Silver dressings in treatment of Mrsa in wounds

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This assignment is a critical systematic review of three research articles whereby the aim is to determine whether silver dressings are actually effective in the treatment of Methicillin Resistant Staphylococcus Aureus (MRSA). The aim is also for health care professionals and nurses to enhance and develop an increased knowledge about the effectiveness of silver dressings in the management and treatment of MRSA. The results and findings of the research papers were reviewed, conclusions were drawn and recommendations for future practice were made.

Findings

All three research papers showed clear evidence that silver dressings do have a beneficial effect on the treatment and management of MRSA in practice. The dressing acticoat silver was regarded highly by all the authors of the three reports.

Conclusion

By carrying out this critical systematic review, it is clear that the selection of the appropriate dressing is of great importance in the successful management and treatment of MRSA in wounds. Clinical factors that should be taken into consideration when deciding on the choice of antibacterial dressing are the condition of the wound, the type of wound, the healing and exudate handling effects. It is important to be aware of the of the characteristics and the ways in which silver acts physically as well as chemically, especially when trying to understand the statements made by companies that market silver containing dressings.

Introduction

This critical systematic review is related to a specific aspect of practice and aims to provide research based evidence to answer the following question; how effective is the use of silver dressings in the treatment of Methicillin Resistant Staphylococcus Aureus (MRSA) in wounds?

The increased rate of mortalities relating to health care associated infections (HCAI’s) with MRSA has put increased financial pressure on hospitals (Johnson, 2007). Throughout clinical practice there are alarming concerns of the spread and emergence of MRSA, which is antibiotic resistant. Dow (2001) highlights the fact that within the clinical environment the potential sources of infection are chronic and acute wounds when they become colonised with bacteria (White, 2001). Therefore, can silver dressings really have an impact on MRSA, the so called super bug that is wreaking havoc?

As a result, a systematic review of the relevant published articles will be critiqued using the Santy and Neal (1998) tool, thus confirming the validity, reliability and the ethical implication of the three papers along with the recommendations for future practice.

The three papers critiqued in this systematic review are shown in the table below:

Paper One (Appendix A)

Antimicrobial and barrier effects of silver against MRSA.

Edward-Jones, V (2006).

Paper Two (Appendix B)

Antimicrobial activities of silver dressings, an in vitro comparison.

Maragaret, I, P, Sau, L, L, Vincent, K, Poon , M, Iven, L & Burd, A (2006).

Paper Three (Appendix C)

Silver antimicrobial dressings in wound management, a comparison of antibacterial, physical andchemical characteristics.

Parsons, D, Philip, G, Bowler, M, Myles, V & Jones, S (2005).

Polit et al (2001) has placed emphasis on the fact that data used to solve problems or answer questions is of great importance to the nursing profession and the need for nursing research is beneficial not only to the patients within the clinical environment but to the health professionals also. As nurses are accountable under the Nursing and Midwifery Code of Professional Conduct (NMC, 2008) for the care they provide it is essential for it to be evidence based, so that no harm is inflicted upon the patient (Crow, 1982).

The rationale for this chosen topic is based on treating patients who often find that their chronic wounds have become infected (Dow, 2001). As ever, MRSA burdens the health care service with increasing financial costs and represents an increasing threat to the health and well being of vulnerable patients (Johnson, 2007). Therefore, finding ways through research to effectively treat MRSA can only have positive results and outcomes. MRSA is also a recurring topic under the attention of the media and emphasis is placed upon hospitals when it comes to blame.

As a result, this systematic review also aims to inform and enlighten health care professionals about the effectiveness of the silver dressings in the management and treatment of MRSA in wounds and how vital the selection of the correct dressing is. Another essential aspect is to encourage health care professionals to carry out their own research on the dressings they use and the treatment they provide. The use of silver dressings in wounds is increasingly used for the treatment of contaminated and infected wounds. However, there is a lack of clarity regarding the evidence behind its effectiveness (Vermeulen et al, 2007), hence the purpose of this critical systematic review.

Literature Review

The healing of wounds is a highly complex process as highlighted by Dealey (2005). All wounds are contaminated with bacteria, which Dealey (2005) suggests does not affect healing, however, colonisation occurs when the organisms multiply and progress to infection (Stotts and Whitney, 1999) which does impact upon wound healing. Therefore, this supports the need for healthcare professionals to manage the bacterial load to minimise the risk of infection. Infected wounds can cause prolonged needs for nursing treatment as well as unnecessary pain and in extreme cases can cause death of the patient (Vermeulen et al, 2007).

Staphylococcus aureus is a bacterium found on the skin and in the nose where it resides harmlessly in healthy people, known as colonisation. Although it is usually harmless at these sites, it may occasionally penetrate the body through breaks in the skin such as, abrasions, wounds, cuts, surgical incisions and even indwelling catheters, thus causing infection.

The treatment of infections due to staphylococcus aureus was revolutionised in the 1940’s by the introduction of the antibiotic penicillin. However, most strains of staphylococcus aureus are now resistant to penicillin. This is because staphylococcus aureus can make a substance called B-lactamase, which degrades penicillin, destroying its antibacterial activity. In the early 1960’s, a new type of penicillin antibiotic called methicillin was developed. Methicillin was not degraded by B-lactamase and so could be used to treat infections due to b-lactamase producing strains of staphylococcus aureus. Subsequently, methicillin was replaces by never and better penicillin type antibiotics, such as, flucloxacillin, that were not affected by B-lactamase. Unfortunately, shortly after the introduction of methicillin, certain strains of staphylococcus aureus emerged that were resistant to methicillin (Johnson, 2007), referred to as MRSA.

It is a general agreement that the problem of resistance has been exacerbated by the overuse or misuse of antibiotics so, wherever possible, alternative methods are now required to manage topical infections caused by antibiotic resistant organisms (Thomas, 2004). The knowledge related to the dressings used is a key area of nursing especially in recent times as it is a general agreement that nurse prescribing is on the increase. The choice of dressings and topical agents are not always based on a firm rationale (Lewis et al, 2001).

Topical agents used with dressings to treat wound infection include antibiotics, antiseptics or disinfectants, as these destroy the invading micro organisms or limit their growth. Silver is one of the more popular topical agent added to dressings (Dowsett, 2004).

Nurses should be prepared to objectively evaluate the dressings they use, particularly if they are using new dressings (Dealey, 2005). Many silver dressings available for health care professionals are aquacel ag (Covatec), Acticoat (Smith and Nephew), Urgotul (Urgo) and Contreet (Coloplast). The most frequently observed used products within the authors trust is aquacel Ag and acticoat, therefore, these will be the main dressings that will be reviewed within this systematic review.

Convatec advertise aquacel Ag as the first antimicrobial activity to kill MRSA and other wound pathogens in the dressing.

Smith and Nephew advertise acticoat as a silver dressing, the silver is applied to the polythene mesh by a vapour deposition process, which results in the formation of microscopic nanocrystals of metallic silver. In this nanocrystalline form, metallic silver exhibits pronounced antibacterial activity against a wide range of gram positive and gram negative bacteria including strains resistant to many types of antibiotics. It is also effective against clinically important strains of yeasts and fungi.

Whilst these advertisements have enticed nurses to use the product the evidence to support them may be biased as each company will want their own product to be successful and profitable. As a result, this systematic review aims to demonstrate the efficacy of the product based on valid reliable published evidence.

