3. Intended Learning Outcomes
3
At the end of this lecture, all participants will be
able to provide high-quality care to their patients based
on research and knowledge through:
• Definition of EBP
• Elaborate the aim of EBP in nursing
• Elaborate the benefits of EBP in nursing.
• Discuss the models of EBP.
• Identify levels of EBP.
• Apply the five steps of EBP process.
• Musculoskeletal system
• Application of EBP on musculoskeletal disorders
• ( fracture)
4. Introduction:
- EBN is a process founded on the collection,
interpretation, and integration of valid, important,
and applicable patient-reported, clinician-observed,
and research-derived evidence.
- EBN must use the best research evidence with
clinical expertise and patient values.
4
6. •Today’ nursing practice emphasizes the use of research
to determine best practices, or the interventions or
approaches to patient care that will have the best
impact on patient outcomes.
•Professionals in the past used educational knowledge,
consultation with peers and specialists, and their own
experiences to make decisions about patient care and
to select interventions.
6
7. 7
The modern clinician who uses evidence-based practices
integrates his/her clinical experience with current
research to help guide patient care decisions.
Nurses are now creating evidence-based guidelines using
the results of research that are available in the form of
systematic reviews.
8. Definitions
•Nursing Research:
A scientific process that validates and refines
existing knowledge and generates new
knowledge that directly and indirectly
influences nursing practice.
8
9. •Evidence Based Nursing:
is an approach to make high quality decisions and
providing nursing care based upon personal clinical
expertise in combination with the most current &
relevant research available on the topic.
9
10. 10
It is a problem-solving approach to the delivery of
health care that integrates the best evidence from
studies and patient care data with clinician expertise
and patient preferences and values.
Evidence-based practice (EBP)
11. Aim of EBP
•Provide the highest quality and most cost-efficient
nursing care.
• Advance quality of care provided by nurses.
• Increases satisfaction of patients.
• Focus on nursing practice away from habits and
tradition to evidence and research
11
12. The Benefits of EBP in Nursing
A-To Patients/Consumers:
• Improve the quality of received care.
• Saves patient rights
• Rapid recovery.
B- To Nurses:
• Keep nurses updated by reading the published literature.
• Improve communication skills.
• Increase confidence to EBP Nurse because they provide care
that is supported by facts rather than habits, and can
• take legal accountability for their practice.
12
13. 13
C- To Health Care Organization:
• Enhance marketing of organizations .
• Decrease cost .
• Increase effectiveness.
• Tool for education.
D-To Community:
• Save resources
• Limit the amount of disability and suffering throughout
the community by ensuring the most current and
effective care is provided
14. Misconception about EBP
• Evidence-based nursing ignores patient preferences and
values.
• Evidence-based nursing is theoretical.
• Evidence-based nursing is only about quantitative research.
• Evidence-based nursing overemphasizes randomized
controlled trials and systematic reviews.
14
15. 15
Models of Evidence-Based Practice
-Rosswurm and Larrabee (1999) proposed a model
for guiding nurses through a systematic process for
the change to evidence-based practice.
- This model recognized that translation of research
into practice requires a solid grounding in change
theory, principles of research utilization, and use of
standardized terminology
17. • Five A’S in the evidence based practice
• ASK: Information needs from practice
are converted into focused, structured
questions.
• ACQUIRE: The focused questions are used as a
basis for literature searching in order to identify
relevant external evidence from research.
• APPRAISE: The research evidence is critically
appraised for validity.
• APPLY: The best available evidence is used
alongside clinical expertise and the patient's
perspective to plan care.
• ASSESS: Performance is evaluated through a
process of self reflection or peer assessment.
17
18. step 1: Ask
There are generally four parts to question building: the
patient/problem, the intervention, the comparison and the
outcome. You may have heard of the acronym PICO to refer to this
question building process.
18
Developing a PICO Question
P = patient population of interest. Identify your
patients by age, gender, ethnicity, disease, or health
problem.
