Healthcare Quality Improvement Essay

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Healthcare Quality Improvement Programs

In order to understand continuous quality improvement (CQI) in healthcare, it is first important to understand the history. This knowledge is helpful in assessing CQI, especially when healthcare has utilized many ideas from other sectors of industry, such as manufacturing.

Modern quality improvement in medical care dates back to the Florence Nightingale period. She associated the enhanced result of the injured with the quality of nursing care (Sadeghi, Barzi, Mikhail, & Shabot, 2013). Her use of statistical instruments to interpret information is the heart of evidence-based nursing.

The first physician Ernest Codman was the first physician to officially show interest in the contemporary ideas of medical care quality and quality assessment, which his idea was to follow surgical patients in hospitals and then assess the outcomes, or “end results” in his own words, of these surgeries, including any complications that occurred (Sadeghi, Barzi, Mikhail, & Shabot, 2013). He hoped to set up a database that would allow him to acknowledge diagnostic and therapy mistakes and link them to the result then make these accounts public so that patients could choose where to get care (Sadeghi, Barzi, Mikhail, & Shabot, 2013). He was the founder of the American College of Surgeons ‘ Hospital Standardization Program in 1917 (which later became the Joint Healthcare Organizations Accreditation Commission) (Sadeghi, Barzi, Mikhail, & Shabot, 2013). The fundamental theme in his program was dependence on skilled physicians, communications between physicians, and licensing and oversight of physicians and equipment. From this view, it is evident that quality has been seen as a product of professional judgement and not based on any particular criteria or measure.

In 1952, the American College of Physicians, the American Hospital Association, the American Medical Association and the Canadian Medical Association joined the American College of Surgeons to create the Joint Commission on Hospital Accreditation, which was eventually renamed the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), now known as the Joint Commission, in 1987 (Sadeghi, Barzi, Mikhail, & Shabot, 2013).

Perhaps the most well-known person with significant contributions to quality evolution and its definition in health care is Avedis Donabedian. In many ways, he was the first to acknowledge the systemic nature of healthcare delivery. Donabedian believed that the quality of healthcare is a result of science and technology and its healthcare applications. He has given a framework for assessing the quality of medical care by identifying three aspects that affect care delivery: structure that relates to the environments of care given, process that relates to actions involving the provision and receiving of care, and outcome of the results is the impacts of patient care (Sadeghi, Barzi, Mikhail, & Shabot, 2013).

It took several decades for government and private organizations to embrace the structure of Donabedian for quality measurement in medical care. Interest in more accurate measurement gained momentum with the emergence of two critical developments, the increasing cost and pressure from payers and the public identifying report of bad quality care (Sadeghi, Barzi, Mikhail, & Shabot, 2013).

Much of today’s stress on healthcare is its price. There are many practices that continue to suffer from this. When a person thinks about productivity, it might be the term sales that comes to mind. This could be measured by the products and services a patient could receive when it comes to healthcare (Burrill, Parker, & Fitzgerald, 2019). This could imply prescriptions, hospital visits or stays, or just visiting a primary care physician.  There are many things that come into play when we speak about results in health care. Some of these would be and are not restricted to diet, practice, earnings, or perhaps even substance abuse (Burrill, Parker, & Fitzgerald, 2019). These contribute directly to the status as well as to our access to medical care.

The Affordable Healthcare Act became the healthcare reform law of the nation in March 2010 (Health Reform, 2010).  It called for the reform of private and public health insurance. Not only has this law helped ensure hundreds of individuals and fund health prevention, but it has also permitted customers to lower their expenses (Parry, 2018).

The quality of health care is very crucial, it informs us how the health care system performs and eventually leads to improved health care. This then leads to an overall improvement in healthcare. One of the greatest healthcare characteristics is to prevent misuse of services (Levitt, Claxton, Cox, Gonzales, & Kamal, (n.d.). Also, the overuse of healthcare facilities (Levitt, Claxton, Cox, Gonzales, & Kamal, (n.d.). For instance, for one medical problem, somebody might see various physicians at various practices. Some do this in the hopes that the same prescription will be issued many times. Today’s opioid crisis is at an all-time high, and this crisis can be controlled with physicians, pharmacies, and prescription drug monitoring.


References

NURS 6630 Assignment Treating Clients With Pain

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NURS 6630 Assignment Treating Clients With Pain

NURS 6630 Assignment Treating Clients With Pain

 

Pain can greatly influence an individual’s quality of life,
as uncontrolled pain negatively impacts mood, concentration, and the overall
physical and mental well-being of clients. Although pain can often be
controlled with medications, the process of assessing and treating clients can
be challenging because pain is such a subjective experience. Only the person
experiencing the pain truly knows the intensity of the pain and whether there
is a need for medication therapies. Sometimes, beliefs about pain and
treatments for pain can have an adverse effect on the provider-client
relationship. For this Assignment, as you examine the interactive case study
consider how you might assess and treat clients presenting with pain.

Learning Objectives

Students will:

Assess client factors and history to develop personalized
therapy plans for clients with pain

Analyze factors that influence pharmacokinetic and
pharmacodynamic processes in clients requiring therapy for pain

Evaluate efficacy of treatment plans for clients presenting
for pain therapy

Analyze ethical and legal implications related to
prescribing therapy for clients with pain

Learning Resources

Note: To access this week’s required library resources,
please click on the link to the Course Readings List, found in the Course
Materials section of your Syllabus.

Required Readings

Note: All Stahl
resources can be accessed through the Walden Library using this link. This link
will take you to a log-in page for the Walden Library. Once you log into the
library, the Stahl website will appear.

Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential
Psychopharmacology, 4th ed tab on the Stahl Online website and select the
appropriate chapter. Be sure to read all sections on the left navigation bar
for each chapter.

Chapter 10, “Chronic Pain and Its Treatment”

Stahl, S. M., & Ball, S. (2009a). Stahl’s illustrated
chronic pain and fibromyalgia. New York, NY: Cambridge University Press.

To access the following chapter, click on the Illustrated
Guides tab and then the Chronic Pain and Fibromyalgia tab.

Chapter 5, “Pain Drugs”

ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS:NURS 6630 Assignment Treating Clients With Pain

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New
York, NY: Cambridge University Press.

To access information on the following medications, click on
The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the
appropriate medication.

Review the following medications:

For insomnia

amitriptyline

amoxapine

carbamazepine

clomipramine

clonidine (adjunct)

desipramine

dothiepin

doxepin

duloxetine

gabapentin

imipramine

lamotrigine

levetiracetam

lofepramine

maprotiline

memantine

milnacipran

nortriptyline

pregabalin

tiagabine

topiramate

trimipramine

valproate (divalproex)

zonisamide

American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Note: Retrieved from Walden Library databases.

National Institute of
Neurological Disorders and Stroke. (2016). Pain: Hope through research.
Retrieved from
http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_2

Required Media

Laureate Education
(2016a). Case study: A Caucasian man with hip pain [Interactive media file].
Baltimore, MD: Author

Note: This case study will serve as the foundation for this
week’s Assignment.

To prepare for this Assignment:

Review this week’s Learning Resources. Consider how to
assess and treat clients requiring therapy for pain and sleep/wake disorders.

The Assignment

Examine Case Study: A Caucasian Man With Hip Pain. You will
be asked to make three decisions concerning the medication to prescribe to this
client. Be sure to consider factors that might impact the client’s
pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

Decision #1

Which decision did you select?

Why did you select this decision? Support your response with
evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision?
Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve
with Decision #1 and the results of the decision. Why were they different?

Decision #2

Why did you select this decision? Support your response with
evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision?
Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve
with Decision #2 and the results of the decision. Why were they different?

Decision #3

Why did you select this decision? Support your response with
evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision?
Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve
with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your
treatment plan and communication with clients.

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Prenatal Risk Factors and Helping a Healthy Pregnancy | Case Study

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Women’s Clinic Scholarly Paper


Introduction

Pregnancy is a time of highs and lows, ups and down. But overall it is a period of great growth and development for the mother and the child. Throughout a pregnancy, a mother’s prenatal visits are very important. These are the visits that she looks forward to. She looks forward to coming in, to hear the baby’s heartbeat for the first time, to get ultrasound pictures to show to the family, and to find out the baby’s gender if desired. Prenatal visit are also essential to ensure the health of the mother and the baby. During these visits, the nurses, physicians, and other members of the healthcare team all work together to make sure the mother and the baby are in the best health possible.

For a healthy pregnancy, focus on health should begin even before conception. The mother should work to be an optimal weight, as well as preparing her body by taking prenatal vitamins which supplement a lot of the important substances needed to maintain a healthy pregnancy. An example is folic acid, which prevents neural tube defects. The mother should also focus on her lifestyle choices. For example, a mother should quit smoking, stop drinking alcohol, and stop using illicit drugs. All of these changes to the mother’s life will help to make her pregnancy decreases her risk of multiple complications.

