1. What are the notable advantages and disadvantages of the use of medical records versus administrative sources for collecting quality data2. What are common data-quality data problems in healthcare

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1. What are the notable advantages and disadvantages of the use of medical records versus administrative sources for collecting quality data?

2. What are common data-quality data problems in healthcare performance measurement? How should the sufficiency of data quality be evaluated? What consequences are associated with the use of poor quality data?

3.  Identify 4 ways in which e-health benefits patients. Name two barriers to using e-health. Explain your reasoning for all questions.

Use information from the modular background materials and case assignment narrative as well as any quality resources you can find via the online libraries or Internet.

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Use information from the modular background materials and case assignment narrative as well as any quality resources you can find via the online libraries or Internet.
Module 4 — CASE ASSIGNMENT

For this case assignment, you are surgeon and you will be making a decision
regarding the following case: The Case of Peg-Leg Pete

Pete is a 65 years old man who is an accountant that owns a private firm and has
a wife, 3 children, and 2 grandchildren. He is appears to be very intelligent and
articulate. He enters your office for a surgical consultation and requests that you
amputate is right leg. Upon examination of the leg, it seems healthy. You ask
him why he wants his leg amputated and he says, “I am not happy with my
present body, but long for a peg-leg.” He states he has wanted a peg-leg since
he was 12 years old and considered cutting it off himself many times but
“chickened out” each time. He tells you, “Naturally over the years I have thought
of many arguments against amputation, have … considered them and rejected
them… It is not normal. But what is normal and who is normal? No one has the
right to deny or keep me from this way of life.”
He now states he has the money to do it right and safely. He was considering
going to Mexico to have it done but wanted it performed in an environment he
felt was safer. He offers to pay for the surgery in cash, which is a large sum of
money. This money could help you grow your practice by hiring staff and buying
a new piece of equipment you have put off getting. You fear that if he leaves
your office, you will lose a substantial amount of money to another doctor.
You immediately leave the room and contact a psychiatrist colleague you know and inform him of the situation. He states the patient has a diagnosis called
apotemnophilia, which is a desire for amputation. Although the diagnosis is rare
and uncomfortable, it does not necessarily demonstrate incompetency or
incapacity of mind.

Assessment data use Gordon’s Functional Assessment Patterns and are adequate in depth, scope and accurately presented

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Assessment data use Gordon’s Functional Assessment Patterns and are adequate in depth, scope and accurately presented

 

Community Assessment Project Grading Rubric CONTENT: Category Weight Points (out of 9)
Introduction is included and uses windshield survey to highlight initial community assessment findings
5 %
Assessment data use Gordon’s Functional Assessment Patterns and are adequate in depth, scope and accurately presented
o Health Perception/Health Management Pattern(
o Nutritional/Metabolic Pattern
o Elimination Pattern
o Activity/Exercise Pattern
o Sleep-Rest Pattern
o Cognitive-Perceptual pattern
o Self-Perception/Self-Concept Pattern
o Role-Relationship Pattern
o Sexuality-Reproductive Pattern
o Coping-Stress Pattern
o Value-Belief Pattern
35%
Strengths and weaknesses of the community are identified and are supported by the community assessment data.
5%
The 3 nursing diagnosis are appropriate and supported by assessment data
5%
Proposed intervention(s) is appropriate for the identified problems/risks, and are feasible. Intervention addresses all three levels of prevention
10%
Evaluation criteria are identified, measurable and utilize appropriate data/resources to document outcomes
10%
Clearly identified Healthy People 2020 objective(s) related to the population
5%
STYLE:
Completed project contains: pictures, brochures, etc. within the appendices. Content is presented in a clear and organized fashion without unnecessary repetition. Data/content demonstrates consistency across the sections.
10%
Document contains a table of contents, summary/conclusion, and appropriate supporting materials as appendices.
5%
MECHANICS:
Final document contains proper spelling, grammar, and sentence structure. Sixth ed. APA elements are observed with regard to mechanics (margins, spacing, headings, pagination, etc.) and citation/references

Pressure Ulcers In ICU Custom Essay

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Pressure Ulcers In ICU Custom Essay

A total of four annotated bibliographies are to be submitted (not to exceed one page each). The articles must come from nursing scholarly literature and may not be older than 5 years since publication. Please note that the articles must be research based and reflect a qualitative methodology (review our reading assignments). Web pages, magazines, textbooks, and other books are not acceptable.

Each annotation must address the following critical elements:

•Explanation of the main purpose and scope of the cited work

•Brief description of the research conducted

•Value and significance of the work (e.g., study’s findings, scope of the research project) as a contribution to the subject under consideration

•Possible shortcomings or bias in the work

•Conclusions or observations reached by the author

Prevalence and Spread of TB in the UK

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“Discuss the prevalence and spread of TB in the UK today. Include epidemiology,


vaccination, testing and treatments.” 1650 words

———————————————————————————————————————

‘Tuberculosis figures fall by a third in six years’ (BBC 2018)

Recent headlines testify to a on a downward TB trend nationwide  (ECDC 2019), reaching the lowest ever recorded rates in 2017 (TB Alert 2019). Behind the headlines, the fact remains that despite this reduction in incidence, the UK has one of the highest rates in Western Europe with 8.9 people affected per 100,000 (ECDC 2019). This essay will explore the reasons behind this as well as the strategies being employed to reach the WHO target of elimination of TB as a worldwide public health issue by 2035 (WHO 2018).

