What if there was no collaboration between the other healthcare professionals and the pharmacist, how would this be detrimental to your patient’s care?

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What if there was no collaboration between the other healthcare professionals and the pharmacist, how would this be detrimental to your patient’s care?

Paper , Order, or Assignment Requirements

You are a member of an interdisciplinary team which consists of a:-
? pharmacist (you)
? general practitioner
? registered nurse
? paramedic
? radiographer or radiation therapist
? dietician
? occupational therapist
*Each team will be assigned a patient case by Week 2 after team memberships are finalised.
Your team’s task is to:-
1. Justify your role and the skills you have as a pharmacist that make you integral to the interdisciplinary team and care of this patient. Use the 8 employability domains to help you do this. Hint: what if a pharmacist was not part of the team, what would be missing in your patient’s care?
2. Outline and explain the roles and skills of other non-pharmacist healthcare professionals in your healthcare team that are integral to the care of this patient. Hint: what if a specific healthcare professional were not part of the team, what would be missing in your patient’s care?
3. Explain how collaboration between you, the pharmacist, and each non-pharmacist healthcare professional, results in them doing their job more effectively? Hint: What if there was no collaboration between the other healthcare professionals and the pharmacist, how would this be detrimental to your patient’s care?

Case Study: Elderly Person With Diabetes

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This is a case commentary about a diabetic patient, in regards to the patient interviewed in a clinic setting. The case is studied in a holistic manner, where medical and non-medical aspects were fully covered. A detailed account of the people involved and thoughts are also included.

Patient History

Ms Linda Mogen*, 76, is a retired school teacher who currently lives with her husband in the town area. She pays a visit to the clinic every 3 months for an overall checkup as well as to obtain her medications, which is mainly insulin. Her family is doing fairly well and there is no financial burden, although she prefers to visit this particular clinic although it is relatively further from her house because there are no charges for her as an ex-government employee. She appears as a contented lady who is well-read about her condition.

Aside from that, she also suffered from hypertension, chiefly due to stress from her previous work as a teacher. In the past, Ms Mogen had been diagnosed with a thyroid nodule in the throat, and a cyst in the breast, which were both benign and removed 5 and 8 years ago respectively. As a baby, she used suffer from asthma, but as time passed it became less apparent.

Ms Mogen discovered her condition because her father and two sisters had diabetes too, which appeared to be a hereditary disease in her family. She was strongly recommended by her sister – who is a nurse- to have a checkup. Apart from her course of insulin (pill form), Ms Mogen also consumes alternative medicine, such as Barley Green Herb, as well as other supplements. There are rashes resulting as an allergy to insect bites as well, possibly related to her diabetes.

*Names changed to maintain confidentiality

Biological Aspects

Diabetes mellitus (DM) consists of a cluster of metabolic disorders that presents high unusual levels of blood sugar, analogous to hyperglycemia (Kumar, 2009). Type 1 DM is caused by destruction of pancreatic islet B cell primarily by an autoimmune process, leading to insulin deficiency, where the patient becomes prone to developing ketoacidosis, whereas type 2 DM results from insulin resistance and weakened insulin secretion, aside from disproportionate hepatic glucose production. Some common presenting symptoms of DM are polyuria, polydipsia, weight loss, fatigue, weakness, blurred vision, frequent superficial infections and poor wound healing (Kasper, 2008). From urine testing, patient would also present with glycosuria and ketonuria. Insulin is responsible in stimulating bone formation, thus there might be significant bone loss in untreated diabetes mellitus (Saladin, 2010). In relation to diet, starchy food has to be reduced, i.e. rice, bread, pastries, potatoes and sugar. Ms Mogen had to significantly cut down on her intake of rice, as rice contains complex carbohydrates and the body has a limit of converting the glucose to energy.

Risk factors for type 2 DM includes a family history of diabetes, race or ethnicity, polycystic ovary syndrome or acanthosis nigricans, habitual physical inactivity, obesity and hypertension (Kasper, 2008). In Ms Mogen¿½¿½s case, she had a family history of diabetes, where her father and siblings were also affected and also she had hypertension, which is now under control. Optimal treatment for diabetes is not merely balancing the plasma glucose, but DM-specific complications and risk factors for DM-associated diseases ought to be identified and handled with a wide-range diabetes care. Generally, treatment for type 1 DM is 0.5-1.0 U/kg per day of insulin partitioned into several doses. Mixtures of insulin preparation with variable times of commencement and duration of action should be utilized. Type 2 DM can be controlled with diet and exercise alone or alongside oral-glucose-lowering agents, insulin, or a combination of oral mediators and insulin (Kasper, 2008).

Hypertension is a chronic elevation in blood pressure (>140/90). Most patients are asymptomatic; however, severe hypertension leads to headache, epistaxis or blurred vision. Investigation includes urinalysis for blood, protein and glucose, plasma urea and electrolytes, plasma creatinine, plasma cholesterol and ECG (Haslett, 2006). Optimal goal in controlling hypertension is using a single drug if possible, while maintaining minimal side effects. First line agents include diuretics, beta blockers, ACE inhibitors, angiotensin receptor antagonists and calcium antagonists (Kasper, 2008).

The risks allied with a specified blood pressure depends on a combination of risk factors in the specific individual, which includes age, gender, ethnic origin, diet, smoking, family history, blood cholesterol, diabetes mellitus and pre-existing vascular disease. There are certain special circumstances to be considered when prescribing drugs. For example, in diabetic patients like Ms Mogen, the goal blood pressure to be achieved is <130/85. First-line therapy should include ACE inhibitors and angiotensin receptor blockers to control blood pressure and slow renal deterioration (Kasper, 2008).

Ethical Issues

According to Kumar & Clark (2009), doctors have a clinical responsibility for patients, where the rights of patients may be outlined by the three duties of clinical care: Protect life and health; respect autonomy; protect life and health and respect autonomy with fairness and justice. As such, there are ethical issues that come in association with this.

Consent

As a patient has his/her own rights of speaking or providing information, it is of utmost importance to acquire consent prior to any interviews. As a patient’s given consent is strongly interrelated to legal issues, it must be also noted that the consent is given voluntarily. The circumstances accompanying the obtaining of consent should be pondered upon.

For example, the moment Ms Mogen sees a person in white coat approaching her; it might not have suggested itself to her that we are medical students instead of doctors. At that point, this may have inadvertently created a state of mind that she is compelled to answer our questions. Also, she may not have wanted to appear as an unfriendly individual, hence allowed us to approach her. If this is true, then it would be unethical to have proposed such a pressure, even if unintentionally.

Confidentiality

While building a rapport between the doctor and the patient, it is observed that when the doctor can gain the patient’s trust e.g. patient fully acknowledges that the information they provide is kept secure, an unwavering patient-doctor relationship is successfully built, and this consecutively encourages the patient to offer helpful information without hesitation. Lack of trust prompts a defensive and impersonal approach to medicine by the clinician and patient, leading to the deterioration of the quality of patient care and professional life (Kumar, 2009).

Ms Mogen mentioned that she desires to consult her usual GP whenever possible, as she finds him amicable and feels free to consult his advice while offering her progress on the illness. This is seemingly attributable to a stable foundation of trust that has been built since the past few years.

Duty of Care

Once a patient consults the doctor, the doctor has the duty to cure the patient with the best efforts. He must be empathetic, talk courteously and perform his responsibilities towards the patients. In Ms Mogen¿½¿½s opinion, she think that a good doctor is one who puts themselves in patients¿½¿½ shoes and tries to understand the patient. He must also provide the patient with related information when the patient requires it because this aids in the wellbeing of the patient.

Legal Issues

In addition of providing help and treatments to the patient, it is essential that a doctor abides closely to legal aspects. The two fundamental aspects that cannot be overlooked are those related to consent and confidentiality.

Consent can be obtained in two ways: either verbally or in black and white, typically by signing a consent form; or be implied when the patient accepts the treatment without question, objection or other physical signs that illustrates rejection (Kumar, 2009).

For consent to be legally acknowledged, there are three important requirements, which includes:

1) The patient must be competent i.e. has capacity to consent e.g. is capable mentally and in terms of age.

2) The patient must be adequately informed concerning the risk, benefits, procedures and other matters they are consenting for.

3) The patient has to consent voluntarily, and not be coerced into accepting treatment against their wishes.

Under certain circumstances, such as life saving emergency procedures, there may be exceptions to these rules. However, most or all of the procedures taken has the need of obtaining legal consent, as this serves as¿½¿½insurance¿½¿½ for further matters. Consequence of failure to do so includes being charged in court.

Ms Mogen is of legal age to grant consent, was mentally competent, fully understood the purpose of the interview and was not under any form of pressure by a third party. She was keen to share her personal experience and information for educational purposes as well.

Information gathered from a patient is not to be violated without the patient’s consent, except under obligatory use as evidence in court. As a medical student, I have appropriately de-identified the subject or information by replacing any possible identifiers with pseudonyms and thus have the right to discuss the elements of this case with my peers.

Sociological Aspects

Every single patient has a distinctive personality or feature, based on different aspects. It is therefore practical for us to view the sociological aspect of different patients based on a particularly useful model, CHESS-C:

C Culture

H History

E Emotions

S Structure

S Social support

–

C Critique

Within the adaptable CHESS-C mnemonic (Aroni 2009), [history] is one of the sociological aspects that may possibly explain Ms Mogen’s attitude towards her condition, and how she accepts it as part of her life. Seeing that Ms Mogen’s father and two sisters had been diagnosed with diabetes mellitus, she felt the necessity to have a medical checkup as advised by her sister. She recognized that this may be a hereditary disease in the family.

