Category: Nursing

Enoxaparin (Lovenox) Nursing Implications Question

Before administering medications to a client hospitalized 3 days ago for acute asthma, the nurse compares the morning laboratory results with the admission data.  The nurse should confirm which prescription with the health care provider prior to administration?

Albuterol nebulization every 4 hours

Enoxaparin 40 mg subcutaneously every 24 hours

Methylprednisolone 20 mg intravenously every 6 hours

Potassium chloride 20 mEq/L every 24 hours

Enoxaparin (Lovenox) Nursing Implications Answer and explanation

The corect answer is 2- Enoxaparin 40 mg subcutaneously every 24 hours

Explanation:

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Enoxaparin (Lovenox)
 is a low-molecular-weight heparin anticoagulant administered for prophylaxis of deep venous thrombosis in hospitalized clients.  Bleeding and 
thrombocytopenia
 (platelet count <150,000/mm 3  [150 x 10 9 /L]) are possible complications of anticoagulant therapy.  Heparin-induced thrombocytopenia (HIT) is a serious condition that often develops rapidly, requiring prompt recognition and treatment.  Unlike other drug-induced forms of thrombocytopenia, HIT can result in  arterial or venous thrombosis (eg, stroke, extremity infarction), although the exact association is unknown.  This client’s platelet count (96,000/mm 3  [96 x 10 9 /L]) has dramatically decreased since admission.  The nurse should note this drastic change and question the continuation of the prescription with the health care provider before administering the medication. (Option 1)   Bronchodilators such as albuterol and ipratropium are indicated in acute asthma and chronic obstructive pulmonary disease exacerbations. (Option 3)   Methylprednisolone (Solu-Medrol) is an anti-inflammatory corticosteroid drug indicated for treatment of lung inflammation associated with asthma; the route, dosage, and frequency are correct.  This client’s elevated white blood cell count is likely due to glucocorticoid administration and is an expected effect of corticosteroids. (Option 4)   Potassium chloride is an electrolyte replacement drug and is indicated by the presence of hypokalemia (<3.5 mEq/L [3.5 mmol/L]); the route, dosage, and frequency are correct.  Frequent use of albuterol likely caused hypokalemia in this client. Enoxaparin (Lovenox) Nursing Implications Educational objective: Heparin-induced thrombocytopenia can result in arterial or venous thrombosis.  Platelet counts should be carefully monitored in any client receiving anticoagulant therapy.

Juvenile diabetes (Type I) – childhood diseases that exist in adults essay

In this  assignment, you will be developing a presentation on childhood diseases that exist in adults. To complete this assignment, access the “Collaborative Learning Community: Health Promotion Presentation” resource.

Solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center. APA format.

 

Topic:  Juvenile diabetes (Type I)

 

1. Develop  health screening, promotion, interventions, and education for adults with this condition is accurate and comprehensive, showing evidence of thoughtful reflection.

Describe how the concepts of leadership and management differ from each other. In what areas do they overlap? Explain how the goals of management and leadership may sometimes overlap. As a nurse leader, do you believe you can expand your influence to create change by taking advantage of this overlap? Explain your answer.

Characteristics of a population appropriate to use mean/median/mode

What are the characteristics of a population for which it would be appropriate to use mean/median/mode? When would the characteristics of a population make them inappropriate to use?

The article titled “Who has higher readmission rates for heart failure, and why?: Implications for efforts to improve care using financial incentives” by, Joynt, K. and Jha, A. (2010), will be reviewed and critiqued for this paper. The purpose of this article was to explore factors, which allow some hospitals more successful outcomes at preventing heart failure readmissions than others. The authors evaluated hospital characteristics in the hopes of determining how to “most effectively facilitate quality improvement initiatives to decrease heart failure readmissions.”  (Joynt&Jha, 2010).  The authors imply that understanding what hospital characteristics influence heart failure readmissions can aid in the development of programs to avoid pay-for-performance (P4P) penalties.  Joynt&Jha (2010) also hypothesize hospitals with limited monetary and medical resources will experience higher penalties.

Evaluation of the Concept

Patient Protection and Affordable Care Act of 2010 implemented P4P as a method for influencing quality improvement initiatives for hospitals by offering rewards for those who are highly successful (Medicare.gov, 2015).  Designed to improve quality, these payment programs contain the potential to penalize hospitals who are already resource limited and experiencing financial hardships.  According to the authors, heart failure is the most common cause of admissions and readmissions among Medicare patients costing the nation more than 17 billion dollars a year (Joynt&Jha, 2010).  Estimates claim that one in four patients with heart failure will be readmitted to the hospital within 30 days of discharge.  “These rates suggest tremendous opportunity for improvement.”  (Joynt&Jha, 2010).

