Use of Honey as Medicine in Wound Healing: Analysis

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The aim of the assignment is to critique the research article, “Standardised antibacterial honey (medihoney) with standard therapy in wound care: randomized clinical trial” (2009) by Robson, Dodd & Thomas. The tool used for this is Step by Step Guide to Critiquing Research by Ryan, Coughlan; Cronin (2007). Critique is an objective, critical, and balanced appraisal of a research report’s various dimensions (Polit and Beck, 2004).

The study was on the use of honey as medicine in wound healing. The research was done in the United Kingdom by a group of registered nurses and statistical masters. The study was completed in the year 2007 and was published in the Journal of Advanced Nursing (JAN). The study was based on the use of honey for wound dressing as an antibiotic and wound healing agent.

Arguably, the article is well written as it is concise and it does not contain any languages that are characterised to any particular group and are grammatically correct. The layout of the study is good and are given in a good order and kept the academic style of writing. Research reports are like stories, a story should be written in a way which catches the attention of the reader, like as research report should have a readable style. The current researches writing style is good, and is well understandable. No personal views are expressed in the study. The writer had omitted personal pronouns to get an ease in the reading.

Credibility variables concentrate on how believable the work appears and focus on the researcher’s qualification and ability to undertake and accurately present the study (Coughlan et al, 2007). The researchers were well qualified for the current study as their qualifications were stated in the article. Mostly nurses are eligible to do this type of study as they know the effect of dressing a wound. Statisticians also have a role in a research as there are so many calculations which were also included in the study. Methodology of a study is based on the credibility of the qualitative data and its subsequent findings (Polit &Hunger, 1999)

The title of the article gave an idea of the topic that and what the study is related to. The title is accurate and clear, too long or short titles can make the reader confusing (Coughlan et al, 2007). “Too long or short titles can be confusing and misleading to the readers” (Coughlan et al, 2007). In the study title is concise and is readable and has its reliability, the title is short too. The title is not more than 10- 15 words.

Abstract is a brief description or an outline of the entire article. The abstract should give a clear idea about the research and should include information regarding the purpose of the study, method, sample size and selection which is given clearly in the current article(Coughlan et al, 2007), And from the abstract the reader should able to find out the overall idea about the study. They have also pointed out for further research on this topic with some recommendations. The present study has an agreeable abstract which conveys idea about the study which is simple, clear and interesting for the readers. The abstract is not too long and also explains about the method, sample size and the selection method. The abstract gave an over view of the topic. The abstract also opens an end to further researches.

The introduction of the study will always be based on the research problem. Research problem is an enquiry which can be done through a disciplinary way (Polit and Beck, 2004). The purpose of a research highlights the overall sketch of main arguments and theory of the relevant research (Polit &Hungler, 1999). In the current research the purpose of the study is stated clearly and an overall idea of the study is been included in the introduction of the research. The research problem is identified and clearly stated in the study. The research was carried out in a step by step process. The article has a flow and a have an ease in reading and all the links are clear.

Critical summary of a topic which puts the topic or the research problem into a context is called as the literature review (Polit & Beck, 2004). Literature review always points out to the previous studies of the current topic. The review should be logical and its critical analysis should be balanced (Cougllan et al, 2007). In the present study the literature review is clearly illustrated and it is logically presented. The literature review offers a critical analysis. The reviews are mostly facts which were proved by proceeds. A good literature review will always have a good introduction (Cougllan et al, 2007), which is followed in this by the writer.

Frame work refers to the overall structure of a report which is based on a theory which was previously proved (Polit &Hungler, 1999). Hypotheses are from a primary source and of an empirical nature. Theoretical frame work is what which is found confusing by a researcher. A theoretical frame work is been identified in ethics. The theoretical frame work has been clearly stated step by step clearly. A sound theoretical frame work also identifies the various concepts being studied and relationship between those concepts. The theory is true and the hypothesis is relevant for the study. Theoretical frame work tends to be better developing in experimental and quasi-experimental studies and often poorly developed or nonexistent in descriptive studies (Burns & Grove, 1999).

The purpose of the aims and objectives is to create a link between the initially stated purposes of the study or research problem (Coughlan et al, 2007). Aims and objectives are the observations or measurement that reflects on the physical reality which is interpreted by the individuals, and can be argued that even such observations may be open to subjectivity (Gerrish & Lacey 2006). There is an aim for the study which is clearly stated in the abstract, introduction and also in the study. The hypothesis which is a statement or fact which can be tested or verified (Holloway & Wheeler, 2002). The research questions and the hypothesis is clearly identified and stated in the study. The hypothesis and the research questions reflect on the literature review.

The samples were chose with a great caution so as to minimise the errors. Samples are the selected units from a population, and sampling is the process of selecting appropriate people from a population for the research (Wood & Haber, 1994). The samples were chosen randomly from a group and were informed about the research and the procedures and the effect of the current procedure. The sample which was chose for the study was appropriate as they were patients who were having wounds. The size of the sample was also adequate as a small sample will not help in an appropriate conclusion. The size of the sample is also important in quantitative research as small samples are at risk of being overly representative of small groups within the target population. There was no inclusion or exclusion for the study as they chose an appropriate sample with ethical consideration. The risk of sampling errors decrease as larger sample used (Coughlan et al, 2007).

Autonomy infers that an individual has the right to freely decide to participate in a research study without fear of coercion and with the full knowledge of what is being investigated. Ethical committee or institutional review boards have to give approval before the research can be undertaken. There role is to determine the principles and to evaluate the validity of the research (Coughlan et al, 2007). There was ethical consideration for the data collection. All the participants of the study were fully informed about the research. All the participants were protected from all type of in case after effect, and were autonomous. Confidentiality of the subjects was censured by the researcher, and ensured the permission from an ethical committee.

In a research study the researcher should ensure that the reader should understand what is meant by the terms and concepts which are used in the research. All the operational terms, theories and concepts in the current study has been clearly identified explained and illustrated in the study, and have given proper reference and citations for the rational and the explanations. The organisation, reduction and transformation of the data of a study in order for a review are called as data analysis (Holloway & Wheeler, 2002). The methodology or the research design was clearly given to review the study. One of the main instruments in a study is methodology. The data gathering instruments of the methodology is cited in the study. The instrument used is appropriate as they could clearly get many results out of it. In the study 109 subjects participated in the research.

The system of analysing the facts with the collected data from the research is called as data analysis (Polit &Beck, 2004). Data analysis in quantitative research studies is often seen as a process which loses courage (Coughlan et al, 2007). Most of the data analysis is associated with complex language and statistical notations. The researcher should clearly identify what statistical tests were undertaken why these test was used and what were the results, which have been stated in the current article. In the current study analyse of the data is done in a better way. The strength and limitations of the study is also included in the study to revel the validity and reliability of the study.

The discussion of a study should flow logically from the data and should be related to the literature review thus placing the study in context (Russell, 2002). In the discussion part of the research is linked back to the literature review. The discussion part contains the strength and limitations of the study which is referred to the previous study that are made on the same subjects. All the limitations are also generalizability discussed. The research also extends an open end for further research on different aspects of his study; other recommendations are also given to the current study.

When doing a research or a research critique it is essential to quote the source of the information obtained, that should be included as in text or end text reference. In a research study the significance of the findings should be stated but these should be conceder within the overall strengths and limitations of the study (Polit & Beck, 2006). The reference should help the writer to find the source as quickly as possible (Pears & Shields). The copy of others idea is conceder as plagiarism which is serious offence. For the current study the researcher has used the Harvard referring system. The researcher has referred many books and research articles for his study and all the references have been quoted as in text and end text references. All the books referred for the study are appropriate as they are related to the subject or to the research vocabularies. The researcher was very much cautious about the plagiarism.

Evaluating the research article with the critiquing tool by Michael Coughlan and team members it was found that the study is arguable with credibility and reliability. The writers have carefully used the strategies in doing a research. The research is readable and understanding by lay men.