19. 19
Developing a PICO Question
I = intervention of interest. What is the intervention
you think is worthwhile to use in practice (e.g., a
treatment, diagnostic test, prognostic factor)?
C = Comparison of interest. What is the usual
standard of care or current intervention you use now
in practice?
20. Developing a PICO Question
•O = Outcome. What result do you wish to achieve or
observe as a result of an intervention (e.g., change
in patient’s behavior, physical finding, change in
patient’s perception)?
20
22. Step Two: Acquire
Selecting Resources and Search for the Evidence.
22
In this step, the nurse will locate the highest quality,
relevant information from the medical literature to
answer the question.
The nurse needs to select the databases and journals
that will use to find the answer to her question.
24. Some databases, such as PubMed, have a
controlled vocabulary. For example, instead of
classifying "cancer", they classify "neoplasm". When
using their controlled vocabulary, you may receive
greater accuracy in terms or the topic on which you
are searching.
24
25. Step 3: Appraise
Critical Appraisal/Evaluation of the Literature
• In this step the nurse critically appraises the evidence for its
validity, Relevance, and Applicability in clinical practice.
• Validity (The trustfulness of evidence): Are the results of the study
valid? On the other hand, is the quality of the study good enough to
produce results that can be used to inform clinical decisions?
• Relevance: Does evidence directly answer the question? What are the
results and what do they mean in our context/ for our patients?
• Applicability: Can the results be applied t local population? Can we
apply them in our clinical settings?
• This step can be overwhelming due to the growing body of knowledge
available to nurses. It is important to begin by focusing on one article at a
time. Know the elements of an article, and use a careful approach when
reviewing each one.
25
26. Evidence- based articles include the
following elements :
•Abstract: An abstract summarizes the purpose of the
study or clinical topic, the major themes or findings, and
the implications for nursing practice
•Introduction
•Literature review or background
•Manuscript narrative: The “middle section” or
narrative of manuscript differs according to the type of
evidence-based article, either clinical or research.
26
27. A clinical article:
Describes a clinical topic, which often
includes a description of a patient
population, the nature of a certain
disease or health problem, how it
affects patients, and the appropriate
nursing therapies. Clinical articles
often describe how to use a therapy or
new technology.
A research article:
Describes the conduct of a
research study, including its
purpose statement, methods
or/how the study was designed,
the results or/conclusions, and
clinical implications
27
28. 28
A work sheet
can be helpful
for evaluating
the evidence.
(Hockenberry et al, 2006)
29. Step 4: Apply
Integrate all evidence :with patient preferences, values and clinical
expertise
Once the decision has been made to provide a certain treatment,
application of the treatment is often made .
Successful implementation of EBP is dependent upon
several factors as shown below:
Easy access to library and IT resources.
Finances to support new treatment strategies.
Adequate number of nurses with appropriate skills.
Sufficient time for gathering and appraising research
evidence and implementation activities.
Full co-operation between peers, managers and all other
professionals.
29
30. •Before deciding to apply the results of the study
many questions that should be asked
•Is the treatment feasible(achievable) in my area?
•Is the patient so different to those in the study that
the results can not be applied?
•What alternatives are available?
•Will the potential benefit of the treatment overweigh
the potential harm for my patient?
30
31. Step 5 Assess
• After applying what has been retrieved from the literature to
clinical situation, nurse will need to evaluate as following:
• Assess the effectiveness and efficiency of the evidence-based
process.
• Regard feedback from all staff and from patients.
• Assess if the desired outcome being achieved or not.
• The strengths as well as the drawbacks of the change in
practice.
• Commitment of nurses to the change in practice.
• The consultation with others (especially with the nurse
manager).
31
34. Musculoskeletal system
Consists of the bones, muscles, ligaments,
tendons, and cartilage together with the joints.
Human skeleton has 206 bones
Bone growth and metabolism is affected by vit D,
calcium and phosphorous, calcitonin, growth
hormone, estrogens, testosterone, parathyroid, and
glucocorticoids.
