Respond 

 

As a reminder to those who may have not read my posts in the past six weeks, my PICOT question is: In patients with CHF, would a scheduled education program with booklet versus just education handouts decrease 30 day hospital admissions over a 3 month period?” Heart failure readmission rates cause the Center for Medicare and Medicaid Services to now give hefty penalties to organizations within thirty days so there is currently a tremendous amount of research surrounding this topic. There are two major research studies that really follow the PET model that I am aiming for with this study. My goal is to have approximately 60 test subjects from my primary care practice who fall within the categories of having a low ejection fraction, diagnosed with heart failure, and who do not have severe comorbidities including other systems. I will split this group into a control group and an intervention group. The control group will receive a three-month educational program and booklet while the other will receive the standardized care that has been used in the office.

            The PDSA model was created by Edward Deming and is a great way to implement change and improve quality of care. The PDSA stands for Plan, Do, Act, and Study (Donnelly & Kirk, 2015). The key through the literature research review was that patients’ who had better education about their disease process, diet, exercise, lifestyle modifications, medications, and treatment plan, ultimately had better outcomes than those who are simply receiving the standardized care. Through review of quantitative and qualitative research literature, it was evident that the influence and key tools to self-management precluded better patient outcomes, lower readmission rates, decrease in length of stay in the hospital, and improved quality of life. Using the PDSA model, I will outline my plan and figure out the ultimate goal of this process. This PICOT question would require planning who will be doing the education session, who will create the booklet, how we will fund this project, and how to select as well as the selection process for our test subjects (as well as informed consent). This also includes the approval of an ethics committee for this research in order to protect the test subjects. The “Do” would be to start the research program by following the two groups and providing the education and reference channels to the patients as see fit. It is important to document throughout the course of this research in order to gain the most information possible. The “Study” would be at the conclusion of the three-month period when all the finalized data is collected and analyzed. This is where the researcher would see if their predicaments were correct and how they related to the research literature. The final step is “Act” and this will involve assessing the overall cycle and looking where to make changes to being the next PDSA cycle. In a world of health care where it is constantly changing and evolving, it is important that processes are being assessed in order to change and improve. Following the three-month process of education, intervention, and data collection, it is really important to focus on what worked during the process, what didn’t, and what changes can be made to reach the goal of healthier and happier patients.

            One article I found had a very similar PICOT and used a PET method that seemed very relevant to my PDSA. It used a similar number of subjects and also slipt them into groups over a three month period. It had very positive results in a sense that the patients who were in the intervention group were very satisfied with their quality of life and managed to stay out of the hospital. As nurses and a future nurse practitioner, isn’t that what our goal of all this EBP is for – to improve patient outcomes? I think to truly take my study one step further would be to also perform a qualitative study and take a closer look at their perception of the education, self-management, and possibly ways to improve my program.

Alireza, A., Tahereh, N., & Mansoureh, A. (2018). Effect of the self-management education program on the quality of life in people with chronic heart failure: A randomized controlled trial. Electronic Physician, 10(7), 7028-7037. doi:10.19082/7028

Donnelly, P., & Kirk, P. (2015). Use the PDSA model for effective change management. Education For Primary Care: An Official Publication Of The Association Of Course Organisers, National Association Of GP Tutors, World Organisation Of Family Doctors, 26(4), 279–281. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.

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Education is key here regardless of whether the mother wants to breastfeed or formula feed. I think helping the mother see the benefits of breastfeeding is important but also helping her know that she will be supported regardless is also important. Also, providing the mother with education on signs and symptoms of malnutrition such as the amount of wet diapers is important so that she knows what to look for and when to notify a provider should these symptoms start to occur. Situations like this can also cause a lot of stress on the mother and feelings of inadequacy can occur so assessing the mother carefully for any signs of post-partum depression or discouragement is also important as you mentioned. Helping the mother to know that there any many resources available to her is also important.

  

2-Because of the mother’s reluctance to breastfeed, the first assessment I would do immediately is to determine the status of the infant. Checking to ensure adequate hydration by asking about the number of wet diapers and checking the infant for lethargy or dry mucous membranes would be the first priority.

After determining the safety of the infant, I would utilize the rest of the information gained from the functional health assessment to determine the needs and decisions the mother would like to made.

In either case, I would be interested to know if she has adequate support systems in place, including child care and the nature of her employment because breastfeeding can be impacted by these situations both for timing of feeding, milk supply, and opportunities for pumping. If the mother has decided to breast feed, a lactation consultant might be a good resource for support and education. A website such as womenshealth.gov/breastfeeding could also be given as a resource if there is available access to the internet.

The newborn’s health will be a priority regardless of her decision. Education concerning development will be important, and it would be important to determine the level of understanding the mother has about feeding an infant and what her body requires to provide an adequate and healthy milk supply. Adequate nutrition and hydration through breastfeeding is determined by output and weight gain. Nutritional status of the mother is an important consideration. Referral to public assistance programs specifically geared towards the nutritional health of breastfeeding and pregnant women and children such as the Special Supplemental Nutrition Program for Women, Infant and Children (WIC) would be an important consideration if there is financial concern in the family. In a longitudinal study Sonchak determined that this program did not decrease breastfeeding initiation, and in fact increased breastfeeding (2017). The health benefits of breastfeeding for the infant should be discussed as being the best option for feeding the baby, but without pressure, blame, or shame if that is not a viable option for this mother or family.