Stress

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Stress

Introduction
Stress is a negative kind of concept that affects human mind and their bodily well-being. It is still not clear whether stress is an effect or a cause, or whether it is a connection of the two. According to Keil (2004), stress is a Latin word stringere derivative which means to draw tight (p.659). However, according to Koolhaas (2011), the meaning of the word stress should be really restricted to conditions where environmental demands exceed the natural regulatory capacity of an organism (p.1291).
The brain is said to play an important role in regulating body stress especially the central nervous system. This part of the body regulates the reaction of the body towards the stressors. The central nervous system normally works closely to the endocrine system in regulating the body regulation mechanism. The sympathetic nervous system of the human body becomes very active in response to stress. This helps in regulating most of the psychological duties in the body in order to make one adapt to the surrounding environment.
Effects of stress on immune system
Stress can be regarded as the reaction of the body to any source of disturbing its equilibrium. According to Kansari et al. (1990), if the equilibrium of hormones in the body is altered the resultant changes are harmful to the body immune system (p.170). The stressors reduce the ability of the body to protect it against any foreign attacks. Kansari et al. also noted that in cases of people infected with a certain virus, for example the HIV virus, those with stress were likely to develop AIDS 2 to 3 times than those without.
Chronic stress
One can be said to have acquired chronic stress if they have had a long period of encounter with both internal and external stressors. These stressors are likely to result into bodily manifestations, for example, inform of diseases like back pains, fatigue, irritable bowels syndrome, asthma, ulcers or even headaches. If chronic stress affects the blood pressure, it increases the risk of stroke, heart attack, depression, infertility and even premature aging. Certain events or perceived events may also result in stress that reduces the body immune system. For instance, according to Graham et al. (2006), students have reduced immune system when taking examinations because of the struggles they face during revision and the actual writing of the exams (p.389).
Coping with stress
Human beings respond to stress in various ways, for example, psychological coping like anxiety, stress management, or even depression. They can also adapt to stress. Since stress affects our health, then a proper mechanism of dealing with it must be realized and implemented. These mechanisms are supposed to enable the person faced with stressors to either cope with or better still change the stressors and the environment. One can do this by taking control of the source of this stressor or better still ignore some likely stressors. Taking time in sports and music or other hobbies may also be a good way of diverting stress. They act as ventilators.
One can also perform a cognitive appraisal on the stressed person. According to Lazarus (1966), for a psychological situation to be stressful, then it ought to be appraised as stressful (p.8). It is important therefore to use the cognitive processes in determining the stages of stress for the best treatment. One can adopt the problem focused coping strategy or the emotion focused coping strategy to manage any bad emotions.
Symptoms of stress can be divided into various categories. These include emotional, behavioral and physical. The cognitive symptoms of stress include inability to concentrate, memory problems, anxiety and racing thoughts, poor judgment and constant worrying (Clin 1997, p.4).
The emotional symptoms include feeling overwhelmed, moodiness, senses of loneliness and isolation, depression, agitation and general unhappiness. The physical symptoms include pains and aches, nausea, constipation, dizziness, diarrhea, rapid heartbeat, chest pains, frequent colds and loss of sex drive. The behavioral symptoms include eating more food or even very little food, isolating oneself from the rest, loss of sleep or sleeping too much, neglecting ones responsibilities or procrastinating issues, over use of drugs, cigarettes and alcohol abuse, nervous habits like biting of nails and pacing.
Psychologists have classified stress into various stages. These stages include alarm stage, which is further divided into shock stage where the body can endure the stressors, and anti-shock stage when the stressors can be realized. The resistance stage is where the body fights the stressing mechanism and the recovery where the body resistance mechanisms completely overdo the stressors. The exhaustion phase is where the body retreats due to its exhaustion and the resistance is completely overcome by the stressors effects on the systematic nervous system becomes evident for example increased rate of heartbeat, and the body immune system become weak hence the victim becomes prone to opportunistic diseases.

References
Graham, J., Christian, L. & Kiecolt-Glaser, J. (2006). Stress, Age, and Immune Function: Toward a Lifespan Approach. Journal of Behavioral Medicine, 29, p.389.
Khansari, D., Murgo, A., & Faith, R. (1990). Effects of stress on the immune system. Immunology Today, 11, p. 170.
Keil, R.M.K. (2004) Coping and stress: a conceptual analysis. Journal of Advanced Nursing, 45(6), 659–665
Koolhaas, J., et al. (2011) “Stress revisited: A critical evaluation of the stress concept.” Neuroscience and Biobehavioral Reviews 35, p. 1291
J. Clin Psychiatry (1997). 58(suppl. 2) p. 4.
Lazarus, R.S. (1966). Psychological Stress and the Coping Process. New York: McGraw-Hill.

Non-Medical Nurse Prescribing Custom Essay

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Non-Medical Nurse Prescribing Custom Essay

This paper will demonstrate the author’s ability to prescribe safely from the Nurse Prescribing Formulary (NPF 2009-2011). A prescribing situation undertaken by myself while supervised by my mentor will be discussed. The patients name, address, date of birth and GP details have been changed to ensure patient confidentiality in accordance with the Nursing and Midwifery Council (NMC)(2004). The patient therefore will be referred to under the pseudonym Prince Charming. Nurse prescribing was first suggested by the Royal Collage of nursing (RCN) in 1980, it was to take another six years for it to become part of the government’s agenda with the Cumberlege Report in 1986 (Department of Health and Social Security (DHSS)(1986). These two report as well as the Crown report (DH 1989), Prescription by Nurses Act, (1992) and the Medical Prescription by Nurses Act (1994), lead to The Nurse Prescribing Formulary being introduced nationally in 1998.

Physical and Psychosocial Problems of Radiation Therapy

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Introduction and background:

The word “cancer” itself is traumatic in nature. It effects a person not only physically but also psychologically, financially, culturally, socially, and spiritually etc. According to World Health Organization( WHO) report (2014), in 2012 worldwide 14.1 million adults were diagnosed with cancer, and among them 8.2 million were died. Moreover, breast cancer is the fifth leading cause of death. In the USA, among all types of cancers the breast cancer is the highest incidence rate because one in ten women is having breast cancer (Njeh, Saunders, & Langton, 2012). Breast cancer incidence increased more than 20% (WHO Press Release, 2013). Furthermore, cancer is also one of the leading causes of deaths in the developing countries. In Pakistan, the most frequently diagnosed cancer is breast cancer for females. The incidence of breast cancer is higher in western countries but Pakistan has the highest rate of breast cancer among all the Asian countries, (Pink Ribbon Pakistan). It is estimated that 1 in 9 Pakistani women will develop breast cancer at some stage of their life. (Shokat Khanum Cancer Hospital and Research Center). The cancer patient suffers a lot from the physical and psychosocial problems not only because of the disease process but also from the treatment related problems. As, one out of two patients with cancer experience psychiatric disorder especially depression (Reyes-Gibby, Anderson, Morrow, Shete & Hassan, 2012; Spoletini, et al, 2008).

There are certain treatment modalities for cancer such as surgery, chemotherapy and radiotherapy. Each of them is potential to produce various threats for the cancer patient. Radiation therapy is also an important treatment performed before and after surgery which also has various harmful effects on the patient. Beside that it is significant part of cancer treatment but its impact on patient’s quality of life and nursing management is less addressed in literature. According to Welle, (1998) radiotherapy patients are perceived as self-caring and their needs are not taken care of.

However, numerous researches have been conducted nationally and internationally to identify the different problems and their intervention of the cancer patients treated with chemotherapy and surgery. As a result evidence based body of knowledge have been generated this is contributing in quality nursing care and health teaching, impacting on the patient’s quality of life. Moreover, some of the international studies highlighted the problems faced by the patients receiving radiation therapy but as per my best knowledge very little work has been done in the field of nursing to remedy these problems. Most importantly, in the context of Pakistan very little work has been done pertinent to this issue.

However this study is significant to contribute in the existing body of knowledge for nurses to care for breast cancer patient more holistically. Moreover, this study may be helpful to develop the teaching material for patients receiving radiotherapy to enhance their quality of life. In addition, the findings of this study will be helpful for nurses working in Pakistan.

This study may improve the teaching interventions of nurses caring for cancer patients in government hospital and may have positive effect on their knowledge, attitude, and skill pertinent to RT.


Purpose:

The aim of this paper is to identify the physical and psychosocial problem of the patient pertinent to radiation therapy, as well as the nursing management and health teaching for the patients for enhancement of their quality of life.


Study Questions

Question 1: What are the different physical and psychological problems of the breast cancer patients undergoing RT in Pakistani context?

Question 2: Is there any association between RT and compromised quality of life of the patient.

Question 3: What kind of health teaching is necessary for the nurse to give the patient before and after RT?

Question 4: what are the feeling and perceptions of breast cancer patients undergoing radiation therapy ?


Data sources

The review of literature was conducted through data bases CINAHL PubMed , Mosby’s Nursing Consult, Science Direct, and Google Scholar were search for published research articles relevant to this paper. The combination of the following key terms was used to retrieve relevant literature by punching “physical/psychological problems, breast cancer, problems with radiation therapy, quality of life, patient education etc”. Search generated 283 articles, 52 duplicate results excluded. Through a selection process title and abstract screened, among those 20 were found to be relevant to the topic.


Literature review

Radiation therapy is one of the options totreat the cancer, uses high-energy x-rays or gamma rays targeted at the tumorto shrink the tumors or kill cancer cells(Radvansky, Pace, &Siddiqui, 2013). During the course of the treatment about two-thirdsof patients will undergo radiation therapy(Guo et al. 2013).According toPotthoff et al (20013). More than 90% of all breast cancer patients receive adjuvant radiotherapy, given after breast conserving surgery as well as after mastectomy to avoid recurrence of cancer. Darby et al (2011) found in their meta-analysis study that RT after breast conserving surgery reduces 15-year risk of breast cancer death rate from 25•2%. This widely used therapy has its side effects like other cancer treatments; it is also potential for causing great physical as well as psychosocial problems as other cancer treatment do (Egestad, 2013).