35. Figure 41-1 Bones of the human skeleton.
Axial Skeleton
Appendicular Skeleton
37. Functions
1. Supports soft tissue and provides attachment for
skeletal muscles
2. Assists in mov’t, along with skeletal muscles
3. Protects internal organs
4. Stores and releases minerals
5. stores fats
6. produces blood cells
38. Tendons
Connect bone to muscles, and aids movement when muscles
contract.
Ligaments
Connect bone to bone
Provide joint stability and strength
Joints (Articulations)
Area where two or more bones meet
Holds skeleton together while allowing body to move
39. Types of joints
Fibrous - Immovable
Cartilaginous - Slightly movable
Synovial - Freely mobile
Synovial Joints
Found at all limb articulations
Surface covered with cartilage
Joint cavity covered with tough fibrous capsule
Cavity lined with synovial membrane and filled with synovial
fluid.
41. (Fractures)
Is a break in the continuity of bone when it is
subjected to stress greater than it can absorb.
Causes
• A metabolic bone disease /pathological such as osteoporosis
• An endocrine disorder E.g. Hyperparathyroidism
• Direct force/ trauma or crushing force
• Sudden twisting motion
• Powerful muscle contraction pulls against the bone
• Bone tumors, which weaken the bone structure
42. When the bone is broken, adjacent structures are also
affected,
Resulting in soft tissue edema, hemorrhage into the
muscles and joints, joint dislocations, ruptured tendons,
severed nerves, and damaged blood vessels.
43. Types of Fractures
• Based on cross-section of the bone involved:
1.Complete fracture: involves a break across the entire cross-
section of the bone and is frequently displaced (removed from
normal position(
2.Incomplete fracture (
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3.Comminuted fracture :is one that produces several bone
fragments.
44. Based on involvement of the skin:
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membrane wound extends to the fractured bone.
Open fractures are graded according to the following criteria:
A. Grade I: is a clean wound less than 1 cm long.
B. Grade II: is a larger wound without extensive soft tissue
damage.
C. Grade III: is highly contaminated, has extensive soft tissue
damage, and is the most severe.
45.
46. Clinical Manifestations
Pain
loss of function
Deformity
shortening of the extremity
crepitus (a grating sensation palpation)
swelling and discoloration.
False movement
Note: all of these clinical manifestations may not present in
every fracture.
47. Emergency Management of Fractures
Immediately after injury, whenever a fracture is suspected,
immobilize the body part before the patient is moved.
Splints are applied for immobilization.
If an injured patient must be removed from a vehicle before
splints can be applied, the extremity is supported above and
below the fracture site to prevent rotation as well as angular
motion.
With an open fracture, the wound is covered with a clean
(sterile) dressing to prevent contamination of deeper tissues.
Do not attempt to reduce the fracture, even if one of the bone
fragments is protruding through the wound.
48. Medical and surgical Management
1. REDUCTION
-Reduction refers to restoration of the fracture fragments to
anatomic alignment and rotation.
1. Closed Reduction: closed reduction is accomplished by bringing
the bone fragments into apposition (ie, placing the ends in
contact) through manipulation and manual traction.
2. Open Reduction: Through a surgical approach, the fragments are
reduced .
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49. 2. IMMOBILIZATION
After the fracture has been reduced, the bone fragments must be
immobilized, or held in correct position and alignment, until union
occurs.
Immobilization may be accomplished by external or internal
fixation.
50. 3. Maintaining and restoring function
Swelling is controlled by elevating the injured extremity and
applying ice as prescribed.
Neurovascular status (circulation, movement, sensation) is
monitored, and the orthopedic surgeon is notified immediately if
signs of neurovascular compromise are identified.
Isometric and muscle-setting exercises are encouraged to
minimize disuse atrophy and to promote circulation.
