Nursing (Evolution and practice issues)

Question:

Question 1: Identify which issue is being discussed by the authors in the article “Scope of practice for Australian enrolled nurses: Evolution and practice issues”.

Question 2: What are the two (2) main reasons cited for the issue?

Question 3: The authors provide a number of important reasons in explaining the changes to Enrolled Nurse practice and the current situation. Which two (2) factors/reasons do you think are most significant and why?

Question 4: In the article, identify two (2) of the different considerations, in terms of viewing scope of practice for nurses.

Question 5: In the article, a number of professional and practice issues impacting on nursing are identified as a result of expanding the scope of practice of the Enrolled Nurse. Identify two (2) of these issues.

Answer:

Q1: Jacob et al. (2013) in their article “Scope of practice for Australian enrolled nurses: Evolution and practice issues” have highlighted the issue of significant changes brought about in the scope of practice for enrolled nurses in Australia in the past one decade. The main concern is that enrolled nurses have moved into clinical areas that were previously conventionally the domain of domain of registered nurses in Australia. The responsibilities of an Enrolled nurse have seen drastic expansion in the recent past to include care settings such as anesthetics, operating theaters, and emergency departments acute medical and surgical wards. Earlier, registered nurses used to handle these areas. Further, enrolled nurses at present have taken up enhanced roles including education, bereavement counseling and wound care. The researchers highlighted that the change in the scope of practice for enrolled nurses had the characteristic of accelerating in a rapid pace that has given rise to a number of questions relevant to the quality of care delivered. This is a serious concern since these questions is still unanswered without any precision being achieved. It has been found that due to the changes in the scope of practice there have been changes in the set of activities that enrolled nurses as healthcare practitioners perform within the particular professional domain. The nature of tasks that the nurses of the country are to perform have undergone an evolution, and it is to be mentioned that the scope of practice has been enhanced, expanded and extended. The movement of the role of enrolled nurses into different practice domain has drawn attention since the expansion of the role into diverse domains of practice retained for pharmacists, and most importantly registered nurses have been prominent in the recent past.

Q2: The two primary reasons that have been cited behind the issue of changes brought about in the scope of practice for enrolled nurses in Australia are role confusion and overlap between enrolled nurses and registered nurses in Australia, and education and employment of enrolled nurses. The scope of enrolled nurses initially was focused around providing basic patient care like monitoring of health status of patients and assisting patients with daily activities of living. Since the role of enrolled nurses has expanded, they are at present contributing to the role of registered nurses such as administration of medications. Such role changes, or rather the addition of responsibilities have led to role confusion and role overlap. The majority of issues due to role overlap and confusion have been witnessed in rural settings and aged care sector.

The education and responsibilities that enrolled nurses have shown huge variation from one state of Australia to another. Therefore there has been issues with setting up the appropriate the system of education that can lead to improved career paths for enrolled nurses through the development of standards. The advanced and evolved courses have incorporated advanced skills that are effective in promoting the further enhancement of the scope of practice of enrolled nurses as well as their employment in healthcare service centers (Jacob et al. 2013).

Q3: Jacob et al. (2013) had identified a number of important reasons to explain the changes brought about in the enrolled nurse practice and the current situation. Two factors that are most significant are workforce shortage and economic constraints. As per the author, the changes have largely occurred as a consequence of economic pressure and staff shortage at all levels of the healthcare domain. The percentage of enrolled nurses in the country’s healthcare professional workforce has seen major variations in the past twenty years. Initial peaks in workforce numbers were due to the increased use of enrolled nurses when there had been a shortage of a number of registered nurses. This trend has continued till present times further influenced by the fact that there has been an irregular flow of unregulated healthcare workers. The healthcare departments have been responsible for not increasing provision for adequate funding that can promote professional development of registered nurses. Economic pressure has been felt while bringing changes in the skill mix and stimulating better nursing goals. Due to financial constraints, the recruitment of registered nurses into healthcare settings have not been feasible, compelling the recruitment of enrolled nurses in place of registered nurses. There lies evidence for workforce shortage and economic constraints being the two most significant factors behind changes to Enrolled Nurse practice and the current situation. According to Buerhaus et al. (2017), the clinical staff are the health system’s most crucial inputs and shortage in one nurse professional group needs to be compensated by another group. Further, with economic restrictions in the care settings, advanced care delivery is not possible wherein each healthcare professional has a designated role and distinct set of responsibilities.

