What do you think are the most important issues that surround end of life?

What do you think are the most important issues that surround end of life?

The question is ….The end of life and how people die has changed a great deal in the past century. Thanks in large part to advances in public health, medicine, and health care, most Americans no longer die suddenly from injury or infection. Instead, we live longer and, more often than not, die after a period of chronic illness. How can people/families prepare for the end of life? What do you think are the most important issues that surround end of life?

Respond to classmates answer……There are many important aspects to consider when it comes to preparing for and discussing end of life. Changing of living situation such as moving to a nursing home is something that needs to be discussed if and when an older adult may not be able to care for themselves anymore. It would be helpful to discuss this before the adult gets to this point so they can have a more active role in picking a placement and other services. Preparing for a funeral and the wishes of that individual are important to discuss, especially since many cultural and religious differences exist. A living will and distribution of assets can be helpful for the family after death, as many times the emotional stress of a death in a family and then dividing up possessions and assets can be a cause of significant tension among family members. Other important aspects to consider are DNR orders, organ donor wishes, etc. The primary goal for families when dealing with a family member that is dying is to make them as comfortable as possible and to simply spend time with them. Pain reduction, being in your own home, friend and family presence can make that individual feel much more at peace with the process.

A 60 year old African American woman with metastatic ovarian cancer is experiencing chronic pain.

A 60 year old African American woman with metastatic ovarian cancer is experiencing chronic pain.

A 60 year old African American woman with metastatic ovarian cancer is experiencing chronic pain. her pain ratings have been between 3 and 8 on the 0-1- verbal pain scale. Her vital signs remain within normal ranges. She is fully able to participate in her daily care. She describes herself as the matriarch of her family, and looks forward to daily visits from her family even when her pain rating is high. Her church pastor calls and visits her several times per week. She anticipates discharge in a few days. Initial Discussion post: 1. Identify and state a priority nursing diagnosis for yours assigned patient related to pain. 2. Develop and state three(3) nursing interventions for this nursing diagnosis or patient problem. When planning individualized nursing intervention consider the patient’s type of pain and cultural perspective. 3. Provide your rationale or reasoning for each intervention chosen. Please use this text book as reference: hinkle, J & Cheever, k 2014 brunner and suddarth’s textbook of medical surgical nursing 13 ed. treas, l. wilkinson 2014. Basic nursing: concepts, skills and dreasoning. plus any nursing diagnosis guidebook. plus any other textbook you see fit. thank you in advance.

Health Gaps in the Indigenous Culture



Introduction

This assignment will be focusing on indigenous culture and their health. A national strategy ‘Closing the Gap’ will be initially summarised to explore the current gaps and the plans that have been taken by the Australian state and federal governments. The health issues of indigenous Australians will be reviewed in comparison with the non-indigenous population, which will include a discussion about how the European settlers are considered to have contributed to the current health and psychosocial concerns of indigenous people. Additionally, the health of indigenous Australians will be compared with other indigenous groups in the world. Finally, health promotion strategies initiated by the governments to improve indigenous health outcomes will be identified and additional interventions will be proposed.



Closing the




G




ap




Campaign

Although Australia is considered one of the richest countries in the world, indigenous Australians continue to suffer systematic inequalities and can expect to live 10-17 years less than non-indigenous Australians (Australian Human Rights Commission, 2014). In 2008, a formal apology was made to indigenous Australians and the Government acknowledged, recognised and apologised for their past wrongdoings and committed to taking further steps for indigenous health equality (Australian Government, 2009). This is known as the Closing the Gap Campaign. The goal of the Closing the Gap Campaign is to close the health and life expectancy gap between Indigenous and non-indigenous Australians within a generation. The Australian Governments committed to working towards reaching six targets to reduce the visible gaps in life expectancy, infant and child mortality, childhood education, literacy and numeracy skills, school completion rates and employment rate (Commonwealth of Australia, 2010). The Governments have implemented strategies to the recognised areas, or the Building Blocks: early childhood, schooling, health, healthy homes, safe communities, economic participation, governance and leadership. Also, a report is being published annually on the progress that Australia has made towards this national objective.



Morbidity and Mortality

In 2006-2010, the mortality rate for indigenous Australians was 1.9 times greater than for non-indigenous people across all age groups. Approximately 50% of indigenous people reported having a disability or long-term health condition and hospitalisation rate for indigenous people were 40% higher than other Australians (Commonwealth of Australia, 2011)

Babies born to indigenous families were twice as likely to be of low birth weight compared to non-indigenous babies, in 2005-2007. The death rate of indigenous infants and children is double the rate of non-indigenous infants. Maternal mortality rates for indigenous women were 2-5 times greater than for the non-indigenous women (Australian Institute of Health and Welfare, n.d).

In 2008, 32% of young adult indigenous people (aged 16-24 years) reported having high levels of psychological distress, which was 2.5 times the rate for non-indigenous people (Commonwealth of Australia, 2011). Moreover, indigenous young adults died at a rate 2.5 times as high as that of the non-indigenous population. For adults aged 35-45, the death rate was 6-8 times higher than the national average (Australian Indigenous Health

Infornet

, 2013a). It was estimated that 12.4% of indigenous people aged over 45 years have dementia, compared to 2.6% of non-indigenous people in that age group (National Aboriginal Community Controlled Health Organisation, 2012). Around 44% of older indigenous adults reported their health as poor and the mortality rate in aged indigenous population is doubled the non-indigenous rate.



Health Issues

For many thousands of years before European settlement in1788, indigenous people enjoyed good health and harmonious existence, relying on a hunter and gatherer life. Connection to the land is fundamental to indigenous wellbeing and the core of all spirituality (Aboriginal Heritage Office, n.d.). Both men and women participated in hunting and they sourced food from the water, hinterlands of the area and the surrounding bush. Since European settlement, indigenous cultural heritage has been broken and indigenous people have experienced disadvantage in aspects of living standards, life expectancy, education, health and employment (Australian Government, 2009).

Outcomes for education, employment, income and housing are much poorer than that of non-indigenous people (Australian Indigenous HealthInfornet, 2013a). During the 2004-2005 National Aboriginal and Torres Strait Islander Health Survey (Australian Bureau of Statistics, 2006), around 12% of indigenous people reported having long term cardiovascular diseases and this rate was 1.3 times higher than non-indigenous. Many indigenous people experience significantly higher rates of cancer, diabetes, psychological distress, renal disease and respiratory disease than the national average.



Influence of Non-indigenous population

European settlement has had a devastating impact on indigenous health and psychosocial wellbeing, which can be traced back to the beginning of colonisation. In the time following settlement in 1788, 10 million people have arrived in Australia and made it their home (National Museum Australia, n.d.). In this time, many of the natural resources were affected: fish supplies were depleted, native animal population were reduced and feral animals introduced, land was cleared and waterways were polluted. It is believed that many infectious diseases, such as measles, smallpox, influenza and tuberculosis, were introduced by the new settlers (The Fred Hollows Foundation, n.d.). These diseases caused major loss of life among indigenous populations and resulted in depopulation and social disruption. Direct conflicts and occupation of indigenous homelands meant that indigenous people lost control over many aspects of their lives. This loss of autonomy affected the capability of indigenous people to adapt to changes, which would eventually have consequence in poorer health status (Australian Indigenous Health

Infornet

, 2013b).

From the time European settlers first arrived in Australia, they had attempted to ‘civilise’ the ‘black races’. The Native Institution was designed to educate indigenous children in the European way; the policy of ‘protection’ led to indigenous people being placed on government reserves or in church missions; the policy of assimilation forced indigenous people to live in the same way and hold the same belief and values as the white Australians; many children were forcefully taken away from their families and placed in institutions or white families (Australian Museum, 2009). The children were brought up in Christian way, taught in English and raised to think and act as ‘white’.

