Liberty university cjus 330 ch.15-study questions / cjus 330 chapter

/in /by

Liberty University – CJUS 330 Ch.15-Study Questions / CJUS 330 chapter 15 Study Questions/ CJUS 330 Questions

How much deference (or conversely, scrutiny) an appellate court will afford to the decisions of a judge, jury, or administrative agency in an appeal is referred to as the ____________.

a. deferential standard

b. appellate standard

c. principle or review

d. standard of review

Which court is responsible for hearing cases for which there are automatic reviews?

a. trial court

b. intermediate court of appeals

c. state court of last resort

d. federal circuit court

If a defendant loses an appeal, what is the first step to take in order to file a subsequent appeal?

a. File a notice of appeal.

b. File a petition for a writ of certiorari.

c. File a writ of habeas corpus.

d. File a motion for appeal.

Which of the following statements is true?

a. Criminal appeals always involve questions of fact decided by a judge or jury.

b. In contrast to the highly deferential appellate review of factual issues, questions of law are reviewed without deference on appeal.

c. Appellate courts are willing to second-guess findings of fact made in lower courts.

d. Many appeals are “routine,” which means they have the likelihood of succeeding.

____________ errors are defects that seriously affect substantial rights.

a. Substantial

b. Reversible

c. Plain

d. Grievous

If a defendant convicted in a U.S. circuit court files for an appeal, which type of court has jurisdiction?

a. U.S. Supreme Court

b. intermediate courts of appeals

c. state courts of last resort

d. U.S. circuit courts

Which of the following are opinions written “by the court” without attribution to a specific judicial author?

a. dissenting opinion

b. concurring opinion

c. plurality opinion

d. per curium opinion

During trial, attorneys must make timely objections to the judge’s rulings on points of law or the objections will be deemed waived. This is known as which of the following?

a. mandatory objection rule

b. contemporaneous objection rule

c. appellate objection rule

d. interlocutory objection rule

The ____________ consists of the materials that advance to the appellate court.

a. writ of certiorari

b. standards of review

c. appellate court record

d. notice of appeal

A defendant who makes a guilty plea on a felony charge, therefore accepting the sentence recommended by the prosecutor, subsequently requests an appeal. The appeal is based upon the failure of the court to inquire as to whether the plea was voluntary. In this example, the error is subject to which type of test?

a. classic trial errors rule

b. reversible error rule

c. plain error rule

d. harmless error rule

Losing parties at trial have the discretion to file an appeal except in what type of cases?

a. felony cases

b. civil cases

c. misdemeanor cases

d. capital punishment cases

How does the role of the appellate court differ from the trial court?

a. It retries cases sent from the lower court.

b. It focuses on the evidence and how it was obtained.

c. It focuses on how decisions were made in the trial court.

d. It reexamines the facts presented during the trial.

The leading causes of ____________ include mistaken identifications, improper forensic evidence, false confessions, unreliable informants, tunnel vision and misconduct by justice professionals, and inadequate defense representation.

a. appeals

b. wrongful convictions

c. hung juries

d. postconviction reviews

Why do criminal appeals rarely succeed?

a. The appellate court reversal often produces only minor victories for many criminal defendants.

b. If the appellate court reverses and remands the case to the lower court for a new trial, many defendants will be convicted a second time.

c. The appellate standards of review often find that no reversible error was committed during the trial court proceedings.

d. The appellate courts are reluctant to overturn decisions by the lower courts because of time and cost constraints.

Which court is seen as more conservative with rulings that cut back on abortion rights, condoned mandatory drug testing, and permitted capital punishment for juveniles and developmentally impaired persons who were convicted of murder?

a. the Warren Court

b. the Burger Court

c. the Rehnquist Court

d. the Roberts Court

What was the purpose of the Antiterrorism and Effective Death Penalty Act of 1996?

a. It restricted the time periods and the number of habeas corpus petitions prisoners file.

b. It restricted courts from hearing habeas corpus petitions from convicted terrorists.

c. It restricted courts from pursuing all terrorism cases as death penalty cases.

d. It increased penalties for those convicted of domestic terrorism

What does it mean when a case is reversed and remanded?

a. The case is overturned and sent back to the lower court for further hearing.

b. The case is overturned and terminated.

c. The case is returned to the lower court for a retrial.

d. The case is affirmed and returned to the lower court for further hearing.

What are the two primary functions of appeal?

a. judicial oversight and checks on prosecution

b. error correction and policy formation

c. error correction and process oversight

d. crime control philosophy enforcement and compliance

Which of the following is NOT one of the ways in which postconviction differs from appeals?

a. They may be filed only by those actually in custody.

b. They may raise only constitutional defects, not technical ones.

c. They may be somewhat broader than appeals.

d. Many state court systems limit postconviction remedies.

The U.S. Supreme Court and most state high courts of last resort have largely ____________.

a. discretionary appellate jurisdiction

b. mandatory appellate jurisdiction

c. limited appellate jurisdiction

d. constitutional appellate jurisdiction

Which of the following has led to an increase in the broader range of criminal cases being appealed?

a. relaxation of appellate court rules

b. increase in the penalties for crimes

c. increase in meritorious issues of broader concern

d. public awareness of trial rules

How do state courts of last resort and the U.S. Supreme Court help set justice policy?

a. By utilizing the political associations that come with the appointment of the judges.

b. By exercising caution as to how they word their opinions.

c. Through their exercise of their discretionary appellate jurisdiction.

d. Through their exercise of their experience in handling difficult questions of law.

Which of the following terms refers to the movement in the state supreme courts to reinvigorate state constitutions as sources of individual rights over and above the rights granted by the U.S. Constitution?

a. new judicial federalism

b. rights-generous doctrine

c. state constitutional reformation

d. restorative representation

Postconviction reviews are termed collateral attacks because they are attempts to ____________.

a. avoid the effects of a prior court decision by bringing a different action in new court proceedings

b. overturn prior court decision by bringing in new evidence

c. affirm prior court decisions by bringing a different action in new court proceedings

d. change the way the process was handled in the lower court

A defendant has been acquitted by a jury of charges filed against him by the state. The prosecution subsequently discovers incriminating evidence that was not presented during the trial. The prosecutor decides to recharge the individual with the crime. However, the court denies the motion for a new trial. Under what rules is the judge basing the denial?

a. Fifth Amendment protection against double jeopardy

b. Fifth and Fourteenth Amendment violation of due process

c. Fourth Amendment protection against admissibility of illegally obtained evidence

d. Eighth Amendment protection against cruel and unusual punishment

The research is based on a multiple case study strategy with a qualitative research approach. As of the complexity of the explored topic this type of strategy will be preferred because of the inconclusive answers, a vast variety of resources and information will be required to create a foundation of knowledge in order to answer the questions.

/in /by

The research is based on a multiple case study strategy with a qualitative research approach. As of the complexity of the explored topic this type of strategy will be preferred because of the inconclusive answers, a vast variety of resources and information will be required to create a foundation of knowledge in order to answer the questions.

The research is based on a multiple case study strategy with a qualitative research approach. As of the complexity of the explored topic this type of strategy will be preferred because of the inconclusive answers, a vast variety of resources and information will be required to create a foundation of knowledge in order to answer the questions. Due to the short time frame in which this research has to be done, this method is considered best fit.

Secondary Data will be utilized from the case studies(challenges, solutions and results) as the collection process is easy and quick, there is basically no collection cost and the collection time is relatively short in comparison to Preliminary data collection(Yin, 2003).

3.2 Data Collection
The thesis concerns a desk research in which data from academic journals and information from the internet has been utilized for the results. The objective is to summarize and analyze available information as‐it‐is. The collection and utilization of information should be replicated in such manner that the operations of the research are confirmed as reliable(Yin, 2003). This is secured by the conducted analysis on a wide variety of sources, as mentioned above, in order to minimize errors and biases in this study (Yin, 2003). The case study sample was selected in order to support the notion of the research question and to create a visible and coherent link between the literature review and the results. The proposed six case studies were selected to underline that wearable devices and the internet of things able to improve the quality of healthcare and/or reduce the cost of it.

Utilization Pattern of Personal Protective Equipments (PPE)

/in /by


Utilization Pattern of


Personal Protective Equipments


a


mong


Industrial Workers of Nawalparasi, Nepal


  • Shiva Raj Acharya


ABSTRACT


INTRODUCTION

Personal protective equipments is one of the important measures to safeguard workers from exposure to occupational hazards. It includes Face Mask, Goggle, Helmet, Gloves, Boot, Ear Plugs, Protective clothing, Belts, etc.

The use of personal protective equipment (PPE) usually implies that the worker is expected to operate in a potentially hazardous environment with the protective device as one of the key means of preventing exposure.

