Category: Health & Medicine

Etiology of the lesion

The cause of most stomach cancer is believed to be through the infection of Helicobacter pylori (Kumar, Suzan and Robbins 134). However, other conditions increase the risk levels including aspects such as genetic factors, intestinal metaplasia and autoimmune atrophic gastritis. Some of the most common risk factors include;

Poor diet: Excessive cholesterol and fats in the diet increase the chance of stomach cancer. Salted meat and fish, smoked foods and pickled vegetables appear to raise the risk to adenocarcinoma of the stomach (Wang and Giraud 123). Cured meats contain nitrites and nitrates, which can be converted by bacteria, H. pylori, into compounds, which cause stomach cancer (Wang and Giraud 123).

However, the consumption of fresh fruits and vegetables that contains antioxidant vitamins such as A and C do considerably lower the risk of stomach cancer (Kumar, Suzan and Robbins 198). Taking a balanced diet is recommended to curb the disease. There has been a correlation between iodine deficiency and cancer (Wang and Giraud 123). There was a case of reduced mortality rates after the implementation of I-prophylaxis (Wang and Giraud 83).

Smoking and alcohol consumption: A great percentage of patient suffering from stomach cancer is smokers (Wang and Giraud 78). Heavy smoking increases the chances of this disease to about eight-two percent. Additionally, drinking and smoking elevate the situation to more severe levels.

Genetic factors: Stomach cancer shows male dominance with one female affected for every three males (Baynes and Dominiczak 78). Some hormones are effective especially estrogen in women that help in minimizing chances of developing cancerous cells. Alternatively, some percentage of this cancer has been identified to be hereditary (Baynes and Dominiczak 78).

Macroscopic and microscopic findings

The microscopic and macroscopic findings of stomach cancer revealed the following cases. Macroscopically, the cyst around the duodeni had cognate mucosa without communication with gastric (Baynes and Dominiczak 94). The existence of muscular wall was histologically confirmed within the gastric duplication cyst and stomach. There are more than 4 microscopic foci of intramucosal signet ring of adenocarcinoma cell in six macroscopically normal stomachs, often foci size 0.1-10mm diameter (Baynes and Dominiczak 94).

Symptoms and signs and laboratory findings caused by the lesion

In the early stages of stomach cancer, only nonspecific symptoms are observable (Baynes and Dominiczak 114). Once the symptoms are manifested, the cancer is fully-fledged and this is a reason for poor prognosis. Stomach cancer poses the following signs:

• Stage 1: This stage has mild and generally nonspecific symptoms (Kumar, Suzan and Robbins 124). Some signs at this stage include heartburn with indigestion and burning sensation in the gastric, irritation and abdominal disturbances and lack of appetite, mostly for meat (Baynes and Dominiczak 99).
• Stage 2: Symptoms that clearly manifest at this stage are bloats in the stomach often after meals and fatigue with weak body.
• Stage 3: This stage represents the maturity of the cancer and it shows clear signs and symptoms that can be associated with the cancer. Having abdominal pains mostly in the upper abdomen with constipation and diarrhea will be felt. Considerable weight loss, blood in stool or vomiting blood that appears blackish occurs and may lead to anemia (Kumar, Suzan and Robbins 208). Dysphagia, tumor in the cardia or elongation of gastric tumor, is common (Kumar, Suzan and Robbins 208). Occasional vomiting and nausea is also featured at this stage. These symptoms however, can be as a result of other problems such as ulcers, stomach virus or tropical sprue (Kumar, Suzan and Robbins).

Treatment and prognosis

Prognosis is relevant because its application increases chances of a patiehelps in the recovery process (Wang and Giraud 78). Stomach cancer prognosis is based on research collected over many years and statistics from groups who present similar situation to that of the patient are utilized. The process of prognosis only gives prediction; therefore, doctors are not certain on the outcome or reaction of specific patient (Kumar, Suzan and Robbins 213).

The treatment for adenocarcinoma for stomach includes chemotherapy, radiation therapy surgery and biological therapy, which form the new treatment approach.

Surgery is the most common treatment approach. A surgeon removes all or part of stomach with the aim of removing the cancerous cell with some part of normal tissues (Wang and Giraud 231). Depending on the extent and location of the tumor cell, parts of the pancreas or intestines can be removed. With the tumors located in the lower part of the stomach Billroth I or Billroth II procedure can be invoked (Wang and Giraud 123).

The EMR (Endoscopic mucosal resection) is the pioneered treatment for early stomach cancer that is currently used. The procedure involves the removal of the tumor, together with the mucosa (the inner lining of the stomach) using electrical wire loop through the endoscope (Wang and Giraud 215). It is more relevant and beneficial since it does not advocate for removal of the stomach, but removes a portion of it. The ESD (Endoscopic submucosal dissection) is used to resect large mucosal area in one piece (Baynes and Dominiczak 112).

Use of Chemotherapy in treatment does not utilize specific established care principles. Gastric cancer pose less sensitivity to the chemicals and the use only reduces the size of the tumor, prolongs survival, and acts as pain reliever. Some of the drugs used are 5-FU fluorouracil, carmustine BCNU and doxorubicin (Adriamycin) (Baynes and Dominiczak 152). In addition, Mitomycin C, cisplatin and taxotere can be used. Because chemotherapy kills cancer cells along with other cells, the side effects are many including hair loss, illness blood disorders and drop in blood count (Baynes and Dominiczak 115). Therefore, patients are programmed to on and off therapy to minimize the side effects.

Radiotherapy is the use of high-energy rays such as X-rays, to kill cancerous cells and stop them from growing (Baynes and Dominiczak 52). It is mostly used with combination of other procedures such as surgery or chemotherapy to cure this cancer. this forms of treatment is useful in reducing pain since it by shrinks tumor cells (Wang and Giraud 123). Rays from radiation are released at an angle to provide best strike on the tumor cells (Baynes and Dominiczak 88).

Lastly, combination of treatment methods such as chemotherapy, surgery and radiotherapy provides a survival benefits to patients with non-metastatic, completely resected stomach cancer (Wang and Giraud 123).

Relevance to dental practice

The relevance of this research to dental practice is of great significance. The knowledge acquired from the study provides adequate tools, which can be applied in the field of dentistry. Measures taken to prevent stomach cancer are correlated to those of curbing oral cancer. Avoidance of smoking and drinking significantly contributes to good dental health.

Statistics shows that stomach cancer is the fourth most common cancer in the world and it has high death rates being second to lung cancer with men being highly affected (Wang and Giraud 45). This type of cancer is relatively high in under developed and developing countries because of poor hygiene and diet issues. The study of this type of cancer helps in dental management as well. The cancer management will adversely improve the oral health. This type of cancer has challenges in its prognosis since it portrays asymptomatic features, which cannot be easily recognized and often mistaken for other problems such as stomach ulcers.

Works Cited

Baynes, John, and Marlek Dominiczak. Medical biochemistry. (3rd edn.). Philadelphia: Elsevier, 2009. Print.

Kumar, Vinny, Suzan Cotran Robbins Leornards. Basic Pathology. (8th edn.). Philadelphia, PA: Saunders, 2007. Print.

Wang, Timothy and Adrew Giraud. The Biology of Gastric Cancers. Tsinghua University Press: Springer-Verlag, 2009. Print.

The senior center is a facility that deals with the provision of national leadership and public health concerns with an aim of facilitating healthy aging, and prevention of diseases and injuries in the aging population. The aging population is associated with various injuries caused by falls such as hip fractures and traumatic brain injuries (TBI). This poses a serious risk to the health of older adults. However, an older adult can avoid these injuries and accidents in various ways.

