Occlusal Stent Construction Case Study

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Initial examination was carried out consisting of evaluation the periodontal condition of the teeth. After selecting the suitable patients for the study, all of them received supra gingival scaling and polishing with a good motivation and instruction in oral hygiene measures including brushing, using dental floss and interproximal brushes as indicated and demonstration was given to them about the work of perio Q gel and it’s application .

An alginate impression was taken and an occlusal stent was constructed for each patient. After completion of the occlusal stent construction, the patient was recalled again and this was considered the first visit. In this visit the clinical periodontal examination was carried out for the selected sites and it included the following parameters:


  • Plaque Index (PLI) :- (Silness and Loe 1964)

A periodontal probe was used after air drying of the teeth and the selected sites were examined for plaque. The periodontal probe was gently passed along the gingival crevice. The criteria was the following:


Score 0

: No plaque in the gingival area.


Score 1

: A film of plaque adhering to the free gingival margin and adjacent area of the tooth surface, which cannot be seen with the naked eye but only by using disclosing solution or by using probe.


Score 2:

Moderate accumulation of soft deposits within the gingival pocket, on the gingival margin and or adjacent tooth surface which can be seen by naked eye.


Score 3

: Abundance of soft matter within the gingival pocket and or on the gingival margin and adjacent tooth.


  • Gingival Index


    (GI)


    :



    (Loe, 1967).

The occurrence of gingival inflammation was assessed using the criteria of gingival index system


Score 0:

Normal gingiva.


Score 1:

Mild inflammation, slight change in color, slight edema, and no bleeding on probing


Score 2

: Moderate inflammation, redness and glazing, bleeding on probing.


Score 3

: Severe inflammation, marked redness and ulceration, tendency to spontaneous bleeding.


  • Bleeding on Probing (BOP) :- (Carranza, 2012).

A blunt periodontal probe inserted to the bottom of the periodontal pocket/sulcus and is moved gently along the root surface. If bleeding occurred within 30 seconds after probing, the site was given positive

score (1),

and a negative

score (0)

for the non-bleeding site


  • Probing Pocket Depth (PPD):


    (Lindhe et al.,1998)

The probing pocket depth was measured with a William’s periodontal probe at four sites of all teeth on (mesial, buccal, distal and lingual), the distance from gingival margin to the most apical extent of the probe inserted parallel to the long axis of the tooth to the nearest millimeter (mm) was recorded only for the sites exhibiting probing depth of (5-8)mm.


  • Relative Attachment Level (RAL):

The occlusal stent was adjusted to fit the teeth, then vertical grooves or holes corresponding to the probed site were made using rotary fissure bur, these grooves provided a fixed reference mark for probe insertion and angulation. The stent was putted on the occlusal surfaces to cover half or 2/3 of the crown. The distance

from the base of the pocket to the lower border of the stent at the base of the groove was considered as the RAL. The measurement was made to the nearest mm .

The clinical periodontal recordings were repeated after 3 and 6 weeks.


Treatments

After recording of all periodontal parameters for the selected sites, the patient mouth was splitted into three quadrants, each quadrant received different treatment modality and as follows:

Initial visit (1stday): patient selection, supra gingival scaling, alginate impression, motivation, instruction.

.

Gel group

: 111 sites in this group received intra pocket application of perio Q gel. The selected sites were isolated by cotton rolls and dried the teeth by air, and then dried the pockets by paper point size (30, 35, 40, and 45).the application of the gel was made using disposable syringe of 5ml. the sharp tip of needle was removed by rotary bur to avoid hurting the gingival tissue and smoothened it, then 1 ml of the gel was pulled by the syringe and the needle gently placed down through the pocket until it reach to the bottom of the pockets then placed the gel while worked the way up until the gingival margin. Each pocket was received a range of (0.1-0.3) ml., the excess gel oozing from the pockets was removed by Cotton rolls The patients were instructed to avoid spitting, washing, eating and drinking for 2 hours of the gel application. Toothbrush and interdental aids should paused of the day after the gel application.

First visit (1day)

Clinical periodontal parameters recorded, gel application.

Second visit (after 3 weeks)

Clinical periodontal parameters recorded

Third visit (after 6weeks)

Clinical periodontal parameters recorded


Combination group


:

106 sites in this group received scaling and root planing, then after one hour, the patient examined if there was no blood oozing,then the gel applied as was described previously. If not, the patient was referred to the next day.

First visit (1day)

Clinical periodontal parameters recorded, root planning to the selected sites, after 1 hour putted the gel.

Second visit (after 3 weeks)

Clinical periodontal parameters recorded

Third visit (after 6weeks)

Clinical periodontal parameters recorded


Scaling and root planning group:

106 sites in this group received scaling and root planning only.

First visit (1day)

Clinical periodontal parameters recorded, root planning to the selected sites.

Second visit (after 3 weeks)

Clinical periodontal parameters recorded

Third visit (after 6weeks)

Clinical periodontal parameters recorded


Pilot study

To perform intra examiner calibration and inter examiner calibration with clinical periodontal parameters used in this study (PLI, GI, BOP, PPD, RALI), a pilot study was carried out in Department of periodontics, College of Dentistry, Baghdad University. It was carried at about four weeks before the conduction of the actual project on two subject with twelve-sites. The intra examiner calibration was repeated after an appropriate period (usually 2-4 weeks) to resolve any memory bias. While the inter examiner calibration was repeated by another trained professional at the same time. The consistency (calibration) should be at least 90% and if it is low, the measurement should be repeated.


Statistical Analysis

Data were processed and analyzed using SPSS 16 for windows8 (statistical package for social science) and excel 2013.both descriptive and inferential analyses

Descriptive Statistics

  • Tables (Range, Frequencies and Percentage)
  • Arithmetic Mean
  • Standard Deviation
  • Mean Difference.
  • Median
  • Minimum and Maximum
  • Graphical Presentation by Bar Charts and Scattered Plots.

Inferential Statistics

There was used to accept or reject the statistical hypotheses, which included:

  • Analysis of Variance Test(ANOVA) One Way
  • Student t-Test for equality of means of two independent groups.
  • Wilcoxon Signs rank test
  • Mann Whitney U Test


References

  • Lindhe J Karring T Lang N. Clinical periodontology and implant dentistry. 3rd edition. Copenhagen, Munksgaard,1998
  • Löe, H. The Gingival Index, the Plaque Index and the Retention Index Systems. Journal of Periodontology, Vol. 38, No. 6 (November-December 1967), pp. 610-616.
  • Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:112-135

Patients With Post Stroke Dysphagia Health And Social Care Essay

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This chapter deals with discussion, summary and conclusions drawn. It clarifies the limitations of the study, the implications and recommendations given for different areas in Nursing practice, Education, administration and research.

