarding the use of laparoscopy coupled with ERAS in the treatment of Crohn’s disease (Zhu, 2018).


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This is a quantitative study that consists of a controlled, randomized single-blind trial. A consecutive cohort of 32 patients between the ages of 14 and 70 with histologically confirmed Crohn’s disease isolated to the terminal ileum or ileum and cecum were included. The study participants were randomized into 2 groups: both groups would undergo laparoscopic surgery, but one group would receive conventional perioperative care and the other would receive ERAS. The participants were blinded to which group they were sorted (Zhu, 2018).


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The researchers prospectively recorded preoperative, operative, and postoperative data for all patients in both groups including age, BMI, sex, ASA score, length of surgery and complications, preoperative therapy type, compliance, length of stay, morbidity, mortality, hospital costs, and readmission. The intention to treat principle was used to analyze the data obtained, which was then presented as interquartile ranges and medians or means +/- standard deviation. Chi-squared tests were used to compare data and the Mann-Whitney

U

test for abnormal distribution. The independent sample

t

-test was used for data with normal distribution (Zhu, 2018).


Researcher’s Conclusion

The researchers concluded that using the ERAS protocol in conjunction with minimally invasive laparoscopic surgery for patients with Crohn’s disease requiring ileocectomy was safe and effective, and that patients had fewer complications, faster return of bowel function, and shorter hospital lengths of stay (Zhu, 2018).


Quantitative Researcher’s Conclusions

The researcher’s goal in conducting this study was to see if laparoscopic surgery in conjunction with using an ERAS protocol was safe, practicable, and beneficial in improving patient outcomes. The literature cited many studies comparing different surgical techniques and perioperative care, but very little information existed on laparoscopy coupled with ERAS and its outcomes. The study methodology and data analysis techniques used were consistent with our reading in Chapter 6. The evidence and data gathered in this study supports the researchers’ conclusion that laparoscopic surgery in combination with ERAS protocol is safe, effective, and improves patient postoperative outcomes (Zhu, 2018).


Quantitative: Protection and Considerations

This study was conducted under the guidelines of the Declaration of Helsinki and approved by the medical ethics review board at SRRSH hospital, Zhejiang University. All study participants were provided written informed consent. The study was registered with the government at ClinicalTrials.gov (Zhu, 2018).


Quantitative: Strengths and Limitations

The strength of this study is that it is a randomized, controlled trial that uses an internet randomization module to sort the study participants. The weaknesses are that it is single-blind as opposed to double-blind, and that the sample size is somewhat small. It is also limited in that it is the first study of its kind, performed at a single institution and limited to a patient population with a particular medical condition.


Quantitative: Evidence Application

The results of this study can inform nursing practice by further reinforcing the benefits of using the ERAS perioperative protocol in conjunction with laparoscopic surgical techniques to improve patient outcomes, reduce costs, and shorten in-hospital length of stay. As a perioperative/PACU nurse I have seen this protocol becoming a standard for elective colorectal surgeries in the last few years, and reading this study helped me to understand why it is becoming more popular for the surgeons to use. Using the ERAS protocol is labor intensive for the nursing staff, but it is gratifying to understand what the end goal of the therapy is and to see hard evidence that it really does work.


Evidence Table


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Qualitative



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Chang, Y.-L., & Tsai, Y.-F. (2017). Research paper: Early illness experiences related to unexpected heart surgery: A qualitative descriptive study

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Australian Critical Care

, 30, 279–285.


https://doi.org/10.1016/j.aucc.2016.11.005


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Many studies exist evaluating patients post discharge after undergoing emergency heart surgery, but very few have been conducted to study patient experiences after transferring out of ICU but prior to discharge. The purpose of this study is to gather information regarding patient’s experiences during this time period of early recovery from emergency heart surgery (Chang, 2017).


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The author cites 44 reference articles covering topics ranging from emergency heart surgery and recovery afterwards to communication techniques, rehabilitation, depression, nightmares, memory loss, and the conducting of qualitative research as well as many others. Most of the studies conducted on patients post emergency heart surgery focused on how they were doing 8-18 months after discharge, and there were very few regarding the psychological impact of this life changing event (Chang, 2017).


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The study was conducted under a qualitative descriptive design, meaning there was no control exerted over their behaviors and these were simply documented. 13 participants who underwent emergency cardiac surgery at a hospital in northern Taiwan were included in the study. The participants were over age 20 without cognitive issues who had had emergency heart surgery, an ICU stay of at least 3 days, had been on the surgical ward for at least 6 days, and were due to be discharged within 3 days. The patients were interviewed by a communications-trained cardiovascular nurse practitioner. The transcripts of the interviews were kept confidential by being assigned a number (Chang, 2017).


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The conversations were transcribed word-for-word and qualitative content analysis was used to find common experiences in the interviews. The authors read, analyzed and discussed all interviews to reach a consensus on what the common themes were. All data was then translated from Mandarin to English by the first author, and the translated data was then reviewed by a bilingual expert in qualitative research (Chang, 2017).


Researcher’s Conclusion

The researchers concluded that interdisciplinary care and education should be provided early in the recovery period. They also concluded that good family relationships, inclusion of religious beliefs, and a strong relationship with their health care professionals were the biggest motivating factors to adapt healthy lifestyle changes that would improve their length and quality of life (Chang, 2017). They also stress the importance of effective management of pain and delirium, minimizing sedation to reduce ICU psychosis and PTSD, and promoting normal sleep patterns (Chang, 2017).


Qualitative Researcher’s Conclusions

The conclusion reached by the authors was reasonable. Based on the interviews conducted, they were able to identify 5 common themes experienced by patients who had undergone emergency cardiac surgery; 1) sudden serious symptoms, 2) nightmares, 3) pain/sleep disturbances/depression/shock/uncertainty about the future/wishing they would die, 4) starting a new life, and 5) adopting a new lifestyle. Subsequent research led them to the conclusion that early interdisciplinary education with family support, including religious values, and support from their medical providers would help exponentially in their recovery process (Chang, 2017).


Qualitative: Protection and Considerations

This study was approved by the Institutional Review Board. All participants received written informed consent including the purpose of the study, the procedures included, and their rights and responsibilities. The transcripts of the conducted interviews were kept confidential by excluding patient names and assigning each interview a number (Chang, 2017).


Qualitative: Strengths and Limitations

The strengths of this study include the triangulation of information sources using observation and interview, the creation of an audit trail, and membser checking. The interviews were halted once data saturation had occurred. The limitations of the study were that it was conducted in a single hospital in north Taiwan. This hospital may have different protocols than other hospitals and may not be representative of the country as a whole. There are also cultural considerations, given that the patient experiences in the study are from an Eastern perspective and may not be generalizable to Western culture and values (Chang, 2017).


Qualitative: Evidence Application

In spite of the cultural differences emphasized by the researchers, it seems reasonable that the experiences reported by the study participants would also be experienced by people of Western cultures, and that the support systems recommended would also apply. This study would inform nursing practice by emphasizing the importance of early education, pain control, minimizing delirium and sedation, promoting normal sleep patterns, including family/religious support systems, and developing a strong partnership with health care providers to promote the adaptation of healthy lifestyle changes that would increase length and quality of life for patients undergoing emergency cardiac surgery (Chang, 2017).


References:

  • Chang, Y.-L., & Tsai, Y.-F. (2017). Research paper: Early illness experiences related to unexpected heart surgery: A qualitative descriptive study

    .




    Australian Critical Care

    , 30, 279–285.

    https://doi.org/10.1016/j.aucc.2016.11.005


  • Zhu, Y., Xiang, J., Liu, W., Cao, Q., & Zhou, W. (2018). Laparoscopy Combined with Enhanced Recovery Pathway in Ileocecal Resection for Crohn’s Disease: A Randomized Study.

    Gastroenterology Research & Practice

    , 1–7.

    https://doi.org/10.1155/2018/9648674


What Is Public Health Health

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Wanless (2004, p.27 [online]) defines public health as “the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, communities and individuals”. From this definition we can establish that the main focus of public health is to reduce health inequalities with the key concepts being to protect the public from transmissible diseases, improving service provision and to promote the health of the population (Naidoo and Wills, 2005, p.8). Health promotion and public health are intricately linked as the idea behind health promotion is to encourage individuals to have greater control over the decisions that affect their overall health.

