The Peplaus Interpersonal Relationship Theory Nursing Essay

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The nurse patient relationship is a key concept in peplaus theory. If switching from a theoretical to practical application is to be effective, the clinicians must establish outcome measures that incorporate the unique needs of the patient(Marchese, 2006). The outcome measures guide the practitioners in the assessment of the patient individual needs, and determine the care required. Peplau stresses that successful intervention only occur, if the patient is valued and accepted by the nurse. Acceptance is attained by seeking active patient participation in the development of the goals for the intervention.

Peplau (1992) theory of interpersonal relations provides a conceptual framework by which the nurse can assess, plan, and intervene for optimal outcomes for the patient. The foundation of her theory explores the primacy of the nurse patient relationship (Forchuck, 1991; Peplau, 1997).

According to peplau (1992), the nurse is a complex individual, who is the sum of all past experiences, rigorous nursing training, and unique personality traits. Also, the patient is a complex individual, has unique personality and knowledgeable within his or her own frame of reference (Peplau, 1992). The nurse patient relationship is initiated with a change in a health status of the patient, and the availability of a nurse with the ability to provide specific skills (Peplau, 1992).

The nurse patient relationship evolves through the phases of orientation, identification, exploitation, and resolution. The nurse must adapt to several roles so that the needs of the patient are met within each different phase (Forchuck, 1991; Peplau, 1997). Nursing roles include stranger, teacher, leader, surrogate, counselor, and resource person (Peplau, 1997).

Patient diagnosed with bladder cancer may require urinary diversion to maximize their health care outcomes. These patients, faced with sudden change in their health status, develop complex unmet need that can be addressed by planned program of education. Peplau’s theory of interpersonal relations offers a framework for patient teaching that emphasizes the importance of the nurse-patient relationship. This therapeutic relationship enable the nurse to provide the patient with the information needed to understand the diagnosis, cooperating in treatment plan, facilitate postoperative recovery, and return to a state of independence with quality of life.

Case study

A 60-years old male is diagnosed with muscle-invasive bladder cancer. He has seen by his urologist after two episodes of hematuria. Patient had no recently body weight, shortness of breathing. He undergoes cystoscopy and bladder biopsy that revealed muscle-invasive bladder cancer. Past history including tobacco use of 30 cigarette per day for 30 years. Before one year ago patient stop smoking post severe upper respiratory tract infection. No other health problem when obtained history from patient. All blood test were within normal and chest x-ray, abdomen pelvic CT scan also normal related to age. The consulting urologist discussed option for continent diversion, and explanation that his chances for long term, disease free recovery were excellent. The patient referring to the registered nurse for additional teaching. The first meeting with the nurse, the patient was very agitated and anxious, announcing he didn’t have time for this teaching session and could not plan any surgery at this time due to the concern of his business. His immediate concern centered on his ability pay his pills, support his family, and maintain his business. Compounding theses concerns were fear, anxiety, grief, and knowledge deficit regarding the cancer diagnosis and the need to undergo surgery to remove his bladder. His wife was present and equally anxious and tearful. When the patient concerns were validated and discussed, potential community resources to help them through this difficult time were identified. These included hiring associates who could work as subcontractors, identifying his wife as temporary bookkeeper, and involving the social worker to mobilize the other available community resources. The initial teaching session was concluded with minimal information being given to the patient about the surgery, but the steps taken to help him plan for his surgery contributed to a significant change in his behavior and willingness to consider future option. Flexibility in addressing the patient’s primary concern rather than implementing the planned teaching session fostered the therapeutic nurse-patient relationship. Until next meeting to the patient, the nurse gives him written material to review. At the second session, readiness to learn was assessed. The first, the patient was asked to explain what he understood about the proposed surgery. Also, he was asked if he read the materials given to him at last interview. The patient was given the opportunity to ask questions. Body language, eye contact, and focused attention span all indicated the patient was expressing his willingness to learn. Based on patient description of the surgery, information about anatomical changes, pre and post operative care, and expected recovery time were discussed. Visual aids used to enhance the teaching session. After deciding the operation date and time, the patient seen by same nurse to review the education material and re-affirm his choice of surgical intervention. Then the patient was marked for a new stoma site in order the neobladder was unable to be performed. After doing the surgery the patient and his wife were taught to irrigate the neobladder, using normal saline (NS) 0.9 in 30 CC increments to remove mucus and blood clots. They were taught how to clean the irrigation equipment and where to purchase additional supplies as necessary. The teaching strategies stressed the importance of maintain the patency of the drainage tube. These lessons involve verbal, written, and hand on demonstration and return demonstration. Short term goals included maintained of integrity of urinary diversion, return to normal activity, improve nutritional status and focusing on psychosocial aspect of recovery. After eight days from operation, patient was discharged, he demonstrates care of the urinary drainage tube and incision. He also has given supplies for home use. Also, the patient verbalized the importance of adequate protein in his diet and the need for six small meals daily. His family members were recruited to assist him in daily walks, and provide needed social contact.

Phases of the interpersonal process in peplau’s theory.

Phases of interpersonal

process

Definition

Teaching activities for the patient undergoing urinary diversion

Orientation

Patient recognition of need for help.

Resources provided on limited basis as acceptable by patient. Initiation of nurse-patient relationship.

1- Assessment of prior knowledge and experience.

2- Assessment of readiness to learn.

3- Presentation of education materials.

4- Involvement of patient in developing mutual teaching goals.

5- Discussion of pre-operative procedures.

6- Different option for diversions; patient pathways.

Identification

Patient identifies problems to be worked on.

The patient has some working knowledge of the health care needs.

Trust level with nurse is in early stages and the patient will selectively begin to assimilate knowledge and accept interaction with nurse.

Imitative behavior begins and gradually switches to a creative constructive response.

1- Demonstration / return demonstration of neo bladder care, bladder irrigation, maintaining tube patency, care and cleaning of equipment, knowledge of emergency situation.

2- discussion on nutrition

A- Reassessment of prior eating habits; reduce empty calories. B- Six small meals daily with attention to five food groups. C- fluid requirement 2 quarts daily.

3- development of activity plan

a- rationales for exercise

b- Intensity and duration.

Exploitation

Comfort and trust level established.

Patient takes advantage of service offered by nurse and benefits from relationship with nurse.

Some vacillation between dependence on nurse and self-direction.

Focus on incorporating learned experiences into future health status and quality of life (QOL).

1- Reaffirm patient’s knowledge and experience.

2- Promote independence.

3- Identify available community resources.

4- Role playing.

5- Present theoretical complex situations and have patient problem solve.

Resolution

Prior goals have been met and new goals are formed.

Patient experiences a sense of security because needs have been met in a timely manner.

Increase in self-reliance and decrease reliance and identification with urologic nurse.

1- Encourage participation in support group for continent diversions.

2- Identify QOL issues and discuss options.

a- nocturnal incontinence.

b- Sexual changes.

c- Alteration in body image.

d- Anxiety about cancer diagnosis.

Summary

In conclusion, a highly skilled nurse with good observation and communication skills plays a critical role in promoting the health of patients undergoing urinary diversion. The scope of patient need required a nurse competent to assume the changing role in the four phases of the interpersonal process described by peplau (1992; 1997). Peplau’s theory emphasize that effective communication is integral to the nurse-patient relationship and necessary for education efforts to be successful. To that end, it is important to involve the patient in establishing the teaching goals and evaluate the efficacy of teaching methods used. Applying this theory to practice help the nurse to evaluate and develop skills and teaching methods to meet the needs of each patient.

Critically evaluate a journal article and discuss its relevance to clinical nursing practice. Task Description (Instructions):

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Critically evaluate a journal article and discuss its relevance to clinical nursing practice.
Task Description (Instructions):

For this task you need to write a 2300 word critical evaluation report. In your report you will critically evaluate a journal article and discuss its relevance to clinical nursing practice. You must choose to evaluate a Randomised Controlled Trial OR a Qualitative Study (see below).

For this report you must use the ‘critical evaluation tool template’ (available below) to guide what information to include in each section. The template is your guide only and is not to be submitted.

In your report you must use the following headings:

Introduction (200 words)
Title and Abstract (100 words)
Structuring the Study (300 words)
The sample (150 words)
Data Collection(300 words)
Data Analysis (300 words)
Findings(300 words)
Conclusion(150 words)
Relevance to clinical nursing practice (500 words)
You need to include a reference list (not included in wo

Analysis and Evaluation of the Theory of Comfort

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Theory Analysis

Scope

The Theory of Comfort by Katherine Kolcaba is middle range theory. Middle range theories contain a limited number of concepts and have a more limited scope. However, Kolcaba’s Theory of Comfort is classified as a high middle range theory making it a more general and abstract theory. Making it closely related to a “Grande Theory” which is very abstract and general and can be applied to a variety of experiences and responses (McEwen & Wills, 2011). This is very true for The Theory of Comfort as many articles have been written adapting the theory to multiple scopes of nursing.

