Weaning From Mechanical Ventilation for Adult Patient

            Abstract

            Weaning normally incorporate the complete procedure of the general liberation of the patient from mechanical support as well as from the endotracheal tubes. Given that mechanical ventilation weaning normally incurs significant costs, mortality and illness and also untimely and delayed extubation can result in harm weaning that can be categorized as safe and speedy is highly required. There are controversial concerns in regard to the best approach that should be utilized in the conduction of the mechanical weaning procedure. Weaning can be fastened by the use of SBT and every day’s screening of the functioning of the respiratory.  Respiratory rate can be categorized as the best successful weaning predictor. The utilization of now- aggressive ventilation models might be useful in improving the general outcome of a number of patients who might acquire respiratory failures during the extubation process. The study established that weaning should be considered the earliest possible. In addition SBT is the prime diagnostic test in the determination of whether extubation would be successful. Non-aggressive ventilation approaches should be utilized in shortening the intubation period but should thus not be utilized as often tools in reference to extubation failure. In achieving the study’s success the study utilized a systematic review approach to the recent evidence-based studies.

            Introduction

            Weaning from Mechanical Ventilation is best described as the general gradual procedures for withdrawing ventilatory sustenance. Close to 800,000 adult patients necessitate the support of mechanical ventilation every year (Chang, 2014). Undoubtedly this is an existence saving intervention but it is one of the approaches that are uptight with the probability of iatrogenesis particularly if the support is utilized extensively than the required period. Based on scientific estimations 90 percent of the critically ill adult patients require the support of mechanical ventilation and while acquiring the support the patients are amid the weaning procedures which account for approximately 40 percent of the general time (Chang, 2014). The discontinuation of mechanical ventilation support and the removal of reproduction Airways occupies a significant portion of the whole duration thus becoming a major concern for those working in the critical units. Delayed weaning procedures can result in complications such as an induced lung injury, pneumonia as well as diaphragmatic dysfunction that is associated with ventilator support. On the other hand, the induction of premature weaning can result in the raise of complications such as defective air exchange, airway, muscle fatigue of the respiratory and aspiration. The predictive level of the successful is accounted to be only about 35 to 60 percent based on physician’s decisions.

            Literature Review

            According to Esquinas, (2016) Mechanical ventilation has been through a radical transformation over the recent years. Contemporary ventilators are becoming highly sensitive thus permitting easy triggering of patients under supported breathing by the utilization of models like extubation. It is universally agreed that reducing the mechanical ventilator assistance and particularly of Endotracheal intubation can be categorized as the extremely significant objective of all the patients in consideration of the high incidences that are linked with illness and the high ventilator costs that are linked to pneumonia and additional critical consequences of the ventilated intubated state. Expeditiously both extubation and weaning should be conducted safely and efficiently as possible given that this is a significant high focus item for every individual participating in the critically sick patient’s management (Waldmann, Soni & Rhodes, 2008).

Based on Silverman, et al., (2007) Spontaneous breathing trials (SBT) evaluates the ability of the patient to breathe while acquiring minimized or zero mechanical ventilator assistance. Weaning and SBT procedures begin by an evaluation of whether the probable source of respiratory failure is resolved or not yet. There is no known agreement in regard to the criteria that is to be utilized in evaluating the existing condition’s reversal. However, the incorporation of both objective and subjective procedure is utilized in establishing reversal of the illness. Normally the utilized process is the development of air exchange, mental status growth, radiographic signs as well as neuromuscular evaluation. It is worth noting that even for the patients who fail to meet the set criteria in most cases they are ultimately weaned efficiently. Weaning can be fastened by the use of SBT as well as often respiratory functions screening. Respiratory level or ventilation ratios are good indicators of efficient weaning. The least effective weaning method is synchronized recurrent obligatory. The general utilization of non-aggressive mechanical ventilation may result in outcomes improvement for those patients that acquires failure of respiratory after extubation procedures (Slutsky & Brochard, 2005).

            According to Boles, et al., (2013) given that conventional aggressive ventilation is linked with several complications like pneumonia and tracheal stenosis most of these complications increases the probability with ventilation duration. It is thus essential to particularly wean patients while utilizing mechanical ventilation process sooner in the avoidance of such issues. Mechanical ventilation weaning involves the general reduction of ventilatory assistance which finally leads to the spontaneous breathing by patients and subjection in extubation. Truwit, (2011) states that the procedures can be achieved in rapid nature amid 80 percent of the involved patients after the initial respiratory failure cause has been developed. The rest of the cases rely on achieving gradual approaches of ventilation withdrawal (Vincent, 2011). Successful weaning is achieved when several factors have been accounted for. In that the existing illness must have been improved, the patient condition being ideal, the establishment of airways issues and appropriate remedies and the achievement of adequate breathing. In that for the success of weaning the initial respiratory cause must be solved to a level that is reasonable. There are numerous uncertainties in regard to the most suitable approaches to conducting the process and this requires the engagement of the patients throughout the recovery session from critical illnesses. This results in weaning being a crucial issue for both physicians and patients.

            Kreit, (2013) asserts that it has been demonstrated comprehensively that having now- healthcare physicians as bed huddles like nurses and therapists can effectively result in the execution of protocols which enhances the clinical results and lower the general costs for patients who are ill critically. Having the team members for the critical units who sticks to the patient's bedsides leads to weaning processes on hourly grounds rather than depending on the intermittent support which is in most cases infrequent, makes an essential sense degree, as well as offers, support to all the decisions of physicians (Papadakos & Dooley, 2007). It has been constantly demonstrated by studies that all the protocols of weaning that are created by physicians but are in turn conducted by nurses or even therapists lead to the reduction of the mechanical ventilation period without creating any advanced consequences. However, the success of the procedures depends on overcoming the associated attitudinal and all other involved challenges have given that the weaning protocols are just more than relying on a single option as they offer the best outcomes. Extubation and weaning are two differing procedures and thus some of the critically ailing patients can acquire weaning from mechanical or conventional ventilation but still necessitate a stimulated airway for the clearance of the secretion or the prevention of the upper sections airways aspiration and obstruction. These aspects should be accounted in that all patients are not to be involved in extubation after an efficient SBT process (Kreit, 2013).

            Respiratory Weaning

Respiratory weaning mainly refers to the general procedure of withdrawing the patients from the ventilator dependability which occurs in three different stages. In that, the patients are removed gradually from the supporting ventilator, after from the tube and then from oxygen support. Mechanical ventilation weaning is normally performed at the earliest possible period which is consistent with the safety of a patient (Ching-Ju, Chouh-Jiaun, Ya-Ling & Ling-Nu, 2009). This decision should be derived from physiologic rather than the consideration of the mechanical perspective. In that, a thorough patient’s status for the patient should be considered so that sound decisions can be derived. Weaning mainly begins after the recovery of the patient from the acute surgical and medical levels which permits the reverse of respiratory causes to be conducted effectively. Weaning success normally incorporates the engagement of the respiratory therapist, nurses as well as physicians. In that, the health providers must in adequacy comprehend their scopes in relation to the weaning of the patients in the conservation of the patient’s wellness and developing successful results (Ching-Ju, Chouh-Jiaun, Ya-Ling & Ling-Nu, 2009).

In the restoration of control since patients are encouraged by the medical givers to engage in decision creation in regard to care and probable treatment. Patients may be withdrawn from mechanical ventilation assistance particularly if the use was extensive. So that effective coping can be promoted progress is normally communicated to the respective patients appropriately.  Diversions such as television and music are usually provided to offer destructions which promote a relaxing surrounding (Montagnani, et l., 2011). Stress decreasing techniques are usually utilized as relaxing measures which helps in relieving tension thus promoting the general capability of patients in dealing with anxiety issues in regard to the dependence and condition of ventilator reliance. Mechanical ventilation is normally a necessity for a number of reasons which include the necessity for the patients to control their respiration or in the case of severe head injury treatment in oxygenating the body blood in instances when the ventilator abilities are not adequate as well as all the breathing muscles (Montagnani et l., 2011).

Spontaneous breathing can be established in patients under ventilator support but the effort that is required in this achievement is fatiguing. The mechanical ventilator can be categorized as negative or positive pressure breathing tool that normally maintains oxygen and ventilatory delivery for the extended period. Offering care to patients under mechanical support has grown to be an essential nursing care part in offering critical health care.  The particular pulmonary needs of the patients must be understood by the caregivers in the setting of achievable and wellness promoting goals (Herlihy, Koch, Jackson & Nora, 2006). Acquiring desirable patient results normally relies on the understanding of mechanical ventilation principles and the needs for offering care to patients with open communication.

            Mechanical Ventilator Weaning

Mechanical ventilation can be considered to be an important lifesaving technological advancement. However, there are several complications associate with the practice given that it influences illnesses and patient’s mortality for those acquiring intensive care. Thus, it is essential to utilize the safest as well as the most effective mechanical ventilation approach for the least period. Mechanical ventilation has a number of indicators (Montagnani et l., 2011). The main rationale is that patients are usually placed under artificial ventilation in the quest of fulfilling their general body’s oxygen demand, as well as carbon dioxide removal, gave that they do not have the capability to achieve this. Mechanical ventilation that is not – aggressive can be achieved via facial masks, nasal and invasive via the use of tracheotomy tubes. Mechanical ventilation period normally differs depending on the respiratory failure causes. For the critically ill mechanical ventilation is an induction control measure and in instances of physiologic functioning failure collapse, it is normally utilized as prophylaxis. Inadequate gases exchange, mechanical and respiratory insufficiencies are some of the physiological indicators (Herlihy, Koch, Jackson & Nora, 2006). Oxygen and carbon dioxide transportation amid the respiration and the surrounding is the operation of ventilation tool support.

Maintaining normal Po2 as well as Pco2 levels in the arterial body blood while the ventilator muscles are being unloaded is usually the desired mechanical ventilation assistance results (Herlihy, Koch, Jackson & Nora, 2006). To most individuals ventilators, are considered as respirators which are understandable based on the fact that their differences in health are technical rather than functional. While ventilators are involved in conveying air from one region to the next the function of respirators is to facilitate gases exchanges. Apparently initiating ventilatory support tends to be much easier than the withdrawal. This is because respiratory needs differ from an individual to another thus returning patients to their normal breathing is to be done based on the needs of each patient. This, therefore, implies that weaning program is to be customized based on the patient’s necessities. A patient under ventilatory support is perceived to be ready in acquiring wean after the need for being supported by ventilators is stabilized. It should be noted that there are a number of ways through which patients can be placed under weaning and conducted in differing modes (Herlihy, Koch, Jackson & Nora, 2006).

The four models of withdrawing patients from the support of mechanical ventilation include the use of SIMV, PSV, SBT (Spontaneous Breathing Trials) which does not incorporate the use of consistent air pressure and NPPV (Unoki, Serita, & Grap, 2008). Most healthcare providers mainly rely on the use of SIMV and NPPV while a number of them prefer the combination for success to be achieved throughout the procedure. NPPV role is currently involved in an evolution given that it is a continuous approach this serves as an Extubation and discontinues approach in those patients that have been intubating as an avoidance association which serves as the prophylactic role in the postoperative patients who are involved in the increased risk of experiencing respiratory issues. SBT, SIMV or even PSV models have demonstrated to be more superior based on the results of a number of studies (Unoki, Serita, & Grap, 2008). In the general quest of achieving mechanical ventilation discontinuation a number of, untraditional approaches have been utilized which includes training for respiratory resistance and minute capacity mandatory ventilation. It has been demonstrated that the triggering flow leads to a decrease of the breathing work in COPD adults and infants. Similarly, t infants COPD patients are usually very vulnerable to auto- looks which may rise the breathing work thus preventing the initiation of ventilatory weaning support (Unoki, Serita, & Grap, 2008).

