Introduction Of Copd Health And Social Care Essay

Introduction Of Copd Health And Social Care Essay Chronic Obstructive Pulmonary Disease is a group of chronic and progressive respiratory disorders that are characterized by an airway obstruction with little or no reversibility. Damage to the lungs continues to make breathing gradually more difficult over time. Two clinical conditions often associated under the diagnosis of COPD are chronic bronchitis and emphysema, which obstruct or limit airflow into the lung fields. Chronic bronchitis is the presence of chronic productive cough for three months in each of two consecutive years in a patient in whom other causes of chronic cough have been excluded. Emphysema is an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis (Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., Bucher, L., 2007, p. 629). Most patients diagnosed with COPD suffer from both pathological conditions, but manifestations can vary significantly from patient to patient. According to Medline Plus (n.d.), Your airways branch out inside your lungs like an upside-down tree. At the end of each branch are small, balloon-like air sacs. In healthy people, both the airways and air sacs are spring and elastic. When you breathe in, each air sac fills with air like a small balloon. The balloon deflates when you exhale. In COPD, your airways and air sacs lose their shape and become floppy, like a stretched-out rubber band (Medline Plus, n.d., para.2). These disease processes affect the bronchi, bronchioles and lung parenchyma with predominance on distal airway. COPD is a growing health problem not only in the United States, but also worldwide. In 2005, approximately one in 20 deaths in the United States had COPD as the underlying cause. Smoking is estimated to be responsible for at least 75% of COPD deaths (Centers for Disease Control and Prevention, 2008, para.1). The Centers for Disease Control and Prevention (CDC) also estimates that there are over 119,000 deaths, 726,000 hospitalizations, and 1.5 million hospital emergency department visits are caused by COPD annually(Centers for Disease Control and Prevention, 2009, para. 2). Even more alarming are the statistics world-wide. The World Health Organization (WHO) (2007), revealed that currently 210 million people have COPD and 3 million people died of COPD in 2005. WHO predicts that COPD will become the third leading cause of death worldwide by 2030 (World Health Organization, 2009, para.3). With statistics this rampant, what exactly are the manifestations that cause COPD? Etiology/Prognosis: There are several causes of COPD. Of all potential inhaled pollutants, cigarette smoking is the primary risk factor thought to contribute to COPD. Patients with a history of smoking a pack per day, over forty years, are especially predictive of COPD development. Exposure to passive cigarette smoking, air pollution, occupational hazards such as dust or fine particles (coal or silica dust, asbestos) and childhood respiratory disorders such as severe viral pneumonia can also contribute to the development of COPD. The elderly, patients with a low body weight and clients with a history of alcohol abuse are also susceptible. Prognosis of COPD is highly dependent upon the degree to which the patients breathing is affected and the ability to manage dyspnea, the ability of the heart to oxygenate other body systems. It is also dependent upon how damaged the lungs are upon diagnosis and if they are able to continue to oxygenate the blood without difficulty. Early diagnosis of COPD can help identify predisposing factors; such as smoking, and help provide a better prognosis through smoking cessation and deep breathing exercises to help ensure that the disease does not progress. A late diagnosis, that has affected the patients ability to perfuse vital organs, can result in organ failure on multiple levels and prognosis can be very grim. Further evaluation may be needed to determine the full extent of damage from lack of tissue perfusion. Pathophysiology: Chronic Obstructive Pulmonary Disease can be a result of chronic bronchitis and emphysema. An enlargement and multitude of mucous glands are produced with chronic bronchitis, resulting in an increased mucous production and a characteristic cough. Apart from the amount of mucous produced; the quality of the mucous also becomes more viscous in nature, making it harder for the patient to expel. Accumulation of excess mucus causes airway obstruction in the peripheral airway and therefore an increase in airway resistance. Lymphocytes, neutrophils and macrophages also accumulate which can lead to fibrosis or a formation of excess fibrous connective tissue in the lung fields as an attempt to repair the area. Emphysema results in large part from an enlargement of airspaces distal to terminal bronchioles. The loss of elasticity of the lung tissue and the closure of small airways is due to the destruction of the alveolar walls. When the connective tissue is destroyed in the alveolar walls, protease is released, further destroying elastin and inhibiting the ability of the alveoli to recoil. Protease affects structural integrity of the alveolar wall. In a healthy individual, the ability of the alveoli to recoil helps to maintain the patency of the airway lumen, especially during expiration. With COPD, there is airflow limitation due to loss of alveolar attachments, inflammatory obstruction of airways and obstruction of the terminal branches with mucus. Airways begin to narrow due to the inflammation, resulting in a loss of elastic recoil and loss of alveolar attachments. Ciliary function in COPD is also abnormally impeded. Cilia in the airway wall normally acts as a force to help thrust mucus or other foreign bodies toward the trachea for expulsion from the body. This function is often impeded by the thick and firm mucus often seen with chronic bronchitis. Lack of ciliary function increases the risk of recurrent infections in the lungs due to accumulation of these foreign particles within the lung fields. Destruction of the alveoli and profuse mucous accumulation destroys the ability of the body to deliver oxygen, resulting in hypoxia. The patient suffering from COPD often struggles to breathe and hypoxic-related dyspnea systemically affects other areas of the body ofte n leading to pulmonary hypertension and heart problems such as heart attacks and right-sided heart failure. Patients with COPD are more prone to respiratory infections, lung cancer and depression. Signs