Health is a difficult term to define as people have different perceptions of what being healthy means and it is linked to the way people live their lives. The most common definition of health was set by the World Health Organisation (WHO) in 1948, which suggests that health is a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2003 [online]). This definition suggests that health is the achievement and maintenance of physical fitness and mental stability however, each individual is unique so the term ‘health’ varies from person to person and can therefore be a number of ideas that people have in their minds at different times of their lives (Pearson, 2002, p.45).

Discuss the following key concepts in public health:

Health inequalities


The particular challenges that clients living in poverty face in relation to improving their health.

Health inequalities can be described as the variation in the health status or the ‘health gap’ between the socio-economic classes. Evidence suggests that there is a link between health and wealth, where people in the upper socio-economic classes have more chance of avoiding illness and living longer than those in the lower socio-economic classes and as a result, mortality rates are greater for the lower social classes than for the higher social classes (Marmot, 2010, p.16 [online] ; Acheson, 1998 [online]). Mortality rates are a useful indicator when assessing health inequalities because of its sensitivity to social conditions and even though the life expectancy years of individuals have increased, the life expectancy gap between the social classes has continued to exist (Marmot, 2010, p.45 [online]). The contributing factors to this life expectancy gap includes issues such as poor diet, obesity,

smoking

and higher drug and alcohol consumption (Marmot, 2010, p.37 [online]) and despite the reduction measures previously taken, this ‘health gap’ between the wealthiest and the poorest continues to increase (Triggle, 2010 [online]).

Access to health care services have also been reported as uneven (Acheson, 1998 [online]) however, an individual’s health can be adversely affected by more factors than just the availability of healthcare and these other factors include gender, ethnic groups, religion, age, geographical location, residential deprivation, education, occupation and economic conditions (Marmot, 2010, p.39 [online]). Many of these factors can independently affect health however, those in the lower socio-economic classes tend to be disadvantaged by most, if not all, of them and the combination of these factors can lead to a significantly higher health burden for those who are living in poverty (DoH, 2010, p.15).

Poverty is when individuals, families and groups do not have the income needed for the minimum standard of living and poverty can be measured as relative or absolute (Alcock, 2006, p.64). Relative poverty is when the income received is less than the average income for the country, where access to goods and services are limited compared to the rest of society and absolute poverty is where the level of income is below the required amount to afford a decent living or be able to sustain human life and as a result, only the bare minimum levels of food, clothing and shelter can be afforded (Alcock, 2006, p.64). Without sufficient money, people are less able to provide themselves and their families with adequate housing, nutrition, clothing and heating. People who live in poverty are also less likely to have the means to travel to specialist clinics and hospitals which may mean that they are less likely to attend appointments or take advantage of health screening opportunities (Kozier, 2008, p.133).

Identify a contemporary public health issue and describe its health consequences.

Obesity is a term which is used to describe a condition where an individual is carrying excess body fat (WHO, 2011 [online]). It is a complex modern health problem facing society today which has both personal and economic consequences. In the UK alone the economic cost of obesity prevention, management and its consequences such as, premature death and employment absence is estimated at up to £4.2billion per annum and is continuing to rise (DoH, 2010, p.20). As such, obesity prevention has become a public health priority, with significant focus being given to childhood obesity (DoH, 2008, p.27).

Children who are obese are likely to suffer both short term and long term adverse health effects, such as increased blood pressure and hyperlipidaemia (NOF, 2011 [online]). They are also at greater risk of developing diabetes, coronary heart disease or even metabolic syndrome prematurely (WHO, 2011 [online]) and as a result, they tend to have a shorter life expectancy (DoH, 2008, p.2). Obese and overweight children also have a tendency to suffer poor psychosocial health and are therefore particularly susceptible to emotional stress, stigmatisation, discrimination and prejudice (NOF, 2011 [online]), which also increases the chances of children suffering with low self-esteem, depression and eating disorders (BMA, 2005, p.8 [online]). One of the biggest concerns of childhood obesity is that it is likely to continue on into adulthood (Coleman, 2007, p.71).

Select a health promotion model and discuss how it applies to your chosen public health issue.

The prevention of obesity is easier than the treatment and prevention relies heavily on education, therefore for this issue the education model will be used. The aim of this approach is to give information to ensure that each individual has the knowledge and a basic understanding about obesity, which allows the individuals to make informed choices about their own lifestyles (Ewles and Simnett, 2003, p.44). A good example of this approach is the school health education programmes, which not only increases the child’s knowledge but also helps the child to the learn skills of healthy living (Ewles and Simnett, 2003, p.44).

Educational programmes could also be targeted at the parents and could involve the promotion of breastfeeding, the delaying of weaning onto solid foods to infants and building an awareness of the types of foods that are available within home. Parental education could also focus around building the self-esteem of the child and an understanding of how to address the child’s psychological issues. Education in early childhood could also include information about healthy diets, workshops (which could include food tasting) and physical activity (NICE, 2006, p.75 [online]).

Identify public health strategies relating to this public health issue at the following levels:

Local

National and Global

The rise in obesity combined with the increased public awareness has prompted new public health initiatives. The white paper ‘Healthy weight, healthy lives’, in conjunction with the National Institute for Clinical Excellence (NICE) guidance, sets out guidelines for action on obesity (DoH, 2008 ; NICE, 2006 [online]). Policies and strategies were introduced following the recommendations outlined in these papers and were developed with the main focus being to assist in the prevention and management of obesity and to encourage healthy eating and physical activity (NICE, 2006 [online]). These strategies include school based educational and physical activity programmes and public health messages through the media such as, television, radio, poster campaigns and leaflet distribution.

Local authorities have developed strategies which tackle obesity from a local level. A great example of a local initiative within the northeast is Medal Motion, which encourages children to walk or cycle to school whilst also working towards preventing obesity (Local Motion, 2011 [online]). Each locality has different needs and local strategies that are in place have been developed in conjunction with government initiatives and influenced by national policy such as, healthy schools.

National interventions include the five a day scheme which encourages people to eat more fruit and vegetables, extended from this is the school fruit and vegetable scheme which helps increase the child’s awareness of the importance of eating fruit and vegetables (NHS, 2011 [online]). Change4life is another example of a nationwide initiative which was launched to improve children’s diets, increase their physical activity and which, in turn, improves their chances of living longer, healthier lives (NHS Northeast, 2011 [online]). The national child measurement programme is a national strategy which requires school nurses to weigh and measure all four to five year olds and ten to eleven year olds annually, this monitors prevalence and evaluates obesity reduction strategies (DoH, 2011 [online]). Other national initiatives include Sure Start, school sports programmes, simplified food package labelling and the regulation of television advertising on children’s channels.

The WHO has launched a major consultation into the diet-related disease and stated that their global strategy would focus on diet, physical activity and health (WHO, 2004 [online]). This global preventative strategy includes reducing the child’s energy intake and improving their intake of nutritional foods, increasing physical activity and reducing time spent in sedentary behaviour, such as watching television (WHO, 2004 [online]). The WHO developed a framework and implementation toolkit which is used to monitor and evaluate their ‘Global Strategy on Diet, Physical Activity and Health’ (WHO, 2008 [online]). Following on from this framework, the WHO called on governments to take action against food marketing to children and to regulate marketing messages that promote unhealthy dietary practices (WHO, 2007, p.9 [online]).

Give an example of how nurses can improve health for this issue

The recent white paper called ‘Healthy Lives, Healthy People’ (DoH, 2010) sets out guidelines for healthcare professionals to support individuals to make their own decisions and choices about their health. Nurses can optimise their role by offering health promotion to individuals who seek help and support in relation to obesity, whilst acting as an advocate for healthy lifestyles and ensuring the clinical environment supports and encourages children to make healthy choices. Healthcare professionals, especially school nurses, are ideally placed to identify if a child is overweight and screening, parental support and health promotion activities should be routinely addressed where possible. Children and families should be offered support to manage weight sensibly, by discussing small incremental changes in family behaviours, and by making any necessary referrals for specialist investigation, psychological help or specific dietician advice (NICE, 2006, p.49 [online]).

