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Patient control analgesia case project.

Part I: Case Description
Our case occurred at an urban, academic medical center with patient Mr. S, who was sent to PACU after a routine surgery.  Standard post-operative orders include a patient-controlled analgesia (PCA) for his type of surgery. In the PACU, the RN started Mr. S on a Morphine PCA, 0.1 mg basal, 0.2 mg demand with a 10 minute lock out.  Two RN’s checked the PCA when initiated, as per policy.   His vital signs were stable, and his pain appeared to be well controlled.
At 16:16, Mr. S was deemed stable for transfer to the floor. The covering resident assessed him and changed his medication from Morphine to Dilaudid.  The PACU nurse switched this medication immediately after receiving the syringe from pharmacy and another independent check was done.   After speaking to the attending, the resident decided to discontinue the basal rate and called the PACU RN regarding the changes, but she replied that, although the computer still listed Mr. S in the PACU census, she had just transferred him to the new floor.  The busy resident was called away to an emergency before he could contact Nursing on Mr. S’s new unit.
The new RN caring for Mr. S was not aware the basal rate order had been discontinued.  Because he had verbally verified the PCA dosing during handoff from the PACU RN, he did not check the actual EMR for orders.  The patient was stable, and the RN was busy with discharge teaching for a non-English speaking patient (no interpreter was on staff that day).  There was no further bedside rounding that occurred on Mr. S for the remainder of his shift. Mr. S’s wife stayed with her husband for the afternoon and assured the RN that Mr. S was comfortable, saying “He hasn’t complained a day since we’ve retired, he’s tough like that.  But I’m here for whatever he needs.”  (However she noted later that he was very sleepy and sometimes would fall asleep mid-conversation.)

The Resident eventually called at 18:00 to confirm Mr. S’s pain was well controlled on this new dosing, but the RN assumed the MD was referring to the switch from Morphine to Dilaudid, as he was still unaware of any rate changes.

On this particular day, Mr. S’s RN was picking up an extra 4 hours on his shift, so he stayed on duty until 23:00.  Nurse handoff was brief for Mr. S’s exhausted RN, as he had finally discharged his patient, gave report on another, and then quickly summed up Mr. S’s report outside the room.  “He’s an easy one, a very nice older gentleman,” the outgoing RN said as he clocked out cheerfully at 22:45.  At 23:30, the night shift RN came in to greet her patient and noticed that Mr. S was very difficult to arouse with a low respiratory rate.  Additionally, Mr. S’s wife sat next to him on the bed, with the PCA demand button nearby.  A quick set of vital signs revealed his pulse ox was <90%. She performed a thorough pain assessment on Mr. S, checked his PCA against the order and realized the error – basal dose was still running.  She realized the wife may have also been delivering Mr. S unneeded (yet well intentioned) demand doses.  The RN educated Mrs. S and quickly called the MD to report the change in vital signs (at this point, the covering night float resident was on duty and was also unaware that there had been any breakdown in communication on the previous shift.)

1.    Briefly discuss what should have happened if good processes were in place; what was the originally designed system/process?  Were there breeches in established steps?

[rewrite in paragraph form]
PACU RN sets up Morphine PCA according to hospital policy.  A 2nd RN verifies the order and double checks the dosage/rate.
o    Review PCA order for appropriateness prior to administration
?    Age/cognitive ability (recommended minimum age for use 7 years old)
?     Alertness
?    Physical ability (must be able to hold and push the button)
?    Moderate to severe pain level with an expected minimum duration of pain for 24-36 hours.
o    Upon transfer from the PACU, Mr. S’s wife is educated by an RN on the purpose and proper use of the PCA.
o    Hospital census is updated in real time to allow the resident to know the patient has been transferred to the floor.
o    Resident calls floor and ensures that the new order is acknowledged by the covering RN (either through verbal confirmation or electronically).
o    Upon receiving Mr. S to the floor, the new RN checks all patient orders in the Electronic Medical Record.      Use this reference for this point   (Authorized and Unauthorized (“PCA by Proxy”) Dosing of Analgesic Infusion Pumps: Position Statement with Clinical Practice Recommendations Elsa Wuhrman, MS, RN,C, FNP, BC?, , , Maureen F. Cooney, MS, FNP, RN,C†, Colleen J. Dunwoody,MS, RN,C‡, Nancy Eksterowicz, MSN,  RN,C APN§, Sandra Merkel, MS, RN,C¶, Linda L. Oakes, MSN, RN,C, CCNS?

o    Ancillary staff, charge RN, or resource RN is available to assist with the RN’s other patients. This includes the hospital interpreter for the non-English speaking discharge.
o    RN performs a thorough physical and pain assessment on the patient upon admission to the floor.
o    Pain scores will be assessed after initiation, after any change in pump setting, and ongoing using a standardized pain rating scale to assess pain relief response to the PCA medication at least every 4 hours
o    V/S checks need to be done for drug doses or dose changes. Patients receiving continuous mode of IV opioids must be on continuous monitoring for heart rate, respiratory rate, and SaO2.
o      Pump history should be assessed frequently after initiation of PCA and following any change in pump settings.
o    PCA settings should be verified during each shift immediately after an updated report about the patient’s condition is received.
– RN notes that the basal rate has been removed, changes the PCA, and a 2nd RN independently verifies this change.