Physical problems related to radiation therapy for breast cancer patients

Radiation therapy affects cancer and normal cells equally within the treated area, result in injuryof the cells which lead to side effects. The radiation therapy induced side effects include skin and mucous membrane toxicities, sleeplessness, pain, swelling, dyspnoea, cough and nausea. (Rose, 2011; Darby et al, 2011; Adams, 2009;Currie& Wheat 2006; Gordils-Perez,&Duell,2003).Skin problems are the most frequent side effect among all and nearly 85%–95% of patients receiving radiation therapy will develop some degree of skin damage (Bergstrom, 2011). There are many long term side effects of breast irradiation like cosmetic changes hyper pigmentation, fibrosis, lymphedema, and damage to underlying normal structures (Perez,&Duell,2003). Therefore it is very important to remedy this problem because this side effect of radiation therapy limits the patient’s ability to tolerate the treatment (Currie,Wheat, 2006).In their study Potthoff et al (20013) .reported that 80% of the patients experience fatiguewho receive RT. They defined fatigue is a “persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning and that is usually not relieved with rest and is not related to an excessive amount of activity” (p.3).In another qualitative study Poirier, (2011) found out that fatigue is also very common in patient getting radiation therapy and it affects their role functioning in daily life. In this way the fatigue may affect the quality of life of the patient. Another side effect of RT is reported in of the studies is sleep disturbance. According to the study conducted by Dhruva, et al (2012).approximately 50% breast cancer patients reported sleep disturbance at the initiation of radiation therapy.


Quality of life of the patients

Breast cancer due to its poor prognosis and treatment related problems affect the quality of life of the patient. Kirchheiner et al. (2013) reported that “mean QOL in the total cohort is 58±27% (100% indicates excellent QOL)” (p.425). Similar to other treatment choice RT related side effects also have impact on the quality of life of the patient. The quality of life is defined by WHO (1997) “concept affected in complex way by the person’s health, psychological state, and level of independence” (p.1). As the National Cancer Institute (2011). Mentioned that 38% of all women diagnosed with breast cancer experience abandoned symptoms resulting from the disease and its treatment. Therefore, the side effects of RT affect the quality of life of the patient (Currie, & Wheat, 2006). In addition, sleep disturbance is another problem found to be an important contributor in affecting the quality of life of the patient. In this connection, a study conducted by Graydon (1994) highlighted that sleep disturbance and fatigues were the main areas of the life of women affected by RT. Since the fatigue, influence the physical, cognitive and emotional aspects and the prevalence ranges from 30-70% in women with breast cancer, reaching up to 80% when they are undergoing radiotherapy (Alcantara-Silva, Freitas-Junior, Freitas, & Machado, 2013). This is one of the most frequent side effects of radiotherapy, and it may interfere with self-esteem, social activities and quality of life.

Moreover, the fatigue and pain related to radiation therapy may affect the sexuality of the patient by decreasing the desire and arousal and skin changes including burns and tattoos affecting body image and self-esteem (Varela, Zhou, & Bober, 2013; Mercadante & Vitrano & Catania , 2010). These symptoms lead to compromised quality of life of the patient. In this regard nurses need to give the high quality care by addressing the all aspect of patient life to enhance the QOL of their patients undergoing RT. Moreover, with the advancement of health science the patients expectquality oflife (QOL) beyond just survival

therapy


Psychological problems

The women diagnosed with breast cancer have remarkable impact on her psychological well being. As Halkett , Kristjanson , and Lobb (2008) highlighted that women with breast cancer receiving radiotherapy, experience many kinds of fears like fear of unknown and getting burnt, damage to internal body parts, and anticipating tiredness. These kinds of fears may threaten the women which may have negative impact on compliance with the treatment. Rose, (2011) highlighted that patient may feel high level of stress at the start RT because of unfamiliar technology, potential side effects and being in an environment with other cancer patients.

Moreover, the outcome of the study of Reyes-Gibby et al. (2012) shown that depression among women was positively associated with symptoms of disease and treatment. Thus the diagnosis and treatment can have a profound influence on a woman’s psychosocial and overall well-being.


Role of nurse in RT patient’s care and education

The above mentioned literature suggests that patients who receive radiation therapy face significant challenges and require care during the period of their treatment. Nurses are direct care provider in any health care setting. They play a significant role in their specialized field in various health care settings. Therefore, they can play a significant role in improving quality of life of the cancer treatment recipients. During the RT course, patients may go through many complex physical and/or emotional responses (Rose, 2011). A randomized trial study conducted by Christman, & Cain, (2004) concluded that patients receiving concrete objective information reported maintaining higher levels of usual function than those not receiving. Furthermore, giving information about symptom experiences helped them to mentally prepare uncertainty about their symptom experiences. Oncology nurses need to own the responsibility of their patient and identify the patient need. The Meta analytical findings support the usefulness of

psychosocial interventions for improving QoL in adult cancer patients.

In this regard a comprehensive nursing care of the patient can improve the physical as well as psychological care of the patients.


Importance of Patient education

Providing cancer patients with appropriate information regarding their treatments, side effects of treatment and coping strategies allows them to feel more control over disease and its related problems. It helps them make better choices of treatment modalities ( Barnett, et al. 2004). The study findings of Zeguers et al (1012) highlighted that now the RT patients want comprehensive information about their disease, treatment, and procedures, side effects, and prognosis with the mean scores between 4.1 and 4.4 on a scale from 1 to 5. In contrast ,Barnett, et al. (2004). Emphasized that information needs vary among different individual therefore, a patient-centred approach must involve according to the tolerance and need of the patient.

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Dhruva, A., Paul, S. M., Cooper, B. A., Lee, K., West, C., Aouizerat, B. E., Dunn, L. B., Swift, P. S., Wara, W., &Miaskowski, C., (2012). A Longitudinal Study of Measures of Objective and Subjective Sleep Disturbance in Patients with Breast Cancer Before, During, and After Radiation Therapy.Journal of Pain and Symptom Management, 44(2)

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Mr. P is a 76-year-old male with cardiomyopathy and congestive heart failure who has been hospitalized frequently to treat CHF symptoms. He has difficulty maintaining diet restrictions and managing his polypharmacy. He has 4+ pitting edema, moist crackles throughout lung fields, and labored breathing.

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Mr. P is a 76-year-old male with cardiomyopathy and congestive heart failure who has been hospitalized frequently to treat CHF symptoms. He has difficulty maintaining diet restrictions and managing his polypharmacy. He has 4+ pitting edema, moist crackles throughout lung fields, and labored breathing.

 

NRS-410V Module 3 Case Study 2 – Mr. P is a 76-year-old male with cardiomyopathy……
Pathophysiology and Nursing Management of Clients Health – Alterations of Hematology and Cardiovascular Systems
Grand Canyon University
Case Study 2
Mr. P is a 76-year-old male with cardiomyopathy and congestive heart failure who has been hospitalized frequently to treat CHF symptoms. He has difficulty maintaining diet restrictions and managing his polypharmacy. He has 4+ pitting edema, moist crackles throughout lung fields, and labored breathing. He has no family other than his wife, who verbalizes sadness over his declining health and over her inability to get out of the house. She is overwhelmed with the stack of medical bills, as Mr. P always took care of the financial issues. Mr. P is despondent and asks why God has not taken him.
Question
Considering Mr. P’s condition and circumstance, write an essay of 500-750 words that includes the following:
· Describe your approach to care.
· Recommend a treatment plan.
· Describe a method for providing both the patient and family with education and explain your rationale.
· Provide a teaching plan (avoid using terminology that the patient and family may not understand).

Control Of Sexually Transmitted Infections Health And Social Care Essay

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The purpose of this paper is to first discuss the public health impact of STIs, followed by the approaches to their control/prevention in the UK. Unfortunately the public health impact of STIs is negative as it causes or contributes to ill-health. In the UK and other parts of the world, STIs pose enormous challenges for the public health which may be individual well-being, mental health or the burden on health costs. Focus of this paper will be mainly on genital Chlamydia, gonorrhoea, syphilis, HIV/AIDS, and Human Papilloma Virus (HPV – [genital warts]) amongst other STIs due to the reported high rates of infection.

Sexually transmitted infections affect people of all ages with the greatest occurrence amongst those under the age of 25 years (Nicoll, 1999; Johnson, 2001). In the UK, certain groups of populations are affected more than others thus creating sexual health inequalities. Primary and secondary syphilis occurs more often in the African community than it does in the White community. Gonorrhoea is reported more commonly among some ethnic minorities while Chlamydia infection rates are disproportionately high in the under 25s. Data on ethnic differences in behaviour and infection susceptibility are meagre and the observed differences are not accounted for. Poverty could be attributable to the high incidence rates in the ethnic minorities as STIs are more common in ethnic minorities than among the white majority which might also be a link between an increased risk and belonging to a minority population. In 2004, women aged 16-24 accounted for 74% of all Chlamydia diagnoses in the UK (anonymous). Chlamydia rate of infectivity at national level for young people aged 15-24 is one in nine supporting the level of sexual activity in that group (NHS, n.d).