Methodology

In order to carry out research for articles on silver dressings in the management of MRSA was undertaken using internet based search engines CINAHL (cumulative index to nursing and allied health literature), OVID, Cochrane Library (WILEY), MEDLINE (OVID) and pubmed. To be able to obtain the maximum evidence and consider new products the most up to date and recent evidence resources and materials were utilised even though there was no date limitation applied. In addition to search engines manual reviews of nursing journals and books was also carried out.

Once the appropriate search engine keywords were used such as, silver dressings and MRSA, separately these searches produced 1529 hits. The subjects were then combined to retrieve the appropriate and relevant articles and this resulted in on seven hits. These articles were then considered and reviewed in depth, the abstracts of the seven articles were read thus giving a concise overview of the content in each article. As a result, four of the seven articles did not meet the specifications for this systematic review.

Inclusion Criteria

Exclusion Criteria

The nature of the research is quantitative

The nature of the research being qualitative or comprising case studies.

In vitro comparisons.

Not including acticoat and aquacel Ag.

There were randomised controlled trials.

Papers from untrustworthy and non reputable sources.

MRSA was included along with acticoat and aqaucel Ag.

The use of other micro organisms as well as MRSA.

From a trustworthy and reputable source and written in English.

Findings

The most valuable piece of research evidence, in the opinion of the author is paper one. This is so because the findings from paper one showed that there was no observed growth of either strain of MRSA on the nanocrystalline silver dressings at any of the time phases, demonstrating that both actisorb and aqaucel Ag were acting as effective barriers by preventing the movement of the bacteria. Throughout this paper, data is analysed in depth and presented in the form of tables and images. The tables show the antimicrobial effect of the four different silver dressings at different time periods whereby the images show the growth of the two strains of MRSA (EMRSA-15 and EMRSA-16) on Columbia blood agar plates at one hour and twenty four hours. This was appropriate and necessary in the light of the study and the tables and images were clearly labelled, well organised and easy to understand.

Paper two, on the other hand, found that all the silver dressings that were tested and analysed on nine different bacterial strains including MRSA were effective, especially contreet and acticoat. The nine different strains comprised: (1) staphylococcus aureus, (2) MRSA, (3) enterococcus faecalis, (4) pseudomonas aeruginosa, (5) Escherichia coli, (6) enterobacter cloacae, (7) proteus vulgaris, (8) acinetobacter and (9) baumannii strain (multi drug efflux positive). A measure of each organism was prepared on blood agar plates and kept overnight. Bacteria, was added to each vial containing the silver dressings which was then incubated.

These were shown as exerting maximum bactericidal activity in the reduction of the growth of bacteria at twenty four hours. Interestingly, contreet had the maximal killing effect of MRSA and this was achieved in four hours. The dressings that were tested were aquacel Ag (ConvaTec), aquacel (ConvaTec), acticoat (Smith and Nephew), urgotul (Urgo), Polymem Silver (Ferris) and contreet (Coloplast). These were then transferred into table format and easily understood but the graph representing the bactericidal activities of silver impregnated dressings appears to be somewhat mind boggling and difficult to read and interpret. As there was no clearly identified conclusion nor further recommendations for future practice in this paper, this was another negative aspect of the article.

Paper three also showed each silver dressing that was examined had a degree of antibacterial activity against the wound pathogens that were tested. The favourite of the dressings being aquacel Ag and acticoat. In this study, seven silver containing dressings were assessed against two common wound pathogens which were staphylococcus aureus and pseudomaonas aeruginosa. The seven dressings were (1) aquacel Ag (ConvaTec – referred to as non woven A), (2) acticoat (Smith and Nephew – referred to as non woven B), (3) silvercel (Johnson and Johnson – referred to as non woven C), (4) Contreet (Coloplast – referred to as foam A), (5) polymem silver (Ferris – referred to as foam B), (6) urgotul (Urgo – referred to as gauze and (7) silvasorb (referred to as hydrogel).

The findings of this paper were then presented using numerous graphs and tables which more than supported the design and the hypotheses of the study. However, two of the charts which incorporated a table and a graph were a drawback and unnecessary. They were difficult to follow as a lot of information was cramped in which would have been easily interpreted in the format of a basic graph showing a correlation between the number of surviving bacteria and the time span over seven days. That aside, this paper was thorough and in depth and the analysis of the tests being carried out were understood easily.

Discussion

The three research papers used in this systematic review and have been critiqued are all quantitative research papers. The papers were also in vitro studies and tested the same variable in a similar type of setting, enabling the comparison of the papers as well as any dissimilarities.

The author of paper one has made it clear that a grant for a small amount was given by Smith and Nephew, the manufacturer of one of the dressings that was tested when this study was being carried out. It can be argued that this is sheer bias on the part of the author but the manner in which this study has been conducted makes you believe otherwise.

In order to determine the facts and the truth, quantitative studies are carried out whereby the researchers remove sources of bias in their study or attempt to control the effects of bias once they have been recognised (Burns and Grove, 2001). Many aspects of the research can be biased, for instance, the data collection process, the researcher, the individual subjects, the sample, the measurement tools, the components of the environment in which the study is performed, the data and the statistics and as in the case of paper one, the manufacturer of the silver dressing acticoat has provided a grant for the funding of the study.

Conclusion

By conducting this systematic review, it has become evident that silver is a broad spectrum agent effective against a large number of gram positive and gram negative micro organisms, many aerobes and anaerobes, and several antibiotic resistant strains such as MRSA. Within the last decade, the field of wound care has been inundated with active dressings, especially those that deliver biologically active substances to the wound site.

More than ten different silver containing dressings, including hydrogels, hydrofibers, and alginates, are currently available worldwide. Although all are assumed to be safe and effective, evidence of their efficacy is limited; few clinical trials have been performed with them. Moreover, claims about how the dressings work, how effective the silver in a specific dressing is, and why one dressing is better than the other are based on sometimes scientifically complex methods of testing and results that yield contradictory or inconclusive statements. It is important for health care professionals to be aware of the ways in which silver acts physically and chemically, especially when trying to understand the statements made by companies that market silver containing dressings.

According to the manufacturers of dressings currently available, each enhances wound healing through the antimicrobial activity of silver. However, with many of these dressings, such claims are not based on clinical trials, but rather on case histories and in vitro studies. The use of silver dressings is still in its relative infancy, and as yet the most appropriate use of these materials is not well understood. Although the rapid release of silver may be desirable from a bacteriological point of view, according to Jorgensen (2005), it is important that the silver present in a dressing is not released into the wound in a short period but slowly over a number of days.

Having critiqued the three research articles, the aim is to utilise these findings by making other health care professionals more aware of the benefits of using such silver dressings and encouraging the use of these dressings in future practice. The indications for the use of silver dressings and the choice of specific products depend upon many factors, but the evidence available to date suggests that they have an important role to play in the treatment of infected exuding wounds, including those containing antibiotic resistant strains of bacteria, MRSA. However, further work is required to determine how and where each should be used in order to gain maximum benefit.

Strategies for Assessing Patient Satisfaction

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Introduction

The price of health care is rising at a quick rate because of the many challenges facing healthcare such as malpractice cost to doctor turnover, healthcare facilities or hospitals needs to take full advantage of their resources and make decisions to continue to be profitable and because of these challenges this is why it is important to improve patient satisfaction. “When”, we improve patient satisfaction we increase productivity. The hospital administration, doctors, and staff spend more time addressing complaints and non-compliant patients, which can damagingly influences the hospital or health clinic productivity. Satisfied patients are easier to care for and less time is spent dealing with complaints, and patient are more compliant with there healthcare. “Focusing”, on making the patient happy decreases the length of patient’s visits and time in the clinic and can cut the cost of treatment and increase patient capacity.