Prenatal visits are the most important part of a pregnancy. While the mother is excited for her coming baby, the health care team is working hard performing multiple tests, and screenings to rule out any risks or complications that may arise. Throughout these visits, there is a lot of education provided. Education regarding the test and screenings being performed, vaccinations that will be administer, expectations during the pregnancy and labor, and education regarding methods of feeding. Overall, prenatal visits are the forefront of a healthy pregnancy and can make a difference in the outcome of a mothers pregnancy. That is why the purpose of this paper is to explore information collected during prenatal visits, pinpoint risk factors related to the mother and baby, and to analyze the teaching done during these visits to ensure that the mother has a healthy, happy, and successful pregnancy.


Health History

AE, is a 20 year old who is 13 weeks and 3 days gestation, due on Aug. 10

th

, 2019. She is Caucasian, and of non-Hispanic or Latino ethnicity. She is a high school graduate, graduating in 2017. The pateint resides in Bloomsburg, where her and her boyfriend have their own apartment together. AE is currently unemployed. She was let go from her job at a call center in Bloomsburg about 2 weeks ago, due to her pregnancy. She claims she was not being treated fairly, since she disclosed to her boss that she was pregnant, and then was let go soon after. This is her first pregnancy GTPAL: 1,0,0,0,0, so she has no past obstetric history. Her last menstrual period fell on Nov. 3, 2018. Since then, she has experienced symptoms such as nausea, vomiting, headaches, fatigue, breast tenderness, mild cramps, light spotting for a day, and right sided pain due to a cyst, that is being monitored on her right ovary.

A.E. has a past medical history that includes Lyme disease, gallbladder disease, frequent dehydration, and fibromyalgia. In 2014, she had two surgeries, one which was a cholecystectomy or removal of her gall bladder due to her gallbladder disease. The other was an EGD, she then had a follow up EGD in 2015. The patient has a mental health history of anxiety and depression, but is currently in good health and has not had any problems associated with her diagnosis in over a year; she is not currently on medication for them. The patient is currently just taking her prenatal vitamins in the gummy form, which the doctor has approved. A.E. was previously taking naproxen for her fibromyalgia but has stopped taking it since she has been pregnant. In regards to her family medical history, there is nothing evident of much concern. Her mother suffers from peptic ulcer disease, while her father has a history of viral hepatitis. Her maternal grandmother has a history of thyroid disorder, and her fraternal grandmother had a cholecystectomy is her md 30’s. She also discussed her mother’s sister has an extensive history dealing with a heart disorder. The father’s family medical history was not obtained during the appointment.

The patient A.E., is 20 years old, she is 5 foot 8 inches tall and before pregnancy she weighted 121 pounds. Her starting BMI was calculated to be 18.44. Upon arrival of her most recent monthly visit A.E. weighs 115 pounds, that is a 6 pound weight loss from her initial prenatal visit. This loss of weight has altered her BMI which is now 17.48, she is now considered underweight and has not effectively gained weight during the first trimester of her pregnancy. This is a slight concern, the patient was referred to maternal fetal medicine and will be closely monitored for the duration of her term. The patient’s dietary intake is very little. She claims that she often does not have an appetite, and even when an appetite is present, she eats very little. On a regular day depending on what time she wakes up ,she might have a small or a half of sandwich and fruit during that day and not eat again until dinner. A consultation with a dietitian was recommended, but the patient refused.

Since being unemployed, A.E. has not been very active. She has no current occupational demands and does not exercise on a regular basis. Most of her days are spent in her apartment. At this moment, she has no physical stressors or limitations. The patient disclosed that her and her partner are still sexually active and have not experienced any problems or discomfort with intercourse. She has no risk of STIs at this moment, all of her screenings came back negative. Overall, the patient lives a pretty healthy lifestyle. She is a former smoker, who went through about a half a pack a day. She has not smoked in over a year and does not plan on starting again. She does not drink and has no history of substance abuse. She has even stopped taking prescription medication that could potentially cause any harm to the baby. She does drink caffeine in sodas occasionally, but not enough for it to be of concern. In conclusion, A.E. is in overall good health for her pregnancy.

For A.E. and her boyfriend, this was not a planned pregnancy. Originally, the couple were very nervous and scared. They were not sure if they were fit to be parents just yet. They are both young and had recently just moved into an apartment together. Their main concern was being financially stable to properly care for the baby. It took a while for them to emotionally adjust, but since their pregnancy journey has begun their attitudes have shifted. A.E. is now extremely excited about not only her experience of being pregnant but excited for the baby to arrive. She is aware that she is still in the beginning stages her pregnancy, but she is anxious to see what the rest of her journey entails. During the appointment, when discussing the baby and movement, A.E. could not stop smiling. She described the baby as a jumping bean especially since the last ultrasound that she had during her appointment with maternal fetal medicine. Together, they are very excited and are trying to mentally prepare for what is to come. The couple, as a whole, has a very strong and supportive family structure. Both the father and mother’s parents are very involved. A.E. claims that she has a family full of nurses and has multiple people to go to, if the couple needed something. She plans on delivering at Danville, where her cousin is a labor and delivery nurse. No culturally or religious needs were specified by the couple. Generally, the couple and the baby seem to have a very strong support system and are in very good hands.


Prenatal Risk Factors

In general, this primigravida mother is healthy. The only risk factor of concern for her pregnancy is her poor diet. However, this is a modifiable risk factor. As discussed previously, the patient had a 6 pound weight loss in the first trimester of the pregnancy. This is sometimes normally seen during this stage of pregnancy due to intolerances to certain food and decreases in appetite as a result of nausea and vomiting (Davidson, 2016). For a women whose pre-pregnancy BMI falls within the healthy range of 18-24.9, the recommended weight gain during pregnancy is somewhere between 25-35 pounds. In general, the mother to gain 2-3 pounds in her first trimester and ¾ – 1 pound per week there after throughout the rest of the pregnancy (Davidson, 2016). However, this is an important time of growth and development for the fetus so inadequate nutrition or poor weight gain puts the mother and the fetus at risk. For the mother, it increases her risk of having a preterm birth. This also puts her at greater risk for anemia, due to decreased iron intake through food. As well as an increased risk of preeclampsia, which can be describes as the toxemia of pregnancy that lead to hypertension, albuminuria, and edema, that can be life threating to both the mother and the fetus (Davidson, 2016). As a result of the mother malnutrition and poor weight gain, the fetus could suffer complications from prematurity, fetal malnutrition, intrauterine growth restriction, or be small for gestation age, which are all concerns for the mother and the Healthcare Provider. Due to the high risk and poor outcomes associated with the mothers poor diet, she was referred to maternal fetal medicine for a consultation and to be closely monitored during her pregnancy. The mother should also be referred to a dietitian to discuss plans for increasing caloric intake and focusing on proper elements of nutrition to incorporate into her diet to ensure proper management of weight for the remainder of the pregnancy. Even though the risk are evident, overall she is not a high risk pregnancy, due to the fact that this risk factor is modifiable. With proper education and lifestyle changes any further complications can be prevented.


Critique of Teaching and Additional Teaching

During the follow up appointment, the mother expressed her concerns about her recent weight loss and lack of appetite during the pregnancy. The patient had already been referred to and seen by maternal fetal medicine. A consultation with the dietitian was also offered, which the patient denied. No further teaching was done in regard to nutrition at this visit. Other education that was discussed was related to second trimester screenings and health as the mother would be approaching her second trimester at the end of the week. Screenings including AFP testing for neural tube defects. The one hour glucose tolerance test done between 24 and 28 weeks, and preparation education for the t-dap vaccine which is administered in the third trimester, between weeks 27 and 36 (Davidson, London, & Ladewig, 2016). The nurse provided the mother and father with brochures and pamphlets that had all the information regarding the topics discussed during the appointment, which was very appropriate for her education level. Overall, the teaching was very family centered. She provided the information to both the mother and the father and assessed both of their understanding of the information presented to them. From observation, the teaching that was provided was effective, relevant, and understood by the young parents.

While the teaching during this follow up appointment was effective, there was a lot more education that could have been done. More recommendations in regard to nutrition and education on adequate weight gain could have been provided. For example, the mother should have been educated on increasing her caloric intake by 300 calories per day (Davidson, London, & Ladewig, 2016). Along with increasing her intake of protein, calcium, iron, and vitamins (Davidson, London, & Ladewig, 2016). Protein is important for muscle growth of the fetus, as well as allows cells to increase in number and size to allow maternal tissue, like the uterus and the breast to grow (Davidson, London, & Ladewig, 2016). Iron is essential to avoid anemia and for the formation and maintenance of blood cells for both the mother and the fetus (Davidson, London, & Ladewig, 2016). In addition, the mother should ensure her intake of folic acid, at least 0.4mg/day, to prevent neural tube defects (Davidson, London, & Ladewig, 2016). This is usually achieved through prenatal vitamins. Tips such as adding a meal a day of nutrient-dense food should have been discussed. This additional meal has been shown to assist in meeting the increased caloric intake needed for the pregnant women and growing fetus, as well as improves the nutritional quality of the mother’s diet to help with consuming adequate amount of necessary micronutrients (Wessells et al., 2018). Proper intake of all these components is important for adequate health of the mother and proper growth of the fetus.