Careful evaluation is normally necessitated in the determination of the readiness of the patients in being removed from mechanical ventilation. If the patient demonstrates stability with a demonstration of improvement signs or a reversal of the initial condition that raised the necessity for mechanical ventilation this calls for the assessment of weaning indices (Unoki, Serita, & Grap, 2008). These indices include maximum inspiratory rate, vital capacity, and tidal volume. Vital capacity refers to the air volume that is usually exhaled or inhaled mainly from the lungs in an effortless breathing.  Shallow breathing incorporates the breathing pattern assessment which is usually calculated by the division of respiratory level by the tidal capacity. The strength of the respiratory muscles is assessed using MIP which in normal context should contain H2O 20cm. when a patient holds breaths that are below 100 this is supposed to achieve successful weaning (Haberthür, et al., 2002). In addition stability of the arterial blood and vital signs are crucial successful weaning predictors.

Mechanical ventilation halting typically refers to two diverse but unswervingly related care aspects which are motorized ventilation discontinuation and false airway removal. The prime issue that is faced by clinicians is the mode of determining the readiness of the patient in resuming ventilation on self-abilities (Haberthür, et al., 2002). It has been demonstrated by a number of studies that the use of direct methodologies in evaluating the readiness in maintaining normal breathing is usually intended a trial to breathe that is not supported. After the patient has acquired the capability to maintain spontaneous breathing the second evaluation is then made to determine the appropriateness of artificial airways removal. These choices are customarily made in orientation to the psychological status of the persevering, their protecting airway instruments, and the proficiency to a cough and emissions character. Given that the patient has acquired enough sensorium with airway protection that is unbroken without excess secretion this creates reasonable grounds to trachea extubation (Haberthür, et al., 2002).

            Predictive Mechanical Weaning Criteria

Weaning procedures begin normally under the existing illness procedure that led to the need for ventilation support has been solved or improved. This infers that the patient should have realized adequate connections of gases a condition that is described as the division of arterial oxygen and the enthused oxygen fraction level upstairs 200 and suitable muscular strength status, and circulatory function constancy (Haberthür, et al., 2002). A number of health limits that are grounded of respiratory mechanisms, breathing patterns and exchanges of gases have been established as useful weaning outcome predictors that would help in offering clinical guidance in establishing the optimal period of mechanical ventilation discontinuation. However, in this context, the prime issue is the usefulness of shallow the-rapid breathing in distinguishing amid those patients that will or not wean efficiently. Weaning success possibilities prior to weaning attempt can mainly be estimated by knowledge physicians based on the setting. The post-test normally predicts the success by accounting for the diagnostic test results such as shallow breathing measures (Haberthür, et al., 2002).

SBT/Extubation Protocol and AM Bed Huddle Effectiveness

After patients have been considered stable and ready to engage in mechanical weaning the best approach is assessing the ability of the patient in breathing based on their own abilities which can be conducted through the conduction of spontaneous ventilation trials (Glossop, Shepherd, Bryden, & Mills, 2012). After the accomplishment of spontaneous breathing tests, instantaneous extubation accelerates weaning and typically decreases the mechanical ventilation duration when being equated with gradual ventilatory sustenance termination. Based on the recent studies it has been demonstrating that approximately 60 to 80 percent of patients under mechanical ventilation can be extubated successfully after they have passed the spontaneous breathing tests. It is apparent that there is minimized reduced risk in conducting closely observed spontaneous breathing tests in those patients whom the acute failure of the respiration can be removed while achieving cardiovascularly stability so that the capability of sustaining effortless breathing can be evaluated (Glossop, Shepherd, Bryden, & Mills, 2012). When patients retain their clinical stability without any signs of inappropriate tolerance till the trials have been completed, tracheal tubes should be removed immediately. However, if the respective patients acquire poor tolerance signs the waning procedure is then categorized as a failed one thus requiring mechanical ventilation reinstitution.

Weaning trails that are categorized as inefficient normally indicate incomprehensive illness resolution that precipitates mechanical ventilation need or the rise of fresh issues. Weaning failure is attributed to the creation of imbalances amid loads that are faced by neuromuscular and respiratory muscles competence if the strength balance and all the acquired loads cannot be balanced adequately achieving effortless breathing might not be productive (Glossop, Shepherd, Bryden, & Mills, 2012).

An illustrative instance on how differing forces can result in ventilatory needs and the capacity of respiratory imbalance is that of critically hyper inflated persons. In this category, inspiratory muscles loads are usually increased for several reasons (Pearl, 2014). To begin with, airway obstruction and hyperinflation tidal breathes that happens in higher pressure capacity lung curve which increases the loads furthers. Hyperinflation is common in COPD patients and would thus play a significant role in weaning failure thus the need to consider PEEP measurements in all the COPDs who fail the weaning procedures (Pearl, 2014). With the understanding of the detrimental implications of PEEP in raising loads, all the efforts should mainly be targeted at lowering it. Airway impediment severity lessening should be dropped by the minimization of treatment, aperture setting adjustment in the establishment of more time in completing complaint occurrence while cultivating tolerance size to effortless conscious through work stimulation lessening by an addition of peripheral PEEP which is the most operative healing health interventions. PEEP addition does not lead to additional hyperinflation or it does not affect the gases exchange rates (Pearl, 2014).

Criteria for Determining Weaning From Mechanical Ventilation Success

Regardless of the weaning approach that has been utilized physicians are required to determine weaning success. Despite the fact that mechanical ventilation has grown to be a life-saving advancement it is inevitable to create decisions on weaning patients from the ventilatory support which normally necessitates the skillful incorporation of technology, teamwork, knowledge as well as proven protocols (Pearl, 2014). Mechanical ventilation weaning can be categorized as central to critically ill individual’s management. Decreased or necessitated prolonged procedural weaning raises ICU to stay duration thus raising costs, reducing beds obtainability which can affect the outcome of patients in general. Mechanical ventilation process discontinuation of challenging and it is completed in a number of stages.

To begin with, patients are required to have recovered adequately from critical imbalances in reference to physiology which resulted in the complication of their critical ailing session so that the weaning commencement can be considered (Balas, et al., 2012). Second, the patient is supposed to be involved in progressive ventilator support reduction until the time when they are able to breathe effortlessly is acquired. Third, disconnection of the patient from extubated, ventilator should be done so that effortless breathing can be achieved. A number of strategies ate also utilized in determining those that suits weaning and the modes through which they can be managed throughout the process. The weaning success criteria should be a simplified one with the easiness of data collection with low-cost insignificances to predict extubation and subsequent weaning success. These criteria are set based on the general needs of the patients to facilitate the acquisition of success in general without creating any form hindrances (Balas, et al., 2012).

Weaning readiness is usually determined by several factors. First, the support must have been able to improve the probable cause that resulted in respiratory failure. This, therefore, means that the illness must have been established, improved or even resolved from the previous critical condition. The procedure in addition must have been able to achieve the absence of the major failure of organs which might affect the individual’s capability to breath without the application of many efforts. Third, the appropriate oxygenation level should be achieved within prior to the removal. This is to ensure that the patient is able to oxygenate the blood flow to provide adequate strength to all the muscles (Balas, et al., 2012). The other requirement is having an adequate ventilatory level which will enable the body to function adequately. In addition, an additional aspect that is necessary for extubation is intact protective airway mechanisms. Ventilatory drive that is adequate for the body refers to the general capability of controlling self-ventilation level. In addition, this is the required conscious level that demonstrates cooperation gag and cough reflex intactness and respiratory muscles that are functions. This implies to the general capability of supporting effective and strong coughs and retaining normal breathing (Pearl, 2014).

Mechanical ventilation weaning necessitates patient’s preparation, readiness evaluation in determining independent breathing and extubation. In addition, a brief test of breathing that holds low assistance is to be conducted (Balas, et al., 2012). This should, therefore, be conducted in a gradual or abrupt withdrawal of the desired pressure in reference to the readiness of the patient. The extubation criteria can, therefore, be stated as first the capability to protecting the upper airway effectively with minimal support, effective cough, consciousness or alertness in regard to the happening in the particular setting, clinical condition improvement, and enough larynx and trachea adequate lumen. This can be evaluated through the use of leak test during the pressurization of the airway with a deflated cuff (Balas, et al., 2012).

            Weaning Protocol and ABCDE Bundle for Weaning

Despite the fact that most of the technology advancement in the health profession in the recent decades it is apparent that mechanical ventilation still remains to be the most complex in the sector.  Mechanical ventilation weaning or liberation creates more challenges that necessitates excellent evaluation skills and practical competence while utilizing the machines (Balas, et al., 2012). While in most cases making the health provision more effective through safer ventilation as well as weaning facilitation the same advancement, in addition, makes success the hardest thing to achieve since these additional developments, in addition, offers more respiratory therapy options. In most scenarios, the fresh technological models have never been justified being more efficient when compared to the conventional modes. However, it can never be denied that they have resulted in weaning procedures simplification as they design patient-centered critical settings. Most health care procedures are simplified via the use of acronyms for easy understanding and convenience. This is an approach that normally reminds practitioners of the most appropriate procedural stages like circulation, breathing, defibrillation and airway in the general cardiac support which is denoted as ABCD (Balas, et al., 2012). The acronym can be utilized in the ventilator mechanical weaning protocol with the addition of a few words.

ABCDE bundle is best described as the coordinated efforts amid a number of management disciplines attending to the patients who are critically ill. The utilization of the approach is normally aimed at lowering immobility, over sedation and delirium development of all that harms the wellness of the patient (Balas, et al., 2012). ABCDE bundle is utilized in the representation of a guide that is based on evidence which is utilized mainly by clinicians in the approach of all changes within the organization so that ICU patient outcomes and recovery can be optimized. The bundle usually incorporate Assessing, prevention, pain management spontaneous awakening and breathing trial and choice of sedation and analgesia. ABCDE bundle usually contributes to weaning ventilation, delirium management as well as early ICU ambulation (Balas, et al., 2012). In that, the bundle usually facilitates all registered nurses, respiratory therapists, and physicians in working together so that the outcome of lowering complications related to ICU can be reduced. Ventilator Weaning normally occurs rather faster since patients are likely to get over-sedated and this results in the reduction of the general ventilatory stay and the associated complexities. Based on research it is indicated that Delirium stays for about for a yearlong after the discharge from hospital can thus be lowered by the identification of those that develop it and managing it aggressively with the adjustment of medications and the caring plan. The earliest ambulation ABCDEF bundle portion is a procedure that incorporates 6 steps that begin as early as the first hospitalization day and continues until the ambulation of critically ill patients even for the ventilated ones. This results in the reduction of muscle wasting thus decreasing the ventilatory period (Truwit, 2011). ABCDEF bundle does not only seek to reduce they general period rate that is utilized under mechanical ventilation but additionally lowers the general death level, and ensures that pneumonia that is associated with ventilatory support are also eliminated which results in successful weaning.

These letters are a representation of the most practical and significant forces that must be accounted for during, prior and post-weaning including extubation processes. ABCDE is a useful model for the simplification of the entire weaning procedure in association with weaning guidelines grounded on evidence (Truwit, 2011). Weaning process cannot be effective without ensuring that all the processes that involve frequent evaluation of the patient which should incorporate a continuous patient’s reevaluation general medical administration on the grounds that these aspects might impact the dependency of ventilatory support. Ventilatory support should be objected and increasing comfort while unloading the involved respiratory muscles. In cases that patients necessitate prolonged support, they should be directed to special facilities that seek to offer gradual support reduction (Truwit, 2011).