The conquest of the majority of communicable disease has been one of the main successes of modern medicine. The diseases have presented the highest causes of mortality and morbidity prior the twentieth century. Until the mid twentieth century in Britain, particularly for women, the pleasures of sex were tempered by the dangers of poor health and social outcomes. However, with the development of modern antibiotics and effective vaccines, communicable diseases menace has mostly been contained and remarkably sex became safer.

Although sex became safer, STIs rates have significantly increased in recent years in the UK predominantly from unsafe sex practices arising from various factors like sexual risk behaviours and poor infection control. They have become a major public health concern as highlighted in the National Strategy for Sexual Health and HIV (Department of Health, 2001). The 16-24 year age group comprising of only 25% of the sexually active population but with the largest diagnosis of STI cases of almost 50% of newly acquired infections. Control of STIs is complicated since many of them are asymptomatic. The economic impact caused by STIs is huge on health services with high costs mostly experienced in the management of infection complications in women. However, older women and men are also at risk especially those entering into new relationships after breaking up from a long-standing relationship. Hence there is ample requirement for protecting, supporting and restoring sexual health in people.

Public Health Impact of Sexually Transmitted infections in the UK

History

Syphilis and gonorrhoea records have been collected for more than 80 years. In England, Wales and Scotland, diagnosis of syphilis and gonorrhoea was recorded highest in 1946, which coincided with the coming back of the armed forces after World War II (Figure 1). A sharp drop was subsequently detected and was linked to the use of penicillin and the re-establishment of social stability.

Figure 1: Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales and Scotland*, 1931 – 2003.

*Corresponding Scotland and Ireland data are excluded as they are not complete from 1925 to 2003.

Source: KC60 statutory returns and ISD(D) 5 data.

During the sixties and seventies, there was a stable rise in STIs diagnosis owing to more relaxed mind-sets to sexual behaviour. There was an upsurge in cases of Syphilis in males, while in women the number of cases continued to be stable. This implied sex among men during that time turned out to be the main route of transmission (CDC, 1999). Yet an increase in diagnosis was recorded in both males and females for gonorrhoea, genital warts and genital herpes signifying that these infections were acquired during heterosexual sex. Probably the rise in a small number of the STIs could have resulted from enhanced diagnostic sensitivity or public awareness, adding to higher rates of infectivity.

However, in the early eighties, HIV and AIDS were first reported which supposedly had considerable effect on other serious STIs. A brisk drop of syphilis and gonorrhoea diagnosis was experienced in early to mid- eighties. This happened simultaneously with the widespread AIDS coverage of embracing of safer sex behaviours, and resulted in a subsequent decline in transmission of HIV amongst male homosexuals (Bosch, 1995).

Sexually Transmitted Infections Trends

Since 1999 to mid 2004, cases of Chlamydia infection rose by 108%, gonorrhoea by 87% and infectious syphilis by 486%. Still the young people bear the greatest burden. In 2001, women under 20 years of age had reported cases of 42% from gonorrhoea and 36% of Chlamydia. As reported by the Department of Health (DH), diagnosis of new STIs and other STI diagnosed cases in the UK such as re-infections made in genitourinary medicine clinics (GUM) showed a gradual rise in 1999-2008. The introduction of the National Chlamydia Screening Programme (NCSP) in 2003 and other health screens in England, Wales and Northern Ireland and in 2005 in Scotland resulted in an increase of sexual health screens from 759,770 to 1,219,308. For the same period, there was an increase of HIV tests recorded from 520,278 to 951,148. In 2008, uncomplicated infections from Chlamydia, syphilis, genital warts, and genital herpes rose considerably from 1999. Yet for the same year, cases of new diagnosis of gonorrhoea and syphilis were reported to have dropped.

The National Survey of Sexual Attitudes and Lifestyles (NATSSAL) identified sexual behaviour as the risk of acquiring an STI in the young age groups. The factors included lower age at time of having sexual intercourse for the first time, partners frequently changed, increased likelihood of being involved with concurrent partnerships, irregular use of condoms and the increased chances of being involved with a partner from a high-risk area of the world other than UK (Hughes, 2000; Johnson, 2001, Mueller, 2008; Skinner, 2010). However, the young people act as a core group for the risk of onward transmission to other groups. Thus prevention should be mostly targeted at this core group which would result in economic benefits.

Literature Review

Sexually transmitted infections still exert a major toll on the human population in the UK and other nations worldwide. Bacterial and protozoan infections are curable with antimicrobial therapy, while viral infections are treatable but not curable in the classic sense. STIs can cause immediate pain and suffering, profound psychosocial stress, and serious, long-term health consequences. Many STIs are asymptomatic, and surveillance systems to track STIs are incomplete in developed and developing countries. STIs have been shown to be important cofactors in HIV transmission (Fleming, 1999). New approaches to STI control and prevention are needed to reduce the spread of infection and minimize associated suffering.

Chlamydia

Chlamydia trachomatis is the most widespread bacterial pathogen transmitted through infected secretions and mucous membranes of urethra, cervix, rectum, conjunctivae and throat following unprotected sexual contact with an infected partner. In addition, an infected mother can infect her baby during vaginal delivery. It is the most commonly diagnosed STI in individuals under 25 years in the UK (Fenton, et al, 2001; Creighton, et al, 2003). Most people infected with Chlamydia show no symptoms until a diagnostic test is performed and in most cases they do not seek medical care. Thus, in those individuals affected by the disease, if efficient and effective health measures are not administered, the STI has the potential of causing a significant amount of health complications to women’s well-being including infertility and pelvic inflammatory disease (Golden, et al, 2000; Garnett, 2008). There is also greater risk in those with recurring infection and untreated infections to spread to other reproductive organs resulting in chronic pelvic pains (La Montagne, et al, 2007). The number of diagnosed episodes of Chlamydia infection has been rising over the past 10 years (Figure 1). Furthermore, the economic impact of Chlamydia infections on the health service is enormous with high cost in the management of female health complications arising from Chlamydia infection (Garside, 2001). Because of the impact of Chlamydia infection on the health of young people, it is important to identify and treat infected patients and their partners and as a result reduce the burden of the disease on the people and health systems.

Figure 1: Rates of genital Chlamydia infection by sex and age group (1995 – 2004).

Source: Health Protection Agency, London

In men Chlamydia infection causes epididymo-orchitis and urethritis. Also rectal pain, discharge and bleeding occur from proctitis which is from infection of the rectal mucosa. Additionally, since the incubation phase of gonorrhoea is less than that of Chlamydia, individuals can develop dysuria after their treatment for gonorrhoea causing postgonococcal urethritis.

HIV/AIDS

In nearly three decades, ever since HIV was first identified, HIV infection has turned out to be a deadly disease and has caused a disturbing adversity to humans, in almost all areas of life. In the early eighties, when the first few cases of AIDS were reported, few might have realised its propensity to become a global public health problem. The UK is facing a sexual health crisis. Between 1999 and 2002, HIV prevalence rose by about 20% annually, and almost a third of HIV-positive individuals did not know their HIV status (HPA, n.d.). Furthermore, the increase in rates of HIV infections could be brought about by the rise in STI incidences in the public as already highlighted in this paper. The number of newly diagnosed cases of HIV increased by 55% from 2000 to 2002 (DH, n.d.). In 2004, a minimum of 49 000 individuals had HIV in England. In the late 1980s and early 1990s in the UK there was a significant drop in STIs figures in reaction to the awareness campaigns on HIV.

The disturbing extent of its increase, infection, very long incubation phase, secondary susceptibility of spread and the absence of a vaccine to prevent it calls for the attainment of comprehensive information about the disease. Currently AIDS prevention mainly relies on health education and behavioural modifications based on AIDS awareness, predominantly in the high risk group of young people.

Gonorrhoea

Gonorrhoea infection is caused by an organism, Neisseria gonorrhoeae (N. gonorrhoeae) which is highly infectious and a bacterial sexually transmitted pathogen. In heterosexuals, its occurrence is associated with age (<25 years), black ethnicity, and socioeconomic deprivation (Bergen, 2006). Estimates from the Health Protection Agency have suggested that the disease may possibly be more common in men who have sex with men than in heterosexual men (McMillan, 2000; Bignell, 2006). At the endocervix and urethra in women, the disease is also asymptomatic, and usually (>90%) asymptomatic in the rectum and oropharynx in both women and men (Hook, 1999; Knox, 2002). In the GUM clinics and various health services, testing for N. gonorrhoeae is a core factor of screening for STIs. Although there is not much evidence to direct testing, every mucosal site correlated with the disease symptoms ought to be tested for infection (Barlow, 1978; Harry, 1997; CDC, 2002; Ghanem, 2004; Bergen, 2006). Screening measures are subjective to an individual’s sexual history and repeat screening may be encouraged (Miller, 2003). Gonorrhoea incidence falls by 11% in the UK: The number of new gonorrhoea infections in the United Kingdom fell from 18 649 in 2007 to 16 629 in 2008, the lowest number recorded since 1999.