It is vitally important that the nurse possesses the necessary skills and adequate knowledge on healthy eating in order to educate children and their families (NICE, 2006, p.44 & p.101 [online]). Additionally, the necessary resources should be readily available such as advice leaflets, to pass on to parents to aid in the communication and teaching process. Evidence suggests that when talking to children and families about obesity and food behaviours, that problem-solving techniques can have some success (Ewles, 2005, p.95) and as such, nurses can interpret when and where eating patterns become an issue and can therefore offer advice and guidance on how to manage in difficult situations (NICE, 2006, p.148 [online]).

Why do people find it difficult to engage in health improvement interventions?

A number of factors can inhibit access to healthcare such as language, age, attitudes to healthcare, disabled access, financial barriers and geographical location (Kozier, 2008, p.133). A geographical barrier can be that some patients may have to travel long distances for certain services or to receive specific treatments. The travel costs for these services may be relatively high and access to transport may also be limited. There is also the issue of the ‘postcode lottery’ of healthcare services where some treatments are only available in certain parts of the country and not in others, such as the ‘Herceptin postcode lottery’ (Kozier, 2008, p.133).

Cost also affects most individuals as some services are not free, such as dental treatment and eye tests and some individuals also have to pay prescription charges which can lead to illnesses being left untreated, as some people afford to pay for their prescriptions. Additionally, due to limited income, some individuals may not have access to the internet and therefore may not be able to access certain services such as ‘Choose and Book’, which is primarily an internet based appointment booking service. Other issues that can inhibit access to healthcare include the cost of health insurance, lack of knowledge and awareness and lack of a support network.

literature review on Change Management in as it relates to a given health information system and/or technology

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literature review on Change Management in as it relates to a given health information system and/or technology

According to HIMSS (2010) Change Management is defined as a “structured process designed to deal directly and intentionally with the human factors involved in not just planning and implementing an EMR but through behavior change, achieving the anticipated benefits that justified the project in the first place” (pg. 3). The change management champion (leader) is ultimately responsible for navigating and guiding a team, department or entire organization through change (from start to finish). The noted paradigm shift of the U.S. health care industry and particularly, the HIM profession, change management is a useful tool/process to facilitate the numerous HIM environmental changes (i.e. technology, landscape, job responsibilities/titles).

The final product is a eight (8) to ten (10) page APA formatted, literature review on Change Management in as it relates to a given health information system and/or technology of choice.. The literature MUST include the following:

Title Page
Table of Contents
Abstract (150-250 words)
Introduction to Change Management (1-2 pages)
Body (5-6 pages)
Change Management Related Theories/Theorist
Change Management deployed in health information systems and technologies
Barriers to Change (Also identify solutions to the identified barriers)
Implementing Change
Conclusion (2 pages)
References (a minimum of seven (7) peer-reviewed references)
8-10 pages (excludes the title page, table of contents, references and appendices)
Avoid writing in first person
Typed; Double-spaced; 12 font Arial or Time New Roman font
Spelling and grammar error free
Sixth Edition APA-format

Discuss the historical perspective of the time when each policy was discussed or implemented. Indicate the context or the problem of the day and the urgency for the policy. Analyze the social, economic, and political environments for the times the policies were discussed or implemented.

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Discuss the historical perspective of the time when each policy was discussed or implemented. Indicate the context or the problem of the day and the urgency for the policy. Analyze the social, economic, and political environments for the times the policies were discussed or implemented.

 

Pick two (2) similar federal policies that were discussed over a span of two (2) different administrations. For example, President Clintons and Obamas healthcare policies or Presidents George H.W. Bushs and George W. Bushs foreign policy.Write a 34 page paper in which you Discuss the historical perspective of the time when each policy was discussed or implemented. Indicate the context or the problem of the day and the urgency for the policy. Analyze the social, economic, and political environments for the times the policies were discussed or implemented. Critique each policy for its effectiveness of the time. Use four to five (45) credible and reputable sources to support your points.Your assignment must Be typed, double spaced, using Times New Roman font (size 12), with oneinch margins on all sides, citations and references must follow Aor schoolspecific format. Check with your professor for any additional instructions. Include a cover page containing the tile of the assignment, the students name, the professors name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.The specific course learning outcomes associated with tassignment are Analyze how historical trends and conditions have affected social, political, and management theories, and how they have influenced the evolution of public administration in theory and practice. Interpret what public policy is and how it is created. Explain how environmental factors (structural, political, economic, demographic) influence the development of public policy. Use technology and information resources to research issues and in politics, policy, and ethics in the public sector. Write clearly and concisely about policy for issues in politics, policy, and ethics in the public sector using proper writing mechanics.

What policies and procedures should be used by the MCOs to reduce costs for their clientele?

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What policies and procedures should be used by the MCOs to reduce costs for their clientele?

Paper , Order, or Assignment Requirements

To support your work, use your course and text readings and also use outside sources. As in all assignments, cite your sources in your work and provide references for the citations in APA format.
Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Complete your participation for this assignment by Wednesday, June 22, 2016.
MCOs
You are a new physician setting up your own practice in a new town. You are researching the different MCOs offered in your area and are considering becoming a physician for one of these networks. You have also invited the sales representatives of several health plans to speak with you about the benefits of choosing their plans.
Based on the above scenario, answer the following questions:
• What effects would joining a MCO have on your clinic regarding staffing, patient volume, and financial stability?
• What policies and procedures should be used by the MCOs to reduce costs for their clientele?
• Discuss the ethical issues or concerns about MCOs providing a lower quality of care compared to traditional fee-for-service (FFS) organizations?
• What are some of the questions you would ask each representative about his or her company’s specific plan that will help you make a decision?
• Do you believe that the evolution of MCOs and consumer driven health plans (CDHPs) has affected the healthcare environment today by integrating the financing and delivery of healthcare services? If yes, how?
• How have the roles and relationships between physicians and patients changed by each of these types of plans?

Preventative Measures for Teenage Pregnancy

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What is your narrowed



topic



? Be detailed in your answer. You can use any of the versions you’ve developed for prior assignments.

The narrowed topic of my research paper is preventative measures for teenage pregnancy. The two preventative measures for teenage pregnancy that I have an argument for are an increase in good parenting practices and expansion of sex education in public schools.


Who is your primary



audience



or reader?



Why



? Be detailed in your answer about your audience.

My first primary audience is parents because they need to know how an increase in good parenting practices can prevent teens from becoming pregnant, and what good parenting practices they can execute to become a preventative measure.

My second primary audience is public school administrators and teachers because they need to know how an expansion of sex education in public schools can prevent teens from becoming pregnant, and what elements they need to include in the program to make it a preventative measure.

My third primary audience is adolescents because they need to know how to take advantage of good parenting practices and sex education in public schools in order to make these preventative measures for teenage pregnancy.


In a sentence or short paragraph, what is your



thesis statement



, including your angle? Write what will appear in your essay.

My point is that an increase in good parenting practices and an expansion of sex education in public schools can be effective preventative measures to reduce instances of teenage pregnancy. Parents can be primary sex educators for children, and public schools can be secondary sex educators for children to reinforce the primary sex educators. More instances of teen pregnancy are occurring because children are not receiving the knowledge they need about sex from parents and/or public schools.


What topic sentences will you use as the foundation of your communication? (If necessary, add more points.)

  • Teenage pregnancy is a social issue that is closely linked to other social issues—poverty and income, health issues, and education.
  • Adolescents can become educated on the subject of sex and the consequences of teenage pregnancy.
  • Parents can become primary sex educators for their children.
  • Public school administrators and teachers can become secondary sex educators to reinforce the primary sex educators.


What



method of organization and development



will you use to develop your paragraphs


?


  • Introduction:
  • “Three in ten girls will be pregnant at least once before their 20

    th

    birthday” (National Conference of State Legislatures, 2014). Will one of those three girls be your daughter, your girlfriend, your son’s girlfriend, a student at your school, or will it be you? This would not have to be a worry if society would help change that statistic. There are preventative measures that can be provided to adolescents, so we can avoid the social issue of teenage pregnancy.