Teaching Plan

1.    Students will prepare at least 2 behavioral objectives in small groups towards development of a teaching plan in response to a case study provided.
•    Time:  10 minutes    Introduce self to students once again.  Explain the reason for the lesson. The lesson is to help students practice preparing a teaching plan for their chosen case studies.
Describe the objectives.
Describe the template components: behavioral objective addressed & time needed for each objective.—
1.    BEHAVIORAL OBJECTIVES
•    Behavioral objectives guide nurses so that the material needing to be taught is focused on the exact needs of the child and parents. It provides a plan for nurses to stay on topic and provide effective instruction, education, and support.
•    Behavioral objectives become the specific behaviors, when demonstrated, described, or stated by the child and parents indicates learning has taken place—these objectives are the means by which nurses can EVALUATE    Students are adult  learners.  Adult  learners need to be involved participating in their own learning. Adults learn best through use of multiple teaching-learning modalities (Vandeveer, 2009).  This lesson will use Case Study, and students will be broken down into small groups to work on the case study. According to Weimer (2002), there are many advantages to empowering students to participate in creating their own learning experiences. Deeper understanding of the topic, a sense of accomplishment, and satisfaction with the teaching-learning process are a few of these advantages.

Group discussion encourages the discovery of various ideas the students may have about how the behavioral objectives relate to the assessment and planning phases of the Nursing Process (Rowles& Russo, 2009).

Large and small group discussion during the case study activity—ongoing evaluation of students’ understanding based on questions students ask and the class discussion that takes place in response to the questions.

Small group completion of at least 2 behavioral objectives applicable to the case study provided.

Assignment 1  preliminary thesis statement.

Write a one to two (1-2) page paper in which you:

1.Explain the reason for selecting topic one (1), identify the audience, and provide a preliminary thesis statement.
2.Explain the reason for selecting topic two (2), identify the audience, and provide a preliminary thesis statement.
3.Explain the reason for selecting topic three (3), identify the audience, and provide a preliminary thesis statement.
4.Identify and document six (6) credible sources (two (2) for each topic) that you would expect to use. Note: Wikipedia and other Websites do not qualify as academic resources.
Your assignment must follow these formatting guidelines:

•Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; references must follow APA

•Include a cover page containing the title of the assignment, the student’s name, the professor’s name, the course title, and the date. The cover page and the reference page are not included in the required page length.

Topics:
1) Should taxes on people making over $250,000 a year be changed?
2) Should Transportation Security (TSA) regulations be changed?
3) Should regulations for home schools be changed?
4) Should funding for the U.S. space program be changed?
5) Should changes be made to the regulations for foods that are served in public schools?
6) Should changes be made to regulations for mental health drugs for minors?
7) Should regulations be changed regarding genetically altering plants and/or animals?
8) Should the Family and Medical Leave Act be changed?
9) Should taxes on alcohol and tobacco be increased to help pay for rising medical costs?
10) Should regulations regarding the use of cell phones while driving be standardized?
11) Should the instant replay used in the NFL be applied to other sports?
12) Should regulations regarding payment of college athletes be changed?
13) Should minors who commit violent crimes be tried as adults?
14) Should child welfare regulations be changed?
15) Should DUI (driving under the influence) laws be changed?
16) Should sex offender registration laws be changed?
17) Should laws governing student laws be changed?

18) Should laws governing nursing homes be changed?
19) Should children of parents who do not allow them to be vaccinated be allowed to attend public school?
20) Should unemployment regulations and benefits be changed?
21) Should rules requiring all members of a jury to agree for conviction be changed?
22) Should financial incentives be offered to high school students to perform well on standardized tests?
23) Should the government offer tax credits for the purchase of hybrid or alternative energy vehicles?
24) Should the U.S. Government prohibit companies from outsourcing jobs to people in foreign countries that do not have unions and / or fair labor laws?
25) Should the U.S. government provide financial assistance to people whose retirement funds were invested in the stock of companies that may have used unethical accounting practices (e.g., Enron, Arthur Andersen, etc.)?
26) Should colleges and universities expel students who are caught cheating on exams and / or plagiarizing their homework assignments?
27) Should the U.S. prohibit trade with countries that have poor records on human rights?
28) Should vehicles (cars, trucks, vans, SUVs) be required to have backup cameras?
29) Should all U.S. students be required to take four years of foreign language in high school?
30) Should the state and / or federal government provide subsidies to organic farmers?
31) Should all states require motorcyclists and passengers to wear helmets?
32) Should state and local governments provide health insurance only for retirees who have served 20 years in government service?
33) Should your state or local government enact different laws regarding certain animals (e.g., pit bulls)?

