For Math Guru

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Thera Bank – Loan Purchase Modeling

This case is about a bank (Thera Bank) which has a growing customer base. Majority of these customers are liability customers (depositors) with varying size of deposits. The number of customers who are also borrowers (asset customers) is quite small, and the bank is interested in expanding this base rapidly to bring in more loan business and in the process, earn more through the interest on loans. In particular, the management wants to explore ways of converting its liability customers to personal loan customers (while retaining them as depositors). A campaign that the bank ran last year for liability customers showed a healthy conversion rate of over 9% success. This has encouraged the retail marketing department to devise campaigns with better target marketing to increase the success ratio with a minimal budget. The department wants to build a model that will help them identify the potential customers who have a higher probability of purchasing the loan. This will increase the success ratio while at the same time reduce the cost of the campaign. The dataset has data on 5000 customers. The data include customer demographic information (age, income, etc.), the customer’s relationship with the bank (mortgage, securities account, etc.), and the customer response to the last personal loan campaign (Personal Loan). Among these 5000 customers, only 480 (= 9.6%) accepted the personal loan that was offered to them in the earlier campaign.

Link to the case file: 

Thera Bank_Personal_Loan_Modelling-dataset-1.xlsx (Xls file attached for data)

You are brought in as a consultant and your job is to build the best model which can classify the right customers who have a higher probability of purchasing the loan. You are expected to do the following:

  • EDA of the data available. Showcase the results using appropriate graphs – (10 Marks)
  • Apply appropriate clustering on the data and interpret the output – (10 Marks)
  • Build appropriate models on both the test and train data (CART & Random Forest). Interpret all the model outputs and do the necessary modifications wherever eligible (such as pruning) – (20 Marks)
  • Check the performance of all the models that you have built (test and train). Use all the model performance measures you have learned so far. Share your remarks on which model performs the best. – (20 Marks)

Hint : split <- sample.split(Thera_Bank$Personal Loan, SplitRatio = 0.7)
#we are splitting the data such that we have 70% of the data is Train Data and 30% of the data is my Test Data

train<- subset(Thera_Bank, split == TRUE)
test<- subset( Thera_Bank, split == FALSE)

Please note the following:

  • Your submission should be a Word Document with a word limit of 3000 words. Appendices are not counted in the word limit.
  • Also, share the R code & Interpretation.
  • You must give the sources of data presented. Do not refer to blogs; Wikipedia etc.
  • Any assignment found copied/ plagiarized with candidate(s) will not be graded and marked as zero.
  • Please ensure timely submission as post deadline assignment will not be accepted.

Create an essay in MLA format 750-1000 words about the Division & Classification Prompt: Habits can either improve our physical- emotional- and/or financial health or negatively impact it. Constru

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Create an essay in MLA format 750-1000 words about the Division & Classification Prompt:

  • Habits can either improve our physical, emotional, and/or financial health or negatively impact it. Construct an essay in which you divide and classify habits based on their potential advantages or disadvantages.

Florence Nightingales Environmental Theory

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Sarah Trafford


Where Did the Theory Come From?

The environmental theory created by Florence Nightingale concentrates on the patient’s environment and the external conditions that effect disease and death. Known as the ‘Lady with the Lamp”, Nightingale’s theory continues to guide nursing practice today. Influenced by her experiences during the Crimean war, Nightingale understood the significance of unsanitary conditions and the impact of the sanitary reforms on death rates. By carefully examining how the environmental conditions impacted patient health and outcomes Nightingale’s environmental theory was formed. In this assignment, Nightingale’s environmental theory is summarized. Throughout this assignment, this writer will explore how Florence Nightingale established the environmental theory through a personal perspective after careful literature review. Through analysis of the concepts, explanations of the relationships, and validation of her theory, Nightingale was able to create a foundation of nursing knowledge that has improved the quality of patient care.


Stage 1: Theorizing

Though my parents disproved of my wish to become a nurse I was determined to following my calling and signed up for nursing school in 1850 at the age of thirty. Expected to marry to maintain my family’s social prominence becoming a nurse which was viewed as menial labor went against my prosperous parent’s expectations. Believing that my life would be more useful I entered nursing to help those in poverty and alleviate suffering and illness. I felt that I was called by God to be a nurse. By becoming a nurse I was able to serve God by providing assistance to those with illness.

I felt that nursing was a calling. Nursing is not only an art but also a science that requires specific education. As a nurse, any lack of understanding or nursing skill can interrupt the process of healing. By using the nursing art of caring and standardized practices nurses can improve the health of patients. I believe that nursing allows nature to influence health. Appropriate nursing care can be achieved through alteration of the environment. Changes in internal and external environmental factors helps to attain a desired health status. Within the nursing role is the responsibility to manipulate the factors that affect heath and illness to enhance patient recovery and outcomes. The practice of nursing is also a rather distinct and separate profession from medicine. Within the nursing practice, one must recognize the body’s essential needs and work accordingly to ensure that there is suitable fresh air, light, warmth, cleanliness and quiet for the patient, this is where nursing differs from medicine.

Upon arrival in Scutari during the Crimean War we were faced with barracks filled to capacity and unsanitary conditions. Horrified by our surroundings, I noted defects in light, ventilation, sewerage as well as structural defects in buildings. Being overtly aware of the sanitary conditions and high death rates the nurses went to work immediately upon arrival to meticulously clean the ward and any soldiers brought in for treatment. Through eliminating unsanitary surroundings and organizing nursing services the mortality rate in Scutari was decreased. In the course of my work at Scutari I completed experimentation and examination of the environment and the care provided by nurses. In turn, guidelines of nursing care were developed. An example of such experimentation was discussed by Mackey & Bassendowski (2017), in which I compared the dirtiness of the water in which you have washed when it is cold without soap, cold with soap and hot with soap. Through this experimentation, it was found that the first cold water without soap hardly removed any dirt at all, cold water with soap a little more and hot water with soap removed much more dirt. Through these observations and having thorough records of death rates and the causes I was able to correlate how improved sanitation and environmental influences played a role in patient outcomes. Researching the causes of high death rates and making comprehensive recommendations for changes ensured that the conditions did not reoccur (McDonald, 2014).


Stage 2: Syntax

The environment includes the external conditions and influences that modify a life. The environment is capable of preventing or contributing to disease or death. Health is not only to be well, but to be able to use well every power we have to use (Butts & Rich, 2015). The concept of health extends further than just the absence of disease. Disease is a process given by nature to clean the body from impurity which has entered the body because one or more of the body’s natural needs is not fulfilled (Rahim, 2013). By making changes to environmental influences these wants can be fulfilled and the episode of disease can be eased. Nursing is an art of nature’s work on humans to make the ill healthy and the health remain the same (Rahim, 2013). The nurse is responsible for maintaining an environment that is adequate to sustain the health of the patient. A person or human being is a member of nature whose natural defenses are influenced by a healthy or unhealthy environment (Medeiros, 2015). By having environmental control around the patient and the relationships and influences of the nurse, the health and disease states of a patient can be enhanced.


Stage 3: Theory Testing

In a quantitative study completed by Taneli (2015), the environmental effects on the elderly were studied. Many factors within the environment of the elderly, including their home, the public, and community environments, can impact human responses, especially when individuals are ill, frail, or cognitively impaired. The environment can affect the elder’s daily activities and their responses to health and illness. According to Taneli (2015), understanding the factors within environments that facilitate or hamper health, behavior, affect, and care delivery can provide new insights of theoretical and practical importance. Through quantitative measure of environmental variables Nightingale’s theory is substantiated within this study.

