Mrs. Morris is a 66-year-old woman with Crohn's disease and diabetes admitted to the hospital with a small bowel obstruction. She will require a bowel resection and will be NPO postoperatively, so total parenteral nutrition (TPN) through a peripherally inserted central catheter (PICC) line is ordered to provide nutrition for at least 10-14 days until her GI tract is accessible again. The nurse must assess relevant clinical data to determine nutritional needs, calculate caloric content of the TPN, and establish priorities to monitor for complications and engage with the patient.
Chemotherapy classes
for more lectures please contact
Dr. Salah Mabrouk Khallaf
MD Medical Oncology & BMT
South Egypt Cancer Institute
Email: salahmab76@yahoo.com
The Impact of Chinese Herbal Medicine on In Vitro Fertilization Outcomes A Sy...keith644288
Many are familiar with acupuncture and its possible benefits for infertility patients. Numerous studies on IVF and acupuncture have been conducted over the last twenty-five years. In the United States fewer are aware that historically in China the specialty of women’s health in Chinese medicine is almost exclusively herbal. In Vitro Fertilization has now been in use for 40 years, originally developed to help women conceive who had blocked fallopian tubes. Recent advances in freezing embryos and preimplantation genetic testing for aneuploidies (PGT-a) have helped physicians gradually increase their IVF rates of success. Pregnancy rates at some of the nation’s top fertility clinics hover at approximately 65%. Physicians and patients alike continue to seek novel methods to further optimize their IVF cycles. This work seeks to explore mechanisms of action and the impact of one of the world’s most ancient medical systems, Chinese medicine’s Chinese herbal medicine (CHM) on the outcomes of IVF.
A randomized, multicenter, placebo controlled trial of polyethylene glycol la...Duwan Arismendy
OBJECTIVES:
Polyethylene glycol (PEG) 3350 (MiraLAX) is currently approved for the short-term treatment of occasional constipation. This study was designed to compare the safety and efficacy of PEG laxative versus placebo over a 6-month treatment period in patients with chronic constipation.
METHODS:
Study subjects who met defined criteria for chronic constipation were randomized in this double-blind, placebo-controlled, parallel, multicenter study to receive PEG laxative as a single daily dose of 17 g or placebo for 6 months. Baseline constipation status was confirmed during a 14-day observation period. As a primary efficacy variable, treatment success was defined as relief of modified ROME criteria for constipation for 50% or more of their treatment weeks. Various secondary measures were assessed. An Interactive Voice Response System (IVRS) recorded daily bowel movement experience and study efficacy and safety information. Laboratory testing at baseline and monthly for the study duration was analyzed for hematology, blood chemistry including amylase, GGT, uric acid, lipids, and urinalysis.
RESULTS:
A total of 304 patients were enrolled and received treatment at one of 50 centers. Successful treatment according to the primary efficacy variable was seen in 52.0% of PEG and 11% of placebo subjects (P < 0.001). Similar efficacy was seen in a subgroup of 75 elderly subjects. According to the primary efficacy definition (based on individual treatment weeks), 61% of PEG treatment weeks versus 22% of the placebo weeks were successful (P < 0.001). There were no significant differences in laboratory findings or adverse events except for the gastrointestinal category where diarrhea, flatulence, and nausea were the most frequent with PEG although they were not individually statistically significant compared with placebo. Similar results were observed when analyzed for differences due to gender, race, or age.
Chemotherapy classes
for more lectures please contact
Dr. Salah Mabrouk Khallaf
MD Medical Oncology & BMT
South Egypt Cancer Institute
Email: salahmab76@yahoo.com
The Impact of Chinese Herbal Medicine on In Vitro Fertilization Outcomes A Sy...keith644288
Many are familiar with acupuncture and its possible benefits for infertility patients. Numerous studies on IVF and acupuncture have been conducted over the last twenty-five years. In the United States fewer are aware that historically in China the specialty of women’s health in Chinese medicine is almost exclusively herbal. In Vitro Fertilization has now been in use for 40 years, originally developed to help women conceive who had blocked fallopian tubes. Recent advances in freezing embryos and preimplantation genetic testing for aneuploidies (PGT-a) have helped physicians gradually increase their IVF rates of success. Pregnancy rates at some of the nation’s top fertility clinics hover at approximately 65%. Physicians and patients alike continue to seek novel methods to further optimize their IVF cycles. This work seeks to explore mechanisms of action and the impact of one of the world’s most ancient medical systems, Chinese medicine’s Chinese herbal medicine (CHM) on the outcomes of IVF.