and symptoms of COPD usually do not occur until significant damage to the lungs and other body systems have occurred. Signs and Symptoms: Patients with COPD usually present with signs and symptoms of both emphysema and chronic bronchitis to include a continuous hacking-type cough that produces a thick mucus which is often hard to expectorate. Patient may also complain of significant shortness of breath that presents particularly with exercise or exertion. Clients may also complain of difficulty sleeping with constant fatigue and an abrupt, unplanned weight loss. Patients typically also present with rapid breathing, barrel-like distention to chest and will sit often in a tripod position, leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so that their rectus abdominus, intercostals, and accessory neck muscles all can aid in expiration (Jarvis, C., 2008, p. 449). Due to lack of oxygen the patient might also present with cyanosis of the skin, wheezing and chest tightness, with possible signs and symptoms of respiratory infection. Patients with COPD can also experience exacerbatio ns, which are periods or episodes where the patients COPD symptoms can suddenly worsen. Exacerbations can be caused by influenza, infections or exertion. Other contributing factors include a rapid change in humidity or temperature, exposure to smoke or other pollutants, allergens and dust. According to report from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2009), COPD can be broken down into four various stages to include: Stage I: mild COPD: Characterized by mild airflow limitation predicted. Symptoms of chronic cough and sputum production may be present, but not always. At this stage, the individual is usually unaware that his or her lung function is abnormal. Stage II: moderate COPD: Characterized by worsening airflow limitation with shortness of breath typically developing on exertion, with a productive cough. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease. Stage III: severe COPD: Characterized by further worsening of airflow limitation, patient experiences an even greater degree of shortness of breath, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on patients quality of life. Stage IV: very severe COPD: Characterized by severe airflow limitation with the presence of chronic respiratory failure. Respiratory failure may also lead to effects on the heart such as cor pulmonale (right heart failure). At this stage, quality of life is very appreciably impaired and exacerbations may be life threatening (GOLD Report, 2009, p.4). With the varying manifestations in the progression of the disease, providers must take into account the assortment of challenges and medical interventions necessary in the treatment of COPD. COPD: Medical Interventions Diet Plan: Needs and Modifications: Individuals with COPD have overall muscular weakness, including the respiratory muscles, that relates to systemic inflammatory process in the lungs. Diet is an important factor to take into consideration, especially in the elderly because the risk for malnutrition increases. COPD and malnutrition go hand in hand, malnutrition and a low BMI of Individuals who are underweight have an underlying problem that relates to an increased metabolism and the breakdown of essential nutrients for energy requirements. In these individuals it is best to modify their eating habits, with frequent breaks to decrease fatigue. It takes a lot of energy to metabolize food, breathing and eating become harder, [the individual] may have to choose between taking a gasp of air or a bite of food (ONeill, 2004, para. 3). For those who are overweight, the problem as it relates to COPD is due to excess abdominal fat. Abdominal fat prevents the diaphragm from expanding completely, which causes a decrease in oxygen availability. This decrease in oxygen compromises the cardiovascular system due to the inadequate amount of oxygen being delivered to the heart and throughout the body. Both malnourished and obese individuals need to monitor weight, food and fluid intake daily. According to Peggy ONeil (2004), intake of fluids, calories, protein, calcium and potassium all play a role in protecting immunity and easing breathing (ONeil, 2004, para. 8). The American Lung Association states that the metabolism of each [nutrient] requires a different amount of oxygen and produces a different amount of carbon dioxide. Metabolism of carbohydrates produces the most carbon dioxide for the amount of oxygen used; metabolism of fat produces the least (American Lung Association, 2010, para. 3). Good sources of fat should come from unsaturated fats such as nuts, olive oil, soy and avocados. Protein is essential for muscle repair and assists in the healing process when an infection or injury occurs. ONeil recommends that generally two cups of milk plus six ounces of protein from other sources each day provide four servings of high-quality protein, good sources of protein, which is adequate for someone with COPD (ONeil, para. 12). Potassium is found in fruits, vegetables, dairy products and meats [and are] key to control blood pressure, muscle contraction, and nerve impulses transmission. Normal serum potassium levels help with optimal muscle contraction to aid breathing (ONeill, para. 15). Excessive need for increased nutritional intake is imperative for the adequate daily functioning and maintenance in the COPD client. In order to facilitate sufficient digestion and proper absorption of food the patient should remain upright after meals to prevent the stomach from pushing on his diaphragmà ¢Ã¢â€š ¬Ã‚ ¦limit intake of carbonated beveragesà ¢Ã¢â€š ¬Ã‚ ¦[and to consume] soft, easy-to-chew foods to prevent him from becoming short of breathe while eating (ONeil, 2004, para. 16). Consumption of clear fluids should be encouraged to prevent dehydration and also to help thin mucous secretions. Appropriate Medications and Diagnosis: Although there is controversy over the amount of oxygen to give a patient with COPD, it is generally understood that the long term use of oxygen therapy improves survival, exercise capacity, cognitive performance, and sleep (Lewis et al., p. 640). There are various ways that oxygen therapy can be administered to a patient with COPD. In hospitals the most precise delivery of oxygen therapy is through the use of the venturi mask, however most patients prefer to use the nasal cannula. The structure of the nasal cannula allows the patient to perform daily activities such as eating and talking without