Q4: The article has identified different considerations in terms of viewing scope of practice for nurses. The two most important ones are task needs and competency statements. Task lists have been implemented by certain organizations for defining practice. Nevertheless, defining role by a list of tasks instead of involvement in patient care is responsible for demarcating the value of nurses in the healthcare team. Task lists cannot identify management of patient care, differences in clinical reasoning, problem-solving and ethical decision-making skills. The ANMC had developed competency standards which both enrolled and registered nurses are to abide by as national guidelines for practice. These competencies are divided into four domains of practice: critical thinking and analysis; professional practice; provision and coordination of care; and collaborative and therapeutic practice (Jacob et al. 2013).

Q5: The article also highlighted that enrolled nurses might be expressing less enthusiasm for undertaking an expanded scope of practice since such an expanded scope demands advanced skills of reasoning, planning, reflection, and evaluation. Enrolled nurses are pressurized to increase their scope of practice since the healthcare settings consider the strategy as a cost-cutting one. As a consequence enrolled nurses might be feeling overloaded with responsibilities apart from their traditional duties, increasing the chances of attrition or absenteeism. Such risks are of much concern in rural settings where there is lack of clarity regarding extended roles and additional demands in educational preparedness and practice time frame.

References
Buerhaus, P.I., Skinner, L.E., Auerbach, D.I. and Staiger, D.O., 2017. Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8 (2), pp.40-46.

Ruth Jacob, E., Barnett, A., Sellick, K. and McKenna, L., 2013. The scope of practice for Australian enrolled nurses: Evolution and practice issues. Contemporary Nurse, 45(2), pp.155-163.

Pathophysiology and Pharmacology in COPD – A case report

 

Question

Task:
Background to Clinical Scenario: Robert is a 51 year old man who lives with his wife in regional Victoria. He has been admitted to your ward from the Intensive Care Unit (ICU), where he had a 3 day stay for an acute exacerbation of COPD, caused by community acquired pneumonia. He required several days of non-invasive ventilation whilst in ICU. Robert tells you his wife (Jill) was very frightened when he was admitted to ICU, and he doesn’t want ‘to put her through that anymore’. He would like some help to understand and manage his COPD. Robert said he was diagnosed with COPD about 18 months ago by his GP, but admits he was sick for ‘a while’ before that. He is a current smoker, and has smoked for about 40 years. He has unsuccessfully attempted to quit on more than 5 occasions. Robert worked for many years on his chicken farm, but now finds he becomes breathless very easily and Robert and Jill have had to hire a farm helper. Robert’s medications include:

Salbutamol 2 – 4 puffs PRN

Budesonide/Efomoterol fumarate dehydrate 2 puffs daily

Metoprolol 25mg daily

Aspirin SR 100 mg daily
Pathophysiology 1.1: Describe the pathophysiology of COPD. Include in your answer the two disease processes contained in the umbrella term ‘ COPD’ and how they develop.
Robert has been diagnosed with a severe exacerbation of COPD, caused by Community-Acquired Pneumonia.
1.2 Explain the term ‘acute exacerbation of COPD’. What factors put patients like Robert at high risk for exacerbations of COPD? What else may contribute to an exacerbation of COPD?

1.3 Describe the pathophysiology of pneumonia
Include in your answer the differences between Community Acquired, Hospital Acquired and Health Care Associated Pneumonia.

Pharmacology: The Respiratory Physician who reviewed Robert in ICU suggested some changes to his current inhaler regime. The physician suggested that Robert cease his Budesonide/Efomoterol fumarate dehydrate, and commence on Tiotropium 2 puffs daily.

2.1 For each of the three inhalers (Salbutamol, Budesonide/Efomoterol fumarate dehydrate and Tiotropium), describe the Mechanism of action in COPD Contraindications and Adverse Reactions Nursing Considerations and Patient Education Points Include in your answer why the respiratory physician might have changed Robert’s medication regime.

CRICOS Provider No. 00103D NURBN 2012 Semester 1, 2018 Clinical Scenario Assignment Page 3 of 3
Robert was diagnosed with Community-Acquired Pneumonia, and Streptococcus pneumoniae was cultured from his sputum.

