Innovative health care delivery model that incorporates an interdisciplinary care delivery team
Describe one innovative health care delivery model that incorporates an interdisciplinary care delivery team. How is this advantageous to patient outcomes?
Voluminous Qualitative Data
Qualitative data has been described as voluminous and sometimes overwhelming to the researcher. In what ways could a researcher manage and organize the data?
Critical Reading and Researching Main Ideas
The Three Main Points from the Journal Article
In the article “Online class size, note reading, note writing and collaborative discourse” Qiu, Hewitt, and Brett (2012) attempt to find the relationship between the class size and the reading and writing loads among students of online graduate courses. The authors’ first main point in the article is that there is a positive relationship between the class size and the total number of notes the students and instructors wrote. The second point of the article is that dividing students into smaller groups for discussion purposes helps to increase the collaborative effectiveness of the online graduate classes. Lastly, the authors present a third main point, which argues that the use of multimedia software can help to increase collaboration between online students and instructors in large classes.
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Rationale for Each Main Point
The analysis of literature explains the first main point in the journal. The authors argue that online class settings affect the structures of asynchronous online discussions to engage the students in meaningful discourse. This point is used to explain the relevance of the research. According to the study, “class size is a major factor affecting note reading and writing loads in online graduate-level courses (Qiu, Hewitt, & Brett, 2012, p. 424).” Secondly, the authors of the article suggested that the division of larger classes into smaller groups would help to deal with the reading and writing issue. The authors suggested that “students in smaller groups tend to learn more (Qiu, Hewitt & Brett, 2012, p. 427). This is an essential point in the journal because it provides the possible solution to the identified problem. Lastly, the authors finished their work and suggested other options to use for managing larger online classes. The authors’ main suggestion was the use of software that will help to improve interaction between students. This is a main point of the journal because it provides a meaningful solution to the identified problem in the research.
Reason for Selecting the Main Points
The reason for selecting the three main points analyzed above as the authors’ main ideas is because of the present the issue and the solutions to it. The fact that the first point identified a positive relationship between class size and effective reading and writing makes it stand out of the other things discussed in the journal. Most of the journal is focuses on showing this relationship. The other two points stand out because they are the major solutions that the authors give for the identified problem. The points are related in that the first is the issue while the second is the solution that can be used by instructors to solve the problem. We can also use the third point which is an alternative solution to the issue in cases where the first solution is not applicable.
References
Qiu, M., Hewitt, J., & Brett, C. (2012). Online class size, note reading, note writing and collaborative discourse.
International Journal of Computer-Supported Collaborative Learning
,
7
(3), 423-442. Retrieved from the Walden Library databases
NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Evidence based practice research is forever leading to changes in procedures, treatments, and policies within the healthcare industry. With the constant flow of new research data, it is important that we are routinely updating our policies and procedures to include the best practice options for our patients. Due to the increased longevity of the geriatric population, the need for Total Knee Replacement (TKA) is steadily increasing. “Approximately 700,000 knee replacement procedures are performed annually in the US. This number is projected to increase to 3.48 million procedures per year by 2030” (Gregory M Martin, 2016). The healthcare field is developing new and inventive techniques that allow for faster and healthier recovery times for post-surgical patients. One of these technologies is the use of Continuous Passive Motion (CPM) in postoperative total knee arthroplasty.
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Although surgeons still use CPM postoperatively, it has recently come under question rather its use makes a difference in increasing mobility and decreasing joint stiffness and swelling. When looking at the research available, there are many qualitative and quantitative research articles available proving the ineffectiveness of using CPM as a treatment option (Maniar, Baviskar, Singhi, & Rathi, 2012). The purpose of this paper is to support the PICOT statement below by reviewing both a qualitative “To Use or Not to Use Continuous Passive Motion Post–Total Knee Arthroplasty: Presenting Functional Assessment Results in Early Recovery” and a quantitative “Aggressive continuous passive motion exercise does not improve knee range of motion after total knee arthroplasty” research article. We will also discuss how the data presented supports the need for evidence based practice changes regarding the use of CPM as a treatment option for postoperative TKA.
PICOT Statement
Problem
Upon arriving to the postoperative orthopedic unit within a few hours after surgery, patients are encouraged to begin physical therapy and range of motion exercises to their new surgical knee. Depending upon the surgeon’s choice of treatment, they may include CPM within the physical therapy regimen. Continuous passive motion is accomplished with the use of a CPM machine. The patients postoperative knee is placed within the machine at a designated degree that is determined by the physician (Brian Hatten, 2016). The machine then moves the knee joint through a controlled range of motions intent on reducing pain, inflammation, and joint stiffness. The larger the degree angle that the patients knee can tolerate, the greater the chance of increased mobility and a faster healing process. However, there is limited research that suggests that the use of CPM alone or in conjunction with therapy is more effective than physical activity alone in reducing these postop complications (Brian Hatten, 2016).
Specific Question
In adult postoperative total knee arthroplasty patients, how effective is continuous passive motion therapy in conjunction with physical activity in relation to pain, joint stiffness, physical mobility, and recovery time compared with physical activity alone starting at post-op day zero until discharge form acute postoperative orthopedic unit/or completion of CPM therapy?
Intervention
The use of Continuous Passive Motion (CPM) in conjunction with physical activity when completing physical therapy.
Comparison
The use of CPM in conjunction with physical activity compared to the use of physical activity alone when performing physical therapy in the acute post-op setting.
Outcomes/Timing
The use of CPM with physical activity does not decrease pain, joint stiffness, or recovery time, as well as increase mobility compared to physical activity alone in the use of physical therapy in the acute post-op setting. The period used for the study is from post-op day 0 – until discharge form acute postoperative orthopedic unit/or completion of CPM therapy.
Qualitative Study
Background
CPM use in postop total knee replacements is becoming increasingly common, although the research on the benefit of its use is conflicting. The authors of the article mention that CPM “in early postoperative recovery is again questionable, with a few studies supporting and others negating the short-term benefits” (Maniar, Baviskar, Singhi, & Rathi, 2012). Due to the questionable nature of the outcome of using CPM, research was conducted with the aim of determining the effect of CPM usage on pain, range of motion (ROM), wound healing, Suprapatellar and Calf Girth (or swelling), and functional mobility (Maniar, Baviskar, Singhi, & Rathi, 2012). The question that the research seeks to answer is if CPM usage after postop total knee replacement increase or decreases the patient’s physical recovery time? Does the amount of time (application time applied and days of usage) that CPM is used in therapy change the results of the healing time for patients? The purpose of this research study and the questions that it seeks to answer will help to determine if continuous passive motion should still be used as a form of therapy treatment in postop total knee arthroplasty.
Method
The hypothesis of this research project was that “CPM may be helpful with initializing knee bending so that further active and passive motion training becomes easier and patient tolerates exercises better” (Maniar, Baviskar, Singhi, & Rathi, 2012). Other research articles regarding the use and effectiveness of CPM were used as references by the authors in their own research. These articles consisted of both qualitative and quantitative data collection (books, articles, tables/figures, and research studies) with the oldest article published in 1982. Although some of the articles used were 20+ years old, they were still relevant and conducive to the authors research and study results. The authors also used the grounded theory as well as the development of graphs, tables, and diagrams to compartmentalize their research findings. This allowed for individuals reading their data to see the big picture of the results they obtained. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
There were several methods used to obtain data within the project. Eighty-four patients were selected and divided into three groups of twenty-eight individuals, who were all scheduled for total knee replacements. Individuals were excluded from the study if they had “medical conditions or diseases that could interfere with test performance, collaboration or comprehension problems, and neuromuscular or neurodegenerative disease” (Maniar, Baviskar, Singhi, & Rathi, 2012). Each patient received the same knee implant all placed by the same surgeon within a one year time span. The researchers understood the importance of minimizing the number of possible variables that could affect the results. The three groups of individuals were labeled no-CPM, 1-day-CPM, and 3-day-CPM. One group had physical therapy with no CPM after surgery, another group had one day of CPM with two segments of 15 minutes, and the third group had three days of CPM with two 15 minute segments each day (Maniar, Baviskar, Singhi, & Rathi, 2012). The VAS scale (0-10 pain scale, qualitative data) was used to measure patients pain level, the TUG test (patient ability to sit, get up from sitting, walk, and turn while walking) was used to determine physical mobility, ROM was evaluated of the postop knee, wound healing was measured by dressing saturation, wound color, and suture/staple approximation, and Suprapatellar and Calf Girth (or swelling) was measured by standard tape measure (Maniar, Baviskar, Singhi, & Rathi, 2012). Within the article the authors state that “All assessments were performed at the same time of day, that is, in the morning before subjecting the patient to physical therapy sessions” (Maniar, Baviskar, Singhi, & Rathi, 2012).