Reviewing the literature, the authors found studies have looked at patients at risk for readmission due to heart failure, but little work has evaluated the hospitals themselves (Joynt&Jha, 2010).  Joynt&Jha (2010) found two studies that concluded no difference between types of hospitals; however, the authors felt both studies used a method designed to reduce variability that could unduly influence the findings of the study.  These hypothesizes are written to lead the reader to believing variability may be the answer to what influences readmission rates among hospitals and support the idea of the study.  With little data to define which hospitals would experience higher readmission rates and would face penalties, the authors furtherconsidered physical resources in an attempt to establish a link to readmitted patients.  In order to establish which hospitals to evaluate for limited resources, Joynt and Jha (2010) appraised public hospitals, hospitals in poor counties nationally, as well as, hospitals without cardiac services.  Small hospitals were also gauged based on the assumption they have few financial and clinical resources and face challenges similar to public and poor hospitals (Joynt&Jha, 2010).  In 2014, Anderson wrote a commentary that discussed the first year of the Hospital Readmissions Reduction Program which issued penalties totaling more than 227 million dollars.  This had the greatest impact on of poorest hospitals in the country and further confirmedJoynt&Jha’sconcern written in 2010.

Utilizing Medicare Provider Analysis Review (MedPAR) data, the authors examined heart failure patient hospitalizations for 23 months and each patient for thirty days post discharge excluding federal hospitals, those outside the United States, and the District of Columbia.  23 months was used as the study took place over two physical years and required a full 30 day review.  Recommendations from the Joint Commission advised that hospitals with less than 25 discharges over the specified time frame also be excluded leaving a total of 4091 hospitals for analysis, a significant sample size (Joynt&Jha, 2010).  Using published survey results from the American Hospital Association of 2007, characteristics of those 4091 hospitals were collected “including hospital size, cardiac services, ownership, nurses on staff, and proportion of hospitalized patients with Medicaid or Medicare insurance, membership in the Council of Teaching Hospitals, location, and region.” (Joynt&Jha, 2010).  Staffing ratios and county median income where the hospital was physically located was also collected to include in the analysis.  Providing analysis around this number of characteristics gave the authors the ability to look at how variable resources may affect readmission rates versus a methodology that normalizes the data in an effort to equalize hospital performance for public reporting (Joynt&Jha, 2010).  Ash, Fienberg, Louis, Normand, Stukel, and Utts (2012) discussed how the Bayesian shrinkage model used by CMS eliminates volume or the ability to adapt for low volumes placing smaller capacity hospitals at higher risk for failure related to performance.  A metric measure where small hospitals are not truly equal or capable to other hospitals; however, are judged in the same manner again echoesJoynt and Jha concerns from 2010.

The authors chose to create “a set of multivariate logistic regression models, using generalized estimating equations, in which the response probability distribution was binary; allowed us to use logistic regression but also to account for clustering of patients within hospitals.” (Joynt&Jha, 2010).  Logistic regression methodology allowed for evaluation of each of hospital characteristics and to then compare the findings to hospitals that would be at risk for penalties.  Both the Bayesian shrinkage model and the multivariable model was used to run the data setting up a compare and contrast.  Differences were obvious and confirmed the author’s hypothesis that the Bayesian shrinkage model penalized smaller hospitals when volume is eliminated.  Joynt&Jha (2010) found that performance was likely to remain in the worst quartile if the hospital was public or lacked the clinical and financial resources just as they had predicted.  All of these characteristics demonstrated a statistical significance when outlined in themultivariate analysis giving the study more credibility and confirming the hypothesis of Joynt and Jha (2010).