DISCUSSION

The present study was designed to assess the effectiveness of Selected Nursing Interventions among patients with Post Stroke Dysphagia at KMCH, Coimbatore-14. The researcher carried out the study among 30 patients and adopted pre-experimental research design with single group pre test post test design. The researcher used non probability purposive sampling technique to select the 30 subjects. The researcher conducted this study to assess the effectiveness of Shaker Exercise and Hyoid Lift Maneuver on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia.

DEMOGRAPHIC DESCRIPTION OF SUBJECTS

The demographic variables included in the study were Age, Sex, Education and Habits.

The mean Age of the subjects was 60. Half of the subjects were in the Age group 50-70 years. Almost equal numbers of subjects were in the 30-50 and above 70 years Age groups and it was about 23 and 27 percent respectively.

Regarding the Sex, nearly equal numbers of subjects were in the male and female Sex group and it showed 53 and 47 percent respectively.

On the basis of their Educational Status, 67 percent of the subjects were studied up to secondary Education. About 33.33 percent of the subjects completed any one of the graduate degree course.

In accordance with their Personal Habits, 53.33 percent had no bad Habits like Smoking and Alcoholism. Ten percent of subjects had the habit of Tobacco use. Seven percent of subjects were consuming Alcohol. Thirty percent of the subjects had the habit of both Tobacco and Alcohol consumption.

CLINICAL DESCRIPTION OF SUBJECTS

The clinical variables include Type of Stroke and Co-morbid Illness.

In consistent with the Type of Stroke, 10 percent of the subjects had Stroke due to the problem in anterior circulation, 40 percent of the subjects had Stroke due to problem in middle circulation and 50 percent of the subjects had Stroke due to problem in the posterior circulation. With reference to the Co-morbid Illness, 13.33 percent of the subjects had No Co-morbid Illness. About 10 and 40 percent of the subjects had the complaints of Diabetes Mellitus and Hypertension respectively. Remaining 36.67 percent of the subjects had both Hypertension and Diabetes Mellitus.

The major findings of the study were discussed according to the objectives:

The first objective was to assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia.

In the pre test assessment of the Swallowing Performance using GUSS Score indicates 23.33% of the subjects had Mild Dysphagia, 40% of the subjects had Moderate Dysphagia and 36.67% of the subjects had Severe Dysphagia. The post-test assessment of Swallowing Performance explains that 16.67% of the subjects were improved to the No Dysphagia stage with good Swallowing and Feeding Performance. About 26.67% of the subjects had Mild Dysphagia and 23.33% of the subjects had Moderate Dysphagia. Remaining 33.33% of the subjects had severe Dysphagia with various improvements in the Swallowing Performance.

The pre test and post test Feeding Performance Score using FOIS describes equal number of subjects in the Tube Dependent (36.67%) and Total Oral Intake category (63.33%). Despite the result revealed an equal number of subjects in the pre and post test assessment, the subjects had an improvement in the Feeding Performance during the post test assessment from no oral intake level to tube supplement with consistent oral intake level in the Tube Dependent category. Likewise, subjects showed an improvement from the intake of single consistency to the total intake with no restriction in the Total Oral Intake category.

The present study was supported by Trapl et al., who conducted study in 2002 and described that out of 30 patients, 30 to 50% had Severe Dysphagia and showed significantly higher risk of aspiration with liquids compared with semisolid textures (p=0.001). Therefore they confirmed the subsequent sequence of GUSS.

The second objective was to determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.

With reference to the Swallowing Performance based on the GUSS Score, the mean pre-test SwallowingS among subjects was 12.50 and the mean post-test Swallowing Score was 13.87 based on the GUSS tool. Paired ‘t’ test was used to compute the mean difference. The ‘t’ value for this mean difference between pre and post test Swallowing Score was 6.150. The ‘t’ value obtained at .001 level of significance and at 29 degrees of freedom. Hence there is a significant difference exist between the mean pre and post test Swallowing Scores. It further implies that the Swallowing Score in the post test was higher than the pre test Swallowing Score. This improvement was due to the Selected Nursing Interventions such as Swallowing Exercises and Positioning while Swallowing. So the Swallowing Exercises such as Shaker Exercise and Hyoid Lift Maneuver found to be effective in improving the Swallowing Performance in Stroke patients. The final result concluded that 22 subjects (73.3%) expressed improvement after the treatment. Remaining 8 subjects (26.7%) had no changes in their Swallowing Performance after the therapy.

The median of pre-test Feeding Score among subjects was 5 and the median of post-test Feeding Score was 6.5. Sign test was computed to find out the difference between the pre and post test median Scores of Feeding. The sign test Score showed the p value 0.000 which was significant at .001 level. It showed that, a significant difference present between the pre and post test Feeding Scores. It further implies that the Feeding Score in post test was higher than the pre test Feeding Score. This improvement in the Feeding Performance was due to the Selected Nursing Interventions. So the Swallowing Exercises were effective in improving the Feeding Performance in Stroke patients having Dysphagia. Median test was used to compare the effect between the pre test and post test group instead of mean as because the FOIS was a 7 point likert scale. As the variables did not follow the normality and the highest Score was 7, parametric test was not applicable. Hence non parametric sign test was adopted which is equivalent to paired ‘t’ test to find out the effectiveness.

The result of the present study was substantiated with a study conducted by Mepani et al., in 2005 on augmentation of deglutitive thyrohyoid muscle shortening by the Shaker Exercise. The study involved the effect of 6 weeks shaker exercise in 11 dysphagic patients; six patients were randomized to control group and 5 patients to the Shaker Exercise group. After the therapy the change in thyrohyoid distance among Shaker Exercise group was significantly greater compared to the control group (p=0.034), this subsequently improve the swallowing function of the patients.

Association of the Swallowing and Feeding Performance with selected Demographic and Clinical variables among patients with Post Stroke Dysphagia

The Fisher exact test was used to associate the selected Demographic and Clinical variables with the Swallowing and Feeding Performance of the patients with Post Stroke Dysphagia.

The calculated p values for the association between the Swallowing Performance of Post Stroke patients with the selected Demographic and Clinical variables such as Sex, Habits, Type of Stroke and Co-morbid Illness were not significant and hence there exist no association between them.

The calculated p values for the association between the Feeding Performance of Post Stroke patients with selected Demographic and Clinical variables such as Sex, Habits, Type of Stroke and history of Co-morbid Illness were not significant and hence there is no association between them.

SUMMARY

The aim of the present study was to assess the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia, for which the following objectives were formulated;

To assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia.

To determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.

To associate the Swallowing and Feeding Performance with selected Demographic and Clinical variables.