51. Nursing Management
Instruct the patient regarding the proper methods to control
edema and pain
Teach exercises to maintain the health of unaffected muscles and
how to use assistive devices such as crutches, walkers.
Teach about selfcare, medication information, and monitoring for
potential complications.
In an open fracture, there is a risk for osteomyelitis, tetanus, and
gas gangrene. Intravenous antibiotics are administered
immediately upon the patient’s arrival in the hospital along with
tetanus toxoid if needed.
52. Complications of Fracture
Complications of fractures fall into two categories
Early complications include:
Shock
Fat embolism
Compartment syndrome
Deep vein thrombosis
Thromboembolism (pulmonary embolism)
Disseminated intravascular coagulopathy (DIC)
Infection.
53. Delayed complications include:
Delayed union and nonunion,
Avascular necrosis of bone,
Reaction to internal fixation devices,
Complex regional pain syndrome (formerly called
reflex sympathetic dystrophy).
54. Stages of Bone Healing
• Hematoma formation within 48 to 72 hr. after injury
• Hematoma to granulation tissue
• Callus formation and Osteoblastic proliferation
• Bone remodeling
• Bone healing completed within about 6 weeks; up
to 6 months in the older person
55.
56. Contusions, Strains, and Sprains
Contusions
• Is a soft tissue injury produced by blunt force, such as a blow, kick,
or fall.
•Many small blood vessels rupture and bleed into soft tissues
ecchymosis, or bruising.
• A hematoma develops when the bleeding is sufficient to cause an
appreciable collection of blood.
•Local symptoms includes pain, swelling, and discoloration
•Most contusions resolve in 1 to 2 weeks.
57. Strains
• Is a “muscle pull” caused by overuse, overstretching, or excessive
stress.
• Strains are microscopic, incomplete muscle tears with some
bleeding into the tissue.
• The patient experiences soreness or sudden pain, with local
tenderness on muscle use.
58. Sprains
• Is an injury to the ligaments surrounding a joint that is caused by a
wrenching or twisting motion.
• The function of a ligament is to maintain stability while permitting
mobility. A torn ligament loses its stabilizing ability.
• Blood vessels rupture and edema occurs; the joint is tender, and
movement of the joint becomes painful.
59. • The degree of disability and pain increases during the first 2
to 3 hours after the injury because of the associated swelling
and bleeding.
• An x-ray should be obtained to rule out bone injury.
• Avulsion fracture (in which a bone fragmented is pulled
away by a ligament or tendon) may be associated with a
sprain.
60. Joint Dislocations
• A dislocation of a joint is a condition in which the articular
surfaces of the bones forming the joint are no longer in
anatomic contact.
• The bones are literally “out of joint.”
• A subluxation is a partial dislocation of the articulating
surfaces.
• Dislocations may be congenital, spontaneous or pathologic or
traumatic.
61. • Traumatic dislocations are orthopedic emergencies because the
associated joint structures, blood supply, and nerves are
distorted and severely stressed.
• If the dislocation is not treated promptly, avascular necrosis
(AVN) (tissue death due to anoxia and diminished blood
supply) and nerve palsy may occur.
63. Osteoporosis “porous bones”
Is a metabolic bone disorder characterized by loss of bone mass, and
an increased risk of fractures.
Pathophysiology
• The reduced bone mass is caused by an imbalance of bone
resorption and bone formation.
• The total bone mass and density is reduced, resulting in bones
that become progressively porous, brittle, and fragile.
64. • Although osteoporosis may result from an endocrine disorder or
malignancy, it is most often associated with aging.
• With aging level of calcitonin and estrogen decreases but levels of
parathyroid hormone increases.
• Estrogen deficiency, which occurs at menopause, is considered the
leading factor in osteoporosis among aging women.
• Osteoporosis can be primary or secondary.
65. • Primary osteoporosis occurs in women after menopause and in
men due to failure to develop optimal peak bone mass during
childhood, adolescence, and young adulthood.
• Secondary osteoporosis is the result of medications and diseases
that affect bone metabolism.