The weaning assessment procedure should include gas exchange adequacy, circulation stability and the general ability in initiating inspiratory or breathing effort. In addition, the assessment should also evaluate Airways before being extubated (Truwit, 2011). It is apparent based on recent literature weaning that not offer any guarantee of extubation success as it would be agreed by many that the prime intention is to proceed with successful extubation post weaning. Given that compromised airways would mainly result in weaning attempt failure airway assessments should be incorporated into the weaning protocol in avoiding prolonged ventilation.  Tracheostomy consideration in the early stages of the process is both reasonable and beneficial given that it expedites weaning which results in the reduction of mortality, illness as well as costs in general that are linked mainly with mechanical ventilation assistance (Truwit, 2011).

Weaning Protocol Outline

1. Some reversal evidence of the existing respiratory failure cause
2. Adequate oxygenation
3. The hemodynamic stability which is described by active myocardial absence and the absence of important clinical hypotension. This is a health situation that necessitates vasopressor therapy.
4. The ability to initiate inspiratory effort including the capability to cough and supporting unsupported breathe with reduced efforts.

Weaning protocol should be safe and effective given that delayed and premature weaning may lead to unintended harm (Truwit, 2011). Additionally, a protocol should be a reflection of the standardized approaches that seeks to liberate patients from mechanical ventilation in improving care continuity as well as the reduction of mortality, illness as well as all the linked costs. Given that standardized protocols might fail to demonstrate effectiveness in all the given cases properly designed, patient-centered protocols can be effective in liberating all patients in about 60 to 70 percent of all the given cases based on most studies (Truwit, 2011). In ensuring successful mechanical ventilation weaning an initial evaluation of the four prime criteria aspects outlined above are to be accounted in the protocol given that it offers the most appropriate weaning readiness evidence.

With respect to ABCDEF model, the logical queries regarding ever letter should be reflected. (A) Refers to the basement is aimed at evaluating the intactness nature of airway to determine whether the results states that any weaning should be conducted (Balas, et al., 2012). On the other hand (B) which represents breathing seeks to ensure that a patient holds the capability of initiating self-effortless breathing. (C) Stands for hemodynamic stability and therefore the stability of the cardiovascular should be assessed (Balas, et al., 2012). (D) Reflects on diffusion which seeks to establish whether the existing respiratory failed issue can be stabilized or resolved. In that, this should establish whether the gas exchanges is one that is adequate and that the patient does not necessitates much effort (Balas, et al., 2012). If all the affirmative logics can be justified then this implies that the next weaning stage can be initiated but for most practitioners, a number of conventional limits must be accessed for the procedure to be grounded as effective.

Pro/Con Ethics Debate

Morally the debate can contribute in the development of firm practices and policies in regard to offering Ventilation and weaning care to critically ill patients. In addition this will result in the development of knowledge and increased abilities and weaning simplicity. However, the information and the proposed protocol might complicate some of the adopted strategies. SBT should be conducted on regular basis in ensuring that the patient’s capability has been assessed. In addition, this will seek to initiate pressure reduction to create more opportunities for the patients in breathing individually (Balas, et al., 2012). This approach helps in strengthen the respiratory muscles and increasing the general gases exchange rates. In that in order for the adults to be liberated from the support they must demonstrate their general capabilities of breathing with minimal support. SBT seeks to ensure that the most suitable care is provided since respiratory support can never be withdrawn one given that it is a continuing procedure. During all the SBTs comfort and tolerance capability of the patients should be accessed while utilizing the ABCDE model. If the patients have the capability of tolerating SBT for above 30 minutes this would imply that permanent ventilator discontinuation, as well as extubation, should be considered (Balas, et al., 2012). With the presence of uncertainty, the trails can be extended up to 2 minutes and stopped after all the criteria have been achieved. The model offers weaning simplicity during the conduction of all the clinical evaluations. In addition, patient’s wellness safety, as well as the accuracy of the weaning procedure, is also ensured. Actually, the use of well-structured protocols is useful in the liberation of patient’s majority while developing care continuity and decreasing costs, deaths and illnesses linked to mechanical ventilation (Truwit, 2011).

Conclusion

Daily spontaneous breathing tests for patients under mechanical ventilation with the objective of establishing those with the capability of effortless breathing is regarded as the most suitable approach in lowering the ventilatory support period. SIMV is known to be the most incapable approach in weaning adult patients with respiratory failure. With respect to the utilization of pressure support, clinicians are to select the approach that they feel to be best based on the patient’s respiratory needs and the approach should be customized in meeting the identified needs. Spontaneous breathing daily trials use for those patients that are difficult-to-wean should mainly be applied. This is because it results in extubation which is double effective when compared to PSV. It normally simplified care management given that the capability of the patients to breathe effortlessly without the support of ventilators requires daily evaluation. This permits a rather prolonged resting period which can be noted to be the most effective approach in increasing muscle recovery adequate timing.

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Bottom of Form

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Outline

Weaning From Mechanical Ventilation for Adult Patient

            Abstract

            Weaning normally incorporate the complete procedure of the general liberation of the patient from mechanical support as well as from the endotracheal tubes. Given that mechanical ventilation weaning normally incurs significant costs, mortality and illness and also untimely and delayed extubation can result in harm weaning that can be categorized as safe and speedy is highly required. There are controversial concerns in regard to the best approach that should be utilized in the conduction of the mechanical weaning procedure. Weaning can be fastened by the use of SBT and every day’s screening of the functioning of the respiratory.  Respiratory rate can be categorized as the best successful weaning predictor. The utilization of now- aggressive ventilation models might be useful in improving the general outcome of a number of patients who might acquire respiratory failures during the extubation process. The study established that weaning should be considered the earliest possible. In addition SBT is the prime diagnostic test in the determination of whether extubation would be successful. Non-aggressive ventilation approaches should be utilized in shortening the intubation period but should thus not be utilized as often tools in reference to extubation failure. In achieving the study’s success the study utilized a systematic review approach to the recent evidence-based studies.

            Introduction

            Weaning from Mechanical Ventilation is best described as the general gradual procedures for withdrawing ventilatory sustenance. Close to 800,000 adult patients necessitate the support of mechanical ventilation every year (Chang, 2014). Undoubtedly this is an existence saving intervention but it is one of the approaches that are uptight with the probability of iatrogenesis particularly if the support is utilized extensively than the required period. Based on scientific estimations 90 percent of the critically ill adult patients require the support of mechanical ventilation and while acquiring the support the patients are amid the weaning procedures which account for approximately 40 percent of the general time (Chang, 2014).

Literature Review

• Mechanical ventilation overview
• Respiratory Weaning
• Mechanical Ventilator Weaning issues
• Predictive Mechanical Weaning Criteria
• SBT/Extubation Protocol and AM Bed Huddle Effectiveness
• Criteria for Determining Weaning From Mechanical Ventilation Success

Project Protocol Elements

1. Some reversal evidence of the existing respiratory failure cause
2. Adequate oxygenation
3. Hemodynamic stability which is described by active myocardial absence and the absence of important clinical hypotension. This is a health situation that necessitates vasopressor therapy.
4. The ability of initiating inspiratory effort including the capability to cough and supporting unsupported breathe with reduced efforts.

            ABCDE Bundle in Mechanical Ventilation

            ABCDEF bundle is best described as the coordinated efforts amid a number of management disciplines attending to the patients who are critically ill. The utilization of the approach is normally aimed at lowering immobility, over sedation and delirium development of all that harms the wellness of the patient (Balas, et al., 2012).

Pro/Con Ethics Debate

Morally the debate can contribute in the development of firm practices and policies in regard to offering Ventilation and weaning care to critically ill patients. In addition this will result in the development of knowledge and increased abilities and weaning simplicity. However, the information and the proposed protocol might complicate some of the adopted strategies.

            Conclusion

            Daily spontaneous breathing tests for patients under mechanical ventilation with the objective of establishing those with the capability of effortless breathing is regarded as the most suitable approach in lowering the ventilatory support period. SBT/extubation protocol and AM bed huddle are effective in decreasing the time to extubation from when an individual passes SAT/SBT AM bed huddle. ABCDE model is useful in decreasing mechanical ventilation duration.

Autism special program

Autism Society of America was established in the year 1965 by a man named Rimland Bernard. In late 1968, Sullivan became the president of the society as an organization that involves human relations. Over the past more than four decades, the organization has developed from just involving the parents to being a leading source of vital information, reference, research, and supporting the autism spectrum. This organization is the oldest and also the largest organization from the grassroots with the community of autism (Nichter & Edmonson, 2005). The organization begun as an advocate in 1969 to being a joint commission for mental health for the children and also played a central role in the legislative efforts like section 504 on development disability acts, campaigning for an increased autism, educating all the handicapped children and much more. Autism Society has always engaged in the systematic difference which has a real impact on the lives of many people. A nationwide campaign by the Autism Society started in the early 1970s and was adopted by the Congress in the year 1984. This move made the society to grow stronger and even caused the release of an awareness ribbon in the year 1999. In 1976, autism society established a foundation that was really into applied research (Gelbar et al., 2014). By law, the program requires that a single or both the parents must be present at any meeting that involves their child who is physically or mentally impaired, teacher or caretaker of the child must at all times be available for any decision making meetings. There has to be a representative of the public agency at the place of any meeting that involves the individual education planning (IEP).

Individuals who have the autism spectrum disorders (ASD) disorders can suffer from developmental impairments such as the social, physical and behavioral issues. People who are known to develop the ASD issues start to display some unusual acts, impaired non-verbal and verbal communication, and paying attention to unnecessary things (Gelbar et al., 2014). Victims of autism start to develop physical ailments like digestive disorders, persistent infections, asthma, and epilepsy. Symptoms and signs of the autism disorder start before the age of three years and can continue for life. ASD can occur in any ethnic, race, and the socioeconomic categories and the highest possibility of occurrence are to boys than to girls.

Autism Society program is very important in schools today as it creates the awareness, inclusion, and acceptance of every child. The main ideology is for every member of the society especially the kids to feel welcomed in the society they live in even with the disability. The educational planning for the children with disability in schools mainly addresses skill development inclusive of the academic considerations such as communication, social skills, behavioral skills, leisure related skills and language development (Wong et al., 2015). It is always recommended that a person should seek a professional guidance especially when it involves autism in order to assist the children to get the best from the autism society program.

The autism society program is mainly intended for the parents but it has its focus on all generations since the main point of the program is to get as many people as possible to feel accepted and part of the larger society. Parents are targeted in the actual sense since they are the most affected by this issue. Once a parent has discovered that the child has an issue or certain symptoms, many of them try to shy away but the program encourages them to come forward and receive the help and assistance they need in making their children have a good life. Without such a program many children could die or get into much more challenging life situations. Currently, the program focuses on individual child meaning that in the event there are two or more suffering from autism, they cannot share the program at any one given time (Nichter & Edmonson, 2005).

The program is being used according to how it is required since the guidelines are followed keenly to ensure that there are no missed steps in the schedule. One program cannot be shared amongst two children and so this is observed with seriousness in every way. According to the individuals with disabilities improvement acts (IDEIA) of 2004, now the parents were to be included in the programs of any group of people who make the decisions on educational strategies and routines of the child. In the development of an individualized educational planning (IEP), the members and the parents of the children always meet to make conclusive and result-oriented plans and schedule for their children. The children and the guardian are expected to complete the individual educational planning and this is done considering whether the parent is around or away meaning that the program is followed effectively (Wong et al., 2015). A number of pages in the IEP must be filled in duly and this is done without failure.

Many of the parents who have their children suffering from autism start getting so committed to their daily routines in ways that make them forget the future of their children and planning is very important especially at this stage. The future of such a condition arrives soon when the parents and the guardian have not planned for it. To take care of a person and especially a young child, quality life is very important financially and legally in order o eradicates the issues that are caused by lack of proper planning. Special needs are required in order to plan and ensure that there is economic security for the children. The future of the autism society program is to continue offering the world with a way in which the children can be comfortable and feel as members of the society (Nichter & Edmonson, 2005). The society has a future of working in a network that will improve the living status of people who have been affected by the autism. Increasing the awareness to the public on the issues that are faced by the people with autism is a strategy that allows a common man to be free with life situations. The program continues to campaign for appropriate and adequate services for the people who are living with or affected by the autism condition. With the research that it carries out on how to make autism disappear forever, the organization continues to share any information with others for quality treatment, education, advocacy, and research.