Pregnant women view nurses in the maternity field as a trusted source of knowledge and guidance. Nurses are in the perfect position to provide education that can promote health in these women during such a critical time. It is essential for nurses in this field to have the proper education and training in order to provide the women with the appropriate education needed to have a healthy pregnancy for both the mother and the baby. Nankumbi, Ngbirano, & Nalwadda (2018), conducted a study, where they performed six in-depth interviews with midwives, who are frequently involved in the care of pregnant women, at an antenatal clinic. The study explained how every pregnant women should be provided education concerning the importance of adequate nutrition, relevancy of weight gain, increased nutrient requirements, nutrient-rich dietary sources, importance of micronutrient supplementation, and appropriate food preparation during routine antenatal visits (Nankumbi, Ngbirano, & Nalwadda, 2018). Not only is all of this crucial to a healthy pregnant women as a source of health promotion but also for women who have specific nutritional needs. As discussed in the article, it was found that education about nutrition provided to pregnant women, has a significantly positive impact on the general outcomes of the pregnancy. Overall, it improved the mother’s awareness of her increased nutritional needs. Hence, contributing to the improved nutritional intake by the mothers who received this education (Nankumbi, Ngbirano, & Nalwadda, 2018). In spite of the increased knowledge, the bulk of education is usually done at the initial or first prenatal visit. Lack of follow-up education and reinforcement or summary of information previously covered can contribute to the parents’ lack of knowledge regarding important topics, such as nutrition. Nutrition, along with other educational material provided during pregnancy, plays an important part in the postpartum period, especially if the mother is planning on breastfeeding.

Another topic not discussed enough during this follow-up prenatal appointment was vaccinations. During the appointment, the nurse explained routine vaccinations that are given during pregnancy. She briefly discussed each vaccination that is recommended and when they are routinely administered. There was no discussion of the reasons for these vaccinations or how these vaccinations work. With the recent controversy surrounding vaccinations, immunizations are a very important topic that should be discussed in detail at every prenatal visit to ensure the health of both the mother and the fetus. One of these immunizations is the T-dap vaccine. As reviewed previously, the t-dap is administered to the mother in her third trimester around 27 to 36 weeks of gestation (Davidson, London, & Ladewig, 2016). The nurse explained that it is used to protect against pertussis and that the mother and father should be vaccinated. A pamphlet with more information was given to the couple but no further information was provided at this time. This could be contributed to the nurse’s lack of information or confidence regarding the topic.

Education regarding the importance of this vaccine and how it works should have been given during the visit. An example is pertussis, which is a common disease that can be easily transmitted to a vulnerable child who is under a year. While adults have the proper immune system to fight this disease, it is life-threatening to infants and young children. Information regarding how this vaccination should be administered to both parents and any immediate family, who may be in contact with the child is extremely important; this information should have also been included in the education session. It has been proven that vaccination of the mother and act of “concooning” or vaccination of immediate family, decreases the incidence of transmission of pertussis to the infant (Unisa, 2017).

Unisa (2017), conducted a study on improving the education of pertussis in postpartum women and their families. The researcher studied staff nurses at a hospital in California. The nurses in the study participated in two educational sessions about importance of vaccination of close family, as well as provide these nurses with a toolkit to help them better educate mothers and families on this topic. The goal of this study was to increase the nurses’ knowledge of the subject, in return making them more confident in educating women and families about the vaccine. In the end, this increased the amount of vaccinations given, due to the education and awareness of the disease. Most pregnant women are not aware of the risk related to not being vaccinated. There is also a lack of knowledge regarding disease, and its mode of transmission (Unisa, 2017). This study supports the claim, that further education is needed on the importance and risk of this vaccine. The author suggests that a toolkit for education should be provided to nurses in order to guide their education and follow up and to ensure that all information is being successfully provided to the mothers and family (Unisa, 2017). It has been proven that patients’ decisions are based on the effectiveness of education and information provided to them by their nurse, especially in a maternity setting (Unisa, 2017). By providing our nurses with further education, it allows them to be better equipped and knowledgeable on topics that allows them to provide proper education to patients. As a result of better educating our nurses, parents and families will be thoroughly educated, not only on topics such as pertussis and its vaccination, but on all health promotion topics. This allows parents to make educated decisions which ensures the health of themselves during pregnancy, as well as their child during a period of growth and development.


Conclusion

Generally speaking, there is a lot that goes in to a healthy pregnancy. Prenatal visits are essential for positive outcomes for the mother and the baby. These appointments, are crucial to identify risk factors, and to prevent complications. The effectiveness of the information gathered from these meetings will make all the difference. In terms of the patient observed, she was mostly healthy and had very few risk factors. Her only risk factor of concern was her recent weight loss during the first trimester of pregnancy, which lead to her being underweight. Aside from her concerns about her weight, she was very excited to be having a baby. Throughout the appointment, she was provided with education on a glucose tolerance test and Tdap vaccination. The education provided could have been in more detail in order for the mother to fully understand the implications on mother and baby.

Through the research presented, it was found that that more in depth education regarding individualized topics specific to the client results in better overall outcomes for the parent and the child. Topics such as nutrition and immunization were discussed during the follow up prenatal visit. Further education could have been provided on both of these topics. Parents rely on healthcare providers for information and recommendations to guide them to make the best decision possible regarding the health of mother and the baby. It was proven that education is a crucial part of health promotion, as well as addressing risk factors present. As nurses and health care providers, it is important to be well educated on topics, in order to provide adequate, updated, evidenced-based information to our patients. The better we educate our patients, the better their overall outcomes will be.



References

  • Davidson, M. R., London, M. L., & Ladewig, P. W. (2016).

    Olds maternal-newborn nursing & womens health across the lifespan

    . Boston: Pearson.
  • Nankumbi, J., Ngabirano, T. D., & Nalwadda, G. (2018). Maternal Nutrition Education Providedby Midwives: A Qualitative Study in an Antenatal Clinic, Uganda.

    Journal of Nutritio nand Metabolism,


    2018

    , 1-7. doi:10.1155/2018/3987396
  • Wessells, K., Young, R., Ferguson, E., Ouédraogo, C., Faye, M., & Hess, S. (2019). Assessment of Dietary Intake and Nutrient Gaps, and Development of Food-Based Recommendations, among Pregnant and Lactating Women in Zinder, Niger: An Optifood Linear Programming Analysis.

    Nutrients,


    11

    (1), 72. doi:10.3390/nu11010072
  • Unisa, M. (2017). Improving Pertussis Education for Postpartum Women and their Family Members.

    Doctor of Nursing Practice (DNP) Projects

    . Retrieved February 11, 2019.

Affective and Organic Disorders: Developing Mental Health Nursing Practice

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Affective and Organic Disorders: Developing Mental Health Nursing Practice


Introduction

Schizoaffective Disorder is a mental health condition in which individuals suffer from symptoms synonymous with schizophrenia and a mood disorder or bipolar disorder. More specifically, when mood disorders are prominent, such that an individual has episodes of mania and severe depression and also struggles with the onset of psychotic symptoms, such as hallucinations and delusions, that person is likely to suffer from the disorder schizoaffective. According to Yasuhiko et al, (2018) schizoaffective disorder is thought to be between the diagnosis of schizophrenia and the diagnosis of bipolar disorder, as the symptoms of both diseases are often manifested. Despite the problem with the term Schizophrenia, we cannot deny that many are very distressed and unhappy because of the experience of hearing voices and delusionary belief (DOH, 1992). However, the presence of schizoaffective disorder may ultimately warrant an alternative diagnosis of bipolar disorder. When an individual suffers from schizoaffective disorder, this is likely to affect their academic or occupational functioning, as well as their ability to interact socially. In addition, people who suffer from this mental illness often have difficulty caring for themselves and experience problems of perception. The life expectancy of a person diagnosed with schizophrenia is reduced by 10 years compare with someone without mental health problem (Brown et al 2000, Mental Health and Disorder 2000).

 


Discussion

Schizoaffective disorder is a serious mental disorder characterized by loss of contact with reality (psychosis), hallucinations, delusions (false beliefs), abnormal thinking and alteration of labour and social functioning. It is a major public health problem worldwide. Its worldwide prevalence appears to be discretely less than 1%, although pockets of greater or lesser incidence have been identified (Andrew, 2015). Schizoaffective Disorder begins most frequently between the ages of 18 and 25 in men and between the ages of 26 and 45 in women. However, it is not uncommon for it to start in childhood or early in adolescence. The installation can be sudden, in the space of days or weeks, or slow and insidious, over the years. There are several disorders that share their characteristics with Schizoaffective Disorder. A schizoaffective disorder that resembles schizophrenia, but in which symptoms were present less than 6 months, are called schizophreniform disorders. Disorders in which psychotic symptoms last for at least one day but less than a month are called brief psychotic disorders. A disorder characterized by the presence of mood symptoms, such as depression or mania, along with other symptoms typical of schizophrenia, is called schizoaffective disorder. A personality disorder that may share symptomatology of schizophrenia, but in which the symptoms are not severe enough to meet the criteria of psychosis, is called a schizotypal personality disorder (Patrick, 2018).