interrupting oxygen delivery. When oxygen therapy is used in conjunction with smoking cessation it improves the patients quality of life by increasing the amount of available oxygen and increasing systemic perfusion. Depending on the severity of COPD, bronchodilators such as beta2-antagonist, anticholinergic, and methylxanthine (Lewis et al., 2007, p. 639) will be given to relax the smooth muscles of the airway, and to increase gas exchange. These medications can be administered as an inhalant or by the oral route. For those experiencing moderate-to-severe COPD, glucocorticoid therapy may be combined with a bronchodilator to decrease inflammation of the airways. Inhaled glucocorticoids are preferred over oral glucocorticoids for long term treatment, because oral treatments can lead to adrenal insufficiency and Cushings syndrome. (See Appendix A). Patient should expect to experience improved oxygen utilization. Diagnostic Tests and Lab Work: Pulmonary functions test measures the intake and output of air in the lungs and is used to confirm the diagnosis of COPD. There are four components to pulmonary function testing, [which consist of]: spirometry, postbronchodilator spirometry, lung volumes, and diffusion capacity (Chronic Obstructive Pulmonary Disease Diagnosis, 2010, para. 3). Also, there are many diagnostic studies that support the diagnosis of COPD, such as chest x-rays, arterial blood gases, echocardiogram and electrocardiogram (ECG) (Lewis et al., p. 638). X-rays are not the preferred method of diagnosing COPD since it cannot pick up abnormalities until COPD is in the later stages. Arterial blood gases are performed to monitor the amount of oxygen and carbon dioxide in the blood. In individuals with COPD typical findings are low PaCO2, elevated PaCO2, decreased or low-normal pH, and increased bicarbonate (HCO3) levels (Lewis et al., 2007, p. 638). COPD can cause right sided heart failure related to pulmonary hypertension so patient should be monitored regularly by ECG and echocardiogram. As discussed earlier, changes in the lungs are related to smoking, toxins in the environment or occupation. In order to identify the causative effects of these toxin, clinical trials are being conducted to development new diagnostic tests that are aimed at identify early neoplastic changes in the lung. For example, advanced imaging techniques such as the PET scan is able to reveal metabolically active nodule [that are] highly indicative of malignancy (Petty Miller, n.d. p. 7), that could not be found with prior diagnostic tests. Also, a tissue autofluorescence, which is an enhanced bronchoscopy technique, can indicate a high likelihood of malignancy (Petty Miller, p. 7) in the lung tissue, that cannot be seen in a CT scan or chest X-ray. Hopefully, these clinical studies as they become available to the general population, will not only identify acute changes in the lung structure in advance, but also could potentially assist in finding a cure for lung diseases. Treatment and Treatment Options: Medications can make COPD patients more comfortable, but there is no overall curative treatment. The disease itself extends beyond the airways and lungs to include other body systems, (Barnett, 2008, p. 30). The goal in treatment is aimed at the controlling the symptoms involved in these various areas of the body and to reduce the inflammatory response in the lungs. To do this, the patient will need to modify their diet and lifestyle habit to prolong the quality of their life. As discussed earlier, emphysema and bronchitis constitute the disease known as COPD. The management and treatment of these two diseases is necessary for the patient to live a quality life. The medical treatments used to treat COPD was reviewed earlier, there are also non-pharmacological treatment options available that slow the progression of the disease and the symptoms of chronic obstructive pulmonary disease. One non-pharmacological treatment option is pulmonary rehabilitation. The goal of this treatment is to: break the vicious cycle of increasing inactivity, breathlessness and physical de-condition, and improving exercise capacity and functional status as well as improving individual patients self-management skillsà ¢Ã¢â€š ¬Ã‚ ¦Pulmonary rehabilitation is conducted by physiotherapist and respiratory nurses. Each session is based on the patient exercise tolerance and consists of one to two sessions a week for about an hour, for 6-8 weeksà ¢Ã¢â€š ¬Ã‚ ¦ then followed by an educational component to enable to the patient to make lifestyle changes to help them cope better with living with COPD (Barnett, p. 31). There are various energy conservation techniques that a patient can use to improve the quality of available oxygen. Often COPD patients struggle to breathe. The overall goal of the following energy conservation techniques is to help the patient breath better and to improve activities of daily living by relieving the distressing symptoms that accompany COPD. According to Barnett (2008), these techniques are: Exhale during strenuous part of an activity and use pursed lips to reduce to work of breathing, alter strenuous activities with easier tasks, place items within easy reach, to reduce bending and stretching for items, If needed, use aids and equipment such as electronic wheel chairs and to sit down to perform many of the daily activities (Barnett, 2008, p. 32). With a healthy individual, there is a low residual of air that remains in the lung. With the COPD patient, the volume of trapped air is increased and therefore decreases oxygen exchange within the lungs. Stress reducing techniques can help relax the patient. Therefore the patient can exhale the excess retained carbon dioxide and inhale even greater amounts of saturated oxygen with each new breathe. Hence, the efficiency of oxygen and carbon dioxide exchange is improved. Individuals should be updated on immunizations, even more so if a patient has COPD. According to the CDC (2010) adult immunization schedule, patients with chronic lung disease are required to have one annual influenza and one or two pneumococcal inoculations within the patients lifetime (CDC, 2010, p. 2). If the patient becomes infected with influenza or pneumonia, damage to the lung fields can be exacerbated if not treated quickly and can possibly lead to death. COPD: Holistic Assessment of Patient Scenario: Mr. Johnson is a 73 year old male who has presented to the Emergency Department for the third time this week with dyspnea. Patient has been smoking a