She had been exceptionally optimistic about her condition when she first found out. This is because she was mentally prepared to get the news. It can also be seen that because there was a family member who was a nurse, and another was a surgeon, she obtained sufficient amount of information about diabetes, and therefore has established a brighter view of her diagnosis.

In terms of [culture], Ms Mogen had identified herself as a strong Catholic who is very into prayers and deems that by being contented and optimistic, life would change for the better. Along with this, her [emotions] helped her cope with her illness as she upholds herself a blissful mind, rid of any negative thoughts in everyday life. This notably lowers her stress levels, which helps her condition.

Besides that, Ms Mogen had a great deal of [social support] as she had a wide social circle – friends whom she knew from church and also her teaching days. Spending time with her friends once in a while kept herself occupied while having supportive companions, apart from her husband, whom she spends most of her time with.

Self Care, Lifestyle and stress

E Education

S Stress management

S Spirituality

E Exercise

N Nutrition

C Connectedness

E Environment

Ms Mogen’s approach and outlook regarding her health can be described using the wellness-based ESSENCE model. [Education] plays an important role in helping patients cope. Ms Mogen as a teacher is fully equipped with common knowledge and is well-educated. She took the initiative to understand and accept her illness by reading and researching as she realized that, by knowing the illness more, she lessened her fear and worry. The factor that she had acquired sufficient knowledge regarding her condition had greatly abridged her worry and subsequently helps her deal with her emotions.

Besides that, Ms Mogen fits a great deal of [exercise] in her daily life as she “feels good when carrying out housework or working out in the gym”. She does her own set of exercise, including bending, stretching, weight lifting and other self-improvised workouts 5 days a week for at least half an hour per session.

[Nutrition] is an especially vital factor for diabetic patients. Ms Mogen found herself adapting fairly well to eating minimal or no rice at all, compared to her old-self, who favored rice for her meals. She also became very conscious about what she feeds her stomach, which are now mainly green vegetables and fruits. This actually helps enhance immunity and increase life expectancy (Hassed 2009). This is accompanied by her minimal consumption of alcohol, only during occasions, and has never smoked.

After retirement, Ms Mogen generally thinks that she carries no more or minimal stress. Her hobbies are inclined towards the creative side as she likes to read, do flower arrangements and gardening. Being a “light sleeper” she gets “woken up easily and can sleep at any time of the day”, but this is not a problem to her.

Patient’s perspective

As mentioned above, Ms Mogen was somewhat optimistic about her illness before and after having it confirmed. Her family was very supportive as well, especially her husband, who assists her in her everyday life. Although her life has undoubtedly been changed by the discovery of her condition, she accepts and tries to gather more information from her regular GP, whom she finds easy to communicate with and therefore finds herself comfortable sharing details with.

Having frequent visits to the clinic had become a routine for her thus she does not treat it as a heavy errand. The clinic basically provided her with the care she needs although certain areas can be improved e.g. the waiting time was relatively long and the clinic could open earlier, but overall the surrounding cleanliness was of satisfactory standard and she was happy with the service provided.

Own perspective

This clinical placement has generally motivated me to understand patients more, whether currently or in the near future. It was a pleasant interview with Ms Mogen and a good first exposure conversing with an actual patient. She advocates strongly for optimism and importance of knowledge, and was eager to share with us her life experience, which motivates me to keep a happy mind when facing difficulties.

It occurred to me that every patient has their own unique experience in the clinic, be it their interactions with their GP or service provided by the staff, therefore a comprehensive approach is required when dealing with a patient. I realized that as a medical staff, it is important to communicate well with patients and be sensitive to their emotions and concerns because every patient thinks differently. Moreover, establishing a good relationship with other colleagues increases work efficiency and build solid teamwork.

Conclusion

The interview with Ms Mogen provided remarkable insight to a patient’s experience whereas the whole visit generally enlightened our view on a patient’s perspective. As such, being given the chance to personally talk to the patients and staff had considerably widened my view in regards to the real life clinical settings and interactions. Basically this provided a vast area of discussion using a holistic approach, which is including a variety of aspects: biological, sociological, ethical, legal and lifestyle, none of which can stand alone.

The Pathogenesis Diagnosis And Treatment Of Leishmaniasis Health Essay

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Leishmaniasis is a tropical, protozoan disease caused exclusively by intracellular parasites belonging to the genus Leishmania. Leishmaniasis is a worldwide problem and due to the various species of Leishmania, can manifest in humans as 3 main clinical forms: Cutaneous Leishmaniasis, Mucocutaneous Leishmaniasis, or Visceral Leishmaniasis. Consequently, the severity of the infection and symptoms differ from self healing infections that produce significant scars to the fatal infections.

Pathogenesis

Leishmaniasis is transmitted by the bite of female insect vector sand flies of the species Phlebotomus in the Old World and Luzomyia in the New World (Figure 1). The life cycle for all Leishmania species is relatively simple and similar (Figure 2).

When the sand fly takes a blood meal, it inoculates the source with the 2-3 mm long parasite. At this stage, the Leishmania parasite is known as a promastigote as it contains a singular flagellum. Promastigotes are injected into the host skin, after which they attach themselves to the hosts’ macrophages, and are induced by phagocytosis. These white blood cells are present at the inoculation site because of the hosts’ natural immune response to the sandfly bite. Once inside the macrophages, the promastigotes transform into their non-flagellate form, known as amastigotes. From here the amastigotes reproduce by binary fission and continue to proliferate within the white blood cells until the cell bursts. The parasites are then free to infect and invade other reticuloendothelial cells, which share the same fate and are destroyed due to the reproduction of amastigotes within. The amastigotes and infected macrophages enter the blood circulation.

The life cycle of Leishmania is continued when a female sandfly feeds on the infected hosts’ blood and the amastigotes are taken up by the sand flies. Amastigotes transform into promastigotes, which proliferate by binary fission in the midgut of the sand and fly over a period of 4-25 days (WHO, 2010). Hereafter, the promastigotes migrate to the fly proboscis or ‘mouthparts’, where the parasite can infect a new host during feeding (Murray et al, 2009), and thus the Leishmania lifecycle is continued.

Mammals are more often reservoirs for infection. As well as humans; dogs, rodents, wolves, and foxes are examples of common reservoirs (Neuber, 2008) and thus, can suffer from leishmaniasis diseases too.

Figure 2: The life cycle of Leishmania. Adapted from Chappuis et al (2007).

Figure 1: A Sandfly vector of Leishmania parasites. Extracted from Neuber (2008).

Epidemiology

Leishmaniasis is endemic in 88 countries, 72 of which are developing countries. An estimated 12 million people are infected with leishmaniasis and 70,000 people die each year (Reithinger et al, 2007). There are currently about 350 million people worldwide that are at risk and threatened by leishmaniasis because they live within 40° north and south of the equator (Jones et al., 2005; Neuber, 2008) and according to the World Health Organisation (2010), there are an estimated 1-2 million new cases each year.

There are approximately 20 species of Leishmania which are pathogenic for humans (Chappuis et al., 2007). These species vary in their geographical location and have an effect on the leishmaniasis which manifests (Table 1).

Cutaneous leishmaniasis is the most common form of leishmaniasis and is endemic in over 70 countries worldwide (Figure 3). It is found throughout Africa and the Middle East in Afghanistan, Algeria, Iran, Iraq, Kabul, Pakistan, Saudi Arabia, Syria; however, more particularly in South America, in Brazil and Peru (Reithinger et al, 2007; Murray et al, 2009).

Over 90% mucocutaneous leishmaniasis often occurs in Bolivia, Brazil and Peru and the majority (over 90%) of visceral leishmaniasis cases, the most dangerous form, is localised to 6 countries; Bangladesh, Brazil, Ethiopia, India, Nepal and Sudan. There are an estimated 500,000 new cases of visceral leishmaniasis each year (WHO, 2010; Chappuis et al., 2007).

Figure 3: Geographical distribution of Cutaneous Leishmaniasis. Extracted from Reithinger et al (2007).

Main Clinical Presentation

Leishmania Parasite

Main Geographical Distribution

Cutaneous Leishmaniasis

L. tropica*

Africa, Asia, Middle East, Mediterranean area

Cutaneous Leishmaniasis

L. major*

Middle East, Africa

Cutaneous Leishmaniasis

L. aethiopia*

Ethiopia, Kenya

Cutaneous Leishmaniasis

L. amazonesis ^

South America (Brazil, Venezuela)

Cutaneous Leishmaniasis

L .columbiensis ^

Northern South America (Columbia, Panama)

Cutaneous Leishmaniasis

L. garnhami ^

South America (Venezuela)

Cutaneous Leishmaniasis

L. peruviana ^

Peru, Panama, Costa Rica, Columbia

Cutaneous Leishmaniasis

L. venezuelensis ^

Northern South America (Venezuela)

Mucocutaneous Leishmaniasis

L. braziliensis ^

Central and South America

Visceral Leishmaniasis

L. donovani*

Africa, Asia

Visceral Leishmaniasis

L. infantum (L. chagasi)

Europe, north Africa, Central and South America, Mediterranean area

Table 1: Overview of clinical presentation and geographical distribution of species of Leishmaniasis that cause human disease. L. = Leishmania. * Leishmania species of the Old World. ^ Leishmania species of the New world. Data adapted from Reithinger et al (2007), Neuber (2008) and Murray et al (2009).