Middle range theories include something specific related to nursing practice such as a situation or condition of a patient or patient population. Middle range theories also take into account the populations age and location when working on the development of a theory. A middle range theory also includes an intervention, proposed outcome, or an action of the nurse. Middle range theories are developed by interpreting and observing lived experiences with a relation to health and nursing (Tomey & Alligood, 2002). In Katherine Kolcaba’s Theory of Comfort she spent much time examining the relationships and outcomes of patients in relation to comfort.

Context

Katherine Kolcaba originally wrote the Theory of Comfort with Alzheimer’s and dementia patients in mind. However, Katherine herself has co-written multiple articles about other scopes of nursing related to her theory. Two recent articles were written applying her theory to perianesthesia nursing and hospice nursing (Kolcaba & Wilson, 2002 and Vendlinski & Kolcaba, 1997).When Kolcaba was developing her theory she utilized logical reasoning. She utilized induction, deduction, reduction. Kolcaba utilized a preexisting framework as her antecedent. The framework was written by Henry Murray (Tomey & Alligood, 2002), it was from a book entitled Explorations in Personality. Henry A. Murray was a professor of psychology at Harvard University; he received the Distinguished Scientific Contribution Award from the American Psychological Association and the Gold Medal Award for lifetime achievement from the American Psychological Foundation. “When it first came out in 1938, this book had a provocative and insightful effect, urging psychologists to study personality holistically and in depth and emphasizing the complex interactions between individual, social, and cultural characteristics.” –Salvatore R. Maddi, Professor, Department of Psychology and Social Behavior, School of Social Ecology, University of California, Irvine (Explorations in Personality, 2007). This was a very good starting point for the theory as comfort is best achieved through holistic treatment. She also began with a concept analysis of the term, “comfort”. Katherine Kolcaba gathered the definition, of “comfort” from many different disciplines. Within The Theory of Comfort the metaparadigm proposition of nursing actions is utilized (Kolcaba, 2001). This is evident in this theory because it is built around evaluating for the lack of comfort and then reevaluating the patient to calculate the success of any implementations made or actions taken.

Katherine Kolcaba utilizes the all four of the metaparadigm concepts: nursing, patient, environment, and health. In nursing there is an assessment of comfort needs, actions to promote comfort, and then the reassessment of comfort levels. The assessment and reassessment can be either subjective or objective. The patient can be an individual or their family. The environment is any part of the patient’s surroundings that can be manipulated by the nurse to enhance the patients comfort. Finally, health is the optimum functioning of the patient (Tomey & Alligood, 2002).The author believes that Kolcaba does utilize all four of the metaparadigm because the patient is the center. The nurse is essential because the nurse provides the care to increase the comfort. The environment also plays an essential role in this theory as comfort or discomfort can be found in the patient’s environment. Finally the author believes that when all of these three are in cooperation to create comfort the patient will then have an increase in their health.

The philosophical claim that The Theory of Comfort is based on is human needs. There are two core components of this philosophy. There first is the motivational drive that is behind human behavior. The second is the force driven by social and cultural politics that influences the patient’s expectations. Patient’s comfort needs are driven by their expectations of competent and holistic nursing care (Kolcaba, 2001).

The world view that fits The Theory of Comfort most concisely is the “reciprocal world view” this fits well because human beings are active and holistic. Humans interact with their environment and this interaction may lead to pain, displeasure, or comfort. Humans learn from their experiences and this leads them to the ability to make decisions that can keep them in a more comfortable environment.

Content

The Theory of Comfort has six basic concepts: health care needs, nursing interventions, intervening variables, patient comfort, health seeking behaviors, and institutional integrity (Kolcaba, 2001). Health care needs are defined as the need for comfort that comes from stressful health care situations. The types of needs that can arise are: physical, psychospiritual, social, and environmental, these are the same terms that Kolcaba uses to evaluate the effectiveness. These needs are made apparent through close monitoring (Tomey & Alligood, 2002). Nursing interventions are defined as the commitment of nursing and health care institutions to promote comfort care and meet the comfort needs of patients (Kolcaba, 2001). Intervening variables is anything that affects the outcome (Kolcaba, 2001). Some possible variables include: past experience, age, attitude, emotional state, support system, prognosis, and finances (Tomey & Alligood, 2002). Patient comfort is defined as, “immediate state of being strengthened by having needs met in 4 contexts of human experience, (physical, psychospiritual, social, and environmental)” (Kolcaba, 2001). Health seeking behaviors is defined as, “the pursuit of health as defined by the recipient, in consultation with the nurse,” (Tomey & Alligood, 2002). Instructional integrity is an institution that possess qualities of completeness, honesty, sincerity and is also appealing (Tomey & Alligood, 2002).

Katherine Kolcaba has a total of six propositions that outline her theory of comfort. The first of the six is that a nurse identifies the comfort needs that have not yet been identified by the patients other support systems. The second proposition is that the nurse is then responsible for designing interventions to address those unmet needs of the patient. The third is taking into account the variables that could affect the intervention that has been proposed to help the patient. The forth proposition by Kolcaba is that once the comfort is met or achieved that patients are encouraged to engage in health seeking behaviors. The fifth proposition is that once a patient has been strengthened and are participating in health seeking behaviors they are then more satisfied with their health care. The last proposition of The Theory of Comfort is when a patient is satisfied with their health care in a particular institution that institution retains its integrity (Kolcaba, 2001). All six of the propositions are relational in the streamline. All six of the propositions have to take effect for the patient to be brought to an acceptable level of comfort with that level of comfort being maintained for an extended period of time. All six of Katherine Kolcaba’s propositions are relational as they are a streamlined reevaluating process that depends on all parts for success and structurally necessary to have holistic health.

Katherine Kolcaba has listed four major assumptions in her Evolution of the Theory of Comfort. The first is “human beings have holistic responses to complex stimuli” (Kolcaba, 2001). The second is that comfort is a desirable holistic outcome that is relevant to the discipline of nursing. The third is, it is an active endeavor to meet and maintain comfort. The fourth and final assumption is that institutional integrity has a large component that is based on a “patient oriented value system” (Kolcaba, 2001).

Katherine Kolcaba’s diagramed conceptual model consists of the basic principles of The Theory of Comfort. The health care needs, nursing interventions, and intervening variables all work in cooperation to become enhanced comfort. Enhanced comfort then leads to health seeking behaviors. The facility or company who has in use best policies and best practices will then be able to promote and relate health seeking behaviors utilizing those policies and practices. Health seeking behaviors then have the ability to become internal and external behaviors which can lead to greater health. The health seeking behaviors may also lead to a peaceful death, (The Comfortliners, 2010) as this is the goal of hospice nursing and the Theory of Comfort has been utilized in hospice nursing (Vendlinski & Kolcaba, 1997). This concept is much easier to visualize than read.

In order to evaluate the success of achieving comfort Katherine Kolcaba has developed a table or taxonomic structure to document comfort. On the left side of the chart are four rows labeled, “physical, psychospiritual, environmental, and social,” (Tomey & Alligood, 2002) which are the context for which comfort occurs. The three columns on top are the types of comfort, “relief, ease, and transcendence,” (Tomey & Alligood, 2002). Kolcaba defines relief as “the stated of having had a specific need met or mediated,” ease is, “the state of calm and contentment,” and transcendence is, “the state in which one rises above problems or pain,” (Kolcaba, 2001). When evaluating a patient’s comfort the nurse fills in the twelve empty squares with what action helps to achieve that level of comfort.

Theory Evaluation

Significance

Comfort is a massively important concept of nursing and The Theory of Comfort is designed to bring comfort to patients. The diagrammed conceptual model provides the simplest explanation for the theory. The metaparadigm concepts are not clearly defined by Katherine Kolcaba; however she does clearly states the philosophical claim and its concepts. The conceptual framework and antecedent knowledge is minimally defined within her work, but they are acknowledged and cited.

Internal consistence

The content and context reflect each other nicely as they are both centered around holistic comfort, however the clarity throughout the theory is minimal. The six propositions of The Theory of Comfort are clearly stated by Katherine Kolcaba. The six propositions flow consistently to outline the theory well. The assumptions are clearly stated and are consistent with comfort and treating the patient holistically. The theory is reciprocal as all parts are dependent on the others for success.

Parsimony

Throughout The Theory of Comfort there is minimal clarity. The propositions and the conceptual diagram are the clearest components of the work. The theory would be more understandable if it were stated more simply.