Findings
The results of the authors study showed no significant difference in results between the individuals who received CPM and those who did not. For pain using the VAS score there was no change in pain level between all three groups within the same time intervals, when interviewed. When assessing ROM, it progressed at the same degree level for each group and resulted in everyone within the group returning to preoperative ROM by day forty-two (Maniar, Baviskar, Singhi, & Rathi, 2012). The TUG test values also showed no significant differences between the results within each of the three groups. For wound healing, it was shown to have a slight increase in wound drainage in the groups who received CPM. The Results showed “that at day 3, when both 1-day and 3-day-CPM groups had had equal duration of CPM application; that is, just 1 day of CPM on day 2, these 2 groups combined had 24.24% of patients with wound staining compared with only 12.12% in the control group who had not had any CPM application” (Maniar, Baviskar, Singhi, & Rathi, 2012). Lastly the results for Suprapatellar and Calf Girth (or swelling) indicated a longer recovery time back to preoperative size in the groups receiving CPM compared to the control group. Each group resumed preoperative state by day forty-two, however “suprapatellar girth took much longer to reduce to the preoperative status in both the CPM application groups compared with the control group” (Maniar, Baviskar, Singhi, & Rathi, 2012). For each of the results obtained, the authors presented research studies that corresponded with the results they obtained, as well as some studies that had conflicting results to their own. In this case, the authors offered reasons for why the differing results may be present. Possible variables that could have affected the research results were type and frequency of pain medication administered as well as patients own perception of pain, motivation towards therapy, comorbidities such as diabetes that could have affected wound healing, and each patient’s height and weight affecting ROM and TUG test scores. Overall, the results from this study indicated that there is no benefit to patient’s physical mobility, pain level, wound healing, or swelling with use of the CPM compared to no CPM usage. In fact, results indicated increased swelling and wound drainage when CPM was used as a part of physical therapy. These results would suggest that the orthopedic nursing and medical boards take a closer look at the allowance of CPM usage in postop total knee arthroplasty
.
Ethical Considerations
When it comes to ethical considerations the research essay does not specify rather an Institutional Review Board approved it. It does state however that “All participants who were eligible and agreed to participate signed an informed consent form” (Maniar, Baviskar, Singhi, & Rathi, 2012). This indicates that all participants were aware of what the research would be used for as well as their role in the study. Each individual was assigned an envelope upon the day of their surgery that designated they would be a part of the control group or one of the groups receiving CPM therapy. The authors also mentioned that “A university-based assistant professor of statistics evaluated the data” (Maniar, Baviskar, Singhi, & Rathi, 2012). The article however does not mention the steps it took to maintain patient privacy or the filing system in which it used.
Conclusions
Through the data collected the answer was derived of the questions presented at the beginning of this paper. Does CPM usage after postop total knee replacement increase or decreases the patient’s physical recovery time? The results showed that the use of CPM does not significantly increase the patient’s recovery time, nor does it increase physical mobility or reduce pain. It does however lead to increased bleeding from operative site and cause a delay in the Suprapatellar and Calf Girths return to normal. This indicated a possible increase in swelling with the use of CPM. Lastly does the amount of time (application time applied and days of usage) that CPM is used in therapy change the results of the healing time for patients? There were also no significant findings to indicate that the duration of the CPM usage would change the data results. Overall the research maintained both certified and ethical planning while using both qualitative and quantitative means to achieve data collection. The article states that “After this study, we have stopped our routine practice of administering CPM in all our postoperative patients with no disadvantage” (Maniar, Baviskar, Singhi, & Rathi, 2012). This is important as the results obtained from this study have led to practice changes by surgeons within certain facilities. It is important for orthopedic nursing and medical boards alike to monitor this type of data collection as it may be of importance in the continual certification and use of CPM in the postoperative total knee arthroplasties.
NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Quantitative Study
Background
As the geriatric population is living longer and the need for TKA is increasing it is important that we discern the beneficence of CPM and rather it is best practice to continue its use as a form of treatment. The article states “As early postoperative ROM is an important prognostic factor for the patient’s ability to walk later, it is important to achieve the best possible knee ROM while the patient is in hospital. Thus, the rehabilitation protocol in the hospital might have consider-able consequences for the patient in the longer term.” (Chen, et al., 2013). The article states a clear identification of the problem that needs to be addressed. The aim of this research was “to evaluate the effects of continuous passive motion on the range of motion, postoperative pain and life quality of patients undergoing total knee arthroplasty within six months after the operation.” (Chen, et al., 2013). The researchers seek to answer the question of rather the use of aggressive CPM in the early postoperative stage increases or decreases the patient’s physical recovery time? Does the use of CPM increase ROM in the postop knee, reduce/increase pain, and overall improve the patient’s quality of life? The questions the study seeks to answer will provide data regarding rather the use of CPM is an appropriate form of treatment for postoperative total knees.
Method
Before beginning the study, the researchers hypothesised that “aggressive CPM in the early postoperative period would improve knee ROM, induce more pain, and improve quality of life” (Chen, et al., 2013). The study was conducted using 107 patients with degenerative osteoarthritis, who were undergoing their first TKA. Patients with rheumatoid arthritis or prosthesis in the ipsilateral hip were excluded from the study. All patients included in the study before surgery could ambulate with/without a walking aid. The surgery was complete by one of two possible qualified surgeons at Kaohsiung Medical University Hospital, and each patient was fitted with the same prosthesis and fixed with cement (Chen, et al., 2013). The information provided in the article indicates that the researchers went to great lengths to minimize outside factors and manipulation of the independent (use of CPM) and dependent (ROM, pain, mobility, overall quality of life) variables. Experimental research design was used to conduct the study. The patients were split into two separate groups. The first group (control group) would receive only basic rehabilitation protocols and the second group (experimental group) would receive basic rehabilitation protocols in addition to six hours or more of CPM a day. The CPM was set to reach seventy degrees with the first treatment, with the intent to reach one-hundred degrees depending on the individual’s ability to tolerate it. “The basic rehabilitation protocols consisted of assisted and active flexion and extension of the hip/knee, active isometric contraction of the quadriceps, straight leg raising training, walking with a high walker or crutches, and eventually climbing stairs on crutches” (Chen, et al., 2013).
Several different types of data collection were used within this study. ROM was measured with the use of a goniometer while the patient was laying supine. “Knee flexion was measured with the hip at 90-degree flexion. The goniometer swivel center was placed on the lateral side of the knee center, with one arm aligned with the greater trochanter and the other along the line running from the fibular head to the lateral malleolus of the ankle. The knee was moved to maximum flexion and the range measured in degrees.” (Chen, et al., 2013). The patients pain scores were measured using the VAS scale (0-100, 0-no pain, 100-unbearable pain). This was recorded at least once per shift. Quality of life was measured through the “modified Short Form-36” questionnaire. This questionnaire had eleven dimensions with scores ranging from 1-5 (lowest score indicating the best condition, and the highest, the worst condition). This article used both quantitative (ROM measurements) and qualitative (Pain score and quality of life) research methods within their data collection process. The data parameters, were collected by the same nurse at both the admission, during the hospital stay, two and six-week follow-up, and three and six-month postop visit (Chen, et al., 2013). The ROM, VAS, and SF-36, were all measured each day during the post-op hospital stay and at each follow up appointment. “The Mann–Whitney test was used to analyze the efficacy between study groups. Repeated analysis of variance (ANOVA) was implemented to examine the differences at various timepoints. All tests were two-sided and performed at the 5% level and analyzed with SPSS statistical software between study groups.” (Chen, et al., 2013).
Findings
The results were obtained within a six-month period (January 2007- June 2007). In terms of ROM, the results were nearly the same between the control and experimental group. “ROM increased from 109 degrees preoperatively to 125 degrees at six months after operation in the treatment group and from 111 degrees preoperatively to 125 degrees at six months after operation in the control group” (Chen, et al., 2013). When it came to patient pain scales using the VAS score, there was no significant differences in the data obtained. “VAS decreased from 7.78 preoperatively to 0.37 at six months after operation in the treatment group and from 7.92 preoperatively to 0.21 at six months after operation in the control group” (Chen, et al., 2013). There was also no significant difference in data obtained from the SF-36 questionnaire used to determine patient quality of life. “The SF-36 improved from 3.76 preoperatively to 1.77 at six months postoperatively in the treatment group and decreased from 3.68 preoperatively to 1.83 at six months postoperatively in the control group.” (Chen, et al., 2013). The data obtained from the research study is written within the article and organized within tables and graphs for easier visualization and understanding. The data comes across as both cohesive and accurate.