The need for patient advocacy in originated with Florence Nightingale. Effective patient advocacy for basic human needs enhances the quality of patient outcomes. In the qualitative study by Davoodvand, Abbaszadeh, & Ahmadi (2016), review of how internal and external risks that jeopardize a patient’s health care environment and how the nurse acts as an advocate to reduce the risk to the patient. Given that disease diminishes an individuals’ ability to defend themselves, patients must have someone to protect them against these dangers while they are ill. Nightingale demonstrated patient advocacy through development of the environmental theory.

Furthermore, Nightingale’s environmental theory is tested in a qualitative study completed by Roque & Carraro (2015), in which high risk post-partum woman’s recovery is influenced by psychological aspects, which can be affected by the elements of the external environment, such as lighting, heating, noise or smell. Throughout the study consideration is taken into how creating an organizational culture within the hospital environment can accommodate the physical and emotional needs of these patients through controlling environmental elements of care.


Stage 4: Evaluation

The environmental theory impacts many areas of current nursing practice including personal hygiene, housekeeping procedures, administration of balanced diets to improve wound healing, observation of the sick and noise to name a few. All of these approaches to care influence patient outcomes. The theoretical principles established by Florence Nightingale remain relevant in nursing practice today.

In a study completed by Weaver (2012), it is discussed that a good standard of hygiene in the home prevents the growth and spread of bacteria, and therefore helps to prevent the development and spread of infections. This study is in line with Nightingale’s canon for personal hygiene that includes keeping patient’s patient clean and dry to prevent infection.

Contamination of environmental surfaces takes part in the transmission of pathogens. Increased attention toward disinfection and environmental cleaning is an important aspect of preventing healthcare acquired infection (Han, Sullivan, Leas, Pegues, Kaczmarek & Umscheid, 2015). This is aligned with Nightingale’s canon for cleanliness of patient rooms that concentrates on keeping the patient’s environment clean. Current evidence based research indicates that proper hygienic practices and environmental cleanliness can reduce the risk for infection and are fundamental aspects of nursing care.

Nightingale’s environmental theory also focused on observation of the sick. This canon included observations and assessments of the patient and appropriate documentation of the observations. Still applicable to nursing practice today, Inan &Dinç, (2013) discuss how poor documentation undermines patient care and threatens the safety of patients. Through appropriate documentation nurses can promotes improved quality of nursing care; enhance communication; ensure continuity of nursing services and also meet current day legal and professional standards of nursing care.

Nightingale’s environmental theory also focuses on sufficient nutritional intake through documentation of the total amount of food and liquids consumed. Malnutrition is a reversible risk factor for pressure ulcers in adults, therefore it is essential that all healthcare professionals are able to correctly identify those at risk early on and provide appropriate management (Taylor, 2016). Through adequate observation and assessment nursing professionals can establish nutritional intake therefore reducing the patients risk of pressure ulcers through implementing interventions that will correct any nutritional deficiencies.

To Nightingale, healing is concerned with bringing the body, mind, and spirit together to maintain balance within the body. Having a healing environment is a crucial element of nursing care. Within the environment are unintended consequences in the form of harmful stimuli such as unnecessary noise, bright lights, and numerous interruptions due to the inevitability of providing twenty-four-hour care. According to a study completed by Halm (2016), unwanted noise has adverse physiological and psychological effects and can adversely effect patient outcomes.


Conclusion

The influence of the Florence Nightingale’s environmental theory serves as a foundation for modern nursing practice. Widely known for instilling her nursing practice with proven evidence to enhance patient outcomes Florence Nightingale is a pioneer of evidence based practice. The development of and continued application of the environmental theory continues to be vital to providing optimal patient outcomes through altering the patient’s environment. The attributes of Nightingale’s theory continue to have merit in current day practice, even 150 years after it was originally written.


References

Butts, J. B., & Rich, K. L. (2015

). Philosophies and Theories for Advanced Nursing Practice

(2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Davoodvand, S., Abbaszadeh, A., & Ahmadi, F. (2016). Patient advocacy from the clinical nurses’ viewpoint: a qualitative study.

Journal Of Medical Ethics & History Of Medicine

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9

(5), 1-8.

Halm, M. (2016). Making time for quiet.

American Journal Of Critical Care

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25

(6), 552-555.

Han, J. H., Sullivan, N., Leas, B. F., Pegues, D. A., Kaczmarek, J. L., & Umscheid, C. A. (2015). Cleaning hospital room surfaces to prevent health care-associated infections: A technical brief.

Annals Of Internal Medicine

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163

(8), 598-607.

Inan, N. K., & Dinç, L. (2013). Evaluation of nursing documentation on patient hygienic care.

International Journal Of Nursing Practice

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19

(1), 81-87.

Mackey, A., & Bassendowski, S. (2017). Original article: The history of evidence-based practice in nursing education and practice.

Journal Of Professional Nursing

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33

51-55.

McDonald, L. (2014). Florence Nightingale and Irish nursing.

Journal Of Clinical Nursing

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23

(17-18), 2424-2433.

Medeiros, A. B. (2015). The Florence Nightingale’s environmental theory: A critical analysis.

Escola Anna Nery

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19

(3), 518-524.

doi.org/10.5935/1414-8145.20150069

Rahim, S. (2013). Clinical application of Nightingale’s environmental theory.

Journal On Nursing

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3

(1), 43

Roque, A. F., & Carraro, T. E. (2015). Perceptions about the hospital environment from the perspective of high-risk puerperal women based on Florence Nightingale’s theory].

Revista Gaúcha De Enfermagem / EENFUFRGS

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36

(4), 63-69.

Taylor, C. (2016). Nutrition and pressure ulcers: putting evidence into practice.

Journal Of Community Nursing

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30

(4), 38-44.

Taneli, Y. (2015). Advancing theory and practice through collaborative research in environmental gerontology.

Research in Gerontological Nursing,


8

(2), 58-60.

Weaver, D. (2012). Promoting personal cleanliness.

Nursing & Residential Care

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14

(3), 116-120.

Psychological and Sociological Factors Influencing Patient Care

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This case study aims to achieve the following learning outcomes:

  • to demonstrate a critical and systematic understanding of the psychological and sociological factors which influence patient care,
  • to critically explore the aspects of risk assessment and safeguarding to promote safe, effective care,
  • to demonstrate detailed and current knowledge of inter-professional working and how it promotes person-centred care.

For confidentiality purpose I would refer to my patient as BA. Patient consent was sought and agreed with my mentor.

Patient BA is a 41yr old man, divorced with two children. He is independent, loves to party with friends. On a night out, patient BA was drunk, got into a fight and got punched in the chest. Unaware of what had happened the previous night, he woke up with pain in the thoracic region. Patient BA thought he had broken some ribs and was in pain and discomfort. After about 3-4weeks BA expected the pain to have been reduced because he had knowledge of broken ribs repairing itself. The pain was not relieved but rather got worse. Patient BA had lost a considerable amount of weight, had reduced appetite, and expressed that ‘I thought I was about to die’, his mum called the emergency services and BA was taken to hospital. On admission patient BA was diagnosed with Community Acquired Pneumonia and Shortness of Breath. Patient BA’s past medical history shows that he is on lifelong Tinzaparin for DVT and is an ex-IVDU.