2.2 Identify three antibiotics that could be used to treat Streptococcus pneumoniae in Robert’s case. For each antibiotic, describe the Mechanism of action Contraindications and Adverse Reactions Nursing Considerations and Patient Education Points
Psychosocial issues 3.1 Discuss three evidence-based interventions to help Robert manage his COPD.

Answer

1. Pathophysiology
1.1 Pathophysiology of COPD
Chronic obstructive pulmonary disease (COPD) is a progressive disorder with emphysema (alveolar destruction) and bronchial fibrosis in variable proportions. Inhalational particles such as allergens and chronic bacterial infections generate inflammatory response resulting COPD (A. Bhat and Panzica, 2015). The inflammatory cells are responsible for COPD are a type of white blood cells which include macrophages and neutrophil granulocytes. People having COPD due to smoking have Tc1 lymphocyte involvement. These inflammatory factors produce chemotactic factor in cell.

The factors which are responsible for lung damage are-

1) Due to tobacco smoke, free radicals are generated which results in oxidative stress
2) Discharge of inflammatory cells
3) Proteases damage the connective tissue of lungs

The term umbrella characterizes the chief persistent disorders of lungs e.g emphysema and chronic bronchitis.

Emphysema- it is a disorder of lungs which is responsible for shortness of breath because of over-inflation of air-sacs present in lungs (Sharafkhaneh, Hanania and Kim, 2008). It comes under umbrella term COPD because in emphysema cessation of airflow occurs due to inappropriate exchange of air on person breathing because air sacs are present in lungs. It develops due to cigarette smoking, air pollution, deficiency of an enzyme known as alpha-1-antitrypsin.

Chronic Bronchitis (CB) – it is explained as the generation of persistent cough and release of sputum from last 3 months to 2 consecutive years. It is comes under the umbrella term of COPD because in CB inflammation and lots of mucus get accumulated in bronchi. It is developing because of smoke inhalation, infections occur due to microorganism, and activation of inflammatory cell of mucin gene transcription which oversecrete the mucus by goblet cells and hence restrict airflow pathway (Kim and Criner, 2013).

1.2 Acute exacerbation of COPD
An acute exacerbation of COPD is explained as incidents described by damaged respiratory symptoms of person which is away from regular day-to-day changes and hence result in alteration in medication (Garvey and Ortiz, 2012).

In patients like Robert exacerbations of COPD get high by various factors-

1) As continuous smoking and especially in older age causes lung destruction which leads to high risk of acute exacerbation.

2) Streptococcus pneumonia virus worsens the condition of COPD and leads to acute exacerbation of COPD.

3) Working in chicken farm, there may be presence of influenza virus which also increases the chances of exacerbation of COPD.
Acute exacerbation is life-threatening and leads to negatively affect the treatment of disease. It is started by infection of microorganisms or pollutants. It retards the quality of life, accelerates death rate, and increases lung function damage specifically among hospitalized patients. In acute exacerbation, air entrapment and lung hyperinflation becomes negligible which leads to poor expiratory air flow and accelerate dyspnoea.

1.3 Pathophysiology of pneumonia

It is defined as an inflammatory condition that affects the small air sacs known as alveoli which are present on lungs which leads to abnormal high body temperature and shortness of breath. It is mainly produced by toxic agent like bacteria, viruses and rarely caused by fungi, parasites, certain medications and due to autoimmune diseases.

The pathophysiology is mostly the same, regardless of causative agent.

In this, microorganism invades into the lung with inhalation although microorganism can enter into the lung through the systemic circulation also if any other body part is infected. Mostly, microorganism resides in upper respiratory tract and breath into the alveoli in continuous manner. On reaching in the alveoli, microorganism moves between the gaps and between the adjacent alveoli through linked pores. Due to this, immune system gets activated. It triggers the leukocytes for attacking microorganism to the lungs. The helpful microorganism (neutrophils) invades harmful microorganism and also releases cytokines (Cilloniz and Ignacio, 2016). Hence as a result, cytokines result boost up the immune system which leads to abnormal rise in body temperature, restlessness, chills. Lung damage occur due to attack of microorganism on it and due to production of cytokine in response to immune system, fluid gets leaked into the alveoli which results in impaired oxygen transportation. In addition to damage to lungs, if there is attack of viral organism, it can affect other organs of body also. On bacterial attack, it mostly travel from the lungs to the surrounding blood vessels which result in ill health like septic shock which leads to hypotension results in multiple damage of body parts including brain, kidney, heart.