5

ILO estimates that more than 250 million workers meet occupational accidents and 160 million are suffering from occupational diseases each year at the global level. Similarly, research conducted by ILO (2003) had concluded that every day, more than 6000 people/workers die, equivalent with one died every 15 seconds, because of the accident and illness related to work in the work places.

7

Occupational and Industrial accidents/hazards are all caused by preventable factors which could be eliminated by implementing available measures such as PPE. This is demonstrated by continuously reduced accident rates in industrialized countries.

2

Nepal is an developing country where various types of industries are in exdending order. All over the Nepal there are different varieties of industries. It is estimated that each year approximately 20,000 workers suffers from accidents at workplace which lead to about 200 lives lost in Nepal. Many incidents have been reported in manufacturing industries where large numbers of workers were injured due to the lack of safety provisions. Nepalease workers are suffering from one or more problems in their workforce.

7

The objectives of this study is to assess the use of personal protective equipments among the workers of Chaudhary Group Industry of Nawalparasi district of Nepal.


METHODS

A descriptive, cross-sectional study was carried out in five industry (Beer, Rio, Chesseball, Chips and Wafer) of the Chaudhary Group Industrial Estate, Nawalparasi from October 20, to November 2013. Total sample size 187 workers were selected through Stratified Random Sample technique having working experience more than one year and age between 16-60 year.

Ethical approval was taken from ethical review board of Pokhara University and Chaudhary Group of Industry. Verbal informed consent of each respondents was taken. The purpose of the study was shared to each respondent.Validity of the research was maintained by consulting with the research expert and supervisor opinions, visiting consult authority and discussion with colleagues and different research articles regarding the use of PPE was references to conduct this research. Questionnaire was pretested and modifications was done if needed.. Questionnaire was back translated English to Nepali language. Face to face interview was used as a technique for data collection and analysis were done by SPSS 17 version. Descriptive study was done to determine the use of PPE. Chisquare test was applied to findout the association between the dependent and independent variables.


RESULTS

The response rate was 100% ( N=187). Average age of the respondents was 34.09 ±8.650 years. The majority of the respondents (35.3%) were in the range of 21-30 years and 31-40 years. Results showed that majority of respondents were male (68.4%) but use of PPE was found high in female respondents (31.6%) as compare to male respondents. Most of the respondents (61.5%) told that there is no any provision of regular health check up in industry. Among the respondents, only 24.6% had ever been formally taught or been advised in using PPE in the workplace. Workers of age group (30-40 years) and workers with income (less than 11450 per month) were more likely to use PPE compared to others. Result of educational status showed that the majority of the respondents had completed secondary level (49.2%).

Among the respondents,only 46 (24.6%) had ever been formally taught or been advised in using PPE in the workplace, while 141 (75.4%) had never been formally taught or been advised in using PPE. Similarly more than half of the respondents 56.5% told last time they received the formal information regarding PPE before one month ago.

Most of the workers were suffered from Accidents/Injuries (60%) while others were suffered from muscoskeletal problems, Ear problems, Skin problems, Eye problems, Typhoid, BP and Respiratory problems within last one year of duration. (Figure 1)

Most of the workers (68.1%) regularly used all relevant PPE in work whereas 31.9% workers didn’t used PPE regularly. More than half (57%) respondents uses the PPE when they needed, 35% respondents use PPE all the time during working and only 8% respondents uses PPE only in the start time of the work. The main reason for not using of PPE by respondents were not availability of PPE (33.3%) and no necessary of using PPE (66.7%). (Table 1)

It was found that 87.2% workers used any kind of PPE in industry, only 12.8% workers didn’t used any kind of PPE while working in worksite. Most of the respondents were used Respirators/mask (78.1%), Handprotectors/gloves (56.7%), Appron/clothing (30.5%) and Head protectors/helmet (26.7%) while 26.7% were used Eye protectors/goggles and 17.1% were used Foot protectors/boot. (Table 2)

The results showed that 88.4% workers use of any type of PPE in Beer industry, 79.4% in Rio industry, 96.4% in Wafer industry, 91.3% in chips industry and 75% workers use PPE in cheeseball industry to ensure health, food and body safety in workplace. (Table 3)

Most of the workers (95.7%) told that there is the regular provision of replacement of the wornout, infected PPE and only 4.3% workers told there is no regular provision of replacement of the wornout PPE in industry. It was found that 77.3% workers didn’t feel uncomfortable while using PPE whereas 22.7% workers feel uncomfortable while using PPE in industry. Most of the workers (89.3%) were found to be encouraged by their co-staffs and officers for the use of PPE while 10.7% workers weren’t encouraged by their co-staffs and officers for the use of PPE in industry.

It was found that 18.4% of the respondents among those who use the PPE told they perceived health safety as benefits through the use of PPE while 40.5% respondents told body protection as perceived benefit, 21.5% respondents told prevention from diseases as perceived benefit, 15.9% respondents told prevention from dust, fumes, chemicals etc. as perceived benefit. Only few respondents told food safety and prevention from injuries/accidents as perceived benefit which accounts 3.1% and 0.6% respectively. (Table 4)

Association of use of PPE with gender (p=0.031) and encourage to use of PPE (p=0.001) were statistically significant whereas association of use of PPE with income(p=0.109), education status (p=0.126), age of the respondents(p=0.071) and working experience (p=0.445) were not significant. Female respondents were likely to use PPE (3.6 times) as compared to male respondents. Respondents who were encouraged used PPE more than 26 times as compared to non-motivated respondents towards the use of PPE. (Table 5)


DISCUSSION

Out of 187 respondents 32.1% workers had faced any type of health problems or hazards under working conditions in industry. Among them most of the workers are suffered from Accidents/Injuries which accounts 60%. The main cause of the health problems/hazards among 60 respondents 75 % was due to the work load, 18.3% was due to chemicals, dust, fumes etc and 6.7% was from lack of PPE provision. Similar study was conducted among cement workers in Arab Emirates showed that only 52.9 % of the workers knew the hazards other than the dust that were associated with their work.

1

In this study, 87.2% of workers found to with use of any types of PPE whereas only 12.8% workers didn’t use any types of PPE available in the workplace. Similar study conducted in Vishakapatnam Steel plant of India which showed that 27.50% of the workers were using personal protective equipment (PPE).

3

A study carried in a sample of 501 male printing workers from 28 factories in Hong Kong showed that 22.05%. of the workers were using PPE.

4

Another study conducted in Southern Tamilnadu of India among dyes printing workers found that 34% of the workers were using personal protective equipment (PPE).

6

Among the respondents, only 24.6% had ever been formally taught or been advised in using PPE in the workplace, while 75.4% had never been formally taught or been advised in using PPE. Study conducted among garment workers in Tamilnadu of India also recommended that the workers need to be trained in the proper use of PPE to reduce the occupational health hazards.

8

Study conducted in Canada showed 22% of respondents reported that they had never received PPE training and 32% had not been trained in the previous 2 years.

10

Study by

Saowanee Norkaew

suggested that regular public health education and training programs including how to use appropriated PPE should be organized for the workers to improve their ability to handle practices and health.

11

Only 12.8% workers didn’t uses any kind of PPE in Chaudhary Group of Industry. The main barriers of not using the PPE were non-availability (33.3%) whereas rest of the workers told there is no necessary (66.7%) to use PPE while working in industry. Similarly another study among garment workers in Tamilnadu of India found non-availability (18%) were the reasons stated by workers for non use of PPE.

8

Another study on KAP regarding usage of PPE in at trade village of Vietnam found that 29% of the respondents have ever used at least one kind of PPE (71% didn’t use any kind of PPE).The majority of the Craftsman was not using PPE because they believe that use of PPE is uncomfortable. But in this study,more than two quarters workers didn’t feel any uncomfortable of using PPE that might influence the increase in the use of the PPE in workplace.

9

Among the PPE users in Chaudhary Group of Industry most of the workers (79.8%) start using PPE since they joined in industry. Most of the workers (68.1%) regularly use all relevant PPE in industry whereas 31.9% workers didn’t use. More than half (57.1%) respondents use the PPE when they needed, 35% respondents uses PPE all the time during working and only 8% respondents uses PPE only in the start time of the work. Similar study conducted by Taha AZ in three industries of Saudi Arab conducted in 2000 AD showed that 12% used personal protective measures all the time while 60% did not use any type of PPE. The main reasons given for not using PPE were non-availability of equipment and that the equipment was too heavy causing inconvenience. A variety of preventive measures and PPE were mentioned, their use was unsatisfactory.

12

According to this study, Statistics shows that there is the significant association of gender of the respondents, encouarge to use PPE with the use of PPE. Whereas, there is no any association of age, educational status, income, working experience with the use of PPE. Similar finding from the study conducted among garment workers in Tamlinadu in India showed the significant association between encourage to use PPE by officers/staffs with the use of PPE.