At school, the program faces a lot of challenges especially in classes where there are lots of noises and the children with autism are present (Gelbar et al., 2014). Children with these disabilities occasionally undergo certain challenges through their daily lives like feeling nausea in any group setting. The program does not recommend a child to be amongst other children when maybe eating since the different aromas can be hard on the spectrum, therefore, adding more challenges than there were before. To be in such a place it requires a lot of sacrifice and degree to socialize but for the small children, this can be a challenge. Stress levels for the child can be very high causing the child with autism to panic in the event and since the settings nature do not allow one to be free, talking it out might be very difficult. This may delay the time expected to get help from the outside, therefore, causing the impairment to become worse. The children with the conditions can be isolated at times and allowed to choose what they feel is comfortable with them. During the times when there are group works, then selective methods should be used to ensure that the child is free and does not have any disturbing smell or issue with the group mates (Wong et al., 2015). Allowing the children to have some time out of the norm is helpful as they will not have to be at the same time for long hours and therefore eliminates anxiety.

The society and the management at schools including the court recognize the idea that children with a disability also have the right to have the education that is free and quality. The rights to having quality education can in the current times not be an issue in the world but the specifics on how to offer such services to the children according to the programs is the main issue (Nichter & Edmonson, 2005). Autism Society program recommends ways in which this can be obtained and allow the children to have the best type of education through the individual educational planning system. Strictness should be observed at all times for quality results according to the guidelines.

References

Gelbar, N. W., Smith, I., & Reichow, B. (2014). Systematic review of articles describing experience and supports of individuals with autism enrolled in college and university programs. Journal of autism and developmental disorders, 44(10), 2593-2601.    

Nichter, M., & Edmonson, S. L. (2005). Counseling services for special education students. Journal of Professional Counseling, Practice, Theory, & Research, 33(2), 50.

Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., ... & Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45(7), 1951-1966.

Urban Affairs issue: Healthcare (Obama Care repeal)

Problem

Obamacare or Afford Care Act (ACA) is a health policy in U.S which was passed on March 2010 for the purpose of providing Americans with essential health services, affordable and quality health insurance. President Barack Obama focused on provision of quality care and health insurance coverage regardless of race, ethnicity and disability, and ensured the prevention of chronic diseases (Stack, 2016). However, ACA is a controversial issue in that the Republicans have created the agenda on repealing the ACA and they have created a slogan ‘Repeal and Replace’ (Stack, 2016).  The big problem with the Republican is that they do not have an alternative while majority of American people argue that there should be no repealing without replacement. The problem with ACA arises since opponents argue the law on ACA is a ‘job killer’ and imposes high costs on business. Private businesses do not benefit from the insurance coverage and indeed, they view it as an unwarranted intrusion. Other problem is that since ACA is constitutional, states were forced to modify the programs on Medicaid and the federal government was required to add more funding to the State to enable them increase the number of people entitled to receive Medicaid (Stack, 2016). However, the court rules out the States may cease to provide Medicaid expansion and this is an indication that poor people were enforced to engage in private insurance. Insurance companies are experiencing a challenge in that fewer Americans are signing up and this is an indication that insurances costs are high and this continues to discourage people from participating. ACA subsidies are few and failure to sign in raises higher fines and discourages middle-income American from enrolling in plans (Stack, 2016). Other problem with ACA is that premiums and government subsidies will increase   but the subsidies are not provided to Medicaid members.  

            The history of Obamacare helps us understand why it has failed. ACA is a debatable issue in political arena and in 2009 when the debate on legislation was high, Republicans were unified to resist and Democratic were unified to support it. In the Supreme Court, the law was changed through Medicaid expansion to cover the disabled and the poor people. The coverage expansion was also aimed to include the middle and lower workers (Stack, 2016. However, in 2014, health insurance exchanges become a heavy burden to insurers. The debate on ACA started back in 20^th century when Americans presidents Theodore and Clinton showed their effort in implementing health insurance program though they failed.  Medicaid was enacted in 1960s by President Lyndon for the purpose of providing health insurance to the old and disabled Americans (Stack, 2016. Children and families health insurance was also passed in 1997. In 2003, Medicaid programs were expanded to include the drug coverage. The major problem as to why America lacks a single payer system is due to capitalism. The latter is associated with government intrusion and both have contributed to problem of ACA.

Issues

Majority of Americans are involved in the intense national debate since they believe that the Obamacare is irreparably flawed.  Opponents offer arguable points that ACA has contributed to several negative issues such as high cost for business and families, high taxation on middle-class and excessive spending on health care, unanticipated consequences among many other issues which will be discussed   in the paper (Lichtenstein, 2017).  The partisan process was successive in the creation of ACA and  majority supported the law. However, survey data showed that after the enactment of the law, 39% favored the ACA while 49.3% were opponents. The issue raised was that even though the healthcare is affordable, majority of family pay 35% for healthcare.  Individuals and business are experiencing the challenges of higher health care costs. Even though premiums have increased, individuals are not protected by previous coverage (Lichtenstein, 2017). ACA’s administration pose challenges to families and individuals and many of the problems are as a result of increasing costs of quality care, financing and more. Even though the ACA’s administration promised Medicaid expansion and additional enrollees, the expansion of Medicaid is still a substandard. The  functionality of the  main provisions  present some issues in that initially, the  ACA had ambitious agenda but  the  approaches used in  solving  problems have been ineffective. Problems arose in 2013 when the federal government introduced health insurance exchanges websites and this revealed operational problems and managerial failure. For example, there were managerial failures which were related with ineffective leadership, poor decision making and poor project tasks (Lichtenstein, 2017). The federal websites lacked effective management and as result, there was a flawed arrangement based on dealing coverage exclusion, there were high   health insurance costs and the overall process of insurance subsidies was complex. The ACA is flawed in that the subsidy programs are not administrated effectively since enrolment on subsidy is measured by eligibility, income, family size and residency. Problems have been encountered by low-income enrollees in that there is inconsistence of data and fraud. In addition, there are unprecedented mandates in that in 2014, American cities were forced to sign in and purchase health coverage but the Obama administration was reluctant and showed exemptions and delays. Due to multiplying exemptions and failure of the administration to delay penalty provisions, out of 30million uninsured, 90% were not fined (Lichtenstein, 2017). In discussing the issue, it is important to understand that ACA is the root cause of centralized power which affects the efficiency and effectiveness of federal government. The problem with centralized power as related with economy is that it will be difficult to poses requisite knowledge which also makes it difficult to gain cost and quality.  The key point which everyone should get from issues contributed by ACA is that families and business are negatively impacted in that the high insurance costs are a   heavy burden to them.  Despite the fact that president promised premiums increase by 10% 13%, there was a premium rate shock in 2014 (Lichtenstein, 2017). The latter led to the out-of pocket costs which are made by premiums and deductibles.  For example, low cost premium plan moves together with higher deductibles and in this case, low middle-income workers are constrained when it comes to insurance choice.

Ponnuru (2017) asserts that repealing is ‘a risky Obamacare strategy’. For seven years now, Republic has not gained the power to repeal and replace the Obamacare. It is true to say that they have the power to repeal because huge support is coming from White House and house of Congress but they lack a strategic approach of making the repeal. The reason why there are some constraints in changing the Obamacare is that almost all Republic supports the end of ACA and they argue with philosophical and practical points of view.  The same people fear that the end of ACA will negatively impact them since they will lose the health coverage. There is also a conflict between the republics since they do not agree on ‘replacement system’ (Ponnuru, 2017). Some argue on implementing catastrophic-insurance policies while others argue on implementing existing government policy or add free market policy. It is important to understand that repealing Obamacare will contribute to disastrous effects. Many will be uninsured according to an estimation which showed that repealing will make 24.0 million to uninsured and 19.4% in the whole population will be uninsured in 2021(Ponnuru, 2017). If ACA will be repealed, Medicaid enrollment will decrease. Since the enactment of ACA, 52.6 million are covered by Medicaid and Health Insurance Program for children and if the enrollment continues, 69.3million will be enrolled by 2021. However, repealing will only enroll 14.5 million. A big effect will be on Insurance Coverage since enactment will increase the Uninsured. Economic Policy Institute sates that repealing will affect spending and taxes which will be approximately $109billiuon federal spending   cuts and $70billion taxes in 2019(Ponnuru, 2017). Both tax cuts and spending cuts will lead to economic damage where job growth will fall by 1.2 million in 2019.  Other point to note is that repealing will affect the purchasing power of working people, and this is an indication that local economy will be affected since people will spend less. Decrease in spending will reduce job growth and about 20million people will lose health insurance (Ponnuru, 2017).

 The Issue on Obamacare repeal has been addressed and the main solution which has been offered is related with ‘if ACA should be repealed, then there should be a replacement (GARLAND, 2017).  However, failure to replace will be a big challenge to the American people.  Furthermore, repeal and replace is not an effective method and it is irresponsible in that it will worsen the health care system. If repeal is done without replacement, there will be uncertainty and Republican must understand that insurance companies and Health Insurance Marketplace will increase the prices. In addressing the issue, the perception that has been used is that individuals and families should be allowed to make decision through a patient-centered system but ACA denies this system since it is strongly fixed on federal government system (GARLAND, 2017). The best solutions have been offered regarding the patient-centered system and to achieve the latter, Obamacare repeal should be implementing in order to allow people have personal ownership and gain free-market innovation. In addressing this issue, it has been found that the ACA is unaffordable and unworkable and so repeal will allow Americans control their health insurance and gain tax relief (GARLAND, 2017). However, the solutions offered in addressing the issue are not implemented since Republicans are in dilemma as they have not set healthy care structure. Current, the issue is on ‘repeal and delay’ and this is another serious issue which will lead to new problems.

Solutions

 First, it is important to understand that Obamacare is rooted from federal power which raises dependence on government, federal micromanagement and tax hikes. In repealing and replacement, individuals are interested with a better system which is able to provide reliable coverage and quality care. However, even though majority focus on repealing, this strategy is not enough since it does not include serious reforms and the few reforms will not address the financing health.  The solutions are identifying the root cause of problem and fix (Hathi & Kocher, 2017).This is because; the health-care system is effective in terms of medical innovation and majority of American people access advanced care which is supported by insurance arrangements. However, rising cost is a big challenge where government’s revenue is spent on economy rather than on health care and this has contributed to deficits and debts. Tax exclusion has also resulted to employer-purchased insurance which has hindered not only consumer market coverage but also cost and value. Now, the solution is developing an insurance reform through developing a ‘defined contribution’ (Hathi & Kocher, 2017). The latter means that assessing the financial health care system will be a key element in creating a market-based approach and allow consumers be cost-conscious. The government should also provide ‘premium support’ which allows consumers to have personal responsibility and individual mandate. To address the pre-existing condition, the federal government should promote individual insurance which will allow individuals to have affordable options. Reform should also correlate with States partnership (Hathi & Kocher, 2017). Under ACA, States embrace federally managed system which allows them to create new programs such as insurance exchange where they pose extra costs. The reform should encourage partnership and allow States adhere to national policy and unite in creating policy innovation, insurance-market reform and safety-net programs. Other reform should be related with employer-sponsored plans and address issues which have been brought by federal tax policy such as higher costs of health care, lack of secure coverage and transparency in financing, discrimination and favoritism. To address this, there should standard tax credit which provides choice for coverage (Hathi & Kocher, 2017). This approach will also develop consumer control and allow them to have control in the health-care marketplace.  Finally, reform should be done on Medicaid since it does not provide high-quality coverage. Medicaid has also resulted to lack of quality health care especially the lower-income people. To address this, individuals should be provided with private health-insurances and this will enable them access quality care (Hathi & Kocher, 2017).

