NURS 5052 – Essentials of Evidence-Based Practice Essay

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NURS 5052 – Essentials of Evidence-Based Practice Essay

Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings.

UNIT BACKGROUND:

Evidence based practices was founded by Dr.Ardice Cochrane , a British epidemiologist.Cochrane was a strong proponent using evidence from randomized clinical trials because he believed that this was the strongest evidence on which clinical practice division is to be based. NURS 5052 – Essentials of Evidence-Based Practice Essay

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Evidence based health care practices are available for a number of conditions such as asthma,smoking cessation,heart failure and others.However these practices are not be implemented in care delivery and variation of practices[CMS,2008;Institute of medicine ,2001].Recent findings in the united states and Netherlands suggest that 30% to 40 % of patients are not receiving evidence based care,and 20% to30% of patients are receiving unneeded or potentially harmful care.

DEFINITION:

The most common definition of Evidence-Based Practice (EBP) is from Dr. David Sackett. EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996) Muir Gray suggests that evidence based health care is: NURS 5052 – Essentials of Evidence-Based Practice Essay

“an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits the patient best”(Muir Gray, 1997)

PURPOSES

1. Evidence based practice is an approach which tries to specify the way in which professionals or other decision mkers should make decisions by identifying such evidence that there may be for a practice and rating it according to how scientifically sound it may be. 2. Its goal is to eliminate unsound or excessively risky practices in favour of those that have better outcomes. 3. Evidence based practices has contributed a lot towards better patient outcomes. 4. The ultimate goal of evidenced based nursing is to provide the highest quality and most cost-efficient nursing care possible. 5. The purpose of evidence based practice in nursing is mainly to improve the quality of nursing care. NURS 5052 – Essentials of Evidence-Based Practice Essay

For example: If you are caring for a child who was in a motor vehicle accident and sustained a severe head injury, would you want to know and use the effective ,empirically supported treatment established from randomized controlled trials to decrease his or her intracranial pressure?

If the answer is “yes“,the empirical evidences are essentially very important in most of the clinical decision-making situations. The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. Conceptually, the trilateral principles forming the bases for EBP can be represented through a simple figure:

STEPS OF EVIDENCED BASED PRACTICE :

Evidence based practice process involves 5 steps as:
1. Formulating a clear question based on a clinical problem 2. Literture review to search for the best available evidences 3. Evaluating and analyzing the strengths and weaknessof that evidence in terms of validity and genelisability 4. Implementing useful findings in clinical practice based lon valid evidence 5. Evaluating efficacy and performance of evidences through a process of self reflection , audit, or peer aseessment 1.Formulating a clear question based on a clinical problem:[ ASK the question ] The first step is to formulate a clear question based on clinical problems.Ideas come from different sources but are categorized in two areas: Problem focused triggers and Knowledgee focused triggers. Problem focused triggers are identified by healthcare staff through quality improvement,risk surveillance,benchmarking data,financial data, or recurrent clinical problems.Problem focused triggers could be clinical problems,or risk management issues.

Example:Increased incidence of deep vein thrombosis and pulmonary emboli in trauma and neurosurgical patients.Diagnosis and proper treatment of a DVT is a very important task for health care professionals and is meant to prevent pulmonary embolism.This is an example of an important re tht more research can be conducted to add into evidence –based practice. Knowledge focused triggers are created when health care staff read research, listen to scientific papers at research conferences.Knowledge based triggers could be new research findings that further enhance nursing ,or new practice guidelines. Example: Pain management .,prevention of skin breakdown , assessing placement of nasogastric tubes, and use of saline to maintain patency of arterial lines.

When selecting a question ,nurses should formulate questions that are likely to gain support from people within the organization.The priority of the question should be considered as well as the sevearity of the problem.Nurses should consider whether the topic would apply to many or few clinical areas.Also,the availability of the solid evidence should be considered.This will increase the staff willingness to implement into nursing practice. NURS 5052 – Essentials of Evidence-Based Practice Essay

When forming a clinical question the following should be considered:the disorder or disease of the patient, the intervention or finding being reviewed, possibly a comparison intervention and the outcome.An acronym used to remember this is called the PICO model.:

P-Who is the patient population?
I-What is the potential intervention or area of interest?
C-Is there a a comparison intervention or control group?
O-What is the desired outcome?