According to NICE Guidelines Pneumonia is an infection of the lung tissues, in which the air sacs in the lungs become inflamed, filled with fluid and microorganism and are not able to function properly.  Diagnosis is usually based on symptoms of lower respiratory tract infection and can be confirmed by a chest x-ray. Pneumonia can be classed as either community acquired, or hospital acquired depending on how patient got the infection. The NICE guideline quality statement states that patients brought into hospital with suspected community acquired pneumonia are to have a chest x-ray and have a diagnosis within 4 hours of coming to hospital. The rationale is that timely diagnosis is obtained by carrying out a series of tests which includes a chest x-ray which has been assessed and where pneumonia is presenting, timely treatment with antibiotics is carried out, and ensures patients are not inappropriately given antibiotics treatment NICE. (2016). Pneumonia in Adults.

On admission onto the ward patient BA admitted to feeling imprisoned and feels stuck in hospital. Patient BA is independent, has capacity to make own decisions in general {activities of daily living}.  The activities of daily living according to Roper Logan Tierney model in practice 2008 identifies twelve activities which are regarded to be the core of the model of living which are: maintaining a safe environment, eating and drinking, communicating, eliminating, breathing, mobilising, sleeping, working and playing, controlling of body temperature, personal care and hygiene, expressing sexuality and dying. These activities of daily living work hand in hand. If any is omitted or is lacking it affects the others. Example without breathing you cannot communicate, eat or drink. Difficulty in breathing affects every other system in the body. Breathing is affected by all the ADL (Holland, K et al., 2008).

In caring for patient BA, the nurses carried out a nursing assessment which aimed to find out information about patient’s background (Psychological, physiological, sociological, spiritual) and enabled them to perform a holistic assessment of patient’s individual needs in other to plan patient’s care and set achievable goals with patient BA’s consent. The Acute Medicine Assessment Document was used by the doctors to reach a diagnosis on patient’s presenting conditions.

Holistic assessment is a process of defining a condition using theory and presence. It is done when a nurse considers the whole health of a person rather than focus on one key area. Reference.com. (2019).

Creating a holistic therapeutic relationship involves physical, psychological and social aspects. The social aspect of this look at patient’s perception of self and others. In other to provide a holistic care requires staff to address patient’s physical and social needs as well. Montgomery and Dossey (2008) cited in Goodman, B. & Ley, T. (2012).  supports meeting patients’ need holistically by engaging in therapeutic relationship.

Goodman, B. & Ley, T. (2012).

Being in hospital can present specific stresses over and above that which is associated with the illness a patient suffers. It ranges from environmental factors like being in an unfamiliar environment, to lack of privacy and independence and uncertainty about health outcomes. When a patient’s needs are not met it could affect them emotionally. Most people can adjust easily whilst others might find that their emotional and social coping mechanisms are challenged. BMA Science and Education. (2011). Patient BA found that he struggled to cope in the confines imposed on him by his illness, though patient BA could self-discharge from the hospital, he understood that he needed to complete his antibiotics treatment and gain confirmation from the multidisciplinary team that he is fit and healthy to go home. Patient BA did not cope well in the hospital settings as stated that “feels imprisoned”. Patient BA’s support system was somewhat unstable as he misused substances on the ward when stressed and became disoriented thereby prompting the need for safeguarding. There was a concern of overdosing as patient BA was prescribed strong painkillers (Oramorph). The nurses had to risk assess patient BA by asking a series of questions to check his alertness and orientation before administering his strong painkillers to avoid/limit any contra-indications or side effects with any substance which he may have taken/not taken.

The RCN outlines 8 principles of nursing care which shows: that nursing staff take responsibility for the care they have provided to the patient and are responsible for their actions and omissions; Care that meets the legal and professional standards and requirements has been agreed with patient and their family or carers; Staff promote safety of patients, self, colleagues and others; Staff promote person centred care that enables decisions and informed choices about care to be made by patients, service users, their families and carers; Confidentiality in dealing with patient record is maintained, effective communication process is carried out and effectively reporting any concerns to appropriate persons;

The principle also states that staff have up to date skills and knowledge about patient care needs. Working together with own team and other professionals to achieve a high standard of care with the best possible outcome for the patient and service user; Development of self and other staff in a way that promotes a holistic person-centred care. Royal College of Nursing. (2019).

principles of nursing practice

Being able to respond to a patient’s care needs is a complex, intricate and subjective process that needs the care giver to understand the patient’s world. By recognising and respecting a patient’s individuality nurses show they are willing to get to know and help the patient. Studies have shown caring to be at the centre of nursing. Heywood Jones, I. (Ed.) (1999). Whilst Saving lives and preventing health deterioration are of much importance, so also is the consideration of the psychological and social needs of patients as part of holistic care delivery. BMA Science and Education. (2011).

The NMC Code of conduct, performance and ethics sets key principles for nurses and midwifes practice and states their professional responsibilities. It is a key tool that is used in safeguarding the health and wellbeing of the wider public (Goldsmith, j. 2011).

The care act 2014 emphasizes the statutory responsibilities for the integration of care between health and local authorities. Adult safeguarding means protecting a person’s right to safety, free from neglect and abuse (NHS England.

The Care Act 2014

). Patient BA found having misused substances on hospital ground, put himself and other vulnerable patients at risk which led to hospital security team involvement.  Section 42 of the Care Act 2014 states that safeguarding enquiries is required where a person needs care and support, is experiencing, or is at risk of abuse or neglect, and because of their care or support needs, they are unable to protect self from abuse, neglect or risks. Somerset adult safeguarding board. 2018. In this case patient misuse of substances.

The fact that patient BA misused substances does not give healthcare professional grounds to abuse or neglect, the Nurses and other healthcare professionals provided adequate care and support needed, adhering to the NMC Codes and safeguarding of other vulnerable adults from abuse or risk of it.

Interprofessional teamworking creates a diverse field of knowledge, skills and talent all working together to achieve a common goal. Scaria, M.K. (2016). Part of the care provided to patient BA included short term oxygen therapy through a nasal cannula to help with shortness of breath. In an article of a research carried out by Zhang, Y., Fang, C., Dong, B.R., Wu, T., & Feng, J.L. (2012).

Oxygen Therapy for Pneumonia in Adult

in the Cochrane database of systematic reviews had the objective of determining the effectiveness and safety of oxygen therapy in treating pneumonia in adults over the age of 18 and the authors concluded that non-invasive ventilation could be of more benefit than standard oxygen supplement through a venturi mask for pneumonia. Though oxygen therapy is commonly prescribed to patients with pneumonia, there have been inconsistent results during their research on the effect of the oxygen therapy on pneumonia.

The Physiotherapists were also involved in patient BA’s care by giving specific advice on what sleeping position to undertake to relieve pain and what sort of exercises would aid in recovery. Physiotherapists are part of the multidisciplinary team and were present in the ward where patient BA was admitted. They consider the body as whole by providing holistic care. Some of the approaches used by physiotherapists includes: education and advice, movement, tailored exercise, physical activity advice and manual therapy. Other therapies such as hydrotherapy and acupuncture can also be carried out by physiotherapists NHS. (2018).