Teenage pregnancy is a social issue that is closely linked to other social issues—poverty and income, health issues, and education. The problem has a significant impact on society as a whole. So, what if society could help reduce this issue from occurring? An increase in good parenting practices and an expansion of sex education in public schools can be effective preventative measures to reduce instances of teenage pregnancy. If children receive more knowledge about sex from parents and/or public schools, society will start to see fewer instances of teenage pregnancy, therefore making teenage pregnancy less of a social issue.

Teenage birth rates were higher prior to 1980. According to the U.S. Department of Health & Human Services (2013), “Teen birth rates in the United States have declined almost continuously since the early 1990s.” There are still instances of teenage pregnancy that can be prevented in today’s world. Adolescents, parents, and public school administrators and teachers all have their part in preventing teenage pregnancy.


  • Body:

    • Teenage pregnancy is a social issue that is closely linked to other social issues—poverty and income, health issues, and education. Teen mothers face financial problems and most likely have to rely on public assistance. The baby can face health issues at birth and later in its life. Teen mothers rarely finish high school and hardly ever get a degree from college.
    • Adolescents can become educated on the subject of sex and the consequences of teenage pregnancy. Teenage pregnancy affects the mother, baby, and others related to the situation. Teens need to take advantage of good parenting and sex education in public schools.
    • Parents can become primary sex educators for their children. They need to have open and clear communication with their children about sex and relationship decisions. Parents need to include their expectations for their child’s sexual behavior.
    • Public school administrators and teachers can become secondary sex educators to reinforce the primary sex educators. They need to include sex education classes in the school curriculum. Children can learn about safe sex and the consequences of unsafe sex.

  • Conclusion:

    • I will state the importance of my claim by stating main points differently than I did in the paper. I will use a dramatic closing that relates to the opening of the paper to hit on the audiences’ emotions and relevance to the topic. I will close with a memorable and logic statement that will keep the readers thinking about what actions they should take after reading the paper.

Preventative Measures for Teenage Pregnancy

“Three in ten girls will be pregnant at least once before their 20

th

birthday” (National Conference of State Legislatures, 2014). Will one of those three girls be your daughter, your girlfriend, your son’s girlfriend, a student at your school, or will it be you? This would not have to be a worry if society would help change that statistic. There are preventative measures that can be provided to adolescents, so we can avoid the social issue of teenage pregnancy.

Not only has teenage pregnancy occurred many times in my hometown, but I have witnessed close friends and family members go through it as well. I have observed the consequences they face on a daily basis, the impact it has on their future, and the effects it has had on their baby. I am not an expert on the topic of teenage pregnancy, so I have included ideas from the National Conference of State Legislatures, Swierzewski, and the U.S. Department of Health & Human Services.

Teenage pregnancy is a social issue that is closely linked to other social issues—poverty and income, health issues, and education. The problem has a significant impact on society as a whole. So, what if society could help reduce this issue from occurring? Adolescents can become educated on the subject of sex and the consequences of teenage pregnancy by listening to their parents and taking sex education classes.

Parents can become primary sex educators for their children by communicating with them about sex and relationship decisions. Public school administrators and teachers can become secondary sex educators to reinforce the primary sex educators by including sex education in the school curriculum. An increase in good parenting practices and an expansion of sex education in public schools can be effective preventative measures to reduce instances of teenage pregnancy.

Good parenting practices will help children learn appropriate sexual behavior, and children will have more clear communication about life decisions with their parents. An expansion of sex education in public schools will help children learn the specifics about safe sex and the consequences about unsafe sex. If children receive more knowledge about sex from parents and/or public schools, society will start to see fewer instances of teenage pregnancy, therefore making teenage pregnancy less of a social issue.

Teenage birth rates were higher prior to 1980. According to the U.S. Department of Health & Human Services (2013), “Teen birth rates in the United States have declined almost continuously since the early 1990s.” “Teen pregnancy has declined 42 percent, and the teen birth rate is down 52 percent” (National Conference of State Legislatures, 2014). Even though research is showing teenage pregnancy instances are declining, “Just over 305,000 babies were born to teen girls in 2012” (U.S. Department of Health & Human Services, 2013).

There are still instances of teenage pregnancy that can be prevented in today’s world. Adolescents, parents, and public school administrators and teachers all have their part in preventing teenage pregnancy, but we will first address the adolescent’s part. If an adolescent is not open to learning from his or her parents or teachers, then he or she is more likely to face the consequences of teenage pregnancy.

Teenage pregnancy affects the lives of the mother, the baby, and others related to the situation. According to the U.S. Department of Health & Human Services (2013), “Teen mothers are less likely to finish high school, more likely to rely on public assistance, more likely to be poor as adults, and more likely to have children who have poorer educational, behavioral, and health outcomes over the course of their lives than do kids born to older parents.” “Only 40 percent of teen mothers finish high school” (National Conference of State Legislatures, 2014). Many teen mothers lose their support system or give up on their goals because they see them as impossible to reach.

Babies born to teen mothers face challenges and sometimes even more than the mother. Many teenage mothers are more likely to give birth to babies with low birthweight. “Low-birthweight babies are more likely to have organs that are not fully developed, which can result in complications, such as bleeding in the brain, respiratory system disorders, and intestinal problems” (Swierzewski, 2011).

Figure 1: Teenage Mother Waits for Her Premature Baby

Premature Baby - Masterfile Image


Figure 1:

This teenage mother is waiting to see if her premature baby made it after birth. Giving birth to premature babies is another risk of teenage pregnancy that can emotionally affect the mother and lead to health risks for the baby. Source: Swierzewski (2011).

As shown in Figure 1, teenage pregnancy causes emotional stress on the teen mother, but the child is at risk for stress later on in its life as well. “Children born to teenage mothers are at an increased risk for abuse and neglect” (Swierzewski, 2011). “Boys born to teen mothers are 13 percent more likely to be incarcerated, and girls are 22 percent more likely to become teenage mothers themselves later in their lives” (Swierzewski, 2011).

It is just as important for male adolescents to be knowledgeable about sex and teenage pregnancy consequences as it is for female adolescents. “An estimated nine percent—or 900,000—of young men between the ages of 12 and 16 will become fathers before their 20

th

birthday” (U.S. Department of Health & Human Services, 2013). Now, adolescents have to decide how they will help prevent instances of teenage pregnancy from occurring.

“The only certain way to avoid unwanted pregnancies is to abstain from sexual intercourse” (U.S. Department of Health & Human Services, 2013). However, adolescents should be open and honest when communicating about sex to their parents and/or teachers. Adolescents should ask specific questions and request specific answers. They should make sure they are listening to the good parenting practices of their parents and take advantage of sex education classes in school. If the school does not offer sex education classes, approach an administrator or teacher to ask if classes can be an option for the school.

References

National Conference of State Legislatures. (2014, January 22).

Teen Pregnancy Prevention

. Retrieved from

http://www.ncsl.org/research/health/teen-pregnancy-prevention.aspx

Swierzewski, S. J., III. (2011, December 9). Teen Pregnancy.

Remedy’s HealthCommunities.com

. Retrieved from

http://www.healthcommunities.com/teen-pregnancy/children/overview-of-teen-pregnancy.shtml

U.S. Department of Health & Human Services. (2013, December 20). Teen Pregnancy and Childbearing.

Office of Adolescent Health

. Retrieved from

http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/teen-pregnancy/index.html#.UufzeaHnbIU

Essay on Periodontal Disease

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This is definition of my topic: “Periodontal disease is defined as an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with increased probing depth formation, recession, or both” (Aguirre, Newman, & Takei, 2015, p. 50-51). To further explain what periodontal disease might look like in a clinical setting, imagine red/purple swollen gums, which are usually tender to the touch and bleed when probed, as well as some recession (bone loss) contributing to tooth mobility, and in really severe cases, puss (from infection). It is important to understand that this disease does not occur overnight, but actually over years of unhealthy habits.  The following is a small summary of  different stages leading to periodontal disease from the microbiologist perspective of Bauman & Primm (2018):

Hard deposits of called

tartar

or

dental calculus

form when calcium salts mineralize plaque. Tartar trapped at the base of the teeth trigger the initial form of periodontal disease —gingivitis. Swelling of the gums, plaque, and tartar can also form oxygen-free pockets that become colonized by anaerobic bacteria, such as

Porphyromonas gingivalis

, compounding the infection and producing a condition called

periodontitis

.