Recommendation

Thus, the best approach is to fix some weaknesses in the health care system and the big challenge to consider is the rising costs (DRUM, 2017). Majorities are unable to pay insurance and government is experiencing challenges due to high budgets. The Medicare is flawed due to its inefficiency and overuse and its effect on economy. Tax exclusion is another problem especially on workers’ taxable income, and this later affects the consumer market. Generally, the big problem which needs to be fixed rather than repealing is cost explosion. In other words, there should be ‘insurance reform’ and this reform will cover all the uninsured, will address the issue of costs explosion and address the insurance coverage on pre-existing conditions (DRUM, 2017).  Note that cost-cutting innovations will lead to new structure of health system and there will be strong financial incentives and highly competitive market place, thereby increase productivity and quality of care. The role of public administration on this reform is to make effective decisions based on provision of quality services. For example, on the issue of controlling cost, professionals of healthcare administration will create health programs and develop strategic planning of government services. It is their role and accountability to bring a systematic improvement on financial, access and quality (DRUM, 2017).

Reference

Stack, S. J. (2016). Health Care Reform in the United States: Past, Present and Future Challenges. World

Medical Journal, 62(4), 153-157.

Hathi, S., & Kocher, B. (2017). The Right Way to Reform Health Care. Foreign Affairs, 96(4), 17-25.

PONNURU, R. (2017). A Risky Obamacare Strategy. National Review, 69(2), 16-18.

DRUM, K. (2017). Here's How to Save Obamacare. Mother Jones, 42(1), 19-21.

GARLAND, S. B. (2017). The Impact on Medicare of ACA Repeal. Kiplinger's Retirement Report, 24(3), 14-

15.

Lichtenstein, N. (2017). Who Killed Obamacare?. Dissent (00123846), 64(2), 121-129.

States Strategies

Maryland All-Payer Model

 The creation of this innovation was enabled by 1971 Maryland legislature act, and through which a Health Services Cost Review Commission (HSCRC) was established with various responsibilities relating to public disclosure of financial information of hospitals and even trustee relationships. This commission was given the mandate to set rates for hospital payments affecting all payers. The implementation of this system was driven by the need to address the rapid rise in hospital costs and risk of insolvency faced by many non-paying patients (Consumers Union, 2015). Hence, those patients who depend on these hospitals for healthcare were faced about to lose access to them.

 This system is enabled partly by a Medical waiver spanning 36 years, and Maryland is exempted from OPPS (Outpatient Prospective Payment System) and also from IPPS (Inpatient prospective Payment System) which accords it the authority to set payment rates for the health care services provided by hospitals. This waiver allows all the third parties to use the same rate while making payment .The expectations are that All-Payer Model can succeed in betterment of the health care provided while minimizing program expenditures among the residents of the State including the beneficiaries of CHIP, Medicaid and the Medicare (Center for Medicare & Medicaid Services, n.d).

 The system has been very effective in serving the purpose for which it was intended since its implementation. The state has been able to moderate the rise in costs for each hospital admission and has seen an improvement in financial stability among the various hospitals across the state. In addition, the state kept increase in costs for each service in the hospitals quite low in comparison to other states. Statistical data shows that the state has gone from 1967 26 % higher than national average to about 2 % lower as per 2007(Consumers Union, 2015).

Reference

State Hospitals

 For Jane Joe, the issues that led to her admission were the difficulties that the Assertive Community Treatment experienced connecting with her and getting her to stay on medication and the deterioration of her situation of her situation especially due to drunkenness. The refusal to take medication was a major problem which made her to remain seriously disorganized and forcing the health care providers to embark on involuntary medications (Radke & Goetz, n.d., 28). The major assessment that is needed for this situation is the medical cause or inherent personal problems that may have made Jane to refuse medication. The community seems to have offered their support for her but failed to bring her under control. Even with such social support there seems to be personal issues that might have led to her drunkenness and whose assessment would lead more light on the same. Jane needed treatments that would control the acute agitation episodes she portrayed even if it had to be done involuntarily (Radke & Goetz, n.d., 28). The treatment seemed to have worked for Jane as she was able take part in groups and even being integrated to the community. The management of the community worked very well for her so that she was able to manage her life after being discharged.

The case of Joe Doe shows neglect by the community around him that avoided him because of the behavior wrought by abuse of methamphetamine. Unlike Jane who the community tolerated her sleeping on door step, Joe had to break into a garage to find a sleeping place. The only way he was admitted to OSH was after he was found unfit to stand trial (Radke & Goetz, n.d., 29).  There various issues that might be assessed in this cause including community neglect, growing up in an abusive home where he had been adopted which made him to drop out of school and early drug indulgence. Unlike Jane who had the care of the community-based organization, Joe had none of it and his admission came after various incarcerations. The medications seem not to have worked for him, since he is barely able to participate in group treatment programs.   The treatment has not prepared him to be reintegrated into the community and even managing his own future. The community providers are quite skeptical and unlikely to embrace him and even his release is not likely to be released (Radke & Goetz, n.d., 29).  The management in the case of Joe seems has not had success in healing the psychological and social issues affecting the patient. Of more concern is lack of community empathy and willingness to walk through with Joe like Jane until substantial control is achieved.

The two admissions involved can only be compared in the role of medication in stabilizing and controlling both situations. Jane and Joe had to be undertaken through an involuntary medication only after their condition had deteriorated so that to control extreme agitation and violence.  For both individuals, psychiatric problems can be attributed to extreme substance abuse which makes them unfit in their own community and hence the admission for treatment. There seems to be deeper social issues that led to substance abuse , and the treatment methods seems not to address the core issues of this case. Unless the two individuals are placed under mandatory medication or hospital care, they cannot bring themselves to gaining control of their life and future.  Lack of resources is major problem as seen in the case of OSH.

The state psychiatric hospitals started out as a refuge for different people including the poor, mentally ill and having developmental disabilities. After they were placed under states’ management, they shaped their roles to serving individuals with persistent and serious mental illness. After deinstitutionalization in 20^th century and with increased population growth, the hospitals failed to grow proportionately to increasing needs and previously deplorable conditions returned (Radke & Goetz, n.d., 28). Presently, these hospitals serve different groups of mental patients including the children, adults and the elderly. The role of these mental health systems also include admitting individuals for forensic commitments , and many acts as tertiary care facilities which both long-term and intermediate range patients (Radke & Goetz, n.d.,36).

The hospitals have faced various challenges ranging from clinical, administrative and financial. The clinical challenges relate to the culture such as the need to phase out the use seclusion and restrained as a health care procedure for psychiatric patients. The clinical challenges also stems from lack of positive care environment at home and even in jail due to increasing cases of violence and even homelessness, conditions that worsen this situation. There are also patients with chronic conditions in state hospitals that are poorly treated or are not treated at all. The administrative challenges are linked to the financial and resource woes facing the hospitals. The high cost of accessing medical care for the patients visiting the community hospitals is a major problem. Meeting the criteria set by the states means that few patients can benefit from the high expertise placed in the community hospitals. The community resources ended up being stretched to their maximum (Radke & Goetz, n.d.,42). A case in example is the present shortage of hospital beds in the psychiatric state hospitals which leads to immature discharge of the patients and end up being readmitted or incarcerated (Torrey,2016,1).  

References

 Radke, A., Goetz, R., (n.d). State Psychiatric Hospitals in the Twenty-First Century.  28-42

Local Health Care Delivery System

Strengths and weaknesses of my local health care delivery system

            The department of Access to Allied Psychological Services (ATAPS) is after bringing proper access to primary mental health and it supports general practitioners to provide services people with mental illnesses. This department of health has various strengths and a number of weaknesses. It has attained a favorable geographical spread including in rural areas. It has assisted in facilitating the innovative service models for example introduction of telephone based CBT American Academy of (Orthopaedic Surgeons & In Pollack, 2018). It has also reinforced the development of local teamwork models such as GPs and psychiatrists. The department has also empowered targeting of particular groups for example the homeless people, the refugees and the indigenous population. It has also empowered the development of mental health programs by developing links at local levels for example drought initiatives. It has worked to secure employment in places where fulltime private practice may not be sustained. This department has also been supported nationally by the primary mental health care network.

            The department has also got its areas of weaknesses that need improvement. First and foremost, it is expensive when compared to quality access. It currently does not provide service delivery to the most needy. In urban areas especially, its services are simply duplicating better access services. There are no enough incentives to fund arrangements for efficiency. Quality assurance has been problematic in certain areas when it comes to selection and training of health professionals (Nwaogu, 2006). Therefore, amidst all the strengths and the achievements of ATAPS, it needs to improve in these specified areas of weakness so as to deliver perfectly quality service to the people.

Conclusion

Access to Allied Psychological Services is a department of health that has exposed communities to primary mental health. It has registered various achievement for instance reaching out to the minority such as the homeless, the refugees and it is widely spread in the rural areas. It has also empowered the establishment of various mental health programs and facilitated them. However it is required make several improvements in its areas of weakness so as to attain highest objective.

References

American Academy of Orthopaedic Surgeons,,& In Pollack, A. N. (2018). Community Health Paramedicine.

Nwaogu, P. O. (2006). Mental retardation: An African perspective. Gaborone, Botswana: Bay Pub.

MGpart1

Article 1

            Neonatal abstinence syndrome (NAS)  is a problem caused by pharmacologic agents.  Newborns are mostly affected by this problem and it mainly occurs when pregnant women take harmful substances such as heroin and cocaine (MacMullen, Dulsk & Blobaum, 2014). Newborn displays various symptoms such as fever, poor feeding, sweating among many.  The problem is associated with possible complication such as premature birth, birth defects and more. The purpose of this article is to conduct systematic and critical review in order to determine evidence-based interventions toward this problem (MacMullen, Dulsk & Blobaum, 2014).

Systematic review

            Literature review was done   where 480 international classic artless not older than 10years were used.  In research, the key words were ‘nursing interventions’ neonates ‘neonatal syndrome’ and ‘substance withdraws system’ (MacMullen, Dulsk & Blobaum, 2014).  Findings were recorded in a table which contained title, author and abstract.  Note that most publication had observational studies which were taken from clinical trials.

 Systematic review results

Twenty journal articles offered supportive interventions such as swaddling, non-nutritive sucking and quiet environment.  Eleven articles recommended that neonatal who are not in drug therapy should prevent physiologic effects through comfort measures such as swaddling. Nine articles supported non-nutritive sucking, vestibular stimulation and   quiet environment. Other recommended interventions include supine position, music therapy, and rooming (MacMullen, Dulsk & Blobaum, 2014).

Article 2

 Nurses use venous access device to treat infant and children and to ensure the delivery of blood and nutrition to the body. However, evidence-based practice has shown that peripherally inserted central catheters (PICCs) are effective, safe and valuable than venous devices (WESTERGAARD, CLASSEN & WALTHER-LARSEN, 2013). This is because, the device has been used in neonatal populations and the outcomes are associated with high insertion success and less catheter complications.

Method and results

 Evidence-best practice was done through a literature search where the key term was ‘PICC and children’.  Relevant articles which conducted observation studies and clinical trials were used.  Conclusion was made by focusing on evidence-based recommendations. The results indicate that PICCs is used in hospitals and are associated with few preoperative risk and long-term complications (WESTERGAARD, CLASSEN & WALTHER-LARSEN, 2013).  .

Reference

MacMullen, N. J., Dulsk, L. A., & Blobaum, P. (2014). Evidence-Based Interventions For Neonatal

Abstinence Syndrome. Pediatric Nursing, 40(4), 165-203.