The MDT have all contributed to the overall treatment and wellbeing of patient BA, the doctors have been prompt in the diagnosis of patient BA’s illness and prescribing of medications and oxygen therapy, the nurses have contributed to ensuring medications are administered appropriately (right patient, right drug, right dosage, right time, right route), the physiotherapists have been able to give advice on the best positioning to relieve pain and exercises to aid breathing, the security team have ensured the safety of vulnerable patients and staffs in general. Part of the MDT also includes the housekeepers and kitchen staffs who ensure the hospital environment is kept clean and free from infection, and the kitchen staff ensuring the patients food are ready on time and served in accordance with hospital policy on food hygiene.

From this case study I have been able to critically research pneumonia, its symptoms and how it could be mistaken for the cold or flu infection. I have also learnt that trauma to the chest could cause pneumonia Ho S, Teng Y, Yang S

, et al

(2017). Pneumonia can be prevented by getting immunisation against the pneumococcus bacteria and having the annual flu vaccine. Stopping smoking also reduces damage to the lining of the airway and reduces infection risks. Patient. (2018).

How the multidisciplinary team contributes to the care delivered to patients and enhances patient’s recovery from their illnesses making their stay in the hospital pleasant.

I have also learnt in detail how care is managed through psychological and sociological approaches and how to ensure future practice includes holistic care which considers the patient as whole and not just focusing only on their illness.

REFERENCES

Lines- Tubes- and Catheters in Radiography

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Lines, Tubes, and Catheters in Radiography Paper

Abstract

This paper is written to explore the application and appearance of lines, tubes, catheters, as well as other medical devices in radiography. In specific, endotracheal tubes, tracheostomy tubes, drainage tubes, chest tubes, nasogastric tubes, nasoenteric tubes, and central lines or central venous lines will be included and discussed. Tubes and catheters are useful for the administration and delivery of nutrients, providing drainage routes, administering medications and fluids, drawing blood samples, and many other functions and uses. A radiographer may not be required to utilize these types of medical equipment, but to have an understanding is still important. It is necessary for patient care to have these medical devices available in order to conduct effective treatment in both trauma or non-trauma situations. Therefore, the radiographer has an imperative role in verification of the proper placement of lines, tubes, and catheters. Knowledge of the medical devices used, placement, and location within the body are essential for quality patient care.

Tubes, lines, and catheters do not always have an apparent difference. A catheter, though, iks defined as a hollow, flexible tube that can be put into a body cavity or vessel to insert or withdraw fluids (Newman, 2017). Tubes, lines, and catheters are hollow inside, and most are flexible for the removal of fluids. Other medical devices, such as cardiac pacemakers and those listed previously serve other purposes. A chest x-ray is the recommended radiograph by the American College of Radiology after tubes, lines, catheters, or other devices are inserted into the patient (Jain, 2011). It provides a go-to window to check position of equipment and other medical procedure issues. Function, location, and follow-up are what constitute the application of tubes, lines, catheters, and other devices.

An endotracheal tube is used for ventilation, maintenance of the airways, prevention of aspiration, and suction of tracheobronchial secretions (Newman, 2017). Patients who need this type of medical device are usually having trouble with their airways staying open or undergoing anesthesia. Placement for an endotracheal tube is into the mouth or nose, through the larynx, and to the trachea (Newman, 2017). An endotracheal tube consists of a terminal hole and cuff. The tube tip can be five to seven centimeters above the carina with the neck in a neutral position and two centimeters caudad or cephalad with the neck in flexion or extension, accordingly. If the carina is not visible, the tube tip should be at the medical clavicle ends and midway between the carina and larynx so extubation and intubation are evaded. A chest x-ray is necessary immediately after the tube is inserted in order to verify there is no extubation or intubation and proper positioning (Jain, 2011). Another landmark to ensure correct positioning is the aortic knob. If the endotracheal tube tip is barely above the aortic knob it is in the right spot. Incorrect placement of the tube may result in hyperinflation or collapse of the lungs (atelectasis) (Newman, 2017). Also, intubation into the esophagus indicated by an overstretched stomach and tracheal stenosis are complications to avoid (Jain, 2011). Endotracheal tubes are to be administered to the patient with precision.

A tracheostomy tube is inserted through an opening into the trachea as a result of a surgical tracheotomy for an airway (Ehrick & Coakes, 2017). This device is needed to handle an obstruction of the respiratory tract due to a cancer or burn in the mouth or throat and also for controlled breathing with a ventilator in patients who have respiratory collapse due to paralysis or trauma (Ehrick & Coakes, 2017). The placement for a tracheostomy tube is midway between the stoma and carina at the D3 vertebra and is kept with flexion and extension of the neck. Tube diameter should be two-thirds of the width of the trachea, the cuff not overstretching the tracheal wall, and the tube parallel with the trachea (Jain, 2011). Improper positioning of a tracheostomy tube can result in surgical emphysema, pneumothorax, hemorrhage, or tracheal stenosis (Jain, 2011). A chest radiography can make sure the tube is placed correctly.

A drainage tube, or pleural tube (intercostal drainage tube) is used to rid the chest of liquids and solids. It is placed through the fourth intercostal space in the anterior or mid-axillary line and then lead to go in a posteroinferior path for effusion and anterosuperior path for a pneumothorax (Jain, 2011). A chest x-ray shows the side holes on the tube in the radiopaque outline of the tube. The side holes should not be outside the chest area and the tube not hover above the effusion that may be present. Both an anteroposterior and lateral chest x-ray will verify the correct positioning of an intercostal drainage tube (Jain, 2011). Other chest tubes include thoracic catheters or thoracostomy tubes. These are used to remove air, liquid, and solids from the pleural space and mediastinum (Newman, 2017). Open suction allows for drainage into the tube due to a difference in pressure between the pleural space and atmosphere or gravity. Closed suction involves a vacuum pump and bottles. The placement for the tube is in the third to sixth intercostal space in the anterior or mid-axillary line. Again, an anteroposterior and lateral chest radiograph will indicate if the tubes are properly positioned (Newman, 2017).

Nasogastric and nasoenteric tubes are administered through the nose and down to the stomach or small intestine. Nasogastric tubes for the stomach help with feeding, decompression, and radiographic examination (Ehrich & Coakes, 2017). A nasogastric tube has many side holes and lead balls at the end of it, and its tip should be placed within the stomach about ten centimeters caudal to the gastroesophageal junction (Jain, 2011). Medication, nutrients, and contrast agents can be given to the patient with a nasogastric tube. The placement of the tube is done by a physician with informed consent from the patient. Improper positioning may result in aspiration or bowel perforation (Newman, 2017). An abdomen radiograph will visualise the location of a nasogastric tube. Nasoenteric tubes are placed in the stomach and moved into the small intestine via peristalsis (Ehrich & Coakes, 2017). A nasoenteric tube can be used to insert contrast for a radiographic evaluation. The tip of this tube is inserted about ten to twelve centimeters into the small bowe. Improper positioning can result in pneumonia, pulmonary contusion, or perforations in the pharynx or esophagus (Jain, 2011). Again, an abdomen radiograph can show if the tube is placed well.