Journal 4

Order Description

Students must submit all journals through the Assignment Tool
The journal due dates are listed on the document titled, “Course Schedule.” and in the Weekly Modules. These due dates are not open to debate or negotiation. As a senior nursing student, your status as a professional nurse is imminent. As such you are expected to manage time effectively and make submissions of critical course requirements on or before due dates. Students not faculty are responsible for deadlines and submitting assignments on or before due dates. Failure to submit the journals will result in zero points for the assignment.
GUIDELINES FOR SUBMITTING CLINICAL JOURNAL #4

Obtain an occupational history on ONE employed worker in an occupational setting. (any occupation or job except nursing) Identify the occupation, associated job tasks, the potential health hazards and interventions to decrease these health hazards. A write-up is due in Journal #4. Journal #4 needs to include:

1. A narrative of the occupational history clinical activity described above. (4 points)
Journal 4 Question 1
Students, the rubric for the occupational interview are very specific. It is worth 4 points. You do not have to follow an assessment guide. Most important is to interview someone in an occupation other nursing or closely related field. Good examples: (factory, farming, etc.)

2. A summary of clinical activities the student (be specific) has done since the submission of journal #3. (Clinical activities must be population –focused) (2 points)

3. Student clinical outcomes met to date. (refer to student clinical outcomes for the course) ) The outcomes and the clinical activity that supports achievement of the outcomes must be written out. (1 point)

4. Documentation of course theory as it relates to clinical activities. (Must document at least three areas of content from classroom theory) (3 points)

5 Documentation of five different concepts the student has been introduced to in the course this semester and how the student will use these concepts in practice. (5 points)

Risk Management/Therapeutic co mmunication with the angry patient”

Order Description

Under assignment question, there is a video

Click on the video below (4min.17sec)

Video: “Therapeutic co mmunication with the angry patient”

This video demonstrates the interaction between a nurse and a client (Carla) who is currently distressed.

Please answer the following questions:
Reflect on the video scenario (link below), observing the interactions between the two individuals. Then answer following three (3) questions:

1. Using your knowledge and skills from previous weeks, analyse the questions asked (verbally, para-verbally) and non-verbal behaviours used in order to assess the client’s level of risk as well as assist the client regain focus, take control of their emotions and ultimately calm down.

a. From your observations of the situation, what did the nurse do well?
b. From your analysis of the situation, what changes would you suggest for Carla’s risk management?
2. What approaches can you use within the assessment process to enhance collaboration and participation when clients are at risk?
3. Reflect on what you think may be the underlying cause for Carla’s behaviour.

CriticalThinkingQuestions
http://relationalcontextofteaching.edublogs.org/2011/06/23/why-did-i-choose-to-show-and-not-tell/

Pleaseanswerthefollowing for professional portfolio

Reflectonthe videoscenario(linkbelow),observing theinteractionsbetweenthe twoindividuals.Thenanswerfollowing three(3)questions:

1.    Using yourknowledgeandskillsfrompreviousweeks,analysethe questionsasked(verbally,para-verbally)and non-verbalbehavioursused in ordertoassessthe client’slevelofrisk aswell as assisttheclient regainfocus,takecontroloftheiremotionsandultimatelycalmdown.

a.    Fromyourobservationsofthe situation,what did thenursedo well?
b.    Fromyouranalysisof thesituation,whatchangeswould you suggestforCarla’sriskmanagement?
2.    What approachescan youusewithinthe assessmentprocesstoenhancecollaborationand participationwhen clientsare atrisk?
3.    Reflect onwhatyou thinkmaybetheunderlying causeforCarla’sbehaviour.

Video:

Clickon thevideobelow(4min.17sec)

Video: “Therapeuticcommunicationwith theangrypatient”

Thisvideodemonstratestheinteractionbetween anurseand a client (Carla)whois currentlydistressed.Fromthisvideo considerthe following:

Readings

Read the followingpagesofthistext.

Hungerford,C.,Hodgson,D.,Clancy,R.,Monisse-Redman,M.,Bostwick,R.&Jones,T.(2015).Mental Health Care –AnIntroduction for HealthProfessionals in Australia(2nded). Milton,QLD:JohnWiley&SonsAustralia,Ltd.

Chapter 6:Caringforpeople displayingchallengingbehavioursp.238-273

Skillsandbehaviours–whatdo I need todo?
http://www.improvizations.com/Portals/42614/images/skills.jpg

Youwill needto completea risk assessment
Within your riskassessmentyou willneed toassessfor riskof:
o    aggression/violence (harmto others)
o    suicide ( harmtoself)
o    self-harm( harmtoself)
o    general vulnerability( exploitation)
o    past/current trauma( incl. sexual/physicalabuse)
o    drugs/alcohol(including withdrawal)
o    absconding ( leaving a place ofsafety)
o    neglect(including physicalneglect of self)
o    relatedtodependents
o    impulsive/reckless/provocativebehavioursYouwill needto:
Identifysignsof predictorsof risk[actual/potential],including static anddynamicfactors.Beableto describeriskand theriskfactors,forexample,low,medium,high levelsof risk.Chronic/ongoing oracuterisk.
Identifyprotectivefactors.