8

Large portion(93.3%) of workers found change after using of PPE. Most of the workers (89.3%) were found to be encouraged by their co-staffs and officers for the use of PPE which ensure the effectiveness regarding use of the PPE in industry. It is found there is the regular provision of replacement of the wornout, infected PPE which is the effective reason behind high practices of PPE and low health hazards.

The findings of this study have quiet good practice regarding the uses of PPE by comparing with the results of others similar studies with this study. It might be due to the workers knowledge on PPE, training regarding PPE, types of industries were research were conducted, provision of PPE, incidence of health hazards/problems, workplace environment, years of experience of working in industry which are clearly illustrated as above.


CONCLUSION

It is found that majority of workers (more than three quarters of respondents) use the PPE in Chaudhary Group of Industry, Nawalparasi.

It is recommended that formal information, education and training on proper uses of PPE should be provided to workers to ensure workplace safety in industry and to reduce workplace hazards. Need of research and indepth studies to assess the industrial health risks.


ACKNOWLEDGEMENT

I would like to extend my sincere graduate to Mr. Ishor Sharma for his supervision during this work. My special thanks goes to Mr. Hari Kafle, Mr. Sudarshan Subedi, Mr. Chiranjivi Adhikari for their valuable suggestion, guidance and support during my research work. I would like to remember my loving family, Mr. Sanjay Adhikari, Mr. Jeevan Bhatta, Mr. Diwash Timilsina, Mrs Roshna Raj Bhandari and classmates of School of Health and Allied Science, Pokhara University.


REFERENCES

1. Ahmed H, Smith MS. Knowledge and practices related to occupational hazards among cement workers in United arab emirates. The Journal of the Egyptian Public Health Association. 2010;85(3-4):149-52.

2. Alli BO. Fundamental Principles of Occupational Health and Safety. International Labour Office, Geneva. 2008.

3. Ziauddin A. A study on knowledge, attitude and practice of personal protective equipment in Visakhapatnam steel plant. Jr of Industrial Pollution Control 2006;22:89-92.

4. Yu TS, Lee NL, and Wong T. Knowledge, attitude and practice regarding organic solvents among Printing workers in Hong Kong. Journal of occupational health. 2005;47(4):305-10.

5. Tam Y,Fung H. A study of knowledge,awareness,practice and recommendations among Hong Kong construction workers on using personal respiratory protective equipment at risk. Open Construction and Building Technology Journal. 2008;2:69-81.

6. Paramasivam P, Raghavan PM, Kumar AG. Knowledge, Attitude, and Practice of Dyeing and Printing Workers. Indian J Community Med. 2010 Oct-Dec;25(4):498–501.

7. Gautam RP, Prasain JN. Current Situation of Occupational Safety and Health in Nepal (A Study Report). GEFONT publication, Kathmandu. 2011:60-62.

8. Parimalam P, Kamalamma N, and Ganguli AK. Knowledge, Attitude and Practices Related to Occupational Health Problems among Garment Workers in Tamil Nadu. India Journal of occupational health. 2007;49(6):528-34.

9. Truong CD, Siriwong W, and Robson MG. Assessment of knowledge, attitude and practice on using of personal protective equipment in rattan craftsmen at trade village, Kienxuong District, Thaibinh Province, Vietnam. Thai journal of health research. 2009

10. Reid SM. Use of personal protective equipment in Canadian pediatric emergency departments. CJEM. 2011;13(2):71-8.

11. Norkaew S. Knowledge, attitude, and practice‪ (KAP)‬ of using personal protective equipment‪(PPE)‬ for chilli-growing farmers in Huarua sub-district, Mueang district, Ubonrachathani province, Thailand. Journal of Medicine and Medical Sciences. 2013;3(5):319-25.

12. Taha AZ. Knowledge and practice of preventive measures in small industries in Al-Khobar. Saudi Medical Journal. 2000;21:740-5.

.

1

Financial statement analysis focuses primarily on isolating information that is useful for making a particular decision. Through ratio analysis- users of financial data can analyze various relationshi

/in /by

Financial statement analysis focuses primarily on isolating information that is useful for making a particular decision. Through ratio analysis, users of financial data can analyze various relationships between items reported.

Respond to the following in a minimum of 175 words:

  • Describe the 3 main categories of ratios and provide a specific example of a ratio that is used in each category. For each of the 3 ratios you selected, describe how it is used in managerial decision-making

Ventilated Patients: Early Mobility and Sedation Management

/in /by


Leslie Bruchey


Abstract

Critically ill patients that need intubated and mechanical ventilation often to have increased hospital length of stay. Throughout this paper, the hospital length of stay in this patient population will be analyzed by research articles to see how early mobility and sedation management effect the hospitalization. Research shows that early mobility in the intensive care unit often decreases the length of stay of a patient who was critically ill and on a ventilator. Nursing plays a large role in providing early mobility to these patients along with sedation management. The implementation of a sedation protocol often allows nurses to control how much sedation is used on a mechanically ventilated patient. The research also shows that with nurse driven sedation protocols, there is a decreased length of stay for these patients. Early mobility and sedation management have effects on the length of stay in the hospital for the critically ill patients that require ventilator management.



Keywords:


mechanically ventilated, critically ill, length of stay, sedation, early mobility


Hospital Length of Stay in Critically Ill Mechanical Ventilated


Patients: Early Mobility and Sedation Management

In the United States, approximately 5.7 million people are admitted to an intensive care unit every year. According to the Society of Critical Care Medicine, of those patients admitted to the intensive care unit, 20-30% will need mechanical ventilation intervention (“Critical Care,” n.d). One of the biggest problems faced in the Intensive Care is decreasing the length of stay in those critically ill patients that require ventilator support. Nursing plays a critical role in providing quality care and needed interventions to improve the length of stay within the intensive care unit. Throughout this paper, the effects of early mobilization and sedation management will be analyzed in relation to the hospital length of stay in the critically ill population that needs mechanical support provided by the ventilator.

Early mobility consists of range of motion, sitting in a chair or the side of the bed and possibly walking as a patient is able to tolerate activity. Clark et al. performed a research study on the effectiveness of early mobilization in an intensive care unit. In this study, the results demonstrated that the hospital length of stay was decreased by 2.4 days with early mobilization (Clark et al., 2013). Early mobility in a hot topic in intensive care units throughout the country to decrease prolonged ventilator time and the risk for infections. In another research study by Stefan et al., early mobilization was tested in a randomized controlled trial. The end results showed early mobility to improve patients mobility by discharge and shorten the length of stay (Schaller et al., 2016). Nursing can utilize this concept to help reduce the length of stay for a patient in the hospital and improve overall patient outcomes for this critically ill population. Sedation management is another great variable to focus on in the critically in intubated patients in relationship to the length of stay. In a research article by Jakob et al., a sedation protocol was analyzed to support vent weaning and the length of stay. The results showed that the time mechanical ventilation was needed decreased by six hours and the length of stay in the intensive care unit reduced from thirty-seven hours to twenty-five hours, P=0.049, which indicated the statistics were significant (Jakob et al., 2007). Oversedation can delay the ventilator weaning progress and prevent patients from participating in early mobilization and extubating, which would increase the length of stay.


Background

Patients that require mechanical ventilation in the intensive care unit, unfortunately, have a prolonged hospital length of stay. In 2005, 790,000 people that were hospitalized needed mechanical ventilation. The average duration of stay for one of these patients was 14 plus or minus 16.9 days, which only accounted for 7% of the days spent in the hospital. Not only is the length of stay extended for a patient that needs ventilator support, but also this intervention is very costly. The average hospital cost is $32,000 which the possibility of increasing that cost by $40,000 (Kirton, 2011). As the population continues to grow and lives longer, more and more patients come to the hospital, the number of patients needing mechanical ventilation and the length of stay will continue to increase. It is important to look at key variables so see how they affect the length of stay, such as early mobility and sedation management. Research studies will be analyzed to evaluate the importance of mobility and sedation management in relation to hospital length of stay for those patients who are critically ill and need mechanical ventilation.


Review of Quantitative Research

McWilliams et al. provided research on enhancing rehabilitation of patients who are on the ventilator in the intensive care unit.The purpose of this study was to evaluate the importance of early mobility in a quality improvement project in a large intensive care in those who are being supported by mechanical ventilation. When reviewing the literature, the authors used 30 different references that were relevant to the study and provided adequate information to support the topic. All but three of the references were from the time range of 2003-2014. The other three articles ranged from 1985-1998.The literature discusses that neuromuscular dysfunction was identified in 46% of critically ill patients, including those who needed mechanical ventilation which was associated with a longer length of stay in the hospital. Also, included in the literature, a decrease in stay in the intensive care unit and hospital has been associated with early mobility The author has a good understanding of research and problem related to the study (McWilliams et al., 2015).