• Prolonged use of medications that increase calcium excretion, such
as aluminum-containing antacids and anticonvulsants, increase the
risk of developing osteoporosis.
• Corticosteroids
66. OSTEOMALACIA
• Often referred to as adult rickets, is characterized by inadequate
or delayed mineralization of bone matrix, resulting in softening
of bones.
• Marked deformities of weight bearing bone and pathologic
fractures occur.
• The two main causes of osteomalacia are
• Insufficient calcium absorption in the intestine due to a lack of
calcium intake or vitamin D deficiency,
• Increased losses of phosphorus through the urine
67. Paget’s Disease
• An imbalance of increased osteoblast and osteoclast cells;
thickening and hypertrophy.
• Results in bone deposits that are weak, enlarged, and
disorganized
• Bone pain most common symptom; bony enlargement and
deformities of long bone usually bilateral, kyphosis,.
69. OSTEOMYELITIS
Is an infection of the bone.
Staph. aureus is the most common infecting organism.
Classified as:
•Contiguous-focus osteomyelitis, from contamination from bone
surgery, open fracture, or traumatic injury (eg, gunshot wound)
•Hematogenous osteomyelitis
•Osteomyelitis with vascular insufficiency eg. DM and peripheral
vascular disease
70. • After entry, bacteria lodge and multiply in the bone, resulting in
the inflammatory and immune system response.
• If the infection reaches the outer margin of the bone, it raises
the periosteum of the bone, spreading along the surface.
• Lifting of the periosteum from the cortex disrupts the blood vessels
that enter the bone, compromising the vascular supply and leading
to ischemia and eventual necrosis of the bone.
• New bone cells are deposited on the periosteum while the
underlying bone becomes necrotic.
71. The pocket of necrotic bone (sequestrum) may remain sequestered for
years or eventually drain by forming a sinus tract through to the
skin; which leads to chronic osteomyelitis.
Complications of osteomyelitis include:
• Septicemia
• Thrombophlebitis
• Muscle contractures
• Pathologic fractures and
• Nonunion of fractures
72. SEPTIC (INFECTIOUS)ARTHRITIS
• Joints can be infected through hematogenous spread or directly
through trauma or surgical instrumentation.
• Infection of the joint leads to synovitis, joint effusion and abscesses
formation; can lead to destruction of the affected joint.
• A single joint, often the knee, is usually affected.
74. OSTEOARTHRITIS (OA)
Degenerative Joint Disease (DJD)
The most common form of arthritis.
degeneration and wearing away of the articular cartilage
exposing bone
Typically affects the weight-bearing joints and those that are repeatedly used for
work.
Unlike RA, DJD has no remissions and no systemic symptoms, such as malaise
and fever.
75. Rheumatoid arthritis
• Systemic autoimmune inflammatory disorder of connective
tissue / joints characterized by chronicity, remissions, and
exacerbations.
• Female-to-male ratio is 2-4:1
• Its cause is unknown
• Particularly affect small joints of the hands and feet,
• can also affect large joints
• Chronic inflammation begins in the synovial membrane
76. GOUT
• A genetic defect of purine metabolism resulting in
hyperuricemia, usually affects the feet (especially the great toe),
hands, elbows, ankles, and knees.
• Over secretion of uric acid or a renal defect resulting in
decreased excretion of uric acid, or a combination of both,
occurs.
• It occurs more commonly in males than females
78. Application
A 60 year old man, avid golfer slip and fall at home. does not
take any medication. He has sever pain, swelling, and
ecchymosis of Rt. dominant shoulder and arm with normal neuro-
vascular exam. Radiographs: fracture of the proximal humorous
and need surgical intervention.
79. 79
Introduction:
In recent years fractures, particularly those occurring in
osteoporotic bone, have become a major health issue. They are
relatively common and treatment has become increasingly
expensive and complicated.