Beabletodemonstrateyourtherapeuticskillsthatwillsupporttheindividualwhois“atrisk”.
Formulate arisk summaryand riskmanagement planand clearlydocumentthiswithintherisk assessment formandtheclinical/electronichealth record. In doing thisyoualso needtoconsiderthemanagementplanswheresomerestrictionsof autonomy andfreedommaycausetheindividualtofeela lossoftheirhuman rights. Youwill needtosupportthisbalanceto ensureindividualrightsaremaintained aswellas theindividual’swellbeing.
Hand overto otherclinicalstaff,thelevelof riskfortheconsumersyou areworking withandthe action plan tosupportthe riskmanagement.
Youmayalsoneedtoconsider:
Themental illnessesthathaveriskimplications andwhy?

Theevidenceisto supportmypractice?

www.thewordworks.co.uk

RiskAssessment

It is importanttounderstand riskassessment and riskmanagement. Riskassessmentsshould alwaysincludesimilarinformationaboutthe typesof riskforthe person andthismaybemorethan one riskdependenton theindividual.Forexample,theindividualmaybeatriskofsuicidalbehaviourandalso riskofabsconding fromthe healthservice.
Risk assessmentsarebasedonstaticand dynamicfactorsandon acuteandchronic risk.Thelevelofriskcan fluctuatedepending on theindividualand theirindividualcircumstances.

RiskManagement

Riskmanagementshould alwaysfollowrisk principlesof need, responsiveness,and least restrictivepractices.
Zero Tolerance: Itis important to notethathealthservicesin Australia,haveadopted a zerotoleranceapproach toaggression,violence,assault,bullying andotheractsofviolencein theworkplace(Hungerford etal,2015).
Thereare a numberofways in whichserviceswillmanage risk, forexamplethemanagement ofclinical aggression (MOCA)is oneway in whichclinicians aretrainedtorespond torisksof aggressionand violence.
Managementofclinical risk is an approach to ensuresafety andquality ofcarewithinthehealthservices. Identifying consumerswhomaybe atriskofharmisvitaltothecareprovision andassisthealth professionalstoprevent,reduceorcontroltheserisks.

Pleaseclickhere onRiskwatch – Volume10,May2013thisbulletinhelpstoprovidesupporttheprocessofreviewofhigh risk incidentswithin healthservices. Itisanopen andtransparent waytoensure thatall casesthat involve adverseeventsormedical errorarereviewedthoroughly
Pleaseclickon workingwith a suicidalpatient/consumerthis is quickguidefortriagestaffwhenworkingwith aperson who maybeatrisk ofsuicide. Theassessment and thenmanagement ofasuicidal personisvitalto ensureappropriateand timelycareand treatment.

TheConsumerand CarerPerspective

Happell etal(2008)discusstheconsumerperspective onriskassessment andmanagement, as aneed toensure thatit iscarried outin anappropriateand timelymanner. It is importantto includeconsumersandcarer/family in all aspectsoftreatmentand planning andthis is nodifferent withinthe riskassessment andmanagement.Supporting theconsumerand carer/familytoidentifyearlywarning signs andtriggerswill assistin themanagement and earlyintervention.Risk assessmentshouldbefocusedonthestrengths and thepositivesnot juston potential riskfactors.
Allconsumers,carers,familiesand friendsalsohavetherighttoreceivehealth care orvisit a healthcare setting that is freefromriskstotheirpersonalsafety(Hungerford et al,2015).
Slade, M(2009)talks aboutwaysin whichservicescanassistpeopleto managetheir risk-takingbehaviours,bypromotinga recoveryoriented frameworktocare.Supporting individuals to haveresponsibilityfortheirownlivesandown riskis an importantintervention formental healthservicesto worktowards.Balancingrisk and riskfactors isvitaltothe careand treatmentweoffer.
Compulsorytreatment during a crisismayneedto beconsidered,our goal istoensure thatwhenthis arisesthatconsumersare treatedwiththe respectand dignity andtoaimforminimallossofpersonalresponsibilityduring thecrisis.

Self-Awareness

Understanding yourself and howyou respond toacute risksituations is important.Peoplereactdifferentlyto situations. Inthe practiceclasswewill exploreresponsesinmoredepth.Thereareanumberof emotionalresponses thatwe allexperience, asthe healthprofessional or as a consumer.
Somepeopleuse of theirdefencemechanisms(howpeopleunconsciously respondtothreats).For
e.g. the useofprojection,howoneperson mayprojecttheiruncomfortablethoughtsand feelingsonto another(Hungerford et al,2015)?
Ina situation somepeoplereporta sense of power,controland calmness;othersreportfeelingshakyandtearfulon theverge ofcollapse; othersdescribe a physicalsensationofnauseaandvomiting.
It is important thatwegainan understanding ofourselvesand howwerespond,sothatwe canprovidean effectivewayto managerisk situations,which causefewertraumastoall individualsinvolved.