A randomized, multicenter, placebo controlled trial of polyethylene glycol la...Duwan Arismendy
OBJECTIVES:
Polyethylene glycol (PEG) 3350 (MiraLAX) is currently approved for the short-term treatment of occasional constipation. This study was designed to compare the safety and efficacy of PEG laxative versus placebo over a 6-month treatment period in patients with chronic constipation.
METHODS:
Study subjects who met defined criteria for chronic constipation were randomized in this double-blind, placebo-controlled, parallel, multicenter study to receive PEG laxative as a single daily dose of 17 g or placebo for 6 months. Baseline constipation status was confirmed during a 14-day observation period. As a primary efficacy variable, treatment success was defined as relief of modified ROME criteria for constipation for 50% or more of their treatment weeks. Various secondary measures were assessed. An Interactive Voice Response System (IVRS) recorded daily bowel movement experience and study efficacy and safety information. Laboratory testing at baseline and monthly for the study duration was analyzed for hematology, blood chemistry including amylase, GGT, uric acid, lipids, and urinalysis.
RESULTS:
A total of 304 patients were enrolled and received treatment at one of 50 centers. Successful treatment according to the primary efficacy variable was seen in 52.0% of PEG and 11% of placebo subjects (P < 0.001). Similar efficacy was seen in a subgroup of 75 elderly subjects. According to the primary efficacy definition (based on individual treatment weeks), 61% of PEG treatment weeks versus 22% of the placebo weeks were successful (P < 0.001). There were no significant differences in laboratory findings or adverse events except for the gastrointestinal category where diarrhea, flatulence, and nausea were the most frequent with PEG although they were not individually statistically significant compared with placebo. Similar results were observed when analyzed for differences due to gender, race, or age.
“My Doctor is Keeping an Eye on Me!”: Exploring the Clinical Applicability of...Myuserable
By enabling people to track their lifestyles, including activity level, sleeping, and diet, technology helps clinicians to treat patients suffering from "lifestyle diseases." However, despite its importance compared to other lifestyle factors, it is not easy to record food intake consistently. Although researchers have attempted to solve this problem, most have not considered its applicability in the clinical context. In this paper, we aim to (1) understand food-journaling practices and (2) explore the applicability of lifestyle data in the clinical context. By observing 20 patients who recorded data including food logs, steps, and sleeping time, we found that patients recorded their food logs diligently, as they were conscious of clinicians. Clinicians were surprised by the high adherence rate of journaling and tried to overlap food data with other data, such as steps, sleeping time, etc. This paper contributes by providing qualitative insights for designing applicable strategies utilizing lifestyle data in the clinical context.
Evidence-Based Nutrition Practice - Critical AppraisalRachel Hinrichs
Presentation and group activity for dietetic interns on critical appraisal of a randomized controlled trial. Uses the CASP checklists found here: http://www.casp-uk.net/casp-tools-checklists
Evidence-Based Practices & Nursing
Introduction
Normally, PICOT format is helpful in formulation of questions in an evidenced based clinical practice. PICOT generated questions generally fall under for main categories of clinical practices. These include; therapy, prevention, diagnosis, etiology as well as Prognosis. The essential elements in PICOT questions. The PICOT format is valuable in addressing research questions comprehensively. Five elements are normally addressed including; population, intervention, comparison, outcome and time as well (Riva, Malik, Burnie, Endicott, & Busse, 2012).
Summary of Case Study
The ever increasingly high incidence of breast cancer conditions has posed serious challenges in the nursing profession. Provision of appropriate healthcare to the cancer patients has been lacking leading to adverse effects of the proliferation of cancerous cells which further worsen the conditions of the patients. As primary care, clinicians have the responsibility to stressing providing healthcare services within healthcare facilities as well as monitoring treatment in home based facilities to help manage cancer condition. Most cancer patient need clinicians who practice evidence-based clinical practices (Riva, Malik, Burnie, Endicott, & Busse, 2012).
Research Question
In cancer patients receiving chemotherapy, will they have better white blood cell count monitoring with a follow-up at home versus follow-up at a health care facility during their treatment?
PICOT Format
1) P-Population: Patients aged 18-60 years-old, breast cancer who have not received chemotherapy in the past six months are subjected to the treatment. Patients with other serious health conditions such as heart diseases were excluded in the study. 30 patients, with 15patients stationed at the healthcare facility while the other 15 patients receiving home-based care, are expected to take part in the study.
2) I -Intervention: The patients will receive dosage based on the age, sex and health general body health as well as the stage of cancer cells proliferation in the body. The patients are required take the prescribed drugs at regular intervals. The subjects will be subjected to treatment under the same during the research study.
3) C-Comparison: All the subject regardless of variations in their level of dose requirement will be subjected to the same treatment for the same duration, 3months. Standardized treatment will be given to subjects with no extreme variations in their level of dose requirement and would be used as an active control group. Using this strategy, it will be possible to minimize the non-specific effects due to a group of the patient receiving treatment within the healthcare.