P. gingivalis

produces five protein-digesting enzymes that break down gingival tissue. Further destruction occurs as bacteria invade the bone, causing osteomyelitis (inflammation of the bone marrow and bone), and teeth become loose and fall out (pg. 713).

This disease progresses slowly over many years, but the initial signs and symptoms to clinically show would be red, swollen, tender, bleeding gingiva also known as gingivitis. Gingivitis is caused by a multiple of microorganisms making your mouth their home to thrive in. Bacteria can grow and survive in many different environments, but the human mouth is especially good for bacteria because it is continuously moistened with saliva, nutrients pass through as food, and can be very hard to keep clean. Not to mention, there may be some behavioral factors of the host that aid the survival of microorganisms such as stress or smoking. We make it very comfortable for hundreds of species of bacteria to thrive, especially at the cemento-enamel junction (CEJ) which is where the crown of the tooth meets the roots.

The best survival technique used by these bacteria is their creation of what it called a biofilm (can also be referred to as slime layer). Here is a short microbiological description, from Bauman & Primm (2018), of how a dental plaque biofilm is formed:

Plaque formation usually begins with colonization of the teeth by

Streptococcus mutans

. This bacterium breaks down carbohydrates, particularly the disaccharide sucrose (table sugar), to provide itself with nutrition and a glycocalyx. One of its enzymes catabolizes into its component monosaccharides – glucose and fructose – which the cells use as energy sources. A second enzyme polymerizes glucose into long, insoluble polysaccharide strands called

glucan

molecules, which form a sticky matrix around the bacteria. Glucan adheres

S. mutans

to the tooth, provides a home for other species of oral bacteria, and traps food particles. A biofilm has formed (p. 169).

At this point, normal brushing and flossing are not strong enough to remove the biofilm that has been created. Seeing a dental hygienist for a teeth cleaning is very important because he/she can manually scrape away this plaque build-up. As mentioned earlier in the description of progression, the biofilm allows for air-tight pockets to form, and if untreated, introduces a new irreversible threat: potential infection and bone loss.

The bacteria are now attached to the teeth and are growing, unscathed by normal brushing and flossing. The host body immune system takes on the fight by sending the blood into the tissues to deliver polymorphonuclear leukocytes (neutrophils), lymphocytes, and plasma cells (Aguirre et all., 2015, p. 220). Unfortunately, the body’s defensive mechanisms are no match for the defensive system of the bacterias’ biofilm but instead can be harmful to the host’s own tissues. “More recently, it was established that the host’s immunoinflammatory response to the initial and persistent bacterial attack unleashes mechanisms that lead to collagen and bone destruction” (Aguirre et all, 2015, p. 279). As the body’s immune system gets involved to try and fight off the bacteria, in turn the tissues and bone surrounding the bacteria is being destroyed. Gingivitis becomes more apparent clinically showing the signs such as gums that bleed when touched, inflammation, and the most prevalent is the formation of pockets around the teeth.

At this stage, if seen by a dentist, periodontal probing depths might be moderate, in the 5-7 range where as normal measurement would be 2-4. A periodontal probing measures the pocket depths around the teeth (specifically from the cemento-enamel junction of the crown, in millimeters deep) to determine how much tissue attachment has been lost and level to which the bone has dropped (caused by both the bacteria and the host’s immune response). Any measurements 8mm+ are in late stage periodontal disease and have major tooth mobility with high risk for extraction. Like any other bone in our body, when in use (relative example: mastication) normal body processes are for osteoclasts to destroy bone and osteoblasts to replace with new bone. Once teeth are mobile enough for extraction, that bone level will dramatically drop because it is no longer “being used”.

Radiographs are a major tool in diagnosing the level of bone loss a person has from periodontal disease. If bone loss is seen on the radiographs, this is a sign that the periodontal disease is past its initial stage (which can only be detected clinically) (Aguirre et all., 2015, p. 379). Bite-wing radiographs capture the crown of the teeth as well as the level of bone. Periapical radiographs capture the apex of the roots in search of any infection which would present itself as a dark, circular shadow surrounding the apex. The level of bone loss cannot be measured from radiographs alone because it can be geometrically inaccurate (for example: 2-D images can have overlap). Since periodontal disease is managed over years, it is helpful to take x-rays yearly to track any progression of bone loss.

A study was done called

Influence of pH on inhibition of Streptococcus mutans by Streptococcus oligofermentans

proving that

Streptococcus oligofermentans

can kill

Streptococcus mutans

by converting the lactic acid (made by the

Streptococcus mutans

) into hydrogen peroxide (Liu et all., 2014).

There is a specialized field of study for dentist’s who are interested in continued education to become a Periodontist. Periodontal disease is not exactly curable, but instead maintained over a lifetime.

Analytical Perspective

Statistics on how many people in the united states have the disease. What age group is it most associated with?

What are the main causes of the disease? Any specific promotions of disease causing agents?

Treatment/Solution: Cost in treating the disease? What procedures are covered by insurance?

“Gingivitis occurs frequently in many people and to varying degrees over the course of one’s lifetime, though it usually first appears during puberty and early adulthood. If not treated, it leads to recurrent gingivitis or periodontal disease, which occurs in about 47% of adults ages 30 to 65 in the United States and in over 70% of people over age 65” (Bauman & Primm, 2018, p. 713).


References:

6-3 discussion: confidence intervals | Statistics homework help

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6-3 Discussion: Confidence Intervals

Previous Next

The B&K Real Estate Company sells homes and is currently serving the Southeast region. It has recently expanded to cover the Northeast states. The B&K realtors are excited to now cover the entire East Coast and are working to prepare their southern agents to expand their reach to the Northeast.

B&K has hired your company to analyze the Northeast home listing prices in order to give information to their agents about the mean listing price at 95% confidence. Your company offers two analysis packages: one based on a sample size of 100 listings, and another based on a sample size of 1,000 listings. Because there is an additional cost for data collection, your company charges more for the package with 1,000 listings than for the package with 100 listings.

Sample size of 100 listings:

95% confidence interval for the mean of the Northeast house listing price has a margin of error of $25,000

Cost for service to B&K: $2,000

Sample size of 1,000 listings:

95% confidence interval for the mean of the Northeast house listing price has a margin of error of $5,000

Cost for service to B&K: $10,000

The B&K management team does not understand the tradeoff between confidence level, sample size, and margin of error. B&K would like you to come back with your recommendation of the sample size that would provide the sales agents with the best understanding of northeast home prices at the lowest cost for service to B&K.

In other words, which option is preferable?

Spending more on data collection and having a smaller margin of error

Spending less on data collection and having a larger margin of error

Choosing an option somewhere in the middle

For your initial post:

Formulate a recommendation and write a confidence statement in the context of this scenario. For the purposes of writing your confidence statement, assume the sample mean house listing price is $310,000 for both packages. “I am [#] % confident the true mean . . . [in context].”

Explain the factors that went into your recommendation, including a discussion of the margin of error

For your response posts to your peers, choose two different confidence intervals for your responses. Do you think the agents would prefer a different confidence interval than their management? What advantages and disadvantages would there be in having different confidence intervals for the agents? Explain your thought process and reasoning in your response.

Teenage Pregnancy Adverse Reproductive Outcomes Health And Social Care Essay

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Teenage pregnancy is a critical public health issue in both the developing and developed world. It has been thought to have an intrinsic effect on the infant and maternal morbidity and mortality statistics worldwide. In its publication, the State of the World’s Children report, UNICEF stated that worldwide over 500,00 women of all age groups die yearly and 70000 females aged 15-19 years would die during child birth [1] . Currently, evidence of ‘causal’ hypothesis is conflicting and inconclusive as to whether adverse outcomes are the result of immaturity of the reproductive system or attributable to other socio-demographic characteristics of adolescents .A study demonstrated that majority of pregnant adolescents had no source of income and lacked health insurance [2] .Teenagers were also found to be more likely to be single, less educated and receive or attend insufficient antenatal care when compared with older mothers [3-5] .