Case

John, male, 23 years old, single, born in London. He was referred to the medical service of the Memory clinicon 06/01/2018, from his residence, to follow up his treatment for being presenting crisis of clinical exacerbation, with symptoms of aggression and agitation. Rio records that John was seen by liaison psychiatry in 2012 after an overdose and was referred to Alan Davis for learning Disability psychology team. He has been hospitalized on other occasions due to psychiatric problems. He lives with his mother, sister and brother in his own house. He does not have an active social life, presents difficulties in family relationships, quiet disposition and isolates himself socially. At home, John has been using medication for about 5 years. He reports that he has no personal morbid antecedents. He is totally independent in meeting the following basic needs: eating and drinking, using the toilet, moving about, dressing and undressing. It does not know exactly its weight and its height presents/displays a good state of hydration and nutrition (Fuller, 2019). He does three meals daily, without restriction of any food according to the possibilities and also does not make use of psychoactive substances (alcohol, tobacco or other drugs). In his family history, there are psychiatric antecedents (sister with mental disorders). He was calm and silent throughout the nursing interview and he has a good standard of hygiene, bathing daily. His previous pathological history is Schizophrenia.


Mental State Examination

The mental state assessment was performed at the time of the interview. These includes the following items: general description (appearance, psychomotor activity and behaviour, HADS, attitude towards the examiner and verbal activity), mood feeling and affection, perception, thought process (the form and content of thought), sensory and cognition (awareness, orientation, concentration, cognition, BADL, memory, information and intelligence), judgment and credibility (Larry, and Leslie, 2015).

 


General Description

:


Appearance

: John presents good hygiene, well kempt with no concerns regarding personal care. He is apparently calm and collaborative, with a low stare, hardly looking at the interviewer.


Psychomotor activity and


behaviour

manifest calm behaviour.


Attitude towards the examiner

: presents itself as collaborative, attentive, but with sometimes reserved attitudes.


Verbal activity

: demonstrates a sometimes incoherent discourse with disorganised, spontaneous thinking on certain subjects and disorganisation of language (jumps from one subject to another and sometimes does not understand what is spoken) (Rosenberg, 2014).


Mood, Feeling and Affection

: John has a sad mood. His affection is appropriate to the situation.


Perception

: John did not present disturbances of the perception manifested by hallucinations (visual and auditory) and delusions. He displays disorganised thoughts and ideas, so in certain subjects, he/she does not have the capacity to respond.


Action

It has a stabilizing action on the central and peripheral nervous system and a selective depressant action, thus allowing the control of the most varied types of excitation. It is therefore of great value in the treatment of mental and emotional disorders (Lakeman, 2006).


Nursing Care

:

Inform John of the adverse reactions most frequently related to the use of  medication and that, in the event of  side effects of any of them, especially drowsiness, torticollis, pressure drop, sedation, the doctor should be informed immediately to guide him avoid alcoholic beverages during treatment (Rosenberg, 2014).

NMC (2007) Clearly specifies standards that registered nurses must meet when administering prescribed medicines to patients. Patients should be adequately informed, using the language they understand, the nature of their illness, medical benefit, action, duration of treatments, and the importance of medications they are taking, with potential side- effects of the medicines. (NICE 2007a).


Causes

The causes of Schizoaffective Disorder and Borderline Learning Difficulties are still unknown. However, there is a consensus in attributing the disorganisation of the personality, verified in Schizoaffective Disorder and Borderline Learning Difficulties patients, to the interaction of cultural, psychological and biological variables, among which the genetic ones stand out (Steven Matthysse, and Seymour, 2014). There is no single cause to explain all cases of Schizoaffective Disorder and Borderline Learning Difficulties. Contrary to popular belief, John with Schizoaffective Disorder and Borderline Learning Difficulties is not a victim of poor background or environmental factors. He is victims of genetically engineered developmental errors. More recent research has found abnormalities in the developing foetus rather than after birth. It can be said that no specific factor causing Schizoaffective Disorder and Borderline Learning Difficulties has yet been known. There is, however, evidence that it  would be due to a combination of biological, genetic and environmental factors that contributed to varying degrees for the onset and development of the disease (Daily, Ardinger, and Holmes, 2000). Another factor is almost every country where surveys have been conducted, the public believes the causes of Psychosis are more likely to be adverse Psychosocial events and circumstances (such as poverty, trauma and abuse) then biogenetic factors (Morrison et al 2005).

 


Clinical Manifestations

The severity and type of symptomatology can vary significantly between different people with Schizoaffective Disorder and Borderline Learning Difficulties. Together, symptoms are grouped into three major groups: delusions and hallucinations, abnormal thinking and behaviour, and negative symptoms (Frederic, 2014). An individual may have symptoms of one, two, or three groups. The symptoms are serious enough to interfere with the ability to work, have relationship with people and care.


Delusions:

Delusions are false beliefs which generally imply a misinterpretation of perceptions or experiences. For example, John exhibits delusions of theft or imposition of thought, believing that others can read his minds, that their thoughts and impulses are imposed upon him by external forces (Frangou, and Byrne, 2000).


Hallucinations:

Hallucinations of sounds, visions, smells, tastes, or touch may occur, although hallucinations of sounds (called auditory hallucinations) are the most frequent. John can “hear” voices that comment on his behaviour, talk to each other, or make critical and abusive comments.


Change of Thought:

It consists of unorganised thinking, which becomes patent when the expression is incoherent, changes from one theme to another and has no purpose. The expression may be slightly disorganised or be completely incoherent and incomprehensible (Frances, 2000).


Inappropriate Behaviour:

This type of behaviour can take the form of simplicity of childish character, agitation or appearance, hygiene or inappropriate behaviour. Catatonic motor behaviour is an extreme form of inappropriate behaviour in which a person can maintain a rigid posture and resist efforts to move or, on the contrary, show movement activity without prior and meaningless stimulation.

Negative Symptoms: Negative or deficit symptoms of schizophrenia include coldness of emotions, poor expression, anecdotal, and associability. The face of John appears immobile; has little eye contact and does not express emotions. There is no response to situations that would normally make him laugh or cry (Tony Thompson and Mathias, 2000).


Risk Factors of Schizoaffective Disorder and Borderline Learning Difficulties

Although no particular cause has been identified that is directly responsible for the development of the schizoaffective disorder, professional practitioners in this field consider that there is a combination of factors that combine to bring about their onset (Voelker, 2002). These factors are described below:


Genetic factors

: Schizoaffective disorder is similar to other health conditions in the sense that its occurrence is related to a genetic component. Individuals who have a first-degree relative with schizophrenia, bipolar disorder, or schizoaffective disorder face an increased risk of developing symptoms of the disease at some point in their lifes, unlike those who do not have a similar family history (Lakeman, 2006).


Physical Factors

: Neuroimaging studies have shown that the brain volume of people with the schizoaffective disorder is lower than that of individuals who do not suffer from this condition. In addition, it is thought that there are real structural differences in the brains of those people suffering from schizoaffective disorder.


Environmental factors

: As with the development of Schizoaffective Disorder and Borderline Learning Difficulties, researchers have discovered that exposure to toxins or viruses within the uterus can potentially lead to the onset of schizoaffective disorder later in life (Frederic, 2014). In addition, evidence has shown that when complications occur during labour, the potential damage to the brain due to such complications may lead to the eventual onset of the schizoaffective disorder.


Diagnosis

There is no definitive diagnostic test for Schizoaffective Disorder and Borderline Learning Difficulties. The psychiatrist establishes the diagnosis based on an overall assessment of the patient’s history and symptoms. For the diagnosis of schizophrenia to be established, the symptoms should persist for a minimum of six months and must be associated with a significant deterioration of the employment, school or social activity (Steven Matthysse, and Seymour, 2014). The information provided by the family, friends or teachers is very  important to establish when the disease started. People with a schizophrenia diagnosis are 10- 15% likely of dying from suicide (DOH, 1992) and early years of the illness may present a particular risk. (McGarry and Jackson, 1999). The physician should rule out the possibility that the patient’s psychotic symptoms are due to a mood disorder. It is common to perform laboratory tests to rule out the possibility of drug abuse or an underlying clinical, neurological or endocrine disorder that may present with psychosis characteristics, such as certain brain tumours, temporal lobe epilepsy, autoimmune diseases, immune disorders, liver diseases and adverse drug reactions. Individuals with schizophrenia have brain abnormalities that can be seen on a CT scan or MRI (Daily, Ardinger, and Holmes, 2000). However, the defects are insufficiently specific to be useful in diagnosis.


Nursing Assessment and Evaluation of Person Centred Recovery

Over the last decade, mental health care has become supported by service users, with recovery as an important aspect of treatment. The recovery-orientated practice has a global concentration and is incorporated into different mental health policies. Recovery concentrates on hope and on reintegrating service users back into society and their life before diagnosis (Larry, and Leslie, 2015). The general objectives of treatment are to reduce the severity of psychotic symptoms, to prevent recurrences of symptomatic episodes and to impair the functioning of the individual and to provide support so that the individual can perform as well as possible. Antipsychotic medications, rehabilitation and community support activities and psychotherapy represent the three main components of treatment. Antipsychotic medications are often effective in reducing or eliminating symptoms such as delusions, hallucinations, and disorganised thinking. After the disappearance of acute symptoms, the continued use of antipsychotic medications substantially reduce the likelihood of future episodes. Unfortunately, antipsychotic drugs produce significant adverse effects, including sedation, muscle stiffness, tremors, and weight gain (Andrew, 2015). A small number of individuals with Schizoaffective Disorder and Borderline Learning Difficulties are unable to live independently, either because they present severe symptoms and are not responsive to therapy or because they lack the skills necessary to live in the community. In such cases, continuous treatment is necessary for a safe and supportive environment. Psychotherapy is another important aspect of treatment. In general, the goal of psychotherapy is to establish a collaborative relationship between the patient, his family, and the physician. Person-centred care support practitioners to consider service users’ personal needs and to allow them to establish informed judgments about their own care and cure with support from health professionals (Yasuhiko et al, 2018).