Clinical Presentation

Cutaneous Leishmaniasis

Cutaneous leishmaniasis is a localised reaction at the inoculation site, which tends to be uncovered areas such as the face, hands and lower legs. Between 2 weeks and 2 months after the sand fly’s bite, a red papule forms. The area begins to swell and become irritated and after 3-4 weeks, flat ulcers form which eventually harden and form crusted margins. The volcano-like lesions that form can heal without treatment; however, sufferers are commonly left with significant, disfiguring scars.

Mucocutaneous Leishmaniasis

Mucocutaneous leishmaniasis, also known as espundia, is most often caused by Leishmania viannia braziliensis and has a similar incubation time as cutaneous leishmaniasis. However, this form causes more devastating disfigurement to disease sufferers as the parasites metastasise towards to the mucosal membranes and destroy them and nearby unrelated tissue structures also (Murray et al, 2009). This form is more commonly seen after a primary infection of cutaneous leishmaniasis, where the lesions have eventually healed. Untreated lesions can transform into mucocutaneous forms and year later the oral and nasal mucosas become infected. Inflammation of the nose, mouth, oropharynx and trachea cause sever mutilation and facial disfigurement. Death can sometimes arise as mucosal lesions do not self-heal and prolonged infection compromises both immune and respiratory systems.

Visceral Leishmaniasis

Visceral leishmaniasis, also known as, kala-azar, dumdum fever or black fever, is the most severe form of leishmaniasis, and if left untreated, those infected will die. It is the most dangerous because parasites leave the skin and colonise the entire reticulo-endothelial system (Neuber, 2008) and spread to internal organs. Incubation period may be from several weeks to a year and can present as a rapidly fatal disease or as an asymptomatic, self-limiting infection (Murray et al, 2009). As the parasites proliferate and destroy the host’s cells, sufferers present with a marked enlargement of the liver, spleen lymph nodes as well as fatigue, weight loss, fever chills, severe anaemia and kidney damage. Death is caused by haemorrhage, complications relating to anaemia or a weakened immune system which cannot deal with bacterial co-infections (Chappuis et al, 2007).

As is the case with all forms of leishmaniasis, the chances of the sufferer developing a secondary infection, such as a bacterial infection, are very high and doing so, can complicate the disease further and may lead to death.

To add: one photo for each CL, ML and VL.

Canine Leishmaniasis

Leishmania infantum not only cause severe disease in humans, but in dogs also. Millions of dogs in Europe, Asia, North Africa, and South America are affected by the parasite. There are some clinical manifestations of the disease in dogs which re similar to that of humans including cutaneous alterations, enlargement of lymph nodes, liver and spleen, weight loss and glomerulopathy. As well as this, ocular lesions, epistaxis (nose bleeds), onycogryphosis (abnormal curving of claws) and lameness (disability in walking) are classic symptoms found in infected dogs (Maia and Campino, 2008). As with visceral leishmaniasis, canine leishmaniasis may also present as an asymptomatic infection, thus delaying necessary treatment.

Diagnosis

Due to the clinical presentations of the disease, a diagnosis can be made; however, for a definitive diagnosis the Leishmania parasite must be detected to confirm the diagnosis. Parasitological techniques are routinely used and involve demonstrating promastigotes in a direct examination of tissue aspirates, or detecting amastigotes in biopsy specimens, which are then, examined using a microscope.

Serological techniques to diagnose leishmaniasis are based upon indirectly identifying specific host humoural and cell-mediated responses after inoculation of the parasite. Diagnostic methods include direct agglutination test (DAT), the immunofluorescence antibody test (IFAT), the enzyme-linked immunosorbent assay (ELISA), immunoblotting and antigen detection.

Molecular techniques involve detecting leishmanial DNA or RNA have been beneficial in not only diagnosis, but species identification also. The molecular techniques include using various versions of polymerase chain reactions (PCR) to amplify species specific parasite sequences, DNA probes, monoclonal antibodies (MAbs) and isoenzyme electrophoresis.

Treatment

All forms of leishmaniasis should be treated due to their mortality and morbidity consequences. Drugs are available to treat the disease and choice for all forms is the pentavalent antimonial compound sodium stibogluconate (Pentostam).

Cutaneous leishmaniasis is also treated with injections of other antimonial compounds, such as fluconazole and litefosine, directly into the infected lesions (* Figure). Miltefosine has also proven to be an effective treatment for visceral leishmaniasis (Murray et al, 2009).

However, as with all drug treatments, the development of drug resistance is a huge issue and over use of this drug in previous years could lead to Leishmania species becoming resistant. As well as this, there are considerable side effects associated with most drugs (Neuber, 2008). A safe and effective vaccine against the various species is urgently required particularly in endemic areas; however, there is currently no vaccine available although work to develop one is still ongoing.

(To add: * Figure of such treatment)

Social and Economical Implications

Leishmaniasis is found in developing countries or the poorer regions of a country and thus commonly affects the poorest of the poor. Having such a disease can cause many problems in the lives of those infected and their families as they become poorer due to the direct and high costs of diagnosis and treatment of the disease, and the indirect costs such as loss of income (Chappuis et al, 2007).

Another impact of the disease is the social and psychological stigma associated with leishmaniasis, because of the disfigurement and significant scarring caused. Thus, even after the disease has been treated or self-healed, patients must deal with a constant reminder of what they had to endure.

Cheap, rapid and accurate diagnostic methods are needed to allow all those infected, especially the poor, to get the medical attention they need, and to also allow treatment to start as soon as possible thus ensuring symptoms may not be as detrimental.

Project Aims

The aim of this project is to compare the different methods for diagnosis of leishmaniasis in humans and dogs. These methods will be critically analysed in order to test the following hypothesis: ‘A Leishmania infection can be detected unequivocally’. In doing so, the necessary requirements for a correct diagnosis for those who live in endemic areas and for those whom leishmaniasis is a threat, will also be discussed.

Concept Of Evidence Based Practice

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In a simple and straightforward meaning, the term Evidence simply refers as a testimony and presentation of documents, records, objects, and other such items relating to the existence or non-existence of alleged or disputed facts into which a court enquires. The rules and regulations that conduct and preside over the formation of a detail before a court, jointly called the act of evidence. Evidence submits to all that is normally used to ascertain and reveal the fact of an statement whereas evidence based practice is one of the interdisciplinary method usually applied in the area of medicine such as nursing, psychiatry, neurology, obstetrics and gynaecology, paediatrics including neonatology, pathology which includes toxicology, emergency medicine, pharmacology, and so on. So, evidence based practice follows the fundamental rule which is affirmed as all the common practical evaluation should be prepared according to the approved research studies which should be chosen and explained as per some standards and feature for evidence based practice. In health care system, Evidence based practice refers to all the clinical judgments that are prepared on the basis of investigation and scientific studies which facilitates in the distribution of the high quality care to the patient to make better results. Evidence-based health care practices are accessible for a number of circumstances such as diabetes, heart failure, kidney failure, and asthma. Nevertheless, these practices are not continuously put into practice in care delivery, and discrepancy in practices proliferate. By tradition, patient protection study has concentrated on data analysis to identify patient protection issues and to exhibit that a new practice will guide to improved quality and patient protection. Executing evidence-based protection practices are complicated and require plan that deals with the difficulty of care systems, individual practitioners, senior leadership, and eventually altering health care traditions to be evidence-based protection practice environments.

There is a great history of practice in nursing field by means of research, initiated by Florence Nightingale. Although for the period of early and mid-1900s, a small number of nurses played a role to this establishment commenced by Nightingale. Through application of research findings in practice, there has been in recent times granted a major control in nursing profession for getting better care. Evidence-based practice (EBP) is the careful and sensible use of the most excellent proof in combination with clinical expertise and patient values to conduct health care conclusions. Observing evidence from randomized controlled trial (RTC) (or randomized comparative trial) which is a specific type of scientific experiment; evidence from other technical approaches like illustrative and qualitative research; as well as utilization of knowledge from technical assumptions, opinion from expertise of the same field, and case reports are the best evidences which support in development of the health care. As soon as there has been an enough evidences from research, the practice should be directed by research evidence in combination with patient values and medical proficiencies. Health care decision making is obtained predominantly from non-research evidence basis like opinion from expert and technical supports. This type of decision is made only when there is lack of sufficient research. As more research is prepared in a particular area, the research evidence must be integrated into the evidence based practice as a tool for the future reference.