Fraser et al conducted a large population-based study which showed that pregnancy in adolescence was associated with an inherently increased risk for obstetric and neonatal outcomes [6] .However, some other studies demonstrated a lack of association attributing the outcome to social factors.

This article aims to review, critically appraise, and synthesise evidence from original publications of observational studies on the relationship between teenage pregnancy and adverse reproductive outcomes. It focuses mainly on prematurity, low birth weight and route of delivery as there are a myriad of adverse birth outcomes-maternal: preeclampsia, anaemia, premature rupture of membranes (PROM), perineal tears, instrumental delivery, caesarean delivery and infant-related complications: prematurity, low birth weight, intrauterine growth restriction, small for gestational age, perinatal morbidity- attributable to teenage pregnancy and there is strict limitation on the article word count.

Methodology: literature search and selection of studies

A literature search on teenage pregnancy and adverse reproductive outcomes of primary studies published in the last 10 years was carried out .Included studies were journal articles published in the English language-this limitation confers some degree of bias to the review. Epidemiological evidence for this review is defined as observational studies- cross-sectional surveys, case-control studies, retrospective cohort studies and prospective cohort studies.

Database searching of Medline (U.S. National Library of Medicine, Bethesda, Maryland) and Embase (Elsevier) was conducted using the following keyword phrases and related terms as search terms – teenage pregnancy or pregnancies, adolescent pregnancy or pregnancies and pregnancy outcome, adverse reproductive outcomes and related terms(refer appendix 1).

The Medline search yielded 110 articles but reviewing the abstracts showed only few of the studies met the inclusion criteria or were readily available online or in print. A similar search conducted on the Embase database yielded less promising results. Additional journal articles were located by reviewing cited references and citation tracking of some of the selected studies. The related article or similar article feature of some journals was used to identify similar studies and their abstracts were reviewed to check if they met the selection criteria. Case studies, case reports, editorials, and reviews were excluded from the search.

Selection criteria

To be included in this review, the selected studies had to meet the following criteria:

-teenage pregnancy is defined as pregnancy in young women under 20 years

-women above 35 years old were either excluded from or treated as an independent category in the study as they are known to have high obstetric risks

-must demonstrate some statistical description and /or analysis of confounding variables in the association between teenage pregnancy and adverse reproductive outcomes

-should have some comparative element in which teenagers are compared with a suitable reference category

-outcome measures include at least two of the following: prematurity preterm delivery, Caesarean section (CS), low birth weight (LBW), infant mortality, neonatal mortality, perinatal mortality, maternal mortality, severe anaemia, preeclampsia and eclampsia

-a significance assessment can be made either by using p-values or confidence intervals

Table 1:Characteristics of selected studies

Authors Publication year(Study period) Setting Study design Sample size Age of teenage subjects(years) Outcome measures of interest Confounding variables considered Other study characteristics Ekwo and Moawad [3] 2000(1989-1995) U.S.A Hospital based retrospective cohort 6,072 3 groups-=15,16-17,18-19

20-24 as reference group Preterm birth, low birth weight Maternal smoking, drug abuse, insurance status, adequacy of prenatal care, median family income, marital status Primaparous black women , singleton pregnancies Bukulmez et al [7] 2000(1990-1998) Turkey Hospital-based matched case-control study 4,470(2,490 cases,3980 controls) Cases:15-19 controls:20-34 stratified during analysis as =17,18-19,20-34 Low birth weight, preterm delivery, pregnancy induced hypertension(preeclampsia, eclampsia),LBW, Antenatal care, gravidity, parity, Singleton pregnancies, subjects matched on marital status, socioeconomic class and ethnicity-white married women of high social status Jolly et al [4] 2000(1988-1997) United Kingdom Hospital based retrospective cohort 341,708 <18,18-34 as reference group Preeclampsia, anaemia, emergency caesarean delivery, preterm delivery, Body mass index, race ,parity , hypertension at booking, pre-existing diabetes, gestational diabetes, smoking Singleton pregnancy Smith and Pell [8] 2001(1992-1998) Scotland Population based retrospective cohort studies 110,233 15-19,20-29 as reference group Stillbirths, neonatal deaths, preterm delivery,

emergency caesarean section, and small for

gestational age Maternal height, maternal weight ,social deprivation Non-smoking mothers, stratified by parity(first and second births) Chen et al [9] 2007(1995-2000) U.S.A Population-based retrospective cohort 3,886,364 <16,17-18,18-19,20-24 as reference category Very preterm delivery, preterm delivery, very LBW,LBW,SGA, Very low APGAR score, low APGAR score Maternal race, age-appropriate educational level, smoking in pregnancy, alcohol use in pregnancy, marital status, prenatal care utilisation Prematurity, very LBW,LBW,IUGR,5min, APGAR score, early neonatal death ,foetal death Igwegwe and Udigwe [10] 20019June 1995-November 2007) Nigeria Hospital based retrospective cohort 58 >20,20-24 Preterm delivery, low birth weight ,preeclampsia, caesarean delivery, APGAR score parity,

occupation, social class, marital status, booking for prenatal care , pregnancy complications, route of delivery Women of the Igbo ethnic group Kongnyuy [5] 2007(November 2004-April 2005) Cameroon Multi-centre cross-sectional questionnaire survey 1,100 = 19,20-29 Low birth weight, prematurity, neonatal deaths, preeclampsia, eclampsia, perineal tears, caesarean delivery Gravidity, frequency of antenatal visits, marital status ,employment status, educational level Primaparas, singleton pregnancy,

Results

Teenage pregnancy and preterm deliveries

Prematurity is said to be the most significant predictor of perinatal mortality [4] . Some of the reviewed studies found an association between teenage pregnancy and prematurity. Jolly et al found that adolescents were about 40 per cent more likely to have very preterm babies i.e. infants less than 32 completed weeks of gestation (OR= 1.41;955 CI=1.02-1.90) [4] .A large hospital-based study conducted using representative data from all 50 states of the U.S and the District of Columbia demonstrated a significantly increased risk of very preterm and preterm infants(infants born at less than 37 completed weeks of gestation) in teenagers when compared with the older women [9] . One cross-sectional evidence also showed the teenage pregnancy was significantly associated with premature births (adjusted OR= 1.77; CI= 1.24-2.52)[5].One study however found that 35ð7% teenagers in the study had preterm birth while the control group had none at all[10]. This may however be due to lack of statistical power to detect any in the control as the small sample size was small, due to inadequately kept hospital records, and there was no adjustment for confounding by other risk factors measured.

Some studies however did not report an increased risk in teenage mothers. One study found no significant difference in preterm births between teenage and older mothers after adjusting for covariates. A reviewed hospital-based study set in Turkey also had similar findings(OR=0.72;95% CI=0.23-2.33;p-value=0.22) [7] . The population-based Scottish study furthermore demonstrated that teenagers having their first babies were significantly at no increased risk for having very preterm infants(OR=1.1; CI=0.9-1.4) [8] .

Teenage pregnancy and birth weight

In one study,31ð4% babies of teenagers and 6ð7% (2) of the older age group had low birth weight (p-value= <0.05) .Another evidence found an independent relationship of teenagers having LBW infants (OR= 1.71; 95%CI=1.15-2.50)[5].A large study demonstrated similar results with adolescent mothers being at a significantly increased risk for both very LBW infants-overall result for 10-19 years group (RR=1.17; 95 % CI=1.14-1.20) and LBW infants [10-15 years (Relative risk(RR)=1.61;95% CI=1,41-1.84),16-17years(RR=1.42;95 % CI=1.35-1.50),18-19(RR=1.17;95% CI=1.13-1.21) and overall for teenage mothers (RR=1.24; 95% CI=1.20-1.27)- when compared with mothers aged 20-29 years[9].