The research design for this was a quality improvement program that analyzed the data before and after the project was implemented. Data was taken from a 75-bed intensive care unit that included people who had been intubated and needed mechanical ventilation for at least five days. The data was then analyzed by SPSS v 21, which is software for statistics. Significance was decided to be 0.05 of probability. A Student t test or Wilcoxon signed rank test was used for a basic comparison of groups and outcomes. Descriptive statistics were utilized in this study. The total length of stay for patients that received early mobility that were also on the ventilator for at least five days was decreased from 35.5 days to 30.1, P=0.016, along with a decrease in ventilator days. The statistics showed the association of decreased ventilator time as P=0.12 (McWilliams et al., 2015). Implementing an early mobility program can be difficult due to lack of funding and available resources. Other limitations consist of patients with comorbidities prior to entering the intensive care unit and being on bed rest for an extended period of time. In summary, in this study, early mobility was found to decrease length of stay for those patients who had been intubated for more than five days and could participate in rehabilitation efforts (McWilliams et al., 2015).

Morris et al., conducted a research study for the purpose of investigate the patient outcomes of variations in the frequency of physical therapy, where treatment begins during the hospitalization which was considered usual care for those who have respiratory failure compared with patients with the same diagnosis who received therapy from the mobility team using a mobility protocol in the intensive care unit (Morris et al., 2008).In the literature review, eighteen different references were used in the study. In the references that were used, early mobility was discussed in the intensive care setting in those who were intubated and ranged from the years of 1985-2007.The majority of the literature and references that are provided are from the early 2000s. There is sufficient information to support the purpose of the study along with a strong understanding of the problem from the authors.  The authors state that common problem from being mechanically ventilated consists of an increased length of stay, and while physical therapy has been said to help with early extubations, there is information supporting early mobility in the intensive care unit (Morris et al., 2008). The research design consisted a cohort study also known as a longitudinal study. A mobility protocol was created to be used in the intensive care setting, which participants were assigned by block allocation. The mobility team rotated through seven different intensive care units until fifty patients had been enrolled and then would move to the next block of patients. Various units were assigned interventions and control groups in every block while three blows were used in the study. Patients who were not part of the intervention group received regular physical therapy (Morris et al., 2008).

Descriptive statistics were used in this study. There was a total of 330 patients that met criteria that were either assigned to usual care or the mobility team. It was discovered through this research that those who received usual care spend an average of 14.5 days in the hospital and those who received care from the mobility team had an average of 11.2 days spent in the hospital, P=0.006 (Morris et al., 2008). Early mobility was found to decrease hospital length of stay for the critically ill patient that required mechanical ventilation. Although there were 3000 patients admitted to the medicine intensive care unit, only 330 of those patients were eligible to participate in the study. Also, another limitation that is discussed is that the mobility team only saw patients in the intensive care setting.The length of stay for patients was found to be decreased without increasing the cost to the hospital (Morris et al., 2008).

Pandullo et al., research article served the purpose of discovering is patient mobility in intensive care is sustained throughout different phases of the hospitalization to other inpatient floors till discharge. The author provided a lot of literature throughout the article to provide background information to the problem of critically ill patients needing progressive mobility to decrease the length of stay and mechanical ventilation days. Thirty-three references were used from the time frame of 1989-2015). The research was collected by a retrospective study in a 24-bed intensive care unit. Those who were included in the study were 18 years or older, admitted to the intensive care unit in the second quarter of 2013, had a length of stay for at least 48 hours and went to an inpatient unit after critical care was needed. Chart reviews were completed by a multi-disciplinary team. Data was recorded to include intensive care length of stay, hospital length of stay and readmission to the intensive care unit along with what therapy disciplines participated in the patient’s care during the intensive care unit stay (Pandullo et al., 2015)

Analysis of the data was performed by IMB SPSS which included descriptive statistics which were categorized in recorded as percentages. Variance tests were used with Bonferroni correction and Spearman correlation.  A significance level of 0.05 was used. The length of hospital stay was rs=-0.22 and p=0.002. In this study, it was confirmed that early mobilization decreases hospital length of stay for those patients who were critically ill in the intensive care unit and received early mobility. Limitations are discussed in this study. Data was collected in a chart rather than direct observation, and charting was sometimes inconsistent. Also, therapy was grouped, and different roles were not considered such as cardiac rehabilitation or nurse-driven early mobility. Overall, the authors believe that early mobility has a positive impact on patient outcomes (Pandullo et al., 2015).

Jones, Newhouse, Johnson & Seidl, authored a research article that addresses health outcomes that are associated with spontaneous awakening and breathing trials. The purpose of this study was to evaluate the evidence-based practice protocols that include spontaneous breathing and awakening trials for mechanically ventilated patients and its effects on length of stay in the intensive care unit, hospital, and reintubations. While reviewing the literature, the authors included twenty-six references ranging from the years of 2002-2013. Mechanical ventilation is discussed prolonging intubation can cause mortality and morbidity. The author provides a lot of background information for the research with a good understand of each variable of the study (Jones et al., 2014).

The research study used a retrospective chart review of discharged patients using a descriptive comparative of those before and after the spontaneous breathing trial and awakening trial was implemented on April 2010. Data included age, sex, race, admitting medical service, date and time of admitting, intubation information and discharge from the intensive care unit. The protocol is used every morning where sedation would be turned off. This study states that a convenience sample included 112 participants. The intensive care unit has 23 beds and was a level 2 trauma center. Data was analyzed by SPSS and a chi-square test was used to gather further information on characteristics of the before and after implementing the new protocol. Mann-Whitney U test was also used to investigate age, weight, and length of stay and medical treatment duration while on the ventilator. The fisher exact test was used for more data on self-extubation and reintubation data (Jones et al., 2014). Of the 112 participants, there were 56 subjects looked at prior to the spontaneous awakening and breathing trial protocol and 56 patients after implementation. Descriptive data was used in the statistical analysis. When the length of stay was investigated, there was no significant data to support the spontaneous awakening and breathing trial affecting the hospitalization course, P=0.29 (Jones et al., 2014). A few limitations are discussed within the research article. Because the data was gathered through a chart review, staff education and follow-up of the protocol was not able to be completed. Also, the authors included that information bias could have been an issue due to measurement errors. The prior power was 0.08, but post analysis showed that power was 0.36, which would affect the number of medical records needed. Another limitation listed is nursing, and the respiratory therapist did not follow the protocol. In conclusion, there was no difference in a patient who follows the spontaneous awakening and breathing trial or does not in relation to the length of stay in a critically ill mechanical ventilated patient (Jones et al., 2014).

Rafiei, Ahmadinejad, Amiri & Abdar provided a research article that focuses on nursing-implemented sedation and pain protocol that is used on opium-addicted critically ill patients. The purpose of this study is to increase the quality of nursing care, and the effects of nursing-implemented sedation and pain protocols and the amounts of medications that are used on patients who are addicted to opium. The authors use a variety of references within the research article. Twenty-two articles are utilized in the year range of 1998-2012. During the intro, sedation and pain control are discussed from a nursing perspective for the critically ill intubated patients in the intensive care unit. The research provided addresses that the sedation protocol may decrease ventilator time and length of stay. The introduction also claims that sedation protocol use has limited information along with the protocol being used in patients who are critically ill and have an opium addiction (Rafiei, Ahmadinejad, Amiri & Abdar, 2013).

The study utilized a randomized controlled trial that took place during September 2011 to June 2012, in three different intensive care units in Iran, which had approximately 33 beds. Criteria for the study consisted of mechanical ventilation, being in the intensive care unit for at least two days, addiction and being between the ages of 15-45. Patients were also hemodynamically stable, and the study excluded those with heart, lung, liver and kidney disease. The random assignment took place and put patients in either the control group or intervention group. Data was collected during the admission; the level of sedation was assessed six times in twenty-four hours on all patients in the trial. Data was analyzed by Statistical Package for the Social Sciences. A t-test was used for comparing the mean of normally distributed samples (Rafiei et al., 2013). Inferential statistics were used in this study. P <0.05 was used to demonstrate statistical significance. The statistics show that the group with the nurse-driven sedation and pain protocol used less sedation P <0.05(Rafiei et al, 2013). Authors discuss that nurse-driven sedation and pain protocols are not only beneficial in those who have opium dependence but also those without. Nurses used less sedation to meet a target sedation goal. Oversedation is related to increasing in length of stay, delayed vent weaning and pneumonia. Limitations of this study consisted of a small sample size and not accurately measuring duration of stay, delirium, and pneumonia created by being on the ventilator (Rafiei et al., 2013).


Summary of Statistical Results

Throughout the research articles discussed above, information can be gathered to see if early mobility and sedation management play a role in the critically ill mechanical ventilated patients. In the research study by McWilliams et al., it was found that by using a t-test and Wilcoxon signed rank test that the length of stay for patients that received early mobility decreased the hospital length of stay P=0.016, which demonstrates statistical significance (McWilliams et al., 2015). The t-test is used to analyze two variables and can be used to verify a hypothesis. A Wilcoxon signed-rank test is used to calculate data into ranks and disregards variances (Gray, Grove & Sutherland, 2017). Overall, the research results supported early mobility in the critically ill population to improve the length of stay within the hospital. Also, descriptive data was used in this research article to analyze how early mobility affects length of stay for those critically ill and required intubation.