Mickibbon (1990) states “evidence based practice involves conscientious as well as complex decision making which is based on available evidence but it will be highly affected by the patients characteristics, situation and priorities”. Health care expertise or we can say professional should be fully trained and should have awareness so that they can appraise the present situation, thoughts, knowledge and use what they have learned from their nursing practices to get better outputs and deliver safe care to the people. They should keep always on track on how to do and what to do in caring the people because delivery of caring job very difficult. Evidence based practice is significant for health professionals for several reasons as it provides evidence for the care of the patient. Evidence subsists in most excellent perform in evaluation of patient health condition, analysis of patient problem , setting up of patient care, intervention to get better function of the patient, or to avoid problem as well as evaluation of patient responses to intervention. Evidence based practice (EBP) is contemplated as one of the significant factor. Most of the health organizations rely on this Evidence based practice for the successful implementation of the care plan. It is found to be the best medical practice. However the idea of Evidence based practice differ in separate places due to its practice sceneries as well as the perspective of different professional may collide due to their level of skills and perception about evidence based practice. Both evidence based medicine (EBM) and evidence based nursing (EBN) come alongside while dealing with Evidence based practice. Therefore, in many difficult situations, there has been involvement of the evidence based medicine and it is said to be one of the key structure while making such decisions. It also helps to simplify the complicated decisions. On the other hand, evidence based nursing is a practical guide to evidence-based nursing for both the students and practitioners. It allows nurses to get better knowledge and review the different types of evidence that are existing simply just by following the techniques step-by-step. It also deliberates the approaches in which these results can be implemented in clinical practice, and how research can be basically applied to clinical-decision making. It helps nurses to give best and safe health care.

In total just considering about the evidence so the source of that evidence can be either primary or secondary. While dealing with evidence based practice topic selection and formulation of question considering the target group of the population is considered as a main key factor. As per Fitzapatrick (2007) skill which is required for the development of effective approach to the EBP is taken as its first approach while second step is critically evaluating the primary sources of evidence which are gathered according to the research question, than the next step is drawing the research together and critically evaluation of systematic review is its last step.

Models of Evidence Based Practice

For a number of clinical settings, there are several models of Evidence Based Practice that have to be involved. The common constituents of these models are choosing the practice subject matter for example discharge consultation for the patient with heart failure, analysis of evidence, implementation, evaluation of the effect on patient care and supplier performance, and deliberation of the situation in which the practice is implemented. The knowledge that takes place through the practice of interpreting examine into practice is important information to summarize and advice into the process, so that formers can adjust the evidence-based instruction and/or the implementation approaches.

Patient Safety and Quality: A latest abstract structure for enlarging and speeding up the transfer of research results from the Agency for Healthcare Research and Quality (AHRQ), delivery of the patient health care was developed by the broadcasting subgroup of the AHRQ Patient Safety Research Coordinating Committee. This model is a combination of ideas from technical information on learning transfer, social promotion, communal and governmental innovation, and behaviour changes.

Steps of Evidence-Based Practice

Before presenting these steps, we identify the massive challenge to most practitioners presented by this approach, and while utilizing these steps there can be involvement of a large amount of time and stress in a careful method. There are basically two options in relating evidence based practice that may assist to alleviate some of that difficult.

First, one option is that you start your activity of evidence based practice step by step. Measure for yourself the time and energy that concerning these evidence based practice steps takes in that case. Like this, you can get knowledge about costs and benefits of evidence based practice and able to judge yourself properly. Definitely, you will get a lot of benefits in applying evidence based practice and increase your capacity depending upon the case and situation. Each and every application will turn out to be easier as you gain experiences with any new approach and new systems.

The second option to consider in fact depends on the types of deals you give in your organization. In many organizations, the task loads include related difficulties, admittedly with discrepancies between individual client. This may signify that review of the literature to determine what will be helpful for evidence based practice with one client, problem arrangement may be simplified to many of your cases. You will save your maximum time and energy in accomplishing these steps.

The following steps are involved in evidence based practice.

Step 1. Develop A Question

“Develop A Question” is one of the important step of evidence based practice and is not easy task. The whole question formulated should be answerable that should give information about patient, intervention as well as should be able to draw the outcome from the designed question. To make it simple and easy to understand, PICO acronym is planned which helps the health care provider to design question while dealing with evidence based practice. Fitzpatrick (2007) states that there are four elements which will help in the development of clinical question which are taken a PICO where ” P ” stands for population which describes the patient group, ” I “stands for intervention which refers treatment, procedure, tests whereas ” C ” describes the alternative intervention and ” O ” stands for outcomes which describes how intervention affect the population weather it improve or affect. In simple words PICO acronym helps us to identify population/intervention/therapy/procedure as well as sometimes comparison is to be made with next intervention and more important desired outcome can be known through the research which is done by our search strategy by searching the relevant articles. In general formulation of question using PICO play a vital role to determine the direction of our research in evidence based practice as well as based on four component of PICO final question is designed which will help in literature search. This is not as easy as it may first appear. The question may be as complicated as, what are the key factors affecting homelessness, or as focused as, what intervention works best with a given problem? For example, we may be working with clients with overwhelming anxiety. We would want to ask questions such as, what are the best methods for assessing anxiety, and what interventions work best with what different types of anxiety? We also want to be aware in seeking answers to our practice questions that characteristics of the client, practitioner, setting, and other environmental variables play an important part in getting the clearest and best answers to our questions. An intervention that cannot be adjusted to account for cultural differences among clients may not be the best answer to your question.

Step 2. Find the Evidence

The next step of the evidence based practice is to find out the appropriate search process and gathering valuable evidence as well as some supportive evidence for the researchable question. Critical Appraisal Skilled Programmed (CASP) is introduced as a tool to carry on this step. In this section, significant examination of the articles is done with the help of CASP. The main section of the guides accessible on evidence based practice is dedicated to this search process. There are several ways of finding evidence, but particularly three ways of finding evidence are important and relevant in search process. These are associated with the use of internet. The first two ways of finding evidence involves of retrieving available analysis of the research literature, while the third way of finding evidence involves do- it-yourself analysis. The first process of finding evidence is to find a meta- analytic review. Meta-analyses are quantitative reviews of the literature. The second process of finding evidence is to find a available conventional analysis of the literature. This is occasionally called the box- score method because the reviewer frequently simply inserts the overall optimistic studies and pessimistic studies and introduces a conclusion. The third process of finding evidence is to accomplish a review of all the available evidence yourself. It takes a lot of time and difficult than the other ways of finding evidence.

Step 3. Analyze the Evidence

The third step is to analyse the particular studies where you are having more than just a exceeding understanding of research design and methodology as well as the commitment to putting in the time to apply your understanding to the analysis of studies.

Step 4. Combine the Evidence with Your Understanding of the Client and Situation

The process of finding, the process of implementing, decision making are all difficult tasks and major keys for evidence based practice. It becomes even more exciting when we think how to acclimatize it to the current client problem and situation arrangement. If you found the evidence that is collected is based on a people that is separate from the client with whom

you are dealing, then you will have to find another most excellent way to adapt what you found

in the literature to the situation in which you are working. The number of such

related changeable that could affect your decision are numerous, together with ethnic

and cultural dissimilarities, income amount and income security, accommodation, family circumstances, and so on.

Step 5. Application to Practice

This is another step that involved in evidence based practice and we can say it is the easiest part of evidence based practice. When decision making is finalized or decision is ready to put into practice the matter you have recognized as evidence-based, all that is left to do is to implement that material. Evidently, a specialist might get that he/she does not have enough knowledge to immediately implement that material; therefore, a period of adjustment will be necessary. This can be completely improved by maintaining in one’s possession a number of books explained already that present the intervention practices that have been found to be efficient in bureaucratic guidebooks.

Step 6. Monitor and Evaluate Results

The last step for evidence based practice is to monitor and evaluate the results that have been implemented. Perfect results are never certain. So, the topic is so vital to evidence based practice. As practitioners, we must put a great effort and find out the effective results using different tools and techniques and other guidelines.

Evidence-Based Practice Implementation

Evidence based practice implementation and evaluation is the final part of evidence based practice and this segment deals about significant study of implementation and evaluation. When the research is carried out, it should be implemented. Implementation is considered as guideline for changing practice which will help to assume and constantly use evidence based research findings and innovations in everyday practice. Implementing and sustaining evidence based practices in health care settings contains complicated interrelationships among the evidence based practice topic (e.g., reduction of medication errors), the organizational social system characteristics (such as operational structures and values, the external health care environment), and the individual clinicians.

When the clinical enquiries of end users can be concentrated through use of existing evidence that is enveloped with end users in mind, steps of the EBP process take less time and more effort can be directed toward the implementation, evaluation, and sustainability components of the process. For example, finding, critiquing, and synthesizing the evidence; setting forth EBP recommendations with documentation of the type and strength of evidence for each recommendation; and determining appropriateness of the evidence for use in practice are accelerated when the knowledge-based information is readily available. Some distilled research findings also include quick reference guides that can be used at the point of care and/or integrated into health care information systems, which also helps with implementation.

Conclusion

Evidence based practice includes implementing the best-known practices into the clinical setting using a systematic methods. As a result, safe, high-quality, and cost-effective care will be more likely to occur consistently. Although the science of interpreting research into practice is quite new, there is some conducting evidence of what implementation interventions to use in supporting patient safety practices. However, there is no special projectile for interpreting what is known from research into practice. To move evidence based interventions into practice, several techniques and methods may be needed. In addition, what works in one situation of care may or may not work in another situation, thus recommending that situation changeable material in implementation.

The scholarly literature is incorporated throughout the analysis.

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The scholarly literature is incorporated throughout the analysis.

 

Defines/explains the concept using scholarly literature (a dictionary maybe used for this section ONLY, and additional scholarly nursing references are required), and Information about the concept as discussed by the theorist from the selected nursing theory is substantively presented.

