CRITICAL QUESTIONS AND REFLECTIONS 

1- Consider your own everyday communications with children – how you approach them and the language you use. How do you include children as active participants in discussions about care choices and planning?

2- After reading this chapter you are ready to undertake a family strengths assessment to apply the principles described to practice. Utilising the AFS Nursing Assessment Guide, engage in a conversation with a family as a group about their strengths and how their family functions across the eight qualities. Explore what goals the family are currently striving towards. Remember, not every strength needs to be explored with every family. What benefits do you think a family strengths assessment can have for clinical practice and promoting family health? What were the challenges to conducting your family strengths assessment?

Write a response to the following question: “What benefits do you think a family strengths conversation can have for clinical practice and promoting family health?” (From the ‘Critical questions and reflections’ on page 107 in Barnes & Rowe text book).

Answer this:

1-Demonstrates a comprehensive understanding of the promotion of family involvement in nursing care with thorough alignment to SBNC principles.

2-Discusses one or more approach or tool useful in guiding a family strengths conversation (e.g. AFSNA). Includes a critique of more than one approach or tool useful in guiding a family strengths conversation.

3-Demonstrates practically how nurse-patient/family relationship and health and wellbeing outcomes bidirectionally interact.

References:

Principles of strengths-based nursing leadership for strengths-based nursing care: a new paradigm for nursing and healthcare for the 21st century.

Gottlieb LN1, Gottlieb B, Shamian J.

Gottlieb, L. N., 2013, ‘Strengths-based nursing care : health and healing for person and family [ebook]’, .

Barnes M., Rowe J., 2013, ‘Child, youth and family health : strengthening communities [ebook]’, .

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Building a Health History

Effective communication is vital to constructing  an accurate and detailed patient history. A patient’s health or illness  is influenced by many factors, including age, gender, ethnicity, and  environmental setting. As an advanced practice nurse, you must be aware  of these factors and tailor your communication techniques accordingly.  Doing so will not only help you establish rapport with your patients,  but it will also enable you to more effectively gather the information  needed to assess your patients’ health risks.

For this Discussion, you will take on the role  of a clinician who is building a health history for a particular new  patient assigned by your Instructor.

                                               To prepare:

By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. (new patient profile):  14-year-old biracial male living with his grandmother in a high-density public housing complex 

How would your communication and interview techniques for building a health history differ with each patient?

How might you target your questions for building a health history based on the patient’s social determinants of health?

What  risk assessment instruments would be appropriate to use with each  patient, or what questions would you ask each patient to assess his or  her health risks?

Identify  any potential health-related risks based upon the patient’s age,  gender, ethnicity, or environmental setting that should be taken into  consideration.

Select one of the risk assessment instruments presented in Chapter 1 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

Post a summary of the interview and a  description of the communication techniques you would use with your  assigned patient. Explain why you would use these techniques. Identify  the risk assessment instrument you selected, and justify why it would be  applicable to the selected patient. Provide at least five targeted  questions you would ask the patient.

Required Readings

Note:  To access this week’s required library resources, please click on the link to the Course Readings List, found in the  Course Materials  section of your Syllabus.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

· Chapter 1, “The History and Interviewing Process”

This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

· Chapter 5, “Recording Information”

This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

· Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12. /orders/doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241-x

Note: You will access this article from the Walden Library databases.

Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508–513. Retrieved from /orders/search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=edsgea&AN=edsgcl.429265076&site=eds-live&scope=site

Note: You will access this article from the Walden Library databases.

Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3. Retrieved from /orders/search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=edsgea&AN=edsgcl.426834285&site=eds-live&scope=site

Note: You will access this article from the Walden Library databases.

Jardim, T. V., Sousa, A. L. L., Povoa, T. I. R., Barroso, W. K. S., Chinem, B., Jardim, L., … Jardim, P. C. B. V. (2015). The natural history of cardiovascular risk factors in health professionals: 20-year follow-up. BMC Public Health, 15(1111), 1–7. /orders/doi-org.ezp.waldenulibrary.org/10.1186/s12889-015-2477-8

Note: You will access this article from the Walden Library databases.

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from /orders/www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from /orders/support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Capstone Project Topic Selection And Approval

In collaboration with the approved course preceptor, students will identify a specific evidence-based topic for the capstone project change proposal. Students should consider the clinical environment in which they are currently employed or have recently worked. The capstone project topic can be a clinical practice problem, an organizational issue, a leadership or quality improvement initiative, or an unmet educational need specific to a patient population or community. The student may also choose to work with an interprofessional collaborative team.

Students should select a topic that aligns to their area of interest as well as the clinical practice setting in which practice hours are completed.

Write a 500-750 word description of your proposed capstone project topic. Include the following:

1. The problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project that will be the focus of the change proposal.
2. The setting or context in which the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project can be observed.
3. A description (providing a high level of detail) regarding the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.
4. Effect of the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.
5. Significance of the topic and its implications for nursing practice.
6. A proposed solution to the identified project topic with an explanation of how it will affect nursing practice.

You are required to cite to a minimum of eight peer-reviewed sources to complete this assignment. Sources must be published within the last 5 years, appropriate for the assignment criteria, and relevant to nursing practice. Plan your time accordingly to complete this assignment.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Prepare this assignment according to the guidelines found in the APA Style Guide. An abstract is not required.

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NSG6020 Final Exam Latest

Question 1

A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct?
A) Infectious
B) Inflammatory
C) Hematologic
D) Traumatic

Question 2

A 35-year-old archaeologist comes to your office (located in Phoenix, Arizona) for a regular skin check-up. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this patient?
A) Age
B) Hair color
C) Actinic lentigines
D) Heavy sun exposure

Question 3

A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter’s weight. You measure her daughter’s height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic.
B) Reassure the mother that this is a normal body weight.
C) Give the patient information about exercise because the patient is obese.
D) Give the patient information concerning reduction of fat and cholesterol in her diet because she is obese.

Question 4

A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several months.They are not painful and he has not noted any bleeding or bruising. He is concerned this may be consistent with a dangerous condition. What should you do?
A) Reassure him that there is nothing to worry about.
B) Do laboratory work to check for platelet problems.
C) Obtain an extensive history regarding blood problems and bleeding disorders.
D) Do a skin biopsy in the office.

Question 5

Jacob, a 33-year-old construction worker, complains of a “lump on his back” over his scapula. It has been there for about a year and is getting larger. He says his wife has been able to squeeze out a cheesy-textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?
A) An enlarged lymph node
B) A sebaceous cyst
C) An actinic keratosis
D) A malignant lesion

Question 6

A patient comes to you for the appearance of red patches on his forearms that have been present for several months. They remain for several weeks. He denies a history of trauma. Which of the following is likely?
A) Actinic keratoses
B) Pseudoscars
C) Actinic purpura
D) Cherry angiomas

Question 7

A 19-year old-college student presents to the emergency room with fever, headache, and neck pain/stiffness. She is concerned about the possibility of meningococcal meningitis. Several of her dorm mates have been vaccinated, but she hasn’t been. Which of the following physical examination descriptions is most consistent with meningitis?
A) Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range of motion
B) Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous muscle spasm and limited range of motion to the right
C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion
D) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with full range of motion

Question 8

A 58-year-old gardener comes to your office for evaluation of a new lesion on her upper chest. The lesion appears to be “stuck on” and is oval, brown, and slightly elevated with a flat surface. It has a rough, wartlike texture on palpation. Based on this description, what is your most likely diagnosis?
A) Actinic keratosis
B) Seborrheic keratosis
C) Basal cell carcinoma
D) Squamous cell carcinoma

