Quiz 3 nursing 1010

What are the six steps of evidence based practice

0. Cultivate a spirit of inquiry 1. Ask a clinical question in PICOT format- always think about your practice when caring for a patients, question what does not make sense to you and clarify, think of a problem area of interest (what is the current evidence to improve pain management in patients with migraine headaches?) 2. Collect the most relevant and best evidence 3. Critically appraise the evidence you gather-after critiquing all articles for a PITCOT question synthesize or combine the findings, consider the scientific rigor of the evidence and whether it has application in practice. 4. Integrate all evidence with ones clinical expertise and patient preferences and values in making a practice decision or change-teaching, assessment or documentation tools, clinical practice guidelines, policies and procedures, applying evidence(staff support, scope of practice), pilot study may be conducted when the evidence is not strong enough to apply in practice. 5. Evaluate the practice decision or changes using evidence-after applying evidence, evaluate the outcome, unexpected events or results may occur, never implement a practice change without evaluating its effects) 6. Share the outcomes of EBP changes with others-after implementing an EBP change, it is important to communicate the results (clinical staff on the unit, nursing reactive council or the research council, clinicians, professional conferences and meetings)

Informed consent means

1. Participants receive full and complete information 2. They can understand the information 3. They have free choice to participate 4. They understand how their confidentiality will be kept- guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to anyone outside the research team

What is considered to be the highest level of research?

A randomized controlled trial

Mobility

A state or quality of being mobile or movable Goes from complete immobility to partial mobility to complete/full mobility Varying degrees of partial immobility between the end points Some patients move back and forth between mobility and immobility. Categories leading to change in mobility: change in general health, musculoskeletal, neurologic, and neuromuscular conditions, medical procedures and diagnostic tests

Elements of an article

Abstract Introduction Literature review or background Manuscript narrative- purpose statement, methods or design, results or conclusions, clinical implications

Validity

Accuracy of application and findings

Congenital or acquired postural abnormalities

Affect the efficiency of the musculoskeletal system and body alignment, balance, and appearance. During assessment observe body alignment and range of motion Can cause pain, impair alignment or mobility or both Knowledge about the characteristics, causes, and treatment of common postural abnormalities is necessary for lifting, transfer, and positioning (28-1)

Alignment and balance

Also refers to posture Refers to the positioning of joints, tendons, ligaments, and muscles while standing, sitting, or lying Body alignment means that the individuals center of gravity is stable Individuals require balance for maintaining a static position(sitting) and moving(walking). Disease, injury, pain, physical development (age) and life changes(pregnancy) compromise the ability to remain balanced Medications tat a use dizziness and prolonged immobility effect balance

Bed rest

An intervention that restricts patients to bed for therapeutic reasons. Nurses and health care providers most often prescribe this intervention Prolonged bed rest cause major physiological, psychological, and social effects. These effects are gradual or immediate and vary from patient to patient

Performance improvement

An organization analyzes and evaluates current performances and uses the results to develop focused improvement actions Typically clinical projects conceived in response to identified clinical problems and designed to use research findings to improve clinical practice

What safety issues do you need to be careful for when using an assistive device?

Appropriate friction-reducing assistive devices and mechanical lifts need to be used for patient transfers when applicable No life policies benefit all members of the health care system: patients, nurses, and administration. Education and training on indications and use of these devises, including assessment and decision algorithms for equipment selection are essential to ensure the safety of the patient and the health care provider

Joints

Are the connections between bones Each joint is classified according to its structure and degree of mobility

Patient movement algorithms serve as what

Assessment tools and guide safe patient handling and movement

Institutional review board

Before conducting any study with human subjects, the researcher obtains approvals from the agency's human subjects committee or institutional review board IRB includes scientists and lay persons who review all studies conducted in the institution to ensure that ethical principles, including the rights of human subjects are followed Part of the research process

Discuss the benefits of evidence based practice

Best evidence in combination with a clinicians expertise, patient preferences and values in making decision about patient care Helps you make effective, timely, and appropriate clinical decisions in response to the broad political professional, and societal forces present in today's health care environment Evidence from the field of health sciences establishes benefit or harm and the best practices in health care Efficiency of treatment Improves quality, safety, and patient outcomes Increases nurses satisfaction Reduces costs

Scope of evidence

Bidirectional because: The focus of bench research(conducted in lab)advances in patient care depend on bench research(not in lab more dependent on nature)

What does the internal structure of long bones contain? What does it participate in? And what does it act as?