Community-acquired pneumonia- it is acquired in community. The main difference between community-acquired pneumonia and hospital acquired pneumonia (HAP) is that persons having HAP resides in hospital from long term or recently admitted in hospital. CAP involves less multidrug-resistant bacteria (W. Pletz and G. Rohde, 2016).

Health care–associated pneumonia (HCAP) – It is an infection associated with current exposure to the healthcare system which includes hospitals, nursing home, and dialysis centre.

Hospital-acquired pneumonia- It is acquired in hospital. It is due to the presence of pathogen in the hospital or it may be acquired due to the other patient’s illness. It mostly occurs after the admission of 2-3 days in hospital. It consists of higher risk of multi-drug resistant bacteria.

2. Pharmacology
2.1 Salbutamol
M.O.A- It causes bronchodilatation through ?2 adrenergic receptors stimulation. These receptor are mainly present in bronchial smooth muscle of lungs. Activation of ?2 receptors causes increased in cAMP formation in bronchial muscle cells which results in relaxation of these smooth muscles cells and reduction of airway blockage by decreasing intracellular ionic calcium concentrations. When cAMP level gets increased then it also retards production of many bronchoconstrictor factors e.g allergic histamine, leukotriene from the mast cells in the airways (Ullmann and Caggiano, 2015).

Contraindication- it is contraindicated in persons having hypersensitive reaction like urticaria, angioedema, in patients having cardiac tachyarrhythmias.

Adverse effect- Tremor in skeletal muscle specially in hands, nervousness, headache, tachycardia, palpitation, muscle cramp, hypokalemia, chest discomfort are adverse effect of salbutamol.

Nursing consideration and patient education points-

1) In the patients who suffer from cardiovascular abnormalities, it should be used carefully.

2) If patient is using both tablets and inhaler at one time, monitor the patient for toxicity.

3) If patient is doing exercise, tell him to take inhaler before 15 minutes to workout to avoid exercise-provoked bronchospasm.

4) The patient should know about the danger of paradoxical bronchospam. If it happens patient should cease the administration of drug immediately.

5) Patient should know how to use inhaler properly. Nurses should properly educate the patient about it.

6) If patient is using the steroid inhaler also, then he/she should use bronchodilator first and after that wait for 5 minutes for using steroid.

7) Between puffs of inhaler there should be gap between 2 minutes.

8) To avoid the dry mouth after inhalation, nurses should teach the patient to wash the mouth with water after using each inhalation.

9) The patient should be informed about noxious taste of salbutamol..

Budesonide-

M.O.A- it retards the activity of broad area of inflammatory cells which includes eosinophils, T lymphocytes, macrophages, mast cells, neutrophils (Iborra, 2014).

Contraindication- it is contraindicated in nasal ulcers and in presence of infections. In the initiative medical care of status asthmatics budesonide is contraindicated. The patients who suffers from hypersensitivity of budesonide, it is contraindicated in these patients.

Adverse effect- ankle edema, hirsutism, nausea, rhinitis, arthralgia.

Nursing consideration and patient education points-

1) Nurses should check patient history like nasal infections, nasal surgery etc.

2) Nurses should teach the patients that they do not cut, crush or chew capsule, it should be swallowed completely.

3) Nurses should motivate the patient to compete the drug therapy of 8 weeks.

4) Nurses should monitor the patients for adverse effect of drug like acne, hirsutism, buffalo hump. If this effect occurs then dosage regimen should be decreases.

5) Nurses should teach the patient if they forget to take a capsule a day, then on the next day take the drug at regular time.

6) Nurses should advise the patient to not to take grapefruit juice with this drug.

7) Nurses should aware the side effect of drug to the patients like dizziness, headache, and nausea.

8) If patient feel chest pain, ankle swelling, respiratory infection during the treatment of this drug, he/she should immediately reported.

Tiotropium-

M.O.A- it is a quaternary ammonium compound which is badly absorbed across cell membranes which leads to reducing its effect to the airways after inhalation. There are three types of muscarinic receptors in human airways i.e. M1, M2 and M3. M1 and M3 trigger the release of acetylcholine from vagal nerve endings and hence results in bronchoconstriction.. Tiotropium antagonize the two receptor and results in potent bronchodilation (Halpin, 2016).