Question 9

A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough?
A) Ophthalmologic
B) Auditory
C) Cardiac
D) Endocrine

Question 10

A 72-year-old retired truck driver comes to the clinic with his wife for evaluation of hearing loss. He has noticed some decreased ability to hear what his wife and grandchildren are saying to him. He admits to lip-reading more. He has a history of noise exposure in his young adult years: He worked as a sound engineer at a local arena and had to attend a lot of concerts. Based on this information, what is the most likely finding regarding his hearing acuity?
A) Loss of acuity for middle-range sounds
B) Increase of acuity for low-range sounds
C) Loss of acuity for high-range sounds
D) Increase of acuity for high-range sounds

Question 11

Mrs.Anderson presents with an itchy rash which is raised and appears and disappears in various locations. Each lesion lasts for many minutes. What most likely accounts for this rash?
A) Insect bites
B) Urticaria, or hives
C) Psoriasis
D) Purpura

Question 12

A new mother is concerned that her child occasionally “turns blue.” On further questioning, she mentions that this is at her hands and feet. She does not remember the child’s lips turning blue. She is otherwise eating and growing well. What would you do now?
A) Reassure her that this is normal
B) Obtain an echocardiogram to check for structural heart disease and consult cardiology
C) Admit the child to the hospital for further observation
D) Question the validity of her story

Question 13

An 89-year-old retired school principal comes for an annual check-up. She would like to know whether or not she should undergo a screening colonoscopy. She has never done this before. Which of the following factors should not be considered when discussing whether she should go for this screening test?
A) Life expectancy
B) Time interval until benefit from screening accrues
C) Patient preference
D) Current age of patient

Question 14

You are speaking to an 8th grade class about health prevention and are preparing to discuss the ABCDEs of melanoma. Which of the following descriptions correctly defines the ABCDEs?
A) A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E = evolution
B) A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm; E = evolution
C) A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution
D) A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6 mm; E = evolution

Question 15

A 79-year-old retired banker comes to your office for evaluation of difficulty with urination; he gets up five to six times per night to urinate and has to go at least that often in the daytime. He does not feel as if his bladder empties completely; the strength of the urinary stream is diminished. He denies dysuria or hematuria. This problem has been present for several years but has worsened over the last 8 months. You palpate his prostate. What is your expected physical examination finding, based on this description?
A) Normal size, smooth
B) Normal size, boggy
C) Enlarged size, smooth
D) Enlarged size, boggy

Question 16

A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small “pits” in his nails. What would account for these findings?
A) Eczema
B) Pityriasis rosea
C) Psoriasis
D) Tinea infection

Question 17

A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which is the most likely pathologic process?
A) Infection
B) Inflammation
C) Allergic
D) Vascular

Question 18

A 68-year-old retired farmer comes to your office for evaluation of a skin lesion. On the right temporal area of the forehead, you see a flattened papule the same color as his skin, covered by a dry scale that is round and feels hard. He has several more of these scattered on the forehead, arms, and legs.Based on this description, what is your most likely diagnosis?
A) Actinic keratosis
B) Seborrheic keratosis
C) Basal cell carcinoma
D) Squamous cell carcinoma

Question 19

An 8-year-old girl comes with her mother for evaluation of hair loss. She denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her hair in braids. On physical examination, you note a clearly demarcated, round patch of hair loss without visible scaling or inflammation. There are no hair shafts visible. Based on this description, what is your most likely diagnosis?
A) Alopecia areata
B) Trichotillomania
C) Tinea capitis
D) Traction alopecia

Question 20

A 19-year-old construction worker presents for evaluation of a rash. He notes that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He does sweat more than before because being outdoors is part of his job. On physical examination, you note dark tan patches with a reddish cast that has sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is your most likely diagnosis?
A) Pityriasis rosea
B) Tinea versicolor
C) Psoriasis
D) Atopic eczema

Question 21

Which of the following booster immunizations is recommended in the older adult population?
A) Tetanus
B) Diphtheria
C) Measles
D) Mumps

Question 22

A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to?
A) Musculoskeletal
B) Reproductive
C) Urinary
D) Endocrine

Question 23

Ms.Whiting is a 68 year old who comes in for her usual follow-up visit. You notice a few flat red and purple lesions, about 6 centimeters in diameter, on the ulnar aspect of her forearms but nowhere else. She doesn’t mention them. They are tender when you examine them. What should you do?
A) Conclude that these are lesions she has had for a long time.
B) Wait for her to mention them before asking further questions.
C) Ask how she acquired them.
D) Conduct the visit as usual for the patient.

Question 24

You have recently returned from a medical missions trip to sub-Saharan Africa, where you learned a great deal about malaria. You decide to use some of the same questions and maneuvers in your “routine” when examining patients in the midwestern United States. You are disappointed to find that despite getting some positive answers and findings, on further workup, none of your patients has malaria except one, who recently emigrated from Ghana. How should you next approach these questions and maneuvers?
A) Continue asking these questions in a more selective way.
B) Stop asking these questions, because they are low yield.
C) Question the validity of the questions.
D) Ask these questions of all your patients.

Question 25

On routine screening you notice that the cup-to-disc ratio of the patient’s right eye is 1:2. What ocular condition should you suspect?
A) Macular degeneration
B) Diabetic retinopathy
C) Hypertensive retinopathy
D) Glaucoma

Question 26

Mrs.Hill is a 28-year-old African-American with a history of SLE (systemic lupus erythematosus). She has noticed a raised, dark red rash on her legs. When you press on the rash, it doesn’t blanch. What would you tell her regarding her rash?
A) It is likely to be related to her lupus.
B) It is likely to be related to an exposure to a chemical.
C) It is likely to be related to an allergic reaction.
D) It should not cause any problems.

Question 27

A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for several years. He normally takes over-the-counter medications to ease the pain, but this time they haven’t worked as well and he still has discomfort. He recently wallpapered the entire second floor in his house, which caused him great discomfort. The pain resolved with rest. He denies fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this description, what is the most likely pathologic process?
A) Infectious
B) Neoplastic
C) Degenerative
D) Traumatic

Question 28

A 28-year-old patient comes to the office for evaluation of a rash. At first there was only one large patch, but then more lesions erupted suddenly on the back and torso; the lesions itch. On physical examination, you note that the pattern of eruption is like a Christmas tree and that there are a variety of erythematous papules and macules on the cleavage lines of the back. Based on this description, what is the most likely diagnosis?
A) Pityriasis rosea
B) Tinea versicolor
C) Psoriasis
D) Atopic eczema

Question 29

Which of the following changes are expected in vision as part of the normal aging process?
A) Cataracts
B) Glaucoma
C) Macular degeneration
D) Blurring of near vision

Question 30

You are examining an unconscious patient from another region and notice Beau’s lines, a transverse groove across all of her nails, about 1 cm from the proximal nail fold. What would you do next?
A) Conclude this is caused by a cultural practice.
B) Conclude this finding is most likely secondary to trauma.
C) Look for information from family and records regarding any problems which occurred 3 months ago.
D) Ask about dietary intake.

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Diary Of Medical Mission Trip

Throughout this course, you have viewed the “Diary of Medical Mission Trip” videos dealing with the catastrophic earthquake in Haiti in 2010. Reflect on this natural disaster by answering the following questions:

1.  Propose one example of a nursing intervention related to the disaster from each of the following levels: primary prevention, secondary prevention, and tertiary prevention. Provide innovative examples that have not been discussed by a previous student.
2. Under which phase of the disaster do the three proposed interventions fall? Explain why you chose that phase.
3. With what people or agencies would you work in facilitating the proposed interventions and why?