Strategies the aging populations use to protect themselves from injuries and accidents

These ways may include a structured exercise program, which is important in serving the purpose of promoting the physical well-being of older adults (LIFE Study Investigators, 2006). This may also help to protect the aging population from walking disabilities. The elderly also use assistive devices to protect themselves from injuries and other accidents. Assistive devices include equipment that enables older patients to do things independently without relying on another person.

Environmental accessibility adaptation is another way that the aging population uses to ensure they are safe. This is simply mastering the residence or home, to facilitate the safety and independence of the older adult.

Polypharmacy

Polypharmacy is a practice that involves taking multiple medications that are not necessarily important (Fulton & Allen, 2005). It is good for older patients, to take more medication compared to younger individuals. However, the more medication an older patient takes, the more exposed to drug-related health problems, because the body responds differently to medication as it ages.

This condition is mainly associated with elderly people of age 65 years and above. An elderly person is susceptible to take wrong or in appropriate medication, or medication that is not well prescribed. This may result into a condition called adverse drug event (ADE), which is mainly caused by interaction of different drugs in the body (Fulton & Allen, 2005).

Polypharmacy may be as a result of doctors/clinicians prescribing more medicine to their aged patients due to the fact that the medicines are readily available. Polypharmacy may also be caused by prescribing cascade, whereby an elderly patient experience side effects from the medication he/she is taking, leading to misinterpretation by the doctor or clinician as symptoms of another disease. The elderly patient is then prescribed another drug, which may also have side effects.

Economic situation confronting older adults

It is statistically proven that more than 9.95% of old adults above 65 years and above, live both at the poverty line and below. 31.4% of these are viewed as economically insecure, in that they may not be able to obtain basic necessities. About 50% of all the older adults of age 65 and above have low income to be able to meet their basic necessities. Female are worse compared to male in terms of extreme poverty (Johnson & Wilson, 2010).

The recent experienced economic crisis was more likely to increase the vulnerability of older people to poverty, because many elderly people are unemployed, and are experiencing credit card debts as well as losses in their savings. Many older adults encountered losses of their wealth, leaving them without any economic security and vulnerable to poverty.

The government should set and maintain programs for the elderly to prevent them from experiencing economic problems in their old age. These may include programs such as security funds, pension schemes etc.

References

Fulton, M. M & Allen, E. R. (2005). Polypharmacy in the elderly: A literature review. 123. J Am Acad Nurse Pract, 17(4) , 123.

Johnson, K., & Wilson, K. (2010). Current Economic Status of Older Adults in the United States: A Demographic Analysis, National Council on Aging. A Demographic Analysis, National Council on Aging , 1-17.

LIFE Study Investigators. (2006). Effects of a physical activity intervention on measures of physical performance: Results of the Lifestyle Interventions and Independence for Elders pilot (LIFE-P) study. Journal of Gerontology: Medical Sciences: 61A(11), 1.

Introduction

Meningiomas are tumor growths that develop and extend from the meninges. These types of tumors are common and comprise a third of all brain tumors. Normally, meningiomas develop as slowgrowing tumors (Lee 10). However, with time, malignancy cannot be overruled. According to medical researchers, most meningiomas are asymptomatic and exhibit no symptoms throughout an individuals life. In addition, there exist no formal treatments other than periodic observation (Ransohoff 15). For these reasons, there are several types of meningiomas based on their locations, which include convexity meningiomas and Olfactory Groove Meningiomas.

Causes

To date, the main causes of meningiomas are still unknown. However, like other cancerous growths, meningiomas are initiated by exposure to unfavorable factors such as atomic radiation and other body elements leading to a genetic disorder in the body. (Lee 20). Physically, the tumors may result from head injuries, though their linkage is unknown (Ransohoff 15).

Convexity Meningiomas

Convexity meningiomas tumors develop on the dural base under the lower occipital, and suboccipital bone overlying the convexity (Mefty 135). As a result, Convexity meningiomas grow on the surface of the brain, beneath the skull. This accounts for more than twenty percent of all meningiomas (Ransohoff 65). Convexity meningiomas are normally asymptomatic until the tumors enlarge in size. After the tumors have enlarged significantly, their symptoms appear based on their location and proximity to the brain. According to health experts, convexity meningiomas normally affect individuals within the age group of the 40s and 70s (Mefty 137).

Symptoms

Headaches

According to medical experts, one of the most common symptoms of convexity meningiomas is headache (Mefty 138). These headaches can be mild or severe, and naturally occur on the forehead. Growth of convexity meningiomas in the brain changes the brain pressure levels. With increased brain pressure, affected individuals typically experience severe headache pain, limiting ones ability to concentrate. In this regard, headache pains among on-convexity meningiomas patients occur regularly or irregularly. However, among convexity patients the headache pains recur frequently.

Seizures

Another major symptom experienced by convexity meningiomas patients are seizures (Ransohoff 78). Seizures results from abnormal disruption of the brain electrical activity. Most of the patients, who have had seizures, have reported experiencing involuntary muscle spasms coupled with visual hallucinations lasting for short periods. Once the seizure ends, affected individuals emerge as confuse, fatigue and complain of muscles pains. In the presence of such symptoms, the affected individuals should seek immediate medical help (Mefty 137). Apart from convexity meningiomas, seizures can result from head injury. Therefore, medical professionals should treat both tumors appropriately.

Neurological deficits

According to Mayfield clinic professionals, convexity meningiomas patients may exhibit neurological deficits in their daily acts (Pamir and Peter 35). Neurological changes are illustrated by patients loss of memory, attention difficulties, character changes, trouble speaking and motor coordination problems. With increase in convexity meningiomas, neurological deficits become fully apparent. Thus, the need to avoid such phenomena, necessitate patients to seek medical attention as fast as possible. This is aimed at reducing the level of neurological malfunction.

Olfactory Groove Meningiomas (OGM)

The World Health Organization (WHO) regards OGM as Grade 1 meningiomas (Mefty 196). As compared to other meningiomas, the tumors account for nearly ten percent of all meningiomas. These tumors arise from behind the eyes, along the sphenoid ridge. Based on their on their name, the tumors develop and affect between the snout and the brain.

With its increase in size, the affected individual might lose his or her sense of smell. Over time, when they are overgrown, loss of vision is eminent. However, despite significant technological advances in neuroimaging processes, Olfactory Groove Meningiomas can be discovered when they are very large (Pamir and Peter 85).

Symptoms

Some of the most common symptoms of these tumors include the changes in individuals personality, judgment and motivation (Mefty 196). Allies of the affected individuals notice these changes.

Normally, Lesions grow to very large sizes before they can be diagnosed. In the late courses of the tumor, individuals exhibit headaches and visual problems. Despite, olfactory smells distorting from the onset of the disease, most patients rarely realize (MacCarty 124). Due to its growth pattern, the tumors extends in such a manner that they compress optic nerves resulting in visual aid defects. Visual defect effects are usually hard to detect in patients with large tumors.

One of the first clinical symptoms of OGM is Anosmia. Due to the OGMs area of concentration, olfactory tract linings are greatly altered by the tumors growth. Due to the gradual decline of the olfactory, patients may not realize the effects of the tumor during its onset stages. With the disease nature of affecting one side of the nose, most patients do mistake the disease for lack or decline of smelling ability.

Nevertheless, with increase in OGM growth down the olfactory patients may experience despair, boredom and retardation (Mefty 201). With advancements in medicine researches, medics have linked both euphoria, insomnia and despair symptoms with progressive growth of OGM down the olfactory tissues.

Towards its late stages, the tumor results in urinary incontinence as well as pace ataxia symptoms. Despite the removal of the tumor, these conditions rarely recover. The cortical neurons responsible for the gait and micturition response arise from the cerebral hemispheres, traveling up and down the lateral ventricles. Thereafter, they travel into the internal capsule. As a result, the growth of the tumors leads to the stretching of the fibers, where the affected individual suffers from incontinence and gait ataxia.