Bone marrow and participates in red blood cell production, and acts as a reservoir for blood

What do bones store?

Calcium and release it into the circulation as needed

What is immobility also associated with

Cardiovascular, skeletal, and other organ changes

What are the three classifications of joints?

Cartilaginous, fibrous, and synovial

Age process and its affects

Changes the components of bone which impractical mobility Elasticity and skeletal flexibility change with age The characteristics of the cartilage change with the aging process

Bones

Come together at joints

Safety guidelines for nursing skills(ensuring patients safety)

Communicate clearly with members of the health care team Assess and incorporate the patients priorities of care and preferences Use the best evidence when making decisions about your patients care

When applying evidence you need to consider what?

Consider the setting and whether or not there is support from staff and available resources

Anatomical structure and attachment to the skeleton enhance what?

Contractile elements of the skeletal muscle

Body mechanics

Coordinated efforts of the musculoskeletal skeletal and nervous systems

Central nervous system (CNS)

Damage to any component of the central nervous system that regulates voluntary movement results in impaired body alignment, balance, and mobility

Developmental changes in older adults

Decreased physical activity Hormonal changes Bone reabsorption A progressive loss of total bone mass occurs with the older adult Some of the possible causes of this loss include decreased physical activity, hormonal changes, and bone resorption. The effect of bone loss is weaker bones Often walk more slowly, take smaller steps, and appear less coordinated Prescribed medications alter their sense of balance or affect their blood pressure when they change position too quickly, increasing their risk for falls and injuries The outcomes of falls include possible injury, hospitalization, loss of independence, psychological effects, possibly death Often experience functional status changes secondary to hospital action and altered mobility status Immobilization of older adults increases their physical dependence on others and accelerates functional losses When providing nursing care for an older adult encourage the patient to perform as many self-are activities as possible, thereby maintaining the highest level o mobility.

Developmental changes for adolescents

Delayed in gaining independence and in accomplishing skills Usually begins with a tremendous increase in growth When the activity level is reduced due to trauma, illness, or surgery, the adolescent are often behind in peers in gaining independence and accomplishing certain skills such as obtaining a drivers license. Social isolation is a concern for this age group when immobilization occurs

Evidence based clinical decision making

Delivery of care to people and consider needs and preferences

Evidence based nursing

Delivery of care to people and consider needs and preferences

Disuse atrophy

Describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage

Outcomes research

Designed to assess and document the effectiveness of health care services and interventions

What points should you remember to follow to ensure safe, individualized patient-centered care?

Determine the amount and type of assistance required for safe positioning, including any transfer equipment and the number of personnel to safely transfer and prevent harm to patient and health care providers Raise the side rail on the side of the bed opposite of where you are standing to prevent the patient from falling out of bed on that side Arrange equipment so it does not interfere with the positioning process (IV) Evaluate the patient for correct body alignment and pressure risks for repositioning

Patients with decreased calcium regulation and metabolism are at risk for what?

Developing osteoporosis and pathological fractures(fractures caused by weakened bone tissue)

Assistive devices

Discuss the use of different assistive devices such as wheelchairs, walkers, crutches, canes and lifts

How is movement impaired?