Hospitals and facilities around the world are focusing their attention on patient satisfaction. To examine patient satisfaction hospital look towards patient satisfaction surveys to help the hospital administration by including the patient viewpoint to generate a philosophy where services are believed to be an important strategy for the hospital or healthcare facility. “Although”, patient surveys has been successful there is still work that needs to be done. Patient surveys are used as a way to measure quality of care and patient safety.


Evaluate and Explain Inconsistency

When evaluating and explaining the inconsistency between customer satisfaction and profitability and why it tends to exist in healthcare organizations, according to an article by Kerfoot, K. (2016. Para 1-7). Hospital Consumer Assessment of Healthcare Providers and Systems scores are based on patient satisfaction by using surveys, which have a direct effect on hospital revenue. “When”, a patient is discharged from the hospital a patient may be asked to complete a survey relevant to their hospital visit and based on the scores the hospital or clinic will either cost or increase profit up to 1.5% to 2% of Medicare payments. This averages about $500,000 to $850,000 a year for each hospital. “Although”, risky Patient satisfaction survey can be rewarding and increase hospital profits.

Several healthcare executives that was surveyed expressed that patient experience and satisfaction was one of the 3 major concerns due to the loss or gain of funding. The link between HCAHPS scores and hospital profitability established through data based on 3,025 critical-care hospital around the world. The higher the HCAHPS score increases profit at a margin of .93, and the lower scoring hospitals for patient satisfaction displayed a lower profit margin of -4.59.

“Because”, of the Affordable Care act more Americans are purchasing health insurance and making patient satisfaction of the utmost importance. The more people that are insured means more people seeking health care cause’s hospital to compete for the patient business. Health care is like a business, it determines how much to patients is worth, because if the patient is unhappy with the service you provide that will not stay loyal to your hospital.

The link concerning profitability and HCAHPS scores is Quality of care which as the greatest influence of patient satisfaction. Hospital staff that work with patients, and their happiness with their job have an impact on the quality of care. Patients believe that hospitals should reduce by 2% for nurses that report displeasure with their occupation seeing a profit rate of 37% and hospitals that score above a 9 see a profit of 80%. “When”, hospital invest in their staff they will see a greater return in the long run. Technology can produce optimistic work setting that provides structure that support members of the hospital by encouraging a balance between life and work. Combining staff and technology can decrease burnout and provider fatigue by decreasing overtime and other factors.


Statistical Procedures or Refute Inconsistency

“When”, applying the statistical procedures discussed in class to support or refute the inconsistencies, there are 4 tests that involve certain expectations be met. The first test is the t-Test which is normally used in literature and used to link two groups with a continuous variable and can be paired or unpaired and A P <0.05 proposes data indicating a difference amongst the two groups one being male and other group female. Chi-Squared of Association test the association of categorical variables and A P<0.05 points out the association among the two variables.

Pearson’s Correlation assess association between two continuous variables and takes on the values between -1 and 1. A positive value increases both variables but if the value is negative, when one variable increases one decrease. Linear relation value is zero and if the value is 0.5 to 0.6 indicate a sensible correlation, 0.6 to 0.7 propose a good correlation and a correlation of 0.7 to 0.8 is an excellent correlation, a correlation above 0.8 magnitude is rare. “Lastly”, linear regression is used when the variable outcome is continuous and there are two types simple linear regression analyze data for the outcome variable alongside a predictor variable and estimates a regression coefficient, which proposes how much the variable outcome increases or change the predictor variable. Multiple linear regression is used to compute coefficients. Material Research Essential. (2014).


Price vs. Quality of Services

MACPAC. (2018. Para 1-24) suggested that several research studies has been done to see if managed care delivery systems improved outcomes there is no evidence that managed care increases or decreases access to quality care for the patient. The enrollee’s access to care is the responsibility of the Medicaid managed care organization which is vital to improving the delivery of quality of care. “For”, each person enrolled in a plan under managed care the state pays a fee at a fixed rate for each member per month to cover services that each enrollee receive. The payer pays the doctors for Medicaid services that the patient needed and contained within the plan under Medicaid.

Doctors are required to keep their patients healthy to preserve cost within the payment rate by providing preventive care to minimize costly hospital and emergency room visits. Some people believe that under the capitated payment system MCOs are paid per patient and not on the amount of treatment, is given an incentive to decrease the cost of treatment. Capitation rates can also impact incentives and if set to low can cause incentives to limit services through the use of the doctor, preauthorization polices and place restrictions on benefits. “With”, the decrease in rate prompt policies to pay less for care and can cut the number of physicians willing to provide care “therefore”, delaying access to care.

Managed care plans can create their own network qualifications, terms of contract and compensation rate set by the state. M CO patients are normally limited to a network of doctors and must deliver satisfactory care. In urban and rural areas across the United States size, range of network will impact the types, availability, and quality of care accessible to patients which can vary largely by state.

The provision of benefits under various delivery systems can present many challenges in management of care because contracts amongst the state and managed care organization recognize which state plan will be the obligation of the MCO, some benefits are the sole responsibility of Medicaid and have been provided through managed care such as long term care and transportation is fixed from the capitated benefit package to continue access to care and because MCOs can offer services including the services accessible under the state plan can be improved for their patients. Contracts must be specific, Medicaid managed care must meet certain criteria that don’t apply to Medicaid, federal and regulatory laws such as standards of access to quality care and conditions of annual quality review, that applies to the MCO’s.

In studying in the relationship concerning managed care, access and quality Medicaid managed care offers payees better quality access, but the scope and level of improvements are specific to the state and variable. A Medicaid managed study conducted in Texas determined patients’ satisfaction reveals that Managed care organizations are meeting their patients’ needs as well as satisfaction scores exceeding national standards on a number of key areas such as readmissions. Another survey of the state Medicaid program indicated that over two-thirds of states conveyed that Medicaid payees experienced some access to care problems because of problems by a patient with other insurance, but at the same time access to care was improved due to managed care fee-for-service.

Managed care on the quality of care can be difficult to evaluate. Quality is a subjective theory and is assessed using both process measures and results. Data published by NCOA from CAHPS survey measures the views of the enrollee’s health insurance plan, physicians, total health, and the ability to access care. Enrollees in the managed care programs rate their health coverage at a higher rate as opposed to private insurance patient with a poorer rating compared to Medicare patients.


High Patient Satisfaction Results

“According”, to Healthcare Financial Management Association, (2018, Para 1-16) when using high patient satisfaction to my advantage negotiating a new managed care contract for the hospital requires planning, establishing a relationship and cooperation amongst all parties involved. Negotiating requires preparation, so that the hospital can establish a payer-provider partnership. The main objective of managed care negotiation is to obtain reasonable compensation for care, the effect patients will have on our workflow and products being offered.

A payer profile should be established before sitting down at the negotiating table. To create a payer profile we must reach out to the contracting partners to collect key information about the goals being negotiated and products or equipment they plan to endorse. Information can also be obtained from data collected inside the organization by researching how much income the payer will bring to the hospital or clinic, how it is a breakdown within the different department in the hospital. We should also analyze denials and reach out to the organization staff via a survey or communication about any problems to collect information.

“Lastly”, if all parties involve maintain communication with a positive approach and payer and health care professional can agree they all win. With the knowledge, expertise and method doctors used to deliver health care for the patients, the patient will be placed at the top of the health care process.

Ethical issues involved when presenting results is giving a false report, bribery, rewards, violating the rules and ignoring the facts or lying. Lying is defined as being dishonest. Additional issues included when presenting results are setting limitations on negotiation before you start talk, taking an offer back that has already been set at a later date and failure to put the contract in writing. Nursing Link. (2018).