Application of Concept

           
About five million people are currently diagnosed with heart failure in the United States according to the Centers for Disease Control and Prevention (2014).  Due to the dynamics of heart failure, more than 32 billion dollars will be spent in an effort to provide care and medications for these patients each year (CDC, 2014).  Based upon these costs, Centers for Medicaid and Medicare Services passed a rule identifying heart failure readmissions within 30 days as an element for penalty under the Hospital Readmissions Reduction Program (CMS, 2015).  Using the findings of Joynt&Jha (2010) hospitals at risk for penalties should evaluate hospitals that were considered resource-poor or financially poor and performed well on avoiding readmissions.  Identifying these differing hospital characteristics allows a smaller organization or an organization with limited financial resources to restructure or redesign their approach to avoiding readmissions.  In an article by Bradley et al. (2013), six strategies were identified which may require little fiscal investment such as medication reconciliation by a registered nurse, arranging a follow up appointment prior to discharge, and partnerships with community physicians to develop solutions to avoid readmissions.As pay-for-performance matures, patients, physicians, and nurses must urge legislation to evaluate the impact of penalties.  Communities with financial and clinical resource limitations must demand that investments be made to enrich the opportunity to obtain quality care in their town or city.  According to James (2012), if resources are not allocated to lower income areas, P4P penalties will only exacerbate the lack of care provided to the patients who need it most.

 

References

Anderson, A. (2014).  The impact of the affordable care act on the healthcare workforce.
The

Backgrounder 2887
:  1-20.

Ash, A., Fienber, S., Louis, T., Norman, S., Stukel, T., and Utts, J. (2012).  Statistical issues in

assessing hospital performance. 
Quantitative Health Sciences Publications and Presentations
.  Paper 1114.  Retrieved on September 8, 2015 from http://escholarship.umassmed.edu/qhs_pp/1114.

Bradley, E., Curry, L., Horwitz, L., Sipsma, H., Wang, Y., Walsh, M…Krumholz, H. (2013).

Hospitals strategies associated with 30-day readmission rates for patients with heart failure. 
Circulation:  Cardiovascular Quality and Outcomes 2013
(6):  444-450.  doi:  10.1161/CIRCOUTCOMES.111.0001.01.

CDC (2014).  Division for heart disease and stroke prevention:  heart failure fact sheet.

Retrieved on September 9, 2015 from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm.

CMS (2015).Readmissions reduction program.  Retrieved on September 9, 2015 from

https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html
.

James, J. (2012).  Pay for performance: new payment systems reward doctors and hospitals for

improving the quality of care, but studies to date show mixed results. 
Health Policy Brief 2012
:  1-6.

Joynt, K., and Jha, A. (2010).  Who has higher readmission rates for heart failure, and why?:

implications for efforts to improve care using financial incentives. 
Circulation:  Cardiovascular Quality Outcomes 2011
(4):  53-39.  doi:  10.1161/CIRCOUTCOMES.110.950964.

Medicare.gov (2015).  Hospital Compare:  linking quality to payment.  Retrieved on September

8, 2015 from
https://www.medicare.gov/hospitalcompare/linking-quality-to-payment.html
.

Financial Management For Nurses Article Critique Assignment

Critique a business-related article with application to the financial management of nursing systems. The article must be from a peer-reviewed journal, which may include a business and/or healthcare journal. The critique must evaluate the concept presented as well as its application to nursing administration/financial management.

· Each critique must be between three and five pages in length and must use APA formatting.

· SEE attachment for journal article to use and a sample article critique

 

Item Points

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Evaluation of concept presented  (20 points)

 

Application of presented concept to financial   management of nursing systems

(20  points)

 

Use of APA formatting, grammar, spelling, sentence   constructions, syntax

(10  points)

Answering this PICO question “Are hand sanitizers more effective than Chlorhexidine disinfectants in the reduction of nosocomial infections in NICU patients?” I need the
Appendix E form
filled out and essay written pertaining to the article attached and following the
Rubric attached

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NUR 3036 Quantitative Research Article Critique

Rubric Template

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Rubric Topic: Quantitative Research Article

A (100-90)

B (89-80)

C (79-70)