Central lines or central venous catheters are used to administer chemotherapy or other long-term drug therapy, total parenteral nutrition, dialysis, or blood transfusions. They are also used for blood draws and checking central venous pressure (Ehrlich & Coakes, 2017). Central venous lines are used to get into the central vessels such as external jugular, internal jugular, common facial, cephalic, and saphenous vessels. A physician places a central venous catheter (Newman, 2017). The tip of the line is distal to the last venous valve where the internal jugular and subclavian veins intersect. A check x-ray will show the value inside the first rib. Improper positioning can result in pneumothorax, perforation of a vessel, or cardiac perforation (Jain, 2011). Proper placement of the central venous catheter, to monitor central venous pressure, is when the tip lies parallel to the wall of the superior vena cava, superior to the right atrium. Postprocedural central venous catheter placement requires a radiograph to confirm accuracy, because improper catheter tip location within the heart can cause cardiac perforation and tamponade (Melarkode, 2009).

Tubes, lines, and catheters are necessary for good and effective patient care. The placement of such medical devices is particular for each one. Chest radiographs are the main indicator that correct positioning has been achieved while abdomen radiographs can also be of use. Many medical devices are not made to be seen on a radiograph (radiopaque), but some endotracheal and nasogastric tubes have radiopaque markers or tips (Newman, 2017). The design and location of a tube, line, or catheter determines the medical attention needed for the patient.

References

  • Newman, J. (2017). Radiographic appearance of tubes, lines, and catheters.

    Radiographic appearance of patient tubes, lines, and catheters,

    5(1), 1-17.
  • Jain, S. (2011). A pictorial essay: Radiology of lines and tubes in the intensive care unit.

    Indian Journal of Radiology and Imaging,

    21(3), 182.
  • Erich, R. A., & Coakes, D. M. (2017).

    Patient care in radiography: With an introduction to medical imagine

    (9th ed.). St. Louis, MO: Mosby.
  • Melarkode, Krishnan, and M. Y. Latoo. 2009. “Pictorial Essay: Central Venous Catheters on Chest Radiographs.”

    British Journal of Medical Practitioners

    2 (2): 55-56

Barriers to Asthma Management

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  • Renate Jimerson, Pat LeBlanc, & Centrella Stacks

Asthma

Asthma, the most common chronic illness of childhood, is an inflammatory disease characterized by hyper responsiveness of the airways to stimuli and reversible airway obstruction (Janson, 1998). According to the American Lung Association (ALA) it affects between 6.7 and 9.6 million U.S. children under the age of 18, American Lung Association (ALA) (as cited in Toole 2013). Asthma is the most common chronic childhood disease with increasing prevalence from 31.4 per 1000 population in 1980 to 54.6 per 1000 population in 2000 despite the advances in asthma pathophysiology understanding and treatment (Tsakiris, Iordanidou, Paraskakis, Talskidis, Rigas, Zimeras, Katsardis, & Chatzimichael, 2013).

Although there have been new medications and medical advances, asthma is a significant cause of a morbidity, school absenteeism, parent lost work days, emergency department (ED) visits, and hospitalizations for children all over the world. Brown, Gallagher, Fowler, & Wales; Martinez; Mattke, Martorell, Sharma, Malveaux, & Lurie (as cited in Toole 2013). Looking into the causes of school absenteeism, it has been found that asthma is the most frequent cause, according to Doull et al., “55% of school students and 55% of asthmatic students missed school days due to respiratory symptoms.” Attendance and the limitation of daily activities are both used as indicators of asthma control level in children. Increased absenteeism interrupts learning processes and participation in daily activities.

Unfortunately “In a study that specifically focused on parents’ report of receiving written self-management tools from pediatric primary care physicians, Cabana et al. (8) found that only about 30% of parents reported receiving these tools known to facilitate children’s medical adherence.” (Orrell-Valente, Jones, Manasse, Thyne, Shenkin, & Cabana (2011).

An initial literature review was done to gain information about what barriers impact medication compliance with school age children. Using different keywords: children, medication compliance, asthma, cost, education, barriers and impact of non­compliance; were used in the CINAHL database, Google Search, and the Simmons Library to locate information on the subject. Further searches were conducted to refine the topic, from medication compliance with school age children to a more specific topic of medication compliance and asthmatic children.

Identifying asthma as the main subject allowed for us to move in a more specific direction. Our next pursuit was in identifying and categorizing the different barriers, determining the major and minor subjects and listing them under specific categories. “No one risk factor is responsible for asthma morbidity; rather a plethora of factors contribute to the high prevalence, which vary dramatically among children with asthma (Clark, Mitchell, & Rand, 2009). Asthma risk factors include living in poverty in the inner-city, being uninsured or Medicaid enrolled, and being African American or Hispanic (Akinbami, Moorman, Garbe, & Sondik, 2009; Bloomber et al., 2009; Gerald et al.; Liu & Pearlman, 2009; Mattke et al., 2009; Smith, 2009) (Toole, 2013 p 115).”

“In 2005, 9% of children under the age of 14 years were diagnosed with asthma and the prevalence of asthma was found to be highest in this age group (Center for Disease Control and Prevention, Control and Prevention, 2006).” (Kamps, J. L., Rapoff, M. A., Roberts, M. C., Varela, R. E. Barnard, M., Olson, N., 2008 p. 206).

Critiquing the research articles that were found has led to three major barriers in asthma management. The first barrier is in cost. Subcategories of cost include insurance availability, income, and socio economic levels. The second is culture. Subcategories of culture include language barriers, legal status, traditions and use of alternative medicine. The last is education. Subcategories of education include health literacy, education level, reading and comprehension abilities, information provided and follow up.

Barriers that impact and interfere with the management of asthma in children are varied. The outcome of ineffective management are increase cost, hospitalizations, improper use of medication and death. Health care providers need to ensure that the patient and parent or guardian understand the proper use of medication, the disease process and associated risk for misuse of medication. Using these categories, a literature review will be a guide in determining the best practice for improving outcomes, decreasing cost, and developing a plan to ensure cooperation between parents, children and the health care provider.

Asthma management requires a multi-faceted approach, including an effective educational component (Ambulatory Pediatrics, 2006). Poor patient outcomes have been associated with a lack of patient and parent compliance with the patient’s individualized treatment plan. There are a number of possible factors that may play a role in patients’ and parents’ noncompliance. They include financial and cultural barriers, and parents’ and patients’ misconception about the disease process and the importance of treatment (Cleveland, 2013). The trends reported in a recent study indicated that asthma education to parents positively impacts asthma-related outcomes in children (Kielb, Lin, & Hwang, 2007). In this small sample, there was a decrease in asthma-related sick visits post-education.

Asthma cost are increasing and responsible for a higher percentage of the total health care cost for treatment. Increasing and changing copayment are leading to more emergency room visits and hospitalizations. The cost of these are not as visible as the direct cost of an inhaler medications. So the need for educating on all the cost of asthma are important.

In the article “Outpatient Management of Asthma in Children” by Andre Schultz and Andrew C. Martin, they discuss the roles of the provider in the diagnosis and treatment of asthma in children. This article determined that one of the critical areas is non adherence to treatment. Having a plan in place is important as well as continued follow up, avoidance of triggers, and use of medication. Non adherence to medication is impacted by the several factors. Socioeconomic status plays a large role in adherence to medication. Data obtained shows that lower adherence is reported in children at a higher rate from low income families.