In the second article by Morris et al., a longitudinal study was completed. Descriptive statistics were provided. Those who received usual care n=136 and those who had the protocol were represented by n=145. All results were presented by confidence intervals. The usual care patients had 12.7-16.7 hospital length of stays while those who had the protocol were 9.7-12.8.1, P=0.006. These numbers were adjusted to factor in BMI, vasopressors and APACHE II. A linear regression was mentioned for other data within the study, but test used for the length of stay data was not indicated (Morris et al., 2008). The results provided by this article also supports that the length of stay was decreased by early mobility. In the third research article discussed by Pandullo et al., indicated variance tests such as Bonferroni and Spearman correlation was used. Descriptive statistics are used in this study. These tests would assess relationships between two variables. Spearman correlation is used to test two ranked variables. The research that was completed demonstrated that early mobility and the length of the hospital stay was p=0.002. With a significance level of 0.05 used in this study, this indicated that there was a statistical relationship between early mobility in the intubated critically ill population and a decreased length of stay (Pandullo et al., 2015). The fourth research article discussed above by Jones et al., used descriptive data to compare spontaneous breathing trials with the length of stay in the hospital in the problem population. A Mann-Whitney U test which is similar to a t-test and used to compare two variables. There was no relationship between having spontaneous awaking trials every day and length of stay in those patients, P=0.29 (Jones et al., 2014). Finally, inferential statistics were also used in the study by Rafieji et al. The nurse-driven protocol was found to be better for patients because less sedation was used and patients could spend less time on the ventilator. The statistics showed that patients had less sedation P< 0.05 which the authors came to the conclusion that because patients were not overly sedated, a decrease in hospital length of stay, delirium, and ventilator acquired pneumonia would occur (Rafiei et al., 2013).


Conclusion

Throughout this paper, literature has been discussed along with the statistical findings of each study to demonstrate the effect of early mobility and sedation management on the length of stay for critically ill patients that require mechanical ventilation. Minhas et al. performed a randomized controlled trial that viewed the effects of a sedation protocol and clinical outcomes. During this study, it was found that with a sedation protocol, the hospital length of stay was decreased by 3.5 days. P=0.004 demonstrated that the statistics were very relevant in this case (Minhas et al., 2015). Hunter, Johnson & Coustasse performed a randomized control trial of 90 patients showed that in an early mobility program in the intensive care setting, there was a significant decrease in length of hospital stay by 13% (Hunter, Johnson& Coustasse, 2014).


References

Clark, D. E., Lowman, J. D., Griffin, R. L., Matthews, H. M., & Reiff, D. A. (2013).

Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit:

A retrospective cohort study.

Physical Therapy, 93

(2), 186-96. Retrieved from

http://www.library.drexel.edu/

Critical Care Statistics. (n.d.). Retrieved from

http://www.sccm.org/

Gray, J., Grove, S., & Sutherland, S. (2017).

The Practice of Nursing Research: Appraisal,


Synthesis and Generation of Evidence (8th ed.).

Elsevier: St. Louis, Mo.

Hunter, A., M.Sc, Johnson, Leslie, DPT,P.T., M.Sc, & Coustasse, Alberto, DrPH, MD,M.B.A.,

M.P.H. (2014). Reduction of intensive care unit length of stay: The case of early

mobilization.

The Health Care Manager, 33

(2), 128. Retrieved from

http://www.library.drexel.edu

Jakob, S. M., Lubszky, S., Friolet, R., Rothen, H. U., Kolarova, A., & Takala, J. (2007). Sedation and weaning from mechanical ventilation: Effects of process optimization outside a clinical trial.

Journal of Critical Care, 22

(3), 219-28. doi:http://dx.doi.org/10.1016/j.jcrc.2007.01.001

Jones, K., Newhouse, R., Johnson, K., & Seidl, K. (2014). Achieving Quality Health Outcomes Through the Implementation of a Spontaneous Awakening and Spontaneous Breathing Trial Protocol.

ACCN Adv Crit Care,


25

(1), 33-43. Retrieved from http://acc.aacnjournals.org/

Kirton, O. (2011). Mechanical Ventilation in the Intensive Care Unit. Retrieved from http://www.aast.org/

McWilliams, D., Weblin, J., Atkins, G., Bion, J., Williams, J., Elliott, C., . . . Snelson, C. (2015).

Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A

quality improvement project.

Journal of Critical Care, 30

(1), 13-18.

doi:http://dx.doi.org/10.1016/j.jcrc.2014.09.018

Minhas, M. A., M.P.H., Velasquez, Adrian G,M.D., M.P.H., Kaul, Anubhav,M.D., M.P.H., Salinas, P. D., M.D., & Celi, Leo A, MD,M.S., M.P.H. (2015). Effect of protocolized sedation on clinical outcomes in mechanically ventilated intensive care unit patients: A systematic review and meta-analysis of randomized controlled trials.

Mayo Clinic Proceedings, 90

(5), 613-623. Retrieved from

http://www.library.drexel.edu

Morris, P.E., Goad, A. Thompson, C., Taylor, K., Harry, B., Passmore, L., Ross, A., Anderson, L., Baker, S., Sanchez, M., Penley, L., Howard, A., Dixon, L., Leach, S., Small. R., Hite, D., & Haponik, E. (2014). Critical Care Source: Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Retrieved from, http://www.lifesynccorp.com

Pandullo, S. M., Spilman, S. K., Smith, J. A., Kingery, L. K., Pille, S. M., Rondinelli, R. D., & Sahr, S. M. (2015). Time for critically ill patients to regain mobility after early mobilization in the intensive care unit and transition to a general inpatient floor.

Journal of Critical Care, 30

(6), 1238-1242. doi:http://dx.doi.org/10.1016/j.jcrc.2015.08.007

Rafiei, H., Ahmadinejad, M., Amiri, M., & Abdar, M. E. (2013). Effect of nursing implemented sedation and pain protocol on the level of sedation, pain and amount of sedative and analgesic drugs use among opium addicted critically ill patients.

Asian Journal of Nursing Education and Research, 3

(1), 5-41. Retrieved from http://www.library.drexel.edu

Schaller, S. J., Anstey, M., Blobner, M., Edrich, T., Grabitz, S. D., Gradwohl-Matis, I., . . . Eikermann, M. (2016). Early, goal-directed mobilisation in the surgical intensive care unit: A randomised controlled trial.

The Lancet, 388

(10052), 1377-1388. doi:http://dx.doi.org/10.1016/S0140-6736(16)31637-3

Describe the relationship between the model and concepts in nursing’s metaparadigm…metaparadigm concepts

/in /by

Describe the relationship between the model and concepts in nursing’s metaparadigm…metaparadigm concepts.

Theoretical Foundations of Advanced Nursing

see attached.

Topic 1: Nursing Philosophy and Models
Select one of the nursing theorists “Florence Nightingale: Modern Nursing” and respond to the following:
• Describe the historical background of the development of the model or framework.
• Identify the concepts in the model.
• Describe the relationship between the model and concepts in nursing’s metaparadigm…metaparadigm concepts (person, health, nursing, and environment)
• Create an example of the model applied to clinical practice.
• Identify strengths and weaknesses of the model for clinical practice.

Textbook Information

Title: Nursing Theorists and Their Work 8th ed.
Author: Alligood, M. R.
ISBN: 978-0-323-09194-7
Publisher: Mosby Elsevie

Examining Ethical Decision Making in Abdominal Pain case

/in /by

In this essay, I am going to discuss the scenario of a 12 years old girl, Christine who has been admitted in a pediatric unit for observation and investigation for recent abdominal pain. I will try to solve the legal and ethical dilemma that the nurse has faced in this case with the use of Kerridge’s model, for ethical decision making with help of code of ethics, code of professional conduct, national competence standard and Australian charter of health care rights.

Kerridge’s model for ethical decision making:

Clearly state the problem

Client does not want the nurse to disclose her physical abuse from her mother, but Nurse has disclosed to the register nurse.

Get the facts

12 year old admitted with severe abdominal pain due to overdose of Panadol. Nurse observed bruises on her arm and back, patient told the nurse that her mother beating her regularly, and do not tell anyone because she fear it will be much worse for her if her mother finds out but the Enrolled Nurse told the Register Nurse for patient wellbeing.

Consider the fundamental ethical principles

Autonomy:

Definition:  “Recognises the rights of a person to have an opinion, make choices, and take actions based on personal values and beliefs” (Gault, 2011)

In the case, EN has breaches Autonomy (patient’s choice) by telling to the Register Nurse.