The authors of the article were quick to point out limitations within their research. “First, this was not a randomized controlled study. Second, the rehabilitation protocol after discharge was not standardized. Third, the number of patients was not so large, which sometimes may result in less ability to tell the difference between groups” (Chen, et al., 2013). One limitation that was not pointed out within the article was the use of the same nurse to collect all data within the study. This lets the possibility of bias or miscalculations enter the data, and would have been much more proficient to have more than one individual collect and analyzed the data. The implication to nursing practice is defined within the article. The number one aspect of patients who have undergone TKA are ROM and pain reduction. The study does conclude that it does not recommend routine use of aggressive CPM for postoperative TKA. “It is important to monitor the effects of aggressive CPM on pain and ROM. The results of this study indicate that patients undergoing TKA can have less pain and better ROM and life quality six months after operation, but aggressive CPM during hospitalization does not provide additional benefits” (Chen, et al., 2013). The results of the data gathered here would be important to orthopedic nursing and medical boards to assist in the determination if the use of CPM is still best practice for treatment in postoperative TKA patients. The data collected here can lead to evidence based practice changes regarding the physical therapy treatment regimen of postoperative TKA, including the removal of CPM as best practice treatment options.
Ethical Considerations
It was not specified within the research article if the participants signed any type of informed consent before taking part in the study. It can be inferred however that the individuals within the study were active participants as they would have had to give consent for not only the measurement of ROM and VAS scale by the nurse, but also actively participate in answering the questionnaire associated with the SF-36. The article does mention that is was supported by the National Health Research Institute of Taiwan and Kaohsiung Medical University Hospital (Chen, et al., 2013). It was also mentioned that each of the research authors did not have a conflict of interest in relation to the research study. The patient’s privacy also seemed to be well respected, as it was mentioned in the article that the same nurse collected the data each time, minimizing the number of individuals to access patient confidential information. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay.
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Conclusions
The data results from this study concluded that there is no significant difference in ROM, pain, and quality of life with implementation of CPM in postoperative TKA therapy. The researcher’s hypothesis “aggressive CPM in the early postoperative period would improve knee ROM, induce more pain, and improve quality of life”, was disproved by the results of the study. The answers to the question, at the beginning of this paper, were determined by the data presented. Does the use of aggressive CPM in the early postoperative stage increases or decreases the patient’s physical recovery time? The answer is that the use of aggressive CPM in TKA does increase physical recovery time, however it is not significantly different from the results obtained from just physical therapy alone. Does the use of CPM increase ROM in the postop knee, reduce/increase pain, and overall improve the patient’s quality of life? The answer again is yes, however there is no significant difference in the results of the above variables with the use of CPM compared to physical therapy alone. The use of CPM in therapy for TKA does not provide additional benefits to the patient. Overall the authors of this article do not recommend the use of CPM for treatment in TKA patients (Chen, et al., 2013). The data provided here is important to nursing research and evidence based practice. It provides nursing and physician national orthopedic boards with a greater knowledge base on rather CPM should still be considered as a certified safe and effective treatment option for total knee arthroplasties.
Evidence-based Practice Change
Within both the qualitative and quantitative research articles provided the end results were both the same. These results both answered and supported the PICOT question above. The use of CPM in the treatment of post-op TKA does not reduce pain, swelling, joint stiffness, or increase physical mobility more substantially than physical therapy alone (Lenssen, et al., 2008). These results show that CPM therapy is neither needed nor does it provide benefits, that physical therapy alone cannot provide. The use of CPM is both time constraining and comes at a higher cost for both healthcare facilities and the patient. “Both rentals and purchased CPM machines are costly, challenge the nursing staff with time effectiveness in their daily tasks, and cause increased pain in some patients. Authors of the current literature also stated there are possibilities
for adverse effects, due to application errors, which can lead to a longer hospital stay” (University, 2015).
The evidence based research provided indicates a need to eliminate the use of CPM as a form of treatment in post-op TKA. The data can be used to show orthopedic nursing/physician boards the need to remove CPM form their choice of treatment regimen. “Decreasing the use of CPM machines creates a source of patient satisfaction as it relates to a decrease in pain, and a reduction in the need for pain medication prior to physical therapy which can reduce the instance of falls.” (University, 2015). Removing CPM as a treatment option will provide cost-effective changes for both orthopedic units within hospitals and rehab facilities. It is important that the data from both this paper and other research studies conducted on the use of CPM, be used to make evidence based practice changes to increase patient safety and health, reduce hospital stays, and increase cost effectiveness within healthcare facilities.
NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
References
Brian Hatten, M. (2016, may).
CPM Machine Assist your early motion after knee replacement.
Retrieved from Mykneeguide.com: https://www.mykneeguide.com/the-hospital/cpm-machine
Chen, L.-H., Chen, C.-H., Lin, S.-Y., Chien, S.-H., Su, J. Y., Chao-Yung Huang, H.-Y. W.-L., . . . Huang, H.-T. (2013).
Aggressive continuous passive motion exercise does not improve knee.
Retrieved from Journal of Clinical Nursing : http://eds.b.ebscohost.com.lopes.idm.oclc.org/eds/pdfviewer/pdfviewer?sid=5cc9803c-34c3-4521-86af-04e02436bf32%40sessionmgr101&vid=9&hid=127. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Gregory M Martin, M. (2016).
Patient education: Total knee replacement (arthroplasty) (Beyond the Basics).
Retrieved from UpToDate: http://www.uptodate.com/contents/total-knee-replacement-arthroplasty-beyond-the-basics. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Grove, S. K., Gray, J. R., & Burns, N. (2015).
Understanding Nursing Research 6th edition .
St. Louis, Missouri : Elsevier, Saunders.
Health, J. H. (2008).
Managing Your Qualitative Data.
Retrieved from Johns Hopkins Bloomberg School of Public Health: http://ocw.jhsph.edu/courses/QualitativeDataAnalysis/PDFs/Session2.pdf. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay.
Lenssen, T. A., Steyn, M. J., Crijns, Y. H., Waltjé, E. M., Roox, G. M., Geesink, R. J., . . . Bie, R. A. (2008).
Effectiveness of prolonged use of continuous passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty.
Retrieved from Bio Med Central: http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-9-60
Maniar, R. N., Baviskar, J. V., Singhi, T., & Rathi, S. S. (2012).
To Use or Not to Use Continuous Passive Motion Post–Total Knee Arthroplasty : Presenting Functional Assessment Results in Early Recovery.
Retrieved from ScienceDirect.com: http://www.sciencedirect.com.lopes.idm.oclc.org/science/article/pii/S0883540311001689
NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Create an Implementation Plan pertaining to PICOT question
Create an Implementation Plan —outline your implementation steps 1-2-3 pertaining to the PICOT question:
In patients that are identified as high risk for developing a pressure ulcer (P), does the implementation of a pressure ulcer protocol initiated in the emergency department (I) as compared to patients who receive usual care (C), reduce the incidence of hospital-acquired pressure ulcers (O) on day 3 of hospitalization (T)?
PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay
Abstract
This paper encompasses nursing knowledge that was used in a PICOT question which was researched through health data bases. The PICOT question explores whether using pre-operative versed (midazolam) in pediatric patients provides better post-operative pain control than not using versed (midazolam). The methodology, levels of evidence and a review of the research literature is produced in detail. Using the results of the research, the significance to nursing and future research are demonstrated and suggestions for changing current practices are noted.
Introduction
Nursing care is directed by Evidence Based Practice (EBP) which in turn is founded on evidence based research. When new data is produced from research it must clearly be communicated within the healthcare setting. Nursing and related personnel must collaborate efficiently in supporting the EBP and incorporating it in their everyday practice. “The purpose of this assignment is to reflect how nursing knowledge is disseminated for use in personal and professional practice” (Ursuy, 2014). This paper explores whether using preoperative versed (midazolam) in pediatric patients provides better post-operative pain control than not using versed (midazolam).