OGM Diagnosis

In the event that an individual is affected by the OGM, a physician should prescribe diagnostic imaging. Thereafter, computer tomography (CT) should be administered on the patients head as the brains first imaging study (MacCarty 198). This medical exercise would depict the status of the brain. As a result, medics will understand the manner to administer medication.

These two forms of tumors, though being relatively uncommon, are among the largest found tumors by medics. Despite the Improvements in both therapeutic and diagnostic advances, olfactory groove meningiomas growth is still considered a puzzle by most medics. However, some medics have attributed this phenomenon to the tumors location in the brain. OMG is located at a silent part of the brain allowing conducive growth of the tumors (Mefty 200).

To avoid late diagnosis and treatments, total awareness of the condition at early periods is essential. In this case, individuals can detect early symptoms before any diagnostic imaging is carried on. Similarly, patients who portray anosmia and depression, particularly the old, should be thoroughly analyzed by physicians. Under this event, medics should adopt methodical analysis on their neurological findings.

Conclusion

Persons with meningiomas experience the above symptoms and signs. However, some individuals do not show these symptoms despite the presence meningiomas (Mefty 201). Similarly, other disease apart from the tumor can equally cause these symptoms. Thus, it is highly advisable for anyone experiencing the symptoms to seek medical help for effective treatment. In both meningiomas cases, there are general symptoms both experienced by the patients.

These general symptoms include headaches, personality changes, blurred vision, nausea, and memory changes. With these symptoms, it will be very difficult to identify the specific meningiomas affecting an individual (Mefty 167). Therefore, if one needs to identify the specific meningiomas, he or she has to analyze the specific symptoms attributed to the type of tumor involved. In regard this, symptoms analyzed will be specific to the each location affected by the involved tumor.

As such, convexity meningiomas patient will experience seizures, personal changes and focal neurological deficits. For olfactory groove meningiomas, the specific symptoms experienced will be loss of smell and distorted vision. As a result, an individual in dilemma who guesses that the tumor is linked to the two meningiomas, has to correlate his or her symptoms with distinct disease symptoms.

This does not only enables one to identify the possible type of meningiomas but also allows the individual to seek earlier medical attention before the growth increases in size. Thus, easing the treatment processes. Similarly, the length of symptoms experienced may aid the medics in the diagnosis exercise to determine the type of the tumor involved. Therefore, it is essential for patients to be open with regard to their conditions, enhance better diagnosis and treatment.

Works cited

Lee, Joung H.. Meningiomas. London: Springer-Verlag London, 2009. Print.

MacCarty, Collin Stewart. The surgical treatment of intracranial Meningiomas. Springfield, Ill.: Thomas, 2000. Print.

Mefty, Ossama. Al-Meftys Meningiomas. 2nd ed. New York: Thieme Medical, 2011. Print.

Pamir, M. Necmettin, and Peter McL Black. Meningiomas. Philadelphia, Pa.: Saunders, 2010. Print.

Ransohoff, Joseph. Meningiomas. Philadelphia: W.B. Saunders Co., 2003. Print.

Clinicians and patients have different views in regard to medication schedules. The difference in perspectives has resulted in substandard compliance with the therapeutic evidence-based directives. When anti-platelets are stopped prematurely, it is likely to cause lethal effects for patients suffering from myocardial infarction, who have been given DES. This article intends to evaluate the similarities between clinicians and patients supposed reasons for clopidogrel discontinuance by patients (Linda, et al., 2011).

Clinical question

What factors compel patients to withdraw early from the medication?

PICOT of the study

1. Patient Problem: Illness or health status (MI patients).
2. Intervention: Therapies and medications.
3. Comparison: No treatment.
4. Outcome: Fewer symptoms.
5. Time: 3-6 months

Databases used

Used cnu.sagepub.com /content/10/1/50 database to access information of this journal. Ebscohost, Cochran database and google books were also used to get information for the study.

Critical Appraisal of the article

Validity of the study

The study was qualitative and used a descriptive method to gather information for analysis. A total of 22 patients and 22 clinicians from different cities of the U.S. were interviewed. For patients who withdrew medication (clopidogrel) prematurely, the first 11 patients in the register and were prescribed medication at the hospital acquit at one-month proceedings were interviewed. Moreover, 11 patients of analogous demographic background and who continued with medication at one-month proceedings were interviewed.

Data collection was done using semi-structured interviews with clinicians and MI patients. Data analysis was done through the coding of transcriptions where texts and codes were inserted into the electronic program for data analysis (Beck & Polit, 2011). The validity of the study was established to ensure that the obtained data met the methodological rigor benchmarks (Dowling, 2007).

Findings of the study

Sample patients

There was no demographic or clinical characteristics distinction between patients who withdrew clopidogrel and those who continued. Both groups ranged from age 45 to 77 years with the mean age being 53 years old. 55% comprised the continuers while 64% comprised discontinuers. The majority of the patients were Caucasians (82%) for both groups and all patients reported being provided with medication directives at discharge. 82% of the patients had high got education up to high school or more. 73% of patients who continued with prescribed medication had health insurance cover.

Sample clinicians

Of all clinicians that were interviewed, 53% of doctors were composed of cardiologists, 33% interior medicine and 13% in the cardiology of intervention. 80% of the physician was male, Caucasian and had an average of 13.8 years experience in the field. 2 nurses who specialized in cardiovascular therapy were also interviewed. Both were women and were Caucasian. They had been in the field for an average of 17 years.

Major topics in the discussion of premature clopidogrel withdrawal include patients lack of awareness of diagnostic specifics, poor communication between clinicians and patients, cost of medication and the discrepancy in the shifts of care (clinicians). The findings of the study are credible and have clearly identified human response and encounters. The proposed connection between cost, awareness and communication error and premature withdrawal from medication is consistent with the findings of the study (Larrabee, 2009).

Application of the results to patient care

These findings may also be useful and applicable in patients of HIV/AIDS because, withdrawal from ARVs may be lethal to them. Since I work with HIV/AIDS patients, the findings would be applicable in the situation. These findings may help physicians and clinicians modify their patients assessments in order to improve health conditions.

This is possible through improvement of communication between clinicians and patients, reducing medical costs and raising awareness on medication guidelines. The results of the study may be used to educate and counsel patients on the importance of complying with medication directives (Lehane, et al., 2008).

The finding can help understand the social-cultural and ethical factor that influence decision making by patients. This is because the study has pointed out such factors as awareness (social-cultural), cost of medication (social-cultural), communication error (ethical) and discrepancy in the shifts of care (ethical) and shown their connection to withdrawal from medication.

References

Beck, C. & Polit, F. (2011). Nursing Research: Generating and Assessing Evidence for Nursing Practice. New York, USA: Lippincott Williams & Wilkins.

Dowling, M. (2007). From Husserl to Van Manen. A review of different phenomenological approaches, 44(1), 131- 42.

Larrabee, J. (2009). Nurse to nurse: evidence-based practice. New York, USA: McGraw-Hill.

Lehane, E., McCarthy, G., Collender, V., & Deasy, A. (2008). Medication-taking for coronary artery disease: patients perspectives. Eur J Cardiovasc Nurs, 7(1), 133  9.

Linda, G., et al. (2011). Clinician Patient Discord: Exploring Differences in perspectives for discontinuing Clopidogrel. European Journal of Cardiovascular Nursing, 10(2011), 50  55.

Subjective

• Patient: 17 years old Latino male
• Chief complaint: sharp abdominal pain

History of present illness

The main symptom is the sharp abdominal pain in the umbilicus area. The patient also has been having nausea with vomiting for the last 3 hours; he denies diarrhea. The abdominal pain is constantly sharp and moved to the right lower quadrant in a previous couple of hours. The pain was exceptionally intense at night; it has not disappeared by now; he describes the pain as sharp, constant, and shooting at the right side of his stomach. It is the first time the patient experiences such pain; its intensity has grown from rate 3 to 7 by now. He did not eat anything in the last 24 hours due to the pain, but he had a Taco and kale salad the day before. The patient denies urinary symptoms and burning, yet he felt hot. There were no recent injuries or accidents that could affect the patients health. He does not have any allergies to medication; he also took ibuprofen at 5:00 AM and 2:00 PM, with no effect on the pain.