Link to the “Diary of Medical Mission Trip” videos:

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Research Methods And Findings Of The Verweij Study Conducted

In a 2- to 3-page, double-spaced paper,

describe three conclusions you have drawn from the findings in this study, taking into consideration the limitations of the study.

Next describe three implications for clinical practice.

Any additional sources are from last 5 years and the attached research article.

The primary purpose of this quantitative research study is to investigate the effectiveness of an intervention to decrease medication errors in a hospital.

The citation and discussion/conclusion information is intentionally deleted so you can draw your own conclusions.

The 2-3 pages double spaced paper should include the following (see template attached):

–Introduces information on the study: includes purpose of the study, methods and findings

-Proposes three conclusions drawn from findings in the study considering limitations of the study. 

-Recommends three implications for clinical practice.

-Concludes paper

-APA Formatting: cover page, title of paper on second page, level headings, Times New Roman 12 font, 1″ margins, and page numbers. APA References: Uses in-text citations appropriately and format correctly. Paraphrases to avoid plagiarizing the source

Abstract Background: The use of drug round tabards is a widespread intervention that is implemented to reduce the number of interruptions and medication administration errors (MAEs) by nurses; however, evidence for their effectiveness is scarce. Purpose: Evaluation of the effect of drug round tabards on the frequency and type of interruptions, MAEs, the linearity between interruptions and MAEs, as well as to explore nurses’ experiences with the tabards. Study Design: A mixed methods before-after study, with three observation periods on three wards of a Dutch university hospital, combined with personal inquiry and a focus group with nurses. Methods: In one pre-implementation period and two post-implementation periods at 2 weeks and 4 months, interruptions and MAEs were observed during drug rounds. Descriptive statistics and univariable linear regression were used to determine the effects of the tabard, combined with personal inquiry and a focus group to find out experiences with the tabard. Findings: A total of 313 medication administrations were observed. Significant reductions in both interruptions and MAEs were found after implementation of the tabards. In the third period, a decrease of 75% in interruptions and 66% in MAEs was found. Linear regression analysis revealed a model R2 of 10.4%. The implementation topics that emerged can be classified into three themes: personal considerations, patient perceptions, and considerations regarding tabard effectiveness.

The possible effect of medication errors (MEs) on patient safety raises concerns for healthcare safety boards

worldwide. In reaction to this problem, boards incorporate quality items and safety goals into their programs

340

C

that require action by the hospitals (Institute for Safe Medication Practices, 2014; World Health Organization High 5, 2014). Literature indicates that the ME rate may vary from 5% to 25% in all episodes of in-hospital drug administration, but only 19% are reported (Antonow, Smith, & Silver, 2000; Krahenbuhl-Melcher et al., 2007; Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). This could indicate that the actual incidence rates might be higher. Therefore, MEs endanger the safety of patients. MEs occur in every stage of the medication process, with 50% of them associated with medication administration (Krahenbuhl-Melcher et al., 2007). In hospitals, nurses are generally responsible for this stage in the medication process. In general, interruptions or distractions are recognized toreduceefficiency andcontributetoerrors(Brixeyetal., 2007). In specific, interruptions appear to be a prominent causative factor for medication administration errors (MAEs; Biron, Loiselle, & Lavoie-Tremblay, 2009; Freeman, McKee, Lee-Lehner, & Pesenecker, 2012; Trbovich, Prakash, Stewart, Trip, & Savage, 2010; Westbrook et al., 2010). The literature describes several initiatives that influence nursing medication practice to reduce MAEs (Hodgkinson, Koch, Nay, & Nichols, 2006; Raban & Westbrook, 2013). One of these interventions includes tabards, or vests, with the inscription “do not disturb” or visible signage. The use of drug round tabards is a widespread, inexpensive intervention that is thought to reduce the number of interruptions during drug rounds and MAEs. However, in practice the tabards are unpopular among nurses; they doubt their effectiveness and do not feel comfortable wearing them. Additionally, the evidence on effectiveness of using tabards is limited (Raban & Westbrook, 2013; Scott, Williams, Ingram, & Mackenzie, 2010). When evidence is lacking, the incentive to wear a tabard will be especially weak and one can become reluctant to implement interventions (Glasziou, Ogrinc, & Goodman, 2011; Smeulers, Onderwater, van Zwieten, & Vermeulen, 2014). If the effectiveness of these tabards can be established and barriers and facilitators can be identified, implementation in clinical practice will be facilitated and endorsed. Therefore, the aim of our study is to evaluate the effect of drug round tabards on (a) the frequency and type of interruptions, (b) the number and type of MAEs, and (c) the magnitude of the relation between interruptions and MAEs during the process of preparation, distribution, and administration of medication in hospital wards. In addition, we explored nurses’ perspectives and experiences with drug round tabards to identify barriers and facilitators for implementation.

Methods Setting

Three wards in a Dutch 1,024-bed university hospital contributed to this study: neurology, neurosurgery, and a combined ward with dermatology, ophthalmology, and ENT services. In total, these wards contain 60 beds. Each ward has a closed medication storage and preparation room where medication carts are stored for use during drug rounds. These carts are equipped with drawers and files containing computer-printed medication prescriptions for each patient. All oral medications are distributed for 24 hr and are checked once by the ward’s night shift. Fluids, intravenous medications, and other medications for injection are prepared and doublechecked during each drug round directly before drug administration.

Population

The participants were all registered nurses. Each had an individual responsibility for distributing medications to their assigned patients.

Study Design

We performed a mixed method study, using a beforeafter design to collect the number of interruptions and MAEs during drug rounds before the implementation of the tabard in April 2012 (period 1), as well as 2 weeks and 4 months after tabard implementation (i.e., in May and September 2012, respectively periods 2 and 3). An interruption or a distraction was defined as an event initiated by another professional(s) or something else, and when a nurse interrupted him- or herself. In this study, the term interruption was used for distractions as well as for interruptions. MAEs are defined as a breach of one of the seven rights of medication administration: correct patient, drug, dose, time, route, reason, and documentation (Pape, 2003). During period 2, nurses’ perspectives regarding the tabard were collected by documenting spontaneous remarks and asking a single question at the end of the observation: “What is your experience with the drug round tabard?” In period 3, in-depth information on nurses’ perspectives, experiences, and views was collected in a focus group setting to gain insight in barriers and facilitators for implementation of the drug round tabards.

Ethical Approval

Ethical approval was not considered necessary by the Institutional Review Board of the Academic Medical

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Center at the University of Amsterdam. This is in accordance with the Dutch Medical Ethics Law.

Intervention

Following baseline observation period 1, the intervention was introduced during a 5-day implementation week. All nurses working on the participating wards were instructed to wear the tabards while preparing and administering the medications. Instructions were given by e-mail, posters, and a promotional film. Tabards were fluorescent yellow with printed text on the back and small text on the chest, reading “Do not disturb, medication round in progress.” After the implementation week, we refrained from instruction on behavior during the drug rounds to determine the unbiased effect of the tabard. Information on the exact observer’s task, documentation frequency, type of interruptions, and MAEs per observed nurse remained blinded.

Observers All observers (n = 6) were final phase baccalaureate nursing students who have followed approximately 2 years of apprenticeship. The observers got instruction on how to score and interpret the items on the observation checklist and also to interfere if they observed MAEs that might be harmful to the patient. Although the students had not graduated yet at the time of the study, we were convinced that they had sufficient knowledge and awareness to assess the severity of clinical situations.