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Clinical Question
Working in the Surgery, Prep and Recovery Unit of a local hospital, I encounter pediatric patients that are having surgical procedures. Children under the age of 10 years old have their IV started in the operating room under general anesthesia, while children over the age of 10 years old have their IV started in the preoperative area. Both categories of children could be given oral midazolam preoperatively, however, due to limited IV access, IV midazolam is not given, only oral midazolam. The anesthesiologist is the one who evaluates the children and orders the midazolam, however there is no set policy or protocol for that. I began to notice inconsistencies of the children being medicated with midazolam prior to surgery and it appeared the children who were medicated with midazolam preoperatively had better post-operative pain control.
When questions arise for discussion or research, the acronym PICOT is a common way to format the question. P stands for the population/patient, I stands for the area of interest/intervention, C stands for the comparison/current practice, O stands for the desired outcome and T denotes the time frame (Niewswiadomy, 2012, p. 282). The PICOT question being explored in this paper is “Does medicating with oral versed (midazolam) preoperatively reduce post-operative pain compared to patients who do not receive preoperative versed (midazolam) in pediatric patients?” P is represents pediatric patients, I is represented by the administration of oral versed, C is comparing not medicating preoperatively, O signifies post-operative pain management and T is during the post-operative period. It is believed the quality and safety of the pediatric population undergoing surgical procedures would be improved if there were consistent preoperative medication policies and procedures in place. Post-operative pain could be improved, thus patient and parent satisfaction could also potentially increase. PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay.
Methodology
When researching the PICOT question at hand, I utilized three databases relevant to the nursing/medical field, which were Cinahl, Cochrane Reviews and Pub-Med. In each database, I would use the advance search when possible and included key words or phrases. At first, using the word versed did not reveal many articles, but upon advancing the search to include midazolam and adding parenthesis around the key words provided more options. So, the search included (versed or oral midazolam), (pediatric or children) and (post-operative pain or preoperative pain). PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay.
The selection process was further narrowed down after reading the abstracts of numerous articles. The abstracts provided me with valuable information that easily allowed me to either include or exclude the article. I tried to include articles that were current, 12 years ago to present.
Levels of evidence is a way to categorize articles based on types of trials, studies, and expert opinions by using a numerical hierarchy. Each article reviewed was assigned a level of evidence using the following level of evidence chart, one being the highest level and seven being the lowest level.
Levels of Evidence
Level 1- Systematic review and meta-analysis of randomized controlled trials
Level 2- One or more randomized controlled trials
Level 3- Controlled trial (no randomization)
Level 4- Case-control or cohort study
Level 5- Systematic review of descriptive and qualitative studies
Level 6- Single descriptive or qualitative study
Level 7- Expert opinion
(Melnyk & Fineout-Overholt, 2011)
Choosing the levels of evidence to assign to the chosen articles was not an easy process and the articles chosen for the PICOT question were not done so based only on the level of evidence given to them. Nursing articles were favored along with the content relevant to the PICOT question in conjunction with the level of evidence assigned.
Resource utilization is something all nurses in healthcare should participate in according their scope of practice (White & O’Sullivan, 2012, p. 194). Nurses often shy away from research and quality related utilization because change is often difficult and why change something that is working just fine? At the registered nurse level, an RN should evaluate evidence in deciding the level of care and interventions for the patient outcomes (White & O’Sullivan, 2012, p. 194).
Discussion of Literature
Article One
The first article reviewed is called “Premedicating children for painful invasive procedures” by Elizabeth R. Klein, which is nursing research. Klein used a descriptive survey/questionnaire for her research questions and there were 108 participants. The participants were broken down to include 55 physicians and 53 nurses. The physicians were pediatric professors and staff oncologists while the nurses involved were clinical nurses or clinical nurse specialists (Klein, 1992, p. 172). Questions included on the questionnaire reflected current premedicating practices in their pediatric clients and then they were asked about the patients post procedure pain using the Likert Scale of 1 to 5 (1 being no pain and 5 being excruciating pain) (Klein, 1992).
Several drug combinations were used along with oral and intravenous midazolam in practices of premedicating pediatric patients prior to painful procedures, such as lumbar punctures. Although the article is only an evidence level of six (Melnyk & Fineout-Overholt, 2011), the results are significant and can be useful to pediatric nurses. The results revealed that there was a significant reduction of pain if a pediatric patient was medicated prior to a painful procedure with agents such as midazolam. Further implications for nursing are standardizing premeditation care and practices for pediatrics undergoing painful procedures (Klein, 1992, p. 177).
Article Two
The second article, “Pre-anesthetic medication with intranasal dexmedetomidine and oral midazolam as an anxiolytic. A clinical trial” (Linares et al., 2014) is a comparison trial between two medications for preoperative anxiety. This trial was a prospective, randomized, double-blind, controlled trial that was conducted on children 2-12 years of age (Linares et al., 2014). There were 108 pediatric patients in the trial and their anxiety was assessed using a modified Yale scale. Anxiety is closely related to pain and pain perception with children.
Evidence level is a four (Melnyk & Fineout-Overholt, 2011) and the trial was done in 2013, so I chose to include the article based that the information was relevant to the PICOT question. Although the findings were suggestive of the dexmedetomidine being superior to the midazolam in reducing anxiety, which could also reduce the pain perception for the children, the findings were significant and supportive to the issue that pediatric patients could have better post procedure pain if they were medicated preoperatively. Further research and studies need to be conducted and standardized practices should be made available.
Article Three
The last article to be discussed is by Fazi et al., “A comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient.” This trial was randomized and controlled and was a comparative study (Fazi, Jantzen, Rose, Kurth, & Watcha, 2001). It is located in The Cochrane Central Register of Controlled Trials. The study participants were the ages of 4-12 years old and all were medicated prior to anesthesia with either the midazolam or clonidine. PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay.
Evidence level was rated as a two (Melnyk & Fineout-Overholt, 2011), but the results were significant to the PICOT question and nursing in comparing the preanesthetic sedation and post-operative recovery. The children in the midazolam group required less postoperative analgesia and thus midazolam was considered superior to clonidine as an oral preanesthetic medication (Fazi et al., 2001). Although this trial was limited to patients receiving tonsillectomies, it is indicative of the need for future research on standardizing care practices on medicating children preoperatively to help manage post-operative pain.
Significance to Nursing
When research is conducted, evidence can be supported by Evidence Based Practice (EBP) and thus nursing practice could potentially be changed to increase the safety and efficacy of care. “Interprofessional collaboration will make the research stronger and will increase the likelihood that a satisfactory practice change can eventually be implemented” (White & O’Sullivan, 2012, p. 137). In today’s nursing practice, nurses have the “capabilities to address a wide variety of health issues” (Black, 2014, p. 114), however, nurses must act within their Scope of Practice as defined by the American Nurses Association and outline by The Code of Ethics for Nurses and the Standards of Nursing Practice (White & O’Sullivan, 2012). That is why it is important that nurses participate in nursing research.
Quality and Safety Education for Nurses (QSEN) emphasizes providing quality nursing education to nursing students and that quality is the responsibility of all individuals in healthcare (White & O’Sullivan, 2012). QSEN targets the knowledge, skills and attitude for nurses and incorporates six core competencies. These six competencies are Patient-Centered Care, Teamwork and Collaboration, Evidence Based Practice, Quality Improvement, Safety and Informatics (Quality and Safety Education for Nurses, 2013). With the inquiry of this PICOT question, patient-centered care, evidence based practice, quality improvement and safety were all explored and utilized. I have gained knowledge and insight to information that is not only significant to my own nursing practice, but that could potentially impact others.
Conclusion
The PICOT question explored had supportive and non-supportive data revealed. Material was overwhelming supportive of pediatric patients being medicated prior to painful procedures or surgery. Reducing anxiety and pain preoperatively and postoperatively is imperative for the healing process and patient satisfaction. Midazolam may or may not be the medication of choice to reduce the pain and anxiety, but it is evident that further research is needed in order to establish a set of standardized care practices in regards to medicating pediatric patients preoperatively. This is significant to nurses caring for children to provide optimal and quality care.
PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay
References
Black, B. P. (2014).
Professional Nursing Concepts & Challenges
(7th ed.). St. Louis, Missouri: Elsevier Saunders.
Fazi, L., Jantzen, E. C., Rose, J. B., Kurth, C. D., & Watcha, M. F. (2001, January). A Comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient.
Anesthesia and Analgesia
,
92
. PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay. PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay.