Disorders that alter neurotransmitter production, transfer of impulses from the nerve to the muscle, or activation of muscle

EBP, research, QI

EBP: use of info from research and other sources to determine safe and effective nursing care with the goal of improving patient care and outcomes Research: systematic inquiry answers questions, solves problems. And contributes to the generalizable knowledge base of nursing, may or may not improve patient care QI: improves local work processes to improve patient outcomes and health system efficiency, results usually no generalizable

Evidence based clinical decision making

Evidence from research, theories, clinical experts and opinion leaders Evidence from assessment of patients history and physical and available health care resources Clinical expertise Information about patient preferences and balues

What happens to patients with altered bone marrow function or diminished RBC production?

Fatigue easily because of reduced hemoglobin and oxygen carrying ability This fatigue decreases their mobility and increases the risk for falling, which impacts a patients mobility status

Reliability

Findings are consistent

Replicability

Findings are verified when repeated in other studies

Newborn infants spine

Flexed and lacks anteroposterior curves of the adult As the baby grows, musculoskeletal development permits support of weight for standing and walking Posture is awkward because the head and upper trunk are carried forward. Because body weight is not distributed evenly along a line of gravity, posture is off balance, and falls occur often

Why are bones important

For mobilization because they are firm, rigid,a don elastic

Friction

Force that occurs in a direction opposite to movement The greater the surface area of the object that moved, the greater the friction Large objects produce greater resistance to movement, this is why nurses need to be aware of the friction that can cause a patients skin to shear or tear

Evaluation research

Form of quantitative research that determines how well a program, practice, procedure,or policy is working

What are some collaborative interventions for general care guidelines for immobilized patient?

Frequent turning, positioning,alignment Skin assessment and skin care Range of motion Deep breathing Weight bearing(if possible) Measures to optimize elimination Nutrition Exercise therapy- ambulatory, joint mobility, stretching,balance Pharmacological agents-anti inflammatory agents, analgesics, nutrition supplementation Surgical interventions-curative versus palliative Immobilization-casts and splints,braces,traction,slings,shoulder immobilizers, pillows Assistive devices- crutches, canes,walkers,wheelchairs,prostheses Use findings from evidence based practice nursing research about safe patient handling to prevent injuries to nurses and patients when moving and transferring

Skeletal muscles

Have the ability to contract and relax The working elements of movement

Evidence and interrelated concepts

Health policy, health care economics, safety, technology and informatics affect evidence

Explain the different modes in applying evidence into practice

Heirarchy of evidence 6 steps of evidence based practice Nursing techniques:performance improvement, improvement quality, EBP, research, qual and quan

What does outcomes research provide?

Helps patients, health care providers, and those in health care policy make informed decisions on the basis of current evidence Typically focuses on the benefits, risks, costs, and holistic effects of a treatment on patients Outcomes must be observable or measure able

The research problem usually consists of what steps

Identifying the problem Designing the study Conducting the study Analyzing the data And using the findings

Why do we need evidence based practice?

Improves quality, safety, and patient outcomes Increases nurses satisfaction Reduces costs

The nursing process and critical thinking assist you in what?

In providing care for patients who are experiencing or are at risk for the adverse effects of impaired body alignment and immobility

Musculoskeletal trauma

Injury and disease to many alterations in musculoskeletal function Direct trauma to the musculoskeletal area can cause bruises, contusions, sprains, or fractures. Treatment often includes positioning the fractured bone in proper alignment and immobilizing it to promote healing and restore function. Even this temporary immobilization results in some muscle atrophy(loss of muscle tone, and joint stiffness)

What does firmness result from?

Inorganic salts such as calcium and phosphate that are in the bone matrix

Cause and effects of mobility

Intracranial regulation, nutrition, pain, gas exchange, perfusion can all cause immobility and this causes tissue integrity and elimination(constipation or urinary retention)

What is impaired balance a major threat to?

Mobility and physical safety and contributes to a fear of falling and self-imposed activity restrictions

Cartilage

Nonvascular (without blood vessels) supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear

Patients with impaired body alignment require what?

Nursing care to maintain correct positioning such as the supported fowler so, supine,prone,side-lying, and sims postions

What is a challenge of EBP?