The study was based on Ernesteine Wiedenbach’s helping art of clinical nursing theory (1970). The research design applied for the study was pre experimental single group pre test-post test design. Study was conducted in KMCH. 30 samples were selected by non probability purposive sampling technique. The tool used for data collection consists of Demographic and Clinical variables, Gugging Swallowing Screen (GUSS) and Functional Oral Intake Scale (FOIS) to assess the Swallowing and Feeding Performance in Post Stroke Dysphagic patients. The data were collected for a period of 6 weeks. Descriptive and inferential statistics were used in statistical analysis, to assess the effectiveness of Selected Nursing Interventions among patients with Post Stroke Dysphagia. Fisher exact test was used to find out the association between the selected Demographic and Clinical variables with the Swallowing and Feeding Performance in patients with Post Stroke Dysphagia.

Major findings of the study

On the basis of Gugging Swallowing Screening (GUSS), the investigator observed the degrees of improvement in Swallowing difficulty after the therapy among patients with Post Stroke Dysphagia. About 16.67% of the subjects had No Dysphagia, 26.67% had Mild Dysphagia, 23.33% had Moderate Dysphagia, and 33.33% had Severe Dysphagia.

In accordance with the Functional Oral Intake Scale (FOIS), 36.67% of the subjects were in Tube Dependent category and 63.33% were in Total Oral Intake category with sustained improvement in the Feeding Performance.

The mean pre test score of the Swallowing Performance using Gugging Swallowing Screening (GUSS) tool was 12.50. The mean post test Score of the Swallowing Performance using GUSS evaluation tool was 13.87.

There was a significant difference between the mean pre-test and post-test Swallowing Performance Score. The ‘t’ value obtained was 6.150 which is significant at 0.001 level and at 29 degrees of freedom.

The final result explained that, 22 subjects (73.3%) expressed Swallowing improvement after the treatment. Remaining eight subjects (26.7%) had no changes in their Swallowing Performance after the therapy.

Median test was used to compare the Feeding Performance Score of the pre and post test groups. The median pre test Feeding Performance of the patients with Post Stroke Dysphagia was 5 with a range of 1 to 6 and that of post median test was 6.5 with a range of 1 to 7.

The non parametric sign test was used to find out the effectiveness of the therapy on Feeding Performance. The obtained p value was 0.000 at 0.01 level of significance. This revealed a significant improvement in the Feeding Performance of Post Stroke Dysphagic patients.

The final result revealed that 24 respondents (80%) showed an improvement in their Feeding Performance after the therapy and was assessed by FOIS scoring. But remaining six respondents (20%) showed no changes in the Feeding Performance when assessed by FOIS.

There was no significant association exist between the Swallowing and Feeding Performance of the Post Stroke Dysphagic patients with the selected Demographic and Clinical variables.

CONCLUSION

The study was tested and accepted the hypothesis that there is a significant difference in Swallowing and Feeding Performance before and after the implementation of Selected Nursing Interventions in Post Stroke patients with Dysphagia.

The result concluded that the study group had better outcome than the others. There was a significant improvement in the Swallowing and Feeding Performance of the Post Stroke Dysphagic patients after the Exercise and Positioning therapy. The participants had reduced the risk of aspiration and aspiration related complications after the therapy. Hence, Selected Nursing Interventions such as Swallowing Exercises like Shaker exercise and Hyoid Lift Maneuver and positioning during Swallowing can be recommended for the patients with Post Stroke Dysphagia.

IMPLICATIONS

The present study has its own implications in nursing practice, nursing education, nursing administration and nursing research.

Nursing practice:

Dysphagia is one of the major complications among Post Stroke patients. This study implies the effectiveness of Selected Nursing Interventions in the improvement of Swallowing and Feeding Performance among the Post Stroke Dysphagic patients.

This study creates awareness among the nursing personnel about the importance of the various complications after the Stroke and its various evidence based management.

The present study shows that the exercise intervention for the Post Stroke Dysphagic patients can prevent the risk of aspiration and aspiration pneumonia.

The result shows that, Selected Nursing Intervention for the Post Stroke patients can reduce the risk of malnourishment.

Nurses can gain skill for providing Swallowing Exercises in the Post Stroke Dysphagic patients to improve their quality of life.

Nursing Education:

The nurse educator can create awareness among the health care professionals about the complicated effects of Stroke and its various evidence based management.

The nurse educator can arrange in-service Education programs to update their knowledge regarding the new techniques and modalities to manage the Post Stroke Dysphagia.

The nurse educator can teach the students about the present study findings and its implication in patients with Post Stroke Dysphagia. This will help to improve the knowledge of the students on Swallowing Exercises.

The nurse educator can motivate the nursing personnel and students to use this Swallowing Exercises and positioning in the improvement of Swallowing and Feeding Performance and in the reduction of aspiration risk in Post Stroke Dysphagic patients.

Nursing administration:

Nurse administrator should aware of the problem experienced by the clients after the Stroke.

Nurse administrator can provide continuing education or short term courses in the clinical area for preparing the nurses with competence in managing the after effects of Stroke especially Dysphagia.

Nurse administrator can plan and organize seminars, workshops and conferences about “Selected Nursing Interventions for the improvements of Swallowing and Feeding Performance among patients with Post Stroke Dysphagia.

Nurse administrator can formulate protocol to incorporate the study findings in nursing intervention.

Nursing research:

This study provides a basis for further studies.

The findings of the study can be a foundation for conducting the study on large sample to strongly support the efficacy.

The implications of the study can be used as a motivation for nurses to conduct research in India, where the health care system is advancing.

This study helps to update the knowledge and proper utilization of resources in the field of nursing practice.

LIMITATIONS OF THE STUDY

The study was limited to small sample size of 30 subjects.

The study was limited to a single setting.

The study was conducted using a single group.

RECOMMENDATIONS

A similar study can be conducted with large number of subjects to generalize the research findings.

A study can be conducted at different settings.

Similar study can be undertaken using different Swallowing and lingual exercises.

This study can be conducted with experimental and quasi experimental design.

A comparative study can be conducted between different types of Swallowing Exercises in Post Stroke Dysphagic patients.

A similar study can be done to assess the effectiveness of Swallowing Exercises among patients with Dysphagia who are receiving head and neck radiation for cancer.

ABSTRACT

The present study entitled “Effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance among patients with Post Stroke Dysphagia at KMCH, Coimbatore-14. This study was undertaken during the year 2012-2013, in partial fulfillment of requirement for the degree of Master of Science in Nursing at KMCH College of Nursing, Coimbatore, which is affiliated to the Tamilnadu Dr. M.G.R. Medical University, Chennai.