Syphilis

Syphilis is caused by infection from Teponema pallidum subspecies pallidum, is a mucocutaneous STI with high infectivity the early infectious stages. It may also be transmitted through the placenta in pregnant women from week nine of gestation onwards. Screening is recommended for all asymptomatic patients attending GUM clinic or those attending other health services are referred appropriately (Nicoll, 2002). Incidence of syphilis also showed a 4% fall, from 2633 in 2007 to 2524 in 2008, (HPA, n.d). Over the last year, there has been almost three times the number of heterosexual cases of syphilis in south London than were diagnosed in 2001 (25 in 2001, 72 in 2002 and over 40 cases in the first five months of this year) (HPA, 2008).

Human Papilloma Virus

The spread of genital HPV is normally spread during intimate, skin to skin or sexual contact. It is also asymptomatic and can be dormant for years. HPV high risk strains are 16, 18, 31, 33 and 45, which are likely to increase the probability of getting cervical cancer. These strains exist in nearly every woman with cancer of the cervix. Although HPV testing is still not regularly accessible, the National Health Service is considering it to be included in the screening programme of cancer of the cervix. Women who test positive for high risk types of HPV are more likely to need treatment for borderline or mildly abnormal cervical smears. Although in ninety percent of HPV cases, clearance of the virus occurs naturally within two years. Yet, continued use of condoms may possibly facilitate in lowering the risk of infection from genital HPV. Infection from HVP is now being prevented through administration of vaccines for types of HPV that causes cervical cancer. The Gardasil and Cervarix cervical cancer vaccines were licensed in the UK in 2007.

However, the genital warts strains 6 and 11 which can be diagnosed by inspecting the genital area of an individual and are usually in the form of small (or large) bump or groups of bumps. They normally develop within weeks or months following sexual contact with an infected partner who might be asymptomatic. Sometimes if treatment is not administered, they might disappear, or remain unaltered and not cancerous.

Approaches to prevention and Control of sexually transmitted infections

The health of the people and the social and economic success of the UK are extremely connected. The related economic and social costs to public health are enormous and surpass UK’s future. Marmot’s (2010) six recommendations further support the prevention and control of STIs in UK’s population. In two of the six recommendations he states that, “enabling all children, young people and adults to maximise their capabilities and have control over their lives” and that of “strengthening the role and impact of ill-health excellent well-being over their lives”. It is vital that UK’s population is educated on sexual health issues so that they are able to make well informed sex decisions that contribute to their well-being and reducing the burden caused by STIs. Marmot’s report further emphasised other research work (Picket & Wilkinson, 2009) that “it is not only the poor who suffer from the effects of inequality, but the majority of the population”. High priority should therefore be given to the integration of STI control measures into primary health care. The worldwide interest in and resources committed to preventing AIDS provide a unique opportunity for health workers to make considerable progress in controlling the other STIs.

Sexually transmitted infection control programmes have been and will continue to be the most prominent in public health management and have been at an increase since the mid nineties with rates of unwanted pregnancies still being reported to be high. Strategies to prevent transmission of organisms spread by intimate human contact must remain flexible and adapt to the social, technical, clinical, financial and political realities. A strategy of primary prevention, based on sexual behavioural change combined with the provision of adequate clinical services, is vital for the control of STI. In response to the re-emergence of these diseases in the UK, it was decided by the Department of Health to open for the first time ever STD clinics across the country to help reduce the burden of the STIs. These clinics are staffed with a multidisciplinary group of specialists that offer sexual health services to different age groups of the community.

Given the unequal burden of STIs for young people, it is imperative to ascertain effective prevention programmes. Although enhancing access to Chlamydia testing has been an important and urgent focus of Chlamydia awareness programmes and has led to renewed efforts to increase access to Chlamydia testing (WHO, 2001; Santer 2000; Santer, 2003). As more people including this identified group learn their Chlamydia status, and in recognition of the long latent period of the disease before symptoms prevail, factors related to Chlamydia awareness remain crucial to identify in order to design comprehensive Chlamydia management services that meet the needs of the population at risk of infection (Brabin, et al, 2009).

A study by Shiely, et al (2009) showed that in Ireland, age specific behavioural interventions could be effective by targeting increased use of condoms to decrease STI incidences. Also in order to boost condom use, a 5% reduction from 13.5% in taxation on condoms could be implemented at policy level. Other studies also revealed age as a risk factor for STI transmission and to that regard there should be enhanced sex education promotion to the target group to enhance behavioural changes (Manhart, et al, 2004; Fenton, et al, 2005). A further study also showed that diagnosis of a viral STI was not associated with multiple partners but however it was possible for females who had more than one sexual partner to be more likely to use protection since they will be more experienced and aware of STI infection (Fenton, et al, 2005).

Although condom use has increased in prevalence almost everywhere, but rates remain low in the UK and many other developing countries. The huge variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.

Accomplishing excellent sexual health for the population of the UK has always created its own distinctive challenges. Meagre sexual health is often disproportionately impacting on those who are already at risk and experiencing inequalities, for instance the young people, black and minority ethnic groups, those in lower socio-economic class, and gay men. While there has been so much public health interest and commitment of resources to preventing AIDS, an opportunity exists for health workers to make significant progress in the control of other STIs as well. Thus the need for comprehensive behavioural interventions that would tackle the social context for individual-level programmes, support and sustainability of behavioural change, and the structural factors that is contributory to risky sexual behaviour.

The National Institute for Health and Clinical Excellence (NICE) suggested the need for health professionals to identify individuals at higher risk of becoming infected with STIs, ascertained by one’s sexual history, and organize one to one talks to minimise the risk of infection. However, the sexual health guidance recommends a variety of circumstances for assessing risk of infections which include opportunities where a health professional discusses with a patient contraception, abortion or pregnancy or when conducting cervical smear test, giving an STI test, giving travel immunisation, and during regular care or a new registration by a patient. Any individual identified to be at high risk of getting infected, should be referred to trained health worker for one-to-one talks in an attempt to minimise risky behaviour. Additionally for those who have been tested positive, should be assisted in having their partners tested and treated.

Responsibility for the National Chlamydia Screening Programme (NCSP) was taken over in 2005 by the Health Protection Agency from the Department of Health. Screening is conducted in various locations across the UK, the main ones being youth services, community contraceptive services, general practices, education premises (universities or colleges). Statistics for the programme have revealed that more women are getting screened than men, while an increased number of men are testing positive. Efforts are still being made in most areas to attempt to tackle this variance in trying to reach out to the young men. More partnership work is required to tackle the variances including that of offering screening in health clubs such as gyms and boxing clubs. Although diagnostic testing in sexual health has now been increasingly quicker and easier for patients and the staff, it is crucial that care was personalised especially when engaging with a health worker. Since STIs are prevalent in both asymptomatic and symptomatic individuals, due to their behaviour, diagnosis, management and follow up require skilled and trained individuals. If a health worker is adequately trained and has knowledge of STIs, it helps in preparing the patient for an STI test and understanding the effects if the test was to be positive.

Change Process In Nursing

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Change Process In Nursing

SCENARIO:
You are a Nurse Manager of a health care facility. You are advised to cut cost by not hiring new nurses. How would you encourage the nurses you currently have to work smarter to provide safe and efficient patient care without feeling burnt out?

PLEASE INCLUDE THE FOLLOWING IN THE ESSAY:

1. Identify need for the change or enhancement, including driving forces such as:
a) Regulatory agencies
b) Benchmarking
c) Patient satisfaction (Press Ganey or HCAHPS)
d) Joint Commission standards e.g. safety issues

2. Describe and apply a Management theory AND A Leadership style you would use to bring about this change, please provide examples.

3. Analyze the role of the Professional Nurse as a change agent in motivation, morale building, need satisfaction and job enrichment. Please provide examples.

4. Identify the specific motivation theory and rationale for the use of that theory. Please provide examples.

5. Please use research literature to support the proposed change process in professional nursing practice, use articles from nursing journals such as ANA, etc.

PLEASE FOLLOW THE INSTRUCTIONS CLOSELY. THERE IS NO LIMIT TO SOURCES. PLEASE USE AS MANY AS NECESSARY TO GET PAPER DONE.

Abdominal Aortic Aneurysm (AAA) Post Surgery Care

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Introduction

Nursing care of the patient following major surgery is a complex task, involving holistic management of patient wellbeing in the light of several challenges to health and homeostatic stability. This essay sets out to discuss the care of one such patient, following surgery to repair an abdominal aortic aneurysm. In order to address the issue and provide the highest possible standards of individualised care, nurses need a considerable knowledge base, gleaned from training, from ongoing updating, from the available evidence, and from their experience as professionals in their field. This essay will also set out to explore how nursing knowledge is applied to practice, always keeping the patient as the focus of care, with reference to the underlying physiology which relates to the patient’s condition.