Qualitative and Quantitative

Qualitative data can be used to help hospital improve market share because it is used as a plan by the hospitals to help patients see the bigger picture and help marketers gather numerous amounts of information about the patients. Qualitative research focus on the primary reason, opinions, and why patients act a certain way.

“When”, studying the qualitative data you will understand what influences patients to take action and getting to the basic core of what makes a patient tick. Marketers might look at numbers to see why patients may not return to the hospital or clinic though numbers but don’t say why, another qualitative approach is videoing a method used to record a patient thought as they continue to deliver correct, clear and actionable reasons for their choices. This kind of videoing captures things that analytical data cannot.

“Finally”, qualitative research can be looked at as a study that focus on the role of the patient. Analytical numbers are used in controlling technical mishaps, uncovering avenues and other areas where primary numbers make difference. Marketing persona is based on personal information collected from those numbers such as a patient’s gender or location. Patel, N. (2018, Para 1-14).

“According”, to an article by New Perspective. (2015, Para 1-6). Quantitative data can be used to help hospital improve market share to improve patient satisfaction, health specialists work life, ways to avoid patient illness and hospital safety. Quantitative research focuses on statistical, mathematical or numerical results and can help hospitals increase services and influence actions.

Studies are conducted to help hospitals recognize their patients who needs care are in pain or feeling discomfort. “Though”, patient surveys physicians can find more information about their patient and to see if they are happy with their care. Studies are conducted by surveys such as patient satisfaction surveys, marketing research, and Pain assessment surveys this information allows healthcare workers find out what patients needs and how they will improve, as well as learn patient demographic to structure their services.

Doctors can learn more about a patient diseases by conducting research to get essential data for qualitative research. Viewpoints uses both quantitative and qualitative research to study data that is aimed at helping the hospital improve its decision making information. Hospital administration may seek input from the patient bout the appearance of the office, improving the hospital is a good way to obtain patient/staff satisfaction. “Lastly”, interviewing the hospital staff can be used to learn common practices in regard to educating and supplying the patient with the information needed, this is used to obtain more resources that will be shared with patients and then quantitatively tested.


Conclusion

I believe that patient surveys and using the outcome of the results will add value and allow patients to help improve quality care. Implementation of surveys depend of the project and applications for conducting the project. “In”, the health-care setting surveys are use as tools that are tailored to improve quality care. I often hear patients and hospital staff say that surveys are a waste of time because the outcome will not result in a quality improvement plan. Some hospitals have been known to use surveys incorrectly to attain financial gains.

It is vital for hospital employees to establish partnerships with patients, with the goal to build trust and instill an attitude to benefit both parties. The sharing of information and being clear with the investor can help influence when negotiating is needed. Teamwork and benchmarking is essential for best practices. “When”, conducting surveys information should be obtained from more than one source to get a better outcome and not used to make changes or policy decisions.


REFERENCES

         Healthcare Management Financial Association. (2018).

Successfully Negotiating Managed Care Contracts

Retrieved from

http://www.hfma.org/Content.aspx?id=16658

         Kerfoot, K. (2016).

Patient Satisfaction and the Bottom Line

Retrieved from

http://www.apihealthcare.com/blog/healthcare-trends/patient-satisfaction-and-the-bottom-line

         MACPAC. (2018). Managed care’s effect on outcomes Retrieved from https://www.macpac.gov/subtopic/managed-cares-effect-on-outcomes/

         Patel, N. (2018).

How to Use Qualitative Research to Expand on Your Marketing Personas

Retrieved from

https://neilpatel.com/blog/qualitative-research-marketing-personas/

Safeguarding Vulnerable Individuals from Harm

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Safeguarding


Introduction

To safeguard vulnerable individuals is to take actions that will reduce or prevent the risk of harm, abuse or neglect that could happen to those individuals who are vulnerable to these actions, while also being able to support them to maintain their right to independence. A service that provides support for these individuals will have strict safeguarding policies and procedures in place that the health and social care practitioners who provide the service for the individuals must know to be able to provide the ultimate service to support these vulnerable individuals with their needs.


3.1.: Explain factors that may contribute to an individual being vulnerable to harm or abuse.

When safeguarding individuals it is important that health and social care practitioners are aware of the factors that could contribute to that individual possibly becoming vulnerable to harm, abuse or neglect so they are able to take the correct precautions to prevent that individual becoming a victim of these actions. There are two categories these factors can come under and those are environmental and individualistic.

For environmental factors, it could mean that the ‘environment’/setting that these individuals are in could contribute to the individual becoming vulnerable to harm, abuse or neglect; for example, if the individuals residence is in a secluded area then it could be a high possibility that they may become a victim to harm, abuse or neglect because it will not be noticed by a significant amount of people because of the location of their residence. If an individual uses a service where the health and social care practitioners have a lack in training, they are not supported well by their mentors and a lack of monitoring the work ethic of practitioners, can increase the likelihood of an individual becoming vulnerable to harm, abuse or neglect. For example, if an individual lives in an assisted living residence due to not having the mental capacity, because of a mental illness or other conditions, to make decisions about their own safety; if the staff of the residence are not trained in that area of mental illness and conditions then they may work in a way that will not promote the individuals well-being or value the needs of that individual due to lacking the knowledge of those conditions. The result of this would be that the individual could challenge the staff who provide their care and assistance in saying that their care and assistance is not enough for what they need support with. This in turn can have an impact upon the staff’s stress levels and can result in the staff becoming agitated with the individual which can cause them to become vulnerable to harm, abuse or neglect. Another example of a environmental factor would be that if a nursery nurse feels that they have unreasonable workloads or feel that they are not being supported well by their management then it could effected their work ethic and cause them to work in an unprofessional manner; this could result in the children who attend that nursery to be placed in, unknown to their caregivers, a position that makes them vulnerable to harm, abuse or neglect due to the nursery nurse not carrying out their roles correctly.

For individualistic factors, it can mean that the care and support an individual need due to the very nature of their needs, such as mental health conditions and dementia, can be more vulnerable to harm, abuse or neglect. These individuals who suffer with these types of conditions may be reluctant in reporting the incident(s) as the health and social care practitioners who support them with their day-to-day living may lose their jobs or that the service that is provided to them because of their needs could be withdrawn. If an individual has communication difficulties because of a disability or illness could become vulnerable to harm, abuse or neglect because they struggle to communicate what has happened to them which makes them an easy target for an abuser. Similarly, individuals who suffer with certain conditions such as mental health illnesses or dementia are at a higher risk of becoming a victim to harm, abuse or neglect.  For example, if the individual has been diagnosed with dementia then they can be highly vulnerable due to having trouble with remembering events that have occurred. This would make them an easy target for an abuser because they know that the vulnerable individual is unlikely to be able to recollect the incident that has occurred and therefore be unable to tell anyone about it. Another example would be that if an individual suffers from a mental health condition then this can lead to other behaviours that are linked to their condition and this can result in extra support for their needs; the by-product of this would be more stress upon the health and social care practitioners who provide the support for the individual.


1.3.: Explain how health and social care practitioners can take steps to safeguard themselves.