Role of the Mental Health Nurse

Although Larry and Leslie, (2015)point out that nurses face difficulties to work with aspects related to mental health in basic care, the need for care of the individual with a mental disorder and his family is a reality. This creates new perspectives for the work of the nurse in the field of mental health, characterized by the transition from Memory clinic practice to treatment of the “mentally ill” to another that incorporates new principles and knowledge, based on interdisciplinarity and recognition of the other as a human being, inserted in a family and community context. People must not worry about how the nurse has acted in this process, since most of the time he/she is the care coordinator of the Memory clinic team, and one of the great challenges to mental health is to establish competence.

Nurses play an important role in assisting people with mental disorders, such as raising the awareness to the population about the importance of their insertion in the community, including collaborating and taking responsibility for the construction of new spaces for psychosocial rehabilitation, if valued; after all, the citizenship of these patients and their families are assured in the policy of deinstitutionalisation. Nurses, therefore, need to be ready to work with John with limitations and his family. The activities that the professional performs in the Memory clinic and attitudes that aim to support him and treat him in order to value not only the illness but, mainly to the person of integral form, favours the reintegration of the patient to the social life with qualified measures (Fuller, 2019).


Care Plan

While the aetiology is unknown, all the therapeutic methods attempted in schizophrenia have the stamp of empiricism and groping. As a general rule, it is said that in the acute or initial periods the medications are justified (the remission or social cure of Schizoaffective Disorder and Borderline Learning Difficulties, compatible with a certain professional activity and the extra-senatorial life, is obtained in about 60% of the cases) and physical-chemical, whether to stimulate or correct the organic functions, or to imprint new rhythm to the body (shock therapy), and that in the phases of remission and chronicity fit psychotherapy and other methods such as praix-therapy are used (Yasuhiko et al, 2018). In response to major harm occurrences that have demonstrated a need for multidisciplinary teams and agencies, co- ordinated by a consistent key worker to actively involve the patient, family and carers, the Care Programs Approach (CPA) (DOH, 1990; reviews 2000a) was developed. The main purpose of nursing care is to awaken the schizophrenic’s interest in John’s life, a dignified life and participation in his family and social environment, despite the illness. It is important to value and encourage John to participate in his clinic treatment, so that the chances of adherence to treatment may be greater. Nursing care should aim to improve symptoms, prevent relapse and avoid institutionalisation.


Discussion

The patient (John) is a carrier of Schizoaffective Disorder and Borderline Learning Difficulties based on such findings: persecutory delusions, hearing unpaid voices, unreasonable ambitions, and loss of contact with reality, simulation of difficulty in walking, psychotic episodes associated with aggression, agitation the exaggerated libido and carelessness with personal hygiene (Larry, and Leslie, 2015). The great question about the patient is the continuity of treatment and their awareness of the importance of adherence to treatment. Drug therapy associated with psychosocial model is essential because it is also a reflection of the entire history of each patient. The pharmacological evolution of antipsychotics has provided a high drug potency with satisfactory results in the course of treatment. Thus, maintenance of drug treatment will lead the individual during the evolution of the disease to an improvement in symptoms. But there are undesirable side effects, such as extrapyramidal manifestations (akathisia, acute dystonia, and parkinsonian symptoms) in addition to silk, weight gain and impotence. All these effects compromise the acceptance of the drug, but with the progress of its use, the maintenance phase has a control and a decrease in these symptoms (Lakeman, 2006).

Discontinuation of treatment may lead to further seizures, the need for higher doses of the drug, and often the need for internal doses. It is of great importance to offer patient individual therapy, support groups, occupational therapy and guidance for the family. A multidisciplinary team is essential for adherence to treatment (Patrick, 2018). However, medical staffs are confronted with patients who perform all these activities and do not evolve to improvement due to lack of psychosocial and family support, as is the case of this patient. If they ask the reason for his carelessness with treatment outside the Institution, they find that being a homeless street patient, without psychological, economic and effective support, he would end up needing internal translations, mostly for the same reason, or the medicines.


Conclusion

Through this case study, it was possible to know a little more about the Schizoaffective Disorder and Borderline Learning Difficulties. Above all, this work made it possible to obtain a holistic view of nursing action and not just a technical-pharmaceutical approach. It was concluded that the systematisation of nursing care is favourable for a good prognosis. In practice, the best care is the individualized and humanized, assisting the patient as a unique being, respecting their biopsychosocial needs. It can be seen that the promotion of care is not necessarily done through technical procedures, in a hospital bed or in an outpatient clinic. Listening attentively, respect, willingness to interact, trust and bonding are elements that need to be used to provide qualified care, especially in psychic patients. Through the study carried out, we were able to value these concepts even more and realize their importance in the act of caring and, thus, lead them to apply in future practice.


References

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    Psychotherapy for People Diagnosed with Schizophrenia

    : Specific techniques, The International Society for Psychological and Social Approaches to Psychosis Book Series, Publisher Routledge.
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    Risk Management in Social Work

    : Preventing Professional Malpractice, Liability, and Disciplinary Action, Publisher Columbia University Press.
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. List and briefly define the fundamental security design principles. 2. Describe the risk analysis approach and the steps in a detailed or formal risk analysis.

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. List and briefly define the fundamental security design principles.
2. Describe the risk analysis approach and the steps in a detailed or formal risk analysis.

3. Describe the basic principles utilized in mandatory access control. How do these basic principles help MAC control the dissemination of information?

4. What is a message authentication code?

5. What is the security of a virtualization solution dependent upon? What are some recommendations to address these dependencies?

6. List the items that should be included in an IT security implementation plan.

7. Describe the inference problem in databases. What are some techniques to overcome the problem of inference?

8. Assume you have found a USB memory stick in the parking lot at work. What threats might this pose to your work computer should you just plug the memory stick in and examine its contents? What steps could you take to mitigate those threats and safely determine the contents of the memory stick?

9. Explain why input validation mitigates the risks of SQL injection attacks.

10. What are the benefits and risks of server-side scripting?

11. What is the difference between persistent and non-persistent cross-site scripting attacks?

12. Briefly describe how Unix-like systems, including Linux, use filesystem quotas and process resource limits. What type of attacks are these mechanisms useful in preventing?

13. Why are pharming and phishing attacks often used in concert with each other?

14. Describe the Windows 10 security feature, Control Flow Guard, and the type of attack it helps to prevent. Who is responsible for implementing Control Flow Guard—the system administrator or application developer?

15. Define three types of intellectual property.

16. Give an example of a computer crime. What are some unique issues associated with such crimes?

17. Briefly summarize one federal law or regulation that addresses confidentiality, privacy, or security. Give an example of how the law is applied to ensure confidentiality, privacy, or security.

18. List and briefly describe three cloud service models.

19. What are the disadvantages to database encryption?

20. What are three broad mechanisms that malware can use to propagate?

21. What are the typical phases of operation for a virus or worm ?

22. Imagine you are the database administrator for a military transportation system. There is a table named cargo in the database that contains information on the various cargo holds available on each outbound airplane. Each row in the table represents a single shipment and lists the contents of that shipment and the flight identification number. Only one shipment per hold is allowed. The flight identification number may be cross-referenced with other tables to determine the origin, destination, flight time, and similar data. The cargo table appears as follows: Flight ID Cargo Hold Contents Classification 1254 A Boots Unclassified 1254 B Guns Unclassified 1254 C Atomic Bomb Top Secret 1254 D Butter Unclassified

There are two roles defined: Role 1 has full access rights to the cargo table. Role 2 has full access rights only to rows of the table in which the Classification field has the value Unclassified. Describe a scenario in which a user assigned to Role 2 uses one or more queries to determine there is a classified shipment on board the aircraft.

23. As part of a formal risk assessment on the use of laptops by employees of a large government department, you have identified the asset “confidentiality of personnel information in a copy of a database stored unencrypted on the laptop” and the threat “theft of personal information, and its subsequent use in identity theft caused by the theft of the laptop.” Suggest reasonable values for the items in the risk register for this asset and threat, and provide justifications for your choices.

24. Consider a popular Digital Rig

After reading The Parable of Sadhu (McCoy, 1997) and Avoiding Integrity Land Mines (Heineman, 2007), what parallels can you draw related to ethics in a professional environment?

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After reading The Parable of Sadhu (McCoy, 1997) and Avoiding Integrity Land Mines (Heineman, 2007), what parallels can you draw related to ethics in a professional environment?

After reading The Parable of Sadhu (McCoy, 1997) and Avoiding Integrity Land Mines (Heineman, 2007), what parallels can you draw related to ethics in a professional environment? Please share an example of how you may relate this to your current or previous place of employment. Use depth of detail to illustrate and apply your learning.

Dental Prosthetic Options

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Introduction:

Prosthetic options to replace a missing tooth fall into two main categories: Fixed prostheses and removable prostheses.