In 2011, TB figures in the UK reached a post-war peak (TB Alert 2019) with 15 people affected per 100,000. Within the UK, England has the highest rates and Wales the lowest (Public Health Wales 2018).


[1]

Whilst the current figures appear to show the successful implementation of strategies to curb that rise, they reveal a stark epidemiological disparity.  As shown in figure 1, those that experience the greatest level of social deprivation are far more likely to suffer from the disease than those that experience the least – the bottom 10% are 7 times more vulnerable that the top 10% (PHE 2017).

Figure 1: TB rates in relation to deprivation status (PHE 2017)

In understanding the epidemiology of TB, it is vital therefore that we also consider the social determinants that contribute to TB’s prevalence and spread and the challenges they present to treatment and efforts to eliminate the disease.

The perception of TB has changed much over the past two centuries. At the end of the nineteenth century, its victims were romantically depicted as suffering from a wasting disease marked by ‘a refinement of the body, heightened artistic sensibilities, and ennoblement of the soul’ (Tabrah 2011). When the scientist Koch isolated the tubercule bacillus, he proved that TB was in fact an infectious disease rather than a consumptive and romantic infliction (Barberis et al 2017). However, as the 2017 Public Health England report (PHE 2017) highlights, factors of socio-economic inequality including unemployment, homelessness, levels of poverty and access to healthcare provision are crucial factors to understanding the disease as it presents in the UK today. Figure 2 highlights identified social risk factors linked to increasedTB incidence.

Figure 2: Social risk factors and TB rates in UK (PHE 2017)

As Koch discovered, tuberculosis is caused by infection with

Mycobacterium tuberculosis

after inhalation of an infected droplet from an infected person. It is also possible to contract TB from unpasteurised milk infected with

M. bovis,

a related organism. In the UK, since most milk is pasteurised, the respiratory route is the primary mode of infection (Smith 2003). It is important to note that development of the disease is determined by the host’s immune response. Only 5% – 10% of those infected will go on to develop active disease within their lifetime (WHO 2018). Both intrinsic and extrinsic factors are involved – crucially the physiological and nutritional state of the person as well as the current state of immune system (Smith 2003). Children, advanced HIV sufferers and people with other immunocompromising conditions are the most vulnerable *(Menzies et al 2018). Given the prevalence of the disease amongst the most deprived including those with risk factors, it is clear that TB is not just a public health issue but a social concern.

Upon infection,

M. Tuberculosis

enters the alveoli and forms granuloma in the lungs. These granuloma then join to form primary lesions, known as pulmonary TB. The bacterial organisms can subsequently spread, either lymphatically or haematogenously, to other organs in the body resulting in extrapulmonary TB. Latent TB infection (LBTI) is the result of the primary lesion being contained within a fibrous capsule (Walker et al 2013). It is asymptomatic and cannot be transmitted though may be reactivated (Menzies et al 2018).  One author states that it is the reactivation of latent TB that causes most adult cases of TB in non-HIV infected people (Smith 2003). A more recent paper challenges this argument, showing that in fact it is only in country with a low TB burden – such as the UK – that this holds true (Behr et al 2018).

Public Health England states that those people born outside of the UK accounted for 71% of reported TB cases (PHE 2017). This may be attributable to both higher TB burden in the country of origin as well as:

‘a wider ‘hostile environment’ [which] includes mechanisms that restrict access to healthcare and housing for migrant populations, which heightens the exposure rate of TB to those already most at-risk of TB.’                            (Race Equality Foundation 2018)

Attempts to control TB levels include pre-entry screening and latent TB testing for all new migrants between the ages of 16-35 from countries with a high incidence of TB (PHE 2017). Screening is also advised by NICE guidelines for those in close contact with TB patients, healthcare workers and immunosuppressed patients such as those with HIV (NICE 2016). Latent TB screening is done either by a tuberculin skin test or  interferon-y assays (IGRA) which are cell mediated blood tests. though poor sensitivity linked to the skin test including from previous TB vaccines suggest combined use or IGRA use alone (Abubakar 2012). The screening for LBTI means early diagnosis and chemoprophylactic treatment and is seen as ‘the cornerstone of TB control in high-income low incidence countries’ (Abubakar n.d.).

As discussed, many of high risk groups within the UK – such as prisoners, the homeless and substance abusers are the hardest to reach. This means that diagnosis and treatment is also challenging (Abubakar 2012).The Find and Reach service in London recognises that the people that it works with often escape early TB detection as symptoms are masked by lifestyle and furthermore they cannot easily access diagnostic services. They offer both latent and active testing. The latter is done by chest radiographs within a mobile unit (UCLH n.d) and can also be detected using sputum smears and culture (Abubakar 2012).

Completion of the six month daily antibiotic treatment regime required for active TB can be challenging. Latent TB patients may also be prescribed antibiotics unless suspected of drug resistance. Both treatment regimes can involve side effects such as peripheral neuropathy and liver damage (NHS 2019). Consequently, patients working with the outreach team have higher transmission rates, greater risk of developing mutliple drug resistant TB (MDR-TB) and relapsing, compounded by poor, unsanitary or no housing (Story et al 2007). Solutions such as directly observed treatment (DOT) are used (UCLH n.d.). There is some discussion over the success of DOT leading to the development and recent trial of Video Observed Treatment (VOT). By giving patients free smartphones and training them to video themselves ingesting their treatment doses, the study showed both a higher uptake rate as well as a greater success rate than DOT. The study also concluded that the technology offered cost savings due to decreased staff time even with the cost of phones taken into account (Story et al 2019).