‘Civilisation’ led to a loss of identity and resulted in cultural and traditional practices being destroyed, families bonds being disconnected, and the whole communities being dispossessed.

Dispossession of traditional lands caused loss, emotional distress, trauma and separation and meant that indigenous people were not able to hunt anymore. (Rowena Ivers, 2011). Indigenous people faced discrimination in education and employment (Northern Territory Department of Health, 2007). People became more dependent on welfare and allowances and rations were paid for laboured work. This led to a change of eating habits.

Traditional food were less encouraged and rations and communal feeding were broadly available and convenient (Northern Territory Department of Health, 2007). Under the influence of rations and communal feeding, a transition of meal patterns from traditional diet to ‘westernised’ food has happened. Contemporary indigenous people may not want to resume the traditional hunter lifestyle or they may have lost the skills to hunt. The community store became their only food source. The community store usually stocked a very limited selection of food and popular foods are tinned meat and fruits, biscuits, tea, flour, sugar and tobacco. Fresh fruits and vegetables are less available in stores.

Indigenous people began smoking when they were paid in tobacco rather than cash. The use of tobacco, alcohol and illicit drugs increases the risk of chronic disease, cancer, as well as other health concerns, such as mental disorders, accidents and injury (Australian Indigenous Health

Infornet

, 2013a). Decreased levels of physical activity, less consumption of traditional diet and overeating of high energy foods are risk factors for non-communicable disorders, such as cardiovascular disease, cancer, diabetes and respiratory diseases.



Australian Indigenous vs. Worldwide Indigenous

Indigenous people are the traditional custodians of the land they have inhabited for thousands of years. There are approximately 370 million indigenous people worldwide, living in more than 70 countries (World Health Organisation, 2007). Despite the great diversity of indigenous peoples, many similarities exist between Australian indigenous and other indigenous groups.

Traditional indigenous people rely on their land for survival and traditional life is linked to the land. Common to many indigenous groups, colonisation negatively affected their physical, emotional, social and mental health wellbeing. Colonisation led to racial prejudice and dispossession of traditional lands which often cause poverty, under education, unemployment and increased dependency on social welfare. The changes of lifestyle caused severe inequalities in indigenous heath status, including emotional and social wellbeing (World Health Organisation, 2007).

Overall, they experience poorer health compared with non-indigenous groups. Their health is associated with a range of environmental and socio-economic factors: poverty, malnutrition, overcrowding, poor hygiene, environmental contamination, and infections (United Nations, 2009). Indigenous people had little natural immunity to microorganisms that were introduced to the land. The devastating infections depopulated indigenous groups.

Child health is influenced by inadequate nutrition, exposure to infectious diseases and poor living conditions. Childhood health complications are common in Australian indigenous groups as other indigenous groups elsewhere: low birth weight, skin infections, ear disease, dental caries, trachoma, parasite infection and respiratory infections. Although some diseases are prevalent in specific areas, the causes are similar: poor hygiene, malnutrition or water contamination.

Many indigenous groups both in Australia and elsewhere do not have access to their traditional food and are highly dependent on commercially prepared food. Indigenous adolescents in Australia and other countries experience similar health related problems, such as tobacco and drug use, violence, mental and emotional disorders (Northern Territory Department of Health, 2007). Urbanisation causes rapid changes to indigenous lifestyle, foods high in calories, fat and salt and low in fibre. People live in an overcrowded and unhygienic environments and having less physical activity. The worsening of lifestyles has resulted in chronic diseases, such as obesity, hypertension, cardiovascular disease, type 2 diabetes and chronic renal disease.

Australian indigenous people in 2001-2004 had the lowest life expectancy for both male and female, compared to indigenous groups from New Zealand, Canada and USA. They also had the highest infant mortality rate and lowest birth weight. When comparing the age standardised mortality rate in 2003, Australian indigenous groups have the highest mortality rate for cancer, cerebrovascular disease, intentional harm, diabetes and HIV.



Health promotion strategies

The Australian Governments have implemented a range of initiatives across the states during 2009 and up to 2014 By recognising the areas that needs to be improved that include improvements to early childhood, schooling, health, healthy homes, safe communities, economic participation, governance and leadership. Delivery of health promotion programs is guided by principles that ensure all programs meet the targets of the Closing the Gap while being appropriate to the communities’ needs. All programs have to engage the local indigenous people and should be time sufficient and accessible to all indigenous residents (Council of Australian Governments, 2009). All initiatives are related to the Building Blocks and best practice has been sought.

For example, according to the latest Closing the Gap Prime Minister’s Report 2013,

health attention has been focused on implementing health promotions in the following areas that considered could facilitate achieving the goal of closing the gap in life expectancy and child mortality between indigenous and non-indigenous Australians. Areas such as chronic disease, primary health care, health service, food security, oral health, ear and eye health, acute rheumatic fever and rheumatic heart disease, substance misuse, Foetal Alcohol Spectrum Disorders, indigenous sexual health, mental health, aged care, sport and recreation, culture, remote airstrips and road safety (Department of Families, Housing, Community Services and Indigenous Affairs, 2013). Comprehensive strategies have been undertaken to encourage people in communities undergo health checks, provide training of healthcare workers, deliver education on lifestyle change and self-management, provide affordable medicines and fund advertisements to increase awareness.

According to the Closing the Gap Clearinghouse annual report 2011-12 and 2012-13, some of the strategies work but may only have a short term effect (Closing the Gap Clearinghouse, 2013). However, some interventions trialled in indigenous community were unsuccessful because they were originally designed for non-indigenous populations and were considered culturally inappropriate. Education programs could have a limited impact on indigenous groups and may need to be employed in conjunction with other interventions. Barriers to the effective provision of program may arise due to short term and one-off funding, and the provision of the program may be discontinued due to indigenous groups’ capacity to provide the service. Often the data is incomplete and cannot be assessed for effectiveness.



Proposal of additional interventions

The traditional indigenous people conceptualise their health as holistic. It encompasses everything: land, environment, family, relationship, community, law and the physical body. Health for indigenous people is the social, emotional and cultural wellbeing of the whole community and the identity of being indigenous (Australian Indigenous Health

Infornet

, 2013b). The author’s proposal of interventions to improve indigenous health outcomes is to return to indigenous people the keys elements that have been taken from them: equality with other Australians, their identity, freedom, culture, self-determination and their traditional lands.

They had good knowledge of their land, sources of water and food, the effects of seasonal cycles on plant foods and animals. Both men and women hunted food, which kept them physically active and emotionally well. The traditional diet had variety and was rich in nutrition: vegetable food provided vitamins and minerals and essential supplements for the body needs; meats were high in quantity and quality (Northern Territory Department of Health, 2007). Health and sickness were shaped by culture beliefs and traditions. Indigenous people believe that the protection of spirituality is fundamental to their health (1). Family relationship is at the core of indigenous kinship systems which is essential to their culture. Kinship helps to define roles and responsibilities for raising and educating children and provides the structure systems of moral and financial support. In indigenous society, family ties are healer to emotional and physical wellbeing.

Indigenous people had a healthier lifestyle, had pride in their identity and their culture heritage was passed through generations. Their traditional cultures helped them to survive for thousands of years. The crisis indigenous people face today is the consequence of continuous years of inequality, disadvantage, discrimination and disenfranchisement. To close the gap between indigenous and non-Indigenous health, health providers need to consider the determinants of health, including socio-economic and political issues and their impact on indigenous people. It may remind non indigenous Australians to apply some self-criticism: to remember that they equal to us and all can enjoy the right to be free and exercise self-determination.