Testability

The Theory of Comfort does not have a very specific evaluation processes aside from the taxonomic structure that the nurse fills in by documenting what implementations help to achieve comfort, which was previously mentioned. However with regular nursing assessments the nurse will know if comfort has been achieved, either objectively or subjectively. The best way to measure comfort rather a nurse is utilizing this theory or not is to frequently ask and objectively assess a patient and notice nonverbal indications of pain. As with any high middle range theory, The Theory of Comfort is very abstract and proves difficult to measure results in a definitive method.

Empirical adequacy

The Theory of Comfort has been adapted to several different fields of nursing aside from its original focus of dementia care. Perianesthesia nursing has adapted this theory to help patients especially by utilizing the table to document different methods of obtaining comfort. It has also lead nurses in this scope of practice to realize the importance of education (Kolcaba & Wilson, 2002). The theory has also been utilized by hospice nurses, this is the ideal scope of nursing to utilize this theory. It has provided hospice nurses with a broader outlook on how to provide holistic comfort to their dying patients (Vendlinski & Kolcaba, 1997).

Pragmatic adequacy

The Theory of Comfort is a very practical concept as everyone feels better when they are comfortable. Patients and families are more able and willing to absorb information when they are comfortable and focused. This theory provides simple steps to ensure comfort is being delivered. The Theory of Comfort encourages nurses to think more deeply about rather or not their patient is comfortable, along with what is causing discomfort and what is promoting comfort. It also encourages nurses to document the variation of methods in which a patient becomes comfortable in different settings. A basic nursing knowledge such as an associate’s degree is necessary for utilizing this theory, however in order to understand the written theory in its entirety a more advanced knowledge level proves to be a necessity.

Case Study of Living with Schizophrenia

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As we have seen the symptoms or rather the results, of Schizophrenia can be life disheartening, depressing and take an emotional toll on the patients and their family. The person is unable to interact within the community and family, express him or herself well and hence unable to continue with his work and social life. Since this is likely to be a life-long condition it is important that every family has, ample schizophrenia education to enable them to detect early symptoms, seek early medical intervention, and be well adapted to help the patient cope with the condition. Just like any other health condition, early diagnosis implies that the condition is less severe and the medical intervention is likely to work better and faster. Currently, though there is no cure, there are successful treatments to ensure that many schizophrenic patients lead satisfying and independent lives.

An approximate 2.4 million United States adults, or basically 1.1%, of the U.S. population aged 18 years and above are diagnosed with schizophrenia each year. In men, it manifests itself in their early twenty’s while in women it manifests itself in their late twenties or early thirties. However, both men and women are equally affected. Being a mental disorder that is usually characterized by the disintegration of the thinking process and emotional responsiveness, Schizophrenia is among the most chronic and severe lifelong brain disorders, especially if not diagnosed early enough. It leads to both occupational and social. (NHMI, 2010).

The complexity of schizophrenia does not make it any easier for the patients. Unlike most mental diseases, schizophrenia is not synonymous with multiple or split personality disorder and most people with it are not violent or dangerous. They simply reside with families, on their own, or in group homes. Schizophrenia diagnosis is dependent on the person’s observed behavior and self-reported experience. However, most people living with a schizophrenic person barely notice that they have a serious mental condition and hence dismiss their symptoms as being paranoid, bizarre delusions, mere hallucinations, disorganized thinking or speech or bizarre delusions. Schizophrenia interferes with a person’s ability to manage emotions, distinguish reality from fantasy, think clearly, relate to others, and make decisions. Nevertheless, just like many mental conditions, schizophrenia has no cure and it is therefore important that all Americans are well versed with the causes, symptoms, diagnosis, prognosis and management of schizophrenia so that they are well aware of the hazardous health, social, and occupational effects that the disease causes and pay attention to the persons living around them to ensure that steps towards earlier medical intervention which can inhibit the progression of the disease and save a patient’s life are taken (NHMI, 2010).

The client (M.J) which I cared for was a 52 year old female. She was unemployed, single, under weight and staying alone in her apartment. She smokes cigarettes, one pack per day. Her sister staying in Maryland was supportive to her. Moreover, her sister was a source of support after discharge. Her mother was bipolar. She also had a history of Asthma. She is also a Hepatitis C carrier.


Causes

Although researchers have not yet been able to identify specific causes of schizophrenia they have been able to ascertain that a combination of various factors such environmental factors, hormonal changes, and genetic factors altering brain chemistry and psychological, places people at a higher risk of having schizophrenia.


Abnormalities in brain structure, chemicals and circuitry:

Using the Magnetic Resonance Imaging (MRI), brain scans have shown a number of abnormalities within the brain structure associate with the condition. Such problems cause damages that cause nerve disconnection and damage in the brain chemical pathways. These problems show up on brain scans of persons with chronic schizophrenia more often than newly diagnosed ones. Schizophrenia is also associated with neurotransmitter imbalances and brain chemicals such as glutamine, dopamine over activity, reelin and others. In abnormal circuitry brain structure abnormalities are reflected in disrupted connection in the schizophrenic patients. This impairs information processing and mental functions coordination which are symptoms in schizophrenic patients (UM, 2010).


Genetic factors

Undoubtedly, research has proven that schizophrenia has genetic components such as OLI2 gene, neuregulin-1 gene, and the COMT gene. The genetic components exhibit a risk of 10% of inheriting the condition if one immediate family member has it and 40% if an identical twin or both parents have it (UM, 2010).


Psychological factors

External pressures and influences play a psychological role in a person’s development. Prefrontal lobes which are the brain areas that lead to the condition are usually extremely responsive to environmental stress. With the fact that schizophrenic symptoms naturally elicit negative responses from a patient’s family circle and acquaintances, negative feedback can intensify deficit in the vulnerable brain and trigger or exacerbate the existing symptoms (UM, 2010).

M.J doesn’t have a good relationship with her father and brother. Her father was abusive to her for not being employed. She was living with her parents; but because of her father’s behavior she was kicked out of her parent’s house by her mother.


Infectious factors

Research has identified that infections such as viruses increases the risk of the condition. The risk of the condition is usually 5-8% higher for persons born in winter and spring when colds and viruses are prevalent. Pregnant mother’s exposure to viral infections such as measles, chicken pox, and rubella among others while the infant is still in the womb increases higher chances of developing schizophrenia. Researchers have also identified that viruses belonging to the HERV-W retrovirus family are found in 30% of schizophrenics, a clear indication that infections play a major role (UM, 2010).

M.J was born in winter on December 2, 1957. According to research the chance for her getting schizophrenia increases up to 8% because she was born during a winter month.


Positive symptoms

These are behaviors not exhibited in healthy persons and even they usually come and go, sometimes they can be hardly noticeable or severe depending on whether the individual is receiving medication or not. Schizophrenics suffer from hallucinations whereby they hear, smell, feel and see persons or things that no one else can. Many hear voices which may order a person to do things, warn them of danger and talk to them about their behaviors. Schizophrenics might hear voices for a long period of time before anyone can notice them. They also suffer from delusions; false beliefs that do not change or are not part of a person’s culture. They believe in delusions even after people prove to them that these beliefs are not logical or true. Their delusions such as; having the belief that neighbors are controlling them through magnetic waves, people on television are directing messages to them, radio stations are broadcasting their thoughts to others, they are a famous historic figure, others are trying to harm them, cheating, poisoning, harassing, plotting and spying on them. Schizophrenics might also experience thought disorders whereby they may experience disorganized thinking. They have trouble connecting their thoughts logically, talk in a garbled way, and experience ‘thought blocking’ whereby they feel that their thoughts has been taken out of their heads. They may also have agitated body movements, repetitive motions, and may even become catatonic.

M.J has an array of positive symptoms like auditory and visual delusions and hallucinations. She was being paranoid from her neighbor. She complains that her neighbors make weird noises so she started to sleep outside. She also tried to commit suicide by jumping into a river. At the time she was not staying at her house. She was frequently found living out on the streets.


Negative symptoms and cognitive symptoms

These are symptoms associated with normal behavior and emotional disruption. They are hard to recognize and often mistaken for depression. They include ‘flat affect’ whereby a person shows no emotions, speaks little, lacks pleasure in everyday life, has an inability to sustain and begin planned activities. Such people neglect the basics of personal hygiene and are often mistaken for being unwilling and lazy. Cognitive symptoms are usually subtle and are barely recognized as part of the condition. They include poor ‘executive function’, inability to focus and pay attention, and poor working memory.

M.J also has negative symptoms which include depression. She lost 34 lbs drastically, without trying, in two month. She refuses to eat an appropriate amount of food and goes days without eating. She does not sleep well. She cannot take care of herself. Layers of unwashed clothes covered in feces and urine drops were found on her body. The client has irregular contact with an assigned case manager, counselor, co-worker, and nurses. In activity group she sits alone in the corner without answering a single question. When somebody sits beside her she walks away immediately. She has very poor concentration. Upon admission she scores 10 on Axis V. M.J stopped taking her medicine. She always says that she doesn’t felt better after she has taken her medicine. M.J was not ready to accept the decision of the treatment even though she was on a very low score of 10. In the court room she always says no to each and every question regardless of the content.