As indicated, failure to complete treatment increases the risk of developing multiple drug resistance. Whilst overall rates of TB have fallen according to 2017 figures, Public Health England notes that the rates for drug resistant TB have not.  Within groups with social risk factors the likelihood of developing MDR TB was almost twice as high (PHE 2017). This once more highlights the importance in addressing those most at risk and the value of work being done by research teams to find new ways to both engage and treat them.

Recent drug trials have also explored shorter treatments of alternative antibiotics to reduce harmful side-effects (Menzies et al 2018). In terms of MDR TB, research shows how genome sequencing can identify mutations  indicative of drug resistance and therefore inform further treatment (Brown 2015). One area that has seen little change is the development of TB vaccines. The only vaccine currently licensed, bacillus Calmette–Guérin (BCG) was introduced over a century ago. Efficacy of the vaccine varies depending on location but it is poorly understood. Genetic variability in the strains used alongside hypotheses relating to pre-sensitisation by environmental mycobacteria and variability in vaccine batches are amongst explanations given (Davenne and McShane 2017). Evidence shows that neo-natal BCG offers good protection against extra-pulmonary and pulmonary TB in young children but offers variable efficacy against pulmonary TB in adults (Dockrell and Smith 2018). The significant heterogeneity seen means that currently it does not offer guaranteed protection against the disease and is therefore limited in its use and reliability. Development of further vaccines is hampered by incomplete understanding of the BCG vaccine’s efficacy (Davenne and McShane 2017).

In concluding this essay, I would like to return to the shocking statistics that frame the UK’s TB figures – that the most deprived are most affected by the disease. There is no way that we can address TB without also putting due attention on the social determinants behind its prevalence in this country. The UK is ranked as the fifth most unequal country in Europe in terms of income distribution (Partington 2018). Homelessness has risen dramatically in the last 20 years – 165% between 2010 and 2018 (Homeless link 2018).  Prison numbers remain high (Houses of Parliament 2018). Figures for class A drug use in the young are on the increase (Home Office 2018). The use of food banks have similarly increased (Trussel Trust 2018). Overall poverty in the UK is on the increase (Fullfact 2018)

Figure 3: Poverty Rates in UK (Fullfact 2018)

As the Public Health England report states, there is no room for complacency in the downward trend in TB figures. TB is a disease associated with poverty (Oxlade and Murray 2012). Furthermore the stigma that it receives means that diagnosis and detection may be complicated. As we see, the current conditions in the UK increase the numbers of people within the most at risk groups as well as overall nationwide trends in poverty – all of which give rise to conditions that favour future TB spread and cause for present concern.



REFERENCE LIST



[1]


Figures for TB are collected by regional Public Health Boards (England, Scotland and Wales. Thiis essay will refer to regional figures where relevant.

Imperforate Hymen: A Case of Pediatric Acute Urinary Retention

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Imperforate Hymen: A Case of Pediatric Acute Urinary Retention


Ricardo González in

Handbook Of Urological Diseases In Children

defines Acute Retention as “… the inability to void occurring in a patient who was until then voiding normally. Chronic retention is the chronic inability to empty the bladder completely. The patient may simple void incompletely in an apparently normal fashion or simply dribble urine constantly (overflow incontinence).” (1) Urinary retention in children is evident through signs of dribbling, weak stream, the inability to initiate bladder emptying, abdominal pain and palpable abdominal mass.

According to the study by Asgari et al the causes of urinary retention in boys found lower urinary tract stones in 38%, neurological disorders in 12%, and local inflammation in 10%; while in girls, urinary retention were caused by ureterocele in 21.4%, trauma in 17.8% and imperforate hymen in 10.7%.(2) They also observe that the incidence of lower urinary tract stones was 5.5-fold in boys (38.5% versus 7%). The rates of injury and stoppage were about equivalent in young men and young ladies. Kind obstructive injuries, prostatic utricle, urethral outside body, and prune midsection disorder were seen exclusively in young men, and ureterocele, imperforate hymen, and Hinman disorder all were seen only in young ladies. In their investigation of 86 patients, 24 (22 male and 2 female) had lower urinary tract stone, in which the most widely recognized area was urethral meatus (75%). Frequently, urethral stone in guys are begun from bladder. Essential urethral stones can likewise be shaped in the setting of urethral stricture, urethral diverticula, or urethral pocket. (2)

In a study by Gatti et al of 53 children, 37 boys 6 months to 17 years old and 16 girls 1 to 17 years old. In this study, Urinary tract infections were 6 times more common in females than males (31% versus 5%). Constipation and local inflammatory processes were twice as common in females than males (19% versus 11% and 12% versus 5%, respectively)(3)

According to Okafor and fellow researchers, Imperforate hymen “occurs when the sinovaginal bulb fails to canalize with the rest of the vagina” (4) and note that this fact can be corroborated by the absence of the track of mucus at the posterior commissure of the labia majora in newborns or by visualization of the bulging hymen after puberty. According to Messina et al, Imperforate hymen (IH) is the most frequent congenital malformation of the female genital tract. (5) Yildirim et al mention that “The estimated incidence of imperforate hymen (IH) is 0.1%–0.014%.” (6)


Incidence in girls

Urinary retention is a more common phenomena in male rather than female. Etiology for urinary retention can be widely classified as neurological, voiding dysfunction, constipation, drug complications, urinary tract infections, inflammation surrounding the area, neoplasm invading locally or any benign pathology obstructing the area.