Klein, E. R. (1992). Premedicating children for painful invasive procedures.
Journal of Pediatric Oncology Nursing
,
9(4
).
Linares, S. B., Garcia, C. M., Ramirez, C. I., Guerrero, R. J., Botello, B., Monroy, T. R., & Ramirez, G. X. (2014, January). Pre-anesthetic medication with intranasal dexmedetomide and oral midazolam as an anxiolytic. A clinical trial.
An Pediatr (Barc
). http://dx.doi.org/10.1016/j.anpedi.2013.12.006. PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay
Melnyk, B. M., & Fineout-Overholt, E. (2011).
Evidence-based practice in nursing and healthcare: A guide to best practice
. Philadelphia: Lippincott, Williams & Wilkins.
Niewswiadomy, R. M. (2012).
Foundation of Nursing Research
(6th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Quality and Safety Education for Nurses. (2013). Retrieved from www.qsen.org
Ursuy, P. (2014). Class Syllabus.
Ferris State University
. Retrieved from www.myfsu/ferrisconnect/blackboardlearn. PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay
White, K. M., & O’Sullivan, A. (2012).
The essential guide to nursing practice
. Washington D.C.: American Nurses Association
PICOT Question Evidence Based Practice Research Paper – Versed (Midazolam) Essay
Treatment of Psychological Disorders Essays, Papers, Questions and Answers
Treatment of Psychological Disorders
Learning Objectives
What do treatments for psychological problems look like?
How did Freud influence psychotherapy?
What is cognitive-behavior therapy?
Does psychotherapy work?
What is the placebo effect? How do placebos work?
Is it important to “click” with your therapist?
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Overview
What helps?
Different treatments work better for different disorders.
Psychotherapy
The use of psychological techniques and the therapist–client relationship to produce emotional, cognitive, and behavior change
Adherents to different paradigms offer very different treatments (Prochaska & Norcross, 2006).
Most mental health professionals describe themselves as
eclectic
.
Using different treatments for different disorders
Evidence-based treatments
The practical and scientific approach to therapy
According to Kessler et al. (2005), about two-thirds of people with a diagnosable disorder fail to receive treatment.
Four Views of Frances
Biological therapist
Draws an analogy with physical illness
Focuses on diagnosis
Considers genetic predisposition or chemical imbalance
Psychodynamic therapist
Likely to focus on the defensive style
Develop the client’s insight
Expect changes as a result of increased emotional awareness
Cognitive-behavior therapist
Focus on cognitive-behavioral patterns
Therapist is directive
Identify cognitive distortions
Assign homework
Change behaviors
Humanistic therapist
Likely to focus on lack of emotional genuineness
Therapist is nondirective
Encourage the client to “own” her feelings
Biological Treatments
First, a diagnosis is developed and refined.
Second, clues about causes are put together.
Third, scientists experiment with various treatments for preventing or curing the disorder until an effective treatment is found.
Treatment focuses on symptom alleviation.
Psychopharmacology
The use of medications to treat psychological disturbances
Psychotropic medications
are chemical substances that affect psychological states.
21% of American women, and half as many men, are taking antidepressants.
Antipsychotic drugs are also highly prescribed.
Often safe and effective
Alleviate symptoms, not cure causes of illness
Many must be taken for long periods of time.
All medications have side effects.
Psychotropic medications are prescribed by primary care physicians, not psychiatrists.
American population wants a quick fix (as a medication) to treat psychological disorders.
Electroconvulsive Therapy (ECT)
Involves causing seizures by passing electricity through the brain
Developed by Ugo Cerletti and Lucio Bini in 1938
ECT involves 6 to 12 sessions over the course of a few weeks.
Electrical current is approximately 100v.
Bilateral ECT
Current passes through both hemispheres
Unilateral ECT
Current passes through one hemisphere
Psychosurgery
Surgical destruction of specific regions of the brain
Developed by Egas Moniz in 1935
Nearly 10,000–20,000 procedures were done in the United States.
Eventually discredited
Cingulotomy is used to treat very severe cases of OCD.
Freudian Psychoanalysis
Psychoanalysis
Free association
reveals aspects of the unconscious mind.
Free associations, dreams, and slips of the tongue—Freudian slips—are “windows into the unconscious.”
Psychoanalytic Techniques
Insight
Bringing formerly unconscious material into conscious awareness
Interpretation
Analyst suggests hidden meanings to patients’ accounts.
Psychoanalytic Techniques
Resistance
Patient must discover the hidden meaning.
Transference
Patients transfer their feelings about some key figure.
The Decline of Freudian Psychoanalysis
Requires substantial amount of time, expense, and self-exploration
Very little research has been conducted on its effectiveness
Psychodynamic psychotherapy
Derived from psychoanalysis
Psychotherapists are more directive and engaged, and treatment may be brief.
Ego Analysis
Emphasized the role of the ego (e.g., the mediator between the id and the superego)
More concerned with unconscious motivations and dealings with the external world
Emphasized the role of the ego (e.g., the mediator between the id and the superego)
Ego analysts
Sullivan
Horney
Erikson
Therapists more actively involved with patients than psychoanalysts
Short-term psychodynamic psychotherapy
Uses many techniques
Is shorter and less expensive
Amenable to research
Interpersonal therapy (IPT)
Focuses on changing emotions and styles of interacting in close relationships
Cognitive-Behavior Therapy (CBT)
Encourages
Collaborative therapist–client relationships
Focuses on the present
Direct efforts to change problems
Use of research-based techniques
Beginnings can be traced to John B. Watson’s behaviorism.
Early behavior therapists relied heavily on classical conditioning (Pavlov) and operant conditioning (Skinner).
Today, CBT incorporates many learning principles based on cognitive psychology. Treatment of Psychological Disorders Essays, Papers, Questions and Answers
A practical approach oriented to changing behavior than focusing on personality.
Embraces empirical evaluation
Asks, “What works?”
Systematic Desensitization
John Wolpe (1915–1997)
Research focused on eliminating phobias.
Assumed that some phobias were learned through classical conditioning
Developed systematic desensitization for eliminating fears by:
Progressive muscle relaxation
Hierarchy of fears
Learning process
Other Exposure Therapies
In order to conquer your fears, you must confront them (Barlow et al, 2002)
In vivo desensitization
Gradually confronting fears
Flooding
Confronting fears at full intensity
Aversion Therapy
The use of classical conditioning to create, not eliminate, an unpleasant response
Used primarily in treating substance abusers
Effectiveness is not clear.
Contingency Management
Contingency
Relationship between a behavior and its consequences
Social Skills Training
Teaches clients new ways of behaving that are both desirable and likely to be rewarded in everyday life
Assertiveness training
Teaches clients to be direct about their feelings and wishes
Teaches clients new ways of behaving that are both desirable and likely to be rewarded in everyday life
Role playing
Rehearses new social skills
Social problem-solving
Teaches clients through solving a variety of life’s problems
Cognitive Techniques
Attribution retraining
: people are “intuitive scientists”
Constantly draw conclusions about the causes of events
Self-instruction training
: adults model an appropriate behavior
Child asked to repeat the action
Develop internalization
Beck’s Cognitive Therapy
Developed by Aaron Beck specifically as a treatment for depression
Depression is caused by errors in thinking.
Challenges cognitive errors by having clients analyze their thoughts more carefully (Beck et al., 1979)
Rational–Emotive Therapy
According to Albert Ellis, emotional disorders are caused by irrational beliefs.
Absolute, unrealistic views of the world
Major difference from CBT: challenge client’s beliefs during the therapy (Ellis, 1962)
“Third-Wave” CBT
Dialectical behavior therapy
Acceptance and commitment therapy
Focuses on broad, abstract principles such as mindfulness, acceptance, values, relationships
Dialectical behavior therapy, used for borderline personality disorder
Acceptance and commitment therapy encourages accepting oneself.
Humanistic Therapies
Developed as a “third force” in psychotherapy
A counterpoint to psychodynamic and cognitive behavior therapy
Values humans’ ability to make choices and ability to be responsible for one’s own life
Encourages people to recognize and experience their true feelings
Views the therapist–client relationship as the method of change
Client-Centered Therapy
Carl Rogers (1902–1987)
Viewed three qualities as essential in a therapist:
Warmth
Genuineness
Empathy
—emotional understanding
Encourages therapist self-disclosure
Therapists do not act as experts.