Objectives: 1.To assess the Swallowing and Feeding Performance of patients with Post Stroke Dysphagia. 2. To determine the effectiveness of Selected Nursing Interventions on Swallowing and Feeding Performance in patients with Post Stroke Dysphagia. 3. To associate the Swallowing and Feeding Performance with selected Demographic and Clinical variables. Research Design: Pre experimental design with single group pre test-post test design. Setting: Neuro inpatient and outpatient department of Kovai Medical Center and Hospital, Coimbatore. Samples: All Post Stroke Dysphagic patients. Sample Size: The sample size was 30. Sampling Technique: Non probability purposive sampling. Conceptual framework: Ernestine Widenbach’s Helping Art of Clinical Nursing Theory (1970) was adopted. Intervention: Selected Nursing Interventions such as Swallowing Exercises and Positioning during the swallowing were incorporated. The clients were instructed to do the Shaker Exercise and Hyoid Lift Manoeuvre 3 to 6 times a day for a period of 6 weeks. The subjects were instructed to elevate or down the chin and tilt the head towards stronger side while Swallowing. Outcome Measures: Swallowing and Feeding Performance was assessed by Gugging Swallowing Screen (GUSS) and Functional Oral Intake Scale (FOIS) respectively. Results: The mean difference between pre and post test Swallowing Score was 6.150 and which was significant at 0.001 level. The p value obtained for Feeding Score was 0.000 at 0.001 level of significance. The result showed a significant improvement in the Swallowing and Feeding Performance. Conclusion: This study proved that the implementation of Selected Nursing Interventions rather than the other conventional treatment will improve Swallowing and Feeding Performance among Post Stroke patients with Dysphagia. Hence the Swallowing Exercises and Positioning can be recommended in clinical practice to improve the Swallowing and Feeding Performance in Post Stroke Dysphagic patients.

Explain how nurses can become more involved in the strategic planning process as it relates to informatics needs in the health care setting

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Explain how nurses can become more involved in the strategic planning process as it relates to informatics needs in the health care setting

 

Shows similarities and differences between the strategic planning process and the nursing process

Relates the nurse’s role in the nursing process to the nurse’s role in the strategic planning process

Explains how nurses can become more involved in the strategic planning process as it relates to informatics needs in the health care setting

Differences between leadership and management. Principally, leadership is viewed as the ability to influence followers by providing guidance, direction, purpose and motivation (MacLeod, 2012).

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Differences between leadership and management. Principally, leadership is viewed as the ability to influence followers by providing guidance, direction, purpose and motivation (MacLeod, 2012).

 

Various suggestions point to the existence of differences between leadership and management. Principally, leadership is viewed as the ability to influence followers by providing guidance, direction, purpose and motivation (MacLeod, 2012). On the contrary, management is perceived as the ability ‘to get things done’, through planning, control, and sticking to established guidelines (Laurent, 2000). As such, traditional concepts of management, as established by Henri Fayol, considers the functions of management to be to plan (budget), organize, staff, and direct/coordinate (MacLeod, 2012). On the contrary, leadership has been associated with developing a vision, guiding (coaching) followers, inspiring (motivating) followers, communicating effectively (charisma), and modeling desired behavior (MacLeod, 2012; O’Neil & Morjikian, 2003). As such, whereas leadership is concerned with developing appropriate environment to encourage performance, management is concerned with effective use of resources to achieve results. Leadership thus taps into the emotional aspects of workplace organization while management focuses on logic.

Despite the differences highlighted, contemporary perspectives of management and leadership highlight various aspects of overlap. One such overlap is the issue of offering direction, which can be found as guiding, in leadership, and directing, in management (McLeod, 2012). Such an overlap has led to conceptualization of management as a form of leadership. This is exemplified in the situational leadership theory, where directing leaders, leaders whose management approach has similarities with autocratic leadership, are argued to be appropriate when leading low skilled or untrained workers (Chaudry, Jain, McKenzie, & Schwartz, 2008). Another aspect of overlap is in the goals of management and leadership. Although they may use different approaches, management and leadership seek to enhance the success of the organization. As such, successful leadership may involve management concepts such as performance monitoring through short-term feedback, which is unlike the traditional view that leadership is concerned solely on long-range perspectives (MacLeod, 2012). In this respect, to achieve aspects of leadership such as realizing the set vision, a management approach of planning (strategic and operational) may be necessary. Accordingly, as Thomas observes (as cited in MacLeod, 2012, p. 60), the most effective people in the contemporary world may be “… those who essentially are both managers and leaders.”

As a nurse leader, I believe that the overlap in management and leadership offers me an opportunity to expand my influence to create change. As observed by Laurent (2000), traditional nursing roles of disease management require management skills, while contemporary nursing roles where nurses are involved in organizational leadership necessitate leadership skills. I believe the overlap in these disciplines can thus help me to advocate for use of evidence-based practices, by enabling me to convince other management stakeholders of the benefits that accrue to the organization from adopting such practices. By so doing, I would facilitate the establishment of a culture where nurses are empowered to implement change in their workplace by adopting evidence in their practice.

References

Chaudry, J., Jain, A., McKenzie, S., & Schwartz, R. W. (2008). Physician leadership: The competencies of change. Journal of Surgical Education, 65(3), 213-220. doi:10.1016/j.jsurg.2007.11.014

Laurent, C. L. (2000). A nursing theory for nursing leadership. Journal of Nursing Management, 8(2), 83-87.

MacLeod, L. (2012). A broader view of nursing leadership: Rethinking manager-leader functions. Nurse Leader, 10(3), 57-61.

O’Neil, E., & Morjikian, R. (2003). Nursing leadership: Challenges and opportunities. Policy Politics Nursing Practice, 4(3), 173-179. doi:10.1177/1527154403254704

Substance abuse and hallucinations

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Substance abuse and hallucinations

Dervid, an adolescent boy was admitted for substance abuse and hallucinations. The client’s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to:

Dervid, an adolescent boy was admitted for substance abuse and hallucinations. The client’s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to:

a. Inform the mother that she and the father can work through this problem themselves.
b. Refer the mother to the hospital social worker.
c. Agree to talk with the mother and the father together.
d. Suggest that the father and son work things out.

Descriptive Epidemiology of Syphilis

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Descriptive Epidemiology measures the frequency of disease in a population, determines the characteristics of diseased individuals, and determines whether the occurrence of disease varies by place and time (Ashengrau & Seage, 2019). Sex is related to disparities in disease existence. Certain diseases are more common among men while other diseases are more prevalent among women (Ashengrau & Seage, 2019). This study was conducted in the country of Sweden resulting in a discussion on descriptive epidemiology for years 2000-2007 on the disease syphilis.

Syphilis a sexually transmitted disease, with different phases. Earlier phases last about three months and are highly infectious. However, the first indication of the first stage is most of the time tiny in shape, and an ulcer which is not painful. (Velicko & Arneborn, 2008). The Ulcer, for the most part, heals, the Bacterial infection grows to the second phase that every so often begins with a rash that can last weeks or months. Spreading can also develop during this stage when it becomes in contact with the mucous membrane of the skin. Syphilis can be controlled early and treated by detection (Velicko & Arneborn, 2008).