Perception of cost and the discussion between the Practitioner and patients is important. Determining how the client feels about the medication, treatment plan and chronic disease is important. This will help to facilitate the response to care. The perception of the cost of medication on the client will play a significant role. Not discussing these important facts with the clients may lead to non-compliance. (Patel, M. R., Coffman, J. M., Tseng, Chien-Wen, Clark, N. M. and Cabana, M. D.).

In a quasi-experimental study done in 2010, they compared participants in a control and intervention group in regards to adherence to medication, healthcare cost and resource utilization. The determined intervention consisted of 2 components. One an average reduction in copayment and the second was mailing educational material for asthma management. Adherence was determine by the medication available during the duration of therapy and total supply of medication divided by the duration of therapy. When refills overlapped, it was assumed that the client consumed all medications. Healthcare resource was determined by office visits, hospitalizations, emergency room visit, short acting beta-agonist canisters and oral corticosteroid prescriptions. Cost were defined as total amount paid for visits, hospitalizations, emergency room visits, and prescription drugs. Overall cost were determined during the twelve month follow up period. Monthly cost were used rather than total cost during the study period. This study showed improved adherence to controller medication which translated into reduced medical cost and increased prescription cost. Although there were an increase in prescription cost the overall expenditure decreased. This study determined that increasing copayments will create a financial barrier to medication adherence. (D’Souza, A., Rahnama, R., Regan, T., Common, B., & Burch, S. (2010).

Understanding that noncompliance to medication comes from the perspective of the client. In children, parents are the main administers of medication. A link between the socioeconomics, cultural values, education and use of medication has been shown to produce a negative effect on adherence. This effect is not a single factor but many factors grouped together to provide a complete picture. Clearly identifying the factors that influence compliance with clients will ensure a more effective management in children with asthma.


References

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Kamps, J. L., Rapoff, M. A., Roberts, M. C., Varela, R. E. Barnard, M., Olson, N. (2008) Improving adherence to inhaled corticosteroids in children with asthma: a pilot of randomized clinical trial.

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Mental Health for Adolescents Experiencing Abusive Relationships

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Collaborative Opportunities

While romantic interests or relationships are normal during adolescence, many adolescents experience several issues, including violence, abuse, and emotional or cyberbullying. According to the [CDC] (2016), adolescent dating violence involves any physical, sexual, and psychological aggression within a dating or intimate relationship. Dating violence also encompasses stalking and aggression transmitted electronically. A 2018 survey of youth showed that nearly 19% of high school students had undergone physical dating violence, nearly 15% had witnessed another friend experienced sexual dating violence, and nearly 12% had been forced into involuntary sexual activities (Centers for Disease Control and Prevention, 2016). Furthermore, several cases display the assumption of teen dating violence being inadequately reported, especially among the LGBTQ population youth (Orpinas, Hsieh, Song, Holland, & Nahapetyan, 2013). Unhealthy or abusive relationships have both short and long-term consequences, including heavy drinking, depression, suicidal ideation, drug use, delinquency, and domestic violence in adulthood (Dank, Lachman, Zweig &Yahner, 2014, Exner-Cortens, Eckenrode & Rothman, 2013; Gomez, 2011). A community based mental health agency offers to collaborate with Deerfield high school, located in Sunrise, Florida, in order to address these issues through two invaluable programs.

Preventive education is a key component of primary mental health care (Cohen-Konrad, 2013). It has shown significant success in reducing the rate and risk factors associated with teen intimate partner violence (Lundgren & Amin, 2015). In this constituent of the collaboration between the community mental health agency and Deerfield high school, mental health professionals would offer two training sessions to all teachers and appropriate staff members at Deerfield high school. The first training session would aim at educating staff members on the incidence and presentation of teen dating violence, symptoms, and preventive resources for prospective victims. A second training session would be provided in a much comprehensive fashion as it would solely pertain to professors appointed to teach the Safe Dates prevention curriculum. In a longitudinal study, the Safe Dates curriculum has displayed a reduction in teen dating violence ranging between 46%-92% (Foshee, De Koker, Bauman, Ennett, Linder, Benefield, & Suchindran, 2004). Thus, other schools with victims of intimate teen violence should follow this Safe Dates prevention curriculum as it has proven to be efficient.

Group counseling represents an ideal manner to offer services to adolescents because it is economical, proficient, and effective (Schechtman, 2017; Kaminer, 2005). It enables mental health professionals to administer therapeutic services therapy to multiple individuals in the shortest time. It further creates a supportive peer group for those victims. The collaboration’s primary purpose would be for mental health professionals to offer biweekly group sessions for victims at the school setting.


Collaborative Challenges

When two entities agree to work together, this can likely produce many benefits as well as several challenges or undesirable situations. For instance, funding streams can create great challenges since both entities work against a budget that becomes tighter annually. Recently, school districts’ annual funding has been cut and the school’s mental health staff has been downsized due to lack of financial help (NAMI, 2011). Oftentimes, the federal government awards mental health agencies with few grants, which lead them to seek for supplemental monetary means to compensate for the lack, including private contributions. Thus, there is a debate about which entity would assume financial responsibility. These issues should be acknowledged and resolved before the collaboration could even proceed in a productive fashion.

Another great challenge has to do with appropriate support for all pertinent host setting parties because in any collaborative effort, every party involved is responsible to provide resources, goods, supports, and services that complement the other party’s efforts. For example, a lack of support or cooperation from the high school’s essential departments might negatively affect the cohesion of the partnership. While the principals, teachers, or parents might be supportive of the collaboration, the administration must also coordinate with them to allocate a closed space for the group counseling, a large room for professors/staff training and meetings, and the custodians must be predisposed to furnish all the rooms with appropriate equipment as well as ensuring their availability for use on the days all meetings are scheduled.

Issues surrounding mental health have been highly stigmatized, undervalued, and unrepresented worldwide, especially within school settings (Overstreet & Quinn, 2013). The space designated for administering group sessions should be consistently available every week. This latter would further create a great sense of safety and security that promote engagement and successful intervention.


Inter-Agency Collaboration Concepts

Inter-agency collaboration usually offers invaluable services and benefits to children, youth, families, and communities ([NTAECSC] 2008; McDonald & Rossier, 2011). Nonetheless, successful collaboration can be challenging, complex, and time-consuming. Fortunately, various strategies are deemed proficient to resolve a few encountered challenges. Cooperation/teamwork, communication, and coordination/harmonization, the three C’s, are concepts debated at the onset of any successful collaborative partnership (Chen, 2010; Horwath & Morrison, 2007).


Cooperation/Teamwork


Shared vision

. An effective collaboration can be launched after the two partnering organizations agree to uphold a shared vision that equally benefits their mutual alliance. In this condition, the shared vision, which mainly focuses on supporting physical and emotional health for adolescents, must be reinforced by both school officials and the local mental health organization.


Benefits to all.

Every participant must clearly comprehend that the collaboration should emphasize on similar benefits and outcomes. For example, it is important that both parties understand and value mutual support in order to achieve their vision. This recognition further creates a relationship that promotes mutual appreciation and respect.


Assessing strengths and resources.

Both parties can begin to collaborate on their shared vision after they have finished identifying each other’s strengths and resources to not only function proficiently but also to provide a complete service. This latter further allows both parties to address their primary encountered obstacle, which pertains to sharing the burden of monetary responsibility for the collaboration. Nevertheless, this program’s overall’s financial price can be reduced if both the school and the mental health agency decide to interchange their resources, including school printers, learning materials, agency’s student interns, and mental health providers.