Imperforate hymen is usually asymptomatic until puberty, as that is when the hormones start kicking in and the uterus is functional. Thus the symptoms are related pubertal phenomena such as menstrual cycle. The most common clinical complaints by the patient is of pelvic pain. A manifestation of this condition in infants due to the influence of maternal estrogen was noted by Farzaneh et al. In this condition, the utero vaginal secretions result in the formation of hydrocolpos. However, this is a very rare condition which is found only in 0.006% of all the patients with imperforate hymen. (7)

In a research by Mustafa Basaran and fellow researchers, the incidence of imperforate hymen at birth is 0.1 to 0.05%, which points to the most common cause of genital flow obstruction. (8) However, other than these syndromes, imperforate hymen is not associated with any urogenital anomalies and the treatment of choice is a simple surgery in which the excess hymen tissue is excised.

Writing from a context like Turkey, they note the meaning of surgical removal of the hymenal tissue. They locate the meaning of this surgical removal having diverse meanings within the sociocultural and connotations. In this context, it is to be noted that the psychological and sociocultural consequences for persons who are located in diverse cultures and religious communities cannot be the same and has repercussions for physicians who advice the same for their patients. The contexts of diagnosis and occurrences of the cases in America, Turkey, India, Bangladesh and Britain can be so different and would demand diverse healthcare responses. In order to authentically understand the nuances of diagnosis, treatment and healing, in diverse sociocultural contexts this is a significant observation to deal with for a range of healthcare professionals and researchers. For instance, such scenarios can be seen as merely healthcare-driven in one context while in other places, it can be also about morality, cultural purity.

Two case studies will be presented here, first one is of a girl around 20 days old. She was premature and born via vaginal delivery and was immediately admitted at the hospital because of abdominal distention and urinary retention. There was no history of trauma, however on physical examination, a large midline mass was palpated above the umbilicus along with obvious mucosal bulging under urethral meatus. Abdominal ultrasonography confirmed bilateral hydronephrosis. Even though the serum creatinine level and the electrolytes were normal, but the catheter insertion seemed impossible. As a first step, 300 ml of cloudy urine was drained through suprapubic access to the bladder. Thus, Magnetic resonance urography was used to rule out its differential diagnosis.

Imperforate hymen can also present with syndromes such as McKusick-Kaufman and Bardet-Biedle syndrome, however, isolated imperforate hymen are more common as compared to these and their prognosis is also good.

There is an ongoing debate on the time when the surgery should be performed. Kahn et al did a research on this phenomenon by assessing conservatively 2 girls who had uncomplicated imperforate hymen who had early (infant) diagnosis. They concluded that imperforate hymen which is asymptomatic can be treated expectantly in which there will be no spontaneous opening. However in symptomatic patients, incision of the hymen is necessary in which the excessive tissue is removed. Going towards delayed treatment when the symptoms arise can be good in the sense that it prevents risk of local anesthesia in children, though it increases the chances of endometriosis. In a study by Posner and Spandorfer, it was found that the earliest age to develop symptoms can be as low as 10.9 years, hence it is important to treat it before menarche. (9)


Underlying causes

In a study regarding associated abnormalities, results concluded that out of the total number 13 girls had an imperforate hymen, 6 had vaginal atresia and 4 had double genital systems, consisting of 2 with unilateral vaginal atresia, and 2 with unilateral imperforate hymen. One girl had-a urogenital sinus, however, there was no genital distension in 3 children, but 6 developed hydrocolpos, one had hydrometrocolpos, one unilateral hydrometrocolpos with hydrosalpinx in a double system, and 7 had haematocolpos, 3 haematometrocolpos, 2 unilateral haematocolpos, and one had unilateral haematometra with haematosalpinx. Further investigation showed that Anorectal abnormalities were present in 9 girls, out of which had a minor, low lesion amenable to anoplasty, and the other girl had high rectal atresia had the common variety with a colovestibular fistula. One girl reported with an anorectal atresia without a fistula.

Four had hydrocolpos with the distal end of the large bowel draining into a closed vagina and one had cloacal exstrophy with a double uterus and a vaginal lesion of which the investigation is still under process. Lastly, One girl was found to have true rectal stenosis (10)



Description of female reproductive structures

Up until about week 7 to

week 8 of pregnancy

, both sexes have what’s known as a “genital ridge” — i.e. an identical preliminary set of genitalia that will eventually differentiate to become either male or female sex organs. That means that all our sex organs come from the same foundations: The testes in men are equivalent to labia and ovaries in women, and the penis is the equivalent of the clitoris.

All babies would develop female sex organs if it weren’t for the male hormone testosterone. At around

week 7

, the Y chromosome signals for the start of testosterone production, and male genitalia begin to develop. Peak concentrations of testosterone in your baby boy’s body are comparable to the amounts found in adult men at around

week 16 of pregnancy

. And then, between 16 and 20 weeks, testosterone levels fall until they reach the range found in early puberty by about

24 weeks

.