Treating adults prevents the abnormality of syphilis, which leads to serious newborn disorders, birth defects, and slower progression of the infant. According to the World Health Organization, there are 12 million newly developed cases that are new yearly and worldwide; in Western Europe, 140,000 new cases occur. (Velicko & Arneborn, 2008). Between the 1980s and 1990s, Syphilis and gonorrhea declined greatly. Increasingly sexual at-risk behavior and population movement have contributed to the rising cases of STDs, since 2000.

Rebirth of syphilis outbreaks occurs amongst men because men partake in sexual encounters with men (MSM) and therefore, increasing the dangers of sexual behavior. This was also learned in Sweden, reporting a decline in syphilis occurrences; in 1982 there were 5.8 cases per 100,000 individuals and in 1999, 0.4 cases per 100,000 individuals and by the year 2000, 1.1 cases per 100,000 individuals, and it has continued to rise. (Velicko & Arneborn, 2008). The age groups affected amongst the Swedish male population were individuals between the ages of 25-44 years old (Velicko & Arneborn, 2008).

Increased trends of syphilis in a 2 to 3-year period from worldwide of the continent were reported, mainly the progressed outbreaks in low inner-city occurrence areas.  Largely, the (MSM) population outbreaks also was recorded between numerous subclasses: Escorts and their clients, Communities of Immigrants, and Heterosexual adults with various sex partners (Fenton, 2004). Various subpopulation epidemics, in Western Europe, affect sexuality, ethnicity, gender, age group, area of residence, and communication with public health services (Fenton, 2004).

Methods of syphilis cases hold data on age, sex, the county of which is reporting, steady gestation period, and the patient’s history. Also, types of infections were reported: showing symptoms or not showing symptoms, a regular diagnostic, and having sexual contact. Phases of the infection including first, secondary, and early stages of syphilis, late stages, the third stage of syphilis and the unknown (Cates, Rothenburg & Blount, 1996). Evidence on population not reporting the disease late dormant and the third stage of syphilis is used to discover the phases of the infection reported by the physicians (Righarts, Simms & Solomou, 2004). Non-notifiable cases are removed upon medical officials within the county if reported. Notifiable cases remain in the surveillance system and the Route of transmission is retrieved (Cates, Rothenburg & Blount, 1996).  During the collection of the route of transmission, patients are expected to indicate if their contacts are sexual if the contacts are sexual the patient must determine whether the contact is a heterosexual or a homosexual partner (Velicko & Arneborn, 2008).

The prevalence in syphilis among (MSM) in Sweden and the United Kingdom was considered based on evaluating the percentage of men reporting having sex with men, accounts for 2.5% between 16 to 44-year-old male population in the UK (Velicko & Arneborn, 2008). From the year 2000, the occurrence of syphilis began rising, in 2004 2.1 cases per 100,000 individuals to approximately 99 cases. In 2007, occurrences of 2.6 cases were reported, a rise of 136% compared in 2000 of 1.1cases per 100,000 individuals (Velicko & Arneborn, 2008). Syphilis occurrence during 2000-2007, was three to seven times higher amongst males than females. In 2001, male to female proportion raised to 7.5 cases, having the highest the 1990s. 80-88% of syphilis cases were reported as men, between 2000-2007 (Velicko & Arneborn, 2008).

During 2000-2007 the average age for females reported with syphilis had an average of 33 years, men disease-ridden through heterosexual interactions was 38 years, and men infected through homosexual contact had a median age of 39 years (Velicko & Arneborn, 2008). In Sweden, countries Skåne and Stockholm; and cities; Malmö and Stockholm reported the largest cases of syphilis between (MSM) during the years 2000-2007. Stockholm County in 2004 stayed focus on the (MSM) epidemic, with most cases reporting from around Stockholm County (Payne, Berglund & Henriksson, 2005).  Projected syphilis occurrences amongst (MSM) in Sweden was 20-28 times higher than that of the Swedish male populace (Velicko & Arneborn, 2008).

Discussing the descriptive epidemiology on syphilis among (MSM) case in Sweden gives insight into the occurrences during the years of 2000-2007 and identifies the most affected population among heterosexual men. This research has been interesting and has broadened my understanding of why the percentages of syphilis in Sweden were much higher among heterosexual men than women. However, in conclusion, the high risk of the disease is primarily due to the lack of using protective devices during sexual intercourse in addition to participating in high-risk sexual behavior.

References

  • Ashengrau, A., & Seage, G. (2019). Descriptive Epidemiology.

    In essentials of epidemiology

    ( 4

    th

    ed.). Burlington, MA: Jones & Bartlett Learning.
  • Cates, W. J., Rothenburg, R. B., & Blount, J. H. (1996). Syphilis control: The historical context and epidemiologic basis for interrupting sexual transmission of treponema pallidum.

    Journal of the American


    Sexually Transmitted Disease Association

    ,

    23

    (1), 68-75. Retrieved from journals.lwww.com/stdjournal/Fulltext/1996/01000/syphilis_Control_The_Historic_Context_and.13.aspx
  • Fenton, K. (2004). A multilevel approach to understanding the resurgence and evolution of infectious syphilis in Western Europe.

    9

    (12),

    Euro Surveillance

    . Retrieved from https://doi.org/10.2807/esm.09.12.00491-en
  • Payne, L., Berglund, T., Henriksson, L., & Berggren-Palme, I. (2005). Re-emergence of syphilis in Sweden: results from a surveillance study for 2004.

    10

    (45),

    Euro Surveillance.

    Retrieved from https://doi.org/10.2807/esw.10.45.02830-en
  • Righarts A A., Simms I, L, W., Solomou M, & A, F. K. (2004). Syphilis surveillance and epidemiology in the United Kingdom.

    Euro Surveillance

    .

    9

    (12), Retrieved from https://doi.org/10.2807/esm.09.12.00497-en
  • Velicko I., Arneborn M, & Blaxhult, A. (2008). Syphilis epidemiology in Sweden: Re-emergence since 2000 primarily due to spread among men who have sex with men.

    Euro Surveillance

    .

    13

    (50) Retrieved from https://doi.org/10.2807/ese.13.50.19063-en

Development of Holistic Teaching Project: Laughter Yoga

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Laughter Yoga: Holistic Teaching Project

Have you ever heard “laughter is the best medicine”?  How do you feel after laughing?  Happy? Carefree?  Laughing always makes me feel good.  It can be said that laughing is good for your body, soul, and it releases stress.  Laughter has many healthy benefits such as increasing blood flow, boosts mood, strengthens your immune system, and releases endorphins; our bodies feel-good chemicals.  In response to laughter, catecholamine levels increase; mental functions improve; and skeletal muscles “massage” the internal organs, improving their blood supply (Lynes, Kawar, & Valdez, 2019).