Obtain the very best most accurate information at the right time when you need it for patient care

Research process

Orderly series of steps that allow a researcher to move from asking the research question to finding the answer Builds knowledge for use in other similar situations provides knowledge that a nurse can apply repeatedly to a whole group or class of patients Nursing process vs. research process Assessment. Identify area of interest or clinical prob Diagnosis. Develop research questions (hypoth) Planning. Determine how study will be conducted Implementation. Conduct the study Evaluation. Analyze results of the study Use of the findings

How do you develop a PICOT question

P- patient population of interest I- intervention of interest C- comparison of interest O-outcomes T-time

Identify changes in physiological and psychological function associated with immobility

Page 410 Physiological- systemic problems Psychological-emotional and behavioral responses, sensory alterations, changes in coping, illness that results in limited or impaired mobility and causes social isolation and loneliness, some depression, don't want to participle in their own care

Develop nursing care plans for patients with impaired mobility

Page 421 ADPIE

Common symptoms associated with altered mobility

Pain Reduced joint movement Reduced sensation or loss of sensation Falls Fatigue Altered gait or imbalance Reduced functional ability

History elements of musculoskeletal assessment

Past medical history Family history Current medications Lifestyle behaviors Occupation Social environment Problem-based history

What are the physiological and pathological influences on mobility

Pathological-postural abnormalities, muscle abnormalities, damage to central nervous system, musculoskeletal trauma Physiological- how the person moves, ability of movement

Developmental changes for adults

Physiological systems are at risk Changes in family and social structures When periods of prolonged immobility occur in adults, all physiological systems are at risk The role of the adult often changes with regard to the family or social structure Some adults lose their jobs, which often addicts their self-concept

PSDA cycle

Plan Do Study Act

What are the pathological influences on mobility (disease)

Postural abnormalities Muscle abnormalities Damage to central nervous system Musculoskeletal trauma

Disuse syndrome

Predicts the adverse affects on body tissues and functions

Developmental changes for infants,toddlers,preschoolers

Prolonged immobility delays gross odor skills, intellectual development, or musculoskeletal development Usually immobilized because of trauma or the need to correct a congenital skeletal abnormality. Prolonged immobilization delays the child's gross motor skills, intellectual development, or musculoskeletal development

Joints

Provide stability to bone and provide skeletal movement

Skeletal system

Provides attachments for muscles and ligaments Protects vital organs Aids in calcium regulation Provides leverage for mobility Bones are long, short,flat, or irregular Joints Ligaments, tendons, and cartilage

What is the purpose of quality improvement

Purpose: improves work processes to improve patient outcomes and efficiency of health systems Focus: measures effects of practice and or practice change on specific patient population Data sources: data from patient records or patients who are in a specific area such as on a patient care unit or admitted to a particular hospital Who conducts the activity: employees of a health care agency, such as nurses, physicians, pharmacists Is activity part of regular clinical practice? Yes Is IRB approval needed? Sometimes Funding sources? Internal, from health care agency

What is the purpose of research

Purpose: systematic inquiry answers questions, solves problems, and contributes to the generalizable knowledge base of nursing: it may or may not improve patient care. Focus: evidence is generated to find answers for questions that are not known about nursing practice Data sources: subjects or participants have predefined characteristics that include or exclude them from the study, researcher collects and Alayna's data from the subjects Who conducts thee activity: researcher may or may not be employed by the health care agency and usually are not part of the clinical health care team Is activity part of regular clinical practice: no Is IRB approval needed? Yes Funding sources: usually external, such as a grant

What is the purpose of evidence based practice

Purpose:Use of information from research, professional experts, personal experience, and patient preferences to determine safe and effective nursing care with the goal of improving patient care and outcomes Focus: implementation of evidence already known into practice Data sources: multiple research studies, expert opinion, personal experience, patients Who conducts activity: practicing nurses and possibly other members of the health care team Is activity part of regular clinical practice? Yes Is IRB approval needed? No Funding courses: internal, from health care agency

Inductive reasoning

Qualitative research Develops generalizations of theories rom specific observations or interviews

Exemplars of evidence

Quan,qual,practice guidelines, expert opinion/commentaries health care polices(healthy people 2020)

What does cultivate a spirit of inquiry mean?