Beneficence:

Definition:  Beneficence is action that is done for the benefit of patient. Beneficent actions can be taken to help prevent or remove harms or to simply improve the situation of patient (Gault, 2011).

In the case, Nurse has done well by reporting to the RN. Reporting may prevent future harm to the client and may stop child abuse or inappropriate treatment.

Confidentiality:

Definition: Respect for confidentiality means that a nurse keeps information that a patient reveals in the context of a nurse-patient relationship to himself/herself (Degree Essays, 2011)

In the case, Nurse has breached the confidentiality of the patient by disclosing the information.

Veracity:

Definition: To recognized client’s right to important information concerning his/her wellbeing to make the informal decision, to tell the truth (Gault, 2011).

In the case, EN has expressed the duty of care by telling the truth to the RN for patient’s wellbeing.

Consider how the problem would look from another perspective

Patient, family (Patient’s Mother) and nurse are involve, nurse may lose the trust of the patient by disclosing the information, the information that client gave to the EN might be false if the patient has some underlying mental illness, patient’s might be in trouble if her mother come to knew that she has told to nurse, her mother might be embrace due to the child violence, patient will be protected by taking the case further.

Identify ethical conflicts

Conflicts between confidentiality and beneficence, conflict between veracity and autonomy.

Code of ethics, there is conflict between nurses value access to quality nursing and health care and respect and kindness and informed decision making.

1) Nurses value quality nursing care for all people.

Nurses should report to an appropriate person regarding patient’s safety and care when necessary. Nurses should take a reasonable action when patient’s safety is the issue as well as to prevent future harm to the patient (ANMC, 2008).

In the case of Christine, nurse has reported to an appropriate authority in regards to patient safety and wellbeing. By doing that, nurse has shown her duty of care towards the patient. l.

2) Nurses value respect and kindness for self and others.

Nurses preserve the dignity of the patient by recognizing the vulnerability of the patient and through practiced sympathy. Nurses should understand the powerlessness and vulnerability of the patient due to illness or other circumstances they are going through. There will be significant power problem between nurses, family of the patient and the patient, mainly where the patient has limited knowledge due to age and fear. In that case nurses must inform the management and addressed the issue (ANMC, 2008).

In the case, there is vulnerability of the patient due to age (below 18), fear of getting worse if her mother come to know that, Christine has told the nurse about her violent behavior. In that context, nurse reported the issue for the patient welfare as well as showed the kindness by recognizing patient situation. And by the law nurse has to inform the management and addressed the issue for client’s wellbeing.

3) Nurses value informed decision making

Nurses respect patient’s moral value, including children to involve in decision making process. When necessary nurses help the patient by giving information about choices they can have to make the decision. And assist as well as advocate for the patient right (ANMC, 2008).

In the case, nurse involved to advocate for the patient’s right not have any physical abuse. And try to discuses with other health care workers to manage the situation professionally.

5) Nurses value a socially, economically, and ecologically sustainable environment promoting health and wellbeing.

Nurses should take in to consideration about patient social, emotional, environmental circumstances for patient wellbeing and recovery of the patient. Nurses should consider culture sensitivity due to dealing with diversity of the culture. Overall aim should be patient centered (ANMC, 2008).

In the case, nurse took steps to manage the situation and for the patient safety as well as positive recovery for the patient. It can be resolved by educating and reassuring the patient and family by law (of child abuse) and also by involving social work, health professional.

Consider the law in this scenario.

Code of conduct:

Nurses should provide safe and competent nursing care in any circumstances,

That may compromise professional standards. If nurse observed any unethical or illegal issue related to patient, it must be addressed immediately to prevent further harm to patient. Nurse must involve other health professional such as social worker etc. nurses where should seek consent from the patient receiving or requiring care before disclosing the information. Nurses should use professional judgment to disclose details, taking in to considerations to the wellbeing, health and safety of the patient. Nurses recognise that, by law to disclose particular information for professional purpose (ANMC, 2008).

In the case, nurse has disclosed the information by law without consent from the patient in regards to patient safety, dignity, wellbeing.nurse informed registered nurse due to her duty of care and professional conduct to being safeguard of the patient. Above scenario nurse showed clinical decision making skills to protect patient’s right and safety.

Nurses should take all reasonable steps for the social, emotional, physical wellbeing for the patient. Nurse should develop trust with patient to share the clinical information (ANMC, 2008).

In the case, Nurse developed trust of the patient, so patient was able to share the information. This helped nurse to make a clinical judgment in regards to help the patients. Nurse discloses the information by law being safeguard for the patient and able to follow up with other member of the health to manage or resolve the situation.

In this case there are some competency standard that are relevant to this scenario, the elements are, 1.3, 1.4, 7.3, 8.1, 8.4, and 9.1

In the situation there is potential harm and should take some action to prevent the harm to the patient. EN discloses the information to RN and follow the policies according to the ANMC national competency standards.

Health care rights:

Respect

Patients are entitled to receive care in a way that is respectful of patient’s culture, age, gender.

In the case, patient is entitled to get the treatment which will give her the best outcome as well as she has the rights to treated according the health care standard. Her age should need to take in to consideration. Nurse has taken all rights of the patient to help the patient (ACHR, 2008).

Communication

Health care will tell the patient about the care, that patient receiving and help patient, understand what is happening to the client. Patient can contribute to the communication by being as open and honest as patient can be (ACHR, 2008)

In the case, nurse should communicate with patient regarding her treatment and her management plan but in this case her age should be taken onto consideration.

Patient has obvious bruises on her arm and back so it’s proves that it is a child abuse from her mother and in Victoria, it is a legal obligation to report suspected child abuse.

7. Make the ethical decision-

12 year old has a right to respect safety, have opinion and make choice. Code of ethics state that nurses value quality nursing care for all people, Nurses value ethical management of information (this includes cases where confidentiality must be breached).

Conclusion:

At the end, nurse has followed code of ethics of nursing, proper conduct of law according to situation. Nurse also reflects clinical judgment to protect patient’s rights and nurse has expressed duty of care towards the patient as well as informing appropriate person to try to manage the situation professionally.

For chemistry I am doing a lab and dont understand. So 1 gram of magnesium was used to create 1.65 grams of magnesium oxide- and 1.3826 grams of…

/in /by

For chemistry I am doing a lab and don’t understand. So 1 gram of magnesium was used to create 1.65 grams of magnesium oxide, and 1.3826 grams of magnesium nitride. Water was used in the lab to be mixed with the magnesium nitride to rid it of nitrogen, and then it was reheated to leave only magnesium oxide. When this reheating occurred would the mass of the final product be increased or decreased based on the numbers given of 1 gram of magnesium creating 1.65 grams of magnesium oxide, and 1.3826 grams of magnesium nitride.

Low Self Esteem and Depression in the Elderly

/in /by

This world would be imbalanced and without love, if the elderly people are endorsed to feel pain. In this world, every individual has his or her self-identification, self-respect and self-esteem. Self-esteem refers to an individual’s overall positive self-evaluation. It is composed of two dimensions, competence and worth. Competence refers to the degree to which people see themselves as capable. Worth dimension refers to the degree to which individuals feel they are persons of value .On contrary, low self-esteem refers to a reflection of negative views about self and person with low self-esteem may feel powerless, incompetent and lonely. Self-esteem is important not only for adults but also for elderly people, which is growing population of current century. Looking at population pyramids, it can be observed that elderly population is growing constantly either due to increased life expectancy or due to advancements in science and technology .This transition has increased the needs of elderly population which may lead to undesirable consequences, if not fulfilled appropriately. Such consequences might include poor quality of life and low self-esteem, which may lead to anxiety and depression.

During clinical rotation, I was assigned to a 70 year old, middle class unmarried female, retired registered nurse, living in a nursing home, having six family members and suffering from diabetes mellitus, hypertension and stroke. During interview, she was unable to express and was hesitant in sharing her views. According to her, she was limited to herself and was unable to interact socially due to her physical disability. She felt unworthy, depressed (got 9 out of 10 score on depression scale). She perceived that she cannot do anything and was discouraged by her colleagues and always been criticized by others. This motivated me to assess the link between low self-esteem and depression among elderly.

Based on the literature review, various reasons of low self-esteem have been reported in developed and developing countries. These reasons may include loneliness, medical conditions, physical disabilities, low socioeconomic status, stigmatization, unemployment, less social interaction, being single or divorced. During my interaction with my client, I observed some of the reasons like less social interaction, physical disability, being single and loneliness, which had some link with her perceived low-self-esteem.

Individuals with low self-esteem have a tendency to withdraw and decrease interpersonal closeness, thereby declining attachment, support, and satisfaction in close relationships, as I found in my client to some extent. Moreover; low self-esteem is a risk factor for depression, which is most common disorder among elderly across the world, causing behavioral changes and may increase tendency of suicide and mortality among the elderly.