Past medical history

The patient is an athlete and visits physical yearly, and the last time was 10 months ago. He did not have any measles, mumps, rubella, strep throat, or other childhood illnesses. There is no history of allergy or diabetes, the patient has never been hospitalized due to traumas or broken bones and has no previous surgeries and abdominal issues. The patient is not sure if the immunizations are up to date. The appendix is not removed; the patient has a Gallbladder as well; he denies urinary or groin pain. The patient is not sexually active and has never been. His family has some illnesses: the uncle had testicular cancer, the grandfather had prostate cancer, and the patients mother has high blood pressure.

• Medications: he gets no daily medications, except for vitamins.
• Review of systems: The patient states that he feels healthy, has no fever, fatigue, congestion, numbness, sore throat, or headaches. His weight, muscle strength, skin, hair, and overall mobility did not change. He denies problems with urination, ejaculation, has no constipation or diarrhea. The last bowel movement was yesterday morning without abnormalities; usually, it goes every day.
• Social history: The patient lives in an apartment with his mother and father, he is the only child. He claims that he feels safe at home, his mother drove him to this visit. He goes to high school and works at the local pool as a lifeguard. The patient frequently exercises as he is at a football team, runs, and lifts weights. He does not smoke, has up to two beers on weekends, and smokes marijuana with friends every other week. He does not do drugs like cocaine or heroin, and the marijuana doses are small as the patient is an athlete.

Objective

• Temp = 101.2
• R = 20
• BP = 110/64
• Hr= 110
• Spo2= 99% RA
• Height = 6 feet 2 inches
• Weight = 180
• BMI = 23.1

General Appearance

17 years old Latino male, NAD, looks distressed and holds his abdomen. He has normal bilaterality, not enlarged, no murmurs, or heart rhythm changes. His muscle, skeleton, and neurotic systems are in normal conditions. The abdomen is flat, and bowel sounds are hypoactive, right lower quad has positive tenderness, no masses.

Assessment

The patient has sharp continuing pain in the lower right quad, vomits, and positive tenderness at McBurneys point. The first possible diagnosis is appendicitis (K35.80) due to vomiting and sharp pain. Another diagnosis is pancreatitis (K86.9) as the patients body temperature increased. The third diagnosis is an abdominal aortic aneurysm (I71.4) due to the constant pain around the belly button.

Differential Diagnosis

1. Appendicitis
2. Pancreatitis
3. Abdominal aortic aneurysm

Plan

1. Medications: no medical prescriptions, the patient is to refer to the surgeon;
2. Further testing: the surgeon will choose proper lab tests and other examinations;
3. Patient education: if the pain is constant and sharp, it is necessary to call an ambulance and visit the Emergency Department for the evaluation. It is incorrect to wait for more than 24 hours with pain before reaching out for help.
4. In case when the pain rate grows to 10, reach out to the emergency for help.
5. The patients overall health conditions will be examined during the following up in two weeks after visiting a surgeon.

Continuously improving the quality of care provided to individuals is essential for meeting accreditation requirements and preventing malpractice. Cases of individual patients are an excellent source of information for care providers that could help to evaluate gaps in the quality of care delivered to patients and design improvements to address them. Furthermore, tracer cases can assist in assessing compliance with accreditation requirements, thus preparing institutions to be accredited by the Joint Commission. In the present case, the patient is a 67-year-old female who had a laparoscopic hysterectomy. Seven days ago, she was readmitted due to concerns regarding a possible postoperative infection. In two days, she received surgery to treat the abscess on the previous surgery site and is currently receiving antibiotic therapy. By reviewing comprehensive information about the case, the Director of Accreditation will identify the required improvements and suggest a plan for their implementation. The conclusions made as part of the evaluations will thus help the institution to meet relevant accreditation standards.

Evaluation

According to the case scenario, the patient was admitted with a postoperative wound infection and received surgery for drainage. She was prescribed a long course of antibiotics to help cope with the infection and should be discharged in a couple of days to obtain further health care at home. The patient did not receive a history and physical exam within 24 hours of admission. In fact, it has the exam delayed by over 72 hours, indicating a critical breach of care standards. The nurse was able to verbalize the medication reconciliation process and had evidence of reconciliation on admission and after surgery. A functional assessment of the patient was also performed, but there was no documentation relating to it. However, the nutritional assessment was documented, and the nurse found indications for social work referral. She also stated that the patient had an advance directive, but the family failed to bring it.

A skin assessment was performed on the patient on admission, indicating a risk of skin breakdown, and the patient was put on a specialty bed. The patients fall risk was also highlighted on the handoff form, necessitating slip-proof socks and night light. The initial nursing plan of care was documented, but no updates to it have been made following the surgeries. The patient had no barriers to learning, and patient education was administered as planned. The care providers involved in the case communicated with one another using process notes and one-on-one conversations. The pain was assessed at regular intervals using a numerical pain scale, and pain medications were offered as required. The environment of care showed some concerns since oxygen tanks were not secured, and air vents were dusty. The nurse claimed to use the read-back process when taking verbal orders over the phone but did not apply it when describing the patients critical values. They were also unable to explain the range order policy and admitted that she would give a maximum doze if the range was 25 to 100 mg. A color-coded armband was used to identify the patients DNR status, blood consent was signed properly, and the blood was double-checked with the RN. The nurse also reported doing rounds when possible and using the SBAR format in communication. Still, the process of handoff was disjointed, with inconsistent use of formal handoff documentation.

Overall, the case offers evidence of several critical issues that threaten the institutions compliance with the requirements of the Joint Commission. However, the most critical breaches were related to documentation and patient assessments. The fact that the patient did not receive a history and physical within 24 hours of admission directly opposes the standard PC.01.02.03. According to the Joint Commission (2019), this standard necessitates hospitals to define time frames for continuous patient assessment during care provision and adheres to these time frames. In the present case, the time frame required for the hospital (24 hours) was not followed. Instead, the patient only received a history and physical after more than 72 hours, which is three times the defined limit. This indicates a serious breach that has threatened the patients health outcomes and life, particularly considering the fact that she was scheduled for surgery 48 hours after admission. For patients undergoing surgery, medical history and physical examination should be administered before the surgery. Therefore, the case shows a breach of the assessment and reassessment standard defined by the Joint Commission.

An initial patient assessment, including history and physical, is essential for understanding the patients condition, evaluating their risks, and defining the course of treatment (Renom-Guiteras, Uhrenfeldt, Meyer, & Mann, 2014; Yamakava et al., 2011). Furthermore, an assessment must be performed prior to the surgery to define if it is safe for the patient or if there are any considerations that anesthesiologists and surgeons have to take into account during the operation (Zambouri, 2007). By not assessing the patients medical history and performing a physical exam within the first 24 hours of admission, the nurses have put the patient at risk of further complications associated with her condition. Moreover, it is unclear whether all of the risk factors of the patient were identified without the data gathered from history and physical. Reports suggest that the Joint Commissions standard regarding patient assessments and reassessments is one of the most frequently breached by institutions. For instance, Patient Safety Monitor (2011) shows that over 30% of hospitals receive a requirement for improvement in standard PC.01.02.03. This suggests that the issue is important to patient safety in contemporary healthcare and that Nightingale Community Hospital should use the tracer patient case as an opportunity to design, plan, and implement the necessary improvements.