Communication


Developing constructive relationships.

The process of creating a mutual relationship must be clearly defined and communicated before a true collaborative program can be implemented between both entities (Politi & Street, 2011). Both providers should accentuate on promoting constructive relationships during meetings. For instance, this collaboration must allow the school’s professors to rely on the mental health agency for educational supplies and tools. Likewise, the mental health providers must be able to depend on the professors for student referrals and support, specifically those who miss classes to attend group counseling. The mutual support that both the school and the agency agree to provide each other would fade away or weaken without positive relationships.


Addressing concerns and conflicts.

During cross-agency meetings, both providers should implement question/answer surveys and other similar formats because this will help them to address potential concerns and conflicts ahead of time, as well as the effective way to resolve future conflicts.


Coordination/Harmonization

Harmonization (coordination) is the third strategy for effective collaborative efforts. This phage begins right after both partners have finished identifying how they would participate and contribute to the alliance and clear avenues of communication have been properly set. This phase mainly describes the partnership’s agreement, including individual responsibilities, duration of the program, assessment measures, collaboration’s procedure, and a program’s plan evaluation. Doing so can help both entities to address the second challenge for practical support of the host setting, ensuring that all parties involved are cognizant of what space to use as well as the person being responsible for both furnishing and unlocking it.


Social Worker Role

To effectively implement this plan, the social worker must be familiar with useful tools and knowledge that relate to the problem and chosen intervention. The social worker is legally mandated to effectively report all cases of teen dating violence occurring at Deerfield high school. Additionally, the social worker should be cognizant of the way to effectively report teen dating violence as the laws for each state vary, with the majority necessitating the involvement of child protection agencies or law enforcement. Aside from reporting to the proper authorities, documentation should be immediate, impartial, and thorough.

Moreover, the social worker must be predisposed to collaborate with school administration to prevent additional trauma from investigation, including substantial education on the emotional, physical, and social distress as well as environmental risk factors that can arise with TDV. According to NASW Code of Ethics [NASW] (2008), social workers must thrive to value the importance of human relationships and seek to strengthen, restore, and the well-being of individuals, families, and communities. The social worker, in conjunction with the school and the mental health agency, must know how to thoroughly inform parents and families about the negative impacts of TDV on adolescents and their respective families. When social workers know how to effectively address issues relating to teen dating violence, this will restore and promote health family relationships and constructive communication. As a result, this will facilitate the production of a supportive and safe school climate while positively impacting the surrounding community.

Several useful strategies can be applied to facilitate the collaborative process between the mental health organization and the school. For instance, the Children’s Safety Network (2012) enlists several strategies that involve the participation of task forces, the focus of advisory committees on TDV, the proper connection and maintenance of a relationship with the state’s Department of Education (DOE), the support of social environment change, violence prevention, and youth community services as well as the eradication of unnecessary school policies. Safe Dates and The Fourth R/Skills are two Evidence Based Programs implemented to proficiently assist victims of TDV, to promote healthy youth and family interactions/ relationships, as well as to raise awareness and prevention of TDV (Child Trend, 2014).


Safe Dates

Safe Dates is a program designed to stop, thwart, and reduce the instigation of physical, sexual, and emotional abuse on dates or within adolescents’ intimate relationships. It targets 9th grade males and females with the final goal to change gender role norms and TDV, promoting dating conflict resolution and peer help-giving skills (Child Trends, 2014). It further enhances the social worker’s ability to help the victims and perpetrators through community resources, which significantly decreases the risk of dating abuse perpetration and victimization (“Prevention Programs”, 2011). There are 14 sessions with a duration of 60 minutes each including group discussions, games, quizzes, case study analysis, surveys, role playing scenarios, and written exercises.


The Fourth R: Skills for Youth Relationships

Similarly to the Safe Date program, the Fourth R targets 9th grade students. The curriculum promotes safe and healthy behaviors pertaining to dating, sexuality, bullying, and substance abuse. This program mainly focuses on the social learning theory and is grounded in stages of social development. This involves three units with seven 75-minute sessions taught by trained professors or mental health professionals, including injury prevention and personal safety, sexuality and healthy growth, and substance use and abuse (Wolfe, Crooks, Jaffe, et al., 2009).


Diversity and Inclusion


Considerations

As previously stated, the C D C (2016) describes adolescent dating violence [TDV] as any physical, sexual, and emotional aggression evidenced in a dating relationship. While both males and females often report similar levels of dating violence with TDV, females reported TDV as defensive (Child Trends, 2014). In 2014, female pupils (19%) were more likely to report TDV than male pupils (8%) and gender differences were less prominent amongst African American students than other races and ethnicities. 8.2% African American males and 12% African American females reported being victims of TDV (Child Trends, 2014); however, the report percentages were 13.6% for Hispanic females and 7.0% for Hispanic males. Finally, Caucasian female students reached 12.9% while the male students were 6.4% (Child Trends, 2014). Thus, teen intimate violence cannot be ignored and must be seriously addressed.

Based on the above information, adolescent females are most likely to experience TDV because the key problem has not yet been identified. For instance, basic factors, including physical, emotional, sexual, financial, electronic, verbal, and digital abuses, must be examined before determining the problem (Child Trends, 2014). Abusive behavior,which includes inhibiting a partner from having friends outside of the relationship or guilt-tripping, should stop being justified as jealousy. Adolescents have become very familiar with having immediate access to their partner’s social media platforms. Adolescents’ level of cognizance is still in the pruning stage and thus they are unable to maturely think that their intimate partners do not belong to them (Wolfe, Crooks, Jaffe, et al., 2009). These normalizations are imposed by peers and social media, which significantly proves why one in three adolescents are reporting TDV monthly. Parents and teachers should provide surveillance and monitor the amount of times adolescents spend on social media in order to solve the problem. Moreover, parents should establish better or sterner age-appropriate dating rules or reinforce curfew’s regulations.


Conclusion

People always assume that adolescents should just walk away from abusing relationships as everyone sees the trouble but never the struggle. It is difficult and even risky for victims of TDV to exit abusive relationships as they are afraid to be murdered by abusive partners (Child Trends, 2014). For instance, some might want to seek professional help before daring to leave their abusive partner. Thus, through the implementation of the interagency collaboration, safe places allow victims to overt their emotions/feelings as well as inform them on the awareness and prevention of TDV. While this will not immediately end TDV, acknowledging its level of severity is significant enough because all involved parties can be informed with proficient knowledge that empowers them to make conscious decisions.

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Hildegard Peplau Nursing Theory

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Hildegard Peplau’s theory of interpersonal relations is a middle range theory that focuses on the nurse – patient relationship and how the two work together toward the common goal of wellness. By working through a set of phases in a particular order, the nurse and patient can reach the goal toward wellness together and the patient can continue that journey after the relationship is terminated. This theory is important because the nurse needs to understand the importance of how the nurse-patient relationship can help the patient achieve a better understanding of the importance of their care. Once the patient has a good understanding of his or her care, he can continue to work toward wellness without having the nurse constantly helping.

I chose Hildegard Peplau because I feel that nursing is more than the passing of medications or doing wound care. Educating patients on the why’s and what’s of their treatment can help the patient remain well or maintain their health to the best of their ability. Peplau’s theory teaches the nurse how to interact with his or her patient so that the patient feels more in control of his treatment which can also give him the sense that the treatment can be done without the assistance of the nurse once the patient is discharged from her care.