Websites:

Thereare a numberofwebsitesthatprovidefactsheetsand information to supportunderstandingof riskandriskfactors inmental health.Risk isinclusive ofa numberof riskfactors andpertainstoarange of risks,belowareexamplesofsomeareasof risk(noterisk is notrestrictedtoriskofaggression/violenceandorsuicide).
Pleasereviewthefollowingwebsites:

When workingwithyouthpeople andadolescents consider the followingwebsite–Reachout.Thissiteprovides generalinformation aboutangerand angermanagement.

http://au.reachout.com/find/articles/anger

http://au.reachout.com/find/articles/being-violent

http://au.reachout.com/find/articles/anger-is-something-that-is-hard-to-deal-with

When workingwith peoplewho are expressing thoughtsofsuicideconsidertheSanewebsite.Thesefactsheetshelp tosupportpeoplewhoareincrisis.

http://www.sane.org/images/stories/information/factsheets/1007_info_25sanesteps.pdf

http://www.sane.org/images/stories/information/factsheets/1110_info_26suicidehelp.pdf

Lifeline isa crisissupportand suicideprevention 24hourservicethatyou can accessvia thetelephone.http://www.lifeline.org.au/

Watch thisbriefvideobyGrahameGould aLifelinemanager–clickhere

Additionalreading

Chapter10:Anger,HostilityandAggression
Evans,J.,&Brown,P.(2012).Videbeck’sMentalHealthNursing.(pp.169-182).Sydney,NSW:LippincottWilliams&Wilkins.

PleasenoteVidebeck’sreferencetosafetyrelatingtopatient/consumerwhomaybeinpossessionofaweapon(pp.174-175),isinrelationtoskilledstaffwhohavebeenproperlytrainedtoassistinmanagementofaconsumer/patientwithaweapon.Thepracticesofremovalofaweaponandorthrowingwateronthepatient/consumerarenotarecommendedpracticewithintheACUundergraduatecourse,SchoolofNursing,MidwiferyandParamedicine.

Chapter11:AssessmentandDiagnosis–Essentialnursingskills
Elder.R.,Evans,K.,Nizette,D.(2013).Psychiatricandmentalhealthnursing(3rded.).Chatswood,NSW:ElsevierAustralia.p203-204

Chapter12:AssessmentEssentialSkills–HoNOS;(p370)
Chapter13:SpecialisedAssessment-RiskAssessment(405&413);

Chapter21Substancerelateddisorders-Assessingrisk(p.469)
Chapter25Schizophrenia-SpecificriskassessmentissuesinSchizophrenia(p.768–770)

Meadows,G.,Singh,B.,&Grigg,M.(2012).MentalhealthinAustralia.Collaborativecommunitypractice(3rded.).SouthMelbourne,Vic:OxfordUniversityPress.
Chapter5:MentalHealthandIllnessAssessment (p.118–119)
Happell,B.,Cowin,L.,Roper,C.,Foster,K.,&McMaster,R.(Eds.).(2008).Introducingmentalhealthnursing:aconsumer-orientedapproach.Sydney:Allen&Unwin.

Pleasenotetherearealsospecificareaswithineachofthedisordersthatdiscusstheriskmanagementspecifictotheillness.

Foryourinterest

AustralianNursingFederation.(2012).ANFPolicy:Zerotoleranceofviolenceandaggressionintheworkplace.Retrievedfrom   http://anmf.org.au/documents/policies/P_Zero_tolerance_violence_aggression.pdf

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2007.04169.x/full

http://bjp.rcpsych.org/content/189/6/520.full

http://www.aenj.org.au/article/S1574-6267%2806%2900076-0/abstract

http://www.health.vic.gov.au/mentalhealth/triage/scale0510.pdf

effectiveness of your proposed solution

Details:

Using 800-1,000 words, discuss methods to evaluate the effectiveness of your proposed solution and variables to be assessed when evaluating project outcomes.
Example: If you are proposing a new staffing matrix that is intended to reduce nurse turnover, improve nursing staff satisfaction, and positively impact overall delivery of care, you may decide the following methods and variables are necessary to evaluate the effectiveness of your proposed solution:
Methods:
1.    Survey of staff attitudes and contributors to job satisfaction and dissatisfaction before and after initiating change.
2.    Obtain turnover rates before and after initiating change.
3.    Compare patient discharge surveys before change and after initiation of change.
Variables:
1.    Staff attitudes and perceptions.
2.    Patient attitudes and perceptions.
3.    Rate of nursing staff turnover.
Develop the tools necessary to educate project participants and to evaluate project outcomes (surveys, questionnaires, teaching materials, PowerPoint slides, etc.).
Refer to the “Topic 4: Checklist.”
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.
6 NRS 441v.11R.Module 4_Checklist.doc

Details:

Using 800-1,000 words, discuss methods to evaluate the effectiveness of your proposed solution and variables to be assessed when evaluating project outcomes.
Example: If you are proposing a new staffing matrix that is intended to reduce nurse turnover, improve nursing staff satisfaction, and positively impact overall delivery of care, you may decide the following methods and variables are necessary to evaluate the effectiveness of your proposed solution:
Methods:
1.    Survey of staff attitudes and contributors to job satisfaction and dissatisfaction before and after initiating change.
2.    Obtain turnover rates before and after initiating change.
3.    Compare patient discharge surveys before change and after initiation of change.
Variables:
1.    Staff attitudes and perceptions.
2.    Patient attitudes and perceptions.
3.    Rate of nursing staff turnover.
Develop the tools necessary to educate project participants and to evaluate project outcomes (surveys, questionnaires, teaching materials, PowerPoint slides, etc.).
Refer to the “Topic 4: Checklist.”
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.
6 NRS 441v.11R.Module 4_Checklist.doc

professionalism in context

Order Description

1

Assignment 2:

Objective(s):
L
Length: Word limits:
Part A: 300 words
Part B: 500 – 600 words maximum
Two choices for Part B
Submission:

See details below for each Part.
One of the most important aspects of any professional portfolio is the ongoing development and monitoring of professional learning goals and needs. These goals are developed by:

1. Assessing the shortfall (learning goals) between where you are now and where you want to be as soon as possible in your new graduate nurse (NGN) transition year. This will become evident through exploration of particular competencies, skills or values as they are presented in nursing literature and through your personal and/or clinical reflections;

2. Prioritising and listing your goals and needs clearly;

3. Determining the learning resources, activities and/or strategies needed to meet your goals and needs;

4. Identifying possible evidence of achievement .
These 4 steps are relevant to Part A and B but the goals are different 92325 Professionalism in Context
2

PART A: –

TASK
Even though there are many areas of practice for which learning goals could be identified, those chosen below reflect the objective and content of this subject and are framed by the transition needs of the NEW GRADUATE NURSE (NGN).
For each of the following topics the group is to identify at least one short-term professional learning goal or need relevant to the transition year and discuss why you believe this to be important in your transition year. All of the areas below must be covered. Ensure your identified goals or needs are supported by reflections on recent clinical activities, subject readings or resources, and class discussion as noted in the 4 steps above:
–
–
–
– The nurse as manager ( keep in mind I’m a NGN )
–
The identification and explanation of the learning goals should be supported by reflection on recent clinical or personal experience, subject readings, subject resources, lectures, and class discussions.
It is important that you evaluate your experiences, strengths and knowledge. Ask yourself “What does this show me about my understanding of the role of the NGN and the transition experience? What does it show me about my potential as a leader, educator, employee or manager”?
Identification of resources, activities and strategies that you could use to meet these learning and professional goals.
Evidence of accomplishment – how might you know that you have achieved your goal?
After you have completed this stage of the assessment the deficits you have identified can be addressed before or during your early new graduate year.

Part B: 500 words
– Consider your career long-term and think about where you would like to be in about five (5) years.
– Identify one (1) long term goal that you can realistically aspire to; one that could provide a focus for your early career development.
– Discuss why this goal has meaning and how it will motivate you. This discussion should be, as in Part A, supported by reflection on recent clinical or personal experience, subject readings, lectures, and class or online discussions, including standards and competencies.
– Describe how you will make progress towards this goal over the early stage of your career – what resources, activities and strategies you will use.

methods to evaluate the effectiveness of your proposed solution and variables to be assessed when evaluating project outcomes.

Details:

Using 800-1,000 words, discuss methods to evaluate the effectiveness of your proposed solution and variables to be assessed when evaluating project outcomes.
Example: If you are proposing a new staffing matrix that is intended to reduce nurse turnover, improve nursing staff satisfaction, and positively impact overall delivery of care, you may decide the following methods and variables are necessary to evaluate the effectiveness of your proposed solution:
Methods:
1.    Survey of staff attitudes and contributors to job satisfaction and dissatisfaction before and after initiating change.
2.    Obtain turnover rates before and after initiating change.
3.    Compare patient discharge surveys before change and after initiation of change.
Variables:
1.    Staff attitudes and perceptions.
2.    Patient attitudes and perceptions.
3.    Rate of nursing staff turnover.
Develop the tools necessary to educate project participants and to evaluate project outcomes (surveys, questionnaires, teaching materials, PowerPoint slides, etc.).
Refer to the “Topic 4: Checklist.”
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.
6 NRS 441v.11R.Module 4_Checklist.doc

investigation the effectiveness of a brief / a low burden intervention in reducing hypnotic prescribing

Order Description

Please be aware that this will be a protocol of my research. I will give you a brief explanation the I will provide you my colleague work that I will do the same thing. I am going to implementing the intervention then looking in depth may be then interviewing the GPs (general practitioners) or patients who come to or did not come the office (doing it in structured manner). please have a look to these work down as I am going to select 2 practices to work with. I am providing my colleagues’ work just to give you an Idea about what can been done.
Hypnotic Audit & Review 2014/15 X Surgery

Practice prescribing of hypnotics & benzodiazepines is measured and compared at a local (prescribing performance) and a national (QIPP indicator) level.

Why Audit?