Plan

In order to address the situation and prevent similar occurrences in the future, it is critical for the hospital to undertake several steps. First of all, interviews with the nurses responsible for the patients admission and care should be performed to clarify the problems that delayed the history and physical assessment. This will help to understand the root cause of the issues evident in the case and design strategies for targeting them. Next, the hospital should also review its current policies to determine if there are any gaps that could mislead the staff to think that initial assessments can be delayed. If so, these gaps should be addressed, and an updated policy enforcing strict initial assessment time frames should be published. Moreover, the personnel should be made aware of the correct admission process to ensure that they understand the requirements and can comply with them in their work.

The hospital would also benefit from introducing new control mechanisms that would help to track admission assessment time frames at the unit level. For example, collecting information on how many hours have passed between each patients admission and the assessment of their history and physical condition would give the Director a clearer picture of the situation, thus showing the trends in the whole institution. If some units perform worse than others, it might be necessary to add more control mechanisms or perform further analysis to understand the reasons for failing the requirements. As part of this process, staffing levels could be taken into account since nurses might forget to perform some duties as required if their workload is too high. On the whole, the proposed plan involves a more in-depth evaluation of the case, the introduction of new controls, and an analysis of the situation in units that do not meet the standard.

Conclusion

The case offered for a review presents several vital problems that mark the institutions lack of compliance with the standards defined by the Joint Commission. This can have a negative effect on the whole institution by inhibiting the accreditation process, as well as on patients, by hurting their outcomes and satisfaction with care. One of the most prominent standards that were not met in the case was the standard for patient assessments and reassessments. Scholars confirm the necessity of evaluating patients history and physical condition within a day of their admission, as well as before the surgery. Failure to comply with this standard limited the quality of care rendered to the patient in this case and identified the need for improvements. The proposed plan could help the hospital to avoid similar problems in the future by addressing the core reasons for delayed admission assessments.

References

The Joint Commission. (2019). Joint Commission standards summary form. Web.

Patient Safety Monitor. (2011). Joint Commission: PC.01.02.03 one of top compliance issues. Web.

Renom-Guiteras, A., Uhrenfeldt, L., Meyer, G., & Mann, E. (2014). Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review. BMC Geriatrics, 14(1), 80.

Yamakawa, K., Tasaki, O., Fukuyama, M., Kitayama, J., Matsuda, H., Nakamori, Y.,& & Shimazu, T. (2011). Assessment of risk factors related to healthcare-associated methicillin-resistant Staphylococcus aureus infection at patient admission to an intensive care unit in Japan. BMC Infectious Diseases, 11(1), 1-7.

Zambouri, A. (2007). Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia, 11(1), 13-21.

Regardless of the fact that diphtheria is regarded by a substantial number of people as an obscure contagious disease from prior years, it currently remains a global illness that attracts the particular attention of scientists, clinicians, and policy-makers. According to the World Health Organization, diphtheria is severe infectious disease caused by the bacterium Corynebacterium diphtheria (WHO 2018). It primarily infects upper airways and the throat and produces a toxin that affects other organs. This toxin kills tissue in the respiratory system and causes the dead tissues membrane to build up over the patients tonsils and throat, making swallowing and breathing difficult (CDC 2020). In general, diphtheria has an acute onset with the major symptoms that include sore throat, weakness, swollen glands in the neck, and mild fever (CDC 2020). In certain circumstances, the diphtheria toxin may cause peripheral neuropathy, airway blockage, kidney failure, myocarditis, paralysis, and death (WHO 2018). In addition, Corynebacterium diphtheria may infect the skin as well, causing ulcers or open sores (CDC 2020). At the same time, diphtheria skin infections do not lead to severe complications in the future.

Diphtheria is traditionally spread from person to person in the result of breathing in the aerosolized secretions from the infected individuals coughs or sneezes (WHO 2018). In the case of diphtheria skin infections, individuals may get the disease from touching other peoples infected ulcers or open sores. Before the introduction of vaccination against diphtheria that has significantly reduced the morbidity and mortality rates, this disease was the major cause of childhood death in the United States and all over the world (Truelove et al. 2020). Due to the successful immunization program for the control over diphtheria of the American public health system, there are almost no outbreaks of this disease across the country. However, in 2018, the World Health Organization recorded more than 16,000 cases of this infection disease worldwide (WHO 2018). Diphtheria remains a severe child health problem, fatal in 5-10% of cases, in developing countries with the poor coverage of the Expanded Program on Immunization (Clarke et al. 2019).

Diphtheria treatment involves the administration of antibiotics and diphtheria antitoxin for the neutralization of the toxins effect. Diphtheria vaccine implies a bacterial toxoid whose toxicity is inactivated, and it is traditionally given in combination with a pentavalent vaccine or DTwP/DTaP vaccine (WHO 2018). For adults and adolescents, the diphtheria vaccine may be combined with the lower concentration of tetanus toxoid (WHO 2018). Diphtheria toxoid vaccine is essential for the control over the disease as it reduces the transmission of diphtheria by 60% (Truelove et al. 2020). In addition, its use is determined by the absence of severe adverse effects  common insignificant adverse effects of this vaccine traditionally include swelling, redness, and pain at the injection site (Liang et al. 2018). However, for the total prevention of subsequent outbreak, isolation of vaccinated individuals, the identification of their contacts, and the use of antibiotics are required (Truelove et al. 2020).

The World Health Organization recommends a three-dose primary vaccination series in children with diphtheria toxoid vaccine and three booster doses that follow it for the control over the disease (WHO 2018). The primary series begins at six-week of age, and subsequent doses should be given with a four-week minimum interval between doses (WHO 2018). Consequently, three booster doses should be given at 12-23 months, 4-7 years, and 9-15 years of age, respectively, and the four-year interval between booster doses is preferable (WHO 2018). It is highly essential for parents to follow their childrens immunization plan as the series of doses that provide high vaccination coverage protects against this life-threatening disease.

Reference List

[CDC] Centers for Disease Control and Prevention [Internet]. 2020. Washington (DC): U.S. Department of Health & Human Services. Web.

Clarke K E N, MacNeil A, Hadler S, Scott C, Tiwari T S P, Cherian T. 2019. Global epidemiology of diphtheria, 20002017. Emerg Infect Dis. 25(10): 1834-1842. Web.

Liang J L, Tiwari T, Moro P, Messonier N E, Reingold A, Sawyer M, Clark T A. 2018. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 67(2): 144. Web.

Truelove S A, Keegan L T, Moss W J, Chaisson L H, Macher E, Azman A S, Lessler J. 2020. Clinical and epidemiological aspects of diphtheria: A systematic review and pooled analysis. Clin Infect Dis. 71(1): 89-97. Web.

[WHO] World Health Organization [Internet]. 2018. Geneva (CH): World Health Organization. Web.

Introduction

The use of differential diagnosis is a vital element of clinical reasoning, allowing to consider various conditions which may cause a patients symptoms. By developing alternatives and prioritizing them by likelihood and urgency, appropriate testing can be conducted to confirm or rule out possibilities to arrive at the final diagnosis. This paper will examine and compare three differential diagnoses of fibrocystic breast disease, breast cyst, and fibroadenoma.

Compare and Contrast

Fibrocystic breast disease is the most prevalent type of benign disease in the breast. The presentation consists of fibrous and cystic changes in the breast. The breast may feel lumpy, tender, and dense, with fibrous (stromal) tissue becoming prominent. Alongside, numerous cysts may form, large and small, pushing against the breast tissue causing pain. Benign cysts are mobile in the glandular breast tissue and are rubber-like in texture, with some cases seeing nipple discharge (Malherbe & Fatima, 2020). A breast cyst is presented as a fluid-filled, round, or oval sac in the breast with distinct edges. It is a movable lump that is tender to the touch, but rarely firm (Mayo Clinic Staff, n.d.). Therefore, despite fibrocystic breast disease also presenting cysts, it is diagnosed based on breast lumps and swelling of the rubbery and firm fibrous tissue that would not be present in breast cysts (American Cancer Society, 2019).