 

This assignment presents a modified method for conducting a concept analysis of ONE concept found in a nursing theory. The source of the concept for this assignment must be a published nursing theory. The selected concept is identified and then the elements of the analysis process are applied in order to synthesize knowledge for application within the model and alternative cases. Non-nursing theories may NOT be used. The paper concludes with a synthesis of the students new knowledge about the concept. The scholarly literature is incorporated throughout the analysis.
Only the elements identified in this assignment should be used for this concept analysis.
Criteria for Content
1. Introduction
The introduction substantively presents all following 4 (four) elements:
Identifies the role of concept analysis within theory development,
Identifies the selected nursing concept,
Identifies the nursing theory from which the selected concept was obtained, and
Names the sections of the paper.

2. Definition/Explanation of the selected nursing concept
This section includes:
Defines/explains the concept using scholarly literature (a dictionary maybe used for this section ONLY, and additional scholarly nursing references are required), and
Information about the concept as discussed by the theorist from the selected nursing theory is substantively presented.

A substantive discussion of this section with support from nursing literature is required.

3. Literature review
This section requires:
A substantive discussion of at least 6 (six) scholarly nursing literature sources on the selected concept.
Themes, ideas, and/or facts about the concept found in the reviewed sources are presented in an organized fashion.

Support from nursing literature is required.
Please Note: Primary research articles about the selected nursing concept are the most useful resource for the literature review.
4. Defining attributes
For this section:
A minimum of THREE (3) attributes are required.

A substantive discussion of this section with support from nursing literature is required.
Explanation: An attribute identifies characteristics of a concept. For this situation, the characteristics of the selected nursing concept are identified and discussed.

5. Antecedent and Consequence
This section requires the identification of:
1 antecedent of the selected nursing concept, and
1 consequence of the selected nursing concept.

A substantive discussion of the element with support from nursing literature is required.
Explanation: An antecedent is an identifiable occurrence that precedes an event. In this situation, an antecedent precedes a selected nursing concept.
A consequence follows or is the result of an event. In this situation a consequence follows or is the result of the selected nursing concept.

6. Empirical Referents
This section requires the identification of:
2 (two) empirical referents of the selected nursing concept.

A substantive discussion of the element with support from nursing literature is required.
Explanation: An empirical referent is an objective ways to measure or determine the presence of the selected nursing concept.

7. Model Cases
1 model case is created by the student and discussed substantively by demonstrating within the case each of the following areas:
Definition,
All identified attributes,
Antecedent,
Consequence, and
Empirical referent or Measurement

Information from selected nursing theory is applied to the created model case.

A substantive discussion of the element with support from nursing literature is required.
Explanation: A model case is an example of the hypothetical individual who demonstrates all of the attributes, antecedents, consequences, and referents noted previously in this assignment.

8. Alternative Cases
This section requires:
The identification of 2 (two) alternative cases correctly created and presented. The two required alternative cases are:
Borderline (absence of one or two of previously identified attributes of the selected nursing concept.
Contrary (demonstrates the complete opposite of selected nursing concept)

Applies information from selected nursing theory.
Explanation: Alternative cases represent the opposite of the model case.
For this assignment, two alternative cases are required. These are:
Borderline case which is a created case where one or two of the previously identified attributes are missing.
Contrary case which is a created case that demonstrate the complete opposite of the selected nursing concept.

9. Conclusion
This section requires:
Summarization of key information regarding:
o Selected nursing concept,
o Selected nursing theory, and
o Application of concept analysis findings to advanced nursing practice.

The concluding statements include self-reflection on the new knowledge gained from conducting a concept analysis.
Textbooks used in this class
McEwen, M. & Wills, E. (2014). Theoretical basis for nursing (4th ed.). Philidelphia, PA: Lippincott, Williams, & Wilkins.
Smith, M. C. & Parker, M. E. (2015). Nursing theories and nursing practice (4th ed.). Retrieved from https://online.vitalsource.com
Please follow all instructions in the attached rubric
Please use Self-care concept of Orems theory for this assignment
The scholarly references must be current peer-reviewed articles less than five (5) years between years 2014-2017.
Please strictly follow the attached rubric in preparing this assignment. Ensure all items are addressed. Do not leave out any given instruction. If possible use headings for each listed items to ensure nothing is left out.
Please do not use textbooks as a reference.
Do not use nursingtheory.org site
Do not use .com sites
A minimum of six(6) scholarly (peer-reviewed articles) within year 2014-2017 references must be used.
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What is the purpose of assessment and assessment tool in nursing.

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What is the purpose of assessment and assessment tool in nursing.

Evaluating Forms Of Leadership In Health Care Management Nursing Essay

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Good leaders develop through a never ending process of self-study, education, training, and experience. Good leaders are continually working and studying to improve their leadership skills. The term leadership means different things to different people. Northouse’s (2007) define leadership is a process whereby an individual influences a group of individuals to achieve a common goal. This definition is supported by Faugier and Woolnough (2002) that they also define leadership is a process that involve the ability to influence or persuade people to achieve the organization goal. They also said that leadership exists in all level on the organization. Bryman (1992) states that most definition of leadership emphasizes three main elements that relates with leadership which are groups, influence, and goal.

In most organizations, there are two groups of leaders which are the governing body, and the chief executive officer and other senior managers. Same with health care organization, but in health care organization certainly hospitals has a third leadership group which are the leaders of the physicians and other licensed independent practitioners (whether employed or “voluntary”) who provide patient care in the organization. In a hospital, the physicians and other licensed independent practitioners are organized into a “medical staff” and the leaders of the medical staff contribute to the leadership of the organization.

In healthcare, decisions about a patient’s diagnosis and treatment are made by “licensed independent practitioners,” most commonly physicians, but also including other clinicians such as dentists, podiatrists, or psychologists who have been licensed by the state to diagnose and treat patients. A person without a license who diagnoses and treats a patient through activities that are covered by any of the licenses is deemed to be practicing illegally which means “practicing without a license.”

In a hospital, this third leadership group comprises the leaders of the organized medical staff. Only if these three leadership groups work together, collaboratively, to exercise the organization’s leadership function, can the organization reliably achieve its goals (as mentioned above: high-quality, safe patient care; financial sustainability; community service; and ethical behavior). A hospital is the most complex healthcare setting in which these three groups of leaders must collaborate in order to successfully lead the organization.

Leadership in today’s Health Care.

Traditionally in healthcare leadership has been hierarchical, often defined by position and job title in many instances no distinction was made between the term management and leadership. Power and authority were determined by the position of a person within the organizational structure. The most effective leader is the one who can accomplish the group purpose while carrying out the main tasks of leadership critical for success. In order to attain such level of leadership and success, several important issues come into play. The most essential and commonly known are: motivation, shared vision, good communication, good time management, and a situational approach to leadership. Appreciating these points and knowing how to enforce them within the relevant context of healthcare management makes all the difference in the success of a leader.

In a scenario involving aggressive behavior among health care providers, participants identified that, before responding, an appropriate leader should collect additional information to identify the core problems causing such behavior. Possibilities include stress, lack of clear roles, responsibilities, and standard operating procedures, and finally, lack of training on important leadership/management skills. As a result of these core problems, several potential solutions are possible, all with potential obstacles to implementation. Additional education around communication and team interaction was felt to be a priority. In summary, clinical leaders probably have a great deal to gain from augmenting their leadership/management skills.

Clinicians today frequently encounter situations in which they are ill prepared for the leadership and management challenges that they will face. In the critical care environment, resource limitations, increasing complexity of care and diversity of personnel involved make a poorly prepared leader vulnerable. Moreover, the current complex and stressful work environment results in a greater need for strategies to manage stress and conflict. Clinicians who are solely schooled in patient care but assume leadership roles are therefore at a great disadvantage.

In health care institutions, leadership skills are recognized as important across all disciplines. The quality of a leader is important to support the managerial function in all organization and not be forgotten in health care environment. So that, in order to get leadership skills, there are several aspect that leader needs in order to improve their skills. Necessary skills include effective communication among team members and subordinates also among customer (in this situation, patient is the customer). The leader must be an effective communicator to achieve high-level of motivation and visionary success. Good communication skills are a must in building confidence and loyalty among the group. It should be the goal of the organization to create a two way communication system that allows information to flow from leader to follower and vice versa, including dissent, should it occur. This provides the opportunity for followers to attain a degree of empowerment and authority in their own right. Achieving such communication requires a leader to have emotional intelligence in order to work with the basics of needs-based motivation, and to encourage a cooperative teamwork. Managing relationships and communication delivery with people is an unquestionable facet of leadership.

Conflict can be resolved when there has understanding of one’s own communication style as well as that of others and having the skills to resolve the arrived conflicts among team members and also management. Leadership training should be available for every team members in reducing error among team members or any miscommunication problem that arise.