Unconditional positive regard
Valuing clients for who they are
Therapeutic alliance
A bond between therapist and client
Research on Psychotherapy
Does Psychotherapy Work?
Psychotherapy outcome research
Examines the outcome, or result, of psychotherapy
Meta-analysis
A statistical procedure that allows researchers to combine the results from different studies in a standardized way
The average benefit of psychotherapy is .85 standard deviation units (Smith & Glass, 1977).
Many benefits of psychotherapy diminish in the year or two after treatments ends (Westen & Bradley, 2005).
Some treatments may harm.
Improvement without Treatment?
Two-thirds of clients improve as a result of psychotherapy
Spontaneous remission (e.g., improvement without treatment)
Hans Eysenck (1916–1997)
Informal counseling vs. psychotherapy
The Placebo Effect
Any type of treatment that contains no known active ingredient for the condition at hand
The recipient’s belief in a treatment, and expectation of improvement, are responsible for much of what works in psychological as well as physical treatments.
Efficacy and Effectiveness
Efficacy
Whether a treatment can work under prescribed circumstances
Effectiveness
Whether therapy does work in the real world
Consumer Reports
(1995, November): psychotherapy helps many people in the real world, not just in the laboratory
When Does Psychotherapy Work?
Depends on:
Nature of client’s problem
Duration of therapy
Client’s background
YAVIS
Young
Attractive
Verbal
Intelligent
Successful
Psychotherapy Process Research
Common Factors
Do different psychotherapies share common factors that help make them effective?
Motivational interviewing: an evidence-based treatment developed to treat alcohol abuse
Therapy as Social Influence
Client’s relationship with his or her therapist
Pain Relief? Treatment of Psychological Disorders Essays, Papers, Questions and Answers
Psychological pain motivates seeking psychological help.
Couple, Family, and Group Therapy
Couple Therapy
Involves seeing intimate partners together in therapy
The goal is to improve the relationship, not to treat the individual, by improving:
Communication and negotiation skills
Conflict resolution
Can be used for treatment of depression, anxiety, substance abuse, and child behavior problems
Supplement to individual therapy
Family Therapy
Might include two or more family members
Goals are to improve communication, resolving conflicts, and perhaps change family relationships and roles.
Family Systems Therapy
Emphasize interdependence among family members and the importance of viewing the individual within the family system
Parent management training
: teaches parents new parenting skills
Family therapist may call attention to
pattern of alliances
.
Family therapists attempt to improve mental health by altering family relationships.
Group Therapy
Involves treating several people facing similar emotional problems or life issues
Group Therapy
Groups may be small; three to four people; or large, 20 or more.
Psychoeducational groups
Teach specific psychological information or life skills
Experiential group therapy
Relationships are the primary mode of treatment
Groups may be small; three to four people; or large, 20 or more.
Self-help groups
Bringing people together who face a common problem
Prevention. Treatment of Psychological Disorders Essays, Papers, Questions and Answers
Social institutions, school, and work environments contribute to mental health.
Community psychology
Improve individual well-being by promoting social change
Primary prevention
Improve the environment in order to prevent new cases
Social institutions, school, and work environments contribute to mental health.
Secondary prevention
Early detection of emotional problems
Tertiary prevention
Any of the treatments.
Specific Treatments for Specific Disorders
The ultimate goal of treatment research is to identify therapies that have specific active ingredients for treating specific disorders (Nathan & German, 2007).
The mental health professional must inform client(s) about evidence on alternate treatments for their problem(s).
Therapists unskilled in a particular approach must refer the client to someone with specialized training (McHugh & Barlow, 2010).
Treatment of Psychological Disorders Essays, Papers, Questions and Answers
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
Abstract
Mechanical ventilation is a life-saving measure utilized when the respiratory status of a critically ill patient has become compromised. Ventilator-Associated Pneumonia (VAP) is a complication of mechanical ventilation. This paper will discuss oral care practices and their aid in the prevention of Ventilator-Associated Pneumonia. This is examined using three research studies discussing the effects of oral care practices in the prevention of Ventilator-Associated Pneumonia. Findings will provide information regarding oral care practices among nurses and if such practices reduce the incidence of Ventilator Associated Pneumonia.
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Oral Care Practices and the Prevention of Ventilator-Associated Pneumonia
“Ventilator-associated pneumonia (VAP) is defined as pneumonia in patients receiving mechanical ventilation that was neither present nor developing at the time of intubation” (Munro, Grip, Jones, McLeish, & Sesser, 2009, p.429). According to Munro et al (2009), VAP is associated with increased mortality, hospital length of stay, and health care costs. Among ventilated patients prevalence rates of VAP are consistently in the 10% to 20% range and mortality rates in the intensive care unit (ICU) are two to three times greater in patients with VAP. Estimates of healthcare costs for individuals with VAP ranges from $11, 897 to $150,000. Oral health can be compromised by critical illness, mechanical ventilation, and is influenced by nursing care (Munro, Grip, Keswick, McKinney, Sesser, & Hummel, 2006).
Working in the critical care unit, I frequently care for ventilated patients. In our unit, we incorporate the use of the VAP bundle to improve patient outcomes and to prevent VAP. This bundle includes using Sage Oral Care Kits and Chlorhexidine, as well as elevating the head of the bed thirty degrees or more, using oral gastric tubes over nasogastric tubes, deep vein thrombosis (DVT) prophylaxis, peptic ulcer disease (PUD) prophylaxis and daily sedation awakening (sedation vacation). In addition many of the critical care physicians use a subglottic evacuation endotracheal tube when intubating patients.
According to Munro et al (2009), many risk factors for VAP have been identified. Major ones include poor hand washing by staff, supine positioning of patients without backrest elevation, previous antibiotic therapy, presence of a nasogastric tube, and gastric alkalization. The interventions include elevating the head of the bed 30 degrees or more, peptic ulcer disease (PUD) prophylaxis, deep vein thrombosis (DVT) prophylaxis, daily sedation awakening, and the assessment of readiness to extubate.
Another risk factor for VAP, according to Munro et al (2009) is the colonization of the oropharynx by potential pathogens. These pathogens include Staphylococcus aureus, Streptococcus pneumonia, or gram-negative rods. “The major route for acquiring endemic VAP is oropharyngeal colonization by endogenous flora or by pathogens acquired exogenously from the intensive care unit environment…” (Garcia et al, 2009, p. 524).
In this first research study, illustrated by Garcia et al (2009), patients at least 18 years old were admitted between January 1, 2001, and December 31, 2004, to a 10-bed medical intensive care unit (MICU). These patients were eligible for the study if they were intubated for more than 48 hours. Patients in the study were followed up for VAP occurrence until they were weaned off mechanical ventilation in the MICU, for 48 hours after their transfer, or until they died. The standards of care for all patients during the 48-month study period included changes in the ventilator circuit every 7 days, replacement of the heat moisture exchange every 24 hours, a closed suctioning system, head of bed 30 degrees of more, peptic ulcer disease prophylaxis, and an active weaning protocol. Oral Chlorhexidine was not used in this study.
During the intervention phase between January 1, 2003 and December 31, 2004, a comprehensive oral and dental care system was implemented (Garcia et al, 2009). This system reduces secretions that accumulate in the oral cavity after the introduction of the endotracheal tube and reduce plaque on the surface of the teeth. The protocol for the system included oropharyngeal suctioning every 6 hours, oral cleaning of the tissue and gums every 4 hours or as needed, and tooth brushing twice a day. The outcome measures were as follows: During the intervention, VAP rates decreased by 33.3%. Both duration of mechanical ventilation and length of stay decreased after implementation of an oral care regimen.
Garcia et al (2009) found the 48-month study yielded 4 important findings:
Risk and incidence of VAP are significantly reduced by the implementation of a multifaceted protocol that includes daily oral assessment combined with procedures and tools specifically designated for bacterial reduction in the oral cavity, subglottic space, and on teeth, and conducted on a daily schedule; (2) infection avoidance can be sustained for considerable periods; (3) despite the establishment of other evidence-based interventions such as elevation of the head of the bed and prophylaxis of stress ulcers, VAP rates of zero did not occur until the new protocol was instituted; (4) a comprehensive oral-dental program has profound effects of reducing the duration of mechanical ventilation (from 7.2 days to 5.1 days) (p.529).
In this study, it would have been beneficial to see the results on random patients. The types of patients admitted to the intensive care unit can vary and there can be extenuating circumstances such as an emergent intubation. Overall though, the findings of this study support that an oral care regiment reduces and prevents VAP.