Incidence
The overall incidence was 1,229 fractures per 100,000 individuals
per year. This gives a person-yearly fracture incidence rate of
1.2%.
Fracture incidence increased with age in both sexes, but age-
adjusted rates were 49% greater among the women.
80. 80
Pain Management in Patients with Fractures
after Surgical Intervention, Using Music
Therapy as a Non Pharmacological Method
• Aim of the study:
• Aim of this study is to determine Pain Management in
Patients with Fractures after Surgical Intervention, Using
Music Therapy as a Non Pharmacological Method
• Research Question
• Dose use of Music Therapy as a Non Pharmacological
Method will management of pain .
81. 81
Formulating patient questions: (Ask)
Evidence based nursing begins and ends with
the patient defining a clinical question in terms
of the specific patient problem: aiding in leading
to clinically relevant evidence(according to
PICO).
82. 82
Population Intervention Compariso
n
Outcome
Patients
with
fracture
Use of music
therapy
Pharmacol
ogical
treatment
without non
pharmacol
ogical
method (
music
therapy)
Music therapy has long
been used to shift
attention away from pain
and generate a state of
relaxation and well-
being. Music decreases
pain intensity as well as
narcotic doses following
surgery( avoid side effect
of medication).
83. 83
B- Setting:
This study will conducted in the orthopedic
department at suez canal university hospitals
84. 84
Acquire: identify all the relevant evidence. Terms
for the search will identified by isolating the
components of the clinical question and breaking
them down into facets, including population,
intervention, comparison, and outcome. The facet
analysis identified terms that described the
components which will then translated into a search
strategy.
85. 85
Adopting a comprehensive search strategy obviously identified a lot
of irrelevant material but did ensure that relevant studies not
missed.
The following data bases will search:
Cochrane library.
Medline.
Literature (CINAHL).
The search strategy avoided long multicomponent terms and
phrases, as this would have further complicated the search.
https://www.researchgate.net/publication/378427259_Pain_Management_i
n_Patients_with_Fractures_after_Surgical_Intervention_Using_Music_Thera
py_as_a_Non_Pharmacological_Method
86. 86
Evidence is accumulating on the positive effect of
using non pharmacological intervention for reducing
pain of fracture after surgery.
There are published cases and cohort studies and
controlled clinical trails using non pharmacological
intervention for reducing pain of fracture after surgery.
87. 87
Appraise:
Assess for : Validity (The trustfulness of evidence): Are the
results of the study valid? On the other hand, is the quality of
the study good enough to produce results that can be used to
inform clinical decisions?
Relevance: Does evidence directly answer the question? What
are the results and what do they mean in the context/ for the
patients?
Applicability: Can the results be applied to local population?
Can we apply them in the clinical settings?
88. 88
The VAS requires the ability to differentiate minute differences
in pain intensity and might even be
difficult for some people to complete. The Verbal Descriptor
Scale (VRS) is an instrument that has
already been expressly certified for use with people (0 = little if
any pain, 4 = incredibly painful
suffering
89. 89
Apply:
Procedure: permission to conduct the study will obtained
from the hospital directors and head of department, informed
patient consents will obtained, data collecting after explanation of
the purpose and nature of the study to them. At the beginning of
the study demographic data will collected by interviewing
subjects.
After completion of data collection variables included in
each data assessment will coded and scored prior to computerize.
Descriptive statistics (frequency, percentage will performed for
qualitative and quantitative variables.
90. 90
All patients after surgery, The pain will assessed daily to
decrease using of pharmacological intervention.
As the objective of measurement of pain . The
subsequent score and actions will also documented. The
pain will also observed in the following conditions:
When dressing removed for new one.
With any procedure.
91. 91
Presentation and analysis of data:
These finding of the study will presented
in 2 parts:
1. Reviews of sociodemographic characteristic
of the study group.
2. Assessment of pain.
92. 92
Assess (Outcome)
Using non pharmacological intervention such as music
therapy has a beneficial action on decreasing pain after surgery.