Style of Leadership

As a matter of fact, there are three style of leadership which are aotocratic, bureaucratic and laissez faire. Autocratic ledership style is often considered the classical approach. In this style, manager is the only one retains as much power and decision making authority as possible. As Faugier and Woolnough (2002) agreed that autocratic leaders set an end goal without allowing others to participate in the decision making process. The manager does not consult employee, nor are they allowed to give any input. Employees are expected to obey orders from employer without receiving any explainations. The motivation environment is produced by creating a structured set of rewards and punishments. Some expert point out the disadvantage of autocratic leadership style but autocratic leadership is not all bad. Sometimes it is the most effective style to use. These situations can include; the effective supervision that can be provided only through detailed orders and instructions; new, untrained employees who do not know which tasks to perform or which procedures to follow; employees do not respond to any other leadership style and so on. Need to highlight that the autocratic leadership style should not be used when employees become tense, fearful, or resentful; employees expect to have their opinions heard; employees begin depending on their manager to make all their decisions; there is low employee morale, high turnover and absenteeism and work stoppage and so on.

Meanwhile, bureaucratic leadership is where the manager manages “by the book” which means that everything must be done according to procedure or policy. If it isn’t covered by the book, the manager refers to the next level above him or her. This manager is really more of a police officer than a leader. This statement supported by Faugier and Woolnough (2002) where they said that bureaucratic leadership occurs when a leader strictly adheres to upon the policies, rules and regulations. Bureaucratic leadership style can be effective when employees are performing routine tasks over and over; employees need to understand certain standards or procedures; employees are working with dangerous or delicate equipment that requires a definite set of procedures to operate and so on. However, this leadership style is ineffective when work habits forms that are hard to break, especially if they are no longer useful; employees lose their interest in their jobs and in their fellow workers; employees do only what is expected of them and no more and so on.

Difference with the autocratic style, laissez faire leadership leaves employees to their own devices in meeting goals, and is a highly risky form of a leadership where the leader switches between the above styles depending upon the situation at hand and upon the competence of the followers. This style of leadership effective to use when employees are highly skilled, experienced, and educated; employees have pride in their work and the drive to do it successfully on their own and when outside experts, such as staff specialist or consultants are being used. But, this style should not be used when it makes employees feel insecure at the unavailability of a manager.

Transactional leadership concerning day-to-day operation in unchanged organizational system (Lindholm et al., 2000). Burns (1978) said that transactional leadership refers to exchange that advance the purposes of each party in economic, political, or psychological ways. Howkins and Thornton (2002) stated that in transactional leadership, one person take the initiative for the activities, actions or exchanges. For that, one person can be seen as having greater power and control and each person having a different investment in that situation. Jones and Jenkins (2006) argue that ‘transactional leadership was seen as encouraging performance by making rewards contingent on delivery and only intervening actively when performance did not meet expectations’. Managers therefore focus on objectives, tasks, procedures and policies. It’s about being orderly and organised with limited freedom for staff and having results around efficiency (being capable), effectiveness (being successful), productivity (being competent) and order. Transactional management is not best suited for the current climate. Traditionally this approach has maintained the status quo, stifled change and disempowered staff. Historically nurses have been criticized for not contributing to policy formulation and placing far too much emphasis on day to day activities.

According to Burns (1978), transformational leadership define the need for change, create a vision, and inspire subordinates to achieve goals. This leadership style more focused on processes that motivate followers to perform to their full potential by influencing change and providing a sense of direction (Cook, 2001). Sofarelli & Brown (1998) argue that transformational leadership is a style which is ideally suited to the present climate of change because it actively encourages innovation and change. This basis of this style of leadership is its interpersonal nature. It is a process that changes and transforms individuals and is driven by a genuine concern for individual needs of those in the team who are the followers. In adopting this style of leadership, leaders have to place emphasis on supporting, encouraging, inspiring, projecting their ideas, working on the longer term rather than the short term and treating staff as human beings. In summary transformational leadership is about interaction with a focus on the management of change and empowering staff in your teams in order to achieve your shared vision in a collegial and collaborative manner

Recommendation: Developing Transformational Leadership in Nursing.

In today’s nursing practice, transformational leadership is more ideal and suitable. Furthermore, adopting transformational leadership in nursing or health care management will enable nurses in order to improve patient care. Nurses also can develop their communication, interpersonal and decision making skills by using transformational leadership. Other than that, by adopting transformational leadership, it can empower nurses to manage innovation, take risks, increase their autonomy and of course expand their role. Nurses also are more motivated and to work more effectively in interprofessional teams and at the same time develop networks and peer groups.

Conclusion

Determine the style of leadership is very important to running the organization so that the organization goals will achieved. To achieve some or all of this there will be a need for a significant cultural change in the culture of many organizations and this will be challenging for many. In addition, high performing clinical teams need information and systems in order to improve performance with regard to quality outcomes, good patient satisfaction survey results, education and training. Lastly, efforts by organizations and individuals to encourage and develop transformational and are needed to enhance nurse satisfaction, recruitment, retention, and healthy work environments, particularly in this current and worsening nursing shortage.

Patient Case Study: Diabetic Ketoacidosis

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Health History

●       Patient: J.D.

●       Age: 30 years old

●       Gender: Female

●       Ethnicity: Hispanic

●       Chief complaint: cold sweats, nausea, vomiting, and disorientation.

●       The patient’s history of present illness on admission includes type I diabetes and missing insulin administration, which led to diabetic ketoacidosis (Bedaso, Oltaye, Geja, & Ayalew, 2019).

●       Past and current medical history: Type I diabetes since she was 9 years old, hypothyroidism, hypertension, and asthma.




Laboratory/ Diagnostic Testing

Diabetic ketoacidosis can be detected by the signs and symptoms the patient presents; however, to confirm the diagnosis laboratory test can be performed (American Diabetic Association, 2019). A patient with diabetic ketoacidosis will display results of metabolic acidosis in the arterial blood gases that contain low bicarbonate and low pH.

○       Ph: 7.20

○       PCO2:50

○       HCO3: 12

○       PO2: 96%

Diabetic ketoacidosis is characterized by the blood sugar above 250 mg/dl (American Diabetic Association, 2019), so the complete blood test is done to see the blood sugar level for this patient.

○       Glucose: 70-110 mg/L (600)

○       BUN: 10-20 mg/dl (13)

○       Na: 135-145 mEq/L (134)

○       K: 3.5-5 mEq/L (5.2)

○       Cl: 96-106 mEq/L (111)

○       Creat: 0.6-1.2 mg/L (1.3)

○       Ca: 9-10.5 mg/L (8.2)

○       Phos: 2.5-4.5 mg/L (2.1)

○       Mag: 1.5-2.5 mg/L (1.6)

○       WBC: 5,000-10,000 (16,500)

○       RBC: 3.8-5.1 (3.58)

○       Hgb: 12-16 g/dl (10.9)

○       Hct: 37%-47% (31.9%)

○       Plt: 150,00- 400,000 (233,000)

●       Urine analysis is required for DKA patients to assess kidney function and the presence of ketones, which can  help diagnose

diabetic ketoacidosis

(American Diabetic Association, 2019).

○       Urine PH: 7.0 neutral (4.0)

○       Protein = 6.0 – 8.3 g/dL (10.0 g/dL)

○       Ketones = 0.6 – 1.5 mmol/L (2.5 mmol/L)


Collaborative Management

Here is a list of medications that the patient is currently on:

●       Lispro (sliding scale) for hyperglycemia

●       Lantus (long-term 15 units) for hyperglycemia

●       Lisinopril for hypertension

●       Gabapentin for diabetic neuropathic pain

●       Montelukast for asthma

●       Levothyroxine for hypothyroidism

Here are some possible treatments for DKA:

●       Administer prescribed D5W to replenish fluids and electrolytes and adjust the rate as lab values change (Smith & Schub, 2018).

●       Glucagon PRN per protocol if less than 40 and symptomatic

●       Glucometer check every 1 to 2 hours

According to the American Diabetes Association, there are certain dietary measures that a patient with diabetes should be complying with and that includes a carbohydrate diet to maintain blood glucose in their normal range, an increase of water intake to flush out excess glucose through the urine and increase their physical activity levels as tolerated to also help maintain glucose levels (2019).

Collaborative care involves various members of the healthcare team and has them work together to have a common goal, which is to promote the patient’s highest quality of life by implementing and reinforcing the goals of each member. As stated in the American Diabetes Association, “it is important to choose diabetes care team members who can provide the level of support you want and provide help when you need it” (2019). The healthcare team members and their goal for this patient includes:

●       Primary Physician – gives an order for routine check including physical exams, lab tests, and medication prescriptions. To ensure the goals are met.

●       Registered Nurse – to ensure the patient is stable and is compliant with her care and is knowledgeable about her condition.

●       Nutrition dietician -to educate the patient on what diet is best for her diabetes, which will help her maintain proper glucose levels.

●       Physical Therapy – to improve the patient’s physical strength and educate them on ways to stay active around the house when discharged.

●       Family Support – families, relatives, and friends play a big role in inpatient care. They promote rapid healing and support any patient education on how to maintain a healthy condition and knowing when to go to the healthcare provider or in an emergency situation.


Nursing Diagnoses

The priority physiological nursing diagnosis for this client would be fluid and electrolyte imbalance related to type I diabetes as evidenced by cold sweats, nausea, vomiting, and disorientation. According to Karlya, fluid and electrolytes are the most important thing we need to monitor closely with DKA patients otherwise the patient might suffer from dysrhythmia (Karlya, 2015).  Short term goal for this patient is to maintain glucose level within their baseline by giving the correct dose of insulin which will minimize the risk of hyperglycemia and electrolyte imbalance. One long term goal for this patient is to identify the early signs and symptoms of hyperglycemia and hypoglycemia before discharge to prevent electrolyte imbalance. The following are the interventions, rationale, and evaluation for this patient:

  1. Monitor cardiac rhythm and LOC changes

    1. Rationale: To identify dysrhythmias and LOC changes due to hypokalemia.
    2. Evaluation: Patient is alert and oriented to person, place, time, and situation and cardiac rhythm is within normal range.
  2. Assess patient compliance with treatment (Ackley, Ladwig, & Makic, 2017).