Hildegard Peplau was a psychiatric nurse who had many accomplishments in life. According to Sills, Peplau, and Reppert (2007), Peplau began her nursing career in 1931. While working as a staff nurse she received her Bachelor’s degree in interpersonal psychology in 1943. She then went on to work in a private psychiatric facility where she worked with Eric and Frieda Reichmann and Harry Stack Sullivan. It was Stack’s interpersonal theory that Peplau based her theory on. Peplau then went on to join the Army Nurse Corp from 1943-1945 working in a military psychiatric hospital. Peplau received her master’s and doctoral degrees from Teacher’s College at Columbia University. It was here that she got her certification in psychoanalysis. From 1954-1974 Dr. Peplau remained on the faculty at Rutgers University College of Nursing. In 1952 Peplau had a book published which she completed in 1948 but could not publish due to the fact that “it was considered too revolutionary for a nurse to publish a book without a physician co-author”. Many awards were received throughout Dr. Peplau’s life such as the Christine Reimman prize which is the highest world of nursing honor. In 1996 she was honored as a living legend, and was inducted into the ANA hall of fame in 1998. Dr. Peplau died at the age of 89 in 1999.

Peplau’s theory of interpersonal relations focuses on the nurse-patient relationship. According to Kearney-Nunnery (2008) there are three phases of this theory. The first phase is the orientation phase. During this phase the nurse identifies herself along with her professional status to the patient and she sets the groundwork down for the nurse-patient relationship. The second phase is the working phase which is broken down into to two sub phases, the identification phase and the exploitation phase. The identification phase is when the patient learns how the nurse-patient relationship will work and the exploitation phase sets the groundwork for what services the patient will use. The third and final phase is the termination phase which is when the completed work for the patient is done and the nurse-patient relationship is terminated. The following web page: http://currentnursing.com/nursing_theory/interpersonal_theory.html discusses the theory in depth and gives the reader a break down of how the theory works with the nursing process. The following table found on the web site shows how the theory and nurse process are related Saleem (2010):

Assessment

Data collection and analysis [continuous]

May not be a felt need

Orientation

Non continuous data collection

Felt need

Define needs

Nursing diagnosis

Planning

Mutually set goals

Identification

Interdependent goal setting

Implementation

Plans initiated towards achievement of mutually set goals

May be accomplished by patient , nurse or family

Exploitation

Patient actively seeking and drawing help

Patient initiated

Evaluation

Based on mutually expected behaviors

May led to termination and initiation of new plans

Resolution

Occurs after other phases are completed successfully

Leads to termination a

This theory seems to be mainly based for the psychiatric community but can be applied to regular nursing as well. By setting the ground work during the orientation phase, the nurse can develop a relationship with her patient and open up the communication necessary for treatment to begin. During the working phase, the nurse and patient can discuss what is necessary for the patient to get well and the nurse can begin her teaching which the patient will need in order to maintain his or her health. Once the patient is able to do all things necessary to maintain their health, the termination phase can proceed. This theory can be applied to the nursing practice but as pointed out on the previous web site Saleem (2010), there are limitations such as:

Intra family dynamics, personal space considerations and community social service

resources are considered less

Health promotion and maintenance were less emphasized

Cannot be used in a patient who doesn’t have a felt need e.g. with drawn patients,

unconscious patients

Some areas are not specific enough to generate hypothesis

Dr. Peplau was able to apply this theory in her practice because of the dynamics of her specialty which was psychiatric nursing. My specialty in nursing is working with heart patients. I tend to see many of the same patients over and over due to the disease process. This theory can be applied to my nursing and may be helpful in slowing down the number of times my patients return. By applying this theory my patients will get the education and the understanding they need to manage their disease at home without the watchful eye of the nurse.

In conclusion, by applying Hildegard Peplau’s nursing theory of interpersonal relations to the nursing practice, the nurse is able to communicate and work with the patient more efficiently toward the common goal of wellness.

Identify gaps in current public health efforts aimed at reduction in incidents of Tuberculosis cases and discusses the implications of these factors.

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Identify gaps in current public health efforts aimed at reduction in incidents of Tuberculosis cases and discusses the implications of these factors.

Identify gaps in current public health efforts aimed at reduction in incidents of Tuberculosis cases and discusses the implications of these factors. Also identify and discuss possible ethical/legal issues associated with Tuberculosis and identify supportive therapies.

Identify gaps in current public health efforts aimed at reduction in incidents of Tuberculosis cases and discusses the implications of these factors. Also identify and discuss possible ethical/legal issues associated with Tuberculosis and identify supportive therapies. Identify gaps in current public health efforts aimed at reduction in incidents of Tuberculosis cases and discusses the implications of these factors. Also identify and discuss possible ethical/legal issues associated with Tuberculosis and identify supportive therapies. Identify gaps in current public health efforts aimed at reduction in incidents of Tuberculosis cases and discusses the implications of these factors. Also identify and discuss possible ethical/legal issues associated with Tuberculosis and identify supportive therapies.Identify gaps in current public health efforts aimed at reduction in incidents of Tuberculosis cases and discusses the implications of these factors. Also identify and discuss possible ethical/legal issues associated with Tuberculosis and identify supportive therapies.

Python : battleship you should write a simplified version of game

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Battleship You should write a  simplified version of game Battleship. While the game is normally played  with two users, we consider only one player. You don’t need to write  any artificial intelligence for the other player, this is a simplified  version – I will play as a player trying to hit computer’s ship with the  lowest number of shots possible. There are many different versions of  Battleship game. You can read about then on Wikipedia. However, you will  have to make a simplified version and here are steps you need to have:  1. Ask player about field size N and then generate a square field NxN  size. The most typical size is 10 by 10 but your game is flexible and  accept any size. Put zeros in every empty cell of the field. Example:  empty field of 6 by 6 [0, 0, 0, 0, 0, 0] [0, 0, 0, 0, 0, 0] [0, 0, 0, 0,  0, 0] [0, 0, 0, 0, 0, 0] [0, 0, 0, 0, 0, 0] [0, 0, 0, 0, 0, 0] 2.  Create and randomly place just one ship of length 5 cells. The ship can  be placed vertically or horizontally (again – randomly). To place a  ship, you change values of the cells on the field to 1. Obviously, the  ship can not go beyond the field. Example: playing field with the ship  (but you don’t show it to the player) [0, 0, 0, 0, 0, 0] [0, 1, 0, 0, 0,  0] [0, 1, 0, 0, 0, 0] [0, 1, 0, 0, 0, 0] [0, 1, o, 0, 0, 0] [0, 1, 0,  0, 0, 0] 3. Final stage-playing. Ask a user about their shot location  and report if it is “hit” or “miss” and count a number of shots till  user hits all ships (or just gives up trying). Example: playing field  with three misses (8) and one hit (2) – you can use any numbers you  like, just make it clear for the player [0, 0, 0, 0, 0, 0] [0, 2, 0, 0,  0, 0] [0, 0, 0, 0, 0, 0] [0, 0, 0, 0, 8, 0] [0, 0, 0, 8, 0, 0] [0, 0, 0,  0, 0, 8] 4. Hint, you might need to create a custom function to print  out your game field as the standard command “print” will produce output  that is difficult to read