Conclusion:

1

Jing Ping PIN10344490

Deathography Essay Example

When I was five, my grandmother passed away in hospital just before Christmas. She had been in the hospital for some time and was very elderly. As my sisters and I were at school, we could only visit the hospital at the weekend, whereas my mother and father would visit during the week. At weekends my sisters and I would be given the choice about going to the hospital with our father to visit, or to stay at home. I often chose to stay at home. I understood that my grandmother was old, however I did not understand how ill she was.

When my grandmother passed away, I felt guilty that I had not chosen to visit her. Although I knew that my grandmother had been ill for some time, I had not understood that she was coming to the end of her life, and it had also not been explained to me by the adults. I knew that death was irreversible, however because her death did not impact on my daily routine as my parents sought to maintain normality as far as possible. I found that my life continued as usual, without any major interruptions.

In the week leading up to my grandmother’s funeral I saw my father crying and remember that seeing my father cry made me feel both frightened and upset. I felt upset because I had never seen my father cry before, and I realised that he was suffering greatly. As a result of this, I tried to behave well at all times as I was worried that my actions would cause my father to cry again. I felt frightened because although my grandmother’s death had not had a large impact on myself, I could see that it was having a profound effect on those that I cared about. As I was only a small child, this was the first time that I had seen such a depth of emotion in those close to me, and I was not sure how to react to this.

Research has demonstrated that children, even very young children, are capable of grieving (Melhern et al, 2011). It is important to note that there are differences in the way that adults and children grieve. In particular, children are likely to show their grief in less direct ways than adults, and can move in and out of grief, almost grieving in bursts (Melhern et al, 2011). It is also important to realise that the child’s age, emotional maturity, circumstances of loss, and the level of relationship between the child and the person who has died are all important factors (Dowdney, 2008).

Piaget’s research demonstrated that toddlers and infants understand events in terms of direct experience, and that the dependable presence and emotional expression of loved people are more important than the language used (Piaget, 2013). Studies which have applied Piaget’s work have demonstrated that even children who cannot yet communicate verbally are aware of the distress of adults around them and are aware of the absence of a loved person (Himebauch et al, 2008). It can therefore be thought that not telling young children about the death of a family member will not protect them from the loss as intended, and will only prevent discussion.

This fits with Piaget’s work, who found that young children (between the ages of 3 – 6) do not think in logical sequences, and therefore have illogical explanations for events (Piaget, 2013). This is reflected in the difficulty they may have grasping that death is not reversible (Brown et al, 2008). Families often find it easier to help children after the loss of a grandparent, as they are often in an age group where death is more common (Brown et al, 2008). In my case, I did not have daily interaction with my grandmother due to geographical distance, however we did have regular contact at weekends. This may have meant that there were fewer obvious changes and reminders of the absence.

This is clearly not applicable to all children and cultures, where the grandparents may play a central role in the child’s life and in the family (Salloum, 2008). In these cases, the effect of the loss may be apparent as regression or behavioural problems in the child (Salloum, 2008). Ongoing discussion of the loss can provide the opportunity for children to reinterpret the death over the years as their cognitive comprehension grows (Salloum, 2008). Research has clearly demonstrated that the lack of a well-structured support system during the mourning period can lead to severe disruption of childhood development (Bonanno, 2004).

One study conducted in the United States found that out of 270 children taken to counselling after the death of a loved one and who lacked a well-structured support system, 66% demonstrated aggressive behaviour, 44% lacked social skills, and 18% had delayed cognitive, fine and gross motor development (McClatchy et al, 2009). However, it is not possible to determine from the study whether these children had developmental difficulties before counselling. If this is true, the quoted percentages may not be a true reflection of the impact of a lack of a well-structured support system.

There is also a clear impact on the academic abilities of children who have suffered loss Shear & Shair, 2005). In addition to this, children often have higher levels of absenteeism from school when a close relative is ill, which could have an impact on their academic performance. This impact on academic performance is often seen in children who have witnessed a traumatic death and subsequently develop post-traumatic stress disorder (Shear & Shair, 2005). I believe that my parents made considerable efforts not to disrupt the daily routines of my sisters and I, particularly around school. I think that this ensured that our academic performance did not suffer as much as it may otherwise have.

It is clear that children’s understanding of death develops in parallel with cognitive maturing throughout childhood (Cohen, 2011). The concept of death may develop at different rates in different children, but the developmental sequence seems to be the same (Cohen, 2011). For example, children below the age of five do not understand that death is irreversible, and will demonstrate this by asking when the person is coming back (Salloum, 2008). As a result of this, children at this age will have difficulty understanding abstract explanations of death, and such explanations such as saying the person has gone to sleep may result in fear of sleep (Cohen, 2011). It is therefore clear that although the concept of death is not fully developed in small children, there is little doubt that they still react strongly to loss at this age (Cohen, 2011).

This does not apply to my experience of loss, as I was slightly older; however it is clear that loss at even a very young age can have a lasting impression on children. Between the ages of four and six, it is thought that children begin to develop a biological understanding of life (Crenshaw, 2005). An example of this is knowing that parts of the body work to sustain life. I feel that this is true of my experience – I knew my grandmother was in hospital because she was ill; however I did not understand the seriousness of her illness, or that she had been in hospital for a considerable length.

Children from five to ten years of age develop an understanding of death as an irreversible process (Currier et al, 2008). Concrete thinking is seen in children until the age of 10, and need concrete expressions such as pictures or visiting graves or memorials as support for their grief (Currier et al, 2008). When my grandmother died, I knew that it was an irreversible event. My parents chose not to take me to the funeral, which I feel was a wise decision. I believe that although I knew my grandmother had died and that this was not a reversible event, I would have found it distressing to see my parents and other adults so openly upset. Research has also found that if children do attend funerals, it should be with someone who can provide emotional support (Currier et al, 2008), and I feel that this would have been an unfair demand on my parents at the funeral, particularly as I was so young.

As I grew older I found that accompanying my parents to the graves of my grandparents, particularly my grandmother, helped me to express my feelings and to ask questions. This is supported by literature which states that visiting graves or memorials can offer children or young adolescents a channel for communicating about the deceased person, which can help them to understand the circumstances of the loss and can also act as an opportunity to express their feelings (Paris et al, 2009). I found that as I matured, I could talk about my grandparents away from their graves, as I came to realise that this would not upset my parents. As a result of this, we were able to talk much more freely and openly about their lives.

My grandmother was the only grandparent that I had known, as my other grandparents had died before I was born. As my grandmother had died when I was relatively young, I have no substantial memories of her. Throughout my childhood this did not have a large impact on my beliefs and attitudes, as I believe that I did not possess the emotional maturity to reflect on the changes this had made to my life, and the impact that her death may have had on those around me. As I grew older, I became aware of the effects of loss on those around me, and in turn this altered my beliefs about life. For example, as I matured I became aware that death can happen at any age and so I was more appreciative of the roles that relatives and friends played in my life, and did not take their presence for granted.

This changed when I was at secondary school and I came to appreciate the roles and relationships that grandparents had in the lives of my peers. I felt, and still feel, that I have missed out on these key relationships, particularly as my parents often comment on how similar I am in both personality and appearance to my grandmother on my mother’s side. As I grew older, particularly in adolescence, I came to value relationships with relatives and friends in a different way from childhood, and I think that experiencing loss early in life was a large part of this. I believe that it is important to work hard to overcome obstacles to maintaining relationships, such as geographical distance and cultural differences, particularly as there is now greater mobility for employment.

In conclusion, although the death of my grandmother was perhaps not a shock to the adults in my life, I had not grasped how ill she was, nor had it been explained to me by adults close to me. As a result of this, I felt guilty because I had not chosen to visit her in the hospital when offered the opportunity. However as we had always lived quite far apart, there was no real impact on my daily life, which research has shown to be particularly disruptive for children going through grief (Bonanno, 2004).

