Review of Literature on Smoking and Urinary Bladder Carcinoma

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Method:

Literature review


Background:

Urinary bladder carcinoma is one of the most prevalent tumors woldwide and smoking is one of its major risk factor ,hence studying the relationship between smoking and urinary bladder carcinoma is of great importance


Results:

Relationship between smoking and urinary bladder carcinoma is not clear although recent studies has shown that it might be related to the VEGF , apoptosis , urinary ph and causes mutation in the DNA. There is equal risk between males and femlesin relation to urinary bladder carcinoma related smoking.

Results have shown that the risk of smoking is more apparent in the current smokers than non smokers and water pipe smoking has a borderline risk.


Conclusion

: Smoking is a major risk factor in urinary bladder carcinoma with equal risk in males and females , cessation of smoking decreases the risk to almost normal

keywords : Smoking, urinary bladder carcinoma , risk factor , pathogenesis


Methodology

literature review made by searching PubMed with following restrictions: 5 years , humans , free full article and English


Background

Urinary bladder carcinoma is one of the most prevalent cancers worldwide, the seventh most common .In North America and Europe is considered the eleventh most common cancer (3), in Egypt it is the most common malignancy in males.(6)

Therefore studying the risk factors for Urinary bladder carcinoma is important to decrease the prevalence and incidence, risk factors include Bilhariziasis, aniline dye.

Smoking is considered one of the major risk factors for urinary bladder carcinoma .


Results

Although the exact relationship between smoking and urinary bladder carcinoma is still unclear, smoking is one of the major and important risk factors for developing of urinary bladder carcinoma. Tobacco smoking contain a lot of the carcinogenic agents like poly cyclic aromatic hydrocarbons and aromatic amines, substances that are excreted by the kidney, known to be harmful to the urinary tract, and cause bladder cancer secondary to genetic damage.

Studies have shown that smoking increases the risk to get bladder carcinoma by 6 times and it is responsible for 50 % of bladder carcinoma , it is more prevalent in developing countries due to the diffuse spread of this ugly habit, the easiness of getting it and the laxity of the governments to fight it . (3)

After filtering of these carcinogenic gents through the urinary tract, it is stored into the urinary bladder which damages its lining epithelium and make transitional cell mutation.

Tobacco smoking is considered as the initiator for the carcinogenesis. Many proteins are showen to be a part of the angiogenesis process in the developing of carcinoma likeP53 and VEGF (vascular endothelial growth factor) which showed to be the main one in this process by increasing the vascular permeability and inducing endothelial cell migration, So the VEGF helps in the progression of the cancer, studies have shown that the degree of severity of bladder carcinoma is directly related to degree of expression of the VEGF. (4)

Studies have shown that apoptosis has higher effect in urinary bladder carcinoma related to smoking more than VEGF, apoptosis is mainly under control of P53 gene which is found to be highly mutated in urinary bladder carcinoma.(4)

Cigarette smoking increases the acidity of urine which causes compounds like Glucuronide conjugates of 4-aminobiphenyl and its N-hydroxy metabolite to be hydrolyzed, and this causes DNA damage and mutation .(1)

A recent study has shown that urine ph is not a good indicator in ex_smokers or non smokers ,while urine ph is strongly related to bladder carcinoma in current smokers , experimentally not proven by studies yet that changing urine ph that decrease the hazardous affect of smoking related to bladder carcinoma (1)

Studies showed that cigarette smoking increases the prevalence of urothelial carcinoma to 77% and sqamaeous cell carcinoma to 69% among men. Also those studies showed that the number of cigarettes smoked per day and risk of urothelial carcinoma, between years smoked and risk of urothelial carcinoma, and between pack-years and risk of urothelial carcinoma were observed. On the other hand former cigarette smokers have no relation between the number of cigarettes smoked per day and risk of urothelial carcinoma, between years smoked and risk of urothelial carcinoma, and between pack-years and risk of urothelial carcinoma.

Researches have shown that those who are smoking water pipe have borderline relationship to the urothelial carcinoma but not with the sqamaseous cell carcinoma. There was no dose-relationship between risk of urothelial carcinoma and number of hagars smoked per day, duration of smoking, or Hagar-year. Patients who have schistosomiasis and smoke have no additional risk for urinary bladder carcinoma.(2)

A study has been made in New England shown equal risk for urinary bladder carcinoma between men and woman. it also shown that pack per year and intensity of smoking have reached the plateau according to the risk but not the duration of smoking, this plateau has been observed in many cancer related smoking . Smoking for a longer time is more hazardous than heavy smoking for a shorter duration. An explanation for the observed plateau is the difference in inhalation pattern , meaning that if u inhaled less this means less exposure to carcinogens per cigarette and subsequently less damage . (5)


Conclusion

Scientists are still unclear about the precise pathogenesis of smoking related urinary bladder carcinoma but studies have shown that smoking increases the risk by 6 times and cause about that 50 % of all urinary bladder carcinoma with equal incidence of males and females .

Studies shown that angiogenesis plays an important role in increasing the progression of urinary bladder carcinoma by the VEGF which increases the vascular permeability and induce endothelial cell damage. The degree of expression of the VEGF is strongly related to the degree of severity of the urinary bladder carcinoma.

A lot of important compounds like Glucuronide conjugates of 4-aminobiphenyl and its N-hydroxy metabolite are hydrolyzed by the acidic urine of the smoker. Recent research showed a strong correlation between the urine ph and current smokers but there is no relation between the urine ph and the former cigarette smoker.

A study showed that number of cigarette per day, duration of smoking and smoking index have a very high effect on the risk of urinary bladder carcinoma in current smokers but they have a lesser effect on the risk in the former smokers. On the other hand water pipe smokers have a borderline risk factor for urinary bladder carcinoma. There was no dose-relationship between risk of urothelial carcinoma and number of hagars smoked per day, duration of smoking, or Hagar-year.

Longtime smoking is proved to be more dangerous than heavy smoking for shorter time in relation to urinary bladder carcinoma ,the pack per year and the interxity of smoking have reached a plateau in the risk possibly due to the differnce in the inhaltion patterns whereas the duration hasn;t reached a plateau.

In case of duration the relationship is pretty simple and obvious, the longer u smoke ,the more likely hood to get cancer, and also justified longer smoking means longer periods of carcinogenic substances to take effect


Recommendation for future research

Studies has to made to detect the exact pathogenesis of smoking on urinary bladder carcinoma.

Also research has to be made to explain the plateau observed in some research


References

1) Urinary pH, cigarette smoking and bladder cancer risk

2) Cancer epidemiology ,biomarkers and prevention

3) Cause–effect? Understanding the risk factors associated with bladder cancer

4) Expressional evaluation of Vascular Endothelial Growth Factor (VEGF) protein in urinary bladder carcinoma patients exposed to cigarette smoke

5) A Case – Control Study of Smoking and Bladder Cancer Risk: Emergent Patterns Over Time

6) Incidence analyses of bladder cancer in the Nile delta region of Egypt

Recurring Pericardial Effusion in a Cancer Patient

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ABSTRACT

A 55 year old woman was admitted to hospital for symptoms of shortness of breath when bent over and a sloshing sensation in her chest. She has been treated with chemotherapy and radiation for cancer in the past. A transthoracic echocardiogram (TTE) was ordered to assess left ventricular function, which demonstrated moderate to severe systolic dysfunction. After being followed with serial echocardiograms, a moderate sized circumferential pericardial effusion with early signs of cardiac tamponade developed. After undergoing pericardiocentesis and upon return to the clinic for a follow up, echocardiography revealed that the effusion had again returned. This case report discusses the patient’s testing, treatment and the possible etiology of the effusion.