* Continuing concern over long term use (1)

* Taking a benzodiazepine and/or hypnotic was associated with double the risk of death from any cause compared with no prescription for these drugs. Dose-response associations were found and there were approximately 4 excess deaths linked to these drugs per 100 people followed for an average of 7.6 years after their first prescription. (2)

* Driving whilst under the influence of drugs is a significant cause of injuries and deaths on the road. (3)

* Patients are not always given appropriate information and advice on the risks associated with long term use (4):

* Tolerance & addiction

* Drowsiness, clumsiness, forgetfulness, confusion, impaired judgement

* Falls & fractures – in people older than 60 years, these drugs are associated with an increased risk of falling of between 50-70% in relative terms. (5)

* Association with increased risk of dementia and increased cancer incidence in those prescribed high doses (6)

How is usage measured? Hypnotic ADQ per STAR PU – This is a measure of the total quantity of Benzodiazepines and Z-drugs prescribed, weighted for age and sex of a practice’s population.

At the start of the project x Surgery was the 4th highest prescriber out of 50 East Berkshire practices. x Surgery Q2 (Oct-Nov 13) 2013/14 ADQ 461

What action was taken in X Surgery?

1. Practice meeting to agree course of action with all prescribers. A consistent message is vital for success and helps to prevent patients pressurising or singling out a particular GP.

2. Search – patients prescribed these drugs during April – July 2013.

* Exclusion criteria: Housebound, care/nursing home (reviewed separately by care home pharmacist & responsible GP) and palliative care patients; one off supplies e.g. for back spasm, fear of flying and for epilepsy treatment.

3. Analysis consistently shows that a simple letter intervention reduces benzodiazepine use in patients who have been using them long-term (7). Letter sent to remaining patients to:

* Explain concern over the patient’s long-term use of named hypnotic/s

* Highlight potential side effects when taken over a prolonged period.

* Ask the patient to consider a reduction in their use. – Include advice on how to gradually reduce or cease use in a manner that is feasible and will decrease the likelihood of withdrawal symptoms.

* Invite the patient to discuss the issue further with own GP or by booking into pharmacist led clinic.

4. For those receiving a letter, these drugs were moved from repeat to acute and limited to 56 days supply.

5. A 2nd short reminder letter sent to non responders 3 months after the initial letter, also informing the patient that the maximum length of supply was now 30 days in line with CD regulations (June 2014).

6. Posters advertising clinics and detailing risks of long term use put up in waiting rooms

7. Agree initiation & prescribing policy for new prescribing – support leaflet supplied

8. Full range of support leaflets and reduction schedules available in all consulting rooms.

9. Monthly pharmacist (independent prescriber) led clinics offering 20 minute appointments. Scope of practice demonstrated by Benzodiazepines learning module via MHRA Training and Continuing Professional Development (CPD) and personal CPD records.

10. Reception staff / prescription clerks’ informed.

11. Raised awareness with local community pharmacies by providing self help leaflets & posters

Main audit observations

o 196 patients prescribed hypnotics, 95 patients prescribed benzodiazepine, 25 prescribed both.

o Included 37 patients care home residents

o 4 RIP during project

o Age range 5 – 101 years

o Length of supply range 1 day – 100 days

o 99% on repeat

o 107 patients with fall/fell in consultation, recording total of 238 falls, often leading to GP appointments, OOH/MIU/A&E attendances & hospital admissions. This included 14 fractures, 54 A&E/admitted and at least 3 road traffic accidents.

o There was occasional documentation of addiction & tolerance discussions.

Clinic Protocol

o Identify & address any underlying cause of insomnia, anxiety & depression

o Promote non drug therapies such as sleep hygiene methods and relaxation techniques using diaries & self help leaflets.

o Involve patient support network

o Guided by patient, negotiate flexible, gradual withdrawal schedule

o Convert to diazepam if appropriate

o Rebook for review, ongoing support and encouragement as appropriate

o Continue dose reduction at pace comfortable to patient

o Monitor withdrawal effects until stopped completely or at lowest dose to control effects of withdrawal. Where complete withdrawal may not be an achievable goal there is still benefit to be gained in reducing use to the minimum effective dose. (Ref BNF).

o Revisit benefits of stopping at every contact

o Highlight risks for drivers, including details of the proposed 2015 drug driving offence for those affected.

o Link patient into support services (Talking Therapies, SMART/T2, age concern, Community Veterans Mental Health Service)

What were the potential barriers to success?

* Not perceived to be a problem

* Cheap drugs – budget not affected

* Time & impact required

* More commonly used Z drugs are perceived to be safer than temazepam

* Patient resistance

* Limited support programmes available within mental health services

Results

Number of patients seen/telephoned by GPs was not measured. Number of pharmacist led clinic sessions 14 (First clinic January 2014: Last clinic January 2015)

> Number of patients seen 45

> Number of patient appointments attended 97

> Number of DNA 2

X Surgery Q2 (Oct-Dec 13) 2013/14 ADQ 461

X Surgery Q2 (Oct-Dec 14) 2014/15 ADQ 263

After the conclusion of the project, X surgery (Q2 2014/15) moved from 4th highest hypnotic ADQ per STAR PU prescribers to 29th out of 50 practices and below England average.