There is clear evidence that experiencing death, particularly a traumatic death, can have a profound effect on childhood, and that a well-established support system is key (Brown et al, 2008). I believe that I had a well-established support system, and this allowed me to adapt to life without my grandmother without great levels of difficulty. Whilst I wish I could have had a longer relationship with my grandmother and have known my other grandparents, I believe it is important not to dwell on things that cannot be changed. Instead I invest my energy in building and maintaining relationships with friends and family. I believe that this attitude comes with maturity and experience of loss, and that small children may not have the emotional capacity to understand this.

References

Bonanno, G. (2004). Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), pp.20-28.

Brown, E., Amaya-Jackson, L., Cohen, J., Handel, S., Zatta, E. (2008). Childhood traumatic grief: a multi-empirical examination of the construct and its correlates. Death Studies, 32(10), pp.323-326.

Cohen, J. 2011. Supporting children with traumatic grief: what educators need to know. Developmental and Educational Psychology, 32(2), pp. 117 – 131.

Crenshaw, D. 2005. Clinical tools to facilitate treatment of childhood traumatic grief. Journal of Death and Dying, 51(3), pp.239-255.

Currier, J., Neimeyer, R., Berman, J. (2008). The effectiveness of psychotherapeutic interventions for bereaved persons: A comprehensive quantitative review. Psychological Bulletin, 134(5), pp. 648-661.

Dowdney, L. (2008). Children bereaved by parent or sibling death. Psychiatry, 7(6), pp.270-275.

Himebauch, A., Arnold, R., May, C. (2008). Grief in children and developmental concepts of death. Journal of Palliative Medicine, 11(2), pp.242-244.

McClatchy, I., Vonk, E., Palardy, G. (2009). The prevalence of childhood traumatic grief – a comparison of violent/sudden and expected loss. Journal of Death and Dying, 59(4), pp.305-323.

Melhern, N., Porta, G., Shamseddeen, W., Walker, M., Brent, D. (2011). Grief in children and adolescents bereaved by sudden parental death. Archives of General Psychiatry, 68(9), pp.911-919.

Paris, M., Carter, B., Day, S., Armsworth, M. (2009). Greif and trauma in children after the death of a sibling. Journal of Child and Adolescent Trauma, 2(2), pp.71-80.

Piaget, J. (2013). The Construction of Reality in the Child. 3rd ed. London: Routledge.

Salloum, A. (2008). Evaluation of individual and group grief and trauma interventions for children post-disaster. Journal of Clinical Child and Adolescent Psychology, 37(3), pp. 495-507.

Shear, K., and Shair, H. (2005). Attachment, loss, and complicated grief. Developmental Psychobiology, 47(3), pp.253-267.

Culturally Competent Care to the LGBT Population

In this paper I will discuss the disparities that the LGBT population faces today, and what we can do to overcome the issues. Such disparities are affecting people’s overall health which is counterproductive to the main objective in healthcare. HCP’s can provide better and more beneficial patient-centered care to the LGBT population as a whole. Empathy and compassion are at the core of the nursing profession, so discrimination, refusal to treat and abuse have no place in this industry. Why is the LGBT population not getting the exact same care as all other patients? This profession was built on providing patient-centered care in a safe space without any judgement or disparities getting in the way of affecting care.


Health disparities of the LGBT population

The term disparity encompasses many different meanings, but a “health care disparity” typically refers to differences between groups in health insurance coverage, access to and use of care, and quality of care (Orgera & Artiga, 2018). All American citizens deserve access to: nutritious food, safe housing, high-quality education, health insurance and culturally sensitive health-care providers (Lesbian, Gay, Bisexual, and Transgender Health). The latter is especially important to ensure that patients are provided with the utmost quality and culturally competent care.

LGBT people are at a higher risk for facing health disparities because overall there is a lack of specific education and training of health care workers, a lack of clinical research on LGBT health-related issues and fear due to stigma, discrimination and institutional bias (LGBT health disparities, 2017). Some specific health disparities that the LGBT population face include; discrimination, refusal of treatment and different forms of abuse.

Discrimination itself or the mere fear of discrimination can deter LGBT people from seeking health care when appropriate. The fear of discrimination is toxic to proper healthcare and can prevent some individuals from seeking medical attention (Health, 2016, para. 3). This plays a key factor in the population not seeking out or receiving proper health screenings for cervical, breast and colorectal cancers, or mental health issues. LGBT people reported difficulty finding hormone replacement therapy, HIV prevention and treatment options, fertility and reproductive services and even just welcoming primary care services (US: LGBT people face healthcare barriers, 2018).

Building trust and rapport with your primary care provider and other medical personnel is essential to laying a good healthcare foundation. Many people do not disclose their sexual orientation because they do not want to subject themselves to discrimination and have their quality of care affected. According to a 2017 study, 8 percent of lesbian, gay and bisexual respondents and 29 percent of transgender respondents reported that an HCP had refused to see them because of their sexual orientation or gender identity (Mirza & Rooney, 2019). Refusal of medical treatment is the ultimate form of discrimination against the LGBT population. LGBT patients have even been victims of abuse according to another 2017 study; 30 percent said that a doctor or other health care provider used harsh or abusive language when treating them and 36 percent said that they experienced unwanted physical contact such as fondling, sexual assault or rape from a doctor or other health care provider (Mirza & Rooney, 2019).


Empathetic patient-centered care for LGBT individual’s

The most substantial way Healthcare Professionals can provide patient-centered care for LGBT individuals is to become more comfortable and confident with obtaining patient sexual histories. Many physicians and nurses are uncomfortable bringing up matters of sexuality or sexual practices and prefer to let the patient initiate the dialog. On the contrary though, and when done properly, initiating a conversation about sexuality and sexual behavior with a patient can promote trust, and provide the patient with necessary reassurance that the environment is safe and without prejudice (Health, 2016). Another way HCPs can provide better patient-centered care is to recognize whether or not they are presenting a non-judgmental attitude towards their patients. This goes for anyone working in the healthcare field. Providing quality care means being empathetic towards all patients. Medical care has nothing to do with an individual’s personal opinion about gender identity or sexual preference. That bias needs to be recognized and personally addressed in order to move forward positively. HCP’s can acquire more empathy and provide better patient care through more extensive education and specific training that pertains to the LGBT population.

Some Health Insurance companies, such as Cigna, are leading the way for LGBT individuals by providing the aforementioned specific training to over 600 of their clinicians. The company has created a National Medical Director for LGBT health and wellness and is working on expanding in-network access to transgender care (LGBT health disparities, 2017).


Conclusion

The Joint Commission recommends that health care facilities begin to transform the health care environment to be a more welcoming, safe, and inclusive environment for LGBT patients and their families (Rowe et al, 2019, para.7). But first the issue needs to be identified and understood before these changes are to be introduced and ultimately put into practice. Morals, ethics and understanding are constantly being questioned or provoked in the medical industry and before we consider anything, Healthcare professionals need to remember to first, do no harm.