2.Literature review to search for the best available evidence :[ ACQUIRE the evidence ]

Once the topic is selected ,the research relevant to the topic must be reviewed . It is important that clinical studies , integrative literature reviewes , meta analysis, and well known and reliable existing evidence based practices guidelines are accessed in the literature retrieval process .The article can be loaded with optionated nd or biased statements that would clearly taint the findings, thus lowering the credibility and quality of article.Time management is crucial to information retrieval.To maintain high standards for evidence based practice implementation, education in research review is necessary to distinguish good research from poorly conducted research.it is important to review the current materials.Once the literature is located, it is helpful to classify the articles either conceptual or data-based.Before reading and critiquing the research ,it is useful to read theoretical and clinical articles to have a broad view of the nature of the topic and related concepts , and to then review existing evidence based practice guidelines. 3. Evaluating and analyzing the strengths and weakness of that evidence in terms of validity and generalisability: [APPRAISE the evidence]. NURS 5052 – Essentials of Evidence-Based Practice Essay

Use of rating systems to determine the quality of the research is crucial to the development of evidence based practice. Once you have found some potentially useful evidence it must be critically appraised to determine its validity and find out whether it will indeed answer your question. When appraising the evidence the main questions to ask, therefore, are: Can the evidence (e.g. the results of the research study) be trusted? What does the evidence mean?

Does this answer my question?
Is it relevant to my practice?

Different appraisal and interpreting skills must be used depending on the kind of evidence being considered. Additionally, guidance and training on appraising different types of evidence are available from some of the websites listed on the Useful Internet Resources. 4.Implimenting useful findings in clinical practice based on valid evidence :Evidence is used alongside clinical expertise and the patient’s perspectives to plan care:[ APPLY:talk with the patient ]

After determining the internal and external validity of the study ,a decisions is arrived at whether the information gathered does apply to your initial question.It is important to address questions related to diagnosis ,therpy ,harm, and prognosis. Once you have concluded that the evidence is of sound quality, you will need to draw on your own expertise, experience and knowledge of your unique patient and clinical setting. This will help you to decide whether the evidence should be incorporated into your clinical practice.

You must consider both the benefits and risks of implementing the change, as well as the benefits and risks of excluding any alternatives. This decision should be made in collaboration with your patient, and in consultation with your manager or multidisciplinary team where appropriate.The information gathered should be interpreted according to many criteria and should always be shared with other nurses . 5.Evaluating efficacy and performance of evidences through a process of self reflection ,audit , or peer assessment: [self-evaluation ]

Finally after implementation of the useful findings for the clinical practices;efficacy and performance is evaluated through process of self reflection ,internal or external audit or peer assessment.Part of the evaluation process involves following upto determine if your actions or decisions achieved the desired outcome. NURS 5052 – Essentials of Evidence-Based Practice Essay

The Steps in the EBP Process:

ASSESS
the patient
1. Start with the patient — a clinical problem or question arises from the care of the patient ASK
the question
2. Construct a well built clinical question derived from the case ACQUIRE
the evidence
3. Select the appropriate resource(s) and conduct a search
APPRAISE
the evidence
4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) APPLY:
talk with the patient
5. Return to the patient — integrate that evidence with clinical expertise, patient preferences and apply it to practice Self-evaluation
6. Evaluate your performance with this patient

BARRIERS IN EVIDENCE BASED PRACTICE

There are many barriers to promoting evidence based practices such as: Lack of professional ability to critically appraise research.this includes having a considerable amount of research evaluation skills ,access to journals ,nd hospital support to spend time are limited to the nurses. Lack of time workload pressure ,and competing priorities of patient care can impede use of evidence based practice. Lack of knowledge of research methods

Lack of support from the professional colleges and organizations , and lack of confidence nd authority in the research area Practice environment can be resistant to changing tried and true conventional methods of practice.It is important to show nurses who may be resistant to changes the nursing practice the benefits that nurses, their patients and their institutions can reap from the implementation of evidence base nursing practices which is to provide better nursing care. Values ,resources and evidence are the three factors that influence decision making with regard to health care.In adition the nurses need to be more aware of how to assess the information and determine its applicability to the practice. NURS 5052 – Essentials of Evidence-Based Practice Essay

Lack of continuing educational programs . Practices donot give have the means to provide workshops to teach new skills due to lack of funding, staff and time ;therefore research may be tossed dismissed.if this will occur valuable treatment may never be utilized in the practice. Another barrier is introducing newly learned method for improving the treatments or patients.New nurses might feel it is not their place to suggest oreven tell a superior nurse that newer , more efficient methods and practices are available. The perceived threat to clinical freedom offered by evidence – based practice is neither logical nor surprising.When we make decisions based upon good quality information we are inconsistent and biased.