4) O-Outcome: The response in chemotherapy treatments will be check by examining the numbers of defective cancerous cells in the body tissues. The patients will report to the theatre in order to be examined by an oncologist. The results will be recorded i ...
Irritable bowel syndrome (IBS) is one of the most common disorders of gut-brain interaction (DGBI) and has a significant impact on patients and the health care system. Making the correct diagnosis can improve patient care, minimize unnecessary testing, and lead to the most appropriate treatment. In this activity, learners will review 5 IBS cases with Brian E. Lacy, MD, PhD, FACG as he discusses different aspects of patient management including diagnosis, IBS-C and IBS-D treatment, pain management, and improving patient-provider communication.
WEEK 6 ASSIGNMENT 1 LAB ASSESSING THE ABDOMEN2WEEK 6 ASSIGNMEN.docxhelzerpatrina
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Walden University
NURS 6512 N
Silifat Jones-Ibrahim
Running head: WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Abdominal Assessment Case Study SOAP Note
Subjective:
•CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
•HPI: JR, 47-year-old WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
•PMH: HTN, Diabetes, hx of GI bleed 4 years ago
•Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
•Allergies: NKDA
•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
•Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
•Heart: RRR, no murmurs
•Lungs: CTA, chest wall symmetrical
•Skin: Intact without lesions, no urticaria
•Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
•Diagnostics: None
Assessment:
•Left lower quadrant pain
•Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Subjective Analysis
According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questi ...
Journal Article Analysis: Medication Errors in Overweight and Obese Pediatric...Paul Pasco
A journal article analysis ("journal club") I completed during an internship/Advanced Pharmacy Practice Experience (APPE) in medication safety at a hospital.
“My Doctor is Keeping an Eye on Me!”: Exploring the Clinical Applicability of...Myuserable
By enabling people to track their lifestyles, including activity level, sleeping, and diet, technology helps clinicians to treat patients suffering from "lifestyle diseases." However, despite its importance compared to other lifestyle factors, it is not easy to record food intake consistently. Although researchers have attempted to solve this problem, most have not considered its applicability in the clinical context. In this paper, we aim to (1) understand food-journaling practices and (2) explore the applicability of lifestyle data in the clinical context. By observing 20 patients who recorded data including food logs, steps, and sleeping time, we found that patients recorded their food logs diligently, as they were conscious of clinicians. Clinicians were surprised by the high adherence rate of journaling and tried to overlap food data with other data, such as steps, sleeping time, etc. This paper contributes by providing qualitative insights for designing applicable strategies utilizing lifestyle data in the clinical context.
Evidence-Based Nutrition Practice - Critical AppraisalRachel Hinrichs
Presentation and group activity for dietetic interns on critical appraisal of a randomized controlled trial. Uses the CASP checklists found here: http://www.casp-uk.net/casp-tools-checklists
Evidence-Based Practices & Nursing
Introduction
Normally, PICOT format is helpful in formulation of questions in an evidenced based clinical practice. PICOT generated questions generally fall under for main categories of clinical practices. These include; therapy, prevention, diagnosis, etiology as well as Prognosis. The essential elements in PICOT questions. The PICOT format is valuable in addressing research questions comprehensively. Five elements are normally addressed including; population, intervention, comparison, outcome and time as well (Riva, Malik, Burnie, Endicott, & Busse, 2012).
Summary of Case Study
The ever increasingly high incidence of breast cancer conditions has posed serious challenges in the nursing profession. Provision of appropriate healthcare to the cancer patients has been lacking leading to adverse effects of the proliferation of cancerous cells which further worsen the conditions of the patients. As primary care, clinicians have the responsibility to stressing providing healthcare services within healthcare facilities as well as monitoring treatment in home based facilities to help manage cancer condition. Most cancer patient need clinicians who practice evidence-based clinical practices (Riva, Malik, Burnie, Endicott, & Busse, 2012).
Research Question
In cancer patients receiving chemotherapy, will they have better white blood cell count monitoring with a follow-up at home versus follow-up at a health care facility during their treatment?
PICOT Format
1) P-Population: Patients aged 18-60 years-old, breast cancer who have not received chemotherapy in the past six months are subjected to the treatment. Patients with other serious health conditions such as heart diseases were excluded in the study. 30 patients, with 15patients stationed at the healthcare facility while the other 15 patients receiving home-based care, are expected to take part in the study.
2) I -Intervention: The patients will receive dosage based on the age, sex and health general body health as well as the stage of cancer cells proliferation in the body. The patients are required take the prescribed drugs at regular intervals. The subjects will be subjected to treatment under the same during the research study.