References

  • Health, L. (2016, September 14). The Fear of Discrimination in LGBT Healthcare. Retrieved from https://publichealth.wustl.edu/fear-discrimination-lgbt-healthcare/
  • Lesbian, Gay, Bisexual, and Transgender Health. (n.d.). Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health
  • LGBT Health Disparities. (2017, February). Retrieved May 26, 2019, from https://www.cigna.com/individuals-families/health-wellness/lgbt-disparities
  • Mirza, S. A., & Rooney, C. (2019, May 16). Discrimination Prevents LGBTQ People from Accessing Health Care. Retrieved from https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/
  • Orgera, K., & Artiga, S. (2018, August 08). Disparities in Health and Health Care: Five Key Questions and Answers. Retrieved from https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/
  • Rowe, D., Ng, Y. C., O’Keefe, L., Crawford, D., Holliday, R., Bonds, S., . . . Msn. (2019, March 27). Providers’ Attitudes and Knowledge of Lesbian, Gay, Bisexual, and Transgender Health. Retrieved from https://www.mdedge.com/fedprac/article/150550/health-policy/providers-attitudes-and-knowledge-lesbian-gay-bisexual-and
  • US: LGBT People Face Healthcare Barriers. (2018, July 23). Retrieved May 26, 2019, from
  • https://www.hrw.org/news/2018/07/23/us-lgbt-people-face-healthcare-barriers#

Development of Person-Centred Care Plan in Residential Care

As part of the module Residential Care Practice we have been asked to complete an assignment regarding devising a person-centred plan for one of the two case studies provided with the main outcome to be aimed for in the person-centred plan is achieving living independently in the community. I have been asked to act as a keyworker to my chosen person. I must provide a fictitious background on the person based on the elements I plan on working on, the personal plans and the outcomes and how they are to be measured. Those involved in the person- centred plan are to be noted throughout. For the purposes of this assignment I will refer to myself as the keyworker and will refer to other individuals involved along the way.

A person-centred plan -more commonly referred to as a PCP- is a plan developed to support a person in care in relation to supporting them to live the lives that they wish to live and what staff can do to make these wishes a reality. Person centred planning is planning that focuses primarily on the person being supported rather than planning for the general area of the service such as disability, youth, etc (Natioanl Disability Authority, 2014). Person centred plans allow for ‘whole person’ orientated plan.

Person-centred care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs. This means putting people and their families at the centre of decisions and seeing them as experts, working alongside professionals to get the best outcome. The ever-increasing demand on healthcare often causes caregivers to lose sight of the person behind the condition they’re treating. Therefore, person-centred care is so important. It helps carers refocus on a crucial aspect of care: fulfilling a patient’s needs beyond their disability or ailment (Burton, 2018).

Person centred planning can be developed by the individual whom the plan is intended to support. Sometimes, the plan may be developed by parents, family, spouses, friends, or advocates on the persons behalf- this usually occurs where “it is not possible for a plan to be guided entirely by an individual due to extreme difficulties with insight, awareness and cognition” (Natioanl Disability Authority, 2014). Most plans are developed by one or more individuals acting independently on the behalf of an individual or with their family or service staff specially trained for the development of the plan.

There are six key principles that underpin person centred planning. These are:

  1. Person centred planning is planning from an individual’s perspective on his or her life.
  2. Person centred planning entails a creative approach to planning which asks, ‘what might this mean?’ and ‘what is possible?’ rather than assuming common understandings and limiting itself to what is available.
  3. Person centred planning takes into consideration all the resources available to the person – it does not limit itself to what is available within specialist services.
  4. Person centred planning requires serious and genuine commitment and co-operation of all participants in the process
  5. Person centred planning is an art – not a science.
  6. The development of a plan is not the objective of person-centred planning (National Disability Authority, 2014).


My Support Network





My Father

My Key Worker

Myself

My Sister (Alex)

My Friends

My Medical Professionals


My Likes

Going Shopping

Meeting with my family

Working

Meeting with my Key Worker

Going for walks

Drinking tea with friends



My Dislikes

New places

Not seeing my friends

Darkness

Being restricted with my activities

Not being listened to


Goals

Short Term Goals –

–         To increase my activities of daily living to help me get closer to living independently

–         To go shopping independently

–         To stay at my sister’s house for a week

Long Term Goals –

–         To go on a weekend trip with my friends

–         To visit another country

–         To move into independent living


My Person-Centred Plan Meeting

People Attending –

Celine Duggan (Person being supported), Heather O’Leary (Key Worker), John Murphy (Unit Manager), David Duggan (Celine’s Father) and Alex (Celine’s Sister).

Date – 23

rd

June 2019

Purpose of the meeting –

This meeting looked at Celine’s progress in relation to the preparations that are taking place currently to aid and support Celine’s wish to transfer from a residential setting into the community, in independent living, a home of her own.


Signed – _____________________ (

Celine Duggan)

Signed – _____________________ (Heather O’Leary)

Signed – _____________________ (John Murphy)

Signed – _____________________ (David Duggan)

Signed – _____________________ (Alex Duggan)


Independent Living – Baseline Assessment



Activity of Daily Living


Under-Developed

In Process

Developed

Any Comments
Washing Clothes See Action Plan 1
Handling Money
Cleaning the Bathroom
Handling Money
Emergency Plans
Garden Maintenance See Action Plan 2
Medical Needs


Overall Action Plan

This action plan is put in place to aid Celine in developing the necessary skills to leave the residential setting and move to independent living. This is the fifth action plan we have created working towards this move, the other four action plans have all been successful in achieving their goal already.


Objectives of Action Plan

  1. To learn,

    with the support of staff,

    how to wash clothes independently. (See action plan 1).
  2. To learn, with the support of staff, to maintain the garden independently. (See action plan 2).


Time Frame

The objectives of this action plan will be reviewed in 3 months (12/11/2019). The objectives will then be separated further into individual sessions in the actions plans. Heather O’Leary (The Key Worker) will develop the action plans for the required objectives. These sessions will require a review after each one to see if the goal was met. The objectives for each session shall be set out in the relevant action plan.

Celine will have 1 session each week with her key worker, Heather O’Leary, to work on the objectives stated above. as she has had up to this point. These sessions will take place each Thursday at 2 o’clock. In the event that Celine or Heather are unavailable at this time, an alternative time shall be agreed upon by both Celine, John, and Heather.


Action Plan One – Learning to Wash Clothes Independently

When Celine moves into independent living, she will need to be able to wash her own clothes. As Celine has not had to care for her own clothing, she is unaware of how to wash her clothes and what the steps involved are. Celine wants to be fully prepared to live independently and is eager to learn. Celine will practice by using the washing machine in her community setting as it is a standard washing machine. This objective will be split into 4 sessions that will get Celine to wash her own clothes independently. These sessions are –

  1. Discuss what a washing machine is used for

In this session, Heather and Celine will sit down and discuss what a washing machine is and see what it looks like.

  1. How to use the washing machine

In this session, Heather will show Celine the washing machine and explain about the different buttons and symbols presented. Celine will be showed which button turns the machine on and off and then will try it herself. Heather will explain which functions Celine will be using commonly and guided on using them. Heather will use clothes as an example to show Celine and then Celine will try independently while supervised by Heather.

  1. Discuss what clothes get washed together

In this session, Heather and Celine will sit down and discuss about not mixing colourful clothes with whites and such. Heather explains how you put whites together and darks together and colours together. They discuss reading labels on clothes and have a look at them. When comfortable, Celine reads a label independently.

  1. Using the washing machine from beginning to end

Celine will use the washing machine independently, supervised by Heather. Heather will not help Celine unless there is a healthy and safety risk or Celine requests her assistance.




Review of Sessions


Session Date Comment Signed
1
2
3
4


Action Plan Two – Learning to Maintain Garden Independently

Celine has expressed that she would like to improve her knowledge and skills in garden maintenance ahead of living independently as she plans on having a garden. As all lawnmowers differ in some respects, David, Celine’s father, has purchased a lawnmower for Celine to learn and use in her new home. The objectives will be broken down into 4 sessions that will get Celine to use the lawnmower independently. These sessions are –

  1. Discuss what a lawnmower is

In this session, Heather and Celine will sit down and discuss what a lawnmower is and its purpose and have a look at it.