Question what does not make sense to you and what needs to clarified Gain evidence based practice knowledge and skills Be committed to providing the best care possible Use problem and knowledge focused triggers Consider data gathered from a health care setting to examine clinical trends

What are primary prevent ions for immobility

Regular physical activity Protection against injury Optimal nutrition Fall prevention measures

Nervous system

Regulates movement and posture

Nature of movement

Requires a coordinated effort between the musculoskeletal and nervous systems. Nurses pay attention to body mechanics to avoid injury to self and patients Need to know how patient physical conditions affect body movement

Scope of evidence

Scope extends form the discovery of evidence to the application of evidence into patient care though patient care standards Major attributes: Replicability, reliability, validity Minor: publicly available, understandable, useable

Historical perspectives in early evidence in health care

Semmelweis- determined that the cause of fever in women after delivery was infection due to inadequate hand washing Nightingale- decreased infection rates during the Crimean war with infection control practices Cochrane- used randomized, controlled trials to incorporate more evidence into the medical profession

Muscle movement and posture

Skeletal muscles are working, elements of movement Movement of the bones and joints involves active processes that are carefully integrated to achieve coordination

Describe interventions for improving or maintaining patients mobility

Slides 22-24

What is the concept of mobility

State or quality of being mobile or movable Goes from immobility to partial mobility to complete/ full mobility

Quantitative nursing research

Study of nursing phenomena that offers precise measurement and quantification. Focuses on numerical data, statistical analysis, and controls to eliminate bias in findings Experimental, no experimental, survey, and evaluation research

Qualitative

Study of phenomena that are difficult to quantify or categorize such as patients perceptions of illness Info obtained in a no numerical form Offers answers when trying to understand patents experiences with health problems and the contexts in which the experiences occur. Patients perceptions of nurses caring in a palliative care unit, ethnography,phenomenology, grounded theory.

Evidence based practice

Testimony of facts tending to prove or disprove a conclusion It is important to translate best evidence into best practices at a patients bed side Problem solving apprach to clinical practice that integrates the conscientious use of best evidence in combination with a clinicians expertise and patient preferences ad values in making in making decisions about patient care An example of this is changing how patients are cared for after abdominal surgery is one way that rick can use evidence at the bedside. You are expected to use currrent data when caring for patients. Textbooks,articles, standards of care, infection control data and research studies are the best places to find evidence The best information is the evidence that comes from well designed,systemically conducted research studies mostly found in scientific journals. You can also ask experts to help (nurses,apn,staff educators, risk managers, medical librarian Even when you use the best evidence available, application and outcomes will differ based on your patients values, preferences, concerns, and expectations. Example: using therapeutic touch is effective in reducing abdominal incision pain however cultural beliefs of touching prevent use of touch. Evidence from the field of health sciences establishes benefit or harm and best practices in health care, evidence supports or disputes the efficacy of treatment, use of a diagnostic tool, transmission of a disease

Without balance control what happens?

The center of gravity is displaced

Evidence based nursing

The conscientious, explicit, and judicious use of theory-derived, research based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences.

"Hazards of mobility"

The effects of muscular reconditioning associated with lack of physical activity Are apparent within a few days the cluster of these symptoms The individual of average weight and height without chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day

The risk of disabilities related to immobilization depends on what?

The extent and duration of immobilization and the patients overall level of health

Shear

The force exerted against the skin while the skin remains stationary and the bony structures move

Scientific method

The foundation of research The most reliable and objective means of acquiring and conducting research and gaining knowledge A step by step process to ensure that findings from a study are valid, reliable, and generalizable to a similar group of subjects

What is a patient with complete mobility restrictions at risk for?