Bukulmez et al did not find an independent association(adjusted OR=2.09;95% CI=0.68-1.64) [7] .The study conducted at a Cameroonian hospital similarly did not demonstrate any significantly increased trend in having LBW infants with decreasing maternal age but mothers in the 16-17 group in the study were more likely to have lighter infants [3] .

Teenage pregnancy and pregnancy induced hypertension

One reviewed evidence found a highly significant increased association between pre-eclampsia (OR=1.99; 95 %CI, 1.24-3.15; p-value=0.004) eclampsia (OR, 3.18; CI, 1.21-8.32; p-value=0.016) [5].The study conducted in Nigeria failed to detect any significantly difference significant in the development of preeclampsia and eclampsia in teenage mothers and older controls. However, another study showed that teenagers were not significantly at risk after adjusting for significant confounders.

Teenage pregnancy and risk of having a caesarean section

Regarding the route of delivery, most studies have shown that there was no significant difference between teenagers and older women[10]. Evidence from the teaching hospital in Nigeria found that there was no statistically significant difference between teenagers and the older age group groups with most teenagers having normal delivery. Caesarean section rates not significantly dif from older women (OR=1.29; 95 % CI=0.80-2.04; p-value=0.295).The Scottish study also reported similar findings showing that teenagers were significantly not at increased risk of having an emergency caesarean section at first delivery adolescents being less likely to have a caesarean (OR= 0.5;CI=0.5-0.6)[8].

Discussion

Study design issues

Cross-sectional studies lack the ability to establish causal relations and also rare outcomes of teenage pregnancy such as intrauterine foetal deaths cannot be studied using this design. In the case-control studies, recall bias pose a validity problem. Longitudinal studies represent a better level of evidence for establishing temporal relationships. The retrospective design of most of the studies allows for data on many outcomes to be readily available and eliminates attrition from loss to follow-up. In reality, the final statistical analysis in these studies is usually cross-sectional using appropriate tests of significance depending on outcome.

However, the prospective design in which carefully planned data can be collected in other to account for all possible confounders of interest in analysis is expensive, time-consuming, and recruiting teenage participants may prove difficult. Ethical consideration of expectation of adverse outcomes is also an issue. Randomised trials, though having a higher level of evidence, would be most suitable in assessing interventions thought to reduce the risk of adverse outcomes such as prenatal care.

Sample size issues and the role of chance

Though most of the studies used a large sample size [4, 9] by increasing their overall statistical power through matching with more controls, the real determinant of an effect is the number of subjects having a particular outcome [7] .A small sample size may yield imprecise results. Only the study carried out in Cameroon included a power calculation in justifying the sample size used [5] .

Data collection issues and the role of chance (random error)

The reviewed cross-sectional study was carried out using questionnaire-based survey with demographic data obtained from obstetric case record and outcome measures recorded after delivery for which the mode of administration was not well explained [5] .The mode of administration, wording of questionnaires and the level of expertise of the interviewer all have an impact of the results. The response rate also affects the validity of the study.

Birth weight measurement using infant weighing scales is also prone to some degree of random error. Sphygmomanometers used in blood pressure measurements also have similar issues.

Definition of study subjects

Most of the reviewed studies considered teenagers as women below 20 years of age; however the UK study [4] defined teenagers as women less than 18 years. A difference in definition across studies makes it difficult to generalise findings.

Selection of study subjects

Selection bias is a particular important issue in longitudinal studies. Most of the studies assessing this hypothesis are retrospective cohort studies and selection of subjects is crucial to validity. A number of studies are hospital-based and unless a well-defined geographical area is served, selection of suitable controls would be a problem and the findings may not be generalisable to the wider population of teenagers.

Definition and measurement of covariates and outcomes

Some of the studies used pre-existing hospital record which reduce the time and expensive required to conduct the study but is highly prone to missing data .Some studies had validated obstetric databases [4] to ensure some degree of data quality while this is uncertain in others. This can introduction selection bias if the data is excluded from the analysis as there may be some systematic difference in outcome and confounders between those included in the final analysis and those accounted for.

The differing birth weight results from the studies might just be inaccurate findings as weighing instruments are highly prone damage from shock and measurement bias. None of the studies described how the birth weight measurements were taken and it was not ascertained if steps were taken to ensure that the infant weighing scales were properly calibrated before use.

A variety of methods was used in assessing the gestational age of infants. One study [3] used either or all of last normal menstrual period, first trimester ultrasound and abdominal assessment for estimating gestational age. Physical examination methods are highly prone to error and may lead to misclassification bias of gestational age in some studies. It is however the most commonly used method in low-resource settings and can miss multiple gestations especially in overweight or obese women. Early ultrasound estimates have however been found to consistently biased towards lower gestational age estimates when compared with dating by last normal menstrual period [11] .

Adequacy of prenatal natal is defined in one study as defined by as more the four clinic visits [5] .This was a subjective definition. Referral filter bias can be a problem in hospital-based studies in which women seen in tertiary or specialist centres may be systematically different from those seen at community health centres and smaller clinics [12] .Studies in which specialist centre records were used are prone to this .

Confounding

Most studies testing the hypothesis between pregnancy in adolescence and its inherent risk for adverse outcomes are longitudinal studies allowing for assessing multiple exposures and multiple outcomes and hence adjusting for a priori and potential confounders. The studies vary greatly in the number and range of confounders considered and some confounders were found to be significant in some studies but not in others.

Bukulmez et al controlled for confounders by matching and restricting the study to white married women of higher social class and stratifying the study population by age in the final analyses but educational status an important potential confounder was not adjusted for [7] .The study conducted in the United Kingdom considered the effect of sexually transmitted infections -bacterial vaginosis specifically- on prematurity [4] but did not control for social class ,an a priori confounder, in the final adjusted model [4] .Complete elimination of the all cofounders is virtually impossible in all studies and results are subject to the effect of residual confounding.

Statistical analyses

Most of the reviewed studies used appropriate analysis methods-Chi square tests, Fischer’s exact test, student’s t-test depending on the outcome of interest and the sample size. Stratification and logistic regression modelling was used for adjusting for confounders but the studies differed in what confounders were just as being most appropriate in the final adjusted model. Studies however differed greatly in their choice of analysis and the reporting of results hence limiting direct comparison.

Conclusion

Evidence linking the biological aspect of teenage pregnancy with adverse birth outcomes is inconsistent and contradictory. This inconsistency in the direction, strength and significance of associations and may be due to the degree of adjustment for confounding [13] ,the sample size and statistical power of the studies, different inclusion and exclusion criteria and to uneven distribution of the socio-demographic characteristics of the studied population. Irrespective of whether the adverse outcomes are the result of reproductive or poor social conditions, teenage pregnancy is a global public health problem at which continued interventions are required. Policy makers worldwide should therefore continue to direct attentions to effective intervention that have impact on reducing teenage pregnancy rates.

Chronic Urinary Tract Infections Treatment Case Nursing Essay

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RP, a 72-year-old Caucasian female, was brought to the emergency room (E.R) from Hillcrest Adult Foster Care via ambulance. Preadmission report to F-300 stated that she came to E.R confused, lethargic and weak, complaining of acute pain upon urination. She also urinated small amounts (< 50 ml) multiple times per hour, without the feeling of completely empting her bladder. Urine sample was obtained using a straight catheter and sent to the laboratory along with a blood sample.

Upon arrival to F-300 RP’s labs revealed significantly lowered thyroid stimulation hormone (TSH), a lowered red blood cell (RBC) count, along with decreased hemoglobin and hematocrit (H&H). Her white blood (WBC) count was elevated, as expected with a urinary tract infection (UTI).

Primary Diagnosis and Priority Secondary diagnosis

The primary medical diagnosis was chronic urinary tract infections, with a secondary diagnosis of hypothyroidism.

Patient History

RP has a history of chronic UTI’s, hypothyroidism, chronic kidney disease (stage III), and chronic anemia. She has several admissions the past few months related mainly to UTI’s and dehydration.