CASE REPORT

A 55 year old woman was referred to the clinic to have a echocardiogram performed in order to assess the function of her left ventricle. She had recently been feeling short of breath, a sloshing feeling in her chest, and discomfort when bent over. After obtaining a medical history from the patient, it was learned that she had been treated 10 years previously for breast cancer- she underwent chemotherapy, radiation treatment, as well as a left breast mastectomy. In 2016 she was diagnosed with ovarian cancer and has since had two recurrences, treated with chemotherapy in each instance. There is no family history of cardiovascular disease, but her father passed away at an early age from cancer. She had also previously been diagnosed with hypertension and was being treated with medication. Upon physical examination, her blood pressure was 138/78 mmHg with normal heart and lung sounds and no edema present. Electrocardiogram (ECG) showed sinus rhythm at a rate of 66 bpm. Chest X-Ray showed a normal cardio mediastinal silhouette, with clear lung and pleural spaces.

The first echocardiogram performed on the patient at the clinic resulted with findings correlating to decreased function of the left ventricle. The left ventricle was mildly increased in diameter (5.6 cm), as well as mass index (107 g/m²). The ejection fraction was estimated to be 25-30% by Simpson’s Biplane Method, correlating to severe systolic dysfunction. The left ventricle appeared to be globally hypokinetic, with grade II diastolic dysfunction. The left atrial volume index was moderately increased (45 ml/m²), with a normal dimension measurement. A trivial pericardial effusion was noted in systole, with no signs of hemodynamic compromise. The findings of this transthoracic echocardiogram (TTE) suggested chemotherapy mediated cardiomyopathy and the patient was treated with medication to improve cardiac output.

patient began treatment for

A series of follow up echocardiograms showed improved, but still present systolic dysfunction. The left ventricle now measured at 5.3 cm- very mildly increased, wall mass measured normal. The ejection fraction was now estimated at 35-40%, correlating to moderately decreased systolic function. Again, the left ventricle appeared to be globally hypokinetic. Diastolic function remained grade II. The left atrial volume index remained moderately increased (40 ml/m²). The major difference from the follow up studies compared to the original was that the trivial pericardial effusion had increased to a more moderate size circumferential effusion. The effusion measuring largest at the basal inferolateral wall (1.3 cm). The right atrium demonstrated early signs of hemodynamic compromise, with diastolic collapse being noted. The patient has been having follow up echocardiograms in short intervals to monitor the effusion progression. Eventually, the effusion increased to

Find report where the effusion got bad enough for tamponade.

The patient underwent a diagnostic pericardiocentesis and a TTE was performed at the clinic to assess her status afterwards. This echo demonstrated similar decreased left ventricular function, a moderately decreased ejection fraction (35-40%) and grade II diastolic dysfunction. The left ventricular cavity dimension now measured moderately abnormal (5.7 cm), while the left atrial volume index and dimension measured normal. The pericardial effusion remained circumferential but was seen predominately near the right atrium and right ventricle, however increasing in dimension from 1.3 cm to 1.4 cm, even after draining of pericardial fluid. The right atrium again demonstrated late diastolic collapse, an early sign of cardiac tamponade.

Another TTE was performed 2 weeks later, demonstrating that the patient’s ejection fraction had improved to an estimated 49%, correlating to mild systolic dysfunction with grade I diastolic dysfunction. The left ventricle now measured normal, and the atria remained within normal limits. The pericardial effusion seemed to worsen, however. It now measured 1.6 cm adjacent to the inferolateral wall and 2.2 cm adjacent to the right atrium and right ventricle. The right atrium again showed signs of hemodynamic compromise with late diastolic collapse. No significant mitral or tricuspid valve inflow variation was demonstrated. After this study, it became apparent that this patient was having recurring and worsening pericardial effusions and a more definitive approach to treatment may be necessary. The patient has been referred for treatment by means of a pericardial window with follow up echo in a two weeks or sooner if symptoms worsen.


DISCUSSION

The discussion to be had about this patient and her pathology is complex. For the purposes of this case report, the focus will be mainly surrounding the diagnosis and treatment of chemotherapy mediated cardiomyopathy, as well as the possible causes for the recurrent pericardial effusion and hemodynamic compromise.

Chemotherapy-mediated cardiomyopathy is a common side effect related to being treated for cancer. The level of cardiotoxicity from treatment is directly related to dose, rate of administration, age, gender, and other comorbidities. In patients who have suspected left ventricular failure as a result of chemotherapy treatment, serial echocardiograms are performed in order to monitor and assess the patients status- changing the course of treatment as necessary. The cardiac effects related to being treated with chemotherapy drugs may manifest early in treatment (acute), or even years after treatment (late onset) (1). There are two types of chemotherapy-mediated cardiomyopathy, related to the type of chemotherapy drug used. Type 1 is associated to anthracycline, Type 2 is associated to trastuzumab. It has been stated that biopsy of the myocardium is the gold standard for determining anthracycline induced cardiomyopathy, however this method is less useful for identifying cardiomyopathy caused by trastuzumab. (2) Cardiotoxicity, or damage to the heart caused by a toxin (in this case, chemotherapy), is treated in a couple of ways. The physician is likely to decrease or stop the treatment which is causing the damage, as well as prescribe medication to improve clinical status. Some common medications used to treat heart failure related to chemotherapy include beta blockers such as metoprolol, digitalis, diuretics such as furosemide, and angiotensin converting enzymes, or ACE inhibitors.


Sources

Draw on an area of lifespan and demonstrate your knowledge and understanding of the developmental theories that relate to a particular service user group. Describe how this knowledge would increase your understanding of the service user and how this might affect your role as a social worker. Briefly Introduce life span theory and the focus on one group eitherLate Adulthood or Early Adulthood

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Draw on an area of lifespan and demonstrate your knowledge and understanding of the developmental theories that relate to a particular service user group. Describe how this knowledge would increase your understanding of the service user and how this might affect your role as a social worker. Briefly Introduce life span theory and the focus on one group eitherLate Adulthood or Early Adulthood

 

Late Adulthood

Assignment Title: Choose either Late Adulthood or Early Adulthood
What are the advantages and disadvantages of viewing behaviour through the life-span perspective for social work practice?Use either Late adulthood or early adulthood
Assignment Guidelines
Draw on an area of lifespan and demonstrate your knowledge and understanding of the developmental theories that relate to a particular service user group. Describe how this knowledge would increase your understanding of the service user and how this might affect your role as a social worker. Briefly Introduce life span theory and the focus on one group eitherLate Adulthood or Early Adulthood
Analyse the implications of relating developmental theories to your personal values and how this will support anti-discriminatory and anti-oppressive practice outcomes.
Critically analyse the theory and the practice implications to formulate a conclusion that answers the assignment question.
The written assignment should be no less that 1700 wordsAll sources must be acknowledged using the Harvard style of referencing.Please use two references in each paragraph, Every paragraph should be supported by at least two references or more, You can use one reference if the paragraph is too small with less than 90 words.
Students are reminded that plagiarism and collusion are serious academic crimes. You should consult the course handbook for further explanation of these terms.