When choosing the suitable treatment option to replace a missing upper incisor, multiple variables involving the patient wishes, expectations, dentist skills and training, cost of treatment, and clinical findings should be taken into consideration (Al-Quran et al., 2011). These factors will have a strong influence on the short and long terms success of the treatment selected.

Based on the conservation of neighbouring teeth and annual failure rates, dental implants are the treatment of choice to replace a missing central maxillary incisor, followed by conventional bridges, and removal partial dentures (Pjetursson & Lang, 2008).


Facial growth in relation to age:

Craniofacial development is a continuous process that starts intra-uterine and has shown different rates between males and females (Brahim, 2005) .

Skeletal maturation in males is reported to be reached at the age of 20, while females reach the maturation phase earlier, at the age of 17-18 years (Heij et al., 2006).

Therefore, it has been recommended, when selecting the prosthetic option to replace a missing tooth, to take the patient’s age into consideration. Dental Implants should be avoided until the cessation of jaw development mentioned earlier (Daftary et al., 2013) or after the end of the growth spurt (Heij et al., 2006).

If dental implants are used before the vertical maturation is reached, it will not grow vertically with the alveolar bone and will be submerged at different levels depending at the patient’s age when the implants were inserted (Brahim, 2005)

.


Dental trauma and the surrounding tissues:

In most scenarios, it is rare that a single incisor will be traumatized with no damage on adjacent incisors, surrounding bone, or soft tissues. If any damage sustained to neighbouring teeth, the status and prognosis of these teeth should be assessed, as it will have a strong impact on the selection of the definitive treatment option.

Traumatic avulsion of teeth, account for 0.5% – 3% of all dentoalveolar trauma, and it is associated with damage to the alveolar bone, specially the buccal plate (Andreasen, 1970).

After tooth extraction, reduction of the alveolar bone height and width can be as high as 50% in the first year (Schropp L, 2004) with the highest amount of bone loss within the first three months (Pietrokovski & Massler, 1967).

Bone loss is not even between the buccal and palatal bone plates, with more bone loss in the buccal plate (Pietrokovski & Massler, 1967) and bone width than height (Van Der Weijden et al., 2009).


There are several treatment options that could be used for replacing a lost maxillary central incisor:


Removable Partial Denture (RPD):

RPD have the advantages of minimal clinical skills required, minimal chair time, and preservation of neighbouring teeth. On the other hand, the patient satisfaction is low, with a sense of insecurity, high risk of accidental breakage, and loss.

Still, RPD is the quickest, cheapest replacement option of a missing incisor, and usually used as a temporary treatment until healing is complete and bone remodelling is minimal.


Resin Retained Fixed Bridges (RRB):

Resin retained bridges share the advantage of removable dentures of having minimal effect on abutment teeth with no risk of pulpal injury and the reversible nature of the prostheses. It is also relatively of low cost and acceptable aesthetic result (metal frame could be masked by opaque cement on expense of translucency).

The commonest failure associated with RRB is frequent debonding of 20% over 5 years (Pjetursson et al., 2008) which could cause social embarrassment to the patient.

The patient could also be given an Essex Type retainer with a single tooth in the gap as an emergency prosthesis until recementation of the resin retained bridge is done.

RRB could be used as a final prosthetic option but more often is used as an interim measure as it could be reversed at any time, with 87.7% 5 years prognosis (Pjetursson et al., 2008)

If the prosthesis is planned to be a temporary option, Rochette type wings are made with holes to facilitate frequent removal.


Conventional Bridge:

This is an irreversible treatment, replacing the missing tooth with a 2 or 3 units’ conventional bridge. These offer superior retention and aesthetics over RRB by the mean of full coverage of the abutment teeth. The main drawback is the need to reduce the sound tooth structure of the abutments with 20% risk of nerve damage and higher caries risk. The reduction of tooth structure is more for porcelain fused to metal or full ceramic/Zirconia crowns than full crown which is a requirement in the anterior aesthetic zone.

According to previous studies, “if the adjacent teeth are severed, or in need of being crowned, the conventional bridge is to be preferred (Annual failure rate: 1.14%)” (Pjetursson & Lang, 2008).

The success rate is reported to be 90 % for 10 years and 72% for 15 years (Pjetursson et al., 2008) and (Burke & Lucarotti, 2012).


Endosseous dental implants:

When considering the success rate, dental implants are reported to have the highest documented survival rate of 94% for 5 years (Attard & Zarb, 2003) and 89% over 15 years (Pjetursson et al., 2008).

Dental Implants have numerous advantages over the previously mentioned treatment options.

Comparing dental implants to other fixed treatment modalities, there is no danger of pulpable damage of adjacent teeth, as no abutment teeth preparation is involved. Implants also facilitate the patient’s daily oral hygiene routines around the prosthesis, since there are no connectors between the prostheses and abutment teeth, making flossing possible.

Furthermore, the maintenance and regular follow ups by the dentist is easier for dental implants. Removing a conventional bridge is a challenging task compared to screw retained implant supported crowns which could be removed and re-inserted multiple times when required (not applicable to cemented crowns).

For implant supported restorations in the anterior maxillary region, a detailed patient assessment, implant site assessment, and proper treatment planning is the key for a successful restoration. The planning should be derived from the restorative point of view not guided by the availability of bone. The following points should be carefully assessed:


Lip position at rest and smile:

The patient’s aesthetic expectations should be coupled with the upper lip position at rest and when smiling.

In most cases, 2 mm of the incisal edge of the central incisors should show at rest, and it could be either 100% of all the incisors (high smile line), more than 75% visible (medium smile line), or (low smile line) showing less than 75% of the incisors.

With low smile line lip position, the aesthetic challenges are lower, and the emphasis on soft tissue contouring and papilla regeneration is also lower (Tjan et al., 1984).

If the patient’s expectations are high while having high smile line, patient education should take place prior to implant treatment as the implant treatment could be deemed a failure if did not meet the patient’s aesthetic requirements despite been successful in every other aspect.


Attached gingiva and surrounding soft tissue:

The attached gingiva could have thick, moderate, or thin architecture. Thick gingiva is more common than the thin biotype; it appears as a more stippled, flat fibrous band of attached mucosa, masking the underlying bony contours. It is associated with higher resistance to recession, better soft tissue contouring, and resistance to peri-implant disease. On the other hand, thin gingival biotypes are found in 15% of population (Tjan et al., 1984) and it is a thinner mucosal layer with the bony scalloping showing through it. This type is more prone to exposure of the implant and compromising the aesthetic result (Tjan et al., 1984).

The thin biotype has been associated with long triangular teeth and more incisally positioned contact points, while the thick biotype is associated with shorter, square crowns with more apically positioned contact points (hence, more papillary regeneration).


Implant size used:

Implant size has a direct effect on the emergence profile of the coronal restoration and aesthetics. Natural existing teeth and available bone are helping factors when selecting the right implant diameter, while implant length should provide a safety distance to the surrounding anatomical structures.

The implant diameter should allow 1.5 mm between implant and neighbouring teeth (and 3mm between adjacent implant fixtures) (Jivraj & Chee, 2006).

The gingival biotype also should not be overlooked when selecting the fixture diameter, for example; if wider implants are used with thin gingival biotype, the risk of recession is higher (Rodriguez & Rosenstiel, 2012).


Implant position:

For the most aesthetic emergence profile, implants should be placed 1.5 mm – 2 mm from the adjacent tooth, 3mm – 4mm apical to CEJ (Jivraj & Chee, 2006), and ideally should be placed under the proposed cingulum of the coronal restoration.

A diagnostic wax up and a prefabricated surgical stent are of very important in deciding the crown and implant positions, and evaluating the amount of bony defect and the need for bone graft. Transfaring the surgical stent into the patient’s mouth will allow the visualization of the amount of incisor show and smile lines.

The implant position and angulation will dictate the abutment type and the retention method used for the restoration (screw or cement retained).


Available bone quality and quantity:

Bone density has been classified by Lekholm and Zarb (1985) into 4 categories:

  1. Homogenous compact bone,
  2. Thick cortical bone around dense trabecular bone,
  3. Dense trabecular bone covered by thin cortical bone,
  4. Very thin cortex enclosing minimal density trabeculae.

Types 3 and 4 are associated with more failure rates, and are more found in the maxilla. Therefore, under -preparation of the osteotomy site could be done to gain higher initial stability.

Branemark et al 1977 defined ossteointegeration as “direct structural and functional connection between living bone and load carrying implant”. Implant fixture should be in direct contact with healthy bone in three dimensions. Therefore, the amount of available bone required around any dental implant is 1.5 mm buccally and palatally, 3 mm between adjacent implants and at least 1.5mm -2mm between implants and adjacent teeth (Misch, 2008) and (Rodriguez & Rosenstiel, 2012).