Different models have related the self-esteem with depression. According to vulnerability model, low self-esteem is a causal risk factor for depression. Beck’s cognitive theory states that, self-negative belief is not only a symptom of depression but play a causal role in its etiology, as was observed in my client. Diathesis-stress model states that low self-esteem is a predisposing factor that exerts causal influence only if the person simultaneously experiences life stress. Through these models, I tried to assess the link between low self-esteem and depression in my client and my client had also multiple life stresses, which confounded the link between low self-esteem and depression.

In the face of challenging life circumstances, people with low self-esteem may have lesser coping means and may prone to develop depression through interpersonal pathways. One interpersonal pathway is that some low self-esteem individuals seek assurance about their personal worth from friends and companions, increasing the risk of being rejected by their companions and thus increasing the risk of depression. A second interpersonal pathway is that low self-esteem motivates social avoidance, thereby delaying social support leading to depression and this path way was almost applicable to my client as she was socially isolated and was criticized by others colleagues, thus making her prone to depression.

Based on experience of my clinical rotation, it can be said that self-esteem may lead to depression; therefore attention should be paid to the psychological needs of the elderly people. It is important to boost the confidence and trust of the elderly people, as I did with my client. During initial conversation, my client was hesitant in sharing her views openly but this hesitation was no more, when space and opportunity was provided to her.

Moreover, knowledge about mediating processes between low self-esteem and depression is important to design interventions. Different strategies could be proposed to promote mental health of the client within the existing context, for example all residents of nursing homes could be encouraged to live together and to share their ideas with each other. This get together activity was very helpful for my client and her colleagues. Different positive ways can be taught not only to client but also to care givers to increase self-esteem of the elderly people. It is essential that, along with the older adults, family and community members should also be equipped with the knowledge regarding the relationship between low self-esteem and depression. Moreover; exercise therapy in older people may be an effective tool to overcome depression and to improve the self-esteem, as I did with my client. Promotion and disease prevention programs and strategies should also focus on elderly people to avoid depression among them. Programs like life review group program (LRGP) are being used to improve the self-esteem and confidence of the elderly people.

Based on personal observation, I would recommend that such clients should be encouraged and counseled appropriately to boost their trust and confidence. There should be some mechanism by which a space can be provided to them to interact with people outside their limited circle and to share their problems openly. This may enhance their self-esteem, and may decrease the likelihood of depression. Moreover, social support networks can be formed through different organizations to arrange preventive programs which may help the elderly people to feel positively about themselves. Policies and laws can be made at national level, which may bind everyone to take care of the elderly people and to resolve their issues by understanding their psychology without any delay.

Thus it is concluded that depression is one of the common problems among elderly people, attributed to low self-esteem. Different models have also explained the relationship between low self-esteem and depression. Such models may help to develop various preventive strategies to build up the confidence and trust of elderly people because elderly people are important assets of our society and without whom world would be imbalanced

Managing a Patient Diagnosed with Breast Cancer

/in /by

Managing a patient diagnosed with breast Cancer Fungating

Care context- The patient assessment and care planning took place in a care home following the patient’s admission due to decline in health, as she was unable to manage independently at home.

In this reflective account of person-centred assessment, I will be comparing and contrasting the resident’s information that I undertook during my time at practical placement, associating it with the (Driscoll 2007) model, a well-known framework for reflection demonstrating (Discoll’s 2007) the three processes when reflecting on a resident’s person-centred assessment. These three processes include: what (description of the event), so what (an analysis of the event) and now what (proposed actions following the event).

Driscoll’s model

will help me apply theory to practice. In accord with the Nursing and Midwifery Council (NMC) Code of Professional Conduct, performance and ethics (2015) protecting confidentiality and privacy of staff members and the patient all names and the place where the person- centred assessment took place will remain unidentified, for this assessment the patient will be known as Mrs Woody.

First, four weeks into practical placement at the care home, I discussed with my mentor who she thought would be a suitable patient, to carry out the person-centered assessment. To prepare for this I read through all the patients care notes, by the end of the week, me and my mentor discussed that Mrs Woody was a good patient to carry out the assessment, as I was involved in the care plan, being involved in the wound dressing, this got me involved with getting to know the different types of dressings and what they were used for. Mrs Woody was diagnosed with breast Cancer with Fungating tumour. Breast tumour is a chronic disease (Lawrence 2016) that causes depression, loneliness, but other days they might feel more positive about their self(MacMillan Cancer 2014). By the end of week 5, Mrs Woody was asked if she could be the person I used for a person-centred account, I wanted to find out more about Mrs Woody’s breast cancer, as I found it interesting. Mrs Woody is a patient who’s got capacity so she could give consent herself. It is important to obtain patient consent before undertaken their care notes, this informs Mrs Woody about how her information is being used (Bowrey and Thompson 2014).

When explaining things to Mrs Woody, both verbal and non-verbal communication was used. It is important that Mrs Woody knew every detail about the person-centred assessment, ensuring that her name, place and other personal details were confidential. (NMC 2015) I found it difficult talking to Mrs Woody who has been diagnosed with depression, quite difficult than I had expected, as I always made time to have a conversation with Mrs Woody, so she wouldn’t feel nervous about answering questions. Mrs Woody got agitated when I spoke to her in a clear calm voice asking her simple sentences, this gave Mrs Woody, the chance to talk directly to me, and to express her feelings. There were times when Mrs Woody pretended to have not hear what I said, so Mrs Woody started talking about what she was more interested in. I then brought her back to the questions, explaining them in more detail, by adding in things about her family, which got her attention again, which is more therapeutic towards her as it is vital to nursing.

I felt confident knowing that Mrs Woody was at ease when she interacted in the person -centred assessment. I interacted with Mrs Woody for the first four weeks of placement, which helped her get to know me better. This was to support and reassure Mrs Woody so she didn’t feel nervous about talking to me for the first time. It also helped me to get to know Mrs Woody before undertaken the assessment, while interacting I was accessing how long, I would have to spend with Mrs Woody, given her enough time to undertake the assessment, as I knew that she liked to talk about her family. Given Mrs Woody more time will help her gather her thoughts, without being rushed.

The information that I gathered from Mrs Woody did match against the information on the medical and nursing notes. The only question that was left blank in the patient and family perspective box was “systems assessment” when Mrs Woody was asked this question she didn’t fully understand what it meant, so I tried to simplify the question, by asking her about her physiological, psychological, sociological, and spiritual status, but Mrs Woody just looked at me and stated: that she did not want to answer that question. I respected Mrs Woody’s wishes and moved on to the next questions. It is very important that Mrs Woody could answer all the questions about herself, as if Mrs Woody couldn’t answer any of the questions about herself then, we would have had to make a review with the doctor to check out Mrs Woody’s signs and symptoms, this could have been a result of Mrs Woody being diagnosed with dementia. The questions Mrs Woody answered were straight forward questions, about her past and relevant questions.

After getting consent from Mrs Woody, I was able to collect relevant case notes under the supervision of my mentor, the case notes contained past medical history, dietitian,doctors notes and care plans. My mentor was involved in the whole interview of Mrs Woody, who was in her bedroom this interview was undertaken in a confidential place (NMC 2015) as it was personal towards Mrs Woody. I explained to Mrs Woody in an informal manner, what was going to happen, and if it was okay to carry out the assessment today. By asking Mrs Woody if it was okay to undertake the person- centred assessment, showed that I was respecting her rights, in what she wanted to do. To improve Mrs Woody’s care needs we could have carried out this assessment when her family was there, this way we could have got more information out of Mrs Woody about her past medical history.

I gathered accurate information on my one-to-one talk, to support Mrs Woody’s clinical care needs, I will be researching nutrition for Anorexia Cachexia Cancer. Doing this condition for Mrs Woody’s clinical care, allows me to see what the problems can cause and how the illness can result in different parts of the body, for example, this can cause loss of appetite due to Mrs Woody having Cancer, Mrs Woody is losing electrolytes and proteins from the wound, as nutrition has a big impact on the wound healing. I felt that doing this type of cancer was good as if I didn’t understand something about the condition I could go back and ask my mentor, this support was good for a student as your learning off another member of staff, in the care setting instead of reading journals.

In conclusion, it is seen that I have mentioned the (Driscoll 2007) model of reflection. Stating the reasons why this framework was chosen as well as why reflection is important in Nursing. By using the three stages in the (Driscoll 2007) model of reflection this has helped to develop a therapeutic relationship with Mrs Woody by using interpersonal skills. This shows that Mrs Woody feels safe and happy within the care setting, and gets on well with staff members, as Mrs Woody was unable to manage independently at home due to her being diagnosed with breast Cancer Fungating. Mrs Woody communicated well with me and the nurse, during the assessment, this is very important. This shows that Mrs Woody feels comfortable and has a good relationship with the health professional staff, when talking to professionals about her personal care plan. Overall, I feel that getting to know the patient before doing the assessment, made it easier for me to communicate with Mrs Woody, as having a relationship with her made the conversation flow more easily, making Mrs Woody not feel nervous. This skill is essential towards nursing, as I found Mrs Woody felt comfortable talking to professionals.