Very Important and Should be Reflected in the Essay
a) Demonstrate knowledge and understanding of the developmental factors that influence individual experience and which contribute to the formation of behaviour.
b) Demonstrate an appreciation of the impact of both positive and negative consequences of major life events and developmental processes upon the experience and functioning of the individual.
c) Demonstrate an understanding of the intervention strategies that social work/ social care can provide throughout key stages of the life cycle.
d) Awareness and sensitivity to issues of inequalities and power differentials and their application to different practice settings (anti oppressive/ discriminatory/ racist practice).
Please use the following reading and Journals listed below
Beckett, C. (2010) 2nd ed. Human Growth and Development to Psychological Introduction. Sage: London
Bee, H. (2002) 3rd ed. Lifespan Development. Collins: New York
Bond,J. et al. (2007) 3rd ed. Aging and Society. Sage: London
Bowlby, J. (1953) (1965 2nd ed.) Childcare and the Growth of Love. Penguin: Harmondsworth
Bruce, E.J. and Schultz, C. (2001) Non-traumatic Loss and Grief.A Psyche Education Approach. Jessica Kingsley: London
Cleaver, H. Unell, T. and Aldgate, J. (2011) 2nd ed. Children’s Needs – Parenting Capacity. The Stationary Office: London
Cooper,C. (1985) Border-Line and Bad Enough Parenting. BAAF: London (chapter from Adcock, A. (1985) Good-Enough Parenting – A Framework for Assessment. BAAF: London
Crawford, K & Walker, J. (2010) 3rd ed Social Work and Human Development Learning Matters
Davenport, G.C. (1994) An Introduction to Child Development. Collins Educational: London
Durkin, K. (1995) Development of Social Psychology: From Infancy to Old Age. Blackwell: Oxford
Gross, R. (2010). 6th ed. Psychology: The Science of Mind and Behaviour. Routledge: London
Howe, D. (1995) Attachment Theory for Social Work Practice. Macmillan: Basingstoke
Howe, D., Brandon, M., Hinings, D., Schofield, G. (1999) Attachment Theory, Child Maltreatment and Family Support. Macmillan: Basingstoke
Johnson, J. and Seater, B. (eds) (1993) Ageing and Later Life. Sage: London
Lindon, J. (2010) Understanding Child Development. Macmillan: Basingstoke (1 e-book available in library)
Noller, P. at al. (2001) Personal Relationships across the Lifespan. Press Psychology: Hove
Santrock, J. W. (2010) 13th ed. Life-Span Development.McGraw-Hill:USA
Schuster and Ashburn (1992) The Process of Human Development: An Holistic Approach. 3rd Edition. J.B. Linnicot Co.: Philadelphia
Seifert K.L. and Hoffnung, R.J. (1999) Child and Adolescent Development 5th Edition. Haughton Miflin: NewYork
Sheridan, M. (2007) 3rd ed. From Birth to Five Years. Routledge: London (1 e-book available in library)
Thompson, H. and Meggitt, C. (1997) Human Growth and Development for Health and Social Care Hodder and Stoughton: London e-book ordered
Vasta, R. (1999) Six Theories of Child Development Jessica Kingsley: London Wrightsman, L. (1988) Personality Development and Adulthood. Sage: London

Please use some of these Journals
Journals (very useful for the most recent research and topical overviews)
British Journal of Social Psychology
British Journal of Social Work,
Community Care
Critical Social Policy
Disability and Society
Journal of Personality and Social Psychology
Journal of Social and Personal Relationships
Practice
Research Matters

WHAT BUSINESS PRINCIPLES ARE ASSOCIATED WITH PATIENT AND SYSTEM COST?

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WHAT BUSINESS PRINCIPLES ARE ASSOCIATED WITH PATIENT AND SYSTEM COST?

Overview
For this assignment, put yourself in a nurse manager, director of nursing, Chief Nursing Officer (CNO), or business owner role. Discuss three or more business principles (in your own words) needed to maintain safe, quality, patient-centered care that is fiscally sound, provide supportive data. In your discussion consider:
Essay must answer the following questions:
1. Why have you selected the business principles?
2. Are the business principles used at your current facility?
If you feel that they are, give supportive examples.
If you feel they are not give examples of how they could be implemented.
3. Why are those specific principles important in health care?
4. Why are those specific principles important to you?
Objectives
Differentiate ways that public and private payment systems impact the health of individuals and populations.

• Introduction must adequately address the manner in which this paper will be addressed.
• Conclusion must conclude the essay and its main points
• Paragraphs are required to be at least five sentences each.
• References must be from within 5 years

Place your order now for a similar paper and have exceptional work written by our team of experts to guarantee you A Results

Journal Entry for Class 8

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Journal Entry for Class 8


(300 words):

1. The report “Delivering Through Diversity” gives a toolkit for businesses to advance D&I. Describe the four steps of this toolkit.

2. Author Chimamanda Ngozi Adichie in her video “The Danger of a Single Story” talks about the importance of not limiting your perspective to a single viewpoint. How can you use this to advantage in your team project?

Comparison between Dementia and Delirium

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Presentation:

Dementia and delirium are two common neurological conditions with varying similarities and differences. Dementia is a neurodegenerative condition with a slow onset ( Fong,  Davis, Growdon, Albuquerque, & Inouye, 2015). Delirium is an acute mental status change ( Fong et al., 2015). An inexperienced  practitioner may have some difficulties in differentiating between the two conditions as certain similarities can present with either condition. Delirium and dementia are two separate mental conditions; however, both can be attributed with impaired memory and judgement, confusion, disorientation, variable degrees of paranoia and hallucinations (Lippmann & Perugula, 2016).

In reviewing specific presentations that differ between dementia and delirium. A consideration of delirium can be suspected if the patient presents with sudden cognitive confusion, while on the contrary a consideration for dementia can be established if the incidence has occurred slowly overtime ( Lippmann & Pergula, 2016).  Delirium duration is variable, whereas dementia duration is chronic and progressive ( Lippmann & Pergula, 2016). Both conditions affect cognition in some aspect. Deciding upon the length of the presenting condition can give the provider a better understating if the condition is dementia or delirium.

Both dementia and delirium tend to affect the elderly more often ( Lippmann & Pergula, 2016). In delirium certain medical complaints are seen such as;  infections, depression, diabetes, substance abuse or exposure to certain poisons or medications( Lippmann & Pergula, 2016). Medical conditions seen with dementia are issues related to a stroke, hypertension, Parkinson’s disease and dispositions to delirium ( Lippmann & Pergula, 2016).

The attention span typically seen in dementia is normal unless the dementia staging is advanced (

Fong et al., 2015

). Delirium attention  is minimized regarding focus, sustainability or shift in attention ( Fong et al., 2015). In delirium the  patient’s speech can be incoherent, disorganized and distractible ( Fong et al ., 2015). In dementia, the speech can be methodical, but may develop anomia or aphasia ( Fong et al., 2015).