The hazards of immobility. When possible it is imperative that patients, especially the older adults, have limited bed rest and that their activity is more than bed to chair The deconditioning related to reduced walking increases the risk for patient falls

Immobility

The inability to move Immobility for some people is absolute and continues indefinitely

Quality improvement

The joint omission defines it as an approach to the continuous study to improvement of the processes of providing health care services to meet the needs of patients and others and inform health care policy Improvement of health care related processes Ex. Medical delivery or fall prevention QI data informs you about how processes work within and organization and this offer information about how to make EBP changes

What are the essential elements in judging a situation?

The legal system is an essential element in judging a situation because it causes guilt

Pre central gyrus or motor strip

The major voluntary motor area In the cerebral cortex

Where do a majority of motor fibers descend from?

The motor strip and cross at the level of the medulla

Why is the rigidity of the bone necessary?

To keep long bones straight and enables bones to withstand weight bearing

Why do nurses use information about alignment, balance, gravity, and friction?

Today nurses use information about body alignment, balance, Gravity, and friction when implementing nursing interventions such as positioning patients, determining the risk of patient falls, and selecting the safest way to move or transfer patients

What can damage the cerebellum or the motor strip in the cerebral cortex

Trauma from head injury Ischemia from a stroke or brain attack (cerebrovascular accident (CVA)) Bacterial infection such as meningitis Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip Trauma to the spinal cord also impairs mobility

What are some individual risk factors?

Traumatic injury-brain, spinal cord, bones, joints, muscles Neurological conditions Chronic conditions and/or treatment interventions

Collecting the best evidence

Use hierarchy of evidence 1.sytematic reviews 2. One well designed RCT 3. Well designed controlled trials without randomization 4. Well designed case control studies 5. Systematic reviews of descriptive and qualitative studies 6. Single descriptive or qualitative studies 7. Opinion of authorities or expert committees\ This offers a guide to the types of literature or information that offers the best scientific evidence

Skeletal

Voluntary control Acts as a structural foundation of body Protects internal organs Provides an attachment site for muscles and ligaments

When evaluating an EBP change you determine what?

Was the change effective? Are modifications needed? Should the change be discontinued?

Nursing research

Way to identity new knowledge, improve professional education and practice, and use resources effectively Involves two broad approaches: Quan and qual

Gravity

Weight force exerted on the body The force of weight is always directed downward. This is why an unbalanced object falls Peoples centers of gravity are usually at 55 percent to 57 percent of standing height and are in the midline, which is why only using principles of body mechanics in lifting patients often leads to injury of the nurse or health care professional

Systemic effects

When there is an alteration in mobility, each body system is at risk for impairment Metabolic changes- immobile-body often excretes more nitrogen than it ingests in proteins(negative nitrogen balance) Respiratory changes- Atelectasis-collapse of the alveoli -hypo static pneumonia-inflammation of the lung from stasis or pooling of secretions Cardiovascular- orthostatic hypotension(drop of blood pressure -thrombus- accumulation of platelets, fibrin, clotting factors, and the cellular elements.

Tendons

White, glistening, fibrous bands of tissue that connect muscle to bone and are strong, flexible, and inelastic

Ligaments

White, shiny, flexible bands of fibrous tissue binding joints together and connecting bones and cartilages They aid joint flexibility and support

Common diagnostic tests

X-Ray MRI Cut scans Bone scan Bone mineral density Myelogram Arthrography Arthroscopy Electromyography General laboratory tests (multiple)

Moving patients

You need to know how to apply scientific principles in the clinical setting to determine the safest way to move patients and to understand the effect of immobility on the physiological, psychosocial, and developmental aspects of patient care To determine how to move patients safely, assess their ability to move Manually lifting and transferring patients contributes to the high incidence of work related musculoskeletal problems and back injuries in nurses and other health care staff