Data Collection

Quantitative data were collected on eight different categories of interruptions that are grouped into either verbal or nonverbal interruptions, based on a previously published observation form (Table 1; Smeulers, Hoekstra, van Dijk, Overkamp, & Vermeulen, 2013). To observe the frequency and type of MAEs, we merged it with the “seven right” items of Pape et al. (2003) that we converted into “seven wrongs”: wrong patient, dose, medication, timing, route, indication, and reporting. In a pilot phase, the observersperformedeight observationsin pairs to validate the checklist. To determine observation agreement on the counting of interruptions and MAEs, the interobserver agreement was calculated using the interclass correlation coefficient (ICC). Of the 14 items, 12 items scored an ICC > .80 (almost perfect agreement) and 2 items (i.e., verbal interruptions caused by patients and nonverbal interruptions caused by the surrounding) scored an ICC between .55 and .60 (moderate agreement;

Table 1. Definition of Interruptions During Medication Preparation and Administration

Category Description

Verbalcolleague Colleagueinitiatesadialogwithnurse Verbalperson Nurseinitiatesadialog Verbalpatient Patientinitiatesadialogwithnurse Nonverbalcolleague Colleaguesinitiatesaninterruption, e.g.,gettingsuppliesinthevicinity Nonverbalperson Nurseinitiatesinterruption,e.g., helpingacolleague,pagerresponse Nonverbalpatient Patientinitiatesinterruption,e.g., beinginthevicinityofthenurse Nonverbalsurrounding Surroundingenvironment,e.g., cleaningorstockworkingstaff Nonverballogistics Missingsuppliesforpreparingthe medications

Table 2. FocusGroupTopics

Topics Subheadings

Drugroundtabardsandsafe medicationadministration

Experiencepositive/negativeand why? Doyouwearthetabardandwhy? Whatadditionalinterventionswill contributetomedicationsafety? Whatdoyouthinkofchecklists, visualreminders,andadonot disturbzone?

Colleagueswhodonotwear thetabard

Doyouordon’tyouconfrontyour colleagueswhentheydonot cooperateandwhy?

Prosandconsregarding implementation

Whatfactorscontributetoyour choicewhethertowearornot towearthetabard? Whatisneededforsuccessful implementation?

Patientsandvisitorsshouldbe informedaboutthepurpose ofthetabard

Whyshouldweorshouldn’twe inform?Howshouldweinform?

Petrie & Sabin, 2009). To solve interobserver variety on the two moderate scored items, they were discussed with the first author. After addressing the disagreements, we considered the observation checklist to be reliable. Observations were performed 7 days per week during six drug rounds per day that occurred at 8 a.m., 12 p.m., 4 p.m., 6 p.m., 8 p.m., and 10 p.m. We randomly selected the nurse to be observed for each drug round, which resulted in a randomly selected patient mix as well. Focus group participants (n = 9) were selected using purposive sampling based on their expressed attitudes regarding the tabard during observations in period 2 to have a representative mix of positive and negative attitudes. Discussion topics were derived from the observations and nurses’ expressions during period 2 (Table 2).

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Table 3. Demographics

Period1 Period2 Period3 Total n(%) n(%) n(%) n(%)

Observations 105 104 104 313 Gender Male 16(15) 27(26) 14(13) 57(18) Female 89(85) 77(74) 90(87) 256(82) Age(year) Median(range) 40(22–64) 42.5(22–63) 45(22–62) 42(22–64) Education Bachelor’s 41(39) 46(45) 53(51) 140(45) Community college 17(16) 15(14) 5(5) 37(12) Inservice 45(42) 43(41) 46(44) 134(42) Other 2(2) 0 0 2(1) Observations/ward Neurology 39(37) 36(35) 37(35) 112(36) Neurosurgery 35(33) 40(38) 33(32) 108(34) DermatologyOphthalmologyENT 31(30) 28(27) 34(33) 93(30) Medicationrounds 8.00 20(20) 19(18) 19(18) 58(19) 12.00 20(19) 20(20) 19(18) 59(19) 16.00 22(21) 20(20) 26(25) 68(21) 18.00 14(13) 15(14) 16(15) 45(14) 20.00 14(13) 15(14) 11(11) 40(13) 22.00 15(14) 15(14) 13(13) 43(14)

The focus group was led by a moderator and an observer. The moderator facilitated an open discussion, which was structured around the derived topics. Special attention was paid to all participants contributing their opinions. The focus group session was taped and transcribed.

Data Entry and Crosscheck

The six observers entered their own data, and they cross-checked each other. One researcher compared all entered data with the original observation.

Sample Size and Data Analysis

Because the effect of tabards on MAEs is unknown, we were unable to calculate the sample size based on this end point; therefore, we used the effects on interruptions. Based on previously published interruption rates of 15% to 50%, we hypothesized an average reduction of 30% for the power calculation (Scott et al., 2010; Smeulers et al., 2013; Trbovich et al., 2010). A sample size of 100 observations before and 100 observations after the intervention would have 90% power to detect the effect of the tabards with a .05 significance level. Descriptive statistics were used to summarize the demographics and frequencies of different types of interruptions and MAEs. A Kruskal-Wallis test was performed to compare the interruptions and MAEs due to a skewed distribution of the data. After a natural logarithmic transformation, we performed a univariable linear regression

analysis of MAEs (dependent) on interruptions (independent). All statistical analyses were performed using IBM SPSS statistics version 18.0 (SPSS Inc., Chicago, IL, USA). Data collected during the observations and the focus group session were analyzed iteratively by four of the six observers. By discussing the interview and focus group items, they coded topics and built a coding tree. Next they grouped the topics and identified the most relevant themes related to nurses’ experiences with the drug round tabards regarding barriers and facilitators for implementation (Boeije, 2008; Lucassen & Hartman olde, 2007).

Results

A total of 313 medication administrations were observed. Distribution of data collection and observations on each ward was distributed evenly on all rounds and for each period, with 40% of the observations occurring during the evening rounds (6 p.m., 8 p.m., and 10 p.m.) and 20% during the weekend rounds. The characteristics of the observed nurses were equally distributed during each period as well (Table 3).

Interruptions

A reduction of 75% of interruptions was found after implementing the drug round tabards (Table 4, Figure 1). The majority of interruptions that were

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Table 4. InterruptionsDuringMedicationAdministrationRounds

Period1 Period2 Period3 (n=105) (n=104) (n=104) Kruskal-Wallis Number Median(IQR) Number Median(IQR) Number Median(IQR) p

Verbaltotal 391 3(4) 297 2(4) 94 1(1) <.05 Verbalcolleague 168 1(2) 122 1(2) 26 0(0) <.05 Verbalpatient 94 0(1) 71 0(1) 44 0(1) .09 Verbalperson 130 1(2) 104 1(2) 24 0(0) <.05 Nonverbaltotal 126 1(2) 151 1(2) 15 0(0) <.05 Nonverbalcolleague 15 0(0) 11 0(0) 1 0(0) <.05 Nonverbalpatient 4 0(0) 4 0(0) 0 NA .13 Nonverbalperson 20 0(0) 24 0(0) 0 NA <.05 Nonverbalsurrounding 94 0(1) 112 1(2) 14 0(0) <.05 Total 517 4(5) 448 4(4) 112 1(2) <.05

Note.IQRinterquartilerange;NAnotapplicable.