WESTERGAARD, B., CLASSEN, V., & WALTHER-LARSEN, S. (2013). Peripherally inserted central catheters

in infants and children - indications, techniques, complications and clinical

recommendations. Acta Anaesthesiologica Scandinavica, 57(3), 278-287.

doi:10.1111/aas.12024

Article 1

Physiotherapists play a significant role in helping patients manage pain and facilitate recovery. This is a science-based profession and physiotherapists focus on managing long-term illnesses and improving functional status (Baidya, Acharya & Coppieters, 2016).  In Intensive Care Unit, physiotherapists play the role of positioning, limb exercise, trachea suctioning and more.  However, it is important to understand the level of evidence in physiotherapy. The purpose of this article is to evaluate the treatment skills and therapeutic intervention in ICU (Baidya, Acharya & Coppieters, 2016)..

Method

            A cross-sectional survey was used and   86 physiotherapists   working in ICU over 2 years and who were qualified with Certificate, Bachelor and Masters were  included.  Questionnaire was used together with reliability analysis. Physiotherapists’ were asked to answer the questions which were based on PT staffing, demographic in primary hospital, mechanically ventilated patients in ICU (Baidya,  Acharya  & Coppieters, 2016).. Statistical method were used where data collected was recorded in Microsoft Excel and descriptive statistics was used to summarize the data.  Chi-square test and ANOVA test were used to   analyze different clinical scenarios.

 Results

            Out of 86 physiotherapists, 11 did not participate and 23 failed to offer response.  Thus, final analysis was made from 52 physiotherapists who participated.  25% were government physiotherapists, 19.2% were worked in semi-government hospitals and 55.8% were private (Baidya, Acharya & Coppieters, 2016). It was found that many physiotherapists in all hospitals offered PT after physician consultation or   there were ‘blanker referral’ which allowed the PT to be done. The services were based on chest PT, positioning and therapeutic exercise or   there were ‘blanker referral’ which allowed the PT to be done.  Finally the study shows that the main role of the physiotherapists was positioning, rotational therapy, and exercise among others (Baidya, Acharya & Coppieters, 2016).

Article 2

 Patients in emergency department face the challenges of pain after traumatic condition.  Studies have found that children experience much pain than adults since they do not get adequate treatment or in other words there is inadequate pain management (Ramira, Instone & Clark, 2016). Long-term effect contributes to pain sensitivity, chronic pain ailment, anti-social behaviors and more. To solve this problem,  health care organization  have  tried to manage pain but the article  assert that  nurses should  apply evidence-based approach  in order  to improve patients’ outcome. In the study, quality improvement project was designed to help nurses improve pain management. Six hundred children aged 3months to 6years   were used for project review before and after the improvement projects.  Project team used literature review where the key term used was inadequate pain management. The literature recommended the use of education   as an effective strategy   for improving nurses’ knowledge and management practices (Ramira, Instone & Clark, 2016). After gaining evidence, the Institution Review Board approved the project and project team   used pain education to address the issue.  Pain education started on July 2011 and topic included were pathophysiology of pain medication and more.  Final data analysis was done on Feb 2012.

 Results

 Nurses who participated in pain educated were full time and part time workless on emergency department.   Nurses conducted pain assessment on pre- and post-intervention.  It was found that there was project effectiveness since ANOVA results showed that nurses improved pain documentation from 17% to 93% (Ramira, Instone & Clark, 2016).  Nurses’ documentation showed big improvement since there was 58 % change.  The project shows that pain education provides nurses with skills and knowledge on pain management. In addition, pain education programs help nurses improve decision and confidence I on managing pain. Thus, improved knowledge is a special tool for better documentation of pain, pain medication and reduction (Ramira, Instone & Clark, 2016).

Reference

 Baidya, S., Acharya, R. S., & Coppieters, M. W. (2016). Physiotherapy practice patterns in Intensive Care

Units of Nepal: A multicenter survey. Indian Journal Of Critical Care Medicine, 20(2), 84-90.

doi:10.4103/0972-5229.175939

Ramira, M. L., Instone, S., & Clark, M. J. (2016). Quality Improvement. Pediatric Pain Management: An

Evidence-Based Approach. Pediatric Nursing, 42(1), 39-49.

Geriatric Dentistry

Introduction

Life expectations of people have been noted with the increase in the number of people who are geriatric. This condition is regarded to be a normal, inevitable and a biological condition or phenomenon. Study of physical and psychological changes which are mostly inclined to old age is known as gerontology and the care to the old age is called the clinical gerontology or simply geriatrics. Geriatric dentistry can similarly be defined as giving dental care to the elderly through diagnosis, the preclusion and the management of the issues which are related with the ordinary aging and also age-related infections as a part of the interdisciplinary team inclusive of other stake holders in healthcare industry (Holm-Pedersen et al,. 2015). Most governments in the world have specifically set the ages for the aged and those presumed to be aged in different categories. In some parts mostly the underdeveloped country, individuals who are 60 years and above of age are regarded as the elderly. The developed countries regard individuals who are 65 and above years of age as elderly (Anil et al., 2016). Worldwide, there are approximately over 600 million people who are 60 years and above and the number is considered to have risen by the year 2025.

The geriatric health in the world is one of the areas of health which are ignored and in most cases under-explored. The oral health gives a reflection to the welfare of the old population in the world. Aged patients are mostly inclined to the verbal situations in relation to their age and the ailments inclusive of some functional changes which might affect them in the process (Holm-Pedersen et al, 2015). Some of the major challenges which affect the practicing of the geriatric dentistry are the lack of a trained member, the system is overcrowded and the main one being the monetary constraints. For a quality and a successful treatment, practitioners have to adopt an approach that is humanitarian and in the act develop an understanding in terms of the attitude and the feelings of the elderly.

Early intervention and prevention strategies have to be formulated in order to lessen the risks of these verbal complications in the elderly inhabitants. Currently, professionals in the dental section have to possess a better perceptive of the level of the types of services which are to be offered in the aged population (Anil et al., 2016). This possibility can only be realized if there is an educational program subjected to the society without a delay in the geriatric dentistry.   

Xerostomia or the dry mouth condition is very common amongst the elderly individuals and is mostly associated with the decreased amount of the salivary gland function. The causes of the xerostomia in the elderly population have been inclined with the continued use of medicines, the chronic disorders, and radiotherapy to the neck and head regions. Patients who are diagnosed with the chronic xerostomia can have more than one oral or dental effect like the periodontal diseases, dental caries, ill-fitting dentures, fungal infections and the alterations of tastes (Gil Montoya et al., 2015). Xerostomia can have a serious effect on the quality of life and also alter a person’s eating style, the speech and also during swallowing. The current therapeutics in the management of the xerostomia is basically grouped as systemic and local salivary stimulation.

Polypharmacy

This is generally a practice of describing four and above medications to the same individuals. This in most cases happens to the older individuals who are affected by diseases. The known hazards of giving such medication include the cause of secondary morbidity due to prescribing inappropriate and unnecessary drugs and medicine incompatibility. The problems can also develop when the patients possess a poor understanding of the goal of their medicine and how to take the prescribed medicine. There are challenges which are related to the physiological changes which alter the ways that a drug is handled by the body (Gil Montoya et al., 2015). Polypharmacy in most cases happens due to multiple pathology poor communication between the providers of health care, lack of knowledge on aging and computerized records which are not updated accordingly. The older people can generally benefit from the many kinds of medicines today but the adverse effects and the side reactions of these medicines can jeopardize their health.

Brain conditions

Taking care of the dental part of the body is very essential. If a person does not take care of the teeth they turn yellow and they physically become painful which will ultimately lead to very many visits to the dentist. Most of these conditions are underestimated by many individuals and it is a dangerous alternative (Anil et al., 2016). The brain is also connected to the teeth and if there is an issue with the brain, then the problem will also affect the teeth and vice verse. The aged people experience memory loss in most cases and when this happens the body can shut down the many parts that depend on the brain. The loss of memory will eventually lead to a lack of concern and unknowingly cause other major issues to the body. People with few teeth are regarded to have a very poor memory (Gil Montoya et al., 2015). As a person becomes old, their teeth tend to become weak and fall off and in some people, they protrude outwards causing a discomfort during eating or brushing and in most cases, duties such as brushing are neglected.

Dentures

A high-quality diet is vital in the improvement and also the preservation of good and strong teeth. Fit teeth are very essential in assisting in the eating of healthy and assorted diet over the phase of a person. Geriatric clients are associated with a steadily increase in the dental services which involve a number of individuals requiring a detailed and complete denture. In America, it is estimated that over 50% of the people who are 65 years and above do were some form of dentures either completely or partially. Many reasons can affect an individual’s probability of wearing the dental prosthesis. One of the reasons is for a maximized taste and the texture sensation due to the covering of the palate. A big percentage of the people wearing the dentures start to develop sores which are very painful (Gil Montoya et al., 2015). For either a complete or a partial denture, a person must undergo a regimented dental protocol in order to ensure that it is appropriate for a laboratory test to a clinical test.

Conclusion

The general and oral health is basically a fundamental right in human beings. Oral health of a person determines the general health of a person and the general health with physically determine the happiness in the lifetime of a person (Holm-Pedersen et al, 2015). Good health is obtained from having a healthy diet and maintaining healthy teeth in the process.

References

Anil, S., Vellappally, S., Hashem, M., Preethanath, R. S., Patil, S., & Samaranayake, L. P. (2016). Xerostomia in geriatric patients: a burgeoning global concern. Journal of investigative and clinical dentistry, 7(1), 5-12.

Gil Montoya, J. A., Ferreira de Mello, A. L., Barrios, L., González Moles, M. Á., & Bravo Pérez, M. (2015). Oral health in the elderly patient and its impact on general well-being: a nonsystematic review. 

Holm-Pedersen, P., Walls, A. W., & Ship, J. A. (Eds.). (2015). Textbook of geriatric dentistry. John Wiley & Sons.

Breast Cancer

Introduction

Cancer of the breast is the most widely observed malignancy in women around the world, and a lot of research has been conduct on this non-communicable disease. Genetic and non-genetic factors are both involved in scientific study of the cause of breast cancer. The studies have involved different set factors that have been related to increased risk of breast cancer development and even reduction of these risks. These aspects include ATM (ataxia telangiectasia mutated) gene polymorphisms, genes related to Vitamin C and the interaction between environment and genes, and the interaction between known Environment Risks Factors and susceptibility of Common Breast Cancer Loci .

There remains gap in the explanations of breast cancer familial clustering other than BRCA1 (Breast Cancer Gene 1), carriers of BRCA2 and breast cancer risk in specific uncommon syndromes resulting from mutations of various genes like TP53. Ataxia telangiectasia disorder affects many body parts and increases the malignancy risks (Nickels et.al 2013). Carcinogens may stimulate different kinds of DNA damages, but ATM protein play a major role in recognizing and repair of DNA DSBs.  ATM protein is activated quickly and may phosphorylate many downstream substrates, and some of these substrates play a key role in regulating the arrest of cell cycle, repairing DNA and even apoptosis, by activating and stabilizing the p53 (Nickels et.al 2013).  

There can also be interaction between ATM protein with oncongenic protein, BRCA1 that suppresses any tumor, checkpoint Kinase and NBSI that repairs DNA.  A research that sought to determine ATM gene polymorphisms genetic frequencies, and examining the link between ATM genotypes and increase breast cancer risk involved the voluntary participation of 1232 cancer patients in Taiwan, China.  The study excluded patients with history of malignancy, metastasized cancer form unknown causes or those with genetic diseases. There were two groups of participants; 1232 cancer patients and 1232 female controls matched by age.  No significant differences were noted between both groups at various ages including menopause, first birth of a baby and enrolment. The results showed that ATM gene increases the risk of cancer, even though it plays a major role in pathways for DNA damage-repair (Nickels et.al 2013). Even though some studies have previous associated the heterozygous carriers of female ATM with increased risk of cancer especially in Westerns countries , there is no association of such relation found in Taiwan  that has a high prevalence of breast cancer , more deaths and early onset  where ATM plays the function of genetic marker. However, the allele for ATM rs189037 A was suggested to be likely to increase breast cancer risk (Nickels et.al 2013).