Contraindication- it is not used for remedial therapy for acute COPD. If after its administration, hypersensitive reactions like urticaria, swelling of lips, toungue, throat, itching occurs then its therapy should be stop immediately. Tiotropium powder should not be used in eyes because dryness of eyes can be occurring by using it which leads to irritation in eyes. In elderly males having prostatic hypertrophy- urinary retention can occur.

Adverse effect- dry mouth, throat infection, urinary retention, palpitation, increased risk of heart attacks, constipation, acute angle closure glaucoma.

Nursing consideration and patient education points-

1) Do not take the capsule by mouth. Take them only by oral inhalation by Handi Haler device.

2) Use only one capsule at a time.

3) The drug should not be administered for acute bronchospasm although it should be used be used for maintenance remedy of COPD.

4) Nurses should monitor the patient for hypersensitive reactions like angioedema and paradoxical bronchospasm.

5) This medicine should be used in same manner as prescribed by doctor for patient.

Respiratory physician might have changed Robert’s medication regime because the role of inhaled corticosteroid in the management of COPD is still uncertain (Qureshi and Sharafkhaneh, 2014).

2.2

Levofloxacin-

M.O.A- it inhibits the enzyme bacterial DNA gyrase. This enzymes nicks double stranded DNA due to which negative supercoiling occur nicked end get resealed. In gram positive bacteria it inhibits the enzyme topoisomerase IV which nicks and separates daughter DNA strand after DNA replication (J. Aldred and J.kerns, 2014).

Contraindication-

It is contraindicated in patients with known hypersensitivity to levofloxacin

Cardiovascular collapse, hypotension, angioedema may occur.

Adverse drug effect-

Hepatotoxicity, peripheral neuropathy, prolongation of QT interval, blood glucose disturbances, hypersensitive reaction, tendon rupture, crystalluria, photosensitivity.

Nursing consideration and patient education points-

1) Nurses should administer the patient for previous sensitivity reaction like rashes, urticaria.

2) Nurses should examine the patient for possible drug induced adverse reaction.

3) Nurses should monitor the patient for hypersensitivity and thrombophlebitis in routine manner.

4) Nurses should advise the patient to take lots of fluid while taking drug

5) Nurses should teach the patient to report if any joint pain, sore throat, itching, occurs.

6) Patients should be advised to use sunscreen or avoid sun exposure to prevent photosensitivity.

Ceftriaxone

M.O.A-

It is bactericidal in nature and inhibits bacterial cell wall synthesis (Leyenaar, 2014).

Contraindications-

Hypersensitivity, crystalline material was observed in lungs and kidney, prolongation of prothrombin time.

Adverse effect-

Pain after i.m injection, diarrhoea, hypersensitivity reactions like urticaria, asthma, nephrotoxicity.

Nursing consideration and patient education points-

1) Patient should monitor for renal and hepatic function.

2) If hypoprothrombinemia occur, then vitamin K should be given.

3) Patient should be assess for thrombophlebitis.

4) Patient should advise to take the dug with food.

5) Nurses should teach to the patient that they have to avoid alcohol while taking the medication and afterward 3 days on completion of course.

Vancomycin-

M.O.A- it is a glycopeptides antibiotic. It acts by preventing the synthesis of bacterial cell wall. It attached to the peptidoglycan units by terminal dipeptide D-ala-D-ala sequence and hence avoid its cross-linking to form the cell wall of bacteria (Kalil, 2010).

Contraindication-

Rapid i.v injection has caused chills, fever, urticaria and intense flushing known as Red man syndrome.

Adverse effect-

Systemic toxicity, skin allergy, fall in B.P, kidney damage.

Nursing consideration and patient education points-

1) Nurses should assess renal function.

2) If red man syndrome occurs during administration of drug, then give antihistamine to patient.

3) Nurses should avoid extravasations during therapy because necrosis can be occur due to it.

4) Patient should be taught if symptom of superinfection, sore throat, fever occur then he/she should be consult to doctor.

Psychosocial issues

1) Inhaled bronchodilators- ?2 agonists which are short-acting inhalation and anticholinergic drugs treat the COPD. Salbutamol act by triggering the release of cAMP (J, 2001).

2) Formoterol which is long acting ?2 inhalation also recommended for treatment of acute exacerbation of COPD in cumulative manner (Qureshi and Sharafkhaneh, 2014).