As well as having the responsibility of safeguarding the individuals they provide a service for, health and social care practitioners also have a duty to safeguard themselves from accusations which could include behaving in an unprofessional manner or causing harm, abuse or neglect to a vulnerable individual who they provide support and care for. Therefore, practitioners who work within the health and social care sector must follow their work setting’s policies and procedures and the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England which explains how practitioners can not cause harm to an individual which can effect their well-being and health, and that they must not harm, abuse or neglect individuals who they provide support and care for. Practitioners who work within the health and social care sector have to have a good awareness of what safeguarding is and by having knowledge of what it is they will also have good knowledge of the six principles; this includes Empowerment, Prevention, Proportionality, Protection, Partnership and Accountability. These principles have influence over the everyday workings of a practice and are another way that help health and social care practitioners to safeguard themselves. For health and social care practitioners to safeguard and protect themselves the choices, actions and decisions they make must be fair when they are working with the individuals, they provide care and support for. But at the same time these choices, actions and decisions the practitioners make must still fall into the guidelines of the agreed work ethic of the organisation they work for and must not put themselves in any unsafe situations that could potentially cause harm to themselves.


1.2.: Explain the role of safeguarding

When safeguarding individual’s health and social care practitioners must consider how to keep individuals safe, to value the individuals needs, and to always protect the individuals who they are providing care and support for.

Safeguarding concerns organisations and practitioners with working together to be able to prevent individuals becoming victims of harm, abuse or neglect, and to do this they have to share the individual’s personal information about their care and their needs they have support with. And this is to keep the individual safe. A consequence of not following this would be the example of Victoria Climbie. She was an 8 year old girl who was tortured and murdered after being placed into the care of her great aunt and the woman’s boyfriend by her parents, and her information about hospital visits and concern reports not being shared between organisations later resulted in her death due to actions not being taken sooner to keep her safe from the abuse she was suffering.

Person-centred care is an approach which is valued in safeguarding; this is recognising an individuals needs, perspectives and preferences, and these have to be the main focus of their care plans and the support which is provided. Because of this an individual will have good knowledge of the high-quality care and support they should receive and as a result of this they are able to oversee their care, and there is a decrease in the likelihood of them becoming vulnerable to harm, abuse or neglect. By giving an individual this incentive it will lead to them gaining more independence and when they have concerns about the care and support, that they are being provided with, they are more likely to speak willingly about these concerns.

Protecting individuals also comes under safeguarding. This is stated along the lines of the Care Act 2014 where each of the local authorities, such as the police, probation services, healthcare and social services, are required to take the main hold of responsibility when it comes to protecting individuals from harm, abuse or neglect. The practitioners and staff of the authorities do this through several ways; the first being that they will overlook and help to organise the safeguarding of the individual who they are providing care and support for, then if there are any concerns when it comes to there being risks to the individual becoming vulnerable to harm, abuse or neglect they have an obligation to investigate it, and the staff and practitioners who are involved in the individuals care will decide upon the right actions to take when it comes to preventing future harm, abuse or neglect and this will be done within the organisations policies and procedures. Together they establish a Safeguarding Adults Board, and they will also ensure that when an individual is going through a safeguarding process, they will have representation. Lastly, all staff and practitioners will work together alongside the individual, who requires the care and support, in partnership.


References

Peripheral Neuropathy among Patients Living with Diabetes

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Update on Foot Care: Identifying Early signs of Peripheral Neuropathy among Patients Living with Diabetes Mellitus


Bernice S. Samuel DNP and Susan J. Appel, PhD, APRN-BC, CCRN, FAHA


Introduction

Among those individuals living with diabetes, peripheral neuropathy (PNP) is a major contributor in the development of foot ulcers.

1

Even though there has been a decline in recent limb amputations due to advanced management of foot ulcers, 7% of those affected with type 2 diabetes (T2D) will still develop foot ulcers.

2

Diabetes-related foot ulcers not only cause further physical disability, they also reduce the quality of life and increase the risks of lower extremity amputations.

3

The CDC

4

reports that 65,700 non-traumatic lower-limb amputations were performed among people living with diabetes. While diabetes is a major cause of complications such as vasculopathies and PNP, foot ulcers are the most easily prevented complications.

5

Therefore, practitioners must be fully apprised of tools and methods used to identify early PNP and prevent foot ulcers. Practitioners should also focus on actively educating the patient and family regarding PNP.

Most practitioners are familiar with the Semmes-Weinstein Monofilament testing (SWMT) as the gold standard used in primary care to assess for PNP. Mayfield and Sugarman reported the use of the SWMT as a useful tool in the primary care office for practitioners to assess patients for PNP, but indicated it is not without limitations.

6

Further interventions are needed when there is a loss of sensation detected, such as proper footwear and patient education, to prevent trauma and foot ulcers.

6

Research has shown that practitioners can continue to assess patients with diabetes using the monofilament testing as long as PNP is not present. Once PNP is noted, additional assessment and management techniques are warranted.

A yearly thorough foot exam by a podiatrist has been recommended by the American Diabetes Association for those living with diabetes.

7

In addition, persons with diabetes and one or more risk factors need frequent assessments of their feet during routine office visits.

5

Patients with known risk factors for foot ulcers (e.g., poor vision, previous foot ulcers or amputation, monofilament insensitivity, and fungal infections of skin or nails) deserve special attention.

8

When practitioners have available clinical information that can help to predict the development of diabetes- related foot ulcers, patients will have better outcomes.

8

These predictors were found to be helpful in accurately targeting clients at high risks of contracting foot ulcers for preventative interventions. The use of proper footwear such as diabetes specialized shoes with proper diabetes foot insoles has been found to be a protective intervention.


Pathophysiology of Foot Ulcers

Diabetes related foot lesions occur as a result of two or more risk factors: PNP and peripheral arterial disease (PAD).

9

Diabetes-related PNP is a leading contributor to foot lesions.

10

The presence of PAD increases the risk for foot infections and ulcers among people living with diabetes.

11

Foot lesions are less likely to heal due to vascular insufficiency.

12

Research shows that there are three factors that leads to foot ulcers and infections: foot deformities, PNP, and minor trauma.

13

It is important to understand that the longer an individual lives with elevated blood glucose, the more likely he or she will develop PNP.

2

Long term hyperglycemia can affect the skin and delay wound healing if minor cuts or sores occur on the foot.

14



PNP

According to Benbow,

14

PNP can be classified as sensory, autonomic or motor. In sensory system PNP, an individual with diabetes has no feeling of sensation on his or her feet, does not feel hot or cold temperature, and does not feel cuts or trauma to his or her feet.

14

When PNP affects the autonomic system an individual will experience a decrease in sweat, resulting in cracked or fissured skin, dilated dorsal veins and an increase in temperature of their feet.

14

When the motor system is affected by PNP, the patient will be at risk for developing foot deformities such as Charcot foot.

14

Commonly, these patients report symptoms of aches and pains with tingling in their feet when PNP is present.

13



Foot Deformities

According to Abad & Safdar,

13

foot deformities are the second causative factor that leads to foot ulcers among people living with diabetes. People affected by neuropathy have decreased sensation in their feet, and are more prone to foot deformities.

13

These foot deformities affect the muscles and bones of the foot leading to bony protrusions that put the individual at increased risk for ulceration especially when PNP is present.

13

The correlation of PNP and foot deformities was examined by Soyupek, Ceceli, Suslu, & Yorgancioglu,

15

utilizing x-rays. Their study showed that the patients with PNP commonly also have foot deformities such as pes planus, pes cavus, tendon calcifications and osteoporosis.

15

Patients living with type 1 diabetes are particularly at risk for developing Charcot neuropathy that causes destruction of the bones of the foot.

16

The resultant bone thinning causes the bones to be fragile and leads to foot deformities.

16



Foot Trauma

Abad & Safar

13

identify foot trauma as the third factor that can lead to foot ulcers. Foot ulceration occurs when there is breaking of the skin, which leads to impaired healing of the lesion.