Pathophysiology





Alzheimer dementia is evident with amyloid plaques and neurofibrillary tangles ( Buttaro, Trybulski, Polgar-Bailey, & Sandburg-Cook, 2017).  Alzheimer dementia is clinically associated with atrophy in the cerebral cortex  and is most noticeable in the frontal, temporal, and parietal lobes (Buttaro et al., 2017).  Catecholaminergic, serotonergic, and cholinergic transmission is affected in dementia; along with a reduction of the enzyme found in cholinergic neurons called choline acetyltransferase (Buttaro et al., 2017).

The exact cause of delirium has not accurately been identified. However, there are many possible causes for the physiological occurrence in developing delirium. One cause is in relation to inadequate cerebral metabolism, reported by areas of slowing on an electroencephalogram (Buttaro et al., 2017). Another physiological occurrence is in relation to central abnormalities, where an imbalance occurs between central cholinergic, cytokine activation and adrenergic metabolism ( Buttaro et al., 2017). Furthermore, changes in inhibitory tone and connectivity can  occur, due to a stress reaction from high levels of corticosteroids (Buttaro et al., 2017). Essentially delirium can be classified as reversible and an impairment of  either cerebral oxidative metabolism or neurotransmitter dysfunctions ( Lippmann & Pergula, 2016). And dementia is ultimately due to altered brain function from exogenous insult or an intrinsic course ( Lippmann & Pergula, 2016).



Assessment:

In both cases of dementia and delirium, a thorough and detailed health history is indicated , preferably from the patient. However, if the patient is unable to communicate,  a thorough health history can be obtained from a guardian, caretaker, or close relative ( Buttaro et al., 2017). A full neurological exam should also be included in suspected dementia or delirium ( Downing, Caprio,  & Lyness, 2013). The provider should also review a medication reconciliation for dementia and delirium  including all over the counter and prescriptive medications, along with questions pertaining to alcohol or substance use ( Buttaro et al., 2017). Specific assessments in relation to  suspected delirium involve close observation of the patient’s ability to ambulate , level of consciousness, speech, appearance and their overall interaction during the exam (Buttaro et al., 2017). Specific assessments in relation to dementia involve neurologic sings, blood pressure, cardiac assessment , cognition, mood, function and overall behavior  (Buttaro et al., 2017). The U.S. Preventative Task Force (2014) stated that nearly 29% to 76% of patients in the primary setting are underdiagnosed with dementia. Clinically the assessments for both diseases are similar in nature, however determining the exact cause of a delirium case can take strong clinical knowledge and skills that will lead to the diagnosis.



Diagnosis:

There are assessment tools that can be utilized in both dementia and delirium. In the case of delirium, the confusion assessment method (CAM)  can be utilized and is known as the most widely used tool in screening for delirium ( Downing et al., 2013). CAM is a brief assessment tool  to diagnose and monitor delirium onset, inattention, disorganized thinking, and altered level of consciousness (Downing et al., 2013). The assessment tools recommended for dementia is the Folstein Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA) ( Downing et al., 2013). The MoCA entails more cognitive domains than the MMSE ( Downing et al., 2013).

Cognitively simple tests that depend on focusing attention versus testing memory is useful in deciphering delirium from dementia (Morandi et al., 2016). Based upon assessment tool results will depend on the clinical need for further neurological testing and referrals. In addition, to a thorough health and physical history a computed tomography (CT) or magnetic resonance imaging (MRI) of the head can be ordered in either case  to rule out various conditions such as mass or vascular lesions, or infections (Buttaro et al.,2017). Blood work and diagnostic testing is not listed as current first line examinations for dementia, however they can be initiated  after a positive assessment screening to diagnose the dementia subtype (U.S. Preventative Task Force [USPSTF], 2014). Specifically, for dementia labs can  include  a vitamin B12,  folate  and a metabolic screen (Buttaro et al., 2017). Additional labs that can be ordered for delirium include drug and alcohol levels and a urine culture and sensitivity (Buttaro et al., 2017).



Treatment





There is no curative treatment for dementia, however there are medications than can slow the progression. The FDA has four approved medications in the treatment of moderate dementia ( Downing et al., 2017). One classification is cholinesterase inhibitors: Donepezil, Rivastigmine, and Galantamine ( Downing et al., 2017). The other classification is an N-methyl-D-aspartate receptor noncompetitive antagonist: Memantine ( Downing et al., 2017). According to Downing ( 2013)  nonpharmacological treatment is geared towards reduction in patient harm and caregiver stress through patient safety measures, functionality and quality of life.

Delirium usually resolves on its own; However, it may take some time to fully resolve ( Downing et al., 2013). Delirium has an abrupt onset, but it can take weeks for complete resolution of symptoms ( Downing et al., 2013). According to Downing ( 2013) treatment necessitates environmental changes along with behavioral support. Patients recovering from delirium should also be monitored closely and provided frequent reorientation reminders (Buttaro et al.,2017). Minimal medication management can be utilized cautiously with symptom control towards agitation, restlessness, and hallucinations with antipsychotics such as; risperidone, quetiapine, and olanzapine (Buttaro et al., 2017).

Providers should be educated and aware that in 2005, the US Food and Drug Administration issued black box warnings in the use of antipsychotics in dementia, related to the risks of cardiovascular events and death ( Downing et al., 2013). Understanding and recognizing the clinical differences between dementia and delirium is imperative in providing patients and their families with the proper medical treatment, education, advice and referrals that are needed.


References

  • Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandburg-Cook, J. (2017).

    Primary care: A collaborative practice



    (5th ed.). Retrieved from

    https://online.vitalsource.com
  • Downing, L. J., Caprio, T. V., & Lyness, J. M. (2013). Geriatric psychiatry review: Differential diagnosis and treatment of the 3 D’s – delirium, dementia, and depression.

    Current Psychiatry Reports

    ,

    15

    (6), 365. Retrieved from https://web-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=4&sid=df34ec4c-79f8-4726-8107-44625d543f73%40sdc-v-sessmgr05
  • Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A., & Inouye, S. K. (2015). The interface between delirium and dementia in elderly adults.

    The Lancet. Neurology

    ,

    14

    (8), 823-832. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535349/
  • Lippmann, S., & Perugula, M. L. (2016). Delirium or dementia?.

    Innovations in clinical neuroscience

    ,

    13

    (9-10), 56-57. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5141598/
  • Morandi, A., Davis, D., Bellelli, G., Arora, R. C., Caplan, G. A., Kamholz, B…Rudolph, J. L. (2016). The diagnosis of delirium superimposed on dementia: An emerging challenge.

    Journal of the American Medical Directors Association

    ,

    18

    (1), 12-18. Retrieved from

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373084/
  • U.S. Preventative Task Force (USPSTF). (2014).

    Cognitive Impairment in Older Adults

    :

    Screening.

    Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cognitive-impairment-in-older-adults-screening?ds=1&s=dementia

Module 11 lab assignment – documentation of complete head to toe | physical assesment

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Module 11 Content

You completed your full head-to-toe assessment skills demonstration last week and now will document your results. Continue to document only the objective findings for this section without bias or explanation. Remember if you can’t feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the same time be brief.

P.S use the word doc I uploaded to answer the above question. follow instruction.