MODELS OF THE EVIDENCE – BASED PRACTICE PROCESS

A number of different models and theories of evidence based practice has been developed and are important resources.These models offer frameworks for understanding the evidence based practice process and for implementing an evidence based practice project in a practice setting.Models that offer a framework for guiding an evidence based practice include the following : Advancing research and clinical practice through close collaboration(ARCC) model [Melynk and fineout-overholt ,2005] Diffusion of innovations theory [Rogers , 1995]

Framework for adopting an evidence –based innovation [DiCenso et.al.,2005] Iowa model of research in practice [titler et al ,2001]
Johns Hopkins nursing evidence based practice models [Newhouse et.al, 2005] Ottawa model of research use [Logan and Graham ,1998]
Promoting action on research implementation in health services (PARIHS] model-,[Rycroft – Malone et.al2002 ,2007] Stetler model of research utilization.[Stetler ,2001]

Although each model offers different perspectives on how to translate research findings into practice .It provides an overview of key activities and processes in evidence based practice efforts ,based on a a distillation of common elements from the various models.The most prominent models are Stetler model of research utilization and Iowa model of research in practice. Stetler model of research utilization: NURS 5052 – Essentials of Evidence-Based Practice Essay

The Stetler model of evidence-based practice would help individual public health practitioners to use evidence in daily practice to inform program planning and implementation. The Stetler model of research utilization helps practitioners assess how research findings and other relevent evidence can be applied in practice. This model examines how to use evidence to create formal change within organizations, as well how individual practitioners can use research on an informal basis as part of critical thinking and reflective practice.

Research use occurs in three forms

Instrumental use refers to the concrete, direct application of knowledge. Conceptual use occurs when using research changes the understanding or the way one thinks about an issue. Symbolic use or political/strategic use happens when information is used to justify or legitimate a policy or decision, or otherwise influence the thinking and behaviour of others.

The Stetler model of evidence-based practice based on the following assumptions 1. The formal organization may or may not be involved in an individual’s use of research or other evidence. 2. Use may be instrumental, conceptual and/or symbolic/strategic. 3. Other types of evidence and/or non-research-related information are likely to be combined with research findings to facilitate decision making or problem solving. 4. Internal or external factors can influence an individual’s or group’s review and use of evidence. 5. Research and evaluation provide probabilistic information, not absolutes.

6. Lack of knowledge and skills pertaining to research use and evidence-informed practice can inhibit appropriate and effective use Phase I: Preparation—Purpose, Context and Sources of Research Evidence Identify the purpose of consulting evidence and relevant related sources. Recognize the need to consider important contextual factors that could influence implementation. Note that the reasons for using evidence will also identify measurable outcomes for Phase V (Evaluation).

Phase II: Validation—Credibility of Findings and Potential for/Detailed Qualifiers of Application

Assess each source of the evidence for its level of overall credibility, applicability and operational details, with the assumption .Determine whether a given source has no credibility or fit and thus whether to accept or reject it for synthesis with other evidence .Summarize relevant details regarding each source in an ‘applicable statement of findings’ to look at the implications for practice in Phase III. A summary of findings should: reflect the meaning of study findings. NURS 5052 – Essentials of Evidence-Based Practice Essay

reflect studied variables or relationships in ways that could be practically used Phase III: Comparative Evaluation/Decision Making—Synthesis and Decisions/Recommendations per Criteria of Applicability

Logically organize and display the summarized findings from across all validated sources in terms of their similarities and differences. Determine whether it is desirable or feasible to apply these summarized findings in practice others involved). Based on the comparative evaluation, the user makes one of four choices: Decide to use the research findings by putting knowledge into effect Consider use by gathering additional internal information before acting broadly on the evidence. Delay use since more research is required which you may decide to conduct based on local need Reject or not use .