Nursing skills are also based on knowledge and experience, both the experience of the nurse themselves and the experience of those who have taught them, who work with them and who collaborate in the provision of care. While this essay focuses on the nurse’s role in relation to the case and the client, it is important to remember that nursing care does not take place within a vacuum, and reference will be made to those with whom the nurse must interact and engage as part of this role.

The care of a patient following surgical abdominal aortic aneurysm repair follows the principles of general postoperative surgical care, along with specific interventions, monitoring and support that are a consequence of the condition and the nature of the surgery. The holistic management of this case must also take into account the psycho-social and emotional factors which may affect the case, given the life-threatening nature of the condition and the potential complications of the surgery.



The Case

David Grainger is a 65 year old man, who is retired and who tries to keep himself fit by playing golf. He had a history of recurrent pain underneath his rib cage for some month, and had been treating himself for indigestion with limited success. His friends became worried about him and his condition when he appeared to be losing weight, and so eventually David plucked up the courage to visit his GP. He was referred to the local hospital for tests, which eventually led to a diagnosis of abominal aortic aneurysm. David was later admitted to the surgical ward for surgery to repair the aneurysm.

On return to the ward David had a blood transfusion running and a wound drain (Redivac) from the abdomen close to the surgical incision site. He had an indwelling Foley catheter with an hourly urine bag, which was changed to free drainage after 12 hours of adequate urine output, and a PCA (patient controlled analgesia) device in situ. He has a mepore dressing to the abdominal wound site.

David has two IVI sites, one in each hand. The blood transfusion was running via the left hand, and normal saline (0.9%) was running in the other, along with the PCA, on a three-way tap. The day following surgery David’s temperature is recorded at 39.6c with an elevated pulse of 90bpm. He repeatedly complains of feeling cold. Discussion with the senior sister and the SHO suggests that David is experiencing a potential pyrexia.



Abdominal Aortic Aneurysm.

Abdominal Aortic Aneurysm (AAA) is a fairly common condition (the 14

th

leading cause of death in the US (Birkmeyer and Upchurch, 2007). It is a life-threatening condition (Isselbacher et al, 2005). The greatest risk of an AAA is the risk of rupture, which has a significant mortality rate attached to it (Birkmeyer and Upchurch, 2007). It is defined as an abnormal localised arterial dilation or ballooning that is greater than one and half times the artery’s normal circumference, and must involve all three layers of the vessel wall (Irwin, 2007). Abdominal aortic aneurysms are those which are located below the diaphragmatic border, and account for 75% of aortic aneurysms (Irwin, 2007). Men are four to five times more likely to develop the condition, and risk factors include smoking, hypertension and dyslipidemia, cellular changes in the tunica media associated with diseases such as Marfan syndrome, inflammation, and blunt trauma (Irwin, 2007). There is also a family history factor, with increased risk amongst primary relatives of someone with AAA (Irwin, 2007). Another risk factor is atherosceloris, although someone without this condition can develop an aneurysm (Irwin, 2007).

Repair is either through open surgical repair, through a large midline incision (Irwin, 2007). The procedure is major surgery, and the aorta is cross-clamped to allow the insertion of a synthetic graft which is attached to proximally and distally to health aortic tissue (Irwin, 2007). Another procedure is endovascular repair using a percutaneous vascular stent (Irwin, 2007; Beese-Bjustrom, 2004). In this procedure, a woven polyester tube covered by a stent is placed inside the aneurismal section of the abdominal aorta, which keeps normal blood flow away from the aneurysm, greatly reducing the risk of dissection and rupture (Bese-Bjustrom, 2004). In this case David underwent open surgery.



Assessment

Assessment of the patient’s condition is the first stage in nursing care planning and management, forming the basis of nursing decision making (Watson-Miller, 2005). A summary of assessment activities carried out for David can be found in Table 1.


Table 1. Nursing Assessment of David on Day 1 Post-Op.


Action


Rationale

Monitor Blood Pressure, Pulse, Pulse Oximetry Respirations

Vital observations indicate changes in underlying condition. Low blood pressure with high pulse, for example, would be suggested of haemorrhage. After aneurysm repair, an elevated BP can stress the graft site and cause graft failure (Irwin, 2007). This also increases myocardial oxygen demand, and an imbalance between oxygen supply and demand may lead to myocardial ischaemia and lead to MI (Irwin, 2007). Respiratory rate must be monitored post-anaesthetic, and observation of respirations allows the nurse to prepare for preventive measures to reduce the risk of atelectasis or DVT. Four hourly observations are usual from 24 hours postoperatively (Zeitz, 2005).

Monitor Temperature

Usually carried out four hourly, to detect potential sings of pyrexia, or reaction to blood transfusion (Jones and Pegram, 2006) or medications. Another complication could be malignant hyperthermia, although this is rare and unlikely to develop this late postoperatively (Neacsu, 2006).

Intravenous Monitoring and Fluid balance

Monitor site for patency and condition; monitor fluid intake and rate; record fluid balance. IVI pump checked at this time. Urinary output via catheter also recorded.

PCA/Pain

Pump check should usually be every hour if a controlled drug is used in the PCA, and recorded on the appropriate chart. Pain levels assessed (Manias, 2003).

Wound

Dressing observed for signs of exudates; wound observed for signs of healing/infection/dehiscence.

Wound drain

Site observed for signs of infection; drain bottle check for amount and type of exudates; fluid balance recorded.

Other monitoring specific to AAA repair.

Fluid and electrolyte balance; neurological status; full blood count (elevated white count indicates infection) (Beese-Bjustrom, 2004)

Assessment during the first 24 hours is usually aimed at establishing physiological equilibrium, managing pain, preventing complications and supporting the patient towards self-care (Watson-Miller, 2005). These are standard post-operative observations, but the care of the person having undergone abdominal aortic aneurysm repair may be somewhat more specific. Some of these areas will be dealt with in more detail below, considering the evidence base and the nature of nursing knowledge applied to the problem. The nursing knowledge applied in the assessment process derives from acquired knowledge (that gleaned during training, and study), and experiential knowledge, from previous experiences of applying theoretical knowledge to practice. If the nurse has previously cared for patients with this condition, she will apply that experience to this case. If not, the application of clinical, theoretical and other knowledge (such as colleagues’ experience) to the scenario, alongside thorough understanding of physiological principles, should result in effective and appropriate care. The evidence base must also be utilised.



Pyrexia

Having identified a potential problem in relation to temperature regulation, it is important to plan for ongoing monitoring, identification of the cause of increased temperature, treatment of the cause and relief of symptoms. The cause of the temperature is most likely to an infection. Nosocomial infection is a concern after surgery, especially when the patient has an incision involving any aspect of the vascular system (Irwin, 2007). In order to prevent wound infection, David will be prescribed IV antibiotics, which will then be changed to oral antibiotics at the appropriate time (Irwin, 2007). Symptomatic relief of the pyrexia can be achieved by fan therapy and the administration of paracetamol, which can be given PR if David remains nil by mouth. However, the nurse would ensure this was prescribed and not contraindicated due to any interactions with David’s other medications. David’s increased temperature may also be due to the development of ischaemic colitis (a complication of abdominal aortic aneurysm repair) and so white cell counts should be checked, as a raised count may be indicative of this (Beese-Bjustrom, 2004). The pyrexia may be in response to the blood transfusion (Jones and Pegram, 2006), although we would expect this to have developed earlier in the treatment.

At this point, David’s pyrexia indicated a potential problem, and may not require paracetamol or fan therapy. Instead, prevention of the development of infection, and reassurance that his feeling of being cold may be due to raised temperature, may suffice.



Blood Pressure Management and Fluid Balance.

Keeping David’s blood pressure within the normal range is critical to maintain end organ perfusion, and so both hypertension and hypotension must be prevented in this case (Irwin, 007). In order to prevent hypertension and the complications described above, David may be given IV beta blockers, and will be monitored for any cardiovascular changes such as chest discomfort, ST-T wave changes, or dysrhythmias (Irwin, 2007). Given his stability 24 hours post-operatively, he may be moved from ITU to a high dependency or standard surgical ward, where telemetry may then be stopped.

Monitoring mean arterial pressure and maintaining a reading of at least 70 mmHg can ensure proper perfusion of major organs, and this can be supported by careful infusion of intravenous fluids as described above (Irwin, 2007). In relation to fluid balance (and continuing organ functioning) a urine output of around 50ml/hour would indicate adequate glomerular filtration rate and renal perfusion (Irwin, 2007). Any deviations from these ‘ideals’ would be recorded and reported promptly to the appropriate members of the multi-disciplinary team (Irwin, 2007).



Pain Management

While David’s pain is being managed effectively with the Patient Controlled Analgesia (PCA) device, the use of a PCA is not a long-term means of pain management. Therefore, the planning stage of management of David’s care for the nurse looking after him should involved a collaborative plan for pain management. This may be in collaboration with the medical team, the anaesthetist, and David himself. A range of medications are available for David to use once he has reached a stage of being able to manage without the PCA, but it is also important that his pain be properly managed during the postoperative period, because good pain management will help David to mobilise properly and reduce the other postoperative risks, such as those of DVT, PE (Irwin, 2007) and pressure sore development.