Many nurses have high levels of stress because of their work environment can be very fast paced, understaffed, and stressful.  The nurses stress can be caused by years and years of stressful patient care, shortage of nurses, and no outlets to relieve stress.  We as nurses are always caring for the patients first and foremost, which leaves self-care last.  If a nurse is unable to relieve her stress, it can be damaging to her health both physically and mentally.  Years of stressful work can lead to health problems, work burnout, and possibly inadequate patient care.  Nurses need to find ways to cope with stress to avoid these damaging problems.  Some ways to relieve stress would be through exercising regularly, therapy groups, retreats, and creative outlet projects.  Many employers now offer wellness programs to their employees as part of the benefit packages offered to employees.  Employers are recognizing that healthy, happy, stress free employees are worth keeping.  We have several wellness classes offered on-site at my current place of employment and they are free to the employees.  Healthy, happy employees equal happy, healthy, and satisfied patients.

My holistic project is on Laughter Yoga.  Laughter Yoga began in 1999 by Dr. Madan Kataria in India.  He believed that laughter benefited our bodies health regardless if it was natural or unnatural laughter.  Our bodies could not distinguish the difference.  Many have done research on the effects of laughter and the benefits one gets from laughing.  After obtaining my information on Laughter Yoga, I will be leading a group of my nursing coworkers through a Laughter Yoga session.  My hope is to help my coworkers relieve some stress, feel better, and strengthen our bond by this group activity.


Assessment of learning needs

I will give each participant a short questionnaire to answer prior to beginning the teaching session.  This questionnaire will also include post evaluation questions that they will be able to complete once the learning session is done.  The pre-questionnaire will address their prior knowledge of Laughter yoga, any special learning needs, cultural considerations, preferred learning style, current health status, and their readiness to participate.  The post evaluation questions will have them rate the effectiveness of the class, what would they like to see next time, and what improvements could the teacher do to improve their experience.   There will also be an area that they can make any additional comments.


Teaching project

I will be teaching a group of three to six of my coworkers in Laughter Yoga.  After everyone completes the pre-questionnaire, I will have them form a circle.  Having them in a circle will allow everyone to see each other and feel as part of the group.  First, I will explain the three phases of Laughter Yoga: clapping, deep breathing, and laughter.  Clapping involves clapping with the hands flat, this activates the acupressure points in the hands.  The deep breathing is taking a deep breath from the belly to fill the diaphragm.  They will breathe in through their nose and exhale out the mouth.  The exhalations will be longer than the inhalations.  The last phase is laughter and I will show them an example of what we will be doing.

I will start off with instructing them on breathing exercises to get their blood flowing and warm up their muscles.  This will last approximately five minutes.  Once the warmup is complete, we will begin the clapping phase.  The clapping phase is a chant that goes like this: ho, ho…. ha, ha, ha.  So, the clapping is two claps together, then three claps together and we will do three sets of this.  This chant will be used throughout the teaching, usually after a laughter session.  Another chant we will be using is called child’s play, which goes like this: Very good, very good, yay(giving thumbs up); very good, very good, yay(thumbs pointing to self); very good, very good, yay( with arms up above the head).  This will be done in sets of two.  I will demonstrate modification of this if there are any participants who cannot raise their arms above their head.  Once the clapping phase is done, we will do 6 deep breathing episodes.  Next, we will begin our laughter session.  This session will last approximately 20 minutes in total.  In between each session, we will use either the clapping chant or the child’s play.

The laughter session will start with:

  1. Shaking hands – shaking hands with their neighbor while laughing and keeping eye contact.
  2. Child’s play – very good, very good, yay! For three sets.
  3. Sumo laughter – like a sumo wrestler position. Stomp one foot then the other then raise the arms up while laughing.
  4. Child’s play – very good, very good, yay! For three sets.
  5. Umbrella – one person holds the imaginary umbrella open and everyone else crowds around trying to get underneath it to get out of the rain while laughing the whole time.
  6. Child’s play – very good, very good, yay! For three sets.
  7. Milkshake – each hand has an imaginary cup in it.  You pour from one cup to the other, then drink it while laughing.
  8. Child’s play – very good, very good, yay! For three sets.
  9. Flossing – act like your flossing your teeth but bigger using their arms and head.
  10. Child’s play – very good, very good, yay! For three sets.
  11. Argument – pointing finger at each other like your arguing, laughing the whole time.
  12. Child’s play – very good, very good, yay! For three sets.
  13. Namaste – hands together like praying, maintain eye contact with each other.

I will end this session with the clapping chant for a set of three.  To finish the Laughter Yoga, I will end with some deep breathing exercises in a soft, soothing voice while their eyes are closed.

Once complete, each participant will be encouraged to complete the post evaluation questionnaire and hand it in to me once they are completed.

References

  • Lynes, L., Kawar, L., & Valdez, R. (2019). Can laughter yoga provide stress relief for clinical nurses? Nursing Management, 31-37.
  • Weinberg, M.K., Hammond, T., & Cummins, R. (2014). The impact of laughter yoga on subjective well-being: A pilot study. European Journal of Humour Research, 1, 4, 25-34.
  • Woodbury-Farina, M.A., Schwabe, M. (2015). Laughter yoga: benefits of mixing laughter and yoga. Yoga & Physical Therapy, 5, 209. doi: 10.4172/2157-7595.1000209
  • Yazdani, M., Esmaeilzadeh, M., Pahlavanzadeh, S., & Khaledi, F. (2014). The effect of laughter yoga on general health among nursing students. Iranian Journal of Nursing and Midwifery Research, 19, 1, 36-40.

Effects of the Gardasil Vaccination

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  • Obispo, Stacey L.

Vaccinations

Despite the Centers for Disease Control and Prevention (CDC) acknowledging vaccinations as one of top 10 impressive public health accomplishments of the twentieth century (Malone & Hinman), vaccines have still been cause for debate over the years. Fears over the years have resonated over vaccination risks and side effects. Sadly, parental unacceptance of general childhood vaccinations may have been persuaded from accepting incorrect beliefs (Gamble, Klosky, Parra, & Randolph, 2010). For example, the early childhood vaccination measles-mumps-rubella (MMR) was of recent controversy because many believed it caused autism (Gamble, et al., 2010). Gamble, et al. (2010) found that this controversy along with some vaccines inability to be fully successful with some recipients has contradicted vaccine effectiveness. As a result some parents within the public question whether all vaccinations which have risks will outweigh the benefits. Today I implore all parents to listen to the research and scientifically proven information I am going to share about vaccines so that your questions about its effectiveness can be put to rest. In addition, I will share with you pertinent facts that you should know about the vaccine Gardasil so that you can make an informed choice as to whether you should get your child vaccinated.

Balancing one’s individual rights with the rights of society to prevent their own illness versus the need for public health officials to prevent large scale epidemics should be thoughtfully considered. Today we can easily say that societal interest has conflicted with some parents’ interest. This occurs because in our society vaccinations are taken in efforts to not just aid the child from disease and illness rather, it is done to protect and prevent diseases and illnesses from the whole community. The way to balance individual rights with the rights of society regarding preventing individual illness and large scale epidemics is by modeling the practices of the US government regarding vaccinations.