minimum of one pack per day for the past 46 years. Patient is currently on two liters of supplemental oxygen at home via nasal cannula and states that he cannot seem to catch his breath. Mr. Johnson is leaning over the side of the bed in tripod position, gasping with supraclavicular retractions noted on inhalation. As a nurse, what do you think could be wrong with your patient? Physical Assessment Upon further evaluation, the nurse notices that Mr. Johnson also has a non-productive hacking-type cough that has persisted throughout the triage process. Mr. Johnson complains, I just cannot seem to get this thick mucus up out of my throat and I feel like I am suffocating, like I cannot catch my breath! Patient appears to be bracing himself over the side of the chair in a tripod position. The nurse is a waiting for the provider to place orders in the computer for the clients chest x-ray. A venturi mask is placed on the patient and oxygen delivery is set to be administered at three liters of oxygen per minutes. This intervention successfully alleviates the patients rapid and shallow respirations, as well as the circumoralcyanosis. Upon auscultation the nurse notices diminished lung sounds over the left and right lower lung fields with auditory wheezing upon exhalation. The nurse also notices a barrel-like distention to the patients chest. The nurse begins to take the patient to radio logy and abruptly stops as the patient begins to weep inconsolably. What could be the likely factor associated with the emotional reaction exhibited with the patient? Psychosocial Assessment: To make an accurate assessment of the patients psychological reaction, the nurse casually begins to inquire about the patients daily activities. The patient divulges to the nurse that he has lost his job, is no longer able to care for himself and feels a sense of guilt that he has become burdensome on his family members. Patient states, I have a loving family, but feel as though they would be better off without me. I know I shouldnt feel this way, but I have been depressed and feeling lonely for some time now. The nurse recognizes that the patient is displaying signs of depression, low self-esteem and lack of autonomy with loss of control over his personal life. The priority nursing interventions for this patient should include a referral to a mental health agency and community outreach programs that can assist the patient to meet the psychological strains produced by his current health situation. The patient then covers his face and whispers in a soft undertone, I cannot even afford to pay for my groceries, much less this visit! How can I afford this referral? With this statement in mind, what priority nursing assessment should the nurse consider? Socioeconomic Assessment: Mr. Johnson is one of many faces dealing with the strains and financial hardship associated with COPD. The overall costs of COPD are overwhelming. According to the Harvard University (2008), the annual cost to the nation for COPD (emphysema and bronchitis) is approximately $32.1 billion, including healthcare expenditures of $18.0 billion and indirect costs of $14.1 billion (Harvard University: Healthcare delivery- Deconstructing the costs, 2008, para 58). The global statistics are even more astounding. According to the American College of Chest Physicians (2003), the global direct yearly costs of chronic bronchitis and COPD patient was $1876. The cost generated by the patients with COPD was $1,760.00 [per patient/year/costs], but the cost of severe cases ($2,911 per year) [per patient/year/costs] was almost double that of mild cases ($1484 per year) [per patient/year/costs] (Miravitlles, Murio, Guerrero, Gisbert, 2003, p.786). With these statistics in mind, what are some of the teac hing points that a nurse can utilize to assist the COPD patient? Health Teaching and Community Resources: The nurse must take in various considerations when assisting the COPD patient. How well is the patient able to tolerate activity? Does the patient suffer from dyspnea related disturbance in their sleep pattern? What are the patients physical or financial resources? A patient that has a hard time meeting monthly utility bills is far less likely to be compliant with a medical regime. The nurse should focus on trying to coordinate social work service to help the patient to meet healthcare needs. If the patient has a family member, how does this affect his or her role if they are primary breed winner in the family? Interview should point out any psychological stressors that may be affecting the patient and should determine if therapy may be required. Primary education should focus on convincing the patient to quit smoking. Inform the patient to keep up to date on immunizations such as annual flu and pneumonia vaccines. Patient should compliantly take prescribed medications and avoid second-hand smoke or exposure to other irritants such as dust, smog, extreme heat or cold and high altitudes, pollutants that can exacerbate symptoms. COPD patients must increase fluid intake to decrease viscosity of mucous secretions in addition to maintaining an adequate nutritional status to facilitate extra nutritional requirements. Diets should be low in saturated fat and should include various fruits, vegetables and whole grains. Highly emphasize to the patient that use of oxygen therapy should be only used as directed and control of respirations with pursed lip technique. Direct the patient to take frequent breaks to minimize fatigue. Pacing of activities throughout the day will minimize undue stress on the lungs. It may be necessary to coordin ate follow-up appointments for the patient; however signs and symptoms such as shortness of breath, wheezing or the desire to lean forward to aid in breathing will warrant an earlier visit. A trip to the emergency room will be necessary if the patient starts to have sudden, severe shortness of breath, or if they become lightheaded, weak, faint or experience chest pain with a rapid, irregular heart rate. Conclusion Chronic Obstructive Pulmonary Disease is a progressive and debilitating disease process that wreaks havoc on the patients cardiovascular and respiratory systems. Management of COPD can be maintained and symptoms minimized through adequate diet interventions, medication regimens, completing diagnostic exams and lab tests. Though COPD is a preventable disease, the realistic nature of the disease process requires a nurse that is knowledgeable, caring and sympathetic to the patients overall needs.