12

People affected by PNP have sensory loss of their feet and are unable to identify foot pain, trauma, calluses or injury to their feet.

13

Wearing ill-fitting shoes, calluses, onychomycosis, and foot infections that are not treated are all causes of foot trauma leading to ulceration. Once ulceration occurs due to trauma, the wound becomes infected.


Testing



Tuning Fork and Neurothesiometer

A study by Kästenbauer, Sauseng, Brath, Abrahamian, & Irsigler

17

investigated the effectiveness of the Rydel-Seiffer tuning fork in helping with the detection of diabetes-related neuropathy and compared its ability with that of the electronic neurothesiometer. In this study a 128-Hz tuning fork and a neurothesiometer were used at the bedside.

17

The results of the study showed that vibration perception threshold (VPT) was normal in 1917 individuals and abnormal in about 105 individuals when the tuning fork was used.

17

The participants who had abnormal results were older and also had elevated A1c results. The researchers used the neurothesiometer and the results showed that VPT was 2.5 times higher among patients who had an abnormal tuning fork test.

17

The researchers concluded that the tuning fork had a higher sensitivity and a better predictive value in diagnosing PNP at the bedside.

17

The tuning fork is a reliable instrument in helping to detect PNP in the outpatient setting. It is an appropriate clinical tool that practitioners can utilize either at the bedside or in primary care.



Neurometer

A double-blinded study by Nather and et al.

18

showed that there were other testing methods that were superior in comparison to the SWMT in detecting PNP. One useful tool was neurometer testing. The neurometer measures readings from rapid current perception threshold (R-CPT) which is derived from the lowest strength of stimulus that the patient could perceive.

18

Three different rates of current signals at levels measuring between 0 and 10 mA were applied by the neurometer to the big toe and ankle.

18

Neurometer testing was found to be highly sensitive as compared to the SWMT. Sensory neuropathy was detected with better accuracy when using the neurometer testing at the big toe and ankle sites in comparison to the SWMT.

18

Studies show that the neurometer is an effective tool that practitioners can use to detect PNP.



Temperature guided avoidance therapy

Research shows that the best intervention in the prevention of foot ulcers was foot temperature guided avoidance therapy (TGAT).

19

A study by Lavery & et al.

20

sought to evaluate the effectiveness of infrared temperature monitoring among individuals at a high risk for diabetes related ulceration and amputations. Patients were placed in a usual therapy group or an enhanced therapy group.

20

The enhanced therapy group had additional tasks such as such as the use of a handheld infrared skin thermometer to measure the temperatures on the bottom of their feet twice a day.

20

Participants contacted a nurse if they noted a difference in temperature >4°F between the left and right foot.

20

The results of the study showed that the enhanced therapy group had notably fewer diabetes related foot complications.

20

The TGAT is an effective method in the detection of PNP where practitioners can assist patients in identifying sensory loss so that foot ulcers and complications can be prevented.



Scales for Neuropathy Symptoms

The Diabetes Neuropathy Symptom (DNS) score is a valuable tool that can be used to screen for and identify PNP.

21

The scoring is based upon symptoms such as ataxic walking, neuropathic pain, paraesthesia, and/or numbness. The DNS criteria are scored with 1 point each and there is a total of 4 points that can be given.

21

Presence of PNP is present with a score of 1, or more.

21

Similarly, the Diabetic Neuropathy Examination (DNE) is another valuable scoring system that helps to identify PNP. This scoring system consists of a total of eight items: two of the items describe the person’s muscle strength; one item addresses reflexes of the tendon and the other five items address sensation.

21

There is a total of 16 points that can be scored with this system. Any score above 3 points is considered to be abnormal and is PNP.

21


Treatment



Educating patients

Educational interventions are an important tool in reducing foot ulcers. A randomized controlled trial by Gershater and et al.

22

was designed to investigate the effectiveness of patients learning in groups versus learning on their own with information that is provided to them. The authors sought to understand what types of learning would decrease the incidence of foot ulcers. The study results showed that about 42% of the patients got foot ulcers.

22

Some of the reasons for ulcer development were: stress- related plantar ulcer and trauma.

22

The study showed that education in group sessions among patients who are at increased risk for foot ulcers did not have an effect on whether they would develop ulcers of the foot.

22

It was concluded that sessions conducted within a group educational method may be suitable for patients who have a low risk of getting foot ulcers. The authors of the study suggests that it is important to educate practitioners involved in the patient’s medical care and also their caregivers regarding improved foot care such as footwear and signs of foot problems.


Implications for Practice

The conclusive results show the best methods to identify PNP and to prevent foot ulcers was the TGAT, the neurothesiometer and the tuning fork. The TGAT method shows that patients can complete this task at home and alert their practitioner about the results. The TGAT is valuable in showing the results of further neuropathy or damage if patients have a prior history of insensitivity to the SWMT. The SWMT is valuable for practitioners to use in the office setting as this is an inexpensive test. The SWMT is not valid once neuropathy is diagnosed. The practitioner should consider the use of the TGAT at this point and teach the patient how to use an infrared sensitive skin thermometer. The patient should be advised to keep a log book and if the temperature on the designated site is >4°F, he or she will need to reduce the number of steps taken in the following days and contact their practitioner. The tuning fork was also validated as being highly sensitive in diagnosing PNP and is a good test for practitioners to use at the bedside.

Certain clinical information about the patient is valuable in predicting future foot ulcers. These predictors were high A1c levels, poor vision, prior history of foot ulcer and/or amputation, monofilament insensitivity, tinea pedis and onychomycosis. The practitioner needs to be aware of these predictors and educate the patient about foot care. Practitioners need to increase monitoring of the patient’s foot at every office visit when these predictors are identified. Education is an important criterion in managing PNP. Patients need to be educated about PNP, foot ulcers, proper fitting shoes and the signs of foot infections.

This review of the evidence- based literature revealed that basic SWMT is useful in predicting neuropathy but is not useful in preventing ulcers once neuropathy is diagnosed. There is a common misconception among practitioners that SWMT can be used even when neuropathy is diagnosed. The re-education of practitioners is important with the introduction of new testing methods such as TGAT once neuropathy is already diagnosed. This best practice will help to prevent ulcers among persons affected by diabetes and therefore improve the quality of their life.

References

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    http://www.cdc.gov/diabetes/statistics/prev/national/figraceethsex.htm
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    Nephrology Nursing Journal, 31

    (1), 53-64.
  1. Mayfield, J. A., & Sugarman, J. R. (2000). The use of the Semmes-Weinstein Monofilament and other threshold tests for preventing foot ulceration and amputation in persons with diabetes.

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    Heagerty, P.J

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    .,

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19. Arad, Y., Fonseca, V., Peters, A., & Vinik, A.( 2011). Beyond the monofilament for the insensate diabetic foot: a systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes.

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Provide a comprehensive statement of the problem using the epidemiological process including the distribution, determinants, and deterrents.

/in /by

Provide a comprehensive statement of the problem using the epidemiological process including the distribution, determinants, and deterrents.

Power point Presentation (20 slides each WITH NOTES, GRAPHICS)

Topics:

1. How to improve Nutrition in the elderly. Target group is nursing staff from one facility.

2. Diabetes in Older Adults. Target group is nursing staff from one facility.

3. How to Overcome Language Barriers in Healthcare. Target group is nursing staff from one facility.

Provide a comprehensive statement of the problem using the epidemiological process including the distribution, determinants, and deterrents.

Incorporate at least four current literature review findings as a theoretical base for your project/paper.