If buccal bone width is not sufficient, a smaller diameter implant that will be functionally and aesthetically sound could be selected. It will also allow slight palatal positioning (Rodriguez & Rosenstiel, 2012). Bone grafting/augmentation procedure could be done to add the bone thickness (Esposito et al., 2009) and bone could be sourced from:

  • Patient’s own bone (Autogenous graft): commonly could be harvested from calvarian bone, iliac crest, mandibular ramus or chin. This provides highest reported success rates (Esposito et al., 2009).
  • Different human bone (Allograft): usually from cadaveric bone. Bone undergoes special treatment to be deproteinized and freezed (Esposito et al., 2009).
  • Animal sources (Xenograft) usually cows or pigs.
  • Synthetic materials (Alloplast): artificial graft material which could be used solely or in conjunction with autogenous grafts (Esposito et al., 2009).
  • Bone regeneration membranes: these are used to act as a barrier between the superficial soft tissue and the grafted bone or material to prevent ingrowth of the fibrous tissue and allow pure bone development. These membranes could be either natural or synthetic, resorbable or non- resporbable.

If block bone graft is used, it should be allowed to heal for minimum 3 months before implant placement, while bone augmentation with alloplastic materials and membranes could be done simultaneously (Esposito et al., 2009).

It is worth mentioning that porcine- derived bone and membranes may not be acceptable by some patients based on their religious beliefs and a specific consent should be obtained.

The bone height will also impact the papilla formation, together with the crown shape and level of contact points; the papilla regeneration is favourable is square crown, broad apical contact points, and when the distance is around 4-5 mm between bone crest and contact points (Rodriguez & Rosenstiel, 2012) and (Tarnow et al., 2003).

Vertical bone augmentation has been shown to be unpredictable (Esposito et al., 2009) and the patient should be aware of the black triangles (lack of papilla) if vertical bone is deficient (Tarnow et al., 2003).


Conclusion:

Based on the previously discussed factors and the evidence available, dental implant would be the treatment of choice if the neighbouring teeth are of good prognosis and the aesthetic results are realistic. It is safe to place an implant in 20 years old male, as the growth of the jaws is complete. A diagnostic wax up and stent could be made to evaluate the aesthetics, and available bone. A 4.5 mm buccal width is not enough to place a suitable size implant in a suitable bony envelope, so a block done graft for will be needed before the implant placement. If the source of the trauma was sports related and likely to occur again, a mouth guard should be worn to protect the implant and teeth during activity.

Related content


Bibliography

Abt, E.C.A.B.W.H.V., 2012. Interventions for replacing missing teeth: partially absent dentition.

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Al-Quran, Firas F., A.-G.R. & N, A.-Z.B., 2011. Single-tooth replacement: factors affecting different prosthetic treatment modalities.

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European Journal of Oral Sciences

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Andreasen, J.O., 2007.

Textbook and Color Atlas of Traumatic Injuries to the Teeth

. 4th ed. Copenhagen: Blackwell Munksgaard.

Attard, N.J. & Zarb, G.A., 2003. Implant prosthodontic management of partially edentulous patients missing posterior teeth: The Toronto experience.

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, 89(4), pp.352-59.

Brahim, J.S., 2005. Dental implants in children.

Oral and maxillofacial surgery clinics of North America

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Burke, F.J.T. & Lucarotti, P.S.K., 2012. Ten year survival of bridges placed in the General Dental Services in England And Wales.

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Daftary, F., Mahallati, R., Bahat, O. & Sullivan, R.M., 2013. Lifelong craniofacial growth and the implications for osseointegrated implants.

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Day, P. & Duggal, M., 2010. Interventions for treating traumatized permanent front teeth: avulsed (knocked out) and replanted.

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Eghbali, A., De Rouck, T., De Bruyn, H. & Cosyn, J., 2009. The gingival biotype assessed by experienced and inexperienced clinicians.

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Esposito, M. et al., 2009. Interventions for replacing missing teeth: horizontal and vertical bone augmentation techniques for dental implant treatment (Review).

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Heij, D.G.O. et al., 2006. Facial development, continuous tooth eruption, and mesial drift as compromising factors for implant placement.

The International journal of oral & maxillofacial implants

, 21(6), pp.867-78.

Jivraj, S. & Chee, W., 2006. Treatment planning of implants in the aesthetic zone.

British Dental Journal

, 201(2), p.77.

Misch, C.E., 2008.

Contemporary Implant Dentistry

. 3rd ed. Mosby.

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The Journal of prosthetic dentistry

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Pjetursson, B.E. & Lang, N.P., 2008. Prosthetic treatment planning on the basis of scientific evidence.

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, 35(1), pp.72-79.

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Clinical Oral Implants Research

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Rodriguez, A.M. & Rosenstiel, S.F., 2012. Esthetic considerations related to bone and soft tissue maintenance and development around dental implants: Report of the Committee on Research in Fixed Prosthodontics of the American Academy of Fixed Prosthodontics.

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Tarnow, D. et al., 2003. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants.

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Identify a recently adopted information, education, or communication technology tool in your specialty area. Reflect on how it is used and how its use impacts the quality of care.

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Identify a recently adopted information, education, or communication technology tool in your specialty area. Reflect on how it is used and how its use impacts the quality of care.

 

nursing4t

Order Description

Readings
American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.). Silver Springs, MD: Author.
“The Future of Nursing Informatics”
McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (Laureate Education, Inc., custom ed.). Burlington, MA: Jones & Bartlett Learning.
Chapter 14, “Improving the Human-Technology Interface”

This chapter describes the human-technology interface and explores some of the problems that result from its usage. The author also reflects on methods for improving the interface.
Chapter 19, ”Telenursing and Remote Access Telehealth”

This chapter explores the usage of telehealth in nursing practice. The authors examine the role of telehealth, along with potential issues that may arise in its usage.
Brewer, E. P. (2011). Successful techniques for using human patient simulation in nursing education. Journal of Nursing Scholarship, 43(3), 311–317.
Retrieved from the Walden Library databases.

This article identifies studies that have used human simulation as an effective instructional tool in nursing education. The article describes different strategies for incorporating human simulation into nursing education, and it also offers insight on improvements that could be made to current practices.
Guarascio-Howard, L. (2011). Examination of wireless technology to improve nurse communication, response time to bed alarms, and patient safety. Herd, 4(2), 109–120.
Retrieved from the Walden Library databases.

The author explains the results of a study on the outcomes of using wireless communication devices to improve patient safety by allowing nurses to communicate more quickly and easily with other nurses. The results indicate that this technology can increase the value of team nursing, improve response time, and increase patient safety, although there are some drawbacks and challenges associated with the devices.
Simpson, R. L. (2012). Technology enables value-based nursing care. Nursing Administration Quarterly, 36(1), 85–87.
Retrieved from the Walden Library databases.

This article describes how technology can be used to address problems in the U.S. health care system, such as lack of consistency and lack of effective treatment. The article explains the use of value-based care initiatives and outlines how nurses can use these initiatives to improve outcomes in treatment and research.
Vinson, M. H., McCallum, R., Thornlow, D. K., & Champagne, M. T. (2011). Design, implementation, and evaluation of population-specific telehealth nursing services. Nursing Economic$, 29(5), 265–272, 277.
Retrieved from the Walden Library databases.
================================================================================================================
To prepare:
Review the various technology tools described in this week’s Learning Resources.
Identify a recently adopted information, education, or communication technology tool in your specialty area. Reflect on how it is used and how its use impacts the quality of care.
Consider how your identified technology tool might impact nursing practice if it were more widely used. What are some barriers preventing increased usage? How could wider implementation be facilitated?
================================================================================================================
Post a description of a current or new information, education, or communication technology tool that is being used in your specialty area and assess its impact on the quality of care. Highlight the effect that increased use of this technology would have on nursing practice and discuss the barriers that are slowing or hindering its adoption. Summarize how adoption of the technology tool could be facilitated.

Examine crucial references for the original and/or current work of the theorist and other authors writing about the selected theory.

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Examine crucial references for the original and/or current work of the theorist and other authors writing about the selected theory.

 

 

Nursing Theory Analysis Paper
Order Description
The purpose of this assignment is to describe, evaluate and discuss application of a nursing grand or mid-range theory. I WOULD LIKE TO USE PENDER’S HEALTH PROMOTION THEORY!!!This assignment also provides the learner an opportunity to connect theory and research to nursing phenomena. Learners will develop a 6 or more pages paper (excluding the title page and references) using APA style to address the elements listed below. The paper should include headings and subheadings with the required info:

1.Theory/Author Name and Background

-Select a Grand or Mid-Range Theory that is appropriate to your practice setting.
-Describe the theorist’s background in detail and discuss how their experiences have impacted the theory development.
-Examine crucial references for the original and/or current work of the theorist and other authors writing about the selected theory.
-Identify the phenomenon of concern or problems addressed by the theory.

2.Theory Description

-Explain whether the theory uses deductive, inductive or retroductive reasoning. Provide evidence to support your conclusion.
-Describe the major concepts of the theory. How are they defined? (theoretically and/or operationally) Is the author consistent in the use of the concepts and other terms in the theory?
-Interpret how the concepts are defined. Implicitly or explicitly?
Examine the relationships (propositions) among the major concepts.

3.Evaluation

-Identify explicit and implicit assumptions (values/beliefs) underlying the theory. On what assumptions does the theory build?
-Examine if the theory has a description of the four metaparadigm concepts of nursing. If so, how are they explained in the theory? If the metapardigm is not explained, what elements do you see as relevant to the theory and why?
-Discuss the clarity of the theory. Did it have lucidness and consistency?