Critique of a Research Article Essay

This paper presents a critique of a qualitative research article titled: ‘Perceived support from healthcare practitioners among adults with type 2 diabetes’ (Oftedal et al, 2010) (appendix 1). To enable the critique of this article the Caldwell critiquing tool (2005) will be utilized. (Appendix 2) Research critiquing is a valuable skill, to gain as it enables student nurses to develop and improve knowledge and skills and also adheres to the NMC code of conduct (NMC, 2008). Polit and Beck (2006) emphasis the ability to analyse research enables individuals to gain knowledge. A great importance of research is that it introduces improvements and changes into practice based from evidence based practice (EBP). According to Pioneer David Sacklett (2000). EBP can be defined as â€Å"the integration of the best research evidence and clinical expertise, and patient values† (Sacklett,2000). This article was selected as diabetes is becoming an international epidemic affecting all healthcare professions (WHO,2012). First point of interest to a reader is the title; giving clear indication of the subject (Polit and beck, 2012). It should grab the attention of a reader as discussed by Parahoo (2006). A good title should contemplate all aspects of the above, also considering Polit and Becks (2012) thoughts on the title being with a 15 word limit. This title is very clear to the reader, in relation to the subject under study being short, concise and use of good language. Appropriate selection for a research paper relies highly on validity and reliability, which can be shown via credentials of authors. Working statues within health studies and behavioural research within university of Stavanger clearly quoted against each of the authors. This article has clearly labelled, educational status and working status of all authors. Willis (2007) believes that an author’s academic background can give validity and credibility within the research itself. Education held by authors was ‘MSc, PhD, RNT’ being of an university level (Oftedal et al, 2010). Further interest to a reader commences from the information shown within an abstract. This has to hold enough information for it to show a brief understanding of the study in place. Holloway and Wheeler (2010) recommend a clear, concise summary of the research and how it should be implemented. Burns and Grove (2007) mention good abstracts convey findings and capturing attention of a reader. A benefit to this article is that it is clear, readable and structured with subheadings providing a deeper structured understanding. The introduction of this article evidently outlines the rationale for the study; with reference of findings from other relevant studies completed. Holloway and Wheeler (2010) declare authors have to provide awareness of their subject and reasons for their study. Suggestions made indicated that it is paramount for study for the improvements to be made, emphasising on the rise in statistics from the condition (Oftedal et al, 2010). Within the article, there is no clear indication of a literature review. Although, through reading this it has become apparent that it has been included within the background section. Polit and Beck (2012) discuss a literature review being a summary of previous research. Explanations are given within reference to other studies such as Schilling et al (2002) which has shown to lack empirical evidence. However, Thorne and Paterson (2001) look at aspects, but indicate more research can be done. The purpose of a literature review is essential as it gives more emphasis on why the study is important; for instance lack of previous research on the subject. Within this article has an disadvantage, because there is no clear stating of a literature review, which would in some circumstances confuse a reader. Research referenced within the article was between the years 1992-2008; mentioning the need for further research (Oftedal et al, 2010). A purpose for an article is to generalise there aims, informing subject under study stating what is likely to be achievable from the study; Polit and beck (2012) emphasis this being an importance. The aim is clearly sub headed giving the reader clear positioning within the report, it is short and concise with relevant information; indicating the subject of study and what is desired. The aim being ‘perceived support from healthcare and different attributes, that influence people’s self-management of the disease’ (Oftedal et al, 2010). The study is complete by using participants. Ethical issues have a vast importance relating to the validity and credibility of the research. Approval of ethical committee’s is exceptional, including reference. Legal rights and ethical aspects for all research methods have to be considered (Holloway and Wheeler, 2002; Moule 2011; Strubert, 2011). The study appears to have been approved by Norwegian regional committee for medical and health research ethics, social science data services all having reference provided. Implications can be studied at length but four rights are paramount in research: the right not to be harmed, the right of full disclosure, the right to self-determination and the right to privacy, anonymity and confidentiality (ICN, 2012). It is apparent from the study that informed consent was gained from participants, as an invitation was sent, and approval from participants was gained. The right to withdraw was shown as two participants never contributed from initial approval. Methodology is discussed by Parahoo (2007) simply as a plan that describes, how, when and where data is to be collected and analysed. This article does not visibly show methodology but it is an interchangeable term such as research design is present. An advantage from the article is that further reading and comprehension is not necessary as it obviously indicates this research as â€Å"interpretive and descriptive qualitative design† (Oftedal et al, 2010). Holloway and Wheeler (2002) state it gives an understanding of human experiences, giving an advantage to this research as it is what they wish to achieve. Additionally, Holloway and Wheeler (2010) discuss, how roots with philology and the human science, especially in history, centring the way humans related to their subjective reality and attaching a meaning to it. Approach taken solely on world life context rather than individuality; allowing more of an understanding of human experiences at a whole. This type of research allows authors to gain characteristics within this field. Usage of the data is to develop theories and identify problems with current practice (Burns and Grove, 2007; Gerrish and Lacey, 2010). Outcomes achieved five themes, namely: an empathetic approach, practical advice and information, involvement in decision making, accurate and individualised information and on-going based support (Oftedal et al, 2010). These are gained via interpretive and descriptive qualitative design, as it focusses more natural environments rather than cause and effect which is quasi-experimental. This concept being noticeably identified via the research, this was conducted. Details of the participants can be found within the article visibly labelled participants. A participant enables the researcher to conduct the study; Burns and Grove (2012) suggest participants are selected due to experience, knowledge and views related to the study in the progress aiding the researcher to gain accurate information. Within this article, the type of sampling which has been declared is purposive sampling; Parahoo (2006) suggests that this type of sampling conducted is chosen because it provides more reliable and valid data as it is represented by participants diagnosed with the condition. Furthermore the participants, who were invited to take part, were recruited via referrals, from local organisations relating to diabetes such as learning and coping. Ability to speak Norwegian and be within an age bracket of 30-65 allows the data to be more accurate. As discussed, sampling was purposeful; therefore it emphasises the reliability. The sample size used for this research was 19 participants recruited from 3 organisations, unemployed to reduce bias. Mixed gender, aged 30-65 and all participants had the condition for a minimum of one year. Although, purposive sampling is used it does not indicate which strategy; for instance, Patton (2002) allocates more than 12 for qualitative research, Polit and Beck (2012) note there being no fixed rules for sample size, although Morse (2000) mentions how much broad the scope, reflects in the sample size. This research has an advantage as it focussed on participants whom are diabetic. However limitations being restricted are age group, and metabolic generalisation. For example: participants within the study all had the controlled blood glucose levels, there was no sample members who shown uncontrolled or unstable diabetes. Data collection from the research conducted was presented within a table. Collected via focus groups, consisting of 6-7 person per session, participants were interviewed at the workplace of the authors and mixture of genders per group. Although as mentioned by Polit and Hungler (1997) advantage being that it increases dialogue; disadvantage being an decrease for those not comfortable voicing within a group. As it has it pros and cons we can establish that all participants’ had type 2 disease therefore would not have much influence on responses. Limits of time, and for 2 sessions was placed by researchers. The authors recommended time for reflection between sessions. The models used, were identified with the data collection section being expectancy-value and social support theory for questions within the focus groups. All the participants spoke one language; Norwegian which is an advantage to others as it is easier to transcribe. The focus groups explained in data analysis was audiotaped and transcribed verbatim, creating auditability. The analysis was as stated â€Å"Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness† (Graneheim and Lundman, 2004; Oftedal et al, 2010, p1503). Processes took place for this study, unmistakably shown as coding to breakdown text into parts; identifying patterns within the data (Burns and Grove, 2006; Holland and Rees, 2010). After identifying codes, this enables the themes to be developed which was interrelated as findings of the study. Furthermore, data management requires clear processes to ensure methodological rigour and credibility of the findings (Burns and Grove, 2007). According to Polit and Beck (2006) a reader should consider if the data is adequate, to be published in a clear and efficient manner. This article has appropriately labelled correctly making it readable and understandable. The results gained from the data analysis, is clearly drawn within the article under the findings section; providing the established themes, creating an understanding for the reader of how and why they found referenced themes. Polit and Beck (2013) discuss how a reader should notably find limitations within the study. this article presents a limitation section outlining a discussion of how it affects the results and further addresses possible queries that can be made such as, different attributes that can be found from people without stable metabolic ranges as it was limited to acceptable metabolic levels (Oftedal et al, 2010). The impact of results found can construct towards EBP. Additionally, the authors have discussed implications for practice within the study. This advantage is a favourable point as it leads the reader of the implications and how it can be implemented. It focuses hugely on how beneficial it is when it comes to practice. According to transferability of these findings it becomes apparent that type 2 diabetes is a worldwide increasing problem. Results can be transferrable to any country to improve better care for those with type 2 diabetes. The study was conduct in Norway, although it is based within another country the prevalence is still applicable in the UK. Holloway and Wheeler (2010) discuss the meaning of transferability as â€Å"findings of one context that can be transferred to similar situations or participants† diabetes is a worldwide known disease (WHO, 2012) it can be transferred. Polit and Beck (2013) reference that for the generalisation of the study; it has to be valid and reliable for this to take place. The role of a nurse becomes paramount within this section. Whether the results can be implemented by a nurse in practice, such as supporting patients in a better manner and referring if needed for more education, giving more individualisation to self-management programmes as discussed within the article (Oftedal et al, 2010). In relation to the conclusion within the article it clearly sums up the findings and how it can be implemented within practice. It states that further research is necessary before definite conclusions can be retained. Transferability of the research to other chronic illness similar to type 2 diabetes was also mentioned. Burns and Grove (2010) express that the findings and the meaning of the research should be placed within the conclusion. The assignment has explored the significance within research and EBP, transferability of research and recommendation have an importance in this. Overall, this article was clear with good use of words, presentation was greatly achieved, allowing the reader to be more focussed. It discussed within itself the limitations, recommendations and the need for further research for this to become meaningful. Recommendations can be viewed as knowledge and implemented within practice from this study. Also showing that evidence based practice does start from research; it is shown that studies are required in some circumstances to gain more knowledge to improve services. References Burns, N, Grove, S K (2006) Understanding nursing research: Building an evidence based practice 4th ed Elsevier Saunders, United States of America Burns, N, Grove, S K (2007) Understanding nursing research: Building an evidence-based practice. 5th ed. Elsevier Saunders, United States of AmericaCaldwell, K., Henshaw, L., and Taylor, G. (2005) Developing a frame-work for critiquing health research, Journal of health, social and envi-ronmental issues, 6(1), pp45-53. [accessed via: https://eprints.mdx.ac.uk/2981/1/Developing_a_framework_for_critiquing_health_research.pdf] [accessed 20/05/2013] Cutcliffe, J. and Ward, M. (eds.) (2007) Critiquing nursing research. 