3) C-Comparison: All the subject regardless of variations in their level of dose requirement will be subjected to the same treatment for the same duration, 3months. Standardized treatment will be given to subjects with no extreme variations in their level of dose requirement and would be used as an active control group. Using this strategy, it will be possible to minimize the non-specific effects due to a group of the patient receiving treatment within the healthcare.
4) O-Outcome: The response in chemotherapy treatments will be check by examining the numbers of defective cancerous cells in the body tissues. The patients will report to the theatre in order to be examined by an oncologist. The results will be recorded i ...
Irritable bowel syndrome (IBS) is one of the most common disorders of gut-brain interaction (DGBI) and has a significant impact on patients and the health care system. Making the correct diagnosis can improve patient care, minimize unnecessary testing, and lead to the most appropriate treatment. In this activity, learners will review 5 IBS cases with Brian E. Lacy, MD, PhD, FACG as he discusses different aspects of patient management including diagnosis, IBS-C and IBS-D treatment, pain management, and improving patient-provider communication.
WEEK 6 ASSIGNMENT 1 LAB ASSESSING THE ABDOMEN2WEEK 6 ASSIGNMEN.docxhelzerpatrina
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Walden University
NURS 6512 N
Silifat Jones-Ibrahim
Running head: WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2
Week 6 Assignment 1: Lab Assessing the Abdomen
Abdominal Assessment Case Study SOAP Note
Subjective:
•CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
•HPI: JR, 47-year-old WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
•PMH: HTN, Diabetes, hx of GI bleed 4 years ago
•Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
•Allergies: NKDA
•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
•Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
•Heart: RRR, no murmurs
•Lungs: CTA, chest wall symmetrical
•Skin: Intact without lesions, no urticaria
•Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
•Diagnostics: None
Assessment:
•Left lower quadrant pain
•Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Subjective Analysis
According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questi ...
Journal Article Analysis: Medication Errors in Overweight and Obese Pediatric...Paul Pasco
A journal article analysis ("journal club") I completed during an internship/Advanced Pharmacy Practice Experience (APPE) in medication safety at a hospital.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Clinical Reasoning Case Study Total Parenteral NutritionName ____.docx
1. Clinical Reasoning Case Study: Total Parenteral NutritionName
_____________________________
Chief Complaint CC/History of Present Illness:
Mrs. Morris is a 66-year-old woman who has been complaining
of nausea, vomiting, weakness, abdominal pain and abdominal
fullness for the past 3 days. She has had a fever for the last 24
hours and reports that her mid-abdominal pain is colicky and
“crampy”. She states her “Crohn’s” has been acting up for the
past 4 weeks with diarrhea, anorexia, extreme fatigue and
weight loss. She is 65 inches tall and weighs 65 kg with a usual
weight of 75 kg. Mrs. Morris was admitted to the Med/Surg unit
with a complete small bowel obstruction, multiple adhesions,
and exacerbation of Crohn's disease. She is NPO and an
exploratory lap is scheduled with lysis of adhesions and small
bowel resection to remove diseased bowel. Mrs. Morris will be
NPO postoperatively and it is expected that her GI tract will not
be accessible for at least 10-14 days.
Social and Past Medical History:
Mrs. Morris currently lives alone in a senior living apartment.
Her husband died of pancreatic cancer 2 months ago and they
had no children. She has had Crohn’s disease since she was 37
years old and was diagnosed with diabetes type 2, five years
ago.
Your Initial Nursing Assessment:
GENERAL APPEARANCE: anxious, appears weak and pale
SKIN/INTEG: skin dry, tenting noted, eyes sunken
RESP: breath sounds clear with equal aeration bilaterally, non-
labored
CARDIAC: skin pale, warm & dry, S1S2, no edema, pulses 2+
in all extremities
2. NEURO: alert & oriented x4,
GI/GU: abdomen firm and distended. Absent bowel sounds, has
not voided yet
MISC: complains of crampy, colicky abdominal pain in RLQ,
8/10, nausea and vomiting
Initial Vital Signs:
T: 100.8 F
P: 110
R: 22
BP: 100/60
O2 sats: 98%
Lab/diagnostic Results:
CBC
Current
High/Low/WNL?
WBC
15000
HGB
9 g/dL
Basic Metabolic panel
Current
High/Low/
WNL?
Sodium
4. Social & PMH:
Nursing Assessment:
Vital Signs:
Labs:
Physician Orders for Mrs. Morris:
Begin Total Parenteral Nutrition (TPN) through peripherally
inserted central catheter (PICC).
2.
Describe the difference between Peripheral Parenteral
Nutrition and Total Parenteral Nutrition.
Peripheral Nutrition
Peripheral Parenteral Nutrition
Total Parenteral Nutrition
% of dextrose allowed
Vascular route required
Advantages
Disadvantages
5. 3.