Describe community resources available to meet the need of the specific community in this problem area. Summarize the resources available and describe their effectiveness for the community.

Describe your selected group. Identify and summarize the learner needs of your selected group. What are the needs? Why does this group need to be educated on your chosen topic?

Identify and describe developmental and teaching/learning theory/theories used and why they are appropriate to the learners you targeted.

Describe in behavioral terms your specific planning process for your project and overall teaching goal for your participants.

Evaluate your teaching experience. Reflect on the following questions. What went well? What did not? What would you change if you were teaching this topic to a similar group at a later date and why?

RUBRICS

Provides a comprehensive statement of the problem using the epidemiological process including the distribution, determinants, and deterrents. Describes the selected group, and identifies and summarizes the learner needs of the selected group, including why this group needs to be educated on the chosen topic.

Describes the community resources available to meet the need of the specific community in this problem area. Summarizes the resources available and describes their effectiveness for the community. Identifies and describes developmental and teaching/learning theory/theories used and why they are appropriate to the learners targeted. Describes in behavioral terms the specific planning process for the project and overall teaching goal for the participants. Incorporates at least four current literature review findings as a theoretical base for the project/paper.

Evaluates the teaching experience. Reflects on the following questions: What went well? What did not go well? What would you change if you were teaching this topic to a similar group at a later date and why?

Writing is clear, concise, formal, and organized. Slides are mostly error free. Information from sources is paraphrased appropriately and accurately referenced and cited in APA style. A title slide, clear introduction and conclusion, and reference slide are included. The number of references required by the assignment is presented. In-text APA citations are used in the presentation.

Good language skills and pronunciation is used; information is well communicated. Still images of the lessons are included if actual video is not.

What type of decisions do patients make as a natural consequence of the influence from providers and physicians?

/in /by

What type of decisions do patients make as a natural consequence of the influence from providers and physicians?

Write an additional 4–5 pages in response to the following:

How do providers influence the decisions that patients make? What type of decisions do patients make as a natural consequence of the influence from providers and physicians?Consider the provider setting, treatment type, and method of reimbursement when formulating a response.How are insurance plans (including government payers) impacted by the decisions that patients and their doctors make?Consider supply and demand concepts when formulating a response.How are physicians and patients regulated by government?Describe how the regulatory environment will impact the health care economy when formulating a response.

Add 3–5 more slides to your presentation covering this additional information.

Please submit your assignment.

Write an additional 4–5 pages in response to the following:

How do providers influence the decisions that patients make? What type of decisions do patients make as a natural consequence of the influence from providers and physicians?Consider the provider setting, treatment type, and method of reimbursement when formulating a response.How are insurance plans (including government payers) impacted by the decisions that patients and their doctors make?Consider supply and demand concepts when formulating a response.How are physicians and patients regulated by government?Describe how the regulatory environment will impact the health care economy when formulating a response.

Critically review personal strengths and weaknesses and evaluate strategies for using the areas of strength to overcome and manage weaknesses, in particular in communication and organisational skills.

/in /by

Critically review personal strengths and weaknesses and evaluate strategies for using the areas of strength to overcome and manage weaknesses, in particular in communication and organisational skills.

 

PLEASE FOLLOW THE LEARNING OUTCOMES AS THAT IS WHAT NEEDS TO BE INCLUDE IN THE ESSAY. ALSO THE REFLECTION WILL BE BASD ON MY personal development plan (PDP)

The aims of the module are that you will be able to:

– Maintain and develop a Personal and Professional Development Plan to integrate classroom learning with learning in practice.

– Build upon the skills acquired in LSD 1 by appreciating the learning and support needs of others and developing coaching and facilitation skills.
.

7. Learning Outcomes

By the end of the module you will be able to:

1. Critically review personal strengths and weaknesses and evaluate strategies for using the areas of strength to overcome and manage weaknesses, in particular in communication and organisational skills.

2. Identify and implement the learning skills required to complete the modules in Year 2 of the programme and recognise the value of continuously improving personal work and career development and to contribute effective care in the workplace.

3. Critically appraise your skills in treating others with honesty and respect as well as that of coaching and facilitation of others in your learning development, in particular to users and their carers.

4. Justify your career choices working with people with different health care needs with reference to the work based learning requirementsCurrently 2 writers are viewing this order

Choose a family in your community and conduct a family health assessment using the following questions below.

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Choose a family in your community and conduct a family health assessment using the following questions below.

Please present a summary of your assessment in an APA format on a 12 Arial font. Please use appropriate scholarly evidence-based practice references to sustain your assessment. 1. Family composition.
Type of family, age, gender and racial/ethnic composition of the family.
2. Roles of each family member. Who is the leader in the family? Who is the primary provider? Is there any other provider?
3. Do family members have any existing physical or psychological conditions that are affecting family function?
4. Home (physical condition) and external environment; living situation (this must include financial information). How the family support itself.
For example; working parents, children or any other member
5. How adequately have individual family members accomplished age-appropriate developmental tasks?
6. Do individual family member’s developmental states create stress in the family?
7. What developmental stage is the family in? How well has the family achieve the task of this and previous developmental stages?
8. Any family history of genetic predisposition to disease?
9. Immunization status of the family?
10. Any child or adolescent experiencing problems
11. Hospital admission of any family member and how it is handle by the other members?
12. What are the typical modes of family communication? It is affective? Why?
13. How are decision make in the family?
14. Is there evidence of violence within the family? What forms of discipline are use?
15. How well the family deals with crisis?
16. What cultural and religious factors influence the family health and social status?
17. What are the family goals?
18. Identify any external or internal sources of support that are available?
19. Is there evidence of role conflict? Role overload?
20. Does the family have an emergency plan to deal with family crisis, disasters?
Identify 3 nursing diagnosis and develop a short plan of care using the nursing process.

Nursing Case Study Parkinsons Disease

/in /by


Thomas Aitken


1)


Introduction

The following discussion shall be about Parkinson’s disease with an emphasis on the disease’s association with John Magill. In Australia, deaths because of Parkinson’s disease comprised 19. 8% of deaths from nervous system disease in 2010 (Australian Bureau of Statistics [ABS], (2012). The aetiology and risk factors associated with the disease shall be discussed, in addition to its clinical presentation and the required essential physical assessments. Furthermore, the medical management of the disease shall be developed before concluding the discussion.

John’s vital signs appear unremarkable although his respirations are slightly elevated which is most likely due to anxiety-worrying about medications. He has a sick wife suffering from multiple myeloma. This is a form of cancer that would reduce her ability to care for John. John may also be suffering from depression, as evidenced by his teary manner.

It was also noted that there was a skin tear to his right hip and that he started to cough when given a drink of water. There could be a risk of infection with the skin tear and the risk of aspiration due to dysphagia. He had a fall, suffered bruising, has tremor’s and moves slowly.


2) Possible causes / risk factors related to the health condition

.

There is no known definitive cause as to why people contract Parkinson’s Disease, although there are several theories regarding the condition. One hypothesis is that it may be due to genetic and environmental components (Schapira, 2010). However, this has not been fully substantiated. It may also involve a combination of factors ranging from environmental influence to viral infections. (Foltynie, Lewis, Barker,2003,).

More males seem to acquire the condition than females and age seems to be connected with the condition most people are diagnosed at about 60-65. Although younger people have also been effected it’s less common. The condition develops slowly and takes about ten to twenty years for the full impact of the condition to be felt. John Magill is about mid-way in terms of this disease and will need careful management. These factors together may result in the death of the dopamine-containing nerve cells. Because, there could be a variety of causes of the condition this could explain why Parkinson’s has different effects on people. The main theories as to why Dopamine cells die, difficulty clearing toxins, inflammation, accelerated aging process, neuron’s inability to clear protein, and genetic factors. (Grimes,2004,)

In the early stages the risks are minimal, but as medication loses its effect risks to sufferers increase. The mains risks are, falls, depression, swallowing, memory, impaired verbal communication, imbalanced nutrition. John has a number of these issues.