Health-Related Quality of Life & Well-Being

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Topic Name:


Health-Related Quality of Life & Well-Being

Health-related quality of life (HRQOL) is a multi-dimensional idea which has domains regarding physical, emotional, mental, and personal performance. Its likeliest past immediate methods of causes, life expectancy, and population health of death, and also concentrates on the effect health condition has on quality of life. Retrieved from https://www.healthypeople.gov

I think about that prior to starting to break down the various topics of the project it’s essential to begin with the 2 fundamental concepts:


Quality of life

Quality of life (QOL) is an extensive multidimensional idea which often features very subjective evaluations of equally negative and positive factors of life.2 What causes it to be difficult to evaluate is the fact that, though the word “quality of life” has meaning for almost everyone and every academic discipline, groups and individuals are able to determine it differently. Although health is among the key domains of general quality of life, you will find other domains also – for instance, schools, housing, jobs, the neighborhood. Elements of culture, values, and humility are crucial domains of general quality of life which contribute to the intricacy of the measurement of its. Nevertheless, scientists have created helpful methods which have helped to conceptualize as well as determine these many domains and the way they connect with one another. Retrieved from https://www.cdc.gov/hrqol/concept.html


Health-related quality of life

The idea of health-related quality of life (HRQOL) as well as its determinants have developed since the 1980s to cover those elements of general quality of life which may be certainly proven to influence health possibly mental or physical. On the unique level, HRQOL incorporates mental and physical health perceptions (e.g., energy level, mood) and also their correlates – along with conditions and health risks, social support, functional status, and socioeconomic status.

On the neighborhood level, HRQOL incorporates community level online resources, policies, conditions, and methods which influence a population ‘s functional status and health perceptions.

According to a synthesis of the medical literature as well as guidance from the public health partners of its, CDC has defined HRQOL as “an individual’s or maybe group ‘s perceived mental and physical wellness after a while. Retrieved from https://www.cdc.gov/hrqol/concept.html

 


Objectives

The very first overarching goal for the Healthy People 2010 decade was increasing years and quality of good living. Methods of healthy life and life expectancy expectancy (HLE) were utilized to report on this particular objective for many populations, which depended on self-reported details regarding wellbeing, which includes worldwide health status, prevalence of some chronic illnesses, plus exercise limitations. For Healthy People 2020, quality of life is essential to every one of the four overarching objectives. Retrieved from https://www.healthypeople.gov


Four Goals

  1. Attain high quality, longer lives totally free of disease that is preventable, injury, disability, along with early death.
  2. Achieve health equity, eliminate disparities, and also enhance saving all organizations.
  3. Create physical and social environments which promote health that is good for all.
  4. Promote quality of daily life, healthy development, and good actions throughout all life phases.

Healthy People 2020 highlights the benefits of health-related quality of well-being and life by along with it as among the initiative ‘s four overarching objectives, “promoting quality of daily life, healthy development, along with health behaviors throughout all life stages.” Additionally, it was started as among the HP 2020 four foundation health methods. Retrieved from https://www.healthypeople.gov


Incidence

The significance of quality of well-being and life as a public health problem isn’t brand new. Since 1949, the world Health Organization (Who) has mentioned that health is “a state of complete actual physical, psychological, and cultural wellbeing without simply an absence of infirmity.” and disease .In 2005, Who recognized the benefits of analyzing as well as enhancing people’s quality of life in a place paper. Because individuals are able to longer than in the past, scientists have transformed the manner they analyze wellness, looking past causes of morbidity and death to look at the connection of wellness on the quality of a private lifestyle. When quality of life is within the context of disease and health, it is known as health-related quality of life (HRQOL). Researchers nowadays concur HRQOL is multidimensional and also has domains which are associated with physical, emotional, mental, and social functioning and also the interpersonal context where individuals live. Retrieved from https://www.healthypeople.gov

Healthy People 2020 is approaching the measurement of health-related quality of well-being and life originating from a multidisciplinary viewpoint which entails three complementary as well as associated domains:

1 – Mental health and self-rated physical

2 – Overall well-being

3 – Participation in society

 


Self-Rated Physical and Mental Health

HRQOL is a multidimensional and subjective concept that includes aspects of physical, mental, and personal health. For Healthy People 2020, the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Items have been identified as valid and reliable measures of mental health and self-reported physical and are now being considered to monitor these two domains across the decade. PROMIS is an NIH Roadmap initiative designed to create an electronic system to collect self-reported HRQOL data from diverse populations of people with an assortment of demographic characteristics and chronic diseases. Currently HHS monitors HRQOL in the United States by administering selected Other HRQOL items and promise on the Behavioral Risk Factors Surveillance System (BRFSS), the National Nutrition and Health Examination Survey (NHANES), and the National Health Interview Survey (NHIS). Retrieved from https://www.healthypeople.gov/


Measured

The PROMIS product banks include much more than 1,000 self-report questions covering numerous HRQOL domains which have undergone thorough qualitative and quantitative analysis by both experts and patients, fifteen  item global HRQOL scale was created to evaluate selected physical as well as mental health symptoms, which includes functioning and common health perceptions.12 The products had been derived from HRQOL item banks which offer much more accurate indicators of domain specific HRQOL. All products had been evaluated in diverse and large samples. Specific items include fatigue, emotional distress, pain, along with social activities. https://www.healthypeople.gov

 


Overall well-being

Individuals with increased levels of well-being judge the life of theirs as going very well. Most people feel very healthful and full of power to take on the daily activities of theirs. People are engaged, interested, and satisfied with the lives of theirs. Individuals have a feeling of accomplishment from the activities of theirs and judge the lives of theirs to become significant. Individuals are much more frequently content or perhaps cheerful than depressed or even anxious. Individuals get together with the others and experience great interpersonal interactions. Personal factors, social conditions, and community locations influence well-being. https://www.healthypeople.gov

Well-being thinks the physical, psychological, and social facets of a person’s life.

Physical wellbeing: Relates to vitality and vigor, feeling really healthful and filled with energy.

Psychological well-being; Includes being satisfied with one is life; balancing negative and positive emotions; accepting one is self; finding objective and meaning in one is life; looking for personal development, autonomy, and then competence; thinking one is life & amp; situations are under one ‘s management and generally experiencing optimism.

Social wellbeing: Involves providing and also receiving quality assistance from loved ones, friends, and even others. https://www.healthypeople.gov


Participation in society

Social participation could be evaluated through a determination on the degree to which individuals experience barriers to complete participation due to the current health state of theirs and also the planet. Participation in society consists of education, employment, along with civic, community, and leisure activities, in addition to family role participation. Participation is calculated in the context of a person’s existing health state and within the individual’s present social and physical environments, thus capturing a far more objective construct on the HRQOL concept. https://www.healthypeople.gov


Data

In 2010 had a rise the proportion of adults that self-report better or good health. Between the 78.8 as well as 79.1 % of adults self-reported good or better brain health within 2010 (age modified to the year 2000 regular population). National Health Interview Survey (NHIS), CDC/NCHS was utilized as information resources. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/health-related-quality-of-life-well-being/objectives

Evidence-based information and recommendations related to Health-Related Quality of Life & Well-Being.


Well-Being and life.

I would like to expose one example which shows the value of the Health-Related Quality of Live as well as Well Being.