  1. How to use the lawnmower

In this session, Heather and Celine will examine the lawnmower and discuss the different functions of the machine. Heather will show Celine how it is turned on and off, what fuel powers it, and the different levels the blades go to. Celine will then be guided by Heather in using these functions and shown to refuel it.

  1. How to clean out the lawnmower

In this session, Heather will explain to Celine about emptying the bag on the back of the lawnmower. Celine will then be guided in doing this and then will independently complete the task while Heather supervises.

  1. Using the lawnmower from beginning to end

In this session, Celine will use the lawnmower independently and demonstrate all the functions as Heather supervises.



Review of Sessions

Session Date Comment Signed
1
2
3
4



Monitoring, Review and Evaluation


Activity of Daily Living

Under-Developed

In Process

Developed

Any Comments
Washing Clothes
Handling Money
Cleaning the Bathroom
Handling Money
Emergency Plans
Garden Maintenance
Medical Needs


Reflection, Discussion and Evaluation

In completing this assignment, I found it extremely educating to complete as it was one of the first assignments that we have been assigned that I can see myself completing when I will be working as a social care worker in the future. I found that it took quite a lot of concentration and time to conjure up the plan as there was so much thought that goes into it. While completing this assignment, I found it slightly difficult to do because I had to create fictitious material. However, I doubt that it will be much easier when it comes to making a person-centred plan on a real person in the future.

When it came to creating this assignment, I went through some of the sample care plans we have been shown and the cases we have been taught about and made my own version.  I tried to include as much personal information regarding Celine as I found it important to incorporate everything about Celine in her PCP.

These plans are a very important part of the service that we are providing. The PCP should be the most updated document used to a residential service as it is focused totally on the person being supported. It also shows that we are helping them to reach their goals and live their lives the way they choose.



Bibliography


  • Natioanl Disability Authority, 2014.

    So what is ‘person centres planning’? Definition and brief history.

    [Online]
    Available at: http://nda.ie/Good-practice/Guidelines/Guidelines-on-Person-Centered-Planning/Guidelines-on-Person-Centred-Planning-format-versions/2-What-is-Person-Centred-Planning-/

    [Accessed 12

    th

    August 2019].

  • National Disability Authority, 2014.

    Key Principles.

    [Online]
    Available at: http://nda.ie/Good-practice/Guidelines/Guidelines-on-Person-Centered-Planning/Guidelines-on-Person-Centred-Planning-format-versions/3-Key-Principles/

    [Accessed 12

    th

    August 2019].

Risk Factors for Stroke: a Prospective Hospital-Based Study


Javed Akhter Rathore,  Zulfiqar Ali kango, Munazza Nazir, Adnan Mehraj

Department of Medicine Combined Military/Sheik Khalifa Bin Zyad Hospital Muzaffarabad Azad Kashmir


Background:

The stroke is third leading cause of death in world and most patients die with an acute event in stroke .Various clinical variable have been investigated as risks factors of stroke. The study was aimed to identify these risks factors for stroke.

Material and Methods:

This prospective study included 205 consecutive patients of stroke. The risk factors of stroke were investigated .Examination included clinical, neurological evaluation, laboratory tests, and brain CT. The follow-up at 14 days were done for all patients. Patients included were with acute first ever stroke onset of 48 hours of hospital admission. All patients completed a structured questionnaire and a physical examination and most provided blood for relevant investigations.



Results:


205 cases stroke subtypes were (n=156, 76%, with ischaemic stroke (CI); n=49, 24%, with intracerebral hemorrhagic stroke (ICH) .The significant risk factors for all stroke were: Hypertension (p=0.003), diabetes (p=<0.001), Hypercholesterolemia (p=0.686); atrial fibrillation (p=0.445),cardiac diseases (p=0.938), smoking (p=0.926) for brain infarction and hypertension (p = 0.002), diabetes (p=< 0. 001), Hypercholesterolemia (p=0.018); atrial fibrillation (p =0. 449), cardiac diseases (p=0. 749),smoking (p=0. 829) for hemorrhagic stroke .Age significance (CI; p=<0.247 vs. ICH ;p=0.013) and age category significance were (CI; p=<0.001vs.ICH;p=0.871) for subtype of stroke . The high mRS (p<0.001 low GCS score (p<0.001) on admission were associated with worst outcome for both stroke subtype. These risk factors were all significant for CI as well as ICH

.



Conclusions:


This study signifies the association of risks factors with acute stroke. Targeted interventions that reduce these risk factors could substantially reduce the burden of stroke



Keywords:


acute stroke; Risk factors, outcome


INTRODUCTION

The stroke is third leading cause of death worldwide and 10% of patients with an acute ischemic stroke die as acute event.

1-5

Stroke has major impact on mortality, morbidity and economic burden. Various clinical risk factors have been associated with stroke. The

i

dentification of these risk factors is of prime importance for specific therapies.

6-8

and underdeveloped countries have largest burden of stroke estimated for more than 85% of stroke mortality worldwide.

4-5

A few studies show data to identify risk factors for stroke specifically for hemorrhagic stroke.

4-8

The international multi centre case-control study designed to establish the association of risks factors of stroke has been reported previously.

9


MATERIAL AND METHODS

The patients who presented within 24 hours after symptom onset to our Hospital with a first-ever acute stroke were prospectively included from January 1

st

2011 to June 2012.The WHO definition of stroke was used to define stroke.

10

The ethics committee approved this study. The stroke was diagnosed when neurological deficits were confirmed on CT scan brain in every patient. Patients with transient ischemic attack (TIAs) and subarachnoid hemorrhage (SAH) were excluded. A 12-lead ECG and echocardiography were done. Stroke severity on admission was assessed with mRS

11

and GCS. The history of preexisting stroke risk factors was assessed. The hypertension was defined as history of hypertension or antihypertensive treatment or had two measurement of blood pressure BP >160/95 mm Hg or single measurement of BP>180/110 Hg during admission

12,13

, diabetes mellitus was defined as by preadmission history of diabetes mellitus and its drugs or venous plasma glucose concentration of 7.0mmol/l after an overnight fast on at least two separate measurement and or 11.1 mmol/l two hour post prandially

14

, current cigarette smoking was defined as who smoked at least one cigarette/tobacco per day for preceding three months or more

7,15

, Hypercholesterolemia defined as by preadmission history with cholesterol >5 mmol/l, and LDL-cholesterol >3 mmol/l

14

and history of coronary artery disease. The cause of death due to stroke declared unless another cause of death was found. Our approach to assessment of all key vascular risk factors, history of hypertension and diabetes mellitus, smoking and ischemic heart disease was consistent with international studies.

16-19

Structured questionnaires were prepared and physical examinations were performed . Patients with stroke measurements were completed in the supine position wherever appropriate. Blood pressure and heart rate were recorded on admission and after hospitalization. Hypertension was defined with self-reported history of hypertension with blood pressure of higher than 160/90 mmHg (mean of two measurements). The data entry and analyses were done on software statistical package SPSS 20. Chi square test both parametric and nonparametric done where appropriate for those in proportion. Quantitative data was expressed as mean and standard deviation. Stroke subtype both CI and ICH were cross tabulated as dependent variable to risk factors of stroke as independent variables to get p value which show association as such to each other. Data was reported in frequency tables. Differences between groups and the effect of patient characteristics on clinical outcome was also assessed


RESULTS

During the January 1

st

2011 to June 31

st

2012, 205patients (mean age +/- SD, 63.78+/-10.03) range 45 to 85 years were admitted to our hospital with a first-ever acute stroke. There were 111 males and 94 women (54.1% vs. 45.9%). The maximum frequency of stroke was seen between ages 55-74 (table). Mean systolic blood pressure was 162+/- 29.14.and mean diastolic blood pressure 102+/- 19.46. Glasgow coma scale (GCS) and mRS were shown in table. Out of 205 stroke patients 156(76%) had brain infarctions and 49(24%) were having hemorrhagic stroke.