The CDC states that some individuals argue that every adult with an s sound mental capacity should have the right to choose what should be done to their body (Malone & Hinman). The CDC’s response to such an argument was directed to the Supreme Court ruling on

Jacobson vs. Massachusetts w

hich upheld the rights of states to mandate vaccinations (Malone & Hinman). The rationale behind the court ruling was this: As long state wide vaccinations exist because of the need to prevent outbreaks of disease individual rights should not be held .The idea that one should have a choice in regard to their own being cannot be upheld because each being affect others .In other words, as long as humans remain social creatures , personal privacy and choice in regards to required vaccinations cannot exist. Each individual makes up a whole community. The ruling concluded that if all individuals had the choice to choose whether or not they should be vaccinated public health and public safety can become endangered when epidemics arise (Malone & Hinman).

The ruling on

Jacobson vs. Massachusetts

is enacted to ensure that through vaccinations disease prevention is granted to everyone. The ruling allowed states to have police power regarding vaccinations (Malone & Hinman). With police power, states are then empowered by the Constitution to make sure those rationale guidelines that were recognized by legislative depiction as will safeguard public health and safety ruing empowered states (Malone & Hinman). Another way states make sure that its constituents are getting vaccinated is through mandating school laws and prohibiting school enrollment to children who have not been vaccinated(Malone & Hinman). States have the authority to assert authority of the welfare of a child (Malone & Hinman). This is called

parens patriae

. Under this doctrine the Supreme Court states that there are no rights of religion or parenthood that are beyond limitation (Malone & Hinman). Furthermore, the Justices state that one’s right to practice religion freely does not give one the liberty to expose the child or community to communicable disease, ill health, or even death (Malone & Hinman).

Despite these safe guards that our government has enacted, there is exemptions that are offered for individuals who elect not to get vaccinated. Currently 48 states have exemption laws which ensure that religious and in some cases philosophic beliefs are protected and allow such individuals to be excluded from vaccinations (Malone & Hinman). Although these individuals have no constitutional rights under religious or philosophic beliefs, states allow these individuals to practice their freedoms (Malone & Hinman). This delicate balance appears to be working well since their has been an growth in numbers of vaccines being presented with a majority of the public taking them and a commonly low level of observable risk from disease (Malone & Hinman).

The vaccine Gardasil protects against precancerous lesions, such as CIN1/2/3,VIN2/3, cervical cancer triggered by the Human Papillomavirus (HPV) 16 and 18, and it also is a defense against infection and disease produced by HPV6 and11 as well as genital warts (Dominiak-Felden, et al., 2013). The age of Advisory Committee on Immunization Practices state that the HPV vaccination is targeted for females aged 11 and 12 years through the series of 3 injections given over 6 months (Gamble, et al., 2010).Boys ages 9-26 can be given the vaccination to prevent genital warts caused by the HPV (Merk- Sharp and Dohme Corp., 2014). The vaccine is approved to be given to girls, boys, women and men that are within the ages of 9-26 years (Merk- Sharp and Dohme Corp., 2014) . The vaccine Gardasil is intended for administration before sexual onset (Merk- Sharp and Dohme Corp., 2014). The HPV virus can be transmitted through: oral and digital infection by digital –genital contact or genital digital contact, vaginal and anal intercourse (Gamble, et al., 2010).

The Gardasil vaccine prevents spread of HPV. Around 70% of sexually active people will contract the Human Papillomavirus within their lifetime (Dominiak-Felden, et al., 2013). The HPV genotypes 16 and 18 have been accountable for approximately 73% of cervical cancers as well as the bulk of HPV-related vulval and vaginal cancers (Dominiak-Felden, et al., 2013). In addition 90% of genital warts affecting men and women are HPV 6 and 11(Dominiak-Felden, et al., 2013). The vaccine Gardasil prevents the transmission of HPV 16 and 18, HPV 6 and 11, and cervical cancers(Dominiak-Felden, et al., 2013).

On the individual level the impact of contracting HPV can be devastating because in some cases genital warts develop or even cancers (Dominiak-Felden, et al., 2013). This can effect not just the quality of one’s sexual life but their life expectancy because in some cervical cancer remains undiagnosed until it’s too late for treatment. The decline of HPV can only be accomplished by targeting the cariogenic types of HPV, making sure the protection is resilient, targeting the appropriate at risk population, and by ensuring that the medical community and public adhere to the recommended screening guidelines(Gamble, et al., 2010).In fact the American Cancer society estimates that 70% of cervical cancers can be prevented if HPV vaccinations are given over several decades(Gamble, et al., 2010).

The most common side effects associated with HPV vaccine Gardasil include: fainting, vomiting, dizziness, nausea, headache ,fever, and at the injection site; pain, swelling ,itching, bruising, and redness


(Merk- Sharp and Dohme Corp., 2014). Like all vaccinations there can be an allergic reaction. Signs of an allergic reaction include: difficulty breathing, rash hives, and wheezing (Merk- Sharp and Dohme Corp., 2014). Inform your child’s doctor if after vaccination they have: chills, skin infection, bleeding or bruising more than normal, swollen glands, joint pain, unusual tiredness, overall feeling of being unwell, pain in the leg, shortness of breath, chest pain, aching muscles, or seizure. (Merk- Sharp and Dohme Corp., 2014). Remember the vaccine Gardasil has been evaluated and approved for use by the FDA and safety is continually evaluated by the CDC for safety on an ongoing basis (Merk- Sharp and Dohme Corp., 2014).

Psycho-social impacts of whether the Gardasil vaccination will be utilized is associated with doctors recommendations, parental views and adolescences attitudes (Gamble, et al., 2010). Health care attitudes and recommendations by doctors impact families because their views influence whether an individual will get vaccinated with Gardasil. For instance, if the pediatricians attitude and intention is to promote the HPV vaccine research has shown that they will have a successful delivery(Gamble, et al., 2010).

The choice as to whether a parent will immunize their child can be influenced by their cultural beliefs and also by a parents view or personal factors regarding one’s susceptibility to HPV(Gamble, et al., 2010). Research documented by Gamble, et al., (2010) states that parents who make the decision to vaccinate against sexually transmitted infections are inclined to do so based on their personal beliefs and their adolescent’s attitudes about contraception use. Parents who have open communication regarding sex with their child have the tendency to vaccinate against HPV(Gamble, et al., 2010).Adolescent attitudes regarding HPV vaccination have been found to be similar to parental views(Gamble, et al., 2010).