Another area to address is the prevention of atelectasis. Regardless of the type of surgical procedure, as many as 90% of patients who have a general anaesthetic develop some degree of atlectasis in the postoperative period ( Irwin, 2007; Pruitt, 2006). Pneumonia is another risk (Irwin, 2007). As well as the risks from having an anaesthetic anyway, David is at increased risk because he is more likely to demonstrate postoperative hypoventilation, because pain from abdominal surgery can prevent him from deep breathing and coughing which helps prevent atelectasis (Pruitt, 2006). David can be taught to splint the surgical site with a pillow or roll of blanket, and then carry out these breathing exercises – incentive spirometry, coughing and deep breathing – to help keep his lungs clear (Irwin, 2007). Adopting a good upright position also helps to increase lung capacity and encourage deeper breaths (Pruitt, 2006), and so good pain management is also important in supporting David to do this (Irwin, 2007). Adequate pain control is also essential to graft patency, because uncontrolled pain causes the release or epinephrine, noreinephrine, and other hormones that active the fight or flight response (Bryant et al, 2002). The consequent vasoconstriction can decrease blood flow through the graft and can increase risk of thrombus formation (Bryant et al, 2002).

Alongside a drug therapy plan for pain management, it might also be appropriate to consider nondrug pain management as well (Tracy et al, 2006). Opioids used to manage postoperative pain can cause respiratory depression (Irwin, 2007). Some of the other advantages of nondrug pain management techniques is that they are readily available, inexpensive, and not associated with side effects, but the biggest advantage in this case is that they promote self-care and enhance personal control for one’s own health (Tracy et al, 2006). For David’s case, promoting self-care may have a number of beneficial effects on him holistically, given that he has recently experienced the diagnosis and treatment of a life-threatening condition (Manias, 2003). There is some evidence to suggest that tailored education and support in such therapies can benefit patient outcomes (Tracy et al, 2006), but this would require that the nurse is knowledgeable about the techniques, and that all members of the multidisciplinary team are equally invested and have been prompted to include nondrug pain management in the care plan (Tracy et al, 2006).



Prevention of Problems Associated with Aneurysm Repair.

There are a number of potential complications of surgical abdominal aortic aneurysm repair, which are in addition to the usual postoperative risks. These include graft rupture, haemorrhage, and graft occlusion (Irwin, 2007). This is another reason for close monitoring of David’s haemodynamic status, because a drop in blood pressure or urine output, associated with increased heart rate and perhaps a change in mental status may indicated shock consequent to blood loss (Irwin, 2007). It is also important to carefully and frequently assess the abdomen, for pain, distension or increasing girth (Irwin, 2007). Graft occlusion may manifest as coronary ischaemia, MI, cerebral ischaemia or stroke, ischaemic colitis or even spinal cord ischaemia resulting in paralysis (Irwin, 2007). Similarly, occlusion of an abdominal graft can also compromise renal blood flow, causing acute tubular necrosis and renal failure, or compromise peripheral circulation, which might lead to limb loss (Irwin, 2007). Therefore it might be prudent to calculcate ankle/brachial index regularly to evaluate lower extremity perfusion (Irwin, 2007).



Nursing Issues

In an empirical study of nursing in patients undergoing procedures for abdominal aortic aneurysm repair, Kozon et al (1998) found that patients who undergo the traditional open procedure require more intensive nursing care of lengthier duration, to move them along the illness-wellness spectrum towards self-care and independence. Kozon et al (1998) demonstrate a tailor made model based on the nursing process, which allows nurses to predict the postoperative course for individual patients. They also consider the psychological aspects of care, discussing the state of fear of patients, which is either externally visible to the nursing staff or is expressed by the patients themselves (Kozon et al, 1998). This is important in ensuring the holistic management of David’s care. However, Kozon et al (1998) also recommend further nursing research on this area to fully optimise nursing and enable the recognition of the nursing needs of the individual patient. This says much about the nature of nursing knowledge and the evidence base on this topic, which remains very much focused on the physical and medical aspects of care. Kozon et al (1998) developed a protocol to apply to such cases, but in terms of evidence, larger scale studies are needed to validate this. The high risks of both the procedure and the repair are highlighted in the literature (Bryant et al, 2002), and so a thorough understanding of these is vital in order to underpin nursing practice and ensure rapid and appropriate prioritisation of care needs, recognition of deviations from the norm and prompt, appropriate referral and treatment.

Another issue which the evidence base throws up is the documentation and monitoring of pain management. In a descriptive, retrospective audit of nursing records, Idvall and Ehrenberg (2002) found that there are many shortcomings in content and comprehensiveness of nurses’ monitoring and recording of patients’ pain. This is of particular importance in relation to postoperative care of those patients having undergoing surgical repair of abdominal aortic aneurysm, given that pain can indicate a number of complications of the procedure.



Conclusion

As can be seen, the care of the patient having an AAA repair is a complex undertaking, requiring a thorough knowledge base on the part of the nurse, and the skills necessary to recognise complications, deviations from clinical parameters, and effects of treatments in order to promptly and appropriately treat and refer the patient (Warbinek and Wyness, 1994). In David’s case, he has presented with a potential complication of his surgery, but the complex nature of his condition could mean that his potential pyrexia is due to a number of causes. Understanding the underlying physiology of his condition is vital in ensuring all his care needs are met and that he is kept in the optimal state of health to promote rapid recovery. This involves an holistic approach, with attention paid to his pain management and psychological state as well as his considerable medical and physical needs. The evidence base for care is suggestive of the existence of some useful nursing evidence on which to base care, but also suggests the need for more concrete and comprehensive research to underpin practice. Nursing assessment and intervention can be crucial to the survival of patients with this condition (Myer, 1995). Thus nursing knowledge must draw upon their own and other’s knowledge and experience, and the knowledge and understanding of the patient, and their reported symptoms and feelings, in order to provide the highest standard of care and promote David’s optimal wellbeing and return to health.



References

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Breastfeeding in first six months and Childhood Obesity

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Can breastfeeding in the first six months prevent childhood obesity?

Childhood obesity is becoming a worldwide concern given the potential health implications in the future. Obese children are more likely to suffer physical and mental health problems and are likely to develop into obese adults (Labayen, Ruiz et al. 2012), thereby increasing the long term risk of developing chronic conditions such as diabetes, cardiovascular diseases and stroke.

The cause of childhood obesity is multifactorial, including hereditary factors, comorbidities, dietary habits and physical activity. There is much debate as to the impact of breastfeeding during the early stages of life and how it correlates with childhood obesity compared with formula-fed newborns.

Breast milk is nutritionally balanced to provide infants with all dietary requirements during the early stages of life. It also provides antibodies to reduce infection risks in newborns. Breast milk constitutes the appropriate amounts of protein, water, fat and sugar for a newborn and changes composition over time to adapt to a growing child’s needs. Formula tends to be higher in protein and fat than the baby actually requires and this excessive intake has been linked with adiposity (Hernell 2011). Marseglia et al have reviewed the potential impact of key breast milk constituents thought to play a role in reducing obesity risk (Marseglia, Manti et al. 2015).

There have been a number of recent reviews discussing the association between breastfeeding and childhood obesity, all of which have concluded that breastfeeding confers a protective effect against childhood obesity and being overweight (Horta and Victora 2013, Aguilar Cordero, Sánchez López et al. 2014, Lefebvre and John 2014, Yan, Liu et al. 2014). The largest reduction in obesity risk was 81%, reported in a study of females aged 11 years of who had been breastfed for more than three months compared with controls who had never been breastfed (Panagiotakos, Papadimitriou et al. 2008). The males in the same study had a reduced risk of 72% and both results were statistically significant. However, other literature reports either no association between breastfeeding and childhood obesity (Burdette, Whitaker et al. 2006, Huus, Ludvigsson et al. 2008, Jing, Xu et al. 2014), or an increased risk of obesity following breastfeeding of 9% (Kwok, Schooling et al. 2010), 10% (Novaes, Lamounier et al. 2012), 11% (Buyken, Karaolis-Danckert et al. 2008), 14% (Sabanayagam, Shankar et al. 2009), 18% He (2000), 29% (Al-Qaoud and Prakash 2009), 34% (Neutzling, Hallal et al. 2009), 40% (Toschke, Martin et al. 2007) and 83% (Araújo, Victora et al. 2006), although none of which were statistically significant.

Some studies suggest that there is a dose-response relationship, with increased duration of breastfeeding resulting in a decreased prevalence of being obese in childhood (von Kries, Koletzko et al. 2000, Fallahzadeh, Golestan et al. 2009, Griffiths, Smeeth et al. 2009, Yan, Liu et al. 2014). In contrast, other studies have reported no significant association between breastfeeding and its duration and obesity prevention (Burke, Beilin et al. 2005, Al-Qaoud and Prakash 2009, Sabanayagam, Shankar et al. 2009, Vehapoglu, Yazıcı et al. 2014).