The second research study shows insight in the prevention of VAP using Chlorhexidine and tooth brushing. In this research study, Munro et al (2009) tested the effect of each individual intervention using Chlorhexidine alone and tooth brushing alone. Chlorhexidine is a broad spectrum antibacterial agent that is used in healthy populations to control dental plaque and prevent gingivitis. Patients were older than 18 years in medical, surgical/trauma/ and neuroscience ICU’s. Patients receiving mechanical ventilation were enrolled within 24 hours of intubation and those with preexisting pneumonia were excluded. “Patients were randomly assigned to 1 to 4 treatments: a 0.12% solution of Chlorhexidine 5 ml by oral swab twice daily, tooth brushing 3 times a day, combination care (tooth brushing 3 times a day and Chlorhexidine every 12 hours), or control (usual care)” (Munro et al, 2009, p.430). According to Munro et al (2009), every patient’s mouth was divided into four quadrants (right upper, right lower, left upper, left lower), and each quadrant was brushed in a defined pattern. This pattern included every quadrant and tooth brushed for 5 strokes on lingual, buccal, and biting services. Chlorhexidine was applied in a defined pattern by using a green Toothette swab to evenly coat each tooth, tongue and palette.
Munro et al (2009) found that Chlorhexidine oral swabbing was effective in reducing early VAP. Tooth brushing did not reduce the incidence of VAP and the combination of Chlorhexidine and tooth brushing did not provide any additional benefit. I found this study to be beneficial in supporting the use of Chlorhexidine in an oral care regiment. At my place of employment in the intensive care units, the facilitation of Chlorhexidine is incorporated with the VAP Bundle.
The third research study includes research on oral comfort and hygiene measures. This article focuses on the impact of nursing care and the prevention of VAP. At the time of this article no comprehensive guidelines existed that defined the method and frequency of oral care. Practices varied from site to site. “The disparity between what nurses think they do and what is actually documented raises questions about the reliability and the consistency of practice” (Cutler & Davis, 2006, p.390). Cutler and Davis (2006) found that healthcare settings with specific protocols and procedures facilitated consistency and quality care through standardization. In this study, observations were made in 8 ICUs, with varying patient diagnoses. None of the study sites had an oral cleansing protocol that defined frequency and the tools for oral care on patients receiving mechanical ventilation. According to Cutler and Davis (2006), nurses and respiratory personnel were educated and trained to follow a standardized oral cleansing regimen for all patients receiving mechanical ventilation. During this period, 24-hour oral kits were mounted on the wall near the patient’s bedside. Observation of nurses and respiratory staff was conducted. The observers noted the frequency, tasks, and tools used for oral care. Also, they recorded the types of oral care cleanser used. The results concluded that with education to the staff, every aspect of oral care performance increased and VAP decreased significantly among patients (Cutler & Davis, 2006).
I agree with this article in that education among staff helped patients have better outcomes. In my own professional practice, the nurses and respiratory staff have been educated on effective oral care. Every month, we have critical care classes that discuss evidence based practice in preventing VAP and other respiratory issues. These classes stress education in prevention and effective nursing care to provide better outcomes for patients. Also, the critical care units have an outcomes specialist who provides us with statistics and keeps the nurses up to date on their progress.
After reviewing the three research articles, I found that they support the ideas of the nursing theorist Betty Neuman. Oral care practices and their role in the prevention of VAP reflect her model of prevention as the primary nursing intervention (“Nursing Theories”, 2010). Her vision of prevention includes health promotion and maintenance of wellness. Her nursing theory focuses on a “comprehensive flexible holistic and system based perspective for nursing” (“Nursing Theories”, 2010). Neuman theorized that “prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body” (“Nursing Theories”, 2010). In addition, Neuman’ theory consists of concentric lines of defense, protecting individuals from negative external and internal variables. When a patient is mechanically ventilated, their body is put through multiple stressors and oral care interventions are imperative for the prevention of VAP. Using Neuman’s model system along with nursing interventions can help eliminate the episodic events of VAP, promoting better patient outcomes.
As a critical care nurse, there are ways that I am able to implement VAP prevention. By being a preceptor in my unit, I can share with new graduates the VAP bundle and the interventions used to prevent VAP. Also by attending monthly respiratory classes, this will impact my practice by keeping me up to date on the current guidelines in VAP prevention. In the future, I will focus on educating staff about VAP prevention and future practice and continue my research into effective oral care interventions to ensure better patient outcomes.
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
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References
Cutler, C. N., & Davis, N. (2005). Improving oral care in patients receiving mechanical ventilation.
American Journal of Critical Care, 14
(5), 389-394.
Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009)
Reducing ventilator-associated pneumonia through advanced oral-dental care:
A 48-month study.
American Journal of Critical Care 18(6)
, 523-531.
Munro, C.L., Grap, M.J., Elswick, R.K., McKinney, J., Sessler, C. N., & Hummell R. S. (2006). Oral health Status and development of ventilator-associated pneumonia: A descriptive
study.
American Journal of Critical Care
,
15
(6), 453-460.
Munro, C. L., Grap, M. J., Jones, D. J., McClish, D. K., & Sessler, C. N. (2009).
Chlorhexidine, tooth brushing, and preventing ventilator-associated pneumonia
in critically ill adults.
American Journal of Critical Care, 18(6),
428-437.
doi: 10.4037/ajcc2009792.
Nursing theories a companion to nursing theories and models. 2010, January 16. Retrieved
from http://www.currentnursing.com/nursing_theory/nursing_theorists.html.
Appendix A
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP) – Checklist for submitting papers
CHECK
DATE, TIME, & INITIAL
PROOFREAD FOR: APA ISSUES
1.
Page Numbers:
Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)]
2.
Running head:
Does the Running head: have a small “h”? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1/2” from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40]
3.
Abstract:
Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with the margin without an indentation? Is your abstract a summary of your entire paper? Is it written in the past tense? Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41]
4.
Introduction:
Did you repeat the title of your paper on your first page of content?
Do not use ‘Introduction’
as a heading following the title. Do not bold your title. The first paragraph clearly implies the introduction and no heading is needed. [p. 27 and example on p. 42]
5.
Margins:
Did you leave 1” on all sides? [p. 229]
6.
Double-spacing:
Did you double-space throughout? No triple or extra spaces between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p. 40-59]
7.
Line Length and Alignment:
Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229]
8.
Paragraphs and Indentation:
Did you indent the first line of every paragraph? See P. 229 for exceptions.
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
10.
Typeface:
Did you use Times Roman 12-point font throughout, even in your header? [p. 228]
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
11.
Plagiarism:
Cite all sources! If you say something that is not your original idea, it must be cited. DO NOT COPY THE EXAMPLE AND USE IT AS YOUR OWN! You may be citing many times…this is what you are supposed to be doing! Is there a citation for every paragraph? [p. 170]
12.
Direct Quote:
A direct quote is exact words taken from another. An example with citation would look like this:
“The variables that impact the etiology and the human response to various disease states will be explored” (Bell-Scriber, 2007, p.1).
Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this, except for block quotes? [p. 170-172]
13.
Quotes Over 40 Words:
Did you make block quotes out of any direct quotes that are 40 words or longer? Did you place the period after the text rather than after the citation? [p. 170-172]
14.
Paraphrase:
A paraphrase citation would look like this:
Patients respond to illnesses in various ways depending on a number of factors that will be explored (Bell-Scriber, 2007). Do all paraphrased citations look like this? [p. 171 and multiple examples in text on p. 40-59]
15.
Headings:
Did you check your headings for proper levels and format? [p. 62-63].
16.
General Guidelines for
References:
Do not bold the word References!
A.
Did you start the References on a new page? [p. 37]
B.
Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same.
C.
Is your reference list double spaced with hanging indents? [p. 37]
PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE
13. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.)
14. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesn’t make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this?
15. Wordiness: check for the words “that”, and “the”. Don’t use the terms ‘I feel’ or ‘I think’. If not necessary, did you omit? Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
16. Conversational tone: Don’t write as if you are talking to someone in a casual way. For example, “Well so I couldn’t believe nurses did such things!” or “I was in total shock over that.” Did you stay in a formal/professional tone?