Phase IV: Translation/Application—Operational Definition of Use/Actions for Change

Write generalizations that logically take research findings and form action terms Identify type of research use (cognitive, symbolic and instrumental). Identify method of use (informal/formal, direct/indirect).

Identify level of use (individual, group, organization).
Assess whether translation or use goes beyond actual findings/evidence. Consider the need for appropriate, reasoned variation in certain cases. Plan formal dissemination and change strategies.

Phase V: Evaluation

Clarify expected outcomes relative to purpose of seeking evidence Differentiate formal and informal evaluation of applying findings in practice. Consider cost-benefit of various evaluation efforts.

Use Research Utilization as a process to enhance the credibility of evaluation data. Include two types of evaluation data: formative and outcome. NURS 5052 – Essentials of Evidence-Based Practice Essay

CONCLUSION

Evidence based practices as using the best evidence available to guide clinical decision making.Evidence based practice in nursing is a pocess of locating ,appraising and applying the best evidence from the nursing and medical literature to improve the quality of clinical nursing practices. Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings.Evidence based practice involves making clinical division on the basis of the best possible evidence ,usually best evidence come from the rigrous research.

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REFERENCE
1. Anne M Barker. Advanced Practice Nursing-Essentials of knowledge for the profession. United States of America: Jons and Batlett publishers; 2009. P.337-338 . 2. Suresh k Sharma. Nursing research and statistics. Haryana: Elsevier; 2011. P. 22-27. 3. Dennise F Polit ,Cheryl Tatano Beck. Essentials of nursing research-Appraising evidence for nursing practice. 7th ed. Noida: Lippincot Willaims and Wilkins; 2009. P. 25-47. 4. Potter Perry. Basic Nursing. 7th ed. Haryana: Rajkamal Electric Press; 2009. P. 54-57. 5. Dr.R.Bincy. Nursing Research-Building Evidence for Practice. NewDelhi: Viva Books; 2013. P. 286-297. 6. Judith Habour. Nursing Research. 5th ed. United States of America: Mosby Elsevier; 2010. P. 386-427. 7. Neelam Makhija. A practice based on evidence based practice. Nightingale Nursing Times-A window for health. 2007 September; Vol 3: 18-21. 8. Models of evidence based practice. www.nccmt.ca/registry/view/eng/83-html. Accesed october 15,  NURS 5052 – Essentials of Evidence-Based Practice Essay

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Discussion: This is a Collaborative Learning Community (CLC) assignment.

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Discussion: This is a Collaborative Learning Community (CLC) assignment. Nursing theories are tested and systematic ways to implement nursing practice. Select a nursing theory and its conceptual model. Prepare a 10-15 slide PowerPoint in which you describe the nursing theory and its conceptual model and demonstrate its application in nursing practice. Include the following: Present […]

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Nursing # Case Study 1: ( 2 pages ), Chapter 46, Management of Patients With Oral and Esophageal Disorders