Describe the types of parenteral nutrition solutions.
2:1 solution
3:1 solution
Draw a picture of the IV set up for a 2:1 solution
4.
Describe the purpose of the components of Parenteral
Nutrition.
Dextrose
Protein
Lipids
Electrolytes
Vitamins
Minerals
Medications that can be added to PN
Rationale:
The TPN ordered is a 2:1 TPN solution of Dextrose 20% and
Amino Acids 2.75% @100ml/hr., and Lipids or IV Fatty
Emulsion (IVFE) 20% to be infused @10ml/hr. (See math
calculations at end of this case study)
5.
Calculate the
total 24 hour caloric content of the Dextrose,
6. Amino Acids and IVFE (Lipids) for Mrs. Morris.
6.
Define central venous catheter therapy
_____________________________________________
7.
Is a PICC line a central venous catheter? And if so,
why? _______________________________
8.
List the 5 key components of the Institute for
Healthcare Improvement (IHI) central line bundle that must be
implemented regarding the central venous catheter (CVC).
9.
Related to Mrs. Morris’s TPN and CVC therapy, what
nursing priority (s) will guide your plan of care? (these nursing
priorities may or may not be written as NANDA diagnostic
statements)
10.
What interventions will you initiate based on the
nursing priority (s) identified in # 9?
Nursing Interventions per Nursing Priority
Rationale:
11.
What body systems will you focus on based on Mrs.
Morris’s
TPN therapy and your nursing priority (s)?
7. 12.
Mrs. Morris is at risk for complications due to the
administration of TPN.
a.
What are the worst possible complications to anticipate
with TPN administration and CVC management?
b.
What signs/symptoms should the nurse anticipate to
identify the development of this complication? What relevant
nursing action will need to be implemented for this
complication?
A.
Potential Complications (list 5)
B.
Signs/Symptoms & relevant nursing action to
implement
13.
What is Mrs. Morris likely experiencing or feeling right
now in her situation?
14.
What can you do to engage yourself with Mrs. Morris’s
experience and show her that she matters to you as a person?
TPN CALORIC CONTENT MATH CALCULATIONS
A. Factors to memorize
1.
8. The percentage of substance in solution tells you how
many grams of that substance are present in 100 mL. For
example,
a. 5% Dextrose means there are 5 grams of dextrose in 100 ml.
(5g/100mL)
b. 4% Amino Acids means there are 4 grams of amino acids in
100 mls. (4g/100mL)
2. There are:
a. 3.4 kcal/gram of dextrose
b. 4 kcal/gram of protein
c. 9 kcal/gram of fat
3. Next, calculate the total amount the patient is receiving in a
24-hour period. For example, 10% Dextrose at 100 mL/hr. =
2400 mL in 24 hours. Calculate for each substance in the
solution or administration of the TPN.
4. Calculating caloric content:
a. A person receiving 1500 ml in a 24-hour period, of 50%
dextrose would receive how many calories in a 24-hour period?
1.)
50 grams dextrose
=
X grams dextrose
100ml
1500ml
9. 100X = 50 x 1500
X =
75000
100
X = 750 grams of dextrose
2.)
3.4 kcal =
X kcal
1 gram 750 gram
1X = 3.4 x 750
X =
2550
1
X =
2550 calories from dextrose/24 hours
5. For
each substance in TPN, (Dextrose, Amino Acids, IVFE),
the above calculations must be done to calculate the
total caloric intake for a 24-hour period.
PAGE
10. 1
Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool
Evidence level and quality rating:
Article title:
Number:
Author(s):
Publication date:
Journal:
Setting:
Sample (composition and size):
Does this evidence address my EBP question?
Yes
No-
Do not proceed with appraisal of this
evidence
Is this study:
QuaNtitative (collection, analysis, and reporting of numerical
data)
Measurable data (how many; how much; or how often) used to
formulate facts, uncover patterns in research, and generalize
results from a larger sample population; provides observed
effects of a program, problem, or condition, measured precisely,
rather than through researcher interpretation of data. Common
methods are surveys, face-to-face structured interviews,
observations, and reviews of records or documents. Statistical
tests are used in data analysis.
Go to
11. Section I: QuaNtitative
QuaLitative (collection, analysis, and reporting of narrative
data)
Rich narrative documents are used for uncovering themes;
describes a problem or condition from the point of view of those
experiencing it. Common methods are focus groups, individual
interviews (unstructured or semi structured), and
participation/observations. Sample sizes are small and are
determined when data saturation is achieved. Data saturation is
reached when the researcher identifies that no new themes
emerge and redundancy is occurring. Synthesis is used in data
analysis. Often a starting point for studies when little research
exists; may use results to design empirical studies. The
researcher describes, analyzes, and interprets reports,
descriptions, and observations from participants.