Diagnosis and Treatment


Diagnosis

Diagnosis is based on the self reported experiences and any abnormalities reported by family members, co-workers, or friends. This is followed by a clinical assessment by a social worker, clinical psychologist, mental health nurse, psychiatrist, or any other mental health professional. Psychiatric assessment involves mental status evaluation and a psychiatric history. However, the American Psychiatric Association Diagnostic and Statistical Manual of Mental Health provides a standardized criteria, version DSM-IV- TR to diagnose schizophrenia. Three diagnostic criteria must be met for a person to be declared schizophrenic including; a continuous disturbance with signs persisting for at least six months, evidence of social and occupational dysfunction, and characteristic symptoms of the condition (NHMI, 2010).


Treatment

The causes of schizophrenia are still unknown and therefore treatment focuses on eliminating the disease symptoms with antipsychotic medications such as Thorazine, Haldol, perphenazine, Fluphenazine, paliperidone, and ziprasidone among others. They eliminate hallucinations, psychotic symptoms, and breaks with reality. However, the medications have side effects such as rapid heartbeat, skin rashes, dizziness, tremor, rigidity, restlessness, drowsiness, menstrual problems, and blurred vision. Sometimes, persons need to try several medications to find the right one and hence, doctors need to work together with patients to find the right medication combination. The treatment is administered once or twice a month as an injection and symptoms such as hallucinations and agitation go away within days and symptoms like delusions after a few weeks. Within six weeks many people are able to see a lot of improvement. People have relapses when they stop taking medication or do not follow doctor’s orders making the symptoms get worse, hence, patients should never skip or stop taking the medication on their own (NHMI, 2010).

After being admitted to MCES medicine was given to M.J on a regular basis which shows continuous improvement in her mental functioning. After three weeks of being admitted in MCES she began to take part in some activities. She also began giving her feedback in the activity room. She still suffers from symptoms of disorganized thinking.

Patients also need psychosocial treatment such as cognitive behavioral therapy and coping mechanisms to help them communicate, work, care for themselves and keep relationships. They may also get rehabilitated and join self help groups to help them learn social and vocational skills that will help them cope with the community (NHMI, 2010).

From my experience with schizophrenic clients, the nursing process for schizophrenic patients is complex because of the wide range of symptoms that patient’s exhibit. During diagnosis I usually avoid ambiguity in use of words and phrases. I use words that can be understood by the patient to avoid misinterpretations that can have adverse effects. However, due to compelling circumstances, at times I forget and touch or cuff the patient before explaining reasons for this. This is often adversarial especially when the patients I am attending to are agitated or suspicious. While I understand that such patients need to be helped to carry out certain duties as stipulated by Edwards, Peterson and Davis (2006), I take measures to minimize dependence but help out with activities I know schizophrenic patients cannot execute individually. In order to encourage quick recovery I reward patients who exhibit good behavior. This has even been encouraged by Coatsworth- Ruspoky, Forchuk and Ward-Griffin (2006) who assert that rewarding patients encourages improved functioning.

My priority nursing diagnosis was Risk for violence: related to prior suicide attempt after reviewing her chart and speaking with her. My intervention was to ask direct questions about any specific plan for suicide. Assess for any sharp instruments she could possibly carry with her. I observed closely for any signs of physical abuse. I assessed her potential to harm others. I taught her healthy coping mechanisms to deal with her feelings. I encouraged her to attend group therapy. My second nursing diagnosis was self care deficit: related to cognitive impairment. My intervention was to give her instruction in small steps to avoid confusion. I encouraged her to bathe every morning to promote independence in daily care. I instructed her to keep journaling about her daily schedule.

In addition to the standard care of schizophrenic patients, the nursing care which I provided to my client was different and was more specific. I allowed her sufficient time to express her feelings verbally. I listened to my client attentively while maintaining eye contact. I built a therapeutic relationship with my client. Sometimes she did not want to talk, but I still spent some time with her sitting in silence. By doing this I tried to establish rapport with her. I encourage her to participate in self care to her fullest extent possible to reduce feelings of helplessness. Moreover, I encourage my patient to establish a self care schedule to enhance feelings of usefulness and control. I also told her that the social worker, case worker, co-worker, nurses and doctor are her support groups I recommended she listen to them and follow their guidelines. Talk with them and express her feelings about sadness, guilt, anger, and depression. I advised her to write the goal a day and try to fulfill it. Moreover, I instructed her to keep a daily activity log to help her achieve a more objective view of her behavior. I encouraged the client to be a part of each and appropriate activity group.

I assessed my client’s personal strengths, including coping and problem solving abilities and her participation level during activities. I encouraged my client to use healthy coping skills to overcome stressful situations, similar to ones in the past, to bolster clients’ confidence in her ability to manage current situations and explore ways to apply coping strategies before she became overwhelmed. I advised her that the use of healthy coping skills would increase her self esteem and could reduce her feelings of dependence. I encouraged my client to identify enjoyable diversions and to participate in them to decrease negative thinking and enhance self-esteem. I strongly encouraged thinking positively which conveys a sense of confidence in her ability to cope with illness and to promote an optimistic outlook. I encouraged my client to continue practicing her spiritual beliefs. I also asked her to keep a sleep log describing any sleep disturbances and their impact on daytime functioning, such as with cognition, mood and coping skills.

In order for the nursing process on schizophrenic patients to yield beneficial results there should be effective and open communication between the patient and nurse. This forms the basement upon which viable relationships are established. When the client is brought in to the medical facility they are taken through the orientation stage. This marks the onset of the client- nurse relationship and nurses assume the responsibility of explaining to the patient why they are in the facility. According to Edwards et al (2006), schizophrenic patients at this particular stage might not be able to express themselves effectively due to anxiety and emotional distress. To help the patient to relax, nurses expose them to palliative measures such as administering painkillers and promoting rest. Patients that exhibit extreme aggression are secluded to prevent them from injuring others (Coatsworth-Ruspoky et al, 2006). Nurses at this point avoid arguing with the clients but exercise empathy by assisting them to carry out certain difficult duties. Also, they keep the levels of noise minimal and clear the environment of objects that may be harmful to the safety of the client.

During the exploration phase that comes after orientation the problems of clients are identified; solutions sought, applied, and evaluated (Edwards et al, 2006). The nurse employs unambiguous communication techniques such as using simple phrases to help the patient cope. For instant, instead of saying ‘Can you pick the spoon up from the floor’, the nurse can say ‘please help me get that spoon’. Elimination of the word floor would be imperative as patients can misinterpret this to mean lie on the floor. Nurses also encourage independence by letting the clients perform most of the tasks (Coatsworth- Ruspoky et al, 2006). At this stage, clients are able to undertake self care tasks such as bathing, eating, cleaning and so forth. Nurses become stricter with the written schedules and lay particular emphasis on the feelings of the patients.

Finally, Edwards et al (2006) indicates that the resolution phase constitutes termination of the nurse-client relationship. Nurses at this stage help make the vital decision of either discharging the patient or transferring them to another facility or department within the same facility. Clients in some instances become anxious and may be hostile or aggressive. In particular, they may not wish to leave the institution and can refuse to speak to anybody. They experience anorexia and sleeplessness as a result of being separated from their nurse (Edwards et al., 2006). Nurses usually intervene by providing patients with their contacts and addresses. In addition, they assure the client that the relationship has not actually ended and that they are welcome at any given time. Encouraging words such as ‘congratulations on recovering’ can also go a long way in helping the client to accept the conditions.

During my initial meeting with the client, I introduced myself and told her that I would like to talk with her. I also assured her that our conversation would be kept confidential. The client refused to speak with me and made no eye contact. I continued to sit with my client but didn’t insist that she talk to me. After 10 minutes she just stood up and walked away. I accepted her behavior and didn’t take anything personal. In our next meeting, I re-introduced myself and continued to approach her with a gentle voice and asked a couple of brief open-ended questions. The client responded positively to me. She answered a few of my questions and began to express her paranoia. I used active listening to encourage her to trust me and open up more emotionally. I continued this method every week. Eventually she started to make eye contact and sat facing towards me. At one meeting I accompanied her to court where she refused treatment. After the hearing was over I sat down and talked to her about her further treatment. As a student nurse I told her that, “I know that you are anxious and frightened.” I am here to help you. Please tell me why you do not want to accept the treatment; they are trying to help you out in getting better. She didn’t respond verbally but nodded her head and left. After that, I didn’t talk about the court meeting again because I did not want to lose her trust. The non-therapeutic technique which I used was providing her pamphlets from the facility; I reviewed them with her and encouraged her to read them again by herself. During the termination phase she expressed her feelings of gratitude and acknowledged my help. This final meeting made me feels like all my patience had paid off and that I was able to assist her with her treatment.