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Nursing # Case Study 1: ( 2 pages ), Chapter 46, Management of Patients With Oral and Esophageal DisordersGeorge Smith, a 55-year-old patient is admitted to the intensive care unit after a thoracotomy approach was used for an esophagectomy to remove an early stage adenocarcinoma of the distal esophagus and gastroesophageal junction. The patient has a history of GERD and Barrett’s esophagus. The patient sought medical treatment for dysphagia with solid foods, feeling that there was a lump in his throat and substernal pain with swallowing and subsequent regurgitation of undigested food and the development of hiccups. The patient has no other medical problems. (Learning Objectives 6 and 7)a.Describe the esophageal cancer that the patient has and how it relates to his history of GERD and Barrett’s esophagus.b.Explain the rationale for the early symptoms and late symptoms of esophageal cancer.c.What course of cancer treatment should the nurse anticipate that the patient in this case study would have?d.What nursing care should be provided for the patient in the intensive care unit in the early postoperative period?e.Explain the care the nurse should provide when the patient begins to eat.Mr. Owens is a 62-year-old man who underwent a neck dissection yesterday due to cancer of the mouth. You are the nurse assigned to care for Mr. Owens during his first postoperative day. Initial assessment finds Mr. Owens sitting up in bed; he is drowsy, but oriented ×3 when aroused. He has significant edema in his neck and mouth area, but does not appear to be in respiratory distress. His respiratory rate is 16 to 18, and his oxygen saturation is 96% on 40% oxygen via face tent. He has two peripheral IV lines both infusing Lactated Ringer’s solution at 75 mL/hr. Two Jackson Pratt drainage tubes are partially filled with serosanguinous drainage. (Learning Objective 5)a.What is the rationale for the patient being placed in Fowler’s position after surgery?b.The nurse notes that there has been 240 mL output in the drainage tubes during the first 24 hours after the surgical procedure. What should the nurse do?c.Postoperatively, the nurse identifies that the patient is at risk for imbalanced nutrition, less than body requirements related to anorexia and dysphagia. The nurse instructs Mr. Owens to eat soft food and suggests that he tilt his head to the unaffected side to facilitate swallowing. What is the rationale for these instructions?d.In reviewing Mr. Owens’ medical record, what findings in his health history are associated with development of oral cancer?Case Study 2: (2 pages), Chapter 47, Management of Patients With Gastric and Duodenal DisordersCrystal Monte, 32 years of age, is a female patient who is admitted to the medical-surgical unit after a laparoscopic Roux-en-Y gastric bypass for weight loss. Prior to choosing the surgery, the patient tried numerous diets and exercise programs without success and developed metabolic syndrome that led to insulin resistance. The patient’s parents both had complications related to morbid obesity and diabetes, so the patient wanted to have successful long-term weight loss and to decrease the risk factors for developing diabetes. The patient met with the multidisciplinary team before surgery, which consisted of a social worker, nurse counselor, dietitian, psychologist, exercise therapist, and surgeon. The patient received intensive preoperative teaching and followed the diet she would follow after surgery for several weeks before the operation.a.What nursing management should be provided for the patient postoperatively?b.What discharge instructions should the nurse provide the patient?Ms. George is a 32-year-old computer programmer. Over the last several months, she has had increased episodes of a burning sensation in the mid epigastrium and back. The pain subsides after eating. Based on her history, the physician orders an endoscopy that reveals several peptic ulcers. Treatment of the ulcers includes antibiotics, proton pump inhibitors, and bismuth salts. (Learning Objectives 1 and 3)a.Correlate Ms. George’s clinical presentation to the pathophysiology of peptic ulcers.b.Ms. George asks why eating decreases her pain; how does the nurse respond?c.Explain the rationale for the prescribed pharmacologic therapy.Case Study 3: (2 pages) Chapter 48, Management of Patients With Intestinal and Rectal DisordersPaul Jones, a 35-year-old patient, presents at the clinic after a CT scan of the abdomen with contrast was positive for diverticulitis. The patient presents with nausea, vomiting, fever, and chills; left lower quadrant abdominal pain described as spasms; and a firm mass. Bowel sounds are present in all four quadrants. The patient reports bouts of constipation with a hard narrow stool that is difficult to pass and periods of diarrhea with abdominal cramping. The stool is negative for occult blood. The patient has no other medical conditions. The vital signs include: BP 110/70, P 100, R 22, and T 101°F. The white blood count and ESR are elevated. The physician orders a broad spectrum antibiotic, amoxicillin clavulanate for 10 days, and propantheline bromide (Pro-Banthine) before meals and at bedtime, psyllium (Metamucil), and docusate sodium (Colace). Diet is as follows: clear liquids until inflammation subsides for 24 to 48 hours, and then advance diet, as tolerated, increasing