Go to
Section II: QuaLitative
Mixed methods (results reported both numerically and
narratively)
Both quaNtitative and quaLitative methods are used in the study
design. Using both approaches, in combination, provides a
better understanding of research problems than using either
approach alone. Sample sizes vary based on methods used. Data
collection involves collecting and analyzing both quaNtitative
and quaLitative data in a single study or series of studies.
Interpretation is continual and can influence stages in the
research process.
Go to
Section III: Mixed Methods
Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool
12. Page 6 of 10
Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool
The Johns Hopkins Hospital/ The Johns Hopkins University
1
Section I: QuaNtitative
Level of Evidence (Study Design)
Is this a report of a single research study?
A
· Yes
· No
Go to B
1. Was there manipulation of an independent variable?
· Yes
· No
2. Was there a control group?
· Yes
· No
3. Were study participants randomly assigned to the
intervention and control groups?
· Yes
· No
If
Yes to questions 1, 2, and 3, this is a
randomized controlled trial (RCT) or
experimental study.
13. LEVEL I
If
Yes to questions 1 and 2 and No to question
3orYes to question 1 and No to questions 2 and 3, this is
quasi-experimental.
(Some degree of investigator control, some manipulation of an
independent variable, lacks random assignment to groups, and
may have a control group).
LEVEL II
If
No to questions 1, 2, and 3, this is
nonexperimental.
(No manipulation of independent variable; can be descriptive,
comparative, or correlational; often uses secondary data).
LEVEL III
Study Findings That Help Answer the EBP Question
Skip to the
Appraisal of QuaNtitative Research Studies
section
Section I: QuaNtitative (continued)
Is this a summary of multiple sources of research evidence?
· Yes
Continue
· No
Use Appendix F
1. Does it employ a comprehensive search strategy and rigorous
appraisal method?
If this study includes research, nonresearch, and experiential
evidence, it is an integrative review (see Appendix F).
· Yes
14. Continue
· No
Use Appendix F
2. For systematic reviews and systematic reviews with meta-
analysis
(see descriptions below):
B
a. Are all studies included RCTs?
LEVEL I
b. Are the studies a combination of RCTs and quasi-
experimental, or quasi-experimental only?
LEVEL II
c. Are the studies a combination of RCTs, quasi-experimental,
and nonexperimental, or non- experimental only?
LEVEL III
A
systematic review employs a search strategy
and a rigorous appraisal method, but does not generate an effect
size.
A
meta-analysis, or systematic review with
meta-analysis, combines and analyzes results from studies to
generate a new statistic: the effect size.
Study Findings That Help Answer the EBP Question
Skip to the
Appraisal of Systematic Review (With or
Without a Meta-Analysis) section
Appraisal of QuaNtitative Research Studies
15. Does the researcher identify what is known and not known
about the problem and how the study will address any gaps in
knowledge?
· Yes
· No
Was the purpose of the study clearly presented?
· Yes
· No
Was the literature review current (most sources within the past
five years or a seminal study)?
· Yes
· No
Was sample size sufficient based on study design and rationale?
· Yes
· No
If there is a control group:
· Were the characteristics and/or demographics similar in both
the control and intervention groups?
· Yes
· No
N/A
· If multiple settings were used, were the settings similar?
· Yes
· No
N/A
· Were all groups equally treated except for the intervention
group(s)?
· Yes
· No
N/A
Are data collection methods described clearly?
16. · Yes
· No
> 0.70)?
· Yes
· No
N/A
Was instrument validity discussed?
· Yes
· No
N/A
If surveys or questionnaires were used, was the response
rate
> 25%?
· Yes
· No
N/A
Were the results presented clearly?
· Yes
· No
If tables were presented, was the narrative consistent with the
table content?
· Yes
· No
N/A
Were study limitations identified and addressed?
· Yes
· No
Were conclusions based on results?
· Yes
· No
17. Complete the
Quality Rating for QuaNtitative
Studiessection
Appraisal of Systematic Review (With or Without Meta-
Analysis)
Were the variables of interest clearly identified?
· Yes
· No
Was the search comprehensive and reproducible?
· Key search terms stated
· Yes
· No
· Multiple databases searched and identified
· Yes
· No
· Inclusion and exclusion criteria stated
· Yes
· No
Was there a flow diagram that included the number of studies
eliminated at each level of review?
· Yes
· No
Were details of included studies presented (design, sample,
methods, results, outcomes, strengths, and limitations)?
· Yes
· No
Were methods for appraising the strength of evidence (level and
quality) described?
· Yes
· No
Were conclusions based on results?