For formula feeding, the developmental milestones and health status would be the same. The method of preparing the feeding would need evaluation to see if education is needed. In feeding formula, the type of formula and the method of preparation are two areas that frequently need education. Cow’s milk should not be an option until after the child is 1 year of age, and the proper concentration of formula must be emphasized in order to ensure the child is receiving the appropriate number of calories and nutrition. WIC will also help provide formula if the mother has a financial need, and dilution of the formula to save money would be less likely.

Finally, the emotional component should be assessed and addressed. Mothers frequently feel guilt, regardless of their choice of method to feed their baby. By providing education on what the baby’s needs are and what the signs and symptoms are for adequate nutrition as well as what to look for if there is a problem, the mother can alleviate guilt by providing the best nutritional plan for whichever method she chooses. By focusing on the health of the infant she will be able to clearly decide how to best meet the nutritional needs in a way that works for her, her budget, and her lifestyle.

References

Sonchak, L. (2017). The impact of WIC on breastfeeding initiation and gestational weight gain: Case study of South Carolina Medicaid mothers. Children And Youth Services Review, 79115-125.

U.S. Health and Human Services, (2018). Breastfeeding. [HTML] Retrieved from https://www.womenshealth.gov/breastfeeding 

  

3-If I found out that the mother of the newborn infant was reluctant to breastfeed her baby, I would get more information from the mother. I would ask the mother if she’s fearful, is it any religious beliefs, does she think it’s painful, or is it because she doesn’t have much information about breastfeeding. It’s important to assess her knowledge of breastfeeding prior to beginning any education to see what areas need further education. Assessing her ability and willingness to learn is also important. After understanding why, she is reluctant to breastfeed, I would educate her on the benefits of breastfeeding. It is easier for babies to digest breast milk than it is to digest formula. Breast milk contains antibodies that help the baby fight of viruses and bacteria later in life. It helps builds the infants immune system and infants tend to get sick less often. “Breast milk has all the nutrients an infant needs to grow. Breastfeeding lowers the infants risk for developing asthma and allergies” (WebMD, n.d.). Breastfeeding is a way that the mother and infant can bond.

It is during infancy that their nutrient requirements per pound of body weight are proportionally higher than any other time during their life cycle (United States Department of Agriculture, 2009). It is important to know if the baby is getting the proper amount of nutrients if the mother breastfeeds or bottle feeds. It is common for a mother who breastfeeds to worry about her infant getting enough because there is no way to measure the breast milk if the infant is drinking from the breast. Unfortunately, this will discourage mothers from breastfeeding. As nurses we can reassure the mother that there are ways to confirm that the baby is receiving enough nutrients needed. If the infant is gaining weight each visit or if the infant is soaking 6 diapers or more in a 24-hour period. If the infant stops eating, isn’t fussy, and seems satisfied than he/she is getting enough to eat. When infants are bottled fed, you can look for these signs to tell you if the infant is getting enough.

As a nurse, our main priority is to always show support with whatever decision our patients. Making sure the new mothers have all the resources available to them is important. As nurses, we can encourage our new mothers to breastfeed and it is important that we are readily available to them when and if they have any questions or concerns.

Department of Agriculture. (2009). Infant nutrition and feeding.

Retrieved 3/26/2018, from https://wicworks.fns.usda.gov/wicworks//Topics

/FG/Chapter1_NutritionalNeeds.pdf

 

Jordan is a 35-year-old woman who presents with intermittent diarrhea with cramping that is relieved by defecation. The diarrhea is not bloody or accompanied by nausea and vomiting. Review of past medical history includes some childhood “stomach issues”, HTN, and a recent cholecystectomy. She works in the environmental department of a large hotel. . She denies alcohol and cigarette.

Diagnosis: Irritable Bowel Syndrome (IBS)

I.      Discuss the epidemiology of IBS?

II.     What is your treatment goals for this patient?

III.    Discuss First line and second line drug therapy for IBS. Please include pharmacotherapeutic information.

  Using APA 6th ed. Work must be supported by peer-reviewed article published within 5 years. 

 

Shelly is a 4-year-old preschooler who lives with her parents and younger brother. She and her brother attend a local daycare center during the week while their parents are at work. In the evenings she and her brother take a bath and then their parents read to them before bedtime at 8 PM. Shelly’s daycare class includes many children her age and she enjoys playing outside with them. Although snack times are planned, Shelly would rather play and does not always finish her beverages.

Shelly’s mother calls the clinic and tells the nurse practitioner that Shelly has been “running a fever of 101 F for the past 2 days” and although her temperature decreases to 37.2 C (99 F) with Tylenol, it returns to 38.4 C (101 F) within 4 hours of each dose. Further, her mother says that Shelly complains that “it hurts when I pee-pee”. Shelly’s mother also has noticed that her daughter seems to be in the bathroom “every hour”. She makes an appointment to see the nurse practitioner this afternoon.

The potential diagnosis is UTI.

1.  What other assessment data would be helpful for the nurse practitioner to have?

2.  What are the organisms most likely to cause an UTI?

3.  What is the pharmacological treatment for Shelly? Keep in mind safe dosing.

4.  What are the teaching priorities for Shelly and her mother prior to her discharge from the clinic?

APA guideline 

Less than 15 % similarity