Renal impairment

Renal impairment occurs in neonates receiving indomethacin for treatment of patent ductus arteriosus. Inhibition of cyclooxygenase within the neonatal kidney results in decreased prostaglandin synthesis and consequent reduction in renal perfusion. Indomethacin has been reported to cause short-term reduction in glomerular filtration that resolves after cessation of the drug. There is little information on the long-term effects of postnatal exposure to indomethacin. The aim of this study was to determine the incidence of renal impairment in infants treated with indomethacin in a single center, to determine whether there is evidence of renal impairment on day 30 or at discharge, and to identify risk factors for renal impairment. In a retrospective study, infants of less than 30 weeks completed gestation who received indomethacin to close the ductus arteriosus were matched with infants of the same gestation, birth weight, and severity of illness. Serum creatinine and glomerular filtration rates (GFR) were obtained prior to commencing indomethacin and on days 2, 7, and 30 following indomethacin administration. Acute renal failure was defined as an increase in creatinine of greater than 25%. Of those infants who were less than 30 weeks completed gestation, 24% had acute renal failure following indomethacin administration. There was a significant elevation in serum creatinine on day 2 and day 7 ( P<0.0001, P=0.002) and a decrease in GFR on day 2 and day 7 ( P<0.0001, P=0.01) following administration of indomethacin. Renal function had normalized by day 30 or discharge. The incidence of acute renal failure in neonates treated with indomethacin is clinically significant. Renal function returns to normal by day 30. Linear regression found no statistical significance for gestational age, day of indomethacin dosing, Clinical Risk Index for Babies (CRIB) score, and presence of an umbilical artery catheter to confound the effect of indomethacin on renal function. (11)


Infertility

Imperforate hymen, if not diagnosed and treated early can lead to some very serious complications like vaginal infection, kidney issues and even endometriosis in severe conditions. Endometriosis is basically a fertility reduction condition which can also lead to infertility. There is a great variation in its signs and symptoms as opposed to the severity. (12) However, the severity of your symptoms in no way indicate the stage of this condition.

Talking about the signs and symptoms, pelvic pain is proven to be the most common followed by many other, such as:

–          Pain during menstrual cycles

–          Pain preceding and proceeding menstrual cycle

–          Severe to moderate cramps when the dates are near

–          Heavy bleeding

–          May bleed on normal days (other than the ones for menstrual cycle)

–          Pain after sexual intercourse

–          Discomfort or pain during bowel movements

–          Sudden lower back pain

Contrary to the mass belief, imperforate hymen is also possible to exist without any sigs and symptoms. Thus, it is very important to get regular gynecology exams, especially during peak ages when the hormonal balance is changing (puberty). Also, it is advised to get regular checkups especially when you have 2 or more of the above listed signs and symptoms.


How is it investigated

Imperforate hymen is a congenital disorder where the hymen completely obstructs the vagina. The main etiology is when the hymen fails to perforate during fetal development. Thus, it is found in young girls as well as women with a varying degree of signs and symptoms. However, depending on factors such as uterus activity and sexual intercourse, the signs and symptoms have peak timings. For example, menstrual blood tends to accumulate in the vagina due to the obstruction, which can only happen after a girl reaches puberty.

It is imperative to understand these peak times in order to make the correct diagnosis and use precise investigative tools. Diagnosis of imperforate hymen is usually done in adolescent girls when they reach the age of menarche. Some of the most common clinical symptoms presented are as follows:

–          Amenorrhea

–          Cyclic pelvic pain

–          Vaginal infections

To further confirm the diagnosis, clinical examinations are down. Clinically it appears as a blue bulging membrane. However, if hematocolpos is present, the mass is pronounced and palpable on abdominal and rectal examination. (13)

Investigations for imperforate hymen mainly relies on clinical inspection, however, if necessary, following procedures can be performed to further confirm its presence;

–          Transabdominal ultrasound

–          Transperineally ultrasound

–          Transrectal ultrasound

Ultrasounds can also detect imperforate hymen during the fetal stage and right after the baby is born. The key finding in babies with imperforate hymen is a bulging mass at the abdominal region or at the pelvic, and at times, a bulging hymen may also be visible. This can be very effective yet while examining a neonatal vagina, there is a slight mucus discharge at the posterior commissure of the labia major. If this secretion is absent, it indicates blockage of the vagina which may be due to imperforate hymen or other vaginal obstructions.


Treatment (hymen incision)

The best way to fix an imperforate hymen is a minor surgical procedure. It is also possible to safely perform this procedure on infants given that an early diagnosis is made. However, most parents opt to wait for pubertal age of the girls as adolescent girls heal much faster and with less complication chances than the infants. (14)

The area is first kept under local anesthesia. After profound anesthesia dose, the surgeon makes a small incision in a way to remove the excess tissue, leaving behind a normal vaginal opening. If any blood is accumulated in the vaginal prior to the procedure, it is carefully removed and cleaned to avoid any infections or delayed healing.

To prevent any relapse or regrowth, the surgeon may also place a ring for a period of time to maintain the normal vaginal opening. Another alternative for rings is dilators that are quite often. Dilators are devices resembling a tampon which are to be placed in the vaginal every day for 15 minutes during the healing phase.

Some people have reservations with surgeries due to certain myths that come along vaginal surgeries. Though contrary to the belief, there are no complications and the vaginal functions normally after surgery. The girl has regular periods without any signs of pain and can also have normal sexual intercourse followed by vaginal delivery during childbirth. (15)


Frequently missed neonatal diagnosis

Diagnosis vary in terms of clinical findings and signs and symptoms. Some patients may present with pronounced masses however some might present with small bulges. The same case is with signs and symptoms. As we discussed above, it is possible to have this condition with literally no signs at all.

Neonatal diagnosis is difficult due to the fragility factor and also that they are under the influence of their mother’s estrogen.