17. Avoid contractions. i.e. don’t, can’t, won’t, etc. Did you spell these out?
18. Did you check to make sure there are no hyphens and broken words in the right margin?
19. Do not use “etc.” or “i.e.” in formal writing unless in parenthesis. Did you check for improper use of etc. & i.e.?
20. Stay in subject agreement. When referring to 1 nurse, don’t refer to the nurse as “they” or “them”. Also, in referring to a human, don’t refer to the person as “that”, but rather “who”. For example: The nurse that gave the injection….” Should be “The nurse who gave the injection…” Did you check for subject agreement? Likewise, don’t refer to “us”, “we”, “our”, within the paper…this is not about you and me. Be clear in identifying. For example don’t say “Our profession uses empirical data to support ….” . Instead say “The nursing profession uses empirical data…..
21. Did you check your sentences to make sure you did not end them with a preposition? For example, “I witnessed activities that I was not happy with.” Instead, “I witnessed activities with which I was not happy.”
22. Did you run a Spellcheck? Did you proofread in addition to running the Spellcheck? Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
23. Did you have other people read your paper? Did they find any areas confusing?
24. Did you include a summary or conclusion heading and section to wrap up your paper?
25. Do not use “we” “us” “our” “you” “I” etc. in a formal paper! Did you remove these words? Only use these if you are the subject of your paper.
26. Does your paper have sentence fragments? Do you have complete sentences?
27. Did you check apostrophes for correct possessive use. Don’t use apostrophes unless it is showing possession and then be sure it is in the correct location. The exception is with the word it. It’s = it is. Its is possessive.
28. Did you use proper punctuation, particularly commas? If you are unsure of when to use them, please contact the writing center.
Signing below indicates you have proofread your paper for the errors in the checklist:
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP) Grading Rubric
Name: _________________________________
DESCRIPTION AND ANALYSIS OF PRACTICE ISSUE
POINTS POSSIBLE
POINTS AWARDED
Clear Introductory Description of Practice Concern/Interest:
Describes reason for interest or concern and description of issue.
10
10
Practice Environment:
Provides clear description of practice area.
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
5
5
Causal Factors:
Personal Perspective and Description/Analysis of Possible Contributing or Causative Factors for the Concern
10
10
Defined Area of Research Search:
Narrows down and defines a specific area for research review and provides a clear statement of same.
5
5
RESEARCH REVIEW
Research Findings:
Shares the findings of a minimum of 3 original research studies from professional journals on the selected topic. Briefly describes the research approaches and findings of each.
20
20
Critique of the Research:
Attempts to point out any research limitations/credibility of the studies.
5
5
Implications For Practice:
Identifies potential practice implications of research. This goes beyond implications included in the study itself, to include perceptions of implications for personal practice.
5
5
Critical Reflection:
Identifies a nursing theory that this practice concern/research findings is an appropriate fit. Includes reflections on the significance/implications of integrating research into practice. Great job with theory
10
10
STANDARDS & APA CRITERIA
APA:
Attaches and adheres APA checklist and APA manual guidelines. Length appropriate (5-6 pages of typed content excluding the reference page, abstract, and title page).
Did someone proof read your Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)?
15
15
Writing:
Development of a clear, logical, well-supported paper. Overall presentation: Grammar, punctuation, clean and legible.
15
15
TOTAL POINTS
100
100
Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
Measuring Quality Guidelines Nursing paper and Grading Rubric
In an 8 to 10-page paper, APA format and 5 references, describe three rate based measurements of quality.
Select three rate based measurements of quality that you will use as the primary basis for this paper.
These measurements must relate to some aspect of clinical or service quality that directly relates to patient care or the patient’s experience of care.
For the purposes of this assignment, an analysis of staffing levels is not permitted.
You can find useful information on quality indicators that are of interest to you on these websites and resources. You may choose only one of the three measures to be some form of patient satisfaction measure.
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Deconstruct each measure to include descriptions of the each of the following as numbered below:
1) The definition of the measure
2) The numerical description of how the measurement is constructed (the numerator/denominator measure counts, the formula used to construct the rate, etc.)
3) Explain how the data for this measure are collected
4) Describe how the measurement is compared externally to other like settings; differentiate between the actual rate and a percentile ranking.
5) Explain whether the measure is risk adjusted or not. If so, explain briefly how this is accomplished.
6) Describe how goals might be set for each measure in an aggressive organization, which is seeking to excel in the marketplace.
Describe the importance of each measure to a chosen clinical organization and setting.
Using these websites and resources you can choose a hospital, a nursing home, a home health agency, a dialysis center, a health plan, an outpatient clinic or private office; a total population of patient types is also acceptable, but please be specific as to the setting. That is, if you are interested in patients with chronic illness across the continuum of care, you might home in a particular health plan, a multispecialty practice setting or a healthcare organization with both inpatient and outpatient/clinic settings. Faculty appointments and academic settings are not permitted for this exercise. For all other settings, consult the instructor for guidance. You do not need actual data from a given organization to complete this Measuring Quality Guidelines Nursing paper and Grading Rubric assignment.
Relate each measure to patient safety, to the cost of poor quality, and to the overall cost of healthcare.
Measuring Quality Guidelines Nursing paper and Grading Rubric Required Readings
Joshi, M.S., Ransom, E.R., Nash, D.B., & Ransom, S.B., (Eds.). (2014). The Healthcare Quality Book, 3rd ed. Chicago, IL: Health Administration Press.
Chapter 5: “Data Collection”
Chapter 6: “Statistical Tools for QI”
Park, J., Konetzka, R. T., & Werner, R. M. (2011). Performing well on nursing home report cards: Does it pay off? Health Services Research, 46(2), 531–554. doi:10.1111/j.1475-6773.2010.01197.x
The study in this article evaluates whether or not nursing homes benefit from improvements in quality measures. Four financial outcomes are measured before and after the improvements are enacted. The study shows that the nursing homes that improved quality measures benefited financially.
Suchy, K. (2010). A lack of standardization: The basis for the ethical issues surrounding quality and performance reports. Journal of Healthcare Management, 55(4), 241–251.
Because performance reports are easily found online, this article supports creating ethical guidelines for the performance reports of the health care industry. It compares nearly ten different organizations that provide performance reporting, and then it proposes an ethical framework and principles for public quality reporting.
Wachter, R. M., & Pronovost, P. J. (2009). Balancing “no blame” with accountability in patient safety. New England Journal of Medicine, 361(14), 1401–1406.
This article addresses the issue of individual accountability in health care organizations. It suggests moving from a culture within health care that does not place blame on individuals to a culture where individuals become more accountable. Measuring Quality Guidelines Nursing paper and Grading Rubric
Centers for Medicare & Medicaid Services. (n.d.). Quality initiatives: Overview. Retrieved from http://www.cms.gov/QualityInitiativesGenInfo/
Created by the U.S. Department of Health & Human Services, this website overviews quality initiatives that affect the health care industry. It also provides information and downloadable PDFs on the Post-Acute Care Reform Plan and Development of Quality Indicators for Impatient Rehabilitation Facilities (IRF).
Required Media – Measuring Quality Guidelines Nursing paper and Grading RubricRequired Media
Video: Laureate Education, Inc. (Executive Producer). (2011). Organizational and systems leadership for quality improvement: External quality improvement. Baltimore: Author.
Note: The approximate length of this media piece is 10 minutes. Measuring Quality Guidelines Nursing paper and Grading Rubric
The presenters in this video discuss various external organizations involved in quality, and examine the enforcement of standards by governmental agencies versus voluntary organizations. This program also addresses the publication of quality information and why organizations should do their own reporting in addition to mandated reporting. Licensing, credentialing, and certification are discussed as they relate to the social compact that health care providers have for quality and safety.
Measuring Quality Guidelines Nursing paper and Grading Rubric
Patient Assessment – 63 year old female with a cystocele, and chief complaint urinary incontinence
For this assessment the patient will be a 63 year old female with a cystocele, and chief complaint urinary incontinence. The rest of the info can be made up such as medical history meds labs just make it believable to the pt age and diagnosis.
Comprehensive Patient Assessment
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When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting.
By Day 7 of Week 9
This Assignment is due. It is highly recommended that you begin planning and working on this Assignment as soon as it is viable.
To prepare
· Reflect on your Practicum Experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
· Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, treatment and management plan, as well as education strategies and follow-up care.
To complete
Write an 8- to 10-page comprehensive paper that addresses the following:
· Age, race and ethnicity, and partner status of the patient
· Current health status, including chief concern or complaint of the patient
· Contraception method (if any)
· Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
· Review of systems
· Physical exam
· Labs, tests, and other diagnostics
· Differential diagnoses
· Management plan, including diagnosis, treatment, patient education, and follow-up care