Figure 1. Meaninterruptionspermedicationadministrationround.

observed during period 1 were of verbal origin, and most werecausedandinitiatedbycolleaguesandpersonsother than patients. The most common nonverbal interruptions were caused by the surroundings (e.g., the telephone, radio, or conversations of others nearby). In period 2, there were fewer interruptions than in period 1. The median total verbal interruptions were reduced over the periods. The median nonverbal interruptions were only reduced in period 3. A significant effect of the tabards was found for both the verbal and nonverbal interruption rates. The individual interruptions showed a significant decrease, with the exception of verbal and nonverbal interruptions initiated by patients. Most decreases in interruptionswereseenatthedrugroundsoccurringat8a.m., 12 p.m., and 6 p.m. For the drug rounds at 8 p.m. and 10 p.m., we observed a slight increase in interruptions in period 2, although in period 3 a further decrease occurred (see Figure 1).

Medication Administration Errors

A 66%, and significant, reduction in MAEs was found after implementing the tabards (Table 5, Figure 2). The most frequent procedural MAEs are the absence of patient identification, incorrect administration time (either too early or too late), and not reporting in accordance with standard procedures. Individual MAEs that did not decrease significantly were administering the wrong medication, administration through the wrong route, and administration for an incorrect indication. Decreased MAEs were mainly found in the drug rounds at 8 a.m., 8 p.m., and 10 p.m. (see Figure 2).

Regression Model

The univariable linear regression model revealed interruptions as a significant predictor for MAEs (p < .05;

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Table 5. MedicationAdministrationErrorsDuringMedicationAdministrationRounds

Period1 Period2 Period3 (n=105) (n=104) (n=104) Kruskal-Wallis Number Median(IQR) Number Median(IQR) Number Median(IQR) p

Wrongpatient 194 2(2) 183 2(2) 119 1(1) <.05 Wrongdose 16 0(0) 9 0(0) 0 NA <.05 Wrongmedication 7 0(0) 6 0(0) 0 NA .08 Wrongtiming 91 0(1) 64 0(1) 1 0(0) <.05 Wrongroute 4 0(0) 4 0(0) 0 NA .13 Wrongindication 0 NA 1 0(0) 0 NA .37 Wrongreporting 126 1(2) 82 0(1) 0 NA <.05 Total 432 3(3) 349 2.5(3) 120 1(1) <.05

Note.IQRinterquartilerange;NAnotapplicable.

Figure 2. MeanMAEspermedicationadministrationround.

Table 6. Parameter Estimate for Intercept Medication Administration ErrorsandVariableInterruptions

Parameter Standard Test Variable estimate(B) error statistic p

Intercept .800 .065 12.361 <.05 Interruptions .271 .045 6.005 <.05

Table 6). The R2 of the model is 10.4%, which indicates that approximately one tenth of the MAEs can be explained by interruptions.

Nurses’ Experiences With Wearing the Tabard

By documenting remarks during the drug rounds and asking a single interview question at the end of drug rounds, we collected nurses’ experiences with and opinions about wearing the tabards. The reactions ranged from positive and enthusiastic to negative and even refusal to wear the tabard. Experiences with wearing the drugroundtabardswererelatedtothreemaintopics:per

sonal considerations, patient perceptions, and considerations regarding the effectiveness of the tabards.

Personal considerations. Frequently mentioned personal considerations include the nurses’ perception of their appearances while wearing the tabards: “I definitely won’t wear the tabard, it is ridiculous! . . . I am in for any kind of intervention and improvement, but in this tabard, I stand just like an idiot.” The nurses also mentioned hygienic issues as a personal barrier to wearing the tabard: “I purposively do not wear the tabard because I think it is filthy. Everybody wears it, contaminating it with sweat or spilling dirt or things on it.”

Patient perceptions. Nurses have concerns about the way in which patients and visitors might perceive the tabard. These remarks sometimes represented the nurses’ opinion that the tabard led the patients to consider the staff to be unapproachable: “I think the tabard gives an unfriendly signal to the patient. When patients have questions or need any kind of assistant or care, they

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should not need to hesitate in asking their nurse.” The nurses sometimes expressed feelings about the opposite effect:

The intention of the tabard is good; it gives a clear signal that you need to concentrate on the medication task. However, the tabard looks quite outstanding, and because of this, it attracts patients’ and visitors’ attention,andthisresultsinquestionsaboutthereason for wearing the tabard, which distracts eventually from your medication task. But overall, they are an excellent idea.

Effectiveness considerations. Perspectives on the effectiveness of the tabard varied. Some felt that it did not work at all: “I think it is nonsense and don’t think it is effective.” Other nurses mentioned that the tabard was only useful at certain times:

It is a very good idea, especially during daytime. It will make people think about “do not disturb,” but I think that during evening shifts it is more efficacious, that is the time when there are many visitors. I really think it is a good idea!

The intervention works as a signal for colleagues, they realise that you are doing medication. However, I do not think the tabard is effective in an evening shift when there are many visitors, no secretary to answer telephone calls etc.

Six of the nine invited nurses were able to attend and participate in the focus group discussion. They discussed the prominent color of the tabard as a barrier for use as some patients complained about the fluorescent yellow color. The participants suggested another color might solve this. Hygiene issues were not considered a problem for exchanging the tabard among nurses; nevertheless, the participants found it important to establish a cleaning protocol for the tabards with the hospital laundry service. All participants frequently were asked questions about the purpose of the tabards from visitors and patients. These questions distracted them from their tasks. Therefore, they suggested informing patients and visitors about the tabard upon admission or entry to the hospital. In addition to the drug round tabards, they expressed thoughts about the importance of focusing on team culture, where it is considered normal to not disturb each other during tasks and where it is acceptable to address disturbances when they do occur. The group also discussed the importance of leadership and team member role models as they considered this to be an important stimulus and good motivation for nurses to wear the tabard.

Discussion

This study shows a significant effect of drug round tabards on interruptions and MAE rate and a significant linearity between interruptions and MAEs (R2 of 10.4%). Therefore, we can conclude that the tabards were effective in improving medication administration safety. However, from the nurses’ experiences it became clear that they have mixed emotions about wearing the tabard. Nurses feel awkward and uncomfortable in the tabard, but they are prepared to wear the tabard if its effectiveness can be demonstrated, as also found by Scott et al. (2010). In the focus group, suggestions were made to change the color and appearance of the tabard. When asked about the effectiveness of the tabard, some nurses had positive experiences, but others expressed doubts about its effectiveness. Patients are not always aware of thetabard’spurpose,andwearingatabarddidnotchange the patients’ attempts to attract the nurses’ attention. This was confirmed by the quantitative outcomes that showed a nonsignificant effect of the tabard on interruptions caused by patients. The nurses also expressed their opinion that patients should always feel free to ask the nurses questions. Additionally, the nurses reported that the main sources of interruptions during drug rounds are colleagues and not patients. Another important item to consider is hygiene; some nurses complained that the tabards are worn by multiple nurses and are not personal items. The focus group suggested a cleaning protocol to address the hygiene issue. In their study concerning the infection risk of tabards, Scott et al. (2010) indicated that all tested swabs were negative for methicillin-resistant Staphylococcus aureus but had a positive general culture. We suggest a well-defined hygiene protocol when implementing the drug round tabard in a hospital. Our results of the regression model show a significant linearity, but the magnitude of the contribution of interruptions on MAEs seems small. This does not support the result found in other studies, which indicate a greater effect of interruptions on MAEs (Biron et al., 2009; ScottCawiezell et al., 2007; Westbrook et al., 2010). In contrast, another study showed the results of implementing a multi-intervention program, including tabards, in which the number of interruptions by staff increased significantly (Tomietto, Sartor, Mazzocoli, & Palese, 2012). This indicates that there are more factors than the tabard alone that influence the resulting effect. Given the literature, we hypothesize that paying attention to the process made nurses more aware of their tasks in medication administration, possibly leading to increased concentration and dedication (Paquet, Courcy, Lavoie-Tremblay, Gagnon, & Maillet, 2012). Another possible contributing factor was more involvement of the ward managers