3.Application

-Examine how the theory would guide nursing actions.
-Describe specifically how you can use this theory in your area of nursing (Practice, Education, Informatics or Administration).

4. Conclusion

Order Description

The purpose of this assignment is to describe, evaluate and discuss application of a nursing grand or mid-range theory. I WOULD LIKE TO USE PENDER’S HEALTH PROMOTION THEORY!!!This assignment also provides the learner an opportunity to connect theory and research to nursing phenomena. Learners will develop a 6 or more pages paper (excluding the title page and references) using APA style to address the elements listed below. The paper should include headings and subheadings with the required info:

1.Theory/Author Name and Background

-Select a Grand or Mid-Range Theory that is appropriate to your practice setting.
-Describe the theorist’s background in detail and discuss how their experiences have impacted the theory development.
-Examine crucial references for the original and/or current work of the theorist and other authors writing about the selected theory.
-Identify the phenomenon of concern or problems addressed by the theory.

2.Theory Description

-Explain whether the theory uses deductive, inductive or retroductive reasoning. Provide evidence to support your conclusion.
-Describe the major concepts of the theory. How are they defined? (theoretically and/or operationally) Is the author consistent in the use of the concepts and other terms in the theory?
-Interpret how the concepts are defined. Implicitly or explicitly?
Examine the relationships (propositions) among the major concepts.

3.Evaluation

-Identify explicit and implicit assumptions (values/beliefs) underlying the theory. On what assumptions does the theory build?
-Examine if the theory has a description of the four metaparadigm concepts of nursing. If so, how are they explained in the theory? If the metapardigm is not explained, what elements do you see as relevant to the theory and why?
-Discuss the clarity of the theory. Did it have lucidness and consistency?

3.Application

-Examine how the theory would guide nursing actions.
-Describe specifically how you can use this theory in your area of nursing (Practice, Education, Informatics or Administration).

Overview of Hyperlipidemia

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Introduction

Hyperlipidemia, involves higher lipids or lipoproteins in blood,is one of the most observed conditions related to cardiovascular system (Hassan, 2013). This small paper focuses on outlining the pathophysiology, signs and symptoms and organs involved in the Hyperlipidemia. Further, this paper also proposes diagnosis and alternative treatment protocols and their success rate for Hyperlipidemia.


The pathophysiology of the Hyperlipidemia

The pathophysiology of the Hyperlipidemia can be classified into primary hyperlipidemia and secondary hyperlipidemia. Whilst genetic factors cause the primary hyperlipidemia, the metabolic disorders cause the secondary hyperlipidemia. The secondary hyperlipidemia can be caused due to diabetes mellitus, high usage of drugs such as beta blockers and estrogens, renal failure, high alcohol consumption etc. (Brown, 2003).

Genetic hyperlipidemia can be categorized into disorders such as familial hypercholesterolemia, familial hypertriglyceridemia, familial dysbetalipoproteinemia and familial combined hyperlipidemia etc. The familial hypercholesterolemia is a genetic disorder caused due to high-levels of low-density lipoprotein in blood (Stang & Story, 2005). On the other hand, familial hypertriglyceridemia is a highly dominant condition caused due to excess production of vey low-density lipoprotein. Familial dysbetalipoproteinemia is a condition characterized by increased low-density lipoprotein and decreased high-density lipoprotein. Finally, familial combined hyperlipidemia is a condition characterized by decreased low-density lipoprotein and increased Apolipoprotein B (Brown, 2003).


The signs and symptoms of Hyperlipidemia

Normally, hyperlipidemia does not show any symptoms in early ears. As days pass on, the symptoms such as manifestation of high cholesterol beneath of elbows, knees and eyes can be seen (Ankur et al, 2012). One can also observe the symptoms such as whitish rings around the eye’s iris in a person suffering from hyperlipidemia. Since the elevated cholesterol blocks the blood vessels, it can lead coronary heart disease or strokes. The frequent heart strokes can also be considered as major symptoms for hyperlipidemia.


The organs and/or system involved in Hyperlipidemia

Hyperlipidemia impacts cardiovascular system and leads to cardiovascular disease. Cardiovascular system, also known as circulatory system, is an organ system that facilitates blood to transport oxygen, carbon dioxide, nutrients to organs and tissues of the body (Stang & Story, 2005). The cardiovascular system helps in fighting the diseases and stabilizing the body temperature. The system is vulnerable to diseases when cholesterol accumulates the inflamed areas of blood vessels leading to reduced flow or blockage.

Since cardiovascular blockage causes reduced blood flow, heart can be considered as most vulnerable organ to hyperlipidemia. Left untreated, hyperlipidemia can lead coronary artery disease and ultimately result to heart attack (Stang & Story, 2005). The organ, artery, is involved in hyperlipidemia because, in most of the cases, cholesterol accumulates in artery that transports blood away from heart. Brain is another organ involved in hyperlipidemia. Since high cholesterol blocks the blood vessel that supplies blood to brain, the possibility of occurring ischemic strokes would be increased (Ankur et al, 2012).


How Hyperlipidemia is diagnosed?

Cholesterol test should be done to diagnose the lipid disorder or hyperlipidemia. The cholesterol test can be conducted with a lab diagnosis test called Lipid Panel. Patients should past for at least 12 hours before undergoing Lipid Panel test because it is important to clear the chylomicron from the blood; the clearance of chylomicron might take 10 to 12 hour. The laboratory testing is conducted to measure the total plasma cholesterol, low-density lipoprotein and triglycerides within the blood (Brown, 2003). In order to measure the very low-density lipoprotein cholesterol levels, the triglyceride should be divided by 5. In the same way, in order to calculate the low-density lipoprotein, it is important to subtract the high-density lipoprotein cholesterol and very low density lipoprotein from total cholesterol.


For total cholesterol:

If the results show that the cholesterol levels are 200 milligrams per decilitre or less, it is considered as a normal condition. The cholesterol levels that fall in between 201 and 240 milligrams per decilitre indicate borderline cholesterol. Similarly, greater than 240 milligram per decilitre indicates higher cholesterol levels.


For high-density lipoprotein:

If the high-density lipoprotein is 60 milligrams per decilitre, it can be considered as good cholesterol (Ankur et al, 2012). Since the higher levels of high-density lipoprotein are good to the body, it is recommended for people to maintain at least 60 milligrams per decilitre. If the high-density lipoprotein falls in between 40 milligram per decilitre and 59 milligram per decilitre, it is considered as acceptable cholesterol level. On the other hand, less than 40 milligram per decilitre increases the risk of heart disease (Ankur et al, 2012).


For low-density lipoprotein:

The optimal low-density lipoprotein for human body is 100 milligrams per decilitre or lesser. If the low-density lipoprotein level falls in between 100 milligram per decilitre and 129 milligram per decilitre, it is considered as near-optimal and does not cause any harm to individual. The low-density lipoprotein level is in between 130 milligram per decilitre and 159 milligram per decilitre, it is considered as a borderline high. Anything higher than 160 milligram per decilitre is considered as bad cholesterol (Hassan, 2013).


Alternative treatment protocols and their success rate

A wide-range of alternative treatment protocols is available to treat hyperlipidemia. A couple of them are mentioned below.


Traditional Chinese Medicine:

Three important approaches such as excretory function enhancement, tonic effect reinforcement and cardiovascular system improvement are used to treat hyperlipidemia. Though there is no scientific evidence of the efficacy of these approaches, they are highly successful in controlling blood lipid levels and adjusting bodily functions (Hassan, 2013).


Acupuncture

: Acupuncture helps in reducing the cellular accumulations of fatty materials and makes the individual less vulnerable to heart disease. By needling the acupuncture point located on the lower leg, it is possible to reduce and prevent the formation of foam cells in the body. With 80% success rate, acupuncture has become one of the best alternative treatment protocols for hyperlipidemia.


Conclusion

Cardiovascular system is highly vulnerable to hyperlipidemia when cholesterol accumulates the inflamed areas of blood vessels. Hyperlipidemia can be caused due to genetic disorders or metabolic disorders. Some of the major symptoms of hyperlipidemia are cholesterol accumulation beneath of elbows, knees and eyes can be seen, whitish rings around the eye’s iris and chest pain. In addition to cardiovascular system, the organs such as artery, heart and brain are also involved in hyperlipidemia. By carrying out Lipid Panel test, it is possible to check the lipid levels in blood. The alternative treatment protocols such as acupuncture and Traditional Chinese Medicine can be used to treat hyperlipidemia.


References

Brown, W.V. (2003). Cholesterol absorption inhibitors: defining new options in lipid management.

Clinical Cardiology

, 26(6), 259–264.

Hassan, B.A.R. (2013). Overview on Hyperlipidemia.

Journal of Chromatography Separation Techniques

, 4 (3), 113.

Stang, J., & Story, M. (Eds.). (2005).

Guidelines for Adolescent Nutrition Services

. Minneapolis: University of Minnesota. Retrieved on 9

th

November, 2014 from <

http://www.epi.umn.edu/let/pubs/img/adol_ch10.pdf

>

Ankur, R., Nidhi, D., Seema, R., Amarjeet, D., & Ashok, K. (2012). Hyperlipidemia- A Deadly Pathological Condition.

International Journal of Current Pharmaceutical Research

, 4(3), 15-18.