(4)

Also, the neonate is still growing and maturing, this what might seem as a probable pathology, can also be pseudo which will be self-resolved in the coming years. Neonates are also not very precise about their signs and symptoms. Since they are still in their learning stage, they might not be able to pinpoint what they exactly feel, which leads to having a list of differential diagnosis.


Requires careful examination

Imperforate hymen presents differently in different ages, depending on the hormone levels. We will classify the ages into two broad domains, infancy and adolescence.

Infants usually present with a hymenal bulge ranging from hydrocolopos or mucocolpos. The main etiology for this is the influence of maternal estrogen which comes in contact with the neonatal hymen. This type is usually self-limiting and asymptomatic. As we discussed earlier, parents opt out of surgical procedures in this age with eh hope of the deformity correcting itself by the time of puberty. (15)

In adolescence, this condition is symptomatically accompanied by a lot of pain and discomfort. It presents with cyclic or persistent pelvic pain and primary amenorrhea. F this condition co exists with pronounced hematometra, an abdominal mass may also be palpated. However, if the condition becomes chronic or severe, there are various other symptoms that start showing up such as constipation, nausea, back pain and pain on defecation. One major complication of this condition is hematosalpinx. In this condition, retrograde passage of blood flows into the fallopian tubes. This further results in endometriosis and adhesion formation. Another variation of this blood sinus is hemoperitoneum, in which the blood flows freely into the peritoneal cavity.


Morbidity associated with missed diagnosis

Morbidity increase as age increases as there are greater chances or infections and other diseases to coexist.Even though imperforate hymen is one of the most common female gynecology problems, but it is also the most commonly missed. Diagnosis for this condition mainly depends on the clinical examinations which should be performed thoroughly. Any missed step may lead to missed diagnosis that might cause problems in the future.

As patients with imperforate hymen are at high risk of endometriosis, they have a much higher chance of secondary infections that might worsen the prognosis. Thus it is advisable to rule out the risks of anesthesia in children and perform the surgery as early as possible (specially before puberty as chances of blood accumulation increase that provide a perfect culture for bacterial infections). It is necessary to have regular gynecological examinations to rule out such potentially morbid conditions and it is imperative for the clinician to perform thorough check each time.


References

  1. González R, Ludwikowski BM. Handbook of Urological Diseases in Children. (1st ed.). Singapore: World Scientific Publishing Co Pte Ltd; 2010.
  2. Asgari SA, Ghanaie MM, Simforoosh N, Kajbafzadeh A, Zare A. Acute Urinary Retention in Children. Urology Journal. [Online] 2005;2(1): 23-27. Available from: http://www.urologyjournal.org/index.php/uj/article/viewArticle/272 [Accessed 17 January 2019].
  3. Gatti JM1, Perez-Brayfield M, Kirsch AJ, Smith EA, Massad HC, Broecker BH. “Acute urinary retention in children”.

    Journal of Urology

    . 2001 Mar;165(3):918-21. Accessed 15 January, 2019.


    https://www.ncbi.nlm.nih.gov/pubmed/11176514


    .
  4. Okafor II, Odugu BU, Ugwu IA, Oko DS, Enyinna PK, et al. Imperforate Hymen Presenting with Massive Hematometra and Hematocolpos: A Case Report.

    Gynecol Obstet (Sunnyvale) 5;(2015): 328

    . Accessed 15 January, 2019.


    https://www.omicsonline.org/open-access/imperforate-hymen-presenting-with-massive-hematometra-andhematocolpos-a-case-report-2161-0932-1000328.pdf


    .
  5. Messina M, Severi FM, Bocchi C, Ferrucci E, Di Maggio G, Petraglia F. “Voluminous perinatal pelvic mass: a case of congenital hydrometrocolpos.”

    The Journal of maternal-fetal and neonatal medicine

    no 15(2) (2004);135-7.  Accessed 15 January, 2019




    https://www.ncbi.nlm.nih.gov/pubmed/15209124


    .
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The Importance of Continuing Competence for Nurses

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The Importance of Continuing Competence for Nurses

Nursing is a self-regulating profession where nurses set their own standards of practice “based on research and clinical evidence” (College of Registered Nurses of British Columbia [CRNBC], 2013), and ensures that patients receive the highest quality care possible (CRNBC, 2013). All nurses are required to meet The College of Registered Nurses of British Columbia’s (CRNBC) annual Continuing Competence Requirements as an indicator to the public that they are maintaining their competence to practice (CRNBC, 2013).

Identification of the characteristics of mentors that have been most successful in recruiting and training diverse nurses and nurse faculty.

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Identification of the characteristics of mentors that have been  most successful in recruiting and training diverse nurses and nurse faculty.

Nurses as Leaders in Health Care Reform
As healthcare delivery in the United States continues to evolve, either through mandates, improved technologies, and training, or other drivers, nurses remain at the forefront in facilitating the success of new initiatives. In 2010, the Institute of Medicine formed a committee of experts to address the following question: “What roles can nursing assume to address the increasing demand for safe, high-quality, and effective health care services?”

Question:
Identification of the characteristics of mentors that have been (or could be) most successful in recruiting and training diverse nurses and nurse faculty.