Table shows the characteristics of the 205 patients with acute stroke. Hypertension was the most common risk factor 156 (76%) followed by hypercholesterolemia 145 (70.7 %) smoking 123 (60.0%) coronary artery disease 49(24%) diabetes mellitus 34 (16.6%)) and atrial fibrillation 23 (11.2%).

The mean fasting blood sugar was 6.50 +/-2.42mmol/l and mean random blood sugar was 6.36+/-3.8 mmol/l. Mean cholesterol was 6.50+/- 1.16 mmol/l.

Out of 205 patients with acute stroke 33(16%) died. Mortality was common between ages 55-74 years. Significant association of stroke observed between age (p=0.013) and age category (p<0.001) as compared to gender .GCS score <1-8 revealed more mortality as compared to patient having GCS >9. Hemorrhagic stroke showed high mortality 17(8.2%) as compared to ischemic stroke 16(7.8%). Both have significant association with mortality .Clustering of risk factors along with comorbidities influenced the hospitals mortality. The mRS score depicting functional disability as well mortality prognosticator was associated with worst outcome with high as compared to lowest score (mRS 6 vs. mRS1-5) shown (Table). In our analysis high mRS score (p<0.001), low GCS score (p<0.001) on admission were associated with high mortality.


DISCUSSION

Out of 205 patients the stroke subtype were brain infarction 156(76%) and intracerebral heamorrhage 49(24%) and in this study of risk factors for stroke all cases completed routine neuroimaging. Our results showed that many risk factors accounted for more than 80% of all stroke, both in ischaemic and intracerebral haemorrhagic stroke. The significant association of risk factors for stroke subtype were: Hypertension (CI ;p = 0.002 vs.ICH; p = 0.002) , diabetes (CI ;p = 0.002 vs.ICH; p = 0.030), Hypercholesterolemia (CI ;p = 0.686 vs.ICH; p = 0.002) as compared to atrial fibrillation (CI; p =0. 445 ICH; p =0. 449), cardiac diseases (CI; p=0. 938vs.ICH;p=0. 749 ),smoking (CI; p=0. .926 ICH; p=0. 829) .Age significance (p=0.013) for ICH as compared to CI (p=.237 whereas age category significance (p=

<

0.001) for ICH as compared to CI (p=.871).The high mRS (p<0.001 low GCS score (p<0.001) on admission were associated with worst outcome .Hypertension , IHD, smoking, diabetes mellitus, are common modifiable vascular risk factors for stroke as shown in previous epidemiological studies

.4,5,20-24

For both subtype of stroke we observed significant association with these risk factors which are modifiable save age .Our study help us to guide optimum selection of risk-factor target population to prevent CVA.

21,22.

Our study showed that hypertension and its level was the most important potential risk factor for both stroke subtype, particularly for intracerebral haemorrhagic stroke as observed previously

23

The hypertension underestimates the association as we used high cut point for blood pressure of 160/90 mm Hg. Estimated actual blood pressure is also problematic as it might be raised in acute stroke phase. Subsequently blood pressure might be lower than usual because of use of antihypertensive drugs and poor food intake. We used two mean reading in order to avoid these biases to minimum levels. The blood pressure is readily reduced by inexpensive drugs and salt reduction.

24

Studies have shown stronger association of stroke risk with waist to hip ratio than with body-mass index as well as lack of physical activity

19

We found cigarettes smoking were associated with stroke. Smoking was a strong risk factor for all subtype of stroke. Few studies showed smoking has no hazard.

25

The alcohol intake has relation with stroke.

26

Our study showed cholesterol have association with stroke as have been shown in other studies.

27

An obvious limitations of our studies are apolipoproteins.

28,

waist to hips ratio, body mass index, diet physical activity and abdominal obesity have not been investigated as risk factors and their clustering in stroke as have been observed in previous studies. Diet has association with stroke.

29

However for almost all risk factors that relied on past medical history were substantiated on examination and investigations to establish their relationship to stroke .In our study 16% died of stroke which is consistent with previous studies in Pakistan,

30-31

and developed countries.

32-33

The largest scale national level case-control studies will be required to assess the importance of risk factors for stroke, but our present sample size might be inadequate to provide reliable information about the importance of each risk factor.


CONCLUSION

Stroke causes great morbidity and mortality. We reports 16 % mortality rate at 14 days after acute stroke. Our findings suggest that risk factors are significantly associated of the risk of ischaemic and intracerebral haemorrhagic stroke .Hypertension, smoking, diabetes, hypercholesterolemia and ischemic heart disease are common risk factors for stroke Others risk factors such as abdominal obesity, alcohol ingestion, abdominal central obesity, diet, lack of physical activity and apolipoproteins are common potentially modifiable vascular risk factors needs to look for in order to prevent stroke .We need a large national epidemiological studies of stroke that requires routine neuroimaging and vascular access should be feasible to effected people of low and middle income. Targeted interventions that reduce blood pressure, hypercholesterolemia diabetes mellitus and smoking, promote physical activity and a healthy diet, could reduce the national burden and costs of stroke.


REFERENCES

  1. Carandang R, Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Kannel WB, Wolf PA. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA.2006;296:2939.46.
  2. Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bullet LM, et al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet. 2004;363:1925.33
  3. KasperDL,Braunwald E, Fauci AS, Hauser SL,Longo DL, Jameson JL, et al, editors. Harrison’s principles of internal medicine. 16th ed. NewDelhi:McGraw-Hill, Medical Publishing Division; 2005.p. 2372-93
  4. Feigin VL. Stroke in developing countries: can the epidemic bestopped and outcomes improved?

    Lancet Neurol

    2007; 6: 94–97.
  5. Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world.

    Lancet Neurol

    2007; 6: 182–87.
  6. O’Donnell M, Yusuf S. Tackling the global burden of stroke: the need for large-scale international studies.

    Lancet Neurol

    2009; 8: 306–07.
  7. Ariesen MJ, Claus SP, Rinkel GJ, Algra A. Risk factors for intracerebral hemorrhage in the general population: a systematic review.

    Stroke

    2003; 34:2060–65.
  8. Donnan GA, Hankey GJ, Davis SM. Intracerebral haemorrhage: a need for more data and new research directions.

    Lancet Neurol

    2010; 9: 133–34.
  9. O’Donnell M, Xavier D, Diener C, et al. Rationale and design of INTERSTROKE: a global case-control study of risk factors for stroke.

    Neuroepidemiology

    2010; 35: 36–44.
  10. Hatano S. Control of stroke in the community, Methodological consideration and protocol of WHO stroke register. Geneva WHO 1973; 98. document no. CVD/S/73
  11. Sandercock PAG, Warlow CP, Starky IR.Predisposing factors for cerebral infarction: the Oxfordshire community stroke project. Br Med J 1989; 298: 75-81.
  12. Caroline TM, Mackerback JP. Socioeconomic difference in stroke among Dutch elderly women. Stroke 1999; 30:357-62
  13. Hamidon BB, Raymond AA.The Impact of Diabetes mellitus on in-hospital strokes Stroke mortality. J Postgraduate Med 2003;49:307-10
  14. Togha M, Bakhtavar K. Factors associated with in-hospitalmortality following intracerebral hemorrhage: a three-year study in Tehran, Iran. BMC Neurology 2004; 4:9-
  15. Song YM, Cho HJ. Risk of stroke and myocardial infarction after reduction or cessation of cigarette smoking: a cohort study in Korean men.