the intake of fresh fruits and vegetables at least five servings per day, and bran cereal every day. The patient is also instructed to eat whole grain bread. (Learning Objective 3)a.What questions should the nurse ask the patient while taking a history?b.What patient education should the nurse provide to the patient being treated for diverticulitis on an outpatient basis?Mr. Thompson sustained a gunshot wound to the abdomen and underwent an exploratory laparotomy and creation of an ileostomy due to damage to the small bowel. You are assigned to care for Mr. Thompson on the third postoperative day. He has a nasogastric tube to low intermittent suction, and he is emitting greenish aspirate. IV access is through a triple lumen right subclavian catheter, and he is receiving D5 0.9% NS with 20 mEq K (potassium)/liter. Mr. Thompson has a dressing to the left abdomen, and there is moderate amount of fluid draining out of his ileostomy.a.What is the rationale for the nasogastric tube to low intermittent suction?b.Mr. Thompson is at risk for which kinds of electrolyte imbalances?c.Upon assessment of the stoma, what findings substantiate a healing stoma?d.Mr. Thompson asks when his bowel output will become more solid and if he will be able to have a continent ostomy. How should the nurse respond?e.What is the rationale for a low residue diet in the patient with an ileostomy?Case Study 4: (2 pages), Chapter 45, Digestive and Gastrointestinal Treatment ModalitiesMolly Baker, a patient 35 years of age weighs 72 kg. She was admitted to the burn unit for full-thickness or third-degree burns over 36% of her body surface according to the use of the rule of nines. She has a paralytic ileus and has high residuals with enteral feeding using the nasojejunal tube. The physician ordered a lower rate for the enteral feeding and ordered total parenteral nutrition (TPN) via a subclavian triple lumen catheter to provide the patient’s nutritional needs. When a patient has burns over a large portion of the body, the patient is in a hypermetabolic state and usually requires 35 to 40 kcal/kg/day and needs 25% of the calories each day in high biologic value proteins.a.What nursing measures should the nurse implement to prevent potential complications related to the patient’s enteral feeding?b.What nursing measures should the nurse implement to prevent potential complications related to the administration of TPN?The nurse working in a rehabilitation facility receives a patient from the acute care hospital for management after a severe closed-head injury. The patient is in a semiconscious state, and has impaired swallowing. The admission orders call for insertion of a nasogastric (NG) tube for feedings and medication administration.a.W
hat is the correct method for measuring the length of an NG tube for correct placement in the stomach?b.You note that the student caring for Mr. Fields is verifying tube placement by listening when a bolus of air is injected into the NG tube via a syringe. How should you intervene? What other methods can the student use to verify tube placement? What is the rationale?c.What is the correct procedure for administering medications via an NG tube that has a continuous feeding infusing?d.The patient develops diarrhea the second day at the rehabilitation facility. The nurse assesses for which electrolyte abnormalities? What actions can the nurse implement to decrease the diarrhea?Case Study 5: (2 pages) –Chapter 24, Management of Patients With Chronic Pulmonary DiseaseHoward Long, 50 years of age, is a male patient diagnosed with bronchiectasis. He has smoked 1 pack per day of cigarettes for 35 years. He has a long history of recurrent bronchial infections. He has a chronic productive cough with copious amounts of purulent sputum. The patient complains that he is short of breath even at rest. He has clubbing of his fingers. The chest CT scan reveals bronchial dilation.a.How should the nurse explain to the patient and family the pathophysiology of bronchiectasis as it is related to the symptoms the patient is experiencing?b.How should the nurse explain to the patient and family the goals of medical management that may be used to treat the bronchiectasis?c.What does the nursing management for bronchiectasis entail?Sallie Thorp, a 21-year-old patient, presents to the physician’s office with an asthma action plan form she acquired from a literature search on the World Wide Web at http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf. She states that she would like to develop the plan with the help of the nurse and physician and review it at each appointment to keep it current. She has had moderate persistent asthma for 5 years, and she has visited the emergency department several times in the past year with severe asthma attacks. She stated that she forgets to take her medications, because the medications are at times that the hospital provided the inhalers (12 noon and midnight), and she gets confused on which inhalers are the long-acting ones and which inhaler is the short-acting rescue inhaler she is supposed to use when she has an exacerbation. She stated that if she could, she would like to take the inhalers at 8 am and again at 8 pm. The patient stated that she has a flow meter and that a respiratory therapist at the hospital taught her how to use it in the past, and he wrote down her personal best peak flow, which is 400 L/sec. The nurse reviews