    1. Rationale: To find out what is leading the patient to hyperglycemia.
    2. Evaluation: Patient had a lack of funds to buy needed medications, so compliance was not consistent and missed a few doses of insulin.
  3. Monitor blood glucose every 1-2 hours.

    1. Rationale- To maintain glucose within normal limits by giving appropriate units of insulin.
    2. Evaluation: Blood glucose is in the desired range.
  4. Monitor fluids (intake and output) and electrolyte lab values.

    1. Rationale: To prevent dehydration or overhydration and electrolyte imbalance.
    2. Evaluation:  Patient is adequately hydrated and there is no sign of fluid overload, i.e no edema and no crackles in the lungs.
  5. Assess vitals (signs and symptoms of infection), listen to the heart, lungs, and bowel-sounds.

    1. Rationale: If temperature, blood pressure, heart rate, and respiratory rate is elevated, that might be the signs of infection which can trigger DKA. Heart and lung sounds are to see if the patient is fluid overloaded.
    2. Evaluation: There is no sign of infection, lung sound is clear and there is no heart murmur.

●       A minimum of 3 potential patient education needs for consideration include:

○       Educate patients about the importance of maintaining blood glucose levels within normal ranges to prevent electrolyte imbalance and dehydration.

○       Educate patient about the importance of maintaining proper diet and exercise.

○       Educate patient about the importance of monitoring blood glucose more than once a day when they are experiencing stress, infection, trauma or if they are feeling sick because those things can fluctuate  the blood glucose level and may cause DKA.

The priority psychosocial nursing diagnosis for this patient is ineffective health maintenance related to insufficient resources as evidenced by the patient’s verbalization of the lack of financial resources. A short term goal for this patient is that the patient will discuss the fear of blocks to implementing a health regimen (Ackley, Ladwig, & Makic, 2017). A long term goal for this patient is that the patient will be following mutually agreed on health care maintenance plan by next scheduled appointment in 2 weeks.

There are five key nursing interventions with rationales and evaluations that we laid out for this patient:

  1. Assess for family patterns, economic issues, spiritual, and cultural patterns that influence compliance with a given medical regimen (Ackley, Ladwig, & Makic, 2017).

    1. Rationale: If the patient does not have adequate support from their family or financially, it will be hard to comply with the given medical regimen,
    2. Evaluation: Husband is the sole provider at the moment, so they do not have adequate insurance to cover medical bills for medications.
  2. Provide culturally appropriate education and health services (Ackley, Ladwig, & Makic, 2017).

    1. Rationale: Each culture has a different way of expressing themselves about their health and how they cope with it. Hispanics do not normally talk about their health issues, so they are reluctant to comply with treatments.
    2. Evaluation: By discharge, the patient will verbalize the kinds of cultural foods that will need to be limited to control glucose levels.
  3. Help patient choose a healthy regimen (diet and exercise) to implement after discharge.

    1. Rationale: a healthy regimen will help the patient prevent complications from any of her medical diagnoses.
    2. Evaluation: By discharge, the patient will verbalize a healthy regimen.
  4. Reinforce education of risk factors related to noncompliance with a treatment regimen.

    1. Rationale: Patient needs to understand why it is important to continue treatment plan to reduce worsening symptoms or prevent complications.
    2. Evaluation: By discharge, the patient will verbalize risk factors related to noncompliance with the treatment regimen.
  5. Use technology to remind patients to refill and pick up prescriptions.

    1. Rationale: By using this technology, the patient can identify how much money is needed to obtain the necessary medication.
    2. Evaluation: By discharge, the patient will demonstrate the use of technology. reminder.

There are three potential patient education needs for consideration which includes:

  1. Provide the family with credible sources where information can be obtained from social media (where most libraries have internet access with printing capabilities) (Ackley, Ladwig, & Makic, 2017).
  2. Increase blood glucose monitoring during times of illness or infection.
  3. Develop collaborative multidisciplinary partnerships (Ackley, Ladwig, & Makic, 2017).


References

Legal And Ethical Issues In Mental Health Nursing Nursing Essay

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This assignment aims to critically appraise an ethical conflict in relation to the care provided to a patient. It will explore how ethical decisions are reached and how they can directly influence patient care. To achieve this aim the author will examine a case study of a patient whose care he was involved with whilst in placement.

We will look at how, after an episode of self-harm, the patient refused any medical treatment for the wound and how this posed an ethical dilemma for the nursing staff involved in their care. Using the application of the Mental Capacity Act (MCA) (Great Britain (GB) 2005) and an established model for ethical decision making, we will look at how the decision of whether or not to enforce treatment for the wound was formulated and actioned.

Ethics can be seen as the study of human conduct and morality (Buka 2008). It is about people reasoning, thinking and applying a process of reflection (Adshead 2010); however these people may have opposing views, values and experiences on which to base their moral judgements to define what is the right and wrong course of action (Hendrick 2009) and the principles used to decide this, not only by the individual but also within social groups and societies. (Adshead 2010). From this we can surmise that ethics is a complex system of reflective thinking, which is used in the search for a standard that can be used to judge your own actions, or the actions of others, within your own moral code.

The Nursing and Midwifery Council (NMC 2008) stipulates that nurses must respect a patients right to confidentiality at all times and ensure that the patient is informed about how information concerning them is shared. In accordance with this the name of the patient has been changed and permission has been sought from the patient to use them in the case study (Appendix 1).

Case Study.

Anita’s story.

Anita is a young woman with a primary diagnosis of emotionally unstable personality disorder borderline type as defined by the World Health Organisation (WHO 2010). During a one-to-one therapeutic session Anita disclosed that she was having strong urges to self-harm. As such the therapeutic session concentrated on exploring her feelings surrounding her impulses, alternative coping mechanisms to manage her thoughts of self-harm and strategies to help maintain her safety upon the ward.

As she felt that the pressure of being constantly watched would unsettle her further, thus not allowing her to manage her own feelings it was initially agreed to place Anita on intermittent observation as opposed to constant within the policy on self harm produced by the service that was caring for her (Oxford Health DATE). This approach was agreed in collaboration with Anita and the wider team as a way of her taking responsibility for her own decisions.

Later in the shift Anita approached staff and stated that she had overwhelming urges to self-harm and that she had acted upon them. She was taken to the clinic room where the wound could be cleaned and assessed. Anita presented with a laceration to the inside of her thigh which was deep enough to expose the adipose tissue beneath, however was not deemed by the medical staff to be life threatening.

Staff explained to Anita that the wound was deep enough to require stitching although not life threatening and advised her that she would need to attend the minor injuries unit of the local general hospital for assessment of the wound. At this time Anita, due to her mental state, could not fully appreciate the nature of the wound and felt that she needed to punish herself further by refusing treatment. The nurses on duty cleaned and bandaged the wound and allowed Anita time to consider the implications of her decision further. When Anita had calmed the nurse had a discussion surrounding the implications of not having the wound sutured such as infection, Anita’s possible need to attack the wound in the future and pain relief issues, However Anita maintained her decision not to have the wound sutured.

Following a wider team discussion around whether Anita understood the severity of the wound, thus having capacity to make a decision to refuse treatment, the Responsible Clinician (RC) spoke to Anita and attempted to persuade her to have the wound sutured. As Anita was still refusing to have the wound sutured the RC decided that an assessment would need to be carried out to ascertain whether Anita had the capacity to decide to refuse treatment. Upon completion of the assessment it was decided that Anita did have capacity to make decisions surrounding treatment at that time, within the framework of the Mental Capacity Act (GB 2005). This decision was reached due to Anita being able to understand the information being given to her, being able to retain the information and weigh it up to make a decision to refuse treatment.

Although this appeared to be an unwise decision, which felt uncomfortable to the team, it was agreed to monitor the wound, keep it clean and dry and continue to talk to Anita about her thoughts and feelings surrounding getting medical treatment for the wound. This collaborative approach allowed Anita opportunities to explore her emotions, thoughts and feelings and promote her autonomy whilst still allowing her to decide to have the wound sutured should she change her mind.

The main legal and ethical dilemmas that can be extracted from this case study are whether the Anita’s capacity to make decisions about her treatment should be overridden by use of the Mental Capacity Act (GB 2005) and whether Anita’s ability to make autonomous decisions surrounding her care should outweigh the nurse’s obligation towards beneficence.

The Legal Dilemma. Mental Capacity.

What legal Dilemma can be hypothesised as underpinning the decision making process of the mental health professionals in this case? Anita initially made her decision to refuse treatment shortly after self-harming. Self-harm has been strongly associated with borderline personality disorder (Motz 2008) where thoughts of self-loathing and self-punishment are common precipitators; the act of self harm can be seen as a symptom of internal turmoil, an expression of internal pain or as controlling factor to maintain a level of care (Grocutt 2009). This may indicate that Anita was under a great deal of distress at the time, which could have affected her capacity to make sound decisions; however her later decision of continuing to refuse treatment was based on her own morals and values towards her body that may have included these thoughts of self-loathing and the need to be punished. Although a person, under part four Mental Health Act (GB 2007) can be treated for mental disorder without their consent, it is important to note that a physical problem can only be treated without consent should the person lacks capacity and treatment is deemed to be in their best interests under the auspice of the Mental Capacity Act (GB 2007, MIND 2009).