Meanwhile, fibroadenomas are solid, benign breast lumps. Lumps are firm, rubbery, smooth, can be mobile, and have a well-defined shape. Most usually fibroadenomas are completely painless (Ajmal & Van Fossen, 2020). In comparing fibroadenomas to breast cysts, there is a difference in texture. Fibroadenomas are not fluid-filled and painless and firm to the touch, while breast cysts are fluid-filled, being soft and tender. Fibroadenoma is more distinct with a discrete, typically individual, well-circumscribed lesion. In comparison, the fibrocystic disease will contain areas that are poorly circumscribed of fibrocystic change alongside the presence of cysts that differ in texture from the fibroadenoma lump.

The pathophysiology of fibrocystic breast disease is based on high values of estrogen and deficiency of progesterone which leads to hyperproliferation of connective tissue (fibrosis) which is then followed by facultative epithelial proliferation. Mammary gland development and maturation which impact hormonal change influence the stromal and epithelial cells. In the late proliferative phase, glandular tissue transforms into hyperplastic stages the likes of sclerosing adenosis or lobular hyperplasia (Malherbe & Fatima, 2020). Similarly, fibroadenoma stems from stromal and epithelial connective tissue cells which contain receptors for estrogen and progesterone. Levels of estrogen and progesterone increase during puberty or pregnancy, which lead to cell proliferation, of these connective tissue cells which originate in the terminal duct lobular unit (Ajmal & Van Fossen, 2020). Breast cysts are much simpler in pathophysiology, resulting due to fluid accumulation inside breast glands. However, the exact causes are unclear, with researchers believing it to be also a result of hormonal changes such as during monthly menstruation with excess estrogen stimulating breast tissue that contributes to breast cyst growth (Mayo Clinic Staff, n.d.).

Fibrocystic breast disease is highly prevalent, affecting women of all ages, but primarily those of child-bearing age. There are ranging estimates to its prevalence, but it is the most common benign breast condition, typically affecting women aged 35-50 at its peak and depending on study, 35-75% of women have indicated the condition in their lifetime (Santen, 2018). Similarly, cysts are seen in women of all ages but most often found in women of pre-menopausal ages 35-50. Breast cysts by themselves are not common, affecting about 7% of women in the Western nations (Mayo Clinic Staff, n.d.). Meanwhile, fibroadenomas are seen primarily in adolescents and young adults, women aged 14 to 35 years old. Typically, fibroadenomas shrink after menopause, therefore less common in older women. Fibroadenomas are the most common benign tumor in adolescents, accounting for 68% of all breast masses but the overall incidence is approximately 2.2% (Lee & Soltanian, 2015).

Testing

After a physical exam, appropriate evaluation for fibroadenomas include a diagnostic mammogram and a breast ultrasound. Diagnostic mammogram can visualize the fibroadenoma which appears as a distinct area from other breast tissue, as either a well-circumscribed discrete oval mass with hypodense or isodense glandular tissue or a mass with partially obscured margins and macro lobulation. Ultrasound also aids in detecting features of the fibroadenoma, easily differentiating it from cysts due to its well-circumscribed and round-oval form (Ajmal & Van Fossen, 2020). Breast cysts are evaluated via physical exam and usually recommend a breast ultrasound. The ultrasound aids in determining whether the lump is filled with fluid or solid. A fluid-filled lump is indicative of a breast cyst. A fine-needle aspiration may be used, where the clinician inserts a needle into the lump with the attempt to aspirate fluid, using the ultrasound to guide the needle. Once the fluid comes out and the lump disappears, it is a confirmed breast cyst and no further testing or intervention is necessary (Mayo Clinic Staff, n.d.).

Fibrocystic breast disease warrants triple testing, combining clinical examination, imaging, and excision biopsy. Any nodularity in women younger than 30 can be observed with clinical surveillance, and short-term follow up of 2-3 months. Women older than 30 should receive further investigation with imaging immediately. Mammography and ultrasound is used for all discrete palpable lesions to distinguish cysts from solid lesions. Complex cysts or solid lesions detected, warrant a core biopsy to determine presence or absence of malignancy (Malherbe & Fatima, 2020).

National Guidelines

National guidelines for these conditions and general benign breast disorders are dictated by the American College of Obstetricians and Gynecologists (2016). Regarding breast cysts, the most common non-proliferative lesion, the guidelines indicate that these can be found through physical examination, imaging studies or breast biopsies, often for other indications. However, simple breast cysts are virtually always benign and require aspiration only if bothersome to the patient. The guidelines indicate to use ultrasonography in distinguishing fibroadenomas from breast cysts since these may appear similar on examination or mammography. Solid masses identified require further diagnostic testing such as biopsies. Fibrocystic breast disease is also viewed as proliferative without atypia, diagnosed with imaging such as ultrasonography, mammography, or digital tomosynthesis based on patients age and clinical suspicion. For all benign breast conditions, core needle biopsy should be used in any solid masses or suspicious lesions in order to evaluate for breast cancer. Excisional biopsy is reserved for specific scenarios (American College of Obstetricians and Gynecologists Committee on Practice BulletinsGynecology, 2016).

Conclusion

The conditions fibrocystic breast disease, breast cyst, and fibroadenoma described and compared in this paper are inherently similar as benign breast disorders. They differ only in small differences in presentation and ages of occurrence. However, for clinical confidence, all of the diagnoses require diagnostic imaging tests to identify the detailed composition of the tissue which is the defining characteristic in distinguishing between the cases.

References

Ajmal, M., & Van Fossen, K. (2020). Breast fibroadenoma. StatPearls Publishing. Web.

American Cancer Society. (2019). Fibrosis and simple cysts in the breast. Web.

American College of Obstetricians and Gynecologists Committee on Practice BulletinsGynecology. (2016). Practice bulletin No. 164: Diagnosis and management of benign breast disorders.Obstetrics and Gynecology, 127(6), e141156. Web.

Lee, M., & Soltanian, H. T. (2015). Breast fibroadenomas in adolescents: current perspectives.Adolescent Health, Medicine and Therapeutics, 6, 159163. Web.

Malherbe, K., & Fatima, S. (2020). Fibrocystic breast disease. StatPearls Publishing. Web.

Mayo Clinic Staff. (n.d.). Breast cysts. Web.

Santen, R. J. (2018). Benign breast disease in women. In K.R. Feingold, B. et al. (eds), Endotext. MDText.com, Inc. Web.

Introduction

America has been, over the past year, faced with a critical shortage of nursing services which is expected to get worse in the near future (Andrews & Dziegielewski, 2005). It is expected that if this problem is not resolved the soonest possible, the demand for nursing services would exceed the supply for the same by the year 2020 (Health Resources and Services Administration, 2002). Thus, sustaining sufficient numbers of proficiently trained and off course registered nurses, is a critical action for nursing leaders in any institution, especially putting into consideration the previously mentioned expected shortage of nursing services. Nursing turnover has, over the past years, been affected by the ever increasing priority regarding work-related stress and job dissatisfaction which has, consequently, influenced nurses intentions forcing them to leave their positions for other preferable career opportunities (OBrien-Pallas, Murphy, Shamian, Li & Hayes, 2010).