If I was to undertake this person-centred assessment again to make it better, I would get the family involved in the person- centred assessment, by getting the family involved they could have supported, what Mrs Woody was saying, by expanding on what she was asked, this could have given me more detail about her past and relevant medical history. This makes it clear why Mrs Woody kept on getting distracted and talking about her family. If Mrs Woody’s family was in the room this might not have happened. When consent was given from Mrs Woody within the end of week 4, I could have given her a date when the assessment was going to be done and should have given her a choice if she wanted her family to be present when the assessment was being done. By given Mrs Woody the choice this was respecting Mrs Woody’s rights.

The main learning that I as a student Nurse, can take from this reflecting practice is that (Driscoll 2007) model is effective on health professionals, as the three reflective questions make you think more as what you have to develop, and analyse what you just done. This model helped me to develop my learning skills. (Driscoll 2007) model can identify weaknesses and strengths when it comes to someone’s care. Developing new skills reflecting on past experience can help me achieve my highest potential, as with the (Driscoll 2007) model it has outlined my weaknesses and strengths.

Part 3 – Using information and data gathered during the assessment process identify one clinical care need for your patient and discuss the evidence based rationale for this choice.

The clinical care need that I have chosen to reflect on within the person-centred assessment is nutrition, for patients with Cancer Anorexia Cachexia.

With Cancer Anorexia Cachexia symptoms it is a metabolic disorder (Tazi and Errihani 2010). Cancer Anorexia Cachexia happens when a patient like Mrs Woody, losses weight, fatigue and feels weak, with increase weight loss resulting in loss of fat mass. This is not the patient’s choice in wanting to lose weight as weight loss is involuntary, it can not be even prevented by nutritional support (Mondello 2015). This condition can be seen as an end of life or chronic condition, such as, ‘infections, acquired immunodeficiency syndrome (AIDS), chronic pulmonary disease and renal disease’ (Tomoyoshi 2015).

Nutriment is important in helping patients with Cancer treatment and the development to become better (Reeves et al. 2007). Having a poor diet when having Cancer Anorexia Cachexia is a common problem with most Cancer patients, as it has been known to have vital symptoms of poor outcomes, such as decreased quality of life, making them weak and losing their ability to mobilise. Cancer patients needs a good balanced diet for the body to store nutrition, and maintain their body weight, a good balanced diet, this will have an effect on good quality life (American Cancer Society 2015). While if cancer patients have a poor diet, this can cause undernutrition, which leads to the patient having a high factor of infections, increasing their end of life care (Vigano et al. 1994)

With Mrs Woody having Cancer Anorexia Cachexia at the age of 83 years old unfortunately, there is no treatment for anyone with this condition (Fearon 2013) having this condition it is vitally important that Mrs Woody’s clinical status is took into consideration when caring for her, as due to the factor that she is 83 and has this condition it does not only lead to weight loss, but can also affect other symptoms,  Promoting positive outcomes from the health professionals for Cancer Anorexia Catherxia by increasing dietary needs, and minimising symptoms which will influence the patient’s quality of life (Bauer 2007).

Due to not having enough nutrition in the body, this has effected Mrs Woody’s mobility making her need assistance with two people. This condition affects the skeletal muscle wasting, and body weight as nutrition has been decrease. Lacking appetite is a problem for Cancer Anorexia Cachexia patients as this might have a different mindset on therapeutic options. Decrease weight loss, could be due to being diagnosed with cancer, causing the patient to have not only have decreased nutritional intake, but swallowing can also be a problem (Bauer 2007) It is important that health professionals detect and treat Mrs Woody with other causes that Cancer Anorexia Cachexia brings to her, such as depression, Mrs Woody is a palliative patient, depression can effect Mrs Woody differently some days, she might get up one morning feeling content, or other mornings it might affect her my getting up feeling depressed and an inability for her mood to be lighted. Pain is another factor effecting Mrs Woody, pain is common in cancer patients, and in lifelong illnesses (Higginson and Costanantins 2008). With Mrs Woody having Cancer Anorexia Cachexia her pain should be well controlled as there is medicine to prevent her feeling in discomfort.

It should be recommended that every patient with Cancer Anorexia Cachexia, to see about nutritional counselling as this will help patients who have this condition, being seen by a nutritional will help a patient like Mrs Woody to establish her physical function and body weight (Ravasco 2007). When attending a nutritional counselling for Cancer Anorexia Cachexia that a patient gets full support out of attending, which will include different nutritional aspects, eating problems and clinical history. This allows the patient with Cancer Anorexia Cachexia to keep a food diary, keeping a diary will help them see if there is any dietary changes, the diary will show the intake of caloric and show if there is any energy deficit. With the increase of caloric intake and nutrition, patients with Cancer Anorexia Cachexia have to understand that sometimes it does not work, with the increase of caloric it is known to help cancers. (Norleena 2011)

Being diagnosed with cancer it is known that having treatment can cause nutrition symptoms. Nutrition systems can cause obstruct oral intake, which then leads to the patient losing weight. This includes, different symptoms like, nausea, sore mouth, problems with swallowing, depression and changes in the smell and taste (Wojtaszek et al 2002) With having any of these symptoms it can impact the patients quality of life. It is advised that patients go and see a Dietician, Oncology, or even a nurse, as having any of these symptoms can affect the patient’s ability to eat. Getting the help from a health care professional will decrease the side effects in some way, as well as helping the patient to eat again and enjoy their food.

Health care professionals, within the care setting are involved in sending Mrs Woody to nutritional screening assessment. There are a variety of assessments that can be carried out for patients who are at a risk of nutrition, they use different assessment like skin testing, hypersensitity (delayed) and guidelines to institution- specific.


Conclusion

With the clinical care need of nutrition for patients being diagnosed with Cancer Anorexia Cachexia this condition is a metabolic disorder. It is important that for the best clinical care for patients being diagnosed with this condition, that they stick with the nutritional assessment of Cancer Anorexia Cachexia. Also having this condition the patient can talk to a health care professional, if they are having problems with eating or swallowing, also professionals help patients to set goals appropriately, which then improves quality of life for the patient. Some researchers have seen Cancer Anorexia Cachexia as an end of life condition, if they don’t have a good nutrition

Identify an outcome focused goal for this clinical care need, ensuring the goal involves the patient and is SMART (Specific, Measurable, Achievable, Realistic, Timely).

The goal that I will be focusing on for Mrs Woody is a 45 diet plan, for patients with Cancer Anorexia Cachexia which will involve the SMART assessment. The SMART assessment is what goal you want to achieve, there are five main parts to this goal and they include “Specific, Measurable, Attainable, Relevant and Timely. “(Haughey. 2015)

A specific goal for a Cancer patient in a care home setting is to improve the increase of calorie, by improving calorie this will improve quality of life to symptom manage nausea . The increase to calorie are different for each patient, this is due to everyone being different sizes, people being taller than others, treatment and side effects. A high calorie should be recommended for the patient, as it prevents the patient losing weight (Wickham et al 2015).

The goal for Measurable in a Cancer patient is weight management. With the increase of calories into the diet will help to maintain some body weight, if the patient is well enough it is vital that they get referred to the dietician, for supplements and weekly weight. The UK guidelines do not have a set guideline for doing physical exercise after treatment (Cancer Research UK 2015). But it is recommended by the (Macmillan Cancer Support 2012) that exercise is a good way to help control weight by muscle strength, and cardiovascular exercise. This will improve the patient’s quality of life, keeping their mind of their condition.

Achievable goals for a Cancer patient, is necessary when on a 45 diet plan, increasing a Cancer patients appetite, sometimes the psychological aspect of Cancer, appetite can be affected by mood, general health and ability to fight infection, so  using a MUST tool will help improve the patients appetite, which will be documented in a food diary. In the food diary the health care staff will keep an eye on the intake of fortifying diet, adding calories and high calorific snacks to the diet. Smoothies are good for adding in calories, as they have a range of vitamins in them. Vitamins are important nutrient for Cancer patients as it will decrease side effects, and helps the immune system (Parker 2017).

A realistic goal for a Cancer patient when on the 45 diet plan, is to increase weight, and not to lose weight. With a patient being underweight it can cause infections. These infections can be hair falling out, or/and decrease body muscle. When a patient is underweight there is a high risk of the patient being diagnosed, with Osteoporosis, being underweight people find it hard to absorb minerals and vitamins (Meghan 2008).

The timely goal will be the end result, which will be then reviewed in 4 weeks to see how well the patients get on, with the 45 diet. The focus within the 4 weeks is to see if there is any improvement in weight.