To help determine whether Anita has capacity, The Mental Capacity Act (2005) sets out a two stage functional approach. Firstly the practitioner needs to ascertain whether the person being assessed has some sort of disturbance of the mind and, if such a disturbance exists then it “must affect their ability to make decisions when they need to” (Department of Constitutional Affairs (DoCA) 2007:45). If this is not the case then the person cannot be seen as lacking capacity under the Act (GB 2005, DoCA 2007). In considering whether Anita needed to make the decision around treatment, we can see that, as the wound was not life threatening, it was decided to allow her time to settle and re-approach the question of treatment. The Mental Capacity Act (GB 2005) is clear in expressing that capacity is time and decision specific. In deciding that the decision could be made at a later time not only complies with the Act but also promotes Anita’s autonomy. As the wound could be safely managed in the short term upon the ward the decision to allow Anita time to weigh up the information was the correct one to make.

Conflicting ethical principles and dilemmas

Lakeman (2009) points out that an ethical dilemma occurs when there are a multitude of alternative courses of action to deal with a particular situation. Conflicting moral principles may create difficult ethical dilemmas for nurses by having to contravene one moral obligation to uphold another (Beauchamp & Childress 2009). Anita’s ability to make autonomous decisions surrounding her care should outweigh the nurse’s obligation towards beneficence. However this may not feel entirely comfortable for the nurse. In mental health nursing, autonomy is sometimes overridden in the interests of promoting the principle of beneficence (Lakeman 2009). Which can make the nurses ethical dilemma difficult to manage due to balancing the two valid ethical principles of autonomy (respecting and supporting decisions making) and beneficence (relieving or minimising harm in the best interest of the patient) (Hendrick 2004, Beauchamp & Childress 2009). To answer the question we need to examine how the dilemma sits within an ethical theory and the principles that apply.

Beauchamp and Childress (2009) devised four basic moral principles which function as guidelines for professional ethical decision making. The principles of autonomy (freedom to act on your own belief), Nonmaleficence (obligation to avoid doing harm), Beneficence (providing benefits and help) and Justice (fair distribution of benefits, risk and cost) which are derived from a duty based theory of Emmanuel Kant (1724-1804) (Beauchamp & Childress 2009).

Principle 1 Autonomy.

Respect for autonomy flows from the recognition that all persons have unconditional worth, each having the capacity to determine his or her own moral destiny. To violate a person’s autonomy is to treat that person merely as a means: that is, in accordance with others’ goals without regard to the persons own goals.

Beauchamp & Childress (2009: 103) after Kant

Autonomy is “the freedom and ability to act in a self determined manner” (Butts & Rich 2008: 42) and the right of a rational person to achieve personal decisions without any outside interference. Therefore the principle of respecting autonomy concerns the nurse’s acknowledgement of, and obligation in respecting, Anita’s decision over her own life.

It may be that Anita is already feeling a loss of autonomy or disempowerment by the very nature of being a patient upon a secure ward and being under the Mental Health Act (GB 2007) and the restriction of her basic autonomous decisions such as when to eat, sleep or who she resides with. Therefore it may need to be considered whether Anita’s is refusal of treatment is something that she feels in control of, thus a way in which she feels empowered.

Principle 2 Beneficence.

Morality requires not only that we treat persons autonomously and refrain from harming them, but also that we contribute to their welfare… and …[is therefore]… a moral obligation to act for the benefit of others. These beneficial actions fall under the heading of beneficence.

Beauchamp and Childress (2009: 197)

Beneficence can be seen as actions to benefit and promote the welfare of others (Butts & Rich 2008). All actions that are performed by nurses can be regarded as having a moral dimension, most of which are for the benefit of the patient (Edwards 2009).

The NMC Code of Professional Conduct is clear in stating that nurses have an obligation to both protect and promote the “health and wellbeing” of patients as their primary consideration (NMC 2008:2) and this is no different for mental health nurses working with patients who self-harm. This statement clearly incorporates the principle of beneficence and shows that the nurses in the case study are considering whether Anita should have medical treatment for the wound enforced upon her due to the principle of beneficence as described due to the worries of the wound becoming infected if not sutured.

The dilemma.

When nurses experience the ethical dilemma of having to enforce treatment irrespective of a patient’s right to autonomy, they can be seen as working in a paternalistic manner (Butts & Rich 2008). In Anita’s case, the nurses worry that the consequences of the wound becoming infected is driving their desire to treat the wound irrespective of Anita’s wishes. However, although the actions on behalf of nurses is clearly driven by obligations towards beneficence, nurses need to weigh up the harms and benefits of enforcing treatment before acting in such a way as to produce the best outcome for Anita (Edwards 2009). A paternalistic approach is frequently used to infringe upon a person’s right to autonomy. This infringement is “supported by the principle of beneficence, which is the argument frequently used to impose treatment on patients whether they want it or not” (Buka 2008: 29).

Should the decision to treat Anita for her self harm regardless of her wishes have gone ahead, there may have been a risk of impacting on the nurse-patient therapeutic relationship. This relationship is built upon trust as well as purposeful and effective communication (Buka 2008) and is considered to be the cornerstone of nursing care (Lakeman 2009, Pryjmachuk 2011).Therefore the nurses would need to consider future risk as part of the ethical decision making process. Enforcing treatment on Anita may produce barriers to the therapeutic relationship such as difficulties in trusting the nurse in the future, disengagement from therapeutic communication, opposition and rejection of future treatment, increased self harming behaviours due to the trauma and hostility towards others (Kettles et al 2007, Byrt 2010), all of which may stop Anita from telling the nursing team when she self-harms in future episodes of distress. Which raises the principle of Nonmaleficence (doing no harm), in this instance to the therapeutic relationship, wellbeing and care of Anita.

The decision to manage the wound on the ward and allow Anita time to calm and consider her options is, in the author’s opinion, the correct course of action to take. As the wound was neither life threatening or of such a degree that it could not be safety managed upon the ward enabled the staff to consider the possibility of allowing Anita to make an autonomous choice. In considering Anita’s wishes and agreeing a management plan to care for the wound incorporates both principles of Anita’s autonomy and the nurse’s obligation towards beneficence.

Beneficence could be interpreted to incorporate the patient’s autonomous choice as “the best interests of the patient are intimately linked with their preferences … [from which]… “are derived our primary duties towards them” (Beauchamp & Childress 2009:207). If the nurse’s obligation to act beneficently is informed by the patient’s choices and preferences, then the respect for the patient’s autonomy will ultimately override any paternalistic actions on the part of the nurse (Beauchamp & Childress 2009). This would not only encourage a supportive nurse-patient relationship but also provides care that is holistic, develops Anita’s confidence in being able to negotiate her care and allows her to take greater personal responsibility, thus instilling empowerment and hope, all of which improve the potential for recovery.

The practice of paternalism is now generally discouraged in health care (Butts & Rich) and is considered unjustifiable in cases where the patient has capacity to make a decision (Edwards 2009, Beauchamp & Childress 2009).

Conclusion.

Every decision that a nurse makes concerning the care of a patient needs to be considered from an ethical base. Any decision made from this ethical viewpoint has a higher probability of producing the best outcome under any given circumstance.

The conflicting principles of autonomy and beneficence that have been presented within this case study would both be ethically and morally correct courses of action to take. From this we can surmise that a morally correct course of action may involve two opposing principles being applicable in any one situation.

Are large proportion of moral and ethical dilemmas that are faced by nurses stem from the conflicting principles of autonomy and beneficence. However, the nurse’s ability to critically appraise risks and benefits will help them to make decisions that are beneficial to the patient involved. In encouraging autonomy for Anita involves taking risks on the part of the nurses’ which may go against their principles of Nonmaleficence and beneficence. However with collaborative working practices this case study has shown that solutions can be found in even the most complicated of nursing dilemmas.

Word Count 2687.

Which philosophy/conceptual framework/theory/middle-range theory describes nursing in the way you think about it?

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Which philosophy/conceptual framework/theory/middle-range theory describes nursing in the way you think about it?

Assignment 2: Personal Philosophy of Nursing

In a 6- to 7-page paper in APA format describe your personal approach to professional nursing practice. Be sure to address the following:

Which philosophy/conceptual framework/theory/middle-range theory describes nursing in the way you think about it? Discuss how you could utilize the philosophy/conceptual framework/theory/middle-range theory to organize your thoughts for critical thinking and decision making in nursing practice.
Formulate and discuss your personal definition of nursing, person, health, and environment.
Discuss a minimum of two beliefs and/or values about nursing that guide your own practice.
Analyze your communication style using one of the tools presented in the course. In your paper, discuss the strengths and weaknesses associated with your style of communication and the impact on your ability to collaborate as part of an interdisciplinary team.
On a separate references page, cite all sources using APA format.
Use this APA Citation Helper as a convenient reference for properly citing resources.
This handout will provide you the details of formatting your essay using APA style.
You may create your essay in this APA-formatted template.