The client belongs to Hispanic culture, in which the father is the head of the family. Everyone should follow his rules and regulation. As she doesn’t have a good relationship with her father, I feel that her father may be major source for the client’s depression. He doesn’t allow the client to be independent in making decision for her own life. Because of mental abuse she got depressed and this led to dependency on others for her ADL’s. In an AA meeting she expressed her feelings of hopelessness and powerlessness and expressed she wanted help from a higher power. She looks up on the ceiling and said may be god will help me. She also said that she prayed to god every morning. According to Erikson’s developmental stage, she belongs to Trust Vs Mistrust. For example, I worked with her for four weeks; she sometimes talked with me and sometimes chose not to. Even after all the time I had spent building a trustworthy relationship with her. When I started to talk about her suicide attempt, she remained silent for a while. Her defense mechanism was to avoid my question and close up emotionally. After that I used a directive statement like “Look at me and listen; whatever you say to me, it will remain with me.” The client suddenly walked away from the activity room. Moreover, it was very hard to develop trust between the nurse-client relationships. For positive coping skills, I taught her that support groups help her to share feelings, prevent isolation, and to learn from others how to cope with difficult situations. Also, expressing her feelings can help her relax. This can be done by writing her thoughts down by keeping a journal. I also encourage her to use different distraction methods such as: talking with friends and/or family, yoga/exercise, arts and crafts, making collages, listening to music, reading, taking a walk, talking to therapist/doctor, breathing exercises, watching TV, and playing a game. As I observed she started to take part in activities. She began talking and playing games with her colleague. She started to make her daily goals and worked toward fulfilling them.

As a provider of care, I established a trusting relationship with my client. The building trust relationship allows my client to be more open. I assessed her feelings and anxiety level. I tried my best to talk with her. I listened to her carefully. I encouraged her to take part in each and every activity and also to seek help from her support group, spiritual direction, and journaling. The patient will strive to enhance coping skills using opportunities to which she feels best suited. I also encouraged taking an active part in setting goals for herself to facilitate independence and self esteem. For competence, I began my communication at my client’s level of comfort. I met my client regularly every week to assist in helping focus on her goals and evaluating her progress. I tried my best to recognize my client’s small attempts at successful coping which encourages patient to increase her efforts. I encouraged her to attend her therapy sessions, and allow my client to demonstrate new skills and abilities. I encouraged client independence helping her reach her maximum functional level. I encouraged the client to be as independent as possible in self care activities to enhance self-esteem and promote optimal functioning. I provided her emotional support by being available to answer questions and listened attentively. I referred her to available support groups to manage her depression by providing emotional support. I assured her that I was there for her treatment. For physical comforting, I monitored my client closely for signs of physical abuse to ensure safety and wellbeing. I helped my client recognize and feel good about her positive personal qualities and accomplishments. As self-esteem increases the patient will feel less need to manipulate others. I never forced her to sit with me but I sat with her for long periods when she allowed it. I felt positive about caring for my client by including all resources that could contribute to her comfort and well-being. I also feel happy by working with client to enhance her decision making capabilities which promote personal actions competence. By doing all this for my client I became more confident and also had a positive attitude towards my career.

As a manager of care, I conveyed a caring, nonjudgmental attitude when talking with my client about her suicide attempt. I asked her directly about any specific plan for suicide. I supervised my client when I was in my clinical rotation according to the protocol of the hospital. I also talked with her about the importance of continuing life. I also made sure she did not have any sharp material like a razor, belts, any glass objects, or unnecessary pills, to ensure her safety. I also encouraged her to take the advantage of the available support group. I also taught her how to follow the daily schedule of the facility and to try to attend each and every appropriate activity group. I also recommend that she read the material provided in the activity session. As an advocate I listened to my client carefully without challenging her statements. These communication techniques provide qualities like caring, support and understanding without reinforcing denial. Moreover, attentive listening also conveys empathy, recognition, and respect for a person.

As a member within my profession, I worked within my scope of practice. I maintained a therapeutic and professional client-nurse relationship. I protected my client’s dignity, autonomy, and rights by following HIPAA laws. I behaved professionally with my client, colleagues and staff members.

In conclusion, I enhanced my knowledge of this disease. I am confident I provided adequate care to my client when needed. People with this disease are often misunderstood in society and at times it is difficult to deal with a schizophrenic person without having enough education about the disease process. Hopefully, through more research and community mental health programs, healthcare providers and society together can improve the quality of life for people suffering with this disease.


Related content

Evidenced-based Practice Proposal Using the Research Process

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Evidenced-based Practice Proposal Using the Research Process

Research is a systematic review of an issue using different approaches. It collects and evaluates data to support problem solving. It provides new data and information in solving problems. Evidenced-based practice combines clinical expertise with research. In this paper, we will discuss an overview of my selected EBP project which provides foundation to the MSN EBP project, identify nursing concern to be improved, the purpose statement for the EBP proposal, PICOT question and literature search process, the theoretical framework to be used in this EBP proposal, and conclusion.


Overview of Selected Evidenced-based Practice Project

Research is the process to gather new data and discover new knowledge. According to the U.S. Department of health and Human Services (n.d.), “research is a systemic investigation designed to develop knowledge”.  Research is a systematic process, not just about discovering knowledge. Research is considered valid and reliable when a scientific method is used in consecutive steps by the researcher. Research assists in applying new treatments, methods, and practices to patient care, which results in increased effectiveness.

Evidence-based practice is a moderately new concept. EBP is a problem-solving approach to clinical decision-making to make patient outcomes better. EBP incorporates knowledge of the research process, and clinical judgement and decision-making. EBP is to improve safety and quality, and enhance optimal care of patient (CCN, 2017). According to Melnyk et al. (2010), there are seven steps of the evidence-based practice process starting with inquiry, come up with clinical questions, Search for the best literature, review the evidence, combine literature review with one’s clinical expertise to make changes, assess the outcomes of changes, and disperse the results. EBP reflects high-quality evidence from research, clinician expertise, patient preferences, available resources, and the context in which care is delivered (Dadich & Hosseinzadeh, 2016). EBP doesn’t always utilize research. It also relies on best evidence by leaders and experts.

Evidence-based practice can’t be implemented without research. Research is conducted to generate new knowledge or to validate existing knowledge based on theories. Evidence-based practice doesn’t validate existing knowledge or develop new knowledge. According to Conner (2014), research is about developing new knowledge, whereas EBP is finding and translating the best evidence into clinical practice. Research uses quantitative or qualitative methodology to develop new knowledge, while EBP uses first-rate clinical evidence from research to make safe decisions for patients (Conner, 2014). EBP is combination of best research evidence, clinical expertise, and patient values in making decisions about the care of individual patients”(Straus and Sackett, 1998).

My MSN program specialty track is Family Nurse Practitioner. My practice focus is primary care setting. Advance practice and master prepared nurses have a better understanding of evidence-based research and implement. As the nursing profession continues to evolve, expectation is that the nurse follows scientific foundation to support the care. As a master’s-prepared advanced practice nurse, we combine past and current evidence-based knowledge and skills, and apply them to current practice to improve patient outcome (CCN, 2017). Masters prepared nurses are responsible for implementing EBP into current practice. The Master’s-prepared advanced practice nurse is expected to improve practice in selected specialty track by examining knowledge gaps, come up with research, and find solutions to improve practice (National League for Nursing [NLN], 2010). Research has proven that when nurses practice using EBP, patient outcomes improve (Black et al., 2014).


Identification of the Nursing Concern to be Improved

I currently work in emergency room, and have seen increased number of patients admitted due to congestive heart failure. Heart failure is also known as Congestive Heart Failure because of fluid buildup in different body organs and extremities (CDC, 2015). In patients with CHF, the heart muscle is too weak to pump enough blood to meet the body’s requirements. Majority of the heart failure cases are chronic or long-term. It affects about 5.7 million adults in the United States (CDC, 2016). According to CDC, approximately 50% of the people who are diagnosed with heart failure die within 5 years of diagnosis. The selected nursing concern is CHF patients fail to manage their care at home, and increased hospital readmissions. More than 20% of the heart failure patients are readmitted within 30 days and up to 50% by 6 months (O’Connor, 2017). Patients with CHF do not weigh themselves at home on regular basis or stop taking their Lasix. By the time they become symptomatic, it is a little late to treat at home. Those patients get admitted to the hospital. It affects their quality of life and affects them financially. Heart failure costs the nation an estimated $30.7 billion each year including the cost of health medical services, pharmacy expenses, and disability. Proposed solution to the selected concern is for CHF patients to use smart phone app where they can record their weight daily, which will be sent to the provider directly and have it recorded in patient’s chart automatically. If patient has gained significant amount of weight, the provider can then call the patient with adjusted Lasix dose or with other medical advice depending on the case. How can the care of CHF patients be improved in order to decrease hospital readmissions and improve quality of life?