    Stroke

    2008; 39: 2432–38.
  16. Yusaf S, Hawken S, Ôunpuu S, et al, on behalf of the INTERHEART Study Investigators. Eff ect of potentially modifi able risk factors associated with myocardial infarction in 52 countries (the INTERHEART study):case-control study.

    Lancet

    2004;36:937–52.
  17. McQueen MJ, Hawken S, Wang X, et al, for the INTERHEART study investigators. Lipids, lipoproteins, and apolipoproteins as risk markers of myocardial infarction in 52 countries (the INTERHEART study): a case-control study.

    Lancet

    2008; 372: 224–33.
  18. Teo KK, Ounpuu S, Hawken S, et al, on behalf of the INTERHEART Study Investigators. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study.

    Lancet

    2006; 368: 647–58.
  19. Yusaf S, Hawken S, Ôunpuu S, et al, on behalf of the INTERHEART Study Investigators. Obesity and the risk of myocardial infarction in 27 000 participants from 52 countries: a case-control study.

    Lancet

    2005; 366: 1640–49.
  20. Sacco RL, Khatri M, Rundek T, et al. Improving global vascular riskprediction with behavioral and anthropometric factors. The multiethnic NOMAS (Northern Manhattan Cohort Study).

    J Am Coll Cardiol

    2009; 54: 2303–11.
  21. Hankey GJ. Potential new risk factors for ischemic stroke: what is their potential?

    Stroke

    2006; 37: 2181–88.
  22. Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, andmodelling.

    Lancet Neurol

    2009; 8: 345–54.
  23. Ezzati M, Hoorn SV, Rodgers A, Lopez AD, Mathers CD,Murray CJL, the Comparative Risk Assessment Collaborating Group. Estimates of global and regional potential health gains from reducing multiple major risk factors.

    Lancet

    2003; 362: 271–80.
  24. Appel LJ, Anderson CA. Compelling evidence for public health action to reduce salt intake.

    N Engl J Med

    2010; 362: 650–52.
  25. Song YM, Cho HJ. Risk of stroke and myocardial infarction after reduction or cessation of cigarette smoking: a cohort study inkorean men.

    Stroke

    2008; 39: 2432–38.
  26. Reynolds K, Lewis B, Nolen JD, Kinney GL, Sathya B, He J. Alcohol consumption and risk of stroke: a meta-analysis.

    JAMA

    2003; 289: 579–88.
  27. Prospective Studies Collaboration. Blood cholesterol and vascularmortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55 000 vascular deaths.

    Lancet

    2007; 370: 1829–39.
  28. Di Angelantonio E, Sarwar N, Perry P, et al. Major lipids, apolipoproteins, and risk of vascular disease.

    JAMA

    2009; 302: 1993–2000.
  29. Di Angelantonio E, Sarwar N, Perry P, et al. Major lipids, apolipoproteins, and risk of vascular disease.

    JAMA

    2009; 302: 1993–2000.
  30. Razzak AA, Khan BA, Baig SM. Ischemic strokes in young adults of South Asia. J Pak Med Assoc 2002; 52:417–22.
  31. Fayyaz M,Hassan MA, Atique MH. Risk factors and early prognosis in stroke. Ann King Edward Med Coll 1999; 5;12–5.
  32. Sarti C, Rastenyte D, Cepaitis Z, Tuomilehto J. International trends in mortality from stroke, 1968 to 1994. Stroke 2000;31:1588–601.
  33. Kelly-Hayes M, Wolf PA, Kannel WB, Sytkowski P, D’Agostino RB, Gresham GE. Factors influencing survival and need for institutionalization following stroke: the Framingham Study. Arch Phys Med Rehabil 1988; 69:415–8.


Table-1: Characteristics of stroke subtype according to risk factors, gender, GCS and mRS score


Total


Cerebral infraction


P-value


Intra cerebral hemorrhage


*P-value

N (%)


205


156(76.0)

49(24.0)

Age (year) mean age +-SD

63.78 +- 10.03

.237

.013

45-54

43 (21.0)

.871

55-64

58 (28.3)

65-74

67 (32.7)


<

0.001


<

0.001

75-84

33 (16.1)

>85

01 (2.0)

Male

111(54.1)

85 (76.6)

.997

26 (23.4)

.983

Female

94 (45.9)

71 (75.5)

23 (24.4)



Risk factors

Hypertension

156 (76.0)

113 (72.4)

.003

43 (27.6)

.002

Hypercholesterolemia

145 (70.7)

109 (75.2)

.686

36 (24.8)

.0181

Smoking

123 (60.0)

94 (76.4)

.926

29 (23.6)

.829

Cardiac Disease

93 (45.4)

72 (77.4)

.938

21 (22.6)

.749

Diabetes

34 (16.6)

25 (73.5)

.023

09 (26.4)

**<0.001

Atrial Fibrillation

23 (11.2)

20 (87.0)

.445

03 (13.0)

.449



Outcome

GCS 1-8

61 (29.8)

.001

.001

9-12

93 (45.4)

13-15

51 (24.9)



mRS Score

Normal =0

4 (2.0)

.002

.001

ADL =1

14 (6.8)

Mod. activity =2-3

37 (18.0)

Mod. sever activity =4

69 (33.7)

Sever disability =5

48 (23.4)

Dead (mRS) =6

33 (16.0) 16(7.8)

17(8.2)

*P-value asym. 2-sided

**P-value Univariate analysis

Veterinary Dental Nursing Procedures

Veterinary Dental Nursing Procedures

For this assignment answer the following questions. Use as much space as you need to adequately answer the questions. You may inset diagrams to illustrate your answers. To answer some questions, you may need to access veterinary dental textbooks or online resources. Remember to reference appropriately (Harvard referencing).

:Discuss the process of creating a budget for a healthcare facility. Why is budgeting in health care different from many other industries?

:Discuss the process of creating a budget for a healthcare facility. Why is budgeting in health care different from many other industries?

1. Describe the various sources of funding beyond third-party reimbursement from which the various types of healthcare facilities can benefit.

3. Discuss the CMS Quality Initiatives that are underway at this time. Do you support these initiatives? Why, or why not? How do you feel these initiatives will affect patient care?

Your response must be at least 200 words in length.

2. Discuss the process of creating a budget for a healthcare facility. Why is budgeting in health care different from many other industries?

What is the research question? What is the research design? Was the hypothesis clearly stated or implied?

What is the research question? What is the research design? Was the hypothesis clearly stated or implied?

Headings are Question 1, Question 2, etc. Use current APA guidelines. Correct grammar, spelling, and punctuation are expected. The critique should include:

1.What is the research question? What is the research design? Was the hypothesis clearly stated or implied? What was the hypothesis for the study?

2.List the variables in this study. Label them as dependent or independent. Describe the level of measurement for each variable.

3.List the statistical analyses, descriptive and inferential, used in the study. What is the purpose of each analysis?

4.Describe the study population.

5.Are the study findings (results) generalizable to other populations? Support your answer.

6.List the findings and report their level of significance.

7.Conclusions: Are they logically related to the hypotheses? Limitations: Are limitations identified? Can you think of others, which are not identified by the authors? If so, what are they?

8.Confidence: How confidant can you be that the results are valid and useable? Are the implications for practice logical? What influenced your opinion

9.APA and Writing Mechanics

The article you will use for this critique, can be accessed here:

Liu, K., You, LM., Chen, SX., Hao, YT., Zhu, XW., Zhang, LF., & Aiken, L.H. (2012). The relationship between hospital work environment and nurse outcomes in Guangdong, China: A nurse questionnaire survey. Journal of Clinical Nursing, 21, 1476-1485