the patient’s medical chart and discovers that she has been prescribed the following from today’s visit:Use albuterol (Proventil): 2 to 4 puffs every 20 minutes for up to 1 hour as rescue inhaler. If symptoms improve, then take the inhaler every 4 hours for 1 to 2 days. If no improvement after 2 days, call the physician.Salmeterol (Serevent): 50 mcg every 12 hoursFluticasone (Flovent): 88 mcg or 2 puffs every 12 hoursCromolyn sodium (Nasalcrom): one spray to each nostril once daily and before being exposed to known asthma triggers. You may use the spray up to every 4 hours.Measure peak flow meter every morning before using inhalers and record. Use peak flow meter, as needed, if you develop symptoms, such as cough, shortness of breath, wheezing, chest tightness; use of neck and chest muscles to breathe; problems talking or walking because of extreme shortness of breath.Follow-up in 3 months.Have the nurse provide education on asthma self-management and fill out the action plan that the patient brought with her today and have the physician review it and sign it.The nurse also notes that the medications have not changed from the last visit.a.Print out the form and complete the form using the information from the case study.b.Explain the medications to the patient and practice filling in the asthma action plan.c.Explain ways to evaluate the patient’s mastery of the content?Case Study 6: (2 pages)– Chapter 12, Pain ManagementMr. Will, a 67-year-old patient, is postoperative day 2 after a coronary artery bypass graft operation to revascularize his coronary arteries that were significantly blocked. He has a midline incision of his chest and a 7-inch incision on the inner aspect of his right thigh where a saphenous vein graft was harvested and used to vascularize the blocked coronary artery. The surgeon ordered Oxycodone 5 mg every 4 hours PRN for moderate pain and Oxycodone 10 mg every 4 hours PRN for severe pain. (Learning Objectives 7 and 8)a.Considering the patient’s age, what medication administration considerations should the nurse incorporate into the pain management plan and why?b.What measures should the nurse provide the patient to prevent adverse effects of analgesic agents from occurring?c.What nonpharmacologic pain management methods should the nurse teach to Mr. Will to assist with pain management?Mr. Rogers is 2 days postoperative of a thoracotomy for removal of a malignant mass in his left chest. His pain is being managed via an epidural catheter with morphine (an opioid analgesic). As the nurse assumes care of Mr. Rogers, he is alert and fully oriented, and states that his current pain is 2 on a 1-to-10 scale. His vital signs are 37.8 – 92 – 12, 138/82.a.What are benefits of epidural versus systemic administration of opioids?b.The nurse monitors Mr. Rogers’ respiratory status and vital signs every 2 hours. What is the rationale for these frequent assessments?c.The nurse monitors Mr. Rogers for what other complications of epidural analgesia?d.Mr. Rogers complains of a severe headache. What should the nurse do?e.Mr. Rogers’ epidural morphine and decreased mobility increase his chances of constipation. What interventions should be included in his plan of care to minimize constipation?Case Study 7: ( 2 pages) Chapter 14, Shock and Multiple Organ Dysfunction SyndromeAdam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the usage of the vasopressor therapy. (Learning Objectives 6 and 7)a.What predisposed the patient to develop septic shock?b.What potential findings would suggest that the patient’s septic shock is worsening from the point of admission?c.The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing implications are related to the usage of a vasoactive medication?d.Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be obtained to help the patient?e.Explain the importance for nutritional support for this patient and which ty
pe of nutritional support should be provided?Carlos Adams was involved in a motor vehicle accident and suffered blunt trauma to his abdomen. Upon presentation to the emergency department, his vital signs are as follows: temperature, 100.9°F; heart rate, 120 bpm; respiratory rate, 20 breaths/min; and blood pressure, 90/54 mm Hg. His abdomen is firm, with bruising around the umbilicus. He is alert and oriented, but complains of dizziness when changing positions. The patient is admitted for management of suspected hypovolemic shock.The following orders are written for the patient:Place two large-bore IVs and infuse 0.9% NS at 125 mL/hr/lineObtain complete blood count, serum electrolytesOxygen at 2 L/min via nasal cannulaType and cross for 4 units of bloodFlat plate of the abdomen STAT(Learning Objectives 1, 4, and5)a.Describe the pathophysiologic sequence of events seen with hypovolemic shock.b.What are the major goals of medical management in this patient?c.What is the rationale for placing two large-bore IVs?d.What are advantages of using 0.9% NS in this patient?e.What is the rationale for placing the patient in a modified Trendelenburg position?The post Nursing # Case Study 1: ( 2 pages ), Chapter 46, Management of Patients With Oral and Esophageal Disorders appeared first on Academic Essay Guru.

Nursing # Case Study 1: ( 2 pages ), Chapter 46, Management of Patients With Oral and Esophageal Disorders was first posted on October 7, 2018 at 5:24 am.

 
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