F (
< 69) Introduction (5 points)     The topic is introduced, and the groundwork is laid as to the direction of the report. Readers are aware of the overall problem, challenge, or topic that is to be examined. The topic is not introduced, and the groundwork is not laid as to the direction of the paper. Does not adequately convey introduce the topic. Does not describe subtopics to be reviewed. Lacks adequate theses statement   Literature Search (20 points)     Demonstrates a sophisticated critique of the sources reviewed; shows a deep understanding of the breadth of the subject. Demonstrates an accomplished critique of the sources reviewed. Demonstrates a less than acceptable critique of the sources reviewed. Inappropriate use of search terms. Demonstrates unacceptable critique of the sources reviewed. Inappropriate use of search terms. Inappropriate use of search sites (e.g. Goggle, Yahoo vs. PubMed, CINAHL). Determination of Level of Evidence (25 points)     Accurately determined the appropriate level of evidence using the Johns Hopkins Research Evidence Appraisal tool. Identified the level, however the one or two of the elements related to independent variable, control group, or random assignment was not appropriately identified.               Level of evidence misidentified completely, however an attempt was made to justify the level’s selection. Complete misidentification of level of evidence and justification for level. Quality of Evidence (25 points)     Accurately determined the appropriate quality of evidence using the Johns Hopkins Research Evidence Appraisal tool.At least 90% of the component questions were accurately identified and answered with the appropriate “yes”, “no”, or “NA”. Determined the appropriate quality of evidence using the Johns Hopkins Research Evidence Appraisal tool. At least 80% of the component questions were accurately identified and answered with the appropriate “yes”, “no”, or “NA”. Determined the appropriate quality of evidence using the Johns Hopkins Research Evidence Appraisal tool. At least 70% of the component questions were accurately identified and answered with the appropriate “yes”, “no”, or “NA”. Determined the appropriate quality of evidence using the Johns Hopkins Research Evidence Appraisal tool. Less than 69% of the component questions were accurately identified and answered with the appropriate “yes”, “no”, or “NA”. Summary (5 points)     The summary is well written, insightful and summarizes all the relevant sections of the paper. The summary section includes some discussion related to each section of the critique, leveling and quality of the research article.                           The summary has elements of the relevant section; however, the flow and connection of each section lack a cohesive writing approach.                     The summary is completely unfocused and lacks continuity for supporting the proposed level and quality of the research article. APA and Grammar (10 points)     Uses APA format accurately and consistently. Sentences are clear, concise, and direct; tone is appropriate.   Grammatical skills are strong with almost no errors per page. Correct use of APA format per 6th edition, and including: · Clear introduction and conclusion, overviewing and reviewing paper’s main topics · Use of headings according to APA · Appropriately formatted in-text citations and reference page · Appropriately formatted title page. Uses APA format with no more than 3 minor violations.           Sentences are generally clear, concise, and direct; tone is appropriate. Grammatical skills are competent with very few errors per page. Correct use of APA format when assigned. Uses APA format with greater than 3 minor violations.           Sentences are occasionally wordy or ambiguous; tone is too informal. Grammatical skills are adequate with few errors per page. Adequate use of APA format when assigned. Reflects incomplete knowledge of APA format.           Grammatical errors or spelling & punctuation substantially detract from the paper

Nursing Evidence-Based Practice: Research Evidence Appraisal Tool

Evidence Level and Quality:_______________________

Article Title:

 

 

Number:

 

Author(s):

 

 

PublicationDate:

Journal:

 

 

Setting:

 

 

Sample

(Composition&size):

 

Does this evidence address my EBP question?

 

 

£Yes

 

£No

Do not proceed with appraisal of this evidence

Level of Evidence (Study Design)

A. Is this a report of a single research study?  
If No, go to B
.

 

1.     Was there manipulation of an independent variable?

Was there a control group?

Were study participants randomly assigned to the interventionand control groups?

 

 

If Yes to all three, this is a Randomized Controlled Trial (RCT) or Experimental Study   

 

 

 

If Yes to #1and #2 and No to #3, OR Yes to #1 and No to #2and#3, this is Quasi Experimental
(some degree of investigator control, some manipulation of

an independent variable, lacks random assignment to groups, may have a control group)

 

 

If No to #1, #2, and #3, this is Non-Experimental
(no manipulation of independent variable, can be descriptive, comparative, or correlational, often uses secondary data)
or Qualitative
(exploratory in naturesuch as interviews or focus groups, a starting point for studies for which little research currently exists, has small sample sizes,  may use results  to design empirical studies)

 

 

 

 

 

NEXT, complete THE bOTTOM SECTION ON THE Following PAGE
, “
STUDY FINDINGS THAT HELP YOU ANSWER THE EBP QUESTION”

 

 

 

 

 

 

 

 

 

 

£ LEVEL  I

 

 

 

 

 

 

£LEVEL II

 

 

 

 

 

 

 

£ LEVEL III

 

 

£Yes

 

£Yes

£Yes

 

£Yes

 

 

£No

 

£No

£No

 

£No

 

 

B.  Is this a summary of multiple research studies?
If No, go to Non-Research Evidence Appraisal Form.

 

1.     Does it employ a comprehensive search strategy and rigorous appraisal method (
Systematic Review)? 
If No, use Non-Research Evidence Appraisal Tool; if Yes:

 

a.     Does it combine and analyze results from the studies to generate a new statistic (effect size)? (
Systematic review with meta-analysis
)

b.    Does it analyze and synthesize concepts from qualitative studies? (
Systematic review with meta-synthesis
)

 

If Yes to either a or b, go to #2B below.