Post a description of the priority above and select the benefits and challenges of further researching this area. Provide an overview of the articles you found (using appropriate APA citations) relating to this priority, and highlight any key findings. Explain how continued research in this area could strengthen the ability of nurses to lead in both individual organizations and as advocates of health care reform.
Topic 2 Mandatory Discussion Question
The American Cancer Society (ACS) is a nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem. Together with its supporters, ACS is committed to helping people stay well and get well by finding cures and by fighting back.
Critical Thinking Questions:
1. Imagine that a family friend or colleague has just been diagnosed with cancer. Explain how the American Cancer Society might provide education and support. What ACS services would you recommend and why?
2. According to statistics published by the American Cancer Society, there will be an estimated 1.5 million new cancer cases diagnosed each year over the next decade. What factors contribute to the yearly incidence and mortality rates of various cancers in Americans? What changes in policy and practice are most likely to affect these figures over time
3. Select a research program from among those funded by the American Cancer Society. Describe the program and discuss what impact the research will have on the prevention or treatment of cancer

Describe advocacy processes needed to address institutional and social barriers that impede access, equity, and success for clients.

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Describe advocacy processes needed to address institutional and social barriers that impede access, equity, and success for clients.

Select and describe one issue of interest. Identify public policies on the local, state, and national levels that affect the quality and accessibility of mental health services.

· Describe advocacy processes needed to address institutional and social barriers that impede access, equity, and success for clients.

· Search the Internet to determine who else might be advocating toward or against this specific policy and list these organizations.

· Discuss why the organizations you identified may or may not be advocating in the same manner as clinical mental health counselors.

· Explain why it is important to support counselor advocacy and influence public policy and government relations on local, state, and national levels to enhance equity, increase funding, and promote programs that affect the practice of clinical mental health counseling.

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Midwifery Practice: Pre-Existing Pathphysiology and Pharmacology Principles

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Iron Deficiency Anaemia in Pregnancy

Anaemia is a condition caused by a reduction in the number of red blood cells or the haemoglobin concentration of blood, resulting in an insufficiency in the body (WHO 2014). Types of anaemia can vary, although the most common type is recognised as iron deficiency anaemia or IDA. Other forms of anaemia include; folate deficiency anaemia, vitamin B12 deficiency anaemia and inherited haemoglobinopathies i.e. sickle cell disorders and thalassaemia (Rankin 2017).

IDA occurs as a result of an inadequate supply of iron. The progressive diminishment of iron stores, in the form of hemosiderin and ferritin, result in a negative iron balance which effects the body’s ability to transport oxygen (Uthman 2009). This type of anaemia is mainly prompted by;

an insufficient intake or absorption of iron,

the increased demand for iron during pregnancy, especially in cases of frequent and multiple pregnancies as ferritin stores have not yet been restored

and blood loss/ iron loss e.g. in menstruation and postpartum haemorrhages.

Based on WHO (2014, 2016) documents, it is estimated that anaemia effects about 40% of pregnancies worldwide, 50% of which are due to iron deficiency. IDA is a pathology more common in pregnancy due to the increased demands for iron in pregnancy. This high incidence is of concern, as IDA in pregnancy can be linked to premature labour, PPH and/or a low neonatal birth weight (Allen 2000), which could have serious implications.

PREVENTION

In view that the prevalence of anaemia is so plentiful in women, caution and appropriate planning is a necessity before entering pregnancy, making sure to tackle factors that may have adverse effects on maternal and neonatal health (Soltani & Fair 2017a). Pre conceptual care can be used as a preventative tool to help rid iron deficiency in pregnancy. Pre conceptual care improves prospective parents’ and their child’s health (short and long term) by creating the optimum environment for conception and early foetal development. Women with high risk factors, e.g. poor dietary habits, should be priority for midwives (Macdonald & Johnson 2017).

The woman should be advised to seek out blood tests in order to check her iron and ferritin levels prior to conception (Dhavliker & Purohit 2017). Screening for anaemia and knowledge of low iron levels preconceptually, will allow time for the woman to build her iron stores.

Timing of the woman’s first visit is key. Anaemia in pregnancy can easily be treated if it is intercepted early on. Because of this, the need for the woman to attend her antenatal appointment should be reinforced. WHO (2016) recommends that women should have their first antenatal visit in the first 12 weeks of pregnancy.

Highlighting risk factors during the woman’s detailed history at the booking visit is important. The woman should be informed who is most at risk of becoming anaemic, in addition to what can put a healthy woman at risk.

Having a healthy balanced diet before, during and after pregnancy, should also be of large focus for the woman. Initial advice given to the woman, by the midwife, should be to alter her diet to incorporate iron rich food, if she has not already begun the process. This is due to the simple reasoning that, anaemia can easily be prevented or reduced by eating iron-rich foods. The woman should focus on eating fresh leafy green vegetables, red meats and poultry, along with whole grain breads and rolls. Furthermore, an increased amount of Vitamin C, i.e. kiwis, oranges, broccoli, should be consumed in order to aid the absorption of iron. Inhibitors such as polyphenols, i.e. teas and coffees, should be avoided (Macdonald & Johnson 2017, NHS 2018).