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during drug rounds. They were eager to reduce MAEs and wanted to contribute to the study. These factors may have caused nurses to realize the importance of theirtask.Becausepreviouslypublishedstudieshavesuggested that nurses should change their behavior to reduce interruptions and MAEs, the drug round tabard can be considered a tool for changing nurses’ behavior (Biron et al., 2009; Relihan, O’Brien, O’Hara, & Silke, 2010). In conclusion, the drug round tabards created an observed effect on MAEs that was most likely not only the result of the tabards. This explains the significant results on both MAEs and interruptions and the low regression model R2. To obtain representative results, we observed all drug rounds, with the exception of night shifts, on both surgical and internal medicine wards. The mixed method approach with a combination of quantitative data collection on the effect of the tabards with experiences and perspectives of the participants in a mixed methods design proved a valuable research design because it uncovered all incentives (Glasziou et al., 2011; Seidl & Newhouse, 2012). The combined checklist was validated during this study using a nested interobserver agreement test (ICC) where 2 of the 14 observation items scored moderate agreement among observers, which could be considered a weakness for the observation process. However, 12 items scored almost perfect agreement, and after discussing the interpretation of the two moderate scored items, we considered the checklist reliable. Furthermore, this study has some limitations. Although some form of observer effect could not be eliminated in our study, we assume that this hardly influenced the effects since Barker, Flynn, and Pepper (2002) stated that observations are a valid, efficient, and accurate method of detecting MAEs and that there is no significant effect of observers on the observed personnel. Secondly, all observers were final phase nursing students, and one can argue their ability to observe the complex task of medication preparation and administration. However, they are trained and experienced in medication management, and since they have no relationship with the team under observation, they are able to get unbiased information and observations. Lastly, in a before-after design, one cannot correct for changes over time. Although we carefully selected the observation periods, we could not prevent the influence of low bed occupancy on all three observed wards during the different observation periods. In future research, one could consider more robust study designs to address this issue (e.g., a cluster randomized controlled trial or a controlled before-after study; Raban & Westbrook, 2013). In contrast to previous studies on multifaceted strategies, we would recommend analyzing the single contribution of each intervention to avoid the implementation of unnec

essary and non-evidence-based interventions (Freeman et al., 2012; Relihan et al., 2010; Tomietto et al., 2012).

Conclusions and Implications for Further Research

Acknowledgments

We would like to thank Mirthe van Loon, Manon Boers, Nousjka Westerlaken, Heleen van Essen, Milou Bakker, Lisa Appelman, Andrea Kuckert, and Marjoke Hoekstra for their contributions to our study.

Clinical Resources

Medication safety: World Health Organization, Action on Patient Safety – High 5s: http://www.who.int/ patientsafety/implementation/solutions/high5s/en/ Institute for Safe Medication Practices, Medications Safety Tools & Resources: http://www.ismp.org/ ECRI Institute, Patient Safety, Risk, and Quality Assessment Services: /orders/www.ecri.org/ Products/PatientSafetyQualityRiskManagement/ Pages/Assessment-Services.aspx The National Coordinating Council for Medication Error Reporting and Prevention: http://www.nccmerp.org/

References

Antonow, J. A., Smith, A. B., & Silver, M. P. (2000). Medication error reporting: A survey of nursing staff. Journal of Nursing Care Quality, 15(1), 42–48.

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Barker, K. N., Flynn, E. A., & Pepper, G. A. (2002). Observation method of detecting medication errors. American Journal of Health-System Pharmacy, 59(23), 2314–2316. Biron, A. D., Loiselle, C. G., & Lavoie-Tremblay, M. (2009). Work interruptions and their contribution to medication administration errors: An evidence review. Worldviews on Evidence-Based Nursing, 6(2), 70–86. Boeije, H. (2008). Analyseren in kwalitatief onderzoek, denken en doen [Analysis in qualitative research, knowledge and practical application] (3rd ed.). Amsterdam: Boom Lemma. Brixey, J. J., Robinson, D. J., Johnson, C. W., Johnson, T. R., Turley, J. P., & Zhang, J. (2007). A concept analysis of the phenomenon interruption. Advanced Nursing Science, 30(1), E26–E42. Freeman, R., McKee, S., Lee-Lehner, B., & Pesenecker, J. (2012). Reducing interruptions to improve medication safety. Journal of Nursing Care Quality, 28(2), 176–185. Glasziou, P., Ogrinc, G., & Goodman, S. (2011). Can evidence-based medicine and clinical quality improvement learn from each other? BMJ Quality & Safety, 20(Suppl. 1), i13–i17. Hodgkinson, B., Koch, S., Nay, R., & Nichols, K. (2006). Strategies to reduce medication errors with reference to older adults. International Journal of Evidence-Based Healthcare, 4(1), 2–41. Institute for Safe Medication Practices. (2014). Regional medication safety program for hospitals. Retrieved from http://www.ismp.org/Tools/MSK.asp Krahenbuhl-Melcher, A., Schlienger, R., Lampert, M., Haschke, M., Drewe, J., & Krahenbuhl, S. (2007). Drug-related problems in hospitals: A review of the recent literature. Drug Safety, 30(5), 379–407. Lucassen, P. L. B. J., & Hartman olde, T. C. (2007). Kwalitatief onderzoek, praktische methoden voor de medische praktijk [Qualitative research, practical methods for medical practice]. Houten, The Netherlands: Bohn Stafleu van Loghum. Pape, T. M. (2003). Applying airline safety practices to medication administration. Medsurg Nursing, 12(2), 77–93. Paquet, M., Courcy, F., Lavoie-Tremblay, M., Gagnon, S., & Maillet, S. (2012). Psychosocial work environment and prediction of quality of care indicators in one Canadian health center. Worldviews on Evidence-Based Nursing.,10(2), 82–94. Petrie, A., & Sabin, C. (2009). Medical statistics at a glance. Oxford, England: Wiley-Blackwell.