BRCA1and BRCA2 have been known to present high risk of mutations and hence breast cancer  even though there other variants that  lead to moderate susceptibility of breast cancer including ATM , CHEK2 and PALB2. In combination, these variants have been shown to explain 20- 25 percent of risks of breast cancer that are familial (Travis et. al 2010). Knowledge about possible modification of common susceptibility loci risks through environmental risk factors – lifestyle risk and reproductive factors – could offer insights into how cancer develops and especially the breast cancer causation for certain types of cancer. After many comparisons in large studies done recently, there has not been found any evidence that is statistically considerable to show multiple interactions between gene-environment and known breast cancer risk factors and susceptibility loci (Travis et. al 2010).  The absence of such evidence can be attributed to partly to limited capacity for detecting weal interaction between gen and environment and failing to take into account certain kinds of breast cancer. An evaluation of whether single-nucleotide polymorphism relative risks at various loci fluctuate in relation to some known risk factors can be done using different studies. In one such evaluation, the breast cancer assessment was done with negative and positive status of estrogen receptor (Travis et. al 2010).

After the evaluation was done with more environmental risk factors and recently established familiar susceptibility loci, there was showed apparent independent replication, and that there is interaction for both Estrogen Receptor – positive and Estrogen Receptor –negative condition. Lack of similarity in interaction can be said to be plausible because birth’s number and SNP do not show heterogeneity through Estrogen Receptor status in relation to risk of breast cancer. As such, the study found finds evidence of any relation between LSP1-rs3817198, which increases cancer risk, and women being porous (Travis et. al 2010). The heterogeneity effect of LSP1-rs3817198 seems to be resulting partly from considerable negative association between births number in porous women and immune genotype. In addition, there is an increased risk of developing cancer of the breast for those women who drink alcohol. Alcohol in this case is an environmental risk factor. Caspase 8 protein is key in initiation of death cells and its activation result from damage of DNA by factors such as alcohol, a big cause of oxidative stress that is ethanol related.  Most SNPs variations have been shown to be only indicators of the impact of present causal variants in a gene (Travis et. al 2010). Hence, the interaction of the gene and the environment with existing causal variants may have a larger modifying impact on breast cancer relative risk.

 Some susceptibility loci of breast cancer that are low-penetrance have been established in various genome related studies, but there is little knowledge about the effect of environmental factors such as behavioral, reproductive and anthropometric risks .A study of interaction between gene and environmental factors done with the participation of 7610 women suffering from breast cancer was done to explore more knowledge on the same. The analysis included 7610 female patients suffering from incident breast cancer and 10196 healthy women, with a mean age of 60 years (Travis et. al 2010). On average , all the cases were probably less porous , were older during first birth , the body-mass index was more ,  more consumption of alcohol , and were more likely to be under Hormone Replacement Therapy than other controls.  Ten environmental factors were assessed to check whether could be linked to 12 SNPs (single-nucleotide polymorphism) variations. After multiple testing was done, there were no considerable relations between eleven of the twelve polymorphisms and the risk factors. The strongest indication of association was the between alcohol consumption and gene CASP8-rs104548 (Travis et. al 2010). There was increased and greater risk for women who reported a history of alcohol intake – one drink each day – than those who took less alcohol.  After many tests were done, the association was not significant. There were no material differences after women were subdivided into more than two groups and the risk factors were considered continuous (Travis at. al 2010).

 Present use of Hormone Replacement Therapies was associated with more risk of developing cancer of the breast and more effect on oestrogen-receptor -positive tumors that the negative ones. But such was not seen after many tests. After multiple tests were done none of the environmental factors showed any significant relations with increased cases of cancer development (Travis et. al 2010). In addition, there was no strong link between the risk factors and the genotype under study were established which seems to show that susceptibility loci examined do not have effect on risk of breast cancer through by use of mechanisms that involve environmental factors (Travis et. al 2010). There are, however, some relative risks associated with some genotype and the relation to between cancer risk and environmental factors could not be proved most likely due to limited power to detect such interaction. While many environmental risk factors are associated with cancer development, few associating is done on genotype factors. For instance, taller women have a slightly higher risk of developing breast cancer than shorter female, and the shorter ones the major carriers of the high risk genes (Travis, et. al 2010).

On the cancer prevention , North- South gradients observations in cancer of breast mortality and prevalence has made researchers to develop a theory holding that  vitamin D may be necessary in cancer prevention . The role of this Vitamin has been supported by huge experimental evidence, in relation to the fact that it regulates proliferation and differentiation of breast cells.  However, there is need to examine the relations between risk of breast cancer and polymorphisms in SNPs genes related to vitamin D (Fuhrman, et. al 2013).  A study in the same, using participants who in previous studies have indicated no history of breast cancer, has been done to examine this association.  More than half of the participants, who passed the criteria, indicated an occurrence of primary cancer of breast in the period between previous surveys. The inclusion of sun exposures measures was necessary since vitamin D is synthesized by the skin after being exposed to sunlight. The various established risk factors for breast cancer were involved including menopause age, menarche age, full pregnancy numbers, and first birth age and breast cancer history (Fuhrman, et. al 2013).

 There was observed a disproportionate trend in risk of breast cancer in relation with rare alleles number for Bsml variant and no material association with such risk was established for polymorphism related to FOK1.  There was no significant difference between breast cancer controls and incidents in regard to a person’s residence geographical location (Fuhrman, et. al 2013).  There is no material risk trend observed across different ambient sunlight average each year. The study established that there was an association between risk of breast cancer and vitamin D genes SNPS.  Such risks are likely to mostly affect younger women in the adolescence since their breast tissues have not differentiated, and may pose a greater risk for cancer in later life (Fuhrman, et. al 2013). Therefore, the Vitamin D pathways were found to be associated with more risk even tough further support was need to prove the case.

Conclusion

Genetic and non-genetic factors are both involved in scientific study of the cause of breast cancer. The association between risk of developing breast cancer, the genotype factors and the environmental factors has been studied extensively over the years. The results of these studies have not been consistent as to clearly establish the cause breast cancer development, even though genetic and environmental risks factors have largely been established.  There different aspects that have been attributed to the limitation of these studies and which need to be addressed to establish breast cancer causation.

References

Wang, H. C., Chang, W. S., Tsai, R. Y., Tsai, C. W., Liu, L. C., Su, C. H., ... & Bau, D. T. (2010). Association between ataxia telangiectasia mutated gene polymorphisms and breast cancer in Taiwanese females. Anticancer research, 30(12), 5217-5221.

Nickels, S., Truong, T., Hein, R., Stevens, K., Buck, K., Behrens, S., ... & Gaudet, M. (2013). Evidence of gene–environment interactions between common breast cancer susceptibility loci and established environmental risk factors. PLoS Genet, 9(3), e1003284.

Travis, R. C., Reeves, G. K., Green, J., Bull, D., Tipper, S. J., Baker, K., ... & Lathrop, M. (2010). Gene–environment interactions in 7610 women with breast cancer: prospective evidence from the Million Women Study. The Lancet, 375(9732), 2143-2151.

Fuhrman, B. J., Freedman, D. M., Bhatti, P., Doody, M. M., Fu, Y. P., Chang, S. C., ... & Sigurdson, A. J. (2013). Sunlight, polymorphisms of vitamin D-related genes and risk of breast cancer. Anticancer research, 33(2), 543-551.

Literature Review of Congestive Heart Failure

Introduction

Congestive heart failure (CHF)’s, frequency is increasing at a warning rate globally because of the increasing lifespan leading to a high elderly populace. CHF can be described as vital to the nursing expertise given that it is among the leading mortality causes among the hospitalized patients with cardiac issues. CHF illustrates the general, incapability of the heart in pumping adequate blood in the quest of meeting the metabolic needs of the body such as the supply of nutrients and oxygen that results in inconsistencies amid my cardinal oxygen demand as well as demand (Carpenter, 2015). America alone has an approximation of 6 million persons affected by CHF. This, therefore, shows that with the growing increase the next few years might present psychological and financial issues to the society on the grounds of CHF. Different strategies have been utilized in teaching the management and prevention of CHF among the elderly and vulnerable patients. Thus the necessity for CHF education and increased understanding of the issue is quintessential so that nurses can combat the increasing CHF victim’s numbers.

Methods

The research is an evidenced based one and thus all the sources needed to be evaluated in such of accuracy, usefulness, and relevance of the given information. Since secondary sources which in this case are focused on articles are to be utilized in the research systematic review was conducted. The evaluation criteria began by assessing the authority of the articles. This involved an assessment of all the articles on the authority held by the publishers and authors. The sources had to contain authoritative authors and had to be peer reviewed for dependability of the information. Despite the fact that the articles were acquired from scholarly sources internet sources are bound to create questions in regard to being reliable if there are no authors. In addition, credible publishers such as government agencies or established organizations tend to be more reliable and accurate if though the author's name may be missing.

Accuracy, content, and relevance are some of the additional factors that were assessed. In that, the sources were evaluated by establishing whether the given content was providing answers to the research queries to establish whether they would help in developing the paper. The relevance of the sources was established by analyzing the introduction and the content table to understand the subject being handled. Accuracy was evaluated on the grounds of clearness, well-cited information with a reference list and information correctness. Moreover, the sources had to be objective and addressing a specific audience. The purpose of the article should not be biased and should be more focused on trying to offer information in regard to a given subject rather than attempting to promote certain opinions. This means that the objective should be an obvious one for credibility to be established. The intended audiences were evaluated based on their authority in influencing the decision and changing the direction of the study. Lastly, the writing style and currency features were evaluated. The organization of the suitable sources had to be a logical one with a clear provision of arguments, a proper structure for easy follow up, formal and proper wording. In addition, the articles ought to have been published within the last five year given that currency is crucial since the topic dictates the utilization of recent information in justification of the need for CHF education based on the current issue.

    Synthesis of Literature Review

The article authored by Carpenter, (2015), is focused on how CHF care can be improved using a clinical decision option. It discusses the manner in which the clinical decisive unit can be implanted in America for patients with CHF. The article established that the implementation would low the mortality rate for the patients with cardiac issues, lead to saving increased costs and provides learning opportunities for the nurses and nursing leadership. In general, this would lower CHF issues, particularly among the elderly persons by learning how their conditions can be monitored best. The study was accomplished via the use of a qualitative approach where cardiac patients were involved in the test based on their hospitalization period. 

The article by Kalter-Leibovici et al, (2017), discusses the effectiveness of the programs utilized in managing diseases in developing heart failure outcome among patients. A qualitative approach was utilized in a hospital setting trial for the patients with access to quality health services and technological care. Services such as care coordination, diseases monitoring as well as patient education were utilized. It was established that among the admitted populace with heart-related issues 70 of them are not aware of how they should manage the conditions. However, based on the study the patients that are subjected to the programs for diseases management held better life quality that is related to health with reduced pressure and depression rate. The article, therefore, supports the study’s PICOT as it describes the issue and proposes for solutions.

The article by Kher, Johnson & Griffith, (2017), discusses the use of online health data for the CHF patients. According to the article, the use of online information in education CHF patients tends to be highly ineffective given that it only incorporates a low group of individuals. The research utilized a systematic review via a quantitative method. Search phrases such as CHF were utilized in the search for the most appropriate articles. For the elderly group, a significant number of them have not acquired education above the 6th grade which makes the information to be unusable for the affected groups. The article, therefore, states that more effort should be made in adjusting education materials that are provided on the online platforms for efficiency to be acquired. 