2nd ed. London: Quay Books. Gerrish, K and Lacey, a (2010) The reseach process in nursing 6th Ed Blackwell publishing: Oxford Graneheim, UH. & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, pp. 105-112. [accessed via: http://www.nurseeducationtoday.com/article/S0260-6917(03)00151-5/abstract][accessed 20/05/2013] Holland, K. and Rees, C. (2010) Nursing: evidence-based practice skills. New York: Oxford University Press. Holloway, I, Wheeler, S (2002) qualitative research in nursing 2nd ed. Blackwell publishing: Oxford Holloway, I, Wheeler, S (2010) qualitative research in nursing and healthcare 3rd ed. Blackwell publishing: Oxford ICN (international council of nurses) (2012) ethical guidelines for nursing research. Geneva ; ICN [accessed via http://www.icn.ch/images/stories/documents/publications/free_publications/Code_of_Ethics_2012.pdf] accessed 20/05/2013. Morse, Janice, M. (2000). Determining sample size. Qualitative Health Research, 10(1), 3-5. [accessed via http://qhr.sagepub.com/content/10/1/3.extract] accessed 20/05/2013 Moule, P, Hek, J (2011) Making sense of reseach; an introduction for health and social care practioners. 4th ed. Sage publications: London Nursing & Midwifery Council (2008) The code: standards of conduct, performance and ethics for nurses and midwives. London: Nursing and Midwifery Council. Oftedal, B, Karlsen, B, Bru E. (2010) Perceived support from healthcare practioners among adults with type 2 diabetes. Journal of advanced nursing, vol 66, issue 7, pp1500-1509. Blackwell publishing [accessed via http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2010.05329.x/abstract] [accessed on 01/03/2013] Patton, M Q (2002): Qualitative Research & Evaluation Methods, Sage: Thousand Oaks. Parahoo, K. (eds.) (2006) Nursing research: principles, process and issues. 2nd ed. Basingstoke: Palgrave Macmillan. Polit, D.F. and Beck, C.T. (eds.) (2012) Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philadelphia: Lippincott Williams and Wilkins. Polit, D.F. and Beck, C.T. (eds.) (2006) Essentials of nursing care: methods, appraisal and utilization. 6th ed. Philadelphia: Lippincott Williams and Wilkins. Polit, D.F. and Beck, C.T. (eds.) (2010) Essentials of nursing research: appraising evidence for nursing practice. 7th ed. Philadelphia: Lippincott Williams and Wilkins. Polit, D.F. and Beck, C.T. (eds.) (2013) Essentials of nursing research: appraising evidence for nursing practice. 8th ed. Philadelphia: Lippincott Williams and Wilkins. Polit,D F, Hungler, B P (1997) Essentials of nursing research; methods, appraisal and utilization. 4th Ed, Lippincott- Raven, Philadelphia: New York David L. Sackett (2000). Evidence based medicine; how to practice and teach EBM. Volume 2 Edition, 2, Churchill Livingstone: University of Michigan. Schilling L.S., Grey M. & Knafl K.A. (2002) The concept of selfmanagement of type 1 diabetes in children and adolescents: an evolutionary concept analysis. Journal of Advanced Nursing 37(1), 87–99.accessed via: .http://www.ncbi.nlm.nih.gov/pubmed/11784402 [Accessed 20/05/2013] Streubert, H J, Carpenter, D R (2011) Qualitative research in nursing: advancing the humanistic imperative 5th Ed, Wolter Kluwer Lippincott Williams & Williams:London. pp56-59 Thorne S.E. & Paterson B.L. (2001) Health care professional support for self-care management in chronic illness: insights from diabetes research. Patient Education and Counseling 42(1), 81–90.Accessed via: http://www.ncbi.nlm.nih.gov/pubmed/11080608 [Accessed 20/05/2013] WHO. (2012) About WHO [online]. World Health Organization. Available from: http://www.who.int/about/en/ [Accessed 17th December 2012]. Willis, J, W. (2007) Foundations of qualitative research. Thousand Oaks, California: Sage.

Facts, Fiction and Persuasive Speech Essay Topics

Facts, Fiction and Persuasive Speech Essay Topics Persuasive Speech Essay Topics - Overview The third step is to make certain that the speech is localized. The variety of body paragraphs will mostly are based on the amount of your paper. The very first step is to obtain a suitable topic for the speech. There are just a few examples of the easy persuasive speech topics we've got on our site. When you compose a persuasive essay speech be sure that it is both factual and informative. Remember your essay shouldn't be a string of jokes, it's a narrative it ought to have a start, middle and the end. Having selected a superior topic to argue about, at this point you will need to make an argumentative essay outline. Fantastic examples are climbing in road accidents and theft. Understanding Persuasive Speech Essay Topics There are range of alternatives for the necessary nutrition. To defend your subject, you can recall the effect of overloaded schedule on college grades. If you've ever taken an on-line class, you understand how different it can be from a classic face-to-face course. There are several persuasive essay topics to select from to finish your high school or college assignment. Students are accustomed to the simple fact which their professors give them with the assignment's topic. They should keep their mobile in silence so as to not disturb the class. They have to complete a lot of writing assignments during college years. They should be allowed to listen to music during prep time. By way of example, such a speech is used if you would like people to vote for a specific candidate, to adhere to the city rules or to change somebody's opinion on an important issue. Persuasive speech refers to a certain kind of speech where the speaker has the objective of persuading the audience to accept their perspective. A persuasive speech is provided with the goal of persuading the audience to feel a particular way, to take a specific action, or to support a particular view or cause. It looks like a tough challenge for many students. There's no demand for smoking cigarettes. Giving up smoking is surely harder than simple talking about the risks of smoking. Preparing a convincing speech about the risks of smoking and the way to give up the habit is something which literally saves lives. A good deal of it simply is dependent on your nature and interests, as what you find easy and interesting, others might come across dull and too complicated. Many people wind up covering the exact tired topics they see in the media daily, only because they can't produce a better idea. Not all individuals are suicidal that manner. There are positive and negative individuals. You can't expect to modify the world in one day! Remember which you are attempting to make your audience except a brand-new vision of the issue. It's best in the event you choose a topic in which you get a genuine interest in as you'll be doing a lot of research on it and if it's something which you take pleasure in the procedure will be significantly easier and more enjoyable. It's good since they can easily find help and it may also prevent them from doing something naughty. When you have the proper knowledge you also need to learn to deliver it in the most convincing method. Your persuasive argument is going to be made stronger if you're able to demonstrate that you're passionate about this issue and have a strong opinion one way or the other. Normally, having three big arguments to demonstrate your point is sufficient for a convincing paper. You may find there's a compelling argument for learning another language after all!