3) Discuss clinical manifestations of Parkinson’s disease and key physical assessment.

The patient is best diagnosed by a neurologist or an expert with this condition, the physical signs are noted and observed over time, the most obvious being the tremor. This is the best way to diagnose Parkinson’s. The disease may present with both non-motor and motor symptoms, sometimes the non -motor precedes the motor symptoms. John has the classic resting tremor in his arm and his movements are getting slower.

John also suffers from secondary motor symptoms, like difficulty in swallowing which can be very serious resulting in weight loss, choking and pneumonia. (Theodoras & Ramig, 2011) Other problems to look for would be speech, gait freezing which can increase a person’s chance of falling. The patients face tends to be less expressive and they have a fixed stare.

There are also the Non-Motor Symptoms, like Depression, anxiety, which are two conditions that have been noted in John Magill. Apathy and hallucinations sleeping fatigue and dementia. Nonmotor symptoms may even occur prior to other symptoms and can be even more debilitating than other aspects.

Physical assessment for John would include the four main clinical features of the disease resting tremor, rigidity, postural instability and bradykinesia. Resting tremor can be assessed with the patient resting and in a relaxed sitting position with arms placed on lap (Hauser, 2016).


4) Discuss medical management including medications.

John would require a team of health professionals to help manage his condition. They would include the following, nurse, physiotherapist, occupational therapist, speech therapist, social worker, psychologist, neurologist, GP and carer. The condition will get progressively worse over time and as John gets older it becomes more difficult to deal with. However, by slowing the progression of the disease and reducing its impact just maybe a cure could be found in the future.

John is already on the best available drugs to control his condition. Levodopa (also called L-dopa) is the most commonly prescribed and effective drug used. (Boelen, 2009) The drug reaches the brains nerve cells that produce dopamine which can help as a neurotransmitter. Carbidopa in addition to Madopar are significant in increasing the bioavailability of levodopa in the brain through the inhibition of decarboxylation and consequent inactivation of levodopa Management of John’s non-motor symptoms is also essential, in particular depression, he has been prescribed Citalopram. With these medications, the correct dosage and the timing of the dosage is critical in achieving their full effect.


5) Develop a holistic nursing care plan using NANDA in order of priority.


The Nursing Process


A) three nursing diagnosis

–

1) Risk of aspiration due to impaired swallowing reflex

2) Impaired skin integrity due to trauma resulting from a skin tear (right hip)

3) Impaired physical mobility related to his fall and body tremor.


b) Goal for each

1) Patient will not aspirate when drinking fluids.

2) Patient skin integrity will heal and remain intact.

3) Patient will maintain optimum mobility and balance to avoid falls.


c) Three nursing interventions for each

1) a) Ensure medications are administered as directed at correct time’s) Ensure patient is sitting upright (greater than 45 degrees) c) Encourage patient to double swallow. Thickened fluids may be required.

2) a) Where able ensure the skin edges are approximated. b) Ensure that the wound is protected from potential contaminates. C) Ensure that a wound assessment and chart is commenced.

3) a) John shall be assessed for mobility skills. b) John shall be tested for balance. c) John can be taught the correct walking technique to avoid falls.


d) Three rationales for each

1) a) Administering Parkinson’s medication at the appropriate time will assist with the swallow reflex. b) By sitting upright there will be less chance of fluid going into lungs. c) Double swallow and thickened fluids will reduce coughing reflex. Use of a straw to help build oral strength (Theodoras & Ramig).

2) a) By ensuring skin edges on wound are approximated wound will heal better and more quickly. b) Good protection of the wound will help prevent infection. .c) The chart will help monitor the progress of the wound and when to change dressing.

3) a) Physiotherapist will assess John’s mobility skills he may need an aid like a walking frame. b) John will be tested for balance can he walk a straight line. c) John will be helped to improve walking technique by demonstrating small steps, and turning techniques.


Evaluation

Diagnosis 1) Patient demonstrates improved swallowing with no coughing

2) Wound appears to have healed or is on the improve with no infection.

3) John has not had any falls for a set time and is using walking frame..


6) Discharge Plan

A discharge plan starts from the moment a patient enters a hospital environment.

Before John can be released from hospital it is very important that a number of things are put in place in order to reduce the chances of John returning to emergency suffering from another fall which may be more damaging to his health. Patient education is significant in order for John to understand and cope with his condition. (Myeres & Gulanick, 2013).

Ideally, John’s family should be included regarding discharge particularly in regards to making adjustments at home so that falls are prevented. John may need to wear hip protectors, rugs on floor may need removing and safety rails installed.

In general, a basic discharge plan will include the following,

Evaluation/, with patient by qualified personnel/ Discussion, with patient/Planning, transfer from hospital to home. / Determining if care at home is sufficient or support may be required/ Referrals, to support agency. Arranging follow up appointments.


7) Conclusion

Parkinson’s disease is a chronic and debilitating condition that effects over 70,000 Australians. There is no cure and this can be a very difficult concept to accept.

John Magill will be faced with many challenges going forward and he will require a dedicated team of health professionals to assist him coping with the rigours of life.

Because John’s wife is not well he will most certainly need home nurse visits if he is to live independently, which is what most people aspire to do. Keeping John as healthy as possible will be the goal of health care providers. The day may come when John must go into full time care. However, it really depends on John maintaining a positive attitude with a strong desire to enjoy life for as long as possible.,

Word Count 1522 within in 10% of Max 1400


REFERENCES

Australian Bureau of Statistics. (2012). Disease of the nervous system. Retrieved

March 5, 2017, from


http://www.abs.gov/ausstats/abs@.nsf/Products/E9AE6DDF5D8153E9CA

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Blockberger, A. & Jones, S. (2011). Parkinson’s disease clinical features and

Diagnosis. Clinical Pharmacist, 3, 361-366.

Bolem,.M.P. (2009). Health Professionals’ Guide to Physical Management of Parkinson’s Disease. Human Kinetics.

Foltynie,T. Lewis,S.& Barker, R. A. Your Questions Answered Parkinson’s Disease.

(2003). Churchill Livingstone.

Grimes, D.A. (2004). Parkinson’s everything you need to know. Firefly Books.

Gulanick, M. & Myers, J.L. (2013). New nursing care plans: Diagnosis, Interventions and Outcomes. (6

th

ed.). St Louis, MO: Elsevier.

Hauser, R.A. (2016). Parkinsons Disease. Retrieved March 5, 2017, from


http://emedicine.medscape.com/article/1831101-overview#a2

Mckenna, L. (2014) Incredibly Easy Pharmacology. Wolters Kluwer/ Lippincott

Williams & Wilkins.

Schapira, A.H. (2010). Parkinson’s Disease. Oxford: Oxford University Press.

Theodoros, D. & Ramig, L. (2011). Communication and Swallowing In Parkinson

Disease. Plural Publishing.

Biomedical ethics in the christian narrative

/in /by

The four principles, especially in the context of bioethics in the United States, has often been critiqued for raising the principle of autonomy to the highest place, such that it trumps all other principles or values. How would you rank the importance of each of the four principles? How do you believe they would be ordered in the context of the Christian biblical narrative? Refer to the topic study materials in your response.

Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years.