A concern that may arise from some parents who may consider giving their adolescent the vaccination is; will the vaccination give my child permission to become sexually active because they have been vaccinated against HPV? According to the American Academy of Pediatrics (2013) research studies demonstrate that children who receive the HPV vaccine do not engage in sex any sooner than those who have been given other teen vaccines. Essentially the findings indicate that children do not see the HPV vaccine as a license to engage in sexual activity (American Academy of Pediatrics, 2013).

In conclusion, parents vaccinating your children with Gardasil will not make them prematurely sexually active. The benefits of taking Gardasil can lessen their risks at cancers and genital warts. This preventive vaccine has the potentially to reduce cervical cancers by 73% and vulvular cancers by 50%. The side effects associated with taking Gardasil are no different than other vaccines your children have already been given. Being uncomfortable about having a conversation about HPV and sex should not deter anyone from getting their child vaccinated. The benefits of being vaccinated are far too great to the individual and society as a whole to let a moment of being uncomfortable potentially dictate an individual’s life expectancy.


Facts about Gardasil and HPV

  • The vaccine Gardasil protects against precancerous lesions, such as CIN1/2/3,VIN2/3, cervical cancer triggered by the Human Papillomavirus (HPV)16 and 18, and it also is a defense against infection and disease produced by HPV6 and11 as well as genital warts (Dominiak-Felden, et al., 2013).
  • The HPV vaccination is targeted for females aged 11 and 12 years through the series of 3 injections given over 6 months (Gamble, et al., 2010).
  • Boys ages 9-26 can be given the vaccination to prevent genital warts caused by the HPV(Merk- Sharp and Dohme Corp., 2014).
  • The vaccine is approved to be given to girls, boys, women and men that are within the ages of 9-26 years (Merk- Sharp and Dohme Corp., 2014) .
  • The vaccine Gardasil is intended for administration before sexual onset (Merk- Sharp and Dohme Corp., 2014).
  • The HPV virus can be transmitted through: oral and digital infection by digital –genital contact or genital digital contact, vaginal and anal intercourse (Gamble, et al., 2010).
  • American Academy of Pediatrics (2013) state that children who receive the HPV vaccine do not engage in sex any sooner than those who have been given other teen vaccines.
  • Most common side effects associated with HPV vaccine Gardasil include: fainting, vomiting, dizziness, nausea, headache ,fever, and at the injection site; pain, swelling ,itching, bruising, and redness (Merk- Sharp and Dohme Corp., 2014).

References

American Academy of Pediatrics. (2013, August 7).

Vaccinating your preteen: Addressing common concerns

. Retrieved from

http://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccinating-Your-Preteen-Addressing-Common-Concerns.aspx

Dominiak-Felden, G., Cohet, C., Atrux-Tallau, S., Gilet, H., Tristram, A., & Fiander, A. (2013). Impact of human papillomavirus-related genital diseases on quality of life and psychosocial wellbeing: results of an observational, health-related quality of life study in the UK. BMC Public Health, 131065. doi:10.1186/1471-2458-13-1065

Gamble, H. L., Klosky, J. L., Parra, G. R., & Randolph, M. E. (2010). Factors Influencing Familial Decision-Making Regarding Human Papillomavirus Vaccination. Journal Of Pediatric Psychology, 35(7), 704-715. doi::10.1093/jpepsy/jsp108

Malone, K. M., & Hinman, A. R. (n.d.).

Vaccination mandates: The public health imperative and individual rights

. Retrieved from

http://www.cdc.gov

.

Merk-Sharp and Dohme-Corp. (2014).

Side effects of Gardasil

. Retrieved from

http://www.gardasil.com/about-gardasil/side-effects-of-gardasil/

Taunton construction inc.s capital situation is described as follows

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P13-25 Taunton Construction Inc.’s capital situation is described as follows:  Debt:  The firm issued 10,000 25-year bonds10 years ago at their par value of $1,000.  The bonds carry a coupon rate of 14% and are now selling to yield 10%. Preferred Stock: 30,000 shares of preferred stock were sold six years ago at a par value of $50.  The shares pay a dividend of $6 per year. Similar preferred issues are now yielding 9%.  Equity:  Taunton was initially financed by selling 2 million shares of common stock at $12.  Accumulated retained earnings are now $5 million.  The stock is currently selling at $13.25. Taunton’s Target Capital Structure is as follows: Debt                             30.0%Preferred Stock                         5.0%Common Equity          65.0%                                   100.0% Other information: ·       Taunton’s marginal tax rate (state and federal) is 40%. ·       Flotation costs average 12% for common and preferred stock.·       Short-term treasury bills currently yield 7.5%.·       The market is returning 12.5%.  ·       Taunton’s beta is 1.2.·       The firm is expected to grow at 6% indefinitely. ·       The last annual dividend paid was $1.00 per share.·       Taunton expects to earn $5 million next year.  ·       The firm can borrow an additional $2 million at rates similar to the market return on its old debt. Beyond that lenders are expected to demand returns in the neighborhood of 14%.·       Taunton has the following capital budgeting projects under consideration in the coming year.    These represent its investment opportunity schedule (IOS).                                                  Capital       CumulativeProject              IRR    Required      Cap. Req.A                     15.0%    $3M             $3MB                      14.0%    $2M             $5MC                      13.0%    $2M             $7MD                     12.0%    $2M             $9ME                      11.0%    $2M             $11M a. Calculate the firm’s capital structure based on book and market values and compare with the target capital structure.  Is the target structure a reasonable approximation of the market value based structure?  Is the book structure very far off?   b. Calculate the cost of debt based on the market return on the company’s existing bonds.   c. Calculate the cost of preferred stock based on the market return on the company’s existing preferred stock.  d. Calculate the cost of retained earnings using three approaches, CAPM, dividend growth, and risk premium.  Reconcile the results into a single estimate.   e. Estimate the cost of equity raised through the sale of new stock using the dividend growth approach. f. Calculate the WACC using equity from retained earnings based on your component cost estimates and the target capital structure.   g. Where is the first breakpoint in the MCC (the point where retained earnings runs out)? Calculate to the nearest $.1M. h. Calculate the WACC after the first breakpoint. i. Where is the second breakpoint in the MCC (the point at which the cost of debt increases.)  Why does this second break exist?  Calculate to the nearest $.1M.   j. Calculate the WACC after the second break. k. Plot Taunton’s MCC. l. Plot Taunton’s IOS on the same axes as the MCC.  Which projects should be accepted and which should be rejected?  Do any of those rejected have IRRs above the initial WACC?  If so, explain in words why they’re being rejected.   m. What is the WACC for the planning period? n. Suppose project E is self-funding in that it comes with a source of its own debt financing.  A loan is offered through an equipment manufacturer at 9%.  The cost of the loan is 9% ´ (1-T) = 5.4%. Should project E be accepted under such conditions?

Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team. How is this advantageous to patient outcomes?

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Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team. How is this advantageous to patient outcomes?

Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team. How is this advantageous to patient outcomes?
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