House Calls - The Metaphors of Dr. Gregory House

Before you can ask if theres a metaphor in the house, Dr. Gregory House will oblige: Have you guys heard any of my metaphors yet? Well come on, sit on grandpas lap as I tell you how infections are criminals; immune systems the police. Seriously, Grumpy, get up here: itll make us both happy.(Dr. Gregory House in the Mirror, Mirror episode of House, M.D.) Over the course of several years, the names of a dozen writers have appeared in the credits to the Fox TV program House, M.D. Each, it appears, owns a well-thumbed copy of the Merck Manual of Medical Information. And by now all must be collaborating on a new edition of the Dictionary of Metaphors. As regular viewers are aware, the shows deeply disturbed protagonist (played by Hugh Laurie) is inclined to deliver inflammatory eructations of festering figures of speech. Houses Medical Metaphors At times House relies on metaphors to translate complex medical conditions into language that his colleagues (and other true idiots) can understand. Cervical lymph node is a garbage dump. Very small one--just one truck comes, and it only comes from one home. Al Gore would be appalled. (97 Seconds)Saying there appears to be some clotting is like saying theres a traffic jam ahead. Is it a ten-car pile-up, or just a really slow bus in the center lane? And if it is a bus, is that bus thrombotic or embolic? I think I pushed the metaphor too far. (Euphoria, Part 1)Dr. House: You know, when the Inuit go fishing, they dont look for fish.Dr. Wilson: Why, Dr. House?Dr. House: They look for the blue heron, because theres no way to see the fish. But if theres fish, theres gonna be birds fishing. Now, if hes got hairy-cell, what else are we gonna see circling overhead? (Role Model)Dr. House: As far as youre concerned, the patient is Osama bin Laden, and everyone not in this room is Delta Force. Any questions?Applicant #11: Were protecting Osama bin Laden?Dr. House: Its a metaphor. Get used to it. (The Right Stuff)The tumor is Afghanistan, the clot is Buffalo. Does that need more explanation? OK, the tumor is Al-Qaeda. We went in and wiped it out, but it had already sent out a splinter cell--a small team of low-level terrorists quietly living in some suburb of Buffalo, waiting to kill us all. . . . It was an excellent metaphor. Angio her brain for this clot before it straps on an explosive vest. (Autopsy)The liver is like a cruise ship taking in water. As it starts to sink, it sends out an SOS. Only instead of radio waves, it uses enzymes. The more enzymes in the blood, the worse the liver is. But once the ship has sunk, theres no more SOS. You think the livers fine, but its already at the bottom of the sea. (Locked In)Dr. Cameron: Idiopathic T-cell deficiency?Dr. House: Idiopathic, from the Latin meaning were idiots cause we cant figure out whats causing it. Give him a whole body scan.Dr. Cameron: You hate whole body scans.Dr. House: Cause theyre useless. Could probably scan every one of us and find five different dooda ds that look like cancer. But, when youre fourth down, 100 to go, in the snow, you dont call a running play up the middle. Unless youre the Jets.Dr. Cameron: I hate sports metaphors. (Role Model) But House is generally more intent on frightening than on edifying. As he once said: The point of metaphors is to scare people from doing things by telling them that something much scarier is going to happen than what will really happen. God, I wish I had a metaphor to explain that better. (All In) At other times the House metaphor is nothing more than a comic exercise in doctor-patient incivility. Once, after discovering that a young man had attempted self-circumcision with a utility knife, House snapped, Stop talking. Im going to get a plastic surgeon. To get the Twinkie back in the wrapper. House Metaphors About Life in General Of course, House himself is a walking, or rather limping metaphor--his crippled leg an emblem of his deformed spirit. And his acerbic metaphorical remarks may be read as symptoms of an undiagnosed malady. No, there is not a thin line between love and hate. There is, in fact, a Great Wall of China with armed sentries posted every twenty feet between love and hate. (Occams Razor)Dr. Wilson: Beauty often seduces us on the road to truth.Dr. House: And triteness kicks us in the nads. (Occams Razor)Lies are a tool: they can be used either for good or--no, wait, Ive got a better one. Lies are like children: hard work, but theyre worth it because the future depends on them. (Its A Wonderful Lie)Dr. House: Nothing matters. Were all just cockroaches, wildebeests dying on the river bank. Nothing we do has any lasting meaning.Evan Greer: And you think Im miserable?Dr. House: If youre unhappy on the plane, jump out of it.Evan Greer: I want to, but I cant.Dr. House: Thats the problem with metaphors. They need interpretation. Jumping out of the plane is stupid.Evan Greer: But what if Im not in a plane? What if Im just in a place I dont want to be?Dr. House: Thats the other problem with metaphors. Ye s, what if youre actually in an ice cream truck, and outside are candy and flowers and virgins? Youre on a plane! Were all on planes. Life is dangerous and complicated, and its a long way down. (Living the Dream)You know me. Hostility makes me shrink up like a . . .. I can’t think of a non-sexual metaphor. (Spin)You know its all nice when people start to dig these holes, but then they start to live in these holes and get angry when someone pushes dirt into those holes. Come out of your holes, people! (House vs. God)Dr. House: Im a night owl, Wilsons an early bird. Were different species.Dr. Cuddy: Then move him into his own cage.Dr. House: Wholl clean the droppings from mine? (Sleeping Dogs Lie) Every now and then, however, House finds himself on the wrong side of a metaphor, as in this exchange with a young patient: Dr. House: Are you going to base your whole life on who youre stuck in a room with?Eve the Patient: Im going to base this moment on who I am stuck in a room with! Its what life is. Its a series of rooms, and who we get stuck in those rooms with, adds up to what our lives are.(​ One Day, One Room) And how does House respond to the womans metaphor? As he must, by silently--and literally--walking out of the room.