· Yes
· No
18. · Results were interpreted
· Yes
· No
· Conclusions flowed logically from the interpretation and
systematic review question
· Yes
· No
Did the systematic review include a section addressing
limitations
andhow they were addressed?
· Yes
· No
Complete the
Quality Rating for QuaNtitative Studies
section (below)
Quality Rating for QuaNtitative Studies
Circle the appropriate quality rating below:
A High quality: Consistent, generalizable results; sufficient
sample size for the study design; adequate control; definitive
conclusions; consistent recommendations based on
comprehensive literature review that includes thorough
reference to scientific evidence.
B Good quality: Reasonably consistent results; sufficient
sample size for the study design; some control, and fairly
definitive conclusions; reasonably consistent recommendations
based on fairly comprehensive literature review that includes
some reference to scientific evidence.
C Low quality or major flaws: Little evidence with inconsistent
results; insufficient sample size for the study design;
conclusions cannot be drawn.
19. Johns Hopkins Nursing Evidence-Based Practice
Appendix E
Research Evidence Appraisal Tool
Section II: QuaLitative
Level of Evidence (Study Design)
A
Is this a report of a single research study?
· Yes
this is
Level III
· No
go to II B
Study Findings That Help Answer the EBP Question
Complete the
Appraisal of Single QuaLitative Research
Studysection
(below)
Appraisal of a Single QuaLitative Research Study
Was there a clearly identifiable and articulated:
· Purpose?
· Yes
· No
· Research question?
· Yes
· No
20. · Justification for method(s) used?
· Yes
· No
· Phenomenon that is the focus of the research?
· Yes
· No
Were study sample participants representative?
· Yes
· No
Did they have knowledge of or experience with the research
area?
· Yes
· No
Were participant characteristics described?
· Yes
· No
Was sampling adequate, as evidenced by achieving saturation of
data?
· Yes
· No
Data analysis:
· Was a verification process used in every step by checking and
confirming with participants the trustworthiness of analysis and
interpretation?
· Yes
· No
· Was there a description of how data were analyzed (i.e.,
method), by computer or manually?
· Yes
· No
Do findings support the narrative data (quotes)?
· Yes
· No
Do findings flow from research question to data coll ected to
21. analysis undertaken?
· Yes
· No
Are conclusions clearly explained?
· Yes
· No
Skip to the
Quality Rating for QuaLitative
Studiessection
For summaries of multiple quaLitative research studies (meta-
synthesis), was a comprehensive search strategy and rigorous
appraisal method used?
B
· Yes
Level III
· No
go to
Appendix F
Study Findings That Help Answer the EBP Question
Complete the
Appraisal of Meta-Synthesis Studies section
(below)
Appraisal of Meta-Synthesis Studies
Were the search strategy and criteria for selecting primary
studies clearly defined?
· Yes
· No
22. Were findings appropriate and convincing?
· Yes
· No
Was a description of methods used to:
· Compare findings from each study?
· Yes
· No
· Interpret data?
· Yes
· No
Did synthesis reflect:
· Yes
· No
· New insights?
· Yes
· No
· Discovery of essential features of phenomena?
· Yes
· No
· A fuller understanding of the phenomena?
· Yes
· No
Was sufficient data presented to support the interpretations?
· Yes
· No
Complete the
Quality Rating for QuaLititative Studies
section (below)
Quality Rating for QuaLitative Studies
Circle the appropriate quality rating below:
No commonly agreed-on principles exist for judging the quality
of quaLitative studies. It is a subjective process based on the
23. extent to which study data contributes to synthesis and how
much information is known about the researchers’ efforts to
meet the appraisal criteria.
For meta-synthesis, there is preliminary agreement that quality
assessments should be made before synthesis to screen out poor-
quality studies1.
A/B
High/Good quality is used for single
studies and meta-syntheses2.
The report discusses efforts to enhance or evaluate the quality
of the data and the overall inquiry in sufficient detail; and it
describes the specific techniques used to enhance the quality of
the inquiry.
Evidence of some or all of the following is found in the report:
·
Transparency: Describes how information
was documented to justify decisions, how data were reviewed
by others, and how themes and categories were formulated.
·
Diligence: Reads and rereads data to check
interpretations; seeks opportunity to find multiple sources to
corroborate evidence.
·
Verification: The process of checking,
confirming, and ensuring methodologic coherence.
·
Self-reflection and self-scrutiny: Being
continuously aware of how a researcher’s experiences,
background, or prejudices might shape and bias analysis and
interpretations.
·
24. Participant-driven inquiry: Participants shape
the scope and breadth of questions; analysis and interpretation
give voice to those who participated.
·
Insightful interpretation: Data and
knowledge are linked in meaningful ways to relevant literatur e.