Evidenced-based Proposal

PICO also known as PICOT is a mnemonic to describe the four elements of a good clinical question. It stands for P: Patient/Problem, I: Intervention, C: Comparison, O: Outcome and T: Time. PICO helps clarify the research question which makes it easier to find answers. PICO terms can be used to re-write your research question or vice versa. My PICOT question for quantitative research approach is: Is there decrease in number of hospital readmissions among CHF patients above the age of 65 who utilize smart phone app or telehealth to manage their care, compared to the patients who do not, over the course of 6 months? The expected outcome is decreased hospital readmissions and improved quality of life. If CHF patients can be monitored routinely by their primary care providers, CHF exacerbation can be caught early and hospital admission can be avoided. With the use of telehealth, patients can be managed more closely. As a future NP, I will be taking care of patients with CHF, and improved care and quality of life of those patients is my responsibility.

Literature review is not a criticism or a compilation of everything written on a particular topic. Literature review is an analysis of scholarly papers that are related to your topic of interest, research question or proposal. It provides background information on your topic. It could be a work of one person or an introduction to a larger research paper. Reviewing literature leads to more research question. Literature review might make you think there is a need to   rewrite or rethink your research question, and you need to find more literature related to a specific aspect of research question (UWF, 2018). It helps you find what studies are already done, and what were the outcomes. Steps of conducting a literature review are as follow: First you need to choose a topic and define your research question, decide on possibility of review, choose the database, find the literature, and review the literature (UWF, 2018). The specific library databases used for this EBP proposal are Chamberlain University online library and American Academy of Family Physicians. The key search terms used were Congestive Heart Failure and Telehealth, CHF and smart phone app, and CHF and readmission rate. Specialty organizations that are relevant to this EBP proposal are American Heart Association and CHF International.


Theoretical Framework

Theoretical framework requires literature review, and defines concepts that are important to your research. Before you define the key concepts of your research, it is important to do a literature review of theories and models that are relevant. It provides scientific justification for your investigation. For my EBP proposal, I have chosen the Patient Centered Nursing and Nola Pender’s Health Promotion model. PCN framework was originally developed in 2006 by McCormack and McCance with intention to evaluate the use of patient-centered nursing. This model addresses all four concepts within the metaparadigm: Person, health, nursing, environment. The PCN framework is developed with the patient at the center of nursing care (McCormack & McCance, 2017). The goal of the patient-centered care is to make patient health and outcomes better. Outcomes are the results of an effective patient-centered care. The expected outcomes with PCN framework include patient experience and satisfaction, engaging patients in their care, feeling of wellbeing, and incorporate mind, body, and soul (McCormack & McCance, 2017). Another theoretical framework which will be used in this EBP proposal is Nola Pender’s Health Promotion model. It was developed after she realized the professional only intervened after patients developed acute or chronic problems. She believed those problems could be prevented before they occurred. It would improve patients’ quality of life and save health care money. The PCN framework is applied to this EBP proposal by involving patients and family in the care planning, which in turn, helps achieve the patient-centered outcomes. In order to prevent CHF exacerbation and avoid hospitalization, it has to be maintained at home, and it cannot be done without patient or family involvement. Pender’s theoretical framework will be applied to this EBP by preventing problems before they occur. It will require the patients to follow their medical regimen such as weigh themselves as per provider’s instructions or take lasix as prescribed so CHF can be maintained and prevent exacerbation.


Conclusion

As we already know research is the process to gather new data and discover new knowledge. It uses systematic process called scientific method. Evidence-based practice is a problem-solving approach to clinical decision-making. EBP is built upon research. However, it doesn’t always use research. EBP uses evidence with clinical expertise. Masters prepared nurses are responsible for implementing EBP into current practice to improve patient outcomes. PICOT question for quantitative research approach was presented along with theoretical framework to be used in this proposal. The PCN and Pender’s theoretical framework will be applied to this EBP proposal.

References

  • Black, A., Balneaves, L., Garossino, C., Puyat, J., & Qian, H. (2014). Promoting Evidence-Based Practice Through a Research Training Program for Point-of-Care Clinicians. JONA

    : The Journal of Nursing Administration

    , 45(1), 14-20. Doi:1097/NNA.0000000000000151
  • Center for Disease control (2015). Other Conditions Related to Heart Disease. Retrieved from

    https://www.cdc.gov/heartdisease/other_conditions.htm

         Chamberlain College of Nursing. Scholarship and Evidence-Based Practice: A Process for Change. Retrieved from

https://chamberlain.instructure.com/courses/24563/pages/week-5-lesson?module_item_id=2691110

  • Connor, B, T. (2014). Differentiating Research, Evidence-based Practice, and Quality Improvement.

    American Nurse Today,

    9(6). Retrieved from

    https://www.americannursetoday.com/differentiating-research-evidence-based-practice-and-quality-improvement/
  • Dadich, A., & Hosseinzadeh, H. (2016). Communication channels to promote evidence-based practice: A survey of primary care clinicians to determine perceived effects.

    Health Research Policy and Systems

    , 14(1). Doi:10.1186/s12961-016-0134-z
  • McCormack, B., & McCance, T. (2017).

    Person-centered practice in nursing and healthcare: Theory and practice.

    (2nd ed.). Chichester, West Sussex; Ames, Iowa: John Wiley & Son LTD.
  • Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: The seven steps of evidence-based practice: Following this progressive, sequential approach will lead to improved healthcare and patient outcomes.

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    of Nursing, 110

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  • National League for Nursing. (2010).

    Outcomes and competencies for graduates of practical/vocational, diploma, associate degree, baccalaureate, master’s, practice doctorate, and research doctorate programs in nursing

    . New York, NY: National League for Nursing.
  • O’Connor, C. M. (2017). High Heart Failure Readmission Rates.

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    5

    (5), 393. doi:10.1016/j.jchf.2017.03.011
  • McCance, T. McCormack, B., & Dewing, J. (2011). An exploration of person-centeredness in practice.

    Online Journal of Issues in Nursing, 16

    (2). doi:10.3912/OJIN.Vol16No02Man01
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    Nola Pender

  • Straus, S.E. & D.L. Sackett. (1998). Using research findings in clinical practice. British Medical Journal 317 (7154):339-42
  • U.S. Department of Health and Human Services. (n.d.). Module 1: Introduction: What is Research? Retrieved from

    https://ori.hhs.gov/module-1-introduction-what-research
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    https://libguides.uwf.edu/litreview

Administrator in a community health center

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Administrator in a community health center

You are an administrator in a community health center. A screening program is necessary for a deadly disease, which is curable only if detected early. The tests available are one with a high sensitivity and low specificity and one with high specificity and low sensitivity. You must make a decision as to which would be more appropriate.

What are your concerns with the test with high specificity and low sensitivity?
What are the considerations in the selection of the test with high sensitivity and low specificity?
Florence Nightingale recognized the connection of environmental conditions to human health. Based on what you have learned from the readings, what are the major environmental conditions affecting the health of people in your community?

How might a community health nurse respond to questions posed regarding the safety of well water versus public water versus bottled water?

Activity 1: Implementation and evaluation of Teaching Session ? Produce evidence of your teaching session in action in a video clip. Clip should not exceed 20 minutes, you only need to upload approximately 10 minutes of the section that you choose to provide. So choose the best section of your teaching session that demonstrates your implementation of specific teaching and learning strategies.

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Activity 1: Implementation and evaluation of Teaching Session
? Produce evidence of your teaching session in action in a video clip. Clip should not exceed 20 minutes, you only need to upload approximately 10 minutes of the section that you choose to provide. So choose the best section of your teaching session that demonstrates your implementation of specific teaching and learning strategies.

Further down on this page you will see a link and instructions on how to upload your videos.( I will do it this part )
Activity 2: Reflection on Teaching (2,500 words)
(this part you will do it)
Reflect on your learning. Your written reflection should demonstrate the following:
? Examination of own values and ideas about teaching and learning in the light of recent learning and literature provide rationale and support with literature).
? Critical reflection on the how the insights you have gained from this activity have impacted on your capacity to develop teaching plans that will promote positive learning environments and learning experiences for future teaching sessions (provide rationale and support with literature)
? Appropriate reference to your piece of evidence to illustrate points made in your critique

1. Using 5 Rs of Critical Reflection

2. Will you read my teaching plan template to understand what is my topic.
3. I give you an example to see how should be look like and use the same headings ( do not copy from the example).