Yoga for Improving Health Related Quality of Life, Mental Cancer-Related and Health Symptoms in women Identified as having Breast Cancer. Two review authors independently collected information on results and methods. They expressed results as standardized mean variations (SMDs) with ninety-five % self-confidence intervals (CIs) and also conducted random effects model meta-analyses. They assessed potential danger of publication bias through visible evaluation of funnel heterogeneity and plot symmetry between studies by utilizing the Chi2 test and also the I2 statistic. They conducted subgroup analyses for existing treatment status, time after diagnosis, stage of type and cancer of yoga intervention. Breast cancer is probably the most common cancer among females worldwide. This systematic review sought to evaluate whether yoga is able to improve quality of life, mental health, as well as symptoms regarding cancer in females having an examination of breast cancer. It identified twenty-four research and also discovered that yoga was better compared to no treatment in enhancing quality of life and decreasing exhaustion and sleep disturbances. Additionally, it discovered that yoga was much better for lowering fatigue, anxiety, and depression in females when compared with educational or psychosocial interventions like counseling. These results suggest that females having an examination of breast cancers is able to use yoga as supportive treatment for raising the quality of theirs of mental health and life, additionally to regular cancer treatments. (Cramer, et al., 2017)

The authors concluded that moderate quality evidence supports the recommendation of yoga as a supporting treatment for improving health-related quality of life and also decreasing exhaustion and sleep disturbances when as opposed with no treatment, and also for reducing depression, fatigue and anxiety, when compared with psychosocial/educational interventions. Very low-quality research indicates that yoga may be as helpful as some other exercise interventions and may be used as a substitute to other workout programmers. (Cramer, et al., 2017)


HRQL importance in Clinical Practice

The increasing value of HRQL estimation is realized by clinicians, medical policymakers, drug regulatory companies as well as pharmaceutical companies all over the world in choosing optimum treatment option for individuals, policy framing, new medication approval and choosing pharmaceutical advertising policies. Physicians are rising utilizing HRQOL to determine the consequences of chronic illness within their people to know how an illness disrupts an individual’s everyday life. (Ghosh, 2010)

HRQL analysis is employed by public health expert to recognize subgroups with bad physical or maybe mental health for far better equitable distribution of healthcare information. Drug regulatory agencies worldwide providing much more focus on quality of life information from medical trials in order provide faster endorsement to a brand-new drug. Pharmaceutical companies also assert superiority of the product of theirs and judge marketing cost primarily based on quality of living information produced from trials. (Ghosh, 2010)


Conclusions

Based on the above mentioned exposed, the health-related quality of life and wellbeing has great value in the lives of ours. It’s great influence on our social, physical, and personal advancement. Health is much more than the lack of disease; it’s a source that enables individuals to realize the aspirations of theirs, satisfy the needs of theirs and also to deal with the planet to live a long, effective, and productive life. In this specific sense, health makes it possible for personal, economic, and social development fundamental to wellbeing. Retrieved from https://www.cdc.gov/

References

  • Cramer, H., Lauche, R., Klose, P., Lange, S., Langhorst, J., & Dobos, G. J. (2017). Yoga for improving health‐related quality of life, mental health and cancer‐related symptoms in women diagnosed with breast cancer.

    Cochrane Library

    , n.p.
  • Ghosh, R. K. (2010). Health-related quality of life and its growing importance in clinical practice.

    The New Zeland Medical Journal

    , n.p.
  • Health People 2020 (2018). Health-Related Quality of Life & Well-Being.

    Office of Disease Prevention and Health Promotion

    , n.p.
  • Health-Related Quality of Life (HRQOL) (October 2018).Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/hrqol/wellbeing.htm

Prevent Hypothermia And Shivering

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Background

Patients undergoing a surgical intervention have the possibility to develop perioperative hypothermia and shivering. The normal human core temperature varies between 36.5°C (Celsius) and 37.5°C (Kiekkas, Poulopoulou, Papahatzi, & Souleles, 2005). Several studies define hypothermia as temperature below 36°C (Smith, Sidhu, Lucas, Mehta, & Pinchak, 2007, Sissler, 1997 and Bitner, Hilde, & Duvendack, 2007). Shivering as defined by (Holtzclaw, 2006, pp. 553-555) is the involuntary shaking of the body as a protection against cold. Intraoperative heat loss can occur to conduction by patients coming into contact with cold surface such as the operating table and convection with the use of cold inhalation gases. Further heat is lost through evaporation due to exposure of large surgical sites and radiation caused by exposure to cold operating room temperatures (DeLaune & Ladner, 2002).

Thermoregulation in humans is accomplished by a physiological control system made up of central and peripheral thermoreceptors, an integrating control centre and afferent response systems, which take compensatory action. The central control mechanism which is located in the hypothalamus, establishes and regulates the body temperature (Buggy & Crossley, 2000). Anaesthetics including opioids and volatile agents affect the thermoregulation and increase the risk of hypothermia (Sessler D. I., 1993, Sessler D. I., 1997, Kurz, Sessler, & Lenhardt, 1996 and Kiekkas et al , 2005).

Perioperative normothermia can be achieved by using warming devices. These include by either warming and humidifying inhaled gases or warming the body by using heated blankets, forced air blankets and fluid warmers. Increasing room temperature is also important, especially when the patient is exposed during skin preparation and positioning (DeLaune & Ladner, 2002). Forced air warming units draw ambient room air through a filter. Filtered air is then passed through a heating element which warms the air to be delivered through a hose into a dedicated blanket (Smith et al, 2007)

Complications which may arise from hypothermia include shivering, which increases oxygen consumption by 400% – 500%, increase mortality in patients less than 55 years old who are exposed to prolonged hypothermia and decreased production of interleukin 2 (Good, Verble, Secrest, & Norwood, 2006). Other consequences include increased risk for, cardiac events, surgical wound infection, need for postoperative mechanical ventilation and need for blood products.

Focused research question

The research question is formulated on the Population, Intervention, Control maneuver and Outcome (PICO) (Straus, Richardson, Glasziou, & Haynes, 2005). As regarding population the author is aiming for surgical patients irrelevant of their age. The intervention and control maneuver the author is comparing active warming system such as forced air warmers and conventional warming such as cotton blankets. The outcome is to evaluate hypothermia and shivering postoperatively.

Hence the PICO question would be “Is a forced air warmer more effective at decreasing hypothermia and shivering postoperatively as compared to conventional warming for patients undergoing surgery?”

Search Strategy

A search was conducted using Ebsco host available through the University of Malta, as well as using internet search engines like ‘Google scholar’. Also a library search and a search through references of references was conducted. CINAHL plus with full text was employed in the search using the word ‘warming’ yielded 1055 articles. Additional filtering resulted in 305 full articles available online. Articles with the subject heading ‘warming techniques’ were selected since the PICO question emphasises the comparison between artificial heating and conventional heating. This further reduced the search to 68 articles. Hypothermia was added and further reduced the search to 41 articles, which were further decreased to 3 articles by applying ‘Intraoperatively’ as a filter from the subject column ‘Major Heading’ criteria. Removing the full text option resulted into 15 relevant articles. The author performed a thorough analysis of the references of the final articles from which other articles were chosen. Articles relevant to the PICO question were saved in ‘my folder’ on the Ebsco website.