CLower-quality studies contribute little to the overall review of
findings and have few, if any, of the features listed for
High/Good quality.
1
https://www.york.ac.uk/crd/SysRev/!SSL!/WebHelp/6_4_ASSE
SSMENT_OF_QUALITATIVE_RESEARCH.htm
2 Adapted from Polit & Beck (2017).
Section III: Mixed Methods
Level of Evidence (Study Design)
You will need to appraise both the quaNtitative and quaLitative
parts of the study independently, before appraising the study in
its entirety.
1. Evaluate the quaNitative part of the study using
25. Section I.
Level
Quality
Insert here the level of evidence and overall quality for this
part:
2. Evaluate the quaLitative part of the study using
Section II.
Level
Quality
Insert here the level of evidence and overall quality for this
part:
3. To determine the level of evidence, circle the appropriate
study design:
·
Explanatory sequential designs collect
quaNtitative data first, followed by the quaLitative data; and
their purpose is to explain quaNtitative results using quaLitative
findings. The level is determined based on the level of the
quaNtitative part.
·
Exploratory sequential designs collect
quaLitative data first, followed by the quaNtitative data; and
their purpose is to explain quaLitative findings using the
quaNtitative results. The level is determined based on the level
of the quaLitative part, and it is always Level III.
·
Convergent parallel designs collect the
quaLitative and quaNtitative data concurrently for the purpose
26. of providing a more complete understanding of a phenomenon
by merging both datasets. These designs are Level III.
·
Multiphasic designs collect quaLitative and
quaNtitative data over more than one phase, with each phase
informing the next phase. These designs are Level III.
Study Findings That Help Answer the EBP Question
Complete the
Appraisal of Mixed Methods Studies section
(below)
Appraisal of Mixed Methods Studies3
Was the mixed-methods research design relevant to address the
quaNtitative and quaLitative research questions (or objectives)?
· Yes
· No
· N/A
Was the research design relevant to address the quaNtitative and
quaLitative aspects of the mixed-methods question (or
objective)?
· Yes
· No
· N/A
For convergent parallel designs, was the integration of
quaNtitative and quaLitative data (or results) relevant to
address the research question or objective?
· Yes
· No
· N/A
For convergent parallel designs, were the limitations associated
27. with the integration (for example, the divergence of quaLitative
and quaNtitative data or results) sufficiently addressed?
· Yes
· No
· N/A
Complete the
Quality Rating for Mixed-Method Studies
section (below)
3 National Collaborating Centre for Methods and Tools. (2015).
Appraising Qualitative, Quantitative, and Mixed Methods
Studies included in Mixed Studies Reviews: The MMAT.
Hamilton, ON: McMaster University. (Updated 20 July, 2015)
Retrieved from http://www.nccmt.ca/ resources/search/232
Quality Rating for Mixed-Methods Studies
Circle the appropriate quality rating below
A
High quality:
Contains high-quality quaNtitative and
quaLitative study components; highly relevant study design;
relevant integration of data or results; and careful consideration
of the limitations of the chosen approach.
B
Good quality:
Contains good-quality quaNtitative and
quaLitative study components; relevant study design;
moderately relevant integration of data or results; and some
discussion of limitations of integration.
C
Low quality or major flaws:
Contains low quality quaNtitative and
quaLitative study components; study design not relevant to
28. research questions or objectives; poorly integrated data or
results; and no consideration of limits of integration.
Week 3: Collaboration Cafe
With new information continually emerging, professional nurses
must be equipped to critique scholarly literature and discern its
value for practice. Select one current, quantitative scholarly
nursing article related to your PICOT question and determine its
strengths, limitations, and potential application.
Complete the
Johns Hopkins Nursing Evidence Based Practice
Appendix E Evidence Appraisal Tool. Once you’ve completed
the tool, use your own words to summarize your appraisal of the
article. Include the following:
· Description of the purpose
· Explanation of research design
· Discussion of sample
· Description of data collection methods
· Summary of findings
· Strengths of the study (minimum of 1)
· Limitations of the study (minimum of 1)
· Recommendations regarding potential application for future
practice that are insightful and appropriate.
Attach the article to your post, in addition to including the full
reference for the article in your post.
During the week, read a minimum of two articles posted by
peers and add your thoughts about whether you feel their article
would support an EBP change.
The John Hopkins tool
does not need to be turned in, it is a worksheet for you
to decide what type of article you have.
29. For full credit, submit your initial post by Wednesday at 11:59
PM MT. Complete your two responses to peers by Sunday at
11:59 PM MT.
**To view the grading criteria/rubric, please click on the 3 dots
in the box at the end of the solid gray bar above the discussion
board title and then Show Rubric.