TEMPLATE FOR TEACHING PLAN

Type of Learning Environment: The Classroom as a Teaching Platform

Title of teaching program: Diabetic Foot Wound Care

Purpose of the Teaching Session
1. To enable the student nurses to outline and provide the relevant explanations for the various concepts involved in diabetic foot wound care as a nursing activity.
2. To give the learner the necessary skills in handling patients with diabetes suffering from the health condition so that they engage in evidence-based practices.
3. To help the learners understand the various dynamics of diabetic foot wound care in relation to nursing practice from the social context.
4. To give the students an opportunity to develop professionalism in practice to improve the health outcomes of the diabetic foot wound patients.
Benchmark Information
Learners entry level
Undergraduate Nursing Students
Learners? special needs

Communication Reflection using the Atkins and Murphy Model

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INTRODUCTION

I will outline a personal experience, which identifies aspects of effective communication. I was a student nurse of about ten weeks on my first placement fourteen years ago. I was working on an acute medical ward when a patient I was looking after became unwell and clammy. I aim to explore my feelings about the events that transpired, and describe what I would do differently if anything similar happens in the future using

Atkins and Murphy’s (1994) framework

for reflection.

DESCRIPTION

A patient I will call Mrs Costa, to maintain confidentiality (UKCC 1998), had been on the medical ward for a week. I was allocated to care for her. I reported to the nurse in charge of the ward that day that Mrs Costa was clammy and looking unwell. I was sent to fetch another nurse. I did not know what was going on and there was lots of shouting and staff running about, then the curtains were closed around Mrs Costa’s bed. The other patients were asking what was happening, so I attempted to reassure them that everything was fine and then I just kept out of the way lacking confidence to do or say anything else.

When the phone started to ring I went to answer it. As I was going a patient with immobility problems decided to walk unaided. She managed about four paces before collapsing in the middle of the ward. Two or three doctors came running into the ward and seeing the collapsed patient thought it was for her, they were called. The staff nurse shouted at me in front of the patients and staff for not letting the doctors know which patient they had been called for. I was very embarrassed and felt really stupid.

The staff nurse told me the patient had died and because she had important things to do I had to phone Mrs Costa’s husband and ask him to come to the ward. I said I didn’t think I should be doing it and she told me it was good experience, but not tell her relatives that Mrs Costa had died on the phone. I had no idea what to say at first. The family were Greek and understood very little English. I just remember Mr Costa asking if his wife was all right. I said she was unwell and could he come in as soon as he was able. As Mr Costa arrived on the ward, the shift ended and nobody really discussed the day’s events. I went home and burst into tears.

ANALYSIS

Having been on placement for only two weeks, I did not have enough knowledge or experience to deal with these events. I remember feeling that I was in too deep I did not know how to help Mrs Costa. I recall how I felt left out and useless in dealing with a cardiac arrest. I am now aware that nurse training in the 1980s was of a low standard and unprofessional (Redfern 1999). I recognise that with experience I would be able to deal with emergency situations and that I did the right thing by reporting Mrs Costa’s condition to the charge nurse. Since the introduction of Project 2000 I am aware that students are not expected to care for patients without the support of qualified staff. I am also aware that a student would not be left alone to tend to the other patients while all the qualified staff assisted the cardiac arrest team.

When I was getting into trouble I felt embarrassed and stupid. Looking back I understand that the staff nurse was probably under a lot of pressure due to the circumstances surrounding the cardiac arrest, but I felt like a naughty schoolgirl. I am also aware of the need for constructive criticism in order to improve my standards of practice (Betts 2002). I do however think that this should be given behind closed doors and in discussion form rather than a row, which appears unprofessional. I felt guilty when the other patient fell. Since reflecting I would make my priority the care of the other patients on the ward and realise that answering a phone would have been less important (Potter and Perry 2001). Mentors are now allocated to students to provide support and guidance including identifying priorities. Spending time with other patients, reassuring them and allaying their fears would be more useful. Again this is something that would come with experience

I also felt very guilty lying to Mr Costa saying his wife was sick when I knew that she had died. I remember the phone call so clearly. I now realise that I should have firmly refused, as I did not have adequate training (UKCC 1992), to make the phone call but listened to a qualified staff member making the call so that I could still gain experience.

I realise that nowadays mentors and charge nurses would help students and other members of staff discuss situations like this to let them reflect on the events. I think that reflective practice would have been useful at the time (Heath and Taylor 2002), as I was unprepared for the events and felt emotionally drained afterwards.

EVALUATION

Although this situation is mainly negative it has provided me with some useful experiences for the future. I know that new student nurses require the knowledge and backup of a qualified member of staff or team. Charge nurses should not vent stress on other staff especially in public, but should take them aside and point out what they could do to improve. I now realise how important it is to have a member of staff tending to the patients and reassuring them when an emergency situation takes place (Heath and Taylor 2002). Although I did not like lying to a relative I also understand the importance of not divulging information (UKCC 1996) over the phone and that news of a sudden death could be very traumatic if the relatives were on their own with no support.

CONCLUSION OF LEARNING

In future I would make sure I knew the ward protocol for emergencies. In any new situation I would try to learn as much as I could about that particular speciality to gain confidence. I would use questioning to improve my knowledge in the area thereby improve my understanding. I would take into account other peoples weaknesses. I would reassure the other patients if I were not directly involved in the emergency. In accordance with UKCC guidelines (1998) I would only take part in practices for which I had relevant training.

Future Impact of Nanotechnology in Dentistry

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Abstract

Dentistry is one of the most important clinical practices provided to the public community in order to maintain good oral health. There are many challenges faced in dentistry especially involving the material used to treat different types of diseases. There are many limitations with the materials currently used in dentistry which has led to the introduction of nanoparticles. Nanoparticles play a major role in dentistry in order to improve the properties of materials. Silver nanoparticles are the most frequently used due to their antimicrobial properties which provide extensive suitability. However there are disadvantages to the use of nanoparticles which will be discussed including toxicity and hazards. Furthermore, the future implications of nanotechnology will be included.


Introduction

The biggest challenge that is faced every day in dentistry is maintaining good oral health. Distinct materials in previous years were used to treat different types of diseases even though treatment success has its own limits due to the biomaterials used and its features. These limitations can be avoided with the incorporations of nanoparticles (NPs) in dental applications such as endodontics, periodontics, tissue engineering, oral surgery, and imaging (Ranjeet A. Bapat 2018).

Nanoparticles have very eccentric properties and this includes their surface:volume ratio, antibacterial exploit, physical, mechanical, and biological characteristics, and distinctive particle size. The dream of nanotechnology was principally presented in 1959 by the famous physicist Richard Feynman in his presentation “There’s Plenty of Room at the Bottom (Patil 2008). This marked out that synthesis was possible with direct manipulation of atoms. This review provides the insights of several applications relating to nanoparticles in dentistry, together with the benefits, limits, properties, actions and future potential.


History of Nanotechnology in Dentistry

Nanoparticles for dental composites are continuously evolving, given this, a sharper focus has been taken into account with reformulations. There are a number of compounds that have been used in the field of dentistry for teeth to be protected by. The main conventional materials that have been used are amalgam, nickel/cobalt chrome alloys, glass ionomer, gold alloy, ceramics and composite resins. These materials have advantages and disadvantages with their own use. An example being Amalgam is used for fillings in teeth because it contains good mechanical properties. A polymerization lamp is used to seal crown and bridges permanently through insertion of the oral cavity. The advantages of using this material is that it is durable and can provide great resistance for corrosion on the surface, as well as it is easy to manipulate. Another benefit it takes less time to get placed compared to other materials and it prevents from bacteria leaking, as well as it lasts long and is cheap. The disadvantages to the use of this material is tooth tissue may be disrupted, qualities of aesthetic are reduced, allergic responses may occur and mercury is a component which has toxic effects.

Glass Ionomer provide visual beauty where it prevents decay by releasing fluoride and allows the tooth to be less sensitive. The disadvantages is the limitations, the material becomes rough overtime and can result in plaque buildup causing periodontal disease (Priyadarsini S 2018). Most of the conventional materials used in dentistry have limited usage and it can become very expensive too. Due to these disadvantages nanoparticles have been introduced in dentistry. The nanoparticles have qualities in which they can improve the properties of products. Nanoparticles are small in size which allows for greater surface area and this leads to improved antibacterial effect. Silver nanoparticles tend to be the main focus in dentistry especially due to their antimicrobial properties.


Silver nanoparticles

The most commonly used nanoparticles in dentistry are silver nanoparticles due to their antimicrobial properties providing extensive suitability in dentistry.  Silver nanoparticles are spherical with a mediocre size of 30 +/- 10 nm and demonstrate to be effective in prosthetic materials, adhesives, implants as well as prevent biofilm forming on the teeth and osteogenic induction (Elkassas D 2017). It has been recently accomplished to form AgNPs by controlling their size and morphology, along with high homogeneity and specific target functions.