Raban, M., & Westbrook, J. I. (2013). Are interventions to reduce interruptions and errors during medication administration effective? A systematic review. BMJ Quality & Safety. Relihan, E., O’Brien, V., O’Hara, S., & Silke, B. (2010). The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. Quality & Safety in Health Care, 19(5), e52. Scott, J., Williams, D., Ingram, J., & Mackenzie, F. (2010). The effectiveness of drug round tabards in reducing incidence of medication errors. Nursing Times, 106(34), 13–15. Scott-Cawiezell, J., Pepper, G. A., Madsen, R. W., Petroski, G., Vogelsmeier, A., & Zellmer, D. (2007). Nursing home error and level of staff credentials. Clinical Nursing Research, 16(1), 72–78. Seidl, K. L., & Newhouse, R. P. (2012). The intersection of evidence-based practice with 5 quality improvement methodologies. Journal of Nursing Administration, 42(6), 299–304. Smeulers, M., Hoekstra, M., van Dijk, E., Overkamp, F., & Vermeulen, H. (2013). Interruptions during hospital nurses’ medication round. Nursing Reports, 3(1). doi:10. 4081/nursrep.2013.e4 Smeulers, M., Onderwater, A. T., van Zwieten, M. C. B., & Vermeulen, H. (2014). Nurses’ experiences and perspectives on the practice of preventing medication (administration) errors, an explorative qualitative study. Journal of Nursing Management, 22 (3), 276–285. doi: 10.1111/jonm.12225 Tomietto, M., Sartor, A., Mazzocoli, E., & Palese, A. (2012). Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round interruptions. Journal of Nursing Management, 20(3), 335–343. Trbovich, P., Prakash, V., Stewart, J., Trip, K., & Savage, P. (2010). Interruptions during the delivery of high-risk medications. Journal of Nursing Administration, 40(5), 211–218. Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683–690. World Health Organization High 5. (2014). Action on patient safety—High 5s. Retrieved from http://www.who.int/ patientsafety/implementation/solutions/high5s/en/

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MN551 Unit 10 Discussion

Case Study: Topic

Case Study Posting Requirements

• Make sure all of the topics in the case study have been addressed.
• Cite at least three sources—journal articles, textbooks or evidenced-based websites to support the content.
• All sources must be within five years.
• Do not use .com, Wikipedia, or up-to-date, etc., for your sources.

Case Study 1

Structure and Function of the Musculoskeletal System

Jennifer belongs to a women’s rugby team. At 23 years old, she has been playing for five years and trains daily to keep up her strength and stamina. During one game, she was injured. Unable to walk, she was carried off the field supported by her coach and an athletic therapist. At the hospital, after an examination and MRI of her right knee, she was given her diagnosis. Jennifer suffered what is often termed the “O’Donoghue triad”: a ruptured medial collateral ligament, a ruptured anterior cruciate ligament, and tear of the medial meniscus.

1. Jennifer’s injury involved the complete tearing of two ligaments. What are the similarities and differences between the anatomy and function of ligaments and tendons?
2. Jennifer’s rehabilitation will include techniques that will increase her joint proprioception. What is proprioception, and what will occur if this neural function is not restored?
3. The knee joint exemplifies a diarthrodial joint. What are the anatomy of the synovial membrane and the importance of synovial fluid in such a joint?

Case Study 2

Disorders of Musculoskeletal Function: Trauma, Infection, Neoplasms

Marvin is a healthy, active 36-year-old who belongs to a martial arts club. Once a week he takes lessons in Judo, and on the weekends, he participates in local competitions. At his last competition, Marvin was paired with a skilled participant from another club. His rival threw him to the mats, and as Marvin struggled, came down hard to pin him down. Marvin heard a snap, followed by instant pain in his left forearm. Radiographs at the local hospital confirmed he suffered a transverse fracture of the distal aspect of his left ulna.

1. What are the typical signs and symptoms of a fracture? Why shortly after the injury does the pain temporarily subside?
2. How does a hematoma form, and what function does it serve in the process of healing a fracture?
3. Marvin was told he would be seeing a physiotherapist as his healing progressed. What are the muscular and joint changes that occur during immobilization and the ways Marvin and his physiotherapist can work to address these changes?

Case Study 3

Disorders of Musculoskeletal Function: Developmental and Metabolic Disorders

Mandy is a 16-year-old competitive figure skater who practices several hours a day with her coach at the skating arena. Because of her extremely active lifestyle and restricted diet to maintain her athletic physique, she experiences ongoing amenorrhea. One day during practice, she landed a jump and fell to the ice in pain. Her left foot swelled up almost immediately, making it difficult for her coach to remove the skate. At the hospital, radiographs revealed a fracture of the fifth metatarsal bone and general radiolucency of all the bones in her foot. A follow-up DXA revealed a bone mass of 2.7 standard deviations below mean.

1. What is the etiology of Mandy’s premature osteoporosis, and how her condition is thought to contribute to a decrease in bone density?
2. Knowing what you do about bone mineralization, why does a deficiency of estrogen in women lead to osteoporotic change?
3. Osteoporosis and osteomalacia both involve abnormal bone mineralization. What are the general macroscopic differences of these two conditions?

Case Study 4

Disorders of Musculoskeletal Function: Rheumatic Disorders

Rick is a 27-year-old who works in an accounting firm. He had started to experience lower back pain and stiffness that he thought were a result of the long hours he spent at his desk. More recently, however, he began to have sleep difficulties. He found that he often woke up during the night feeling hot and sometimes sweaty. Furthermore, his back pain disrupted his sleep, particularly when it radiated around his pelvis and into his thighs. When his lack of sleep began to interfere with his work, he went to an osteopath to see what was wrong. She listened to his case history carefully. Upon physical examination, she noted a slight decrease in his lumbar lordosis and a reduced range of movement in his lumbar spine. His blood tests revealed the presence of HLA-B27, an elevated ESR, and absence of RH. His radiograph showed evidence of sacroiliitis.

1. What is the likely diagnosis Rick received? What are the common clinical presentation and manifestations of the disease?
2. Why is osteoarthritis of the hips a potential secondary complication of this disease? What are the structural changes that occur in the articular cartilage of an osteoarthritic joint?
3. What is the effect of advanced ankylosing spondylitis on lung function?

Case Study 5

Structure and Function of the Skin

Yael is an 18-year-old college student who is bothered by excessive perspiration. She knew she sweat a lot under her arms and kept antiperspirant in her schoolbag to use throughout the day. Yael’s problem was not limited to under her arms, however. Her hands and feet also perspired heavily, and it embarrassed her. She did not like holding her boyfriend’s hand if her hands were particularly sweaty, and she had problems grasping her pen while in class because her palm became slippery. Yael suffered from a condition called primary focal hyperhidrosis, a condition involving hyperactive sweat glands in certain areas of the body.

1. What are the anatomical and functional differences between eccrine and apocrine glands?
2. What autonomic nervous system controls the function of thermoregulation of the skin? How do goosebumpsgoose bumps contribute to heat conservation?
3. Describe the location of the blood plexuses in the skin. How is blood circulation to the skin involved in thermoregulation?

Case Study 6

Disorders of Skin Integrity and Function

Leonard works in the agriculture industry and raises beef cattle. At 60 years of age, he has spent most of his life working outdoors harvesting hay and tending to his herds. His wife was the first to notice a change in his skin. One day, after taking off his shirt, she noticed a significant change in the mole he had on his right shoulder. It not only was darker but was moist and appeared to have been bleeding at one point. Surrounding the mole, his skin was red. His wife remembered hearing stories of Leonard working on his father’s farm, spending long hours out in the hot sun even though his father had gone into the barn to work during the hottest part of the day. She insisted him go to the family physician to have it examined.

1. Leonard’s physician performed a biopsy on the lesion and told Leonard he suspected the growth may be malignant melanoma. What cells are affected in this form of skin cancer? How might his childhood exposures to the sun predispose him to this form of cancer?
2. How do UVA and UVB rays contribute to the process of oncogenesis in skin cells?
3. The mole on Leonard’s shoulder was a nevocellular nevus. What are the cellular composition and appearance of this type of mole before it underwent malignant change?

To view the Grading Rubric for this Assignment, please visit the Grading Rubrics section of the Course Home.

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Legislative Matrix

Student will develop a Legislative Matrix based upon the specific legislators in a residential/geographical legislative district. State and Federal legislators will be identified: State Representatives, Senators, Congressman and Governor. Each legislator’s assigned committees and any active legislation bills and/or past legislative initiatives will be identified. This information will be used to assist in the development of the Legislative Communication assignment.