One meta-analysis analysed the association between breastfeeding duration and obesity (Yan, Liu et al. 2014). As eligible studies reported different durations, the review categorised breastfeeding duration into less than three months, 3-4.9 months, 5-6.9 months and seven or more months. Those exclusively breastfed for at least seven months had a 21% decrease in the risk of childhood obesity, whilst those fed for less than three months only showed a 10% decrease. They concluded that the duration of breastfeeding was associated with a decreased likelihood of childhood obesity and reported a stepwise gradient of decreasing risk with increasing duration of breastfeeding.

Single studies report a significant protective effect against childhood obesity when breastfeeding is done for at least one to three months (Goldfield, Paluch et al. 2006), three months (Twells and Newhook 2010), 13-25 weeks (McCrory and Layte 2012), four months (Scholtens, Gehring et al. 2007, Griffiths, Smeeth et al. 2009, Chivers, Hands et al. 2010), nine months (Nelson and Sethi 2005), 12 months (Burke, Beilin et al. 2005) and two or more years (Rathnayake, Satchithananthan et al. 2013). However, the differences in study design make it difficult to directly compare findings as the comparator groups can be formula-fed babies or babies’ breastfed for short durations.

For studies investigating the impact of breastfeeding for at least six months on childhood obesity, the comparator group can be either newborns breastfed for less than six months (i.e. mixed feeding of variable durations) or newborns exclusively formula-fed. Additionally, the age of the children being assessed also differs in studies. When comparing those breastfed for at least six months with those breastfed less than six months, studies report a reduction in obesity risk of 60% when assessing two year olds (Weyermann, Rothenbacher et al. 2006), 54% and 43% in four year olds (Komatsu, Yorifuji et al. 2009, Simon, Souza et al. 2009), and 67% in six year olds (Thorsdottir, Gunnarsdottir et al. 2003). This suggests that the age of assessment affects the degree of risk reduction observed. However, when comparing against formula-fed newborns there are studies reporting reductions of 14%, 28% and 67% for three year olds (Poulton and Williams 2001, Armstrong, Reilly et al. 2002, Taveras, Rifas-Shiman et al. 2006), 6% for four year olds (Moschonis, Grammatikaki et al. 2008), 45% for seven year olds (Yamakawa, Yorifuji et al. 2013), 60% for nine year olds (Toschke, Martin et al. 2007), 64% for 11 year olds (Poulton and Williams 2001), 21% for 21 year olds (Poulton and Williams 2001) and 6% for 45 year olds (Michels, Willett et al. 2007). This data suggests that observing adults to determine the impact of breastfeeding on obesity is not advisable.

Only one study reported an increased risk of obesity for newborns breastfed more than six months compared with formula-fed newborns, reporting a non-significant 40% increased risk of obesity in nine year olds (Toschke, Martin et al. 2007).

Interestingly, very few detailed, for those breastfeeding for at least six months, whether the feeding duration was exclusively breastfeeding or mixed. Only two studies (Simon, Souza et al. 2009, Yamakawa, Yorifuji et al. 2013) reported on exclusive breastfeeding. There is evidence that exclusive breastfeeding also results in a decreased prevalence of being obese in childhood (Fallahzadeh, Golestan et al. 2009, Simon, Souza et al. 2009, Lefebvre and John 2014). Mayer-Davis et al (2006) compared exclusively breastfed newborns with exclusively formula-fed newborns and found that the breastfed children were significantly less likely to be overweight (34%) and that the results were not affected by maternal weight or diabetes status (Mayer-Davis, Rifas-Shiman et al. 2006).

When exploring the differences between studies who defined breastfeeding as “Never – ever” and those reporting “exposure” to breastfeeding (implying mixed feeding practices of different types), a systematic review found a reduced likelihood of obesity in the exclusive feeding group of 20% and in the mixed group of 27% (Yan, Liu et al. 2014). This was supported by another review comparing “ever” breastfed with “exclusively breastfed for a specific number of months”, the latter showing a 27% decreased risk compared with the former at 21% (Horta and Victora 2013). That review postulated that if there is no critical window effect, but rather a cumulative effect of breastfeeding, studies that compared ever vs. never breastfed subjects will tend to underestimate any association.

Any observed association between breastfeeding and later obesity does not prove causality (Butte 2001). There may be any number of potential confounders impacting on the relationship including geography, social deprivation status, parental weight status, smoking, marital status and education, ethnicity, gender, number of hospital admissions during the early stages of life, diet, sleep duration and physical activity. Whilst a number of studies discuss their impact, very few studies actually provide control for these factors in their analysis.

The issue of geography is a potential confounder of any association between breastfeeding and obesity. In high-income countries, the babies usually receive formula, whereas many

non-breastfed infants in low and middle income countries receive whole or diluted animal milk (Horta and Victora 2013). However, Hancox et al have reported that whilst breastfeeding reduced the risk of obesity slightly, there was no evidence that an association between breastfeeding and body mass index (BMI) was different in lower income countries compared with higher income countries (Hancox, Stewart et al. 2014).

The socio-economic status of the mother may also contribute to the child’s weight status in childhood. The World Health Organisation (WHO) review analysed obesity risk in studies also controlling for social deprivation and found a further 3% decrease in the risk of obesity to 37% compared with studies which did not (34%) (Horta and Victora 2013). Armstrong et al reported that the reduced prevalence in obesity for breastfed children also persisted after adjustment for socio-economic status, birth weight and gender (30% reduction) (Armstrong, Reilly et al. 2002).

The impact of gender was prominent as Nelson et al reported that breastfeeding for at least nine months reduced the risk of being overweight more in girls than in boys (Nelson and Sethi 2005). A similar gender inequality was reported by Panagiotakos et al with girls breastfed for more than three months having a larger reduced risk of obesity than the boys (Panagiotakos, Papadimitriou et al. 2008).

Sibling studies have been unable to rule out the impact of confounders on childhood obesity. One study which controlled for this as part of a sibling study reported the adolescent BMIs were 0.39 standard deviations lower in the breastfed sibling than the non-breastfed sibling (Metzger and McDade 2010). However, another study of sibling pairs was unable to prove a protective effect for breastfeeding (Nelson and Sethi 2005).

As well as the lack of control for confounders, other study limitations may affect the results reported. Definitions of obesity vary from a BMI of ≥90th to ≥97th, making any direct comparison of the outcome problematic. During their meta-analysis Yan et al investigated the association of breastfeeding and obesity, stratifying by the definitions of obesity and found a lower adjusted odds ratio for the BMI ≥ 97th group (25%) than the BMI ≥ 95th group (22%) (Yan, Liu et al. 2014).

Most studies varied in the time when obesity was measured. As the definition of childhood can extend from one year olds to adolescents, there is an increasing influence of external and genetic factors on a child’s weight as potential confounders for any weight gain. When Scholtens et al looked at children breastfed for at least four months they reported a significantly lower BMI at age 1 compared to children not breastfed, but at age 7 this difference was no longer significant (Scholtens, Gehring et al. 2007). The WHO review reported a 38% decreased risk of obesity when assessing 10-19 year olds compared with 23% for 1-9 year olds and 11% for adults aged 20 and over, suggesting that endpoint for analysis is critical in determining the impact of breastfeed on obesity at various stages in childhood (Horta and Victora 2013).

Finally, study design and follow up can affect the findings as high dropout rates affect long term follow ups, and the methodology used to analyse the results can produce unreliable results. Beyerlein et al investigated the impact of breastfeeding on children’s BMI in Germany but was unable to make any firm conclusions as the results differed according to whether they used linear or logistic regression (Beyerlein, Toschke et al. 2008).

To summarise, there is a wealth of literature reporting the decreased risk of childhood obesity for newborns who are breastfed, although there was limited literature exploring those breastfed for at least six months. However, most studies cannot completely control for confounding maternal, child, cultural, genetic and environmental factors. The WHO recommend that infants should be exclusively breastfed for the first six months and that it should be supplemented with additional foods for the first two years (World Health Organisation 2015). Following close examination of the literature, we would conclude that breastfeeding for at least six months should reduce the risk of obesity in early childhood, although the protective effect may be lost in latter childhood depending upon the child’s upbringing.

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Did the author identify a specific perspective from which the study was developed? If so, what was it?

/in /by

Did the author identify a specific perspective from which the study was developed? If so, what was it?

Method of Study:

Were qualitative methods appropriate to answer the research questions?
Did the author identify a specific perspective from which the study was developed? If so, what was it?
Did the author cite quantitative and qualitative studies relevant to the focus of the study? What other types of literature did the author include?
Are the references current? For qualitative studies, the author may have included studies older than the 5-year limit typically used for quantitative studies. Findings of older qualitative studies may be relevant to a qualitative study.
Did the author evaluate or indicate the weaknesses of the available studies?
Did the literature review include adequate information to build a logical argument?
When a researcher uses the grounded theory method of qualitative inquiry, the researcher may develop a framework or diagram as part of the findings of the study. Was a framework developed from the study findings?