 

2.     For Systematic Reviews and Systematic Reviews with meta-analysis or meta-synthesis:

a.     Are all studies included RCTs?

 

b.    Are the studies a combination of RCTs and quasi-experimental or

quasi-experimental only?

 

c.     Are the studies a combination of RCTs, quasi-experimental and

non-experimental or non-experimental only?

 

d.    Are any or all of the included studies qualitative?

 

 

complete THE
NEXT SECTION,
“
STUDY FINDINGS THAT HELP YOU ANSWER THE EBP QUESTION”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

£ LEVEL  I

 

 

£ LEVEL II

 

 

£ LEVEL IIl

 

£ LEVEL IIl

 

 

 

£Yes

 

 

 

£Yes

 

 

£Yes

 

£Yes

 

 

 

 

 

 

£No

 

 

 

£No

 

 

£No

 

£No

 

 

 

 

Study findings that help you answer the EBP question
:

 

 

 

 

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NOW COMPLETE THE FOLLOWING PAGE, “QUALITY APPRAISAL OF RESEARCH STUDIES”, AND ASSIGN A QUALITY SCORE TO YOUR ARTICLE

Quality Appraisal of Research Studies

·         Does the researcher identify what is known and not known about the problem and how the study will address any gaps in knowledge?

·         Was the purpose of the study clearly presented?

·         Was the literature review current (most sources within last 5 years or classic)?

·         Was sample size sufficient based on study design and rationale?

·         If there is a control group:

o    Were the characteristics and/or demographics similar in both the control and intervention groups?

o    If multiple settings were used, were the settings similar?

o    Were all groups equally treated except for the interventiongroup(s)?

·         Are data collection methods described clearly?

·         Were the instruments reliable (Cronbach’s α [
alpha
]
>
0.70)?

·         Was instrument validity discussed?

·         If surveys/questionnaires were used, was the response rate
>
25%?

·         Were the results presented clearly?

·         If tables were presented, was the narrative consistent with the table content?

·         Were study limitations identified and addressed?

·         Were conclusions based on results?

 

£Yes

£Yes

£Yes

£Yes

 

 

£Yes

£Yes

£Yes

£Yes

 

£Yes

£Yes

 

£Yes

 

£Yes

 

£Yes

 

£Yes

 

£Yes

 

 

£No

£No

£No

£No

 

 

£No

£No

£No

£No

 

£No

£No

 

£No

 

£No

 

£No

 

£No

 

£No

 

 

 

 

 

 

 

 

£NA

£NA

£NA

 

 

£NA

£NA

 

£NA

 

 

 

£NA

 

Quality Appraisal of Systematic Review with or without Meta-Analysis or Meta-Synthesis

·         Was the purpose of the systematic review clearly stated?

·         Were reports comprehensive, with reproducible search strategy?

o  Key search terms stated

o  Multiple databases searchedand identified

o  Inclusion and exclusion criteria stated

·         Was there a flow diagram showing the number of studies eliminated at each level of review?

·         Were details of included studies presented (design, sample, methods, results, outcomes, strengths and limitations)?

·         Were methods for appraising the strength of evidence (level and quality) described?

·         Were conclusions based on results?

o    Results were interpreted

o   Conclusions flowed logically from the interpretation and systematic review question

·         Did the systematic review include both a section addressing limitations and how they were addressed?

£Yes

£Yes

£Yes

£Yes

£Yes

 

£Yes

 

£Yes

 

£Yes

 

£Yes

£Yes

£Yes

 

£Yes

£No

£No

£No

£No

£No

 

£No

 

£No

 

£No

 

£No

£No

£No

 

£No

Quality Rating Based on quality appraisal

A
High quality:
  consistent, generalizable results; sufficient sample size for the study design; adequate control; definitive conclusions; consistent recommendations based on comprehensiveliterature review that includes thorough reference to scientific evidence

B
Good quality:
reasonably consistent results; sufficient sample size for the study design; some control, and fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence

C 
Low quality or major flaws
:
little evidence with inconsistent results; insufficient sample size for the study design; conclusions cannot be drawn

post
 an analysis of the obstacles that impact interoperability of the disease surveillance systems.

Propose ways to improve/address the legal, ethical, and practical data-sharing obstacles.

Evaluate how this impacts the future of local, state, national, and international systems/agencies sharing and use of information.

500 words to 600