• Please check rubric for detailed information see attachment

Submission Details:

• Support your responses with examples.
• Cite any sources in APA format.Legislative Matrix Project Week 2: (Indicate your residential/geographical legislative district)

  Full Name

  South University

  Include State Representatives, Governor, along with State and Federal Congressional House Members

  Identify their committees and active and past legislation

  Need to have at least one reference

  Submit to week 2 Project submission area for grading

  Elected Official

  Assigned Committees

  Active Legislation Bills

  Past Legislative Initiatives

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Psychiatric Advance Nursing Practicum

Part 1: Comprehensive Client Family Assessment With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations):  •Demographic information  •Presenting problem  •History or present illness  •Past psychiatric history   •Medical history • Substance use history  •Developmental history  •Family psychiatric history   •Psychosocial history  •History of abuse/trauma  •Review of systems   •Physical assessment  •Mental status exam  •Differential diagnosis  •Case formulation  •Treatment plan

Part 2: Family Genogram Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

Required Readings:

(1) Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

Part 1: Comprehensive Client Family Assessment

Demographic information

J.S is an 8-year-old, African American/Caucasian, male.

Presenting problem

Mother reports that she and J.S’s father separated in October of 2015. She reports J.S wishes for her and his father to reunite and get back together. She believes that he could benefit from additional support with understanding the separation of his parents. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room). Mother reports J.S talks to her, but is uncertain if he has any suppressed thoughts or feelings. She shared that J.S’s father was recently on the phone with a women while he was visiting. Mother reports since this J.S has been having a lot of questions about whether his parents will be together again and whether they have other significant relationships. She shared that she wants J.S to understand the concept of his parents being apart.

History or present illness

Mother reports onset of Jayden’s behavior occurred in 2015 when her and Jayden’s father separated.

Past psychiatric history

Mother reports none

Medical history

Mother reports none.

Substance use history

Mother reports none.

Developmental history

Mother reports no delays.

Family psychiatric history

Mother reports anxiety and depression on both J. S’s paternal and maternal side of family. Father is struggling with addiction.

Psychosocial history

J.S reports having a lot of friends. He reports getting along with his friends.

History of abuse/trauma

Mother reports none.

Review of systems

Gen:  Denies weakness, fatigue, fever, chills, night sweats, heat intolerance.

Head: normocephalic; denies migraine headaches.

ENT: Denies visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty

Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes. Cardiopulmonary: Denies cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.

GI: Negative for decreased appetite. Neg for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.

GU: No dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.

MS: Denies backache, joint pain, stiffness. Gait is normal and steady.

Heme/Skin: Denies bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.

Neuro: Denies seizures, paralysis, muscle weakness, parasthesia, sensation changes.

Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.

Physical assessment

Vital Signs:

47 Height: inches

Weight: 115lbs

Temp: 37 C.

RR: 16

BP: 110/62

Pulse: 82 BPM

Appearance: Slender bi-racial male, slightly tan, appearing younger than stated age in   distress, no acute distress, neatly dressed and groomed.

Mental status exam

J.S presents to the appointment with his mother. He alert and oriented x4. Neurologically intact. J.S. is neatly dressed. Polite mannerism and very social. Mood and affect is euthymic and appropriate. J.S. is comfortable interviewing with therapist while mother steps out. He seems to like talking to therapist and asks many questions about games, books, etc. that are present in the room. J.S. denies any SI/HI or A/V/H. Speech is coherent and clear. J.S. fidgets with his hands during interview and processed better after therapist offered Play-Dough to figet with instead.

Differential diagnosis

Z63.5 Disruption of family by separation and divorce

Diagnosis

Seperation and Anxiety Disorder

Case formulation

Mother reports that her and J.S’s father separated in October of 2015. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room).

J.S attended session with his mother. He completed a Basic Emotion Assessment indicating mixed emotions (sad, angry, happy, excited). J.S rated sadness as a 4 on a scale from 0-5 with 5 indicating very sad. Jayden explained, “I am sad that my dad does not live with me anymore.” He reported that he is happy and excited because he will be going to his grandmother’s home for the summer.

According to the American Psychological Association (2013), diagnosis assigned to individuals who have an unusually strong fear or anxiety to separating from people they feel a strong attachment to. The diagnosis is given only when the distress associated with the separation is unusual for an individual developmental level, is prolonged and severe. In accordance with J.S.’s intake assessment and individual therapy session, he fits the criteria for this diagnosis.

Treatment plan

Treatment Goals

J.S will acknowledge and accept the separation of his parents. He will begin a healthy grieving process and manage reactions experienced due to disruption of family by separation.

Estimated Completion: 3 Months

Objective #1

J.S will bring awareness to thoughts and feelings related to his parents’ separation as evidenced by (a) identifying and listing emotions surrounding two parents and two homes, (b) clarifying his relationship patterns with his custodial (mother) and noncustodial (father) parent, and (c) participating in expressive art activities or psychotherapy exercises to help express thoughts and feelings about parents’ separation. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.

Treatment Strategy / Interventions: Supportive psychotherapy, integrating psychodynamic, cognitive-behavioral, and interpersonal conceptual models and techniques will be used to address and respond to J.S’s thoughts and feelings related to his parents’ separation.

Therapist will educate J.S on how relationships may begin and end. Therapist will elicit J.S’s exploration, description, and ventilation surrounding the disruption of family by separation. Therapist will assist him in developing vocabulary to express emotions. Psychoeducation, Psychotherapy Homework, Psychotherapy Worksheet, Expressive Arts Therapy will be used to help him identify, list, and bring awareness to his emotions and thoughts. Therapist will help Jayden learn how to rate his emotions using basic emotion assessments each session. Supportive Reflection, Interactive Feedback, Symptom Management, Relaxation/Deep Breathing will be used to foster a therapeutic environment and alliance where J.S is comfortable in sharing.

Estimated Completion: 3 Months

Objective #2

J.S will accept parents’ separation with consequent understanding and control of feelings and behavior as evidenced by (a) practicing emotion regulation skills (e.g., opposite actions, checking the facts, focusing on positive events, etc.), (b) developing and using relaxation techniques (e.g., deep breathing, mindfulness, drawing, coloring, etc.), and (c) learning and verbalizing the stages of loss and grief for children whose parents have separated. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.

Treatment Strategy / Interventions: Therapist will gently explore, confront, and address J.S’s reactions to his parent’s separation. Using DBT and CBT approaches, J.S will be educated, taught, and modeled skills he can use to cope with strong negative emotions. Therapist will help J.S understand the stages of loss and grief experienced by children. Therapist will determine what stage of loss and grief he is in and help him move towards acceptance. J.S will be asked to identify and list the advantages and disadvantages of his parent’s separation. He will be encouraged to focus on positive experiences he has had since his parents’ separation to help him accept and embrace changes. Role-Play/Behavioral Rehearsal, Psycho-Education, Psychotherapy Worksheet, Supportive Reflection, Symptom Management, Interactive Feedback, Exploration of Coping Patterns, Exploration of Coping Patterns, Exploration of Emotions will be used.

Estimated Completion: 3 Months

Social Support system:

Mother, maternal grandmother.

Part 2: Family Genogram

Genogram includes J.S. maternal side of family. Mom reports no knowledge of paternal family members by name.

Grand

Father Ed

Grand

mother Judy

Jade

Father

Greg

Mother

Ashley

Great

grandfather

Tom

Great

grandmother

Ann

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