The nursing shortage emphasizes a greater need to better understand how to retain nurses in long-term positions. Much of the published research about nurse retention has focused on reasons which force nurses to leave their jobs rather than what can be done to make them stay in long-term employment. Nurse retention may be better understood from the perspective of nurses who have stayed in healthcare institutions for long periods of time. Previous studies have focused on the impact as well as the key determinants of nurse turnover (Ambur, Palumbo, McIntosh & Mongeon, 2003; Bij, Kummerling, van Dam, Estryn-Behar & Hasselhorn, 2010; Morgan & Lynn, 2009; OBrien-Pallas et al., 2010)

The purpose of this study, therefore, is to use the method of grounded theory research to discover and analyze the reasons why registered nurses choose to stay for long term employment within the same institution as well as providing an insightful perspective on retention of registered nurses. However, the data that will be collected but does not support long term employment will be addressed at the conclusion of this paper and can be used later for further research in the future on related topics.

Literature Review

The review of literature will focus on previous research on provision of nursing services and other professions that address key determinants associated with long-term employment. Literature review will help in identifying gaps in the literature.

Methodology

As discussed earlier, the aim of this study is to discover the experienced nurses who chose to serve long-term employment and remain within the same institution for fifteen or more years. The research study utilized grounded theory methodology. Grounded theory is particularly useful in shedding new light in areas where little is known in the field. It is through this process and innovative perspective that ideas and perceptions become more objective (Glaser & Strauss, 1967, 1999). The grounded theory methodology is appropriate for the purpose of this study, where the research method is based on the experience of the participant group and does not reflect the opinions or bias of the researcher (Glaser & Strauss, 1967). The information provided from the interviews contributed towards a new view of the reasons why individuals stay long term in nursing employments. It is hoped that the results conceptualized from this study would aid administrators and managers with an insightful perspective on retention of registered nurses which would, in turn, help in preventing the expected shortage of the same mentioned earlier.

Sample

The data for this study was collected from 10 participants who met the study criteria which required all the participants to be Registered Nurses who have had stayed in one institution for not less than fifteen years. The primary investigator interviewed all the above participants.

Procedure

Data was collected during one-on-one interviews with the study participants. The interviews were conducted at Loyola University Chicago (LUC) in a conference room. Interviewers were asked to choose the best convenient time for the interviews. The interviews were tape recorded and transcribed verbatim.

Data Analysis

In grounded theory, data analysis usually occurs concurrently with data collection. Constant comparison would be used to generate concepts, without preconceived data, using all the data collected during the interviews (Glaser, 2001). Therefore, constant comparison and open coding were the basic techniques used for data analysis which enabled searching categories of an emergent theory. Several parts of the interviews were underlined and first-level codes were established. Memoing was used to note theoretical ideas and to capture personal biases during data collection. The constant comparative method consists of four main steps: 1) comparing incidents that are applicable to all data categories, 2) integrating categories and their properties, 3) delimiting the theory and 4) writing down the theory (Glaser & Strauss, 1967, 1999). In this paper, the first two-steps will be addressed explicitly.

Five main categories emerged from the collected data that contributed to the nurses ability to stay in a long term position in one institution. The categories obtained were based on appreciation of co-workers, impact of the administration, working environment and related conditions, caring and appreciating benefits. In this section, each main category will be defined and then supported by subcategories.

Appreciating coworkers

One of the main categories that all the nurses interviewed in this study mentioned was the appreciation of their coworkers and this emerged as one the strongest reasons for their long term employment. Coworker, in this case, included all doctors and nurses. More so, several nurses compared these positive relationships to that of their own families. They also emphasized that the strong relationships they experienced with long term employment has positively helped in resolving many of the bothersome issues they encountered in every day to day execution of duty. Some participants really appreciated the physicians relationships because most importantly, the nurses felt important and appreciated since they were given the chance to be heard out especially by their seniors. Coworkers were really appreciated for several reasons which were characterized as subcategories. One of the major reasons as a subcategory was helping each other and boosting one anothers morale when going through tough times.

In addition to the support and closeness they developed with each other over years of being together. The nurses addressed the importance of positive attitude of their coworkers, which was believed to be an essential composition of their relationships. They all had described their coworkers as generous, kind, supportive and respectful. Some believed that the respect they all had for each other was earned in the course of the long term employment which gave the nurses the chance to express themselves and the freedom and authorization of conversing freely with their patients and families without offending the doctors.

Dealing with administration

The interviewed nurses gave interaction with the administration as another key category which influenced the nurses decisions and long term employment in one institution. Nurses noted that the administrations positive leadership and attitudes is equally essential on the same matter. Furthermore, they emphasized on the importance of managers presence in the unit allow the managers to listen to the staffs needs and opinions thus enabling them to reach out to their employers through constructive and productive communication. The ties sub category greatly helped support the decision of long-term employment.

Working environment

Four subcategories emerged from the participants interviews supporting the category of working environment. Participants indicated that flexibility, stability, ownership, continuity and a comfortable zone, all contributed to long-term employment. First of all, the flexibility in changing time and scheduling fostered the nurses decisions for long-term employment. Flexibility in scheduling and having a choice in shifts was also important where there could be accommodations for both the organization and the individual patients. Secondly, some of the interviewed nurses emphasized that with long-term employment they took ownership of situations. They described the institution as their house and this nurtured professional behavior. Thirdly, all the interviewed nurses spoke about comfort level that comes with long-term employment as an essential subcategory in the work environment. Most of the participants used the term of a comfort zone, which they believed could only come along with the long term employment due to proficiency. Some preferred this comfort zone on the fear of the unknown that comes with short-term employment, and that supported their decision to stay and practice efficiently. Additionally, nurses recognized stability and continuity as another two subcategories that contributed to a positive work environment. The interviewed nurses appreciated stability ad continuity in the work setting where both has helped nurses in being clinically competent as they were recognized as role models.

Caring

Caring for patients and families was one of the reasons for long-term employment, which the interviewed nurses discussed explicitly. The caring category has nurtured nurses through satisfaction and rewards from their emotional experiences. The interviewed nurses also emphasized on the importance of interaction between the nurses and the patients as well as their families. This has enabled them to connect and reach out to patients and families for efficiently provision of services. One of the important subcategories is by looking at nursing as either a job or as a calling; nurses believed that those who look at nursing as a calling are the ones who stay in the profession and eventually serve long-term employment than those who see it as a job or simply a source of income.

Appreciating Benefits

The final category is appreciating benefits. The interviewed nurses mentioned retirement plans and other financial benefits they get from the medical institutions, which contributed to long-term employment. Nurses emphasized that benefits should encompass fair compensation as essential component along with retirement plans and educational benefits as subcategories.

Conceptual Map

The conceptual map is included in Appendix representing the arrangement of the five emerged categories that were empirically derived from the data provided by the interviewed nurses.

Conclusion

This study was conducted and initial categories were discovered. As discussed earlier, the study identified five main categories that influenced staff long-term employment. The description of these categories has provided the insight for nurse managers and administrators who are interested in improving both recruitment and retention of nurses from the perspective of the employers themselves. However, the purpose of the next study is to conduct interviews based on the preliminary finding. This was a pilot study with a small sample size whose results from the interviews made were constant in regards to reasons given by all nurses who stayed within the same institution for fifteen year or more.

The five categories that emerged represent significant data that is worthy of further investigation to enhance the knowledge regarding registered nurses long-term employment and retention. From this pilot study, provisional hypotheses were identified for further investigation. These provisional statements are as follows:

1. Coworkers feeling like a family predicted long term employment.
2. Experiencing stability and continuity in the work environment contributes to staff satisfaction and long term employment
3. Flexibly in time and scheduling in the working environment predicted long term employment.
4. Feeling a sense of respect for all including the workers and administrators is a predictor of long-term employment.
5. Reaching a comfort zone in the work environment supports long term employment
6. Financial and educational benefits in an organization are powerful reasons in long-term employment.

The focus of this research was to determine the reasons why nurses choose long-tem employment in the same institution. However, during the interview nurses addressed reasons for resigning and leaving institution. The data obtained that represents the reasons behind resignation by nurses resign from one institution to another should be considered for future research in a follow up study next year. Some of the factors to be researched on include turn off, staffing issues and poor administration.