Smith, (2013), article mainly discusses the telemonitoring interventions that are required in lowering the general readmission of patients suffering from CHF. The study utilized a critical review on the grounds of the data that is available. The results suggested that telemonitoring is an effective approach that can be utilized in lowering CHF associated issues that lead to readmission. This is because readmission holds both financial as well as psychological effects. Most patients are always forced to get back to being admitted after their conditions get worse post their dismissal in hospitals. This is usually the case because of the lack of management education. Nurses offer less or zero education on how they can best handle the conditions and this results in worsening of the symptoms. In addition, those at risk are not aware of the strategies that they can apply in ensuring that they do not suffer from the illness. This results in increased mortality rate since it is usually challenging to rectify the situation after getting worse. The article supports my PICOT because it describes the issue of CHF education and recommends some strategies that can be utilized in being effective.

Vedel & Khanassov, (2015), in the article, was focused on determining transitional care impact as an intervention approach on critical health acre that is utilized by CHF patients. A randomized trial and a systematic data review were conducted. The resulted indicated that transitional care is effective in reducing the risks that are involved that lead to being readmitted. In that, the patients are provided with important information that helps in better condition management. In addition, the study indicated that the implementation of the care should be an intensive one which is highly effective regardless of being applied in the shortest duration. The article’s subjects suit the study’s question because it will help in demonstrating how the use of health intervention in providing education for the patients can help in dealing with the CHF issue that is on the rise. In addition, this will help in demonstrating why education is the best option for solving the issue in the society due to the changing period via technology use.

            The articles are similar as the addresses the issue of CHF education which is of necessity and proposes different approaches that can be utilized in addressing the matter. They, however, differs as they propose different intervention while some advocates for a long run and others short run approaches.

            Future study

            It is apparent that CHF education is of great significance in lowering the mortality rate, readmission rate and preventing the populace from acquiring the disease. However, different strategies with differing application have proved to be effective based on the evaluation of the sources. Some of the areas that require further investigation in the future include how the health care sector can provide more education to nurses in order to ensure that all the clinical needs of these patients are addressed. In addition, the methods through which the interventions such as transitional care and online education as management strategies needs investigation. 

            References

Carpenter, J. E. (2015). Improving Congestive Heart Failure Care with a Clinical Decision Unit. Nursing Economic$, 33(5), 255-262.

Kalter-Leibovici, O., Freimark, D., Freedman, L. S., Kaufman, G., Ziv, A., Murad, H., & ... Israel Heart Failure Disease Management Study (IHF-DMS), I. (2017). Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial. BMC Medicine, 151-13. Doi: 10.1186/s12916-017-0855-z

Kher, A., Johnson, S., & Griffith, R. (2017). Readability Assessment of Online Patient Education Material on Congestive Heart Failure. Advances in Preventive Medicine, 1-8. doi:10.1155/2017/9780317

Smith, A. C. (2013). Effect of Telemonitoring on Re-Admission in Patients with Congestive Heart Failure. MEDSURG Nursing, 22(1), 39-44.

Vedel, I., & Khanassov, V. (2015). Transitional Care for Patients with Congestive Heart Failure: A Systematic Review and Meta-Analysis. Annals of Family Medicine, 13(6), 562-571. doi:10.1370/afm.1844

Negative effects of lack of sleep

Introduction

Sleep is important as it enhances the well-being in terms of emotional regulation and cognitive performance. It is advisable that people should get enough sleep in order to avoid diseases such as coronary heart disease and others which affect mental and physical health. An important point to note is that while sleeping, brain functions effectively and leads to consolidation of memories, brain development and energy conservation. Sleep is also associated with positive growth and development, where human beings develop healthy weight.  In addition, it is important to get enough sleep in order to improve learning (as it is stated by studied), be creative and improve problem solving skills. The purpose of this paper is to examine the negative effects of lack of sleep. Things to note are that lack of sleep or sleep deficiency results to chronic health problems related with neurocognitive disorders, neurobehavioral disorders, psychiatric conditions, cognitive impairment and other problems.

ORZEŁ-GRYGLEWSKA (2010) asserts that lack of sleep or sleep deprivation is a state where human being lack sleep in a certain period or a state where human beings do not get enough sleep as required. People are involved in sleep deprivation due to various factors one of them being work-related factors. Both chronic and acute sleep deprivation is associated with negative consequences which affect cognitive functions and operant memory. This article presents negative effects of lack of sleep from evidence-based practice where in the first study, volunteers experienced sleep deprivation in 90-hours and the second study human beings experienced lack of sleep in one week. The findings showed that lack of sleep is associated with many negative effects.

            The first effect is exteroceptive impairments. Lack of sleep causes visual disruption where human beings create inaccurate image formation and as a result, people experience double vision and hallucinations. What happens is that lack of sleep creates tunnel vision and as a result, human beings develop visual errors (ORZEŁ-GRYGLEWSKA, 2010). Second is the cognitive and operant process. Lack of sleep and prolonged wakefulness leads to impaired cognitive processing. In addition, sleep deprivation results to distraction of thoughts which affects the accurate and effectiveness of performance. For example, lack of sleep in a single night contributes to 20-32% of visual errors and 14% of errors are contributed in an electrocoagulation trial (ORZEŁ-GRYGLEWSKA, 2010). Other point is that prolonged wakefulness is associated with intonation impairments. This means that in the study, individuals who lacked sleep in one week were unable to verbalize their thought, they hard difficulties in reasoning and they could not perform task which required thinking and ability. Third are metabolic alterations. The study showed that individuals who slept only four hours in a single night increased appetite and hunger and this was as a result of leptin hormone. Lack of sleep also increases diabetic conditions and obesity which was as a result of imparement of glucose metabolism and lower energy expenditure. Young children in the study had a high BIM which is responsible for increasing weight. The study showed that reduction of sleep time is associated with risk of overweight.  For example, the study showed that lack of sleep increased the risk of increasing 5kg by 35% and the risk of developing obesity was 27% (ORZEŁ-GRYGLEWSKA, 2010).  Lack of sleep weakens the activities of brain structures. In the study, individuals   who experienced 72-hour wakefulness decreased the metabolic rate of the brain by 6-8%. Other thing which was noticed is the glucose hypometabolism in various parts including hypothalamus, thalamus, cerebellum and others. The hypometabolism affected the   activities in motor speech center where cognitive functions decreased. On the same note, lack of sleep is associated with manic symptoms which affect the mental functions (ORZEŁ-GRYGLEWSKA, 2010).  The study showed that individuals who lacked sleep suffered from interpersonal relationships and emotional intelligence. In addition, these individuals developed aggressive behaviors and other psychopathology behaviors such as insanity. Lack of sleep is associated with therapeutic application in that human beings are unable to perform normal functions. This occur when individuals develops depressive disorders which is contributed by organized activities (ORZEŁ-GRYGLEWSKA, 2010).     

 Christian and Ellis (2011) use psychological and neurocognitive perspectives and state that lack of sleep affects self-control and increases hostility. The two leads to workplace deviance within the organization and as a result, this becomes a big problem to the organization. Workplace deviance is a threat to the well-being of the organization especially when individual develops deviance behaviors such as drug use, poor performance, vandalism and more (CHRISTIAN & ELLIS, 2011). Employees who are exposed to deviant behavior develop stress-related problems and fear at work which leads to turnover. Sleep research is used in many organizations to examine how deviance behaviors are related with   lack of sleep. Many studies and researchers have found that sleep deprivation is associated with disastrous behaviors which range from work performance, decision making, and worker well-being among many.  According to National Center on Sleep Disorder Research, in every year, U.S spends $150billion to cover loss contributed by accidents (CHRISTIAN & ELLIS, 2011). The authors assert that sleep is capable of influencing brain functions and individual alertness. However, sleep deprivation or lack of sleep affects the cogitative capacity. In addition, evidence show that lack of sleep affects self-regulation and affects the innovative thinking skills. Other point is that lack of sleep affects the brain functioning and the effect occurs when the prefrontal part of the brain is affected. This part is critical as it comprises neocortical structures which serve the purpose of controlling emotions, executive and supervisory. What happens is that individuals with sleep deprivation act impulsively-meaning that they act aggressively and violates social norms. This occurs due to the impairment of prefrontal cortex and when this part is damaged, it leads to antisocial behaviors.  The issue of self-regulation arises when brain function (prefrontal cortex) is affected (CHRISTIAN & ELLIS, 2011). What happens that is that brain damage occurs when glucose metabolism is low and glucose plays a significant role in the self-regulation.  When the brain part known as prefrontal cortex is damaged, self-regulatory resource depletion is developed. The article finds that sleep deprivation is associated with workplace deviance behaviors.  Self-regulation encompasses the control of behaviors and emotions, and the occurrence of self-regulatory resource depletion is an indication that individual develops lack of self-control and hostility. The article affirms that when self-regulatory resources which control the behaviors are damaged, individuals develop deviant behaviors. In addition, the individual acts impulsively and creates risky decisions.  Sleep deprivation or lack of sleep affects the emotion regulation (CHRISTIAN & ELLIS, 2011). This happens when prefrontal cortex is damaged which results to negative emotions which means that an individual is unable to regulate negative emotions and thus shows hostility.

Chittora et al (2015) assert that sleep is a physiological process responsible for the development of mental and physical health. However, lack of sleep or sleep deprivation results to neurobehavioral and neurocognitive effects and impaired functionality which leads to neuropathology.  Lack of sleep weakens the functions of brain structures. For example, lack of sleep for about 72hours reduces the brain metabolic rate by 6-8% (Chittora et al, 2015). In addition, the article asserts that lack of sleep increases the level of plasma glucocorticoids and cortisol which leads to brain cells damage. Other negative effects of lack of sleep include muscles ache, memory lapse, hallucinations, headaches, high blood pressure, diabetes, obesity among many. Lack of sleep leads to depressive disorders, cancer and other diseases and these occur due to the suppression of immune system. Behaviors disturbances such as motor activity, body weight and more are contributed by sleep deprivation (Chittora et al, 2015). All these effects occur due to the fact that lack of sleep causes oxidative challenges which interfere with the brain. The latter has high metabolic rate, high oxygen consumption, and high fatty acids which makes it vulnerable be the oxidative challenges. The Oxidative stress interferes with the defense system and fails to remove the free radicals. In addition, the oxidative stress affects the neuron and cause synaptic plasticity impairment which promotes memory deficits and finally causes neurodegeration (Chittora et al, 2015).

Conclusion

Sleep plays a significant role in maintaining the well-being of human beings. Various studies and researches have shown that sleep promotes physiological homeostasis, and for a human being to live healthy life, it is advisable to get enough sleep. In addition, for brain to function properly and make memory consolidation, sleep is needed. Sleep play many roles such as removing waste products from brain, promotes synaptic plasticity, energy conservation, brain development and growth, brain repair among many other functions. However, sleep deprivation is associated with negative outcomes such as brain impairment, verbal disturbances, mental-fatigue, epileptic attack, insomnia, impaired learning and more. The research has also found that lack of sleep interferes with the cognitive and emotional functions. 

Reference

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Chittora, R., Jain, A., Suhalka, P., Sharma, C., Jaiswal, N., & Bhatnagar, M. (2015). Sleep deprivation:

Neural regulation and consequences. Sleep & Biological Rhythms, 13(3), 210-218.

doi:10.1111/sbr.12110

CHRISTIAN, M. S., & ELLIS, A. J. (2011). EXAMINING THE EFFECTS OF SLEEP DEPRIVATION ON

WORKPLACE DEVIANCE: A SELF-REGULATORY PERSPECTIVE. Academy Of Management

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