DETECTION

Per NICE (2008) guidelines, all pregnant women should be provided screening for iron deficiency anaemia (as well as other anaemias) in early pregnancy. This should take place during the woman’s booking appointment and again at 28 weeks. These time frames enable appropriate time for treatment and management of IDA, if detected. While physiological anaemia is a normal occurrence in pregnancy, caused by an increase in plasma volume which provokes haemodilution, pathological anaemia occurs in cases of deficiency, haemorrhage and inheritance (Chowdhury et al. 2014). The midwife should be vigilant in detecting early signs of iron deficiency and distinguishing between these two. Evaluating the woman’s physical appearance for common signs of paleness, pallor of mucous membranes and fatigue can be useful, but it may also be misleading for women with naturally pale skin, darker skin or a naturally tired appearance. Using signs in conjunction with symptoms will help properly assess the woman. Symptoms to look for can include irritability, tiredness, weakness, breathlessness, tachycardia, and chest pains (Rankin 2017, Colman & Pavord 2017). The midwife should take a thorough history including questions regarding; nutritional habits (reduction in consumption amounts), any previous excessive menstrual bleeding/ heavy menses, gastrointestinal upset in prior pregnancies, short gaps between each pregnancy or multiple pregnancies and any previous antepartum or postpartum haemorrhages. The WHO (2011) states that, haemoglobin levels under 11g/dl for pregnant women is categorised as a form of anaemia ranging from mild to moderate to severe. While NICE (2008) defines the normal haemoglobin range for a pregnant woman as, 11 g/dl at first appointment and 10.5 g/dl at the follow on 28-week appointment. Although ranges are given, it is also necessary to be aware that ranges may differ in accordance with different ethnic backgrounds i.e. in various studies African women have shown to have a lower normal haemoglobin baseline in comparison to white women (Johnson-Spear & Yip 1994, Perry

et al.

1992). Any signs of severe anaemia should be referred to the multi-disciplinary team.

MANAGEMENT

Information regarding dietary consumption of iron should be given to the woman. This should highlight how to improve intake and increase absorption. The midwife should consider how dietary habits may be affected by cultural or religious factors.

A full blood count is recommended as a method for checking haemoglobin concentration and screening for anaemia in pregnancy (WHO 2016). Serum ferritin measurement is also an excellent test for IDA. This is because iron deficiency is a microcytic anaemia, which causes a reduction in the mean cell volume and serum ferritin. Checking for this reduction is ideal as it is an earlier sign and occurs before the reduction in Hb (Rankin 2017).

After investigation, only if indicated, iron supplementation should be considered (NICE 2008). The route of administration depends on the severity of anaemia, gestational age and tolerability of iron. The first preferred route for iron supplementation is orally (Rankin 2017) as it is the most effective way to replace the iron needed to increase haemoglobin levels. This can have various preparations, examples being ferrous gluconate, sulphate or carbonate, and carbonyl iron. The NHS (2018) recommends ferrous sulphate tablets for treating IDA, but Gordeuk

et al.

(1986) voiced that, in comparison, carbonyl iron is more tolerable to the stomach than ferrous iron as it enters the system gradually. The recommended daily intake of iron for pregnant women, in settings where anaemia is prevalent (

≥

40%), is 60mg for six months while pregnant and three months post pregnancy (Stoltzfus & Dreyfuss 1998, WHO 2016). If Hb levels fall two standard deviations below the mean for a healthy matched person, a therapeutic dose should be started. This increases the daily dose of iron to 120mg of elemental iron per day until the Hb rises to normal. After a normal baseline is achieved, the standard daily dose is resumed to prevent recurrence of anaemia (WHO 2016) There is often poor compliance associated with the intake of oral iron supplementation. This can often be due to effects it has on the woman’s bowels i.e. bloating and constipation (Soltani & Fair 2017b) (Macdonald & Johnson 2017). Women need to be convinced of the significance of iron for their health and wellbeing and of their unborn child’s (DeMaeyer

et al.

1989).

Parenteral iron is indicated for women who cannot tolerate or absorb oral iron. An intravenous infusion of iron is preferred over an intramuscular injection due to the effects of intramuscular injections. This injection can be painful, cause bleeding into the muscle, and even cause muscle neoplasms (Cirino 2017). The midwife should consider intravenous iron for women who have insufficient time to intake the necessary quantities of oral iron, i.e. women with iron deficiency anaemia (Hb under 10.4) in their third trimester. IV iron increases haemoglobin levels faster and higher than oral iron (Cançad & Muñoz 2011). Intravenous iron sucrose (Venofer) is given as a divided dose. A maximum of 200mg is given per day, not more than three times per week (twice weekly for pregnant women) (Hinchingbrooke Health Care NHS Trust 2008). According to Kriplani

et al.

(2013) and the eMC (2016) dosages can be calculated as followed;

“Pre-pregnancy weight[kg] x (target Hb-actual Hb)[g/dl] x 2.4*+ storage iron[mg]”.

Fall in blood pressure is a common adverse drug reaction of IV iron, and in rarer cases of iron toxicity, anaphylactic shock can occur (Cirino 2017). Hb levels should increase by 1g/week.

Blood transfusion is applicable in severe cases of anaemia. This generally occurs after 36 weeks gestation. This anaemia is due to acute blood loss during APH and/or PPH, or after infection. This procedure is undergone as a last course of action if oral or parenteral therapies are not responded to (RCOG 2015)

The key role of the midwife is to promote normality where possible. Soltani & Fair (2017b) states that no extra iron is needed in healthy women with a balanced diet. Because of this routine iron should not take place as there is no advantage to this and can be harmful.

Uncontrolled iron consumption can possibly lead to a rise in haemoglobin level and blood viscosity or placental blood transfusion. This can have an adverse effect on birth outcome like premature birth, low neonatal birth weight, intra-uterine growth retardation, SIDS, and foetal abnormalities. Maternal preeclampsia can also result (Alizadeh & Salehi 2016).

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