PATHOPHYSIOLOGY/ETILOGY OF THE PRIMARY DIAGNOSIS AND PRIORITY

SECONDARY DIAGNOSIS

UTI’s are the results of infection, mainly from bacteria, fungi, viruses, or parasites. This leads to a condition referred to as cystitis (inflammation of the bladder). Most common of the UTI’s are from infection known as infectious cystitis. A bacterium, the most common cause of infectious cystitis, is from the external urethra, this spreads inwards to the bladder (distal to proximal). Once a bacterium migrates to the bladder and starts the process of growing, it can migrate to other parts of the body (Ignatavicius & Workman, 2006).

UTI’s present with symptoms that include frequency, urgency, retention, burning, foul odor, and incontinence.

According to Wikipedia, four stages must be met in order for bacteria to grow. These include an infectious agent, one that must be able to grow, multiply and enter the body. Once we have the agent, the bacteria must find a portal of entry, (how it enters the body). Once in the body it needs an adequate reservoir, a place where organisms can thrive and multiply and the susceptibility of host, how bacteria affects the body after entry. Determents include age, overall health and other co-morbidities of the host and the susceptibility to pathogens.

Most UTIs first grow in the perineal area due to irritation; in RP’s case this may have been caused by lack of personal hygiene due to being overly fatigued, brought on by her hypothyroidism.

Minton (2009) stated, “Thyroid is the most important hormone in the body. Because it stimulates the production of cellular energy, production of all other hormones will be negatively impacted when thyroid hormone levels are less than optimal. Every aspect of health is affected by low thyroid function. Hypothyroidism is signaled by fatigue and loss of energy”.

According to textbook, hypothyroidism is the result of decreased metabolism from low levels of thyroid hormones (THs). Low levels of THs may be a result of several different reasons: thyroid cells may fail to produce sufficient amounts, or the cells themselves are damaged. The patient may not be ingesting enough of the substances needed to make THs, especially iodide and tyrosine.

Low levels of THs affect most tissue and organs causing decreased cellular energy. The patient could become confused, lethargic, and have slowing of intellectual functions.

ACTUAL OR POTENTIAL IMPACT OF RELEVANT MEDICAL HISTORY ON THE PRIMARY DIAGNOSIS AND PRIORITY SECONDARY DIAGNOSIS

RP has a history of chronic UTI’s that has caused numerous admits to the hospital over the last few months. UTI’s that are left untreated may and can cause damage to the kidneys and start the process of renal failure. Chronic infection of the kidneys causes scar tissue, which decreases the function of the renal system. With renal failure, the body cannot rid itself of certain toxins that may contribute to UTI’s. Chronic UTI’s may lead to chronic pyelonephritis, repeated upper tract infection of bacteria that migrates from the bladder superior (toward the kidney) to the kidneys. RP’s diagnosis of chronic renal failure may be heightened by the chronic UTI’s.

Hypothyroidism and anemia, that cause fatigue and loss of energy, will discourage you from providing adequate hygiene. This encourages bacterial growth, which may start the chain of events leading up to a UTI.

RP resides at an extended care facility that may not have adequate staff to assure that she receives the necessary amounts of iodide and tyrosine needed stimulate TH production. She is also very confused which would decrease her understanding of the importance of proper nutritional intake.

MEDICAL MANAGEMENT: CHRONIC URINARY TRACT INFECTIONS And Hypothyroidism

A urine sample must be obtained either by a clean catch method or if client unable, by straight catheter method. A catheter method was used on RP, due to her confusion and retention.

Urinalysis testing for leukocyte esterase (n=negative) and nitrate (n=none), along with a WBC (n= 0-4) are specifically for diagnosis of a UTI’s (Mosby’s 2006). Normal urine should appear clear with a yellow tint present (Mosby’s 2006). A noticeable smell should not be present in uninfected urine; RP’s urine had a pungent odor noted. RP’s leukocyte esterase was 3+ and her nitrate was positive. WBC’s were to numerous to count. These results determined that RP did have a UTI.

Blood work was noted that RP’s thyroid stimulating hormone (TSH) was 0.05 (n=2-10). This confirmed the diagnosis of hypothyroidism.

NURSING MANAGEMENT: URINARY TRACT INFECTION

Recommended textbook intervention is to monitor for signs of UTI’s. This includes, but not limited to: frequency, urgency, dysuria, incontinence, pyuria. In some older adults the only sign may be an increase in mental confusion or frequent, unexplained falls.

RP was on Q-4 hour vital sign assessment, paying close attention to any increase in temperature and/or heart rate. The patient remained afebrile throughout admission. Heart rate remained between 80-90 beats per minute. Respiratory rate remained between 16-20 breaths per minute.

Due to her confusion, bed alarms and padded side rails were used. She had a high fall risk assessment; therefore fall risk precautions were implemented upon admission.

She was placed on strict intake and output (I&O), and her fluids were monitored. She was instructed to drink required amount of fluid per day (1500ml). Staff member offered bedside commode every two hours to encouraging voiding. She and family members were informed as to the importance of RP to remain dry. This will limit the environmental factors needed for bacterial growth. RN (preceptor) communicated with adult foster care on the needs of the client after discharge. Lab results were also monitored closely for any change that would indicate worsening infection.

PHARMACOLOGICAL MANAGEMENT: URINARY TRACT INFECTION AND HYPOTHYROIDISM

Textbook recommends medications that treat bacteria and the promotion of client comfort. Cure is dependent on the antibiotic level achieved in the urine. Long-term antibiotic therapy is recommended for chronic UTI’s (Ignatavicius & Workman, 2006).

RP received, via intravenous therapy (IV), Azactam (antibiotic) per Dr. order, to treat her infection. Paroxetine mesylate (antianxiety agent, antidepressant) 30 mg by mouth daily, used to decrease anxiety. Also given Levothyroxine (hormone) as a thyroid supplement.

PROVIDER AND MANAGER ROLE: NURSING CARE PLAN

Priority Nursing Diagnosis

“P” Impaired urinary elimination

“R” Incontinence due to urinary tract infection

“C” Acute lower tract pain 7/10 upon urination, < 50 ml of urine voided per attempt, and chronic urinary retention

Priority Patient Goal

The patient will be able to state absence of pain or excessive urination by discharge AEB:

Pain upon urination 0/10, Decreased urge to void, Empting bladder completely

Three Priority Nursing Interventions

The nurse will monitor patient for incomplete emptying of bladder by using bladder scan post void. The nurse will encourage patient to drink water at each meal. The nurse will instruct patient on the signs and symptoms of a urinary tract infection.

Evaluation of Progress toward Patient Goal

The patient was able to recite some signs of UTI’s to nurse. She recognized pain on urination and foul odor as signs of an infection. The patient was reluctant to drink water at any one time. She continued to have incontinent periods, but this was less frequent on day of discharge. The patient partially met the goals put forth for her.

PROVIDER AND MANAGER ROLE

Member of the discipline and the Role of the Multi-Disciplinary Team

As a member of the discipline I was inclined to have verbal interactions with the ER staff before RP had arrived to F-300. Consulted with housekeeping to assure the RP’s room was cleaned and ready for admission. Ward clerk assured that tests were ordered. Dietician was consulted to help with nutritional needs. Discharged planner made transportation arrangement to return patient to long care facility. Social worker discussed local community resources of support with the family.

Provider of Care Role

As provider of care for this patient, I kept this patient cleaned and dry when incontinent. I utilized the fall risk precautions to provided safety. Implemented steps to encourage patient to accept and understand a bladder training routine. Monitored patient labs and reported abnormal results to the doctor.

Manager of Care Role

As manager of care I evaluated the client for her fall risk and implemented fall risk precautions. Delegated the placement of bed alarms and tabs to the LPN assigned to us. My preceptor and I discussed the possible ways to teach client prevention of developing UTI’s. Collaborated with nursing home staff on ways to improve client’s care at extended care facility.

Growth in the Manager of Care Role

In completing these tasks I was able to see the complete picture of the patient. I was educated on the disease process and the effect other co-morbidities had on providing an environment that encourages an infection. In caring for RP I was able to developed and strengthen my delegating skills, learning to rely on others and not solely on myself.