Another search was performed on CINAHL using the keyword ‘hypothermia’ which resulted in 615 articles. The search was further reduced to 48 full text articles by selecting ‘warming techniques’. Different subjects from the ‘Major Heading’ were selected including ‘surgical patients’, ‘intraoperative care’ and ‘postoperative care’. The final number of articles from each search was quite low, so the author could review titles of the relevant articles and saved any new articles, which were not in the Ebsco folder. A final search was made for full text articles with the word ‘Shivering’, and from the ‘Major heading’, ‘hypothermia’ was chosen thus resulting into 8 applicable articles.

The Ebsco folder was subdivided into two sub folders, one named totally relevant and the other named relevant to the question. The saved articles were further filtered one by one and from the 38 saved articles, the author discovered 4 clinical trials, 2 reviews, 13 research articles and 1 qualitative study.

On the PubMed, several combinations of Mesh keywords were explored. Keywords used were hypothermia, shivering and perioperative. Unfortunately a Mesh word for hot air blower or something similar was not found. From this search 28 articles were obtained but only 5 were full texts of which 3 were randomized trials. The best search result achieved was by using the PubMed advanced search and combining ‘forced air warming’ and ‘perioperative hypothermia’ which resulted in 51 articles. The results were further filtered for free full text articles and 19 articles were obtained. Filters on PubMed can be saved as well as searches. The 19 full text articles were again filtered for ‘meta-analysis’, qualitative research’, randomized control trial ‘and ‘systemic review”. The result of the final filter produced 1 qualitative research and 14 randomized control trials.

Google Scholar was also used to find articles related to the Pico question. The term words for the search included, ‘forced air warming’, ‘perioperative hypothermia’ and ‘shivering’. This resulted in 288 articles of which some were fully accessible. Articles must be opened one by one to identify their reliability and type.

An online search in the University of Malta Library was made for books with the word ‘perioperative’ in the title. This resulted into 17 books, of which 6 were relevant to perioperative nursing. The Google book search engine was an aid in exploring some of the contents, including the table of contents and extract pages. This lead to selecting 3 books which were available locally from the library, and included topics about hypothermia and warming patients. The author reviewed the named books at the library.

Criteria Used for included studies

For the PICO question chosen the articles needed to include warming devices, hypothermia and shivering. Relevant articles were saved in the Ebsco search folder and the abstract of each article was read for relevance. The articles relevant to the PICO question had to incorporate at least one comparison between an active and passive warming system. Shivering as described by Alfonsi, (2001) and Kiekkas et al, (2005) is mainly attributed to hypothermia, hence keywords, which included hypothermia were adequate for the included studies. Studies with relevant keywords included; Scott & Buckland, (2006), Bennet, Ramachandra, Webster, & Carli, (1994), Stevens, Johnson, & Langdon, (2000), Ng, et al. (2003), Lindwall, Svensson, Soderstrom, & Blomqvist, (1998) and Smith et al. (2007). The articles included one systematic review and five randomised control trials.

Critique of a research article should be a balanced evaluation of both the strengths and weaknesses of a study (Burns & Grove, 2003). For the critical appraisal, a systematic review was chosen due to its advantages like clear methods to limit bias by identifying and rejecting studies and hence conclusions are more reliable and precise (Greenhalgh, 2001). Another positive of a systematic review is that it incorporates a large amount of information from different relevant researches and hence results of different studies can be formally compared for consistency and generalisability.

Another article was chosen from the randomised control trials (RCT), for which the author opted for an eligible RCT which was not included into the references of the selected systematic review. The article chosen included the most amounts of subjects to be studied.

Critical Appraisal of a Systemic Review

The systematic review chosen by Scott & Buckland (2006) is a review of intraoperative warming in order to prevent postoperative complications.

Study focus issue

The paper explores previous studies on patients of various ages undergoing a surgical procedure under general or regional anaesthesia. The intervention was designed to prevent hypothermia or treat hypothermia intraoperatively. The outcome included any adverse consequences in the postoperative period in the post anaesthesia care unit (PACU) such as pain, thermal comfort and cost of treatment. Postoperative complications included, shivering, wound infections, pressure ulcers, cardiac events and the need for blood transfusion.

Systematic review cover

This article is a systematic review of randomized trials. The review tries to identify any evidence regarding hypothermia during surgery in previous researches, and if it has any adverse consequences afterwards. Hence this study focused on the use of warming devices during surgery, and the effect on patient outcomes postoperatively either in the PACU or after transfer from the PACU.

Methods used for the search

The authors of the article searched the Cochrane Wounds Group Specialized Trials Register and the Cochrane Central Register of Controlled Trials. The search included MEDLINE, CINAHL, EMBASE, and the National Research Register. The included articles ranged between January 1948 and May 2003. The systematic search included the keywords anaesthesia, perioperative care, hypothermia, normothermia, warming, thermoregulation and postoperative complications. The authors did not identify any search for grey literature.

Assessment of studies

The authors of the article Scott and Buckland included solely randomized trials. Only studies including the postoperative phase were assessed. Since the review was treatment focused the authors did not give great importance to the grade of complications or to identify any specific outcome. On the other hand, eligible studies were identified through clearly defined inclusion criteria. There was no restriction on language of the articles. Articles were reviewed twice independently and only included studies with human participants of any age undergoing a surgical procedure under general or regional anaesthesia. The studies had to include evaluated interventions aiming to prevent hypothermia during surgery. The duration of temperature monitoring had to extend the intraoperatively time and include the postoperative stage. Articles were excluded if hypothermia was induced, patients were undergoing cardiac surgery or if the was an efficacy study. Meta analysis was performed to identify clinically important similarities including type of surgery, anaesthesia used, blinding process and the effectiveness of the warming therapy used.

Any disagreement between the researchers, whether the articles were eligible to be included or not, were dealt through discussion. The authors of this study never verified uncertainty directly with the research authors and hence this might bias the selection criteria. One article was in German, and although it had an English abstract the authors had some of the article’s findings translated.

Consistency of the studies

All studies selected, which included 2,070 patients, compared standard treatment to at least one method of preventing hypothermia. Out of the twenty six studies, seventeen included a comparison with a forced air warming system. The method of anaesthesia was standardised in most of the studies. Some studies included a small number of participants, hence the reliability of these results is debatable.

Change in outcomes

Improvement was shown on the outcome from the twenty-six RCT chosen. The RCTs included 2,070 patients. When a comparison was made between patients being warmed or not the results were as follows:

Shivering in the PACU (RR 0.26, 95%, CI 0.20 – 0.35, ARR 21%)

Morbid cardiac event (RR 0.34, CI 0.20 – 0.57, ARR 21%)

Blood transfusion need (RR 0.39, CI 0.22 – 0.68, ARR 18%)

Wound infection (RR 0.26, CI 0.12 – 0.58, ARR 13%)

Pressure ulcer (RR 0.54, CI 0.25 -1.17, ARR 4%)

Complications in major surgery (RR 0.37, CI 0.27 – 0.51, ARR 13%)

No statistically significant results were obtained regarding pain because the studied groups were very small. Insignificant results were also obtained regarding costs.