The inclusion of this prescribing performance indicator meant that all 50 practices received a consistent message regarding harms of long term use together with the offer of additional support material. A decrease can be seen by a large number of practices.

No other practice achieved the same magnitude of reduction as X surgery (as seen in Graph 1 below), who had received a higher level of support in terms of education, letters sent to patients and pharmacist led clinics over this time period. (Latest epact data available Q2 14/15)

Graph 1 – highlighting X Surgery

Medication Results: [12 month time period Oct12 – Nov13 vs Oct13 – Nov 14 (ePACT)]

The number of items dispensed decreased by 572, despite changing prescriptions to 30 days supply and thereby potentially increasing the number of items ordered.

The annual cost of hypnotic and benzodiazepine prescriptions reduced by £8,744.35, despite temazepam price fluctuations.

January 2013: Temazepam 10mg £4.23/28,

August 2013: Temazepam 10mg £27.08/28,

November 2014: Temazepam 10mg £19.77/28,

Table 1. Change in X SURGERY prescribing of hypnotics

X Surgery Previous 12 Months Current 12 Months

Chemical Substance Items Cost Items Cost

Temazepam 415 £13,186.81 205 £6,554.73

Zopiclone 1,023 £1,894.21 842 £1,232.56

Lorazepam 230 £1,096.01 209 £787.14

Oxazepam 147 £545.84 98 £238.27

Nitrazepam 93 £500.10 46 £138.81

Zolpidem Tartrate 175 £457.69 153 £279.15

Lormetazepam 6 £397.92 4 £234.14

Clonazepam 84 £239.44 44 £108.87

TOTAL 2173 £18,318.02 1601 £9,573.67

Melatonin prescribing remained stable, indicating patients had not been switched to melatonin as a non hypnotic alternative.

OUTCOMES – Benefit to individual, practice and wider public health agenda

* Keeping patients from harm by reducing exposure to side effects

* Patient in control, involved in own healthcare decisions & empowered to manage their medicines

* Prescriber education promotes consistent patient experience and raised awareness of potential serious side effects for patient and prescriber.

* Improved patient access to healthcare in convenient location with choice of provider

* Vulnerable or complex patients linked into other support agencies

* Opportunity to discuss other medication, helping patients to get the most from their medicines.

The final word – What particularly went well and what was hard?

Practice engagement over the course of the project was superb. It was well supported from the outset with the delivery of a consistent message, and patients actively encouraged to attend the pharmacist led clinic. GPs held steadfast regarding keeping supply on acute rather than repeat, at least until the patient had received the relevant support information. Initially, pressure on GPs time was high. Inevitably, this quickly decreased, but was time consuming on top of the usual high work load.

References

(1) As long ago as 1988, the Committee on Safety of Medicines advised that benzodiazepine hypnotics should be used only if insomnia is severe, disabling or causing the patient extreme distress. The lowest dose that controls symptoms should be used, for a maximum of 4 weeks and intermittently if possible. NICE guidance also recommends that when, after due consideration of the use of non-pharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life, hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications. NICE also confirms that there is no compelling evidence of a clinically useful difference between ‘Z drugs’ and benzodiazepine hypnotics from the point of view of their effectiveness, adverse effects, or potential for dependence or abuse. There is no evidence to suggest that if patients do not respond to one of these hypnotic drugs, they are likely to respond to another. Despite these national safety warnings and guidance, overall prescribing of hypnotics is not decreasing.

(2) BMJ 2014;348:g1996(published 19 March 2014)Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. After an average of 7.6 years, prescription of an anxiolytic, a hypnotic or both was associated with double the risk of death from any cause compared with no prescription for these drugs, after accounting for pre-existing psychiatric disorders, other diseases and other prescribed drugs.

(3) Report of the Review of Drink and Drug Driving Law, Sir Peter North, June 2010; Department for Transport, Impact Assessment for the new offence of driving with a specified controlled drug Impairment by drugs was recorded as a contributory factor in about 3% of fatal road accidents in Great Britain in 2011, with 54 deaths resulting from these incidents. Some evidence suggests drug driving is a much bigger road safety and may be a factor in 200 road deaths per year. A large study of drivers prescribed sleeping tablets in the previous 7 days had double the risk of road traffic accidents compared with those who did not take them.

(4) PMID:15203405 Aging Ment Health. 2004 May;8(3):242-8.Attitudes to long-term use of benzodiazepine hypnotics by older people in general practice: findings from interviews with service users and providers.

5) Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Intern Med. 2009;169(21):1952-1960. doi:10.1001/archinternmed.2009.357.

(6) BMJ 2014;349:g5205 doi: 10.1136/bmj.g5205 (Published 9 September 2014) Benzodiazepine use and risk of Alzheimer’s disease:case-control study

(7) Vicens C, Bejarano F, Sempere E, et al. Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care. Br J Psychiatry. 2014 Feb 13 and Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X593857.

There is a graph has been sent to me showing the prescribing rate in some practices .The practices in question are the 2nd highest and 4th highest prescribers on the graph above