Attachments of first level codes and conceptual categories are included in the Appendix.

Reference List

Ambur, B., Palumbo, M., McIntosh, B., & Mongeon, J. (2003). A statewide analysis of RNs intention to leave their position. Nursing Outlook, 51(4), 182-188.

Andrews, D., & Dziegielewski, S. (2005). The nurse manager: job satisfaction, the nursing shortage and retention. Journal of Nursing Management, 13(4), 286-295.

Bij, Kummerling, A., van Dam, K., E, Estryn-Behar, M., & Hasselhorn, H. (2010). The impact of social support upon intention to leave among female nurses in Europe: secondary analysis of data from the NEXT survey. International Journal of Nursing Studies, 47(4), 434-445.

Glaser, B. (2001). The Grounded Theory Perspective. Mill Valley, CA: Sociology Press.

Glaser, B. & Straus, A. (1967). The Discovery of Grounded Theory: Strategies for Qualitative Research. New Brunswick: Aldine Transaction.

Health Resources and Services Administration (HRSA) (2002) Projected Supply, Demand, and Shortages of Registered Nurses: 20002020. Web.

Morgan, J., & Lynn, M. (2009). Satisfaction in nursing in the context of shortage. Journal of Nursing Management, 17(3), 401-410.

Obrien-Pallas, L., Murphy, G., Shamian, J., Li, X., & Hayes, L. (2010). Impact and determinants of nurse turnover: a pan-Canadian study. Journal of Nursing Management, 18(8), 1073-1086.

Polit, D. & Hungler, B. (1987). Nursing Research: Principles and Methods (3^rd edition). Philidelphia: J.B.Lippincott Co.

In long term resident with pressure ulcer comparing nutrition intervention plus standard skin care with standard skin care only?

The utilized clinical peer reviewed articles as well as Journals development is done by or in association with well informed health practitioners particularly those specialized in pressure ulcer area. Most of these articles are backed by firmly founded recommendations derived from utilization of literature reviews as well as actual field research studies that is rather exhaustive. These resourceful peer reviewed articles include of the American Geriatrics as well as Critical Care Journals that are reviewed by different authors in a specified span of time. In these articles a comparison is carried out regarding the role of skin care practiced in a standardized manner to nutritional intervention aspect with regards to pressure ulcer care and management.

The various methods of analysis as depicted in each of the articles are diverse and include trials that are rather randomly controlled as well as statistical analysis of secondary sources. Other articles utilized include; health practitioners manuals from where the analyzed study statistics are derived and integrated accordingly.

The resultant understanding from this review is that as much as both practices are effective in their distinct ways of actual pressure ulcer management there is need to have them integrated for complementary purpose. Some authors argue that nutritional intervention may not have much positive impact on the already suffered ulcer but when complimented with skin care of a certain standard the results are promising.

Finucane, T. E. (1995). Malnutrition, tube feeding and pressure sores; Journal of the American Geriatrics Society, 43, 447-451

This particular peer reviewed journal covers a literature search involving articles whose field research was conducted from 1985 all the way to 1994 regarding pressures sores as related to malnutrition. The research also featured tube feeding application in the actual pressure ulcer management. The author notes that in this whole process, a total of twenty two studies were complied for review whereby important information regarding nutritional intake as linked to pressure ulcer was yielded. The results realized in this type of nutrient intervention as a beneficial contribution to pressure ulcer management is said to be inconclusive. According to the author, reviews brought forth specific contradictory results that led to a conclusion that nutrition intervention in form of tube feeding does not form efficient therapy. This articles analysis points out that poor health suffered by particular pressure ulcer patients may be resulting from improper dietary that would not be improved by any form of complementary nutrient intake. The author also notes that there are a number secondary impacts affecting tube feeding which have a capability of worsening pressure ulcers situation. Therefore it occurs that for nutrition intervention to show effectiveness some of levels of skin care need to be applied to complement its deficiencies.

LaMantia, J. G., Hirschwald, J. F., Goodman, C. L., Wooden, V. M., Delisser, O., & Staas, W. E. (1987). A program design to reduce chronic readmissions for pressure sores. Rehabilitation Nursing Journal, 12(1), 22-25.

The authors of this particular article bring out the necessity of success realised in standard skin care practice as a means of managing pressure without any integration of nutrient intake considerations. This case study was conducted in order to evaluate impact of a certain modification program that is expected to bring forth improvement on pressure ulcer situations. The authors also point out that positive results of the study were to be applied in more or less related situations involving spinal cord damage management whereby skin care is integrated. Therapy sessions were set forth and each of the forty participants was expected to adhere to the laid down rules and regulations of which upon completion; results in terms of their health were analysed. The statistical analysis in this particular study was carried out in such a way the percentages of successful and unsuccessful participants were calculated from the beginning of the evaluation to the end. Although the percentage of successful participants kept dropping from the initial 78% to 20%; it occurred that consistency and proper following of required directions to skin care resulted to recovery of intact skin. On the other hand, the group that went against the laid down skin care procedures ended up suffering skin reopening. This article shows that a well strategized skin care management plan is bound to register effectiveness in pressure management as compared to integration of nutrition in the entire process.

Thompson C. & Fuhrman P. Nutrients and Wound Healing: Still Searching for the Magic Bullet. American Journal of Critical Care, 2, 26-29

The author of this article points out the necessity of nutrition intervention in the entire aspect of pressure ulcer management. In this article, it is argued that although nutrition intervention is recommended as a compliment of skin care, clinicians involved in impacting this practice are normally faced with some tough challenges. Among those mentioned by the author are delayed as well as improper wound healing. The author admits that nutritional intervention plays a considerably important role in the entire healing process but also points out the controversy realized in inclusion of the nutrition regimen. This study also features compilation of limitations characterizing research studies involving nutrition recommendations as some form of pressure ulcer management strategy. The author concludes with an invitation of further research studies towards the same as he argues that available clinical studies tend to be deficient of firm founded evidence that would be used on formulating outstanding guidelines regarding the entire aspect of nutrition support.

Cereda, E., Gini, A., Pedrolli, C. and Vanotti, A. (2009), Disease-Specific, Versus Standard, Nutritional Support for the Treatment of Pressure Ulcers in Institutionalized Older Adults: A Randomized Controlled Trial. Journal of the American Geriatrics Society, 57: 13951402

This journals author puts forth a study that tends to compare the important of standard diet as well as skin care as compared to one where particular disease nutritional perspective is utilized with regards to pressure ulcer treatment. A number of elderly patients living in randomly selected institutions are engaged in a controlled trial. The group on trial is divided such that part of it is administered with some standard diet as well as skin care while the other is accorded particular disease nutritional care. In both case, the rate of ulcer management as well as healing was observed and results measured with a specific scale for gauging Ulcer healing process. It occurs that nutritional intervention constituting proteins, vitamin C as well as some zinc supplements had better healing process outcomes hence the recommendation of this kind of intervention as a complement of skin care for Ulcer management.

Bell L. Evaluation of and Caring for Patients with Pressure Ulcers; American Journal of Critical Care. 2008; 17: 348

The author points out the risk associated with pressure Ulcer occurrence suffered by hospitalized patients who are in rather critical conditions. The author notes that among the factors influencing these occurrences are complication of multiple diseases, long and extended bed rest periods as well as adoption of improper body positioning. In order to reduce these fateful instances, the author points out the increased commitment by nurses practicing in this particular area to engage in prevention of hospital associated injury as well as management of already existing ones.

The study has therefore come forth with a number of things that needs to be observed and implemented accordingly including the proper identification of necessary skin care recommendations as well as products. According to the author, this practice ought to be a routine whose results are considerably promising even without engaging in any nutritional intervention since apart from being a management strategy, skin care also serves as an efficient preventive measure.