The clinical bottom line

This systematic review points out that by warming the patient and thus preventing hypothermia intraoperatively can prevent serious postoperative complications. The results showed that by avoiding hypothermia, shivering can be prevented. Shivering can increase oxygen demands and can thus cause strain on the cardiovascular system which ultimately may lead to other complications, especially in older adults. Warming the patient reduces the need for blood transfusion, less wound infections and fewer pressure ulcer formations. The authors also included another meta analysis done by Mahoney & Odom (1999) that identified improved outcomes when normothermia was achieved, and hence the cost of warming a patient is much less than treating any adverse consequences.

Critical Appraisal of an RCT

The RCT chosen for the critical appraisal by Ng et al. (2003) compares three different warming interventions for effectiveness regarding normothermia.

Study focus issue

Ng et al. (2003) wanted to explore the most effective therapy between three different interventions in warming patients. The interventions included warming with two cotton blankets, warming with a reflective blanket and one cotton blanket, and warming with a forced air warming blanket. The standard practice before the study was the use of two cotton blankets. The authors sought to evaluate if the other techniques would yield better results in warming patients.

Selecting criteria

This study (Ng et al. 2003) was a randomised control trial involving three hundred patients scheduled for a unilateral total knee replacement. The participants were divided into three groups, and they were randomised using the sealed envelope method. The control group was those patients warmed with two cotton blankets whilst the other two groups were the intervention participants. Similarity in the group included the selection of patients using the American Society of Anesthesiologists (ASA) physical status of I or II, although any specific medical conditions were not mentioned. The ambient temperatures of both the operating theatre and the recovery room were kept between 19° C and 22° C by the relevant personnel.

Four nurse researchers were trained on data collection and treatment application as to avoid inaccuracies in the results. On the day of the intervention, one of the researchers picked a sealed envelope which included the type of warming technique to be used and a data collection form. One single type of thermometer was used for accuracy and all patients were brought into the operating room 45 minutes before the commencement of surgery. Patients were all donned in a patient gown and covered with one cotton blanket folded into two.

The intervention

Ng et al. (2003) gave a very detailed account on the application of the three different interventions. According to the sealed envelope opened the nurse researcher applied or another cotton blanket, or added a reflective blanket or applied the forced air warming blanket. The common practice of the hospital included a warm water circulating blanket underneath. The cleaning solutions and type of drapes were standardised for all patients.

Differences

Temperature difference was the most prominent in all the results obtained. The researchers measured the difference in patient temperature from the induction room to the recovery room. Temperature dropped significantly for both the two cotton and the reflective blanket group. The forced air warming group had significantly higher temperatures when measured in the recovery room compared to the reflective blanket group (temperature 0.577° C, 95%, CI 0.427 – 0.726, P<0.001) and the two blanket group (temperature 0.510° C, 95% CI 0.349 – 0.672, P<0.001). In the recovery room, the percentage of patients who reached 36.5° C in one hour was 75% in the forced air warming vice 45% in the two blanket group and 40% in the reflective blanket group.

Shivering in this study, was observed in four patients with two cotton blankets, three patients in the reflective blanket group and one in the forced air warming group. However it was not considered statistically significant. Due to this result, the researchers found that there was no connection between shivering and the warming intervention used.

Discussion on citations chosen

Both articles included, identify the importance of warming patients intraoperatively. Postoperative complications can be prevented if patients are actively warmed. In the systematic review by Scott & Buckland (2006) the authors focused on the outcomes rather than the costs. Although all researches included were RCT, the randomization quality was not described in each of the final twenty six researches eligible for the systematic review. Forced air warming was used in most of the RCT (17 out of 26) which ameliorated the outcome postoperatively. This favoured the choice of the systematic review. Ouellette (1993) in a study comparing four different types of patient warming concluded that forced air warming systems were the most effective compared the other three. Blinding was not described in all chosen RCT’s. The article included citations of all studies selected and includes a table with detailed review of important content relevant to the systematic review.

The RCT written by Ng et al. (2003) compare three different warming techniques. The authors took extreme precautions to eliminate variables, and included a very detailed account of the warming techniques used and selection criteria of patients. The chosen clients all underwent the same operation in the same hospital. This eliminated any inconsistency in the results obtained. The authors used a Bair Huggerâ„¢ warming device which is one of the most used warming devices at Mater Dei Hospital besides the Warmtouchâ„¢. In a study by Perl et al. (2003) which compared four forced air warming devices, highlighted that the Warmtouchâ„¢ device was superior to the Bair Huggerâ„¢ warming device. This does not limit the findings if applied locally since both devices are used, hence whichever system is used the incidence of hypothermia can be avoided.

An aid to maintain normothermia, which is not discussed in these studies is, to pre warm the patient prior surgery. Kiekkas & Karga (2005) and Cooper (2006) in their studies on warming patient preoperatively, concluded that when pre, intra and postoperative warming are offered to the patient the possibility of completely avoiding the risk of developing hypothermia and its associated complications can be achieved. Stevens et al. (2000), Lindwall et al. (1998), Smith et al. (2007) and Bennett et al. (1994) had congruent results with the forced air warming system as to maintain normothermia. This emphasizes the reliability of results obtained from the studies chosen for critique, if applied locally.

Conclusion

To conclude both articles gave evidence that warming a patient intraoperatively will decrease hypothermia postoperatively. Ng et al. (2003) did not find any difference in warming techniques used as regarding shivering. Contrarily, the systematic review performed by Scott & Buckland (2006) demonstrated positive results if patients were actively warmed. Patients who are warmed conventionally are more prone to hypothermia postoperatively. This can lead to undesirable complications and surely can be avoided locally due to the number of forced air warming devices available in each theatre and in the recovery room. Hence it is of utmost importance to introduce locally a protocol which highlights the importance of patient warming.

The clinical bottom line to the PICO question asked would be, “patients undergoing surgery, with the use of a forced air warmer rather than conventional warming, will definitely benefit due to a decrease in hypothermia and shivering postoperatively”.

: Apply evidence-based management strategies and best practices for resourcing health care services

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: Apply evidence-based management strategies and best practices for resourcing health care services

#6703 Topic: Heart Failure Clinic Resourcing Plan Number of Pages: 4 (Double Spaced) Number of sources: 4 Writing Style: APA Type of document: Coursework Academic Level:Undergraduate Category: Nursing Order Instructions: Assessment 4 Write a 4 page evidence-based resourcing plan for one component of the Heart Failure Clinic. • Instructions Deliverable: Develop one component of an evidence-based resourcing plan. Scenario: The hospital leadership team has already allocated the major capital expenditures for the heart failure clinic, such as the facility, legal services, IT, and security services. However, as a member of the nurse team, you have been asked to develop one component of a resourcing plan for the next leadership meeting. You may use any combination of documents (for example, a spreadsheet or a table) in addition to explanatory information to convey information clearly and succinctly. Choose one of the following: Budget: o Apply evidence-based management strategies and best practices for resourcing health care services.  Identify the business plan budget categories and subcategories (not necessarily the actual cost) to establish a new clinic.  Start-up expenses.  Examine fixed and variable costs.  Capital budget items.  Examples: salary and benefits, staffing mix, specialized equipment or materials, et cetera.  Contingency fund and parameters. o Apply legal and professional standards for resourcing outpatient services.