Mechanism of silver acting on bacteria

There have been various recognition within the aspects of the antimicrobial action that nanoparticles provide, however the mechanism has not yet been fully clarified. Silver ions have the ability to act on different structures held within the bacterial cell. These ions mainly seem to adhere to the cell wall and cytoplasmic membrane by electrostatic attraction and affinity to sulfur proteins. Given this, the permeability of the membrane is enhanced and led to disrupting these structures. In Gram-negative bacteria, porins in the outer membrane are also involved in the uptake of AgNPs. Bacterial molecules that are capable of being damaged by AgNPs include DNA, proteins and lipids. AgNPs furthermore motivate oxidative stress response that triggers bacterial cell damage and increases dephosphorylation of tyrosine residues on bacterial peptide substrates, preventing bacterial growth and viability.

Bacteria in oral cavity truly prefer being systematized in biofilms and this convenes better conditions for growth, immunological evasion and resistance to antibiotics. Especially with dentistry, preparing nanoparticles must include the biofilm architecture and mechanistic aspects of AgNPs. The properties within the nanoparticle might affect its efficiency and restrict its mechanism of exploit. The vital aspects that should be considered in this construction: (i) the diffusion of nanoparticles in biofilm show inverse relationship between efficiency and size; nanoparticles in excess of 50nm are not capable of penetrating the biofilm due to the virtual self-diffusion coefficients in the biofilm, and this decreases exponentially with the square of the nanoparticle diameter. Another important aspect, (ii) charged nanoparticles are not able to diffuse as easily compared to neutral particles and this is mainly from the presence of phosphoryl and carboxyl groups on the surface of the bacteria giving the cell surface an electronegative character (Noronha V.T 2017). The concentration in formulations is mainly prearranged by the overall quantity of Ag (metallic Ag and Ag+), and the value is provided in g/mL. The universal procedure undertaken to determine the total amount of Ag (per mL) is ICP (inductively coupled plasma spectrometry)


Application of Silver nanoparticles in nanocomposites

AgNPs have been integrated into tissue conditioner, denture resins, and other biomaterials. Antifungal effect in contradiction of Candida albicans with the aid of AgNPs have proven to be effective when added to poly(methyl methacrylate) (PMMA) resins for dentures and silicone-based soft liners. This type of bacteria is able cause denture stomatitis and mucosal infections. Acrylic resin nanocomposites and AgNP (∼38nm) have similarly shown resilient antimicrobial effect against E.coli along with improved flexural strength and modulus. It should be considered in methods to introduce AgNPs into innovative experimental PMMA formulations to reduce microbial adherence and establishment in prosthetic devices in general. An example that relates to this is when AgNPs were incorporated in PMMA denture resins to conjugate antimicrobial properties for comprehensive denture wearers to control infections in oral mucosal tissues. It showed that AgNPs were firmly amalgamated in the acrylic resin in the area of where the denture was composed, and no release of nanoparticle was detected while the denture storage was in deionized water within the 120 days. Another practical method contained AgNPs in acrylic resin denture base material which led to enhancement of storing modulus E’ and loss tangent Tan δ values in concentrations equal to or higher than 2 wt%. This alteration led to resins gaining improvement in the material strength.


Implants modified with Silver nanoparticles

Implant coatingsare a way to obstruct bacterial adhesion to their surfaces and it also allows for stimulation of osseointegration and fibroblast increase. AgNPs have been tested in various ways as well as other antibiotics in coating formulations to show favourable results relating to antimicrobial activity. AgNPs have been used in combination with tantalum nitride for coating of titanium substrates. The composites with a silver concentration of 21.4 wt% displayed substantial antibacterial effect against Staphylococcus aureus.

During biocompatibility tests that were used to evaluate growth of human gingival fibroblasts, the samples that were coated showed greater cell viability and proliferation when they were exposed to AgNPs than uncoated samples (Bapat R.A 2018). Overall, AgNPs were able to demonstrate that it contained properties which prevented contamination of the interior surface of the implantation by C. albicans, produced by the implant/abutment microgap permeation.


Toxicity of Silver nanoparticles

Silver nanoparticles have contributed widely within dentistry, enhancing antimicrobial properties due to increase in surface area in nanoparticle formulation. It has been evident that these properties are also against antibiotic resistance microbe proving synergistic effect with conventional antimicrobials. Even with all these undeniable contribution towards oral health of silver nanoparticles, there are serious opposing actions that must be considered in order to fulfill its safety requirements.

Adverse effects of free Ag

+

in industrial wastes remain noticeable in line for the occurrence of argyria (skin discoloration) and argyosis (discoloration of eyes) as well as other related side effects on renal, hepatic, intestinal, respiratory systems (Bapat R.A 2018). In addition, it has been reported several times that there is evidence of toxicity in AgNPs which can be due to co-exposure with fluorides, or in arrears to cytotoxicity.Preclinical studies on rats demonstrate a rise of toxin buildup in females particularly in the liver, kidney, colon, and jejunum when associated with males. Additional studies have deep-rooted buildup of silver in the glomerulus of the female rat kidneys, as reinforced by the colourations throughout histopathological studies. Also the affinity of silver to sulphur, selenium and chlorine inhibit in signal transduction. Many in vivo studies indicate that silver nanocarriers deposit in parts of the liver to create its hepatic harmfulness. Histopathological analysis can reveal the complex rate of hyperplasia of bile duct when including or excluding necrosis, coloring and fibrosis.


Hazards of Nanotechnology

Nanotechnology is emerging everywhere in science and it does provide many solutions to the problems that we face. Nonetheless, nanotechnology is not always perfect (Schmalz G 2017). Smaller particles tend to become more toxic than larger particles and this has been evident in certain experiments. They have shown that nanotechnology is able to function as venom to the populations that we habitat and nanoparticles are recognized to biomagnify in animal organs. Researchers are correspondingly troubled about soil and plant life. Nanoparticles may lead to lung injuries (Sasalawad S.S 2014). With balancing the risks and benefits, it is possible to maximize applications in medicine deprived of harming the public health as well as the environment.


Future perspectives

As mentioned previously dental materials containing silver nanoparticles present effective antimicrobial properties. However, there is a lot more research that needs to be undertaken in order to discover new information that could be of important use. The experiments that are the most significant used in studies involve the application of bench results on in vivo studies due to laboratory conditions not reproducing oral conditions. Other aspects that need to be investigated include long term effectiveness of AgNPs applied on dental materials, where an enduring antimicrobial potential is required of them (Correa J.M 2014).


Conclusion

Nanotechnology has achieved to produce a strong impact in the field of dentistry. A diverse number of nanostructures have been combined into dental materials with innovative applications. With the promising advantages observed in nanoparticles in dental therapeutics, it is possible to conclude that there is a domination of prolonged endorsement especially in the field of caries prevention, biomimetic repair and dental adhesion of composite medicine. Conversely, further investigations are important to be undertaken so that a better understanding is provided with the possible risks for any human health and environment.


References

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· Late submission will result in ZERO marks being awarded.Q2. The following are account balances (in thousands) for ALLAYAKA Health Plan. Prepare a balance sheet and statement of operations for the year ended December 31, 2012. (4 Marks)

/in /by

· Late submission will result in ZERO marks being awarded.Q2. The following are account balances (in thousands) for ALLAYAKA Health Plan. Prepare a balance sheet and statement of operations for the year ended December 31, 2012. (4 Marks)

· This Assignment must be submitted on Blackboard (WORD format only) via the allocated folder.

· Email submission will not be accepted.

· The work should be your own, copying from students or other resources will result in ZERO marks.

Last Date for Submission 28/02/2018

Q1.What do you mean by financial management of health care organizations? Identify key elements that are driving changes in health care delivery. (2 Marks)

Q2. The following are account balances (in thousands) for ALLAYAKA Health Plan. Prepare a balance sheet and statement of operations for the year ended December 31, 2012. (4 Marks)

Net property and equipment $ 2,000
Accounts receivable $3,000
Medical claims payable $37,000
Patient service revenue (net of contractuals) $ 950,000
Supply expense $ 255,000
Net assets released from restriction for operations $ 45, 000
Depreciation expense $ 35,000
Labor expense $300,000
Provision for bad debts $12,000
Net Assets $61,500
Cash & cash equivalents $97,000
Long-term debt $3,500
Q3. What are the major differences in recording transactions for a for-profit organization versus a not-for-profit one, or are there any? (2 Marks)

Q4. What is the difference between the operating margin ratio and a return on total assets ratio? What is the difference between operating revenue per adjusted discharge ratio and operating expense per adjusted discharge ratio? To what categories of ratios do these ratios belong? (2 Marks)