3) Antibiotics- there are evidence which supports the need of antibiotics in exacerbation of COPD when there are also signs of bacterial infection. Antibiotics decrease the danger of short-term mortality by 77%.

References-

A. Bhat, T. and Panzica, L. (2015). Immune Dysfunction in Patients with Chronic Obstructive Pulmonary Disease. Annals of the American Thoracic Society.

Cilloniz, C. and Ignacio, M. (2016). Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns. International Journal of Molecular Sciences.

Garvey, C. and Ortiz, G. (2012). Exacerbations of Chronic Obstructive Pulmonary Disease. The open nursing journal.

Halpin, D. (2016). Effect of tiotropium on COPD exacerbations: A systematic review. Respiratory Medicine.

Iborra, M. (2014). Long-term safety and efficacy of budesonide in the treatment of ulcerative colitis. Clinical And Experimental Gastroenterology.

J. Aldred, K. and J.kerns, R. (2014). Mechanism of Quinolone Action and Resistance. ACS.

J, M. (2001). Safety of formoterol Turbuhaler at cumulative dose of 90 microg in patients with acute bronchial obstruction. Eur Respir J.

Kalil, A. (2010). Treatment of hospital-acquired pneumonia with linezolid or vancomycin: a systematic review and meta-analysis. BMJ.

Kim, V. and Criner, G. (2013). Chronic Bronchitis and Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine.

Leyenaar, J. (2014). Comparative Effectiveness of Ceftriaxone in Combination with a Macrolide Compared with Ceftriaxone Alone for Pediatric Patients Hospitalized with Community Acquired Pneumonia.

Overington, J. (2014). Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions. Journal Of Throacic disease.

Qureshi, H. and Sharafkhaneh, A. (2014). Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Therapeutic Advances in Chronic Disease.

Sharafkhaneh, A., Hanania, N. and Kim, V. (2008). Pathogenesis of Emphysema. American Thoracic Society.

Ullmann, N. and Caggiano, S. (2015). Salbutamol and around. Italian Journal of Pediatrics.

Van Rensburg, D. (2010). Efficacy and Safety of Nemonoxacin versus Levofloxacin for Community-Acquired Pneumonia. Antimicrobial agents and chemotherapy.

W. Pletz, M. and G. Rohde, G. (2016). Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000 Research.

Influence of Primary Schools In India on personality of Children

 

Question

Task: Whilst more direction, including assessment criteria, will be given for this assignment on the LMS website and during the first two face-to-face meetings, the Literature Review is expected to be a scholarly piece of writing that meets the writing standards expected for post-graduate studies. The Review should include a critical analysis of at least SIX (6) peer reviewed journal articles. The analysis should include an overview of the theoretical significance of selected articles for your research topic of interest and possible implications for your intended research approach. APA 6 referencing should be used. References will be checked.

Information concerning ineffective (or failing HRM)

In brief, critical thinking in the literature review should highlight…

• What is the purpose of the study?
• What is the focus of the study?
• What types of data were collected?
• How were the data managed?
• What analytical approach is used?
• How is validity addressed?
• How are ethical issues handled?

Answer

Introduction to Indian school education
Research methods in education are intensifying due to increasing competition. This has made it important for students to seek professional assistance to help them crack their exams and secure good jobs. It is estimated that India has about 1.5 million schools spread across the country and there are about two hundred and fifty million students enrolled in these schools (Indra, 2017). The mammoth size of the education system, its coordination administration gives it a status of one of the largest education systems second only to China. This vast educational establishment is evolving and changing constantly and has achieved remarkable feats in the last two decades. The net enrollment rate of primary education has crossed the target of 95 percent. i.e. ninety-five percent of the children in the age group of 6 to 11 years age are enrolled in schools and are attending the classes(Mitra, 2018). The present education system has adopted many new goals and objectives but is yet to let off the influence of policies of the yesteryears.

As the academicians across the world consider the Indian school system as one of the largest and most complex in the world, making students need thorough research methods in education. Indian education system especially the primary and high school has the following unique characteristics (Ghosh, 1989). First India is trying to maintain a standard and uniform educational system across the country, second, schools are providing space for diverse Indian culture and heritage to flourish in schools in a balanced manner, and third, the Indian education gives importance to explicit knowledge in various subjects and its academic applications. After India achieved independence, it has tried hard to provide access to basic education to all. Currently, the primary and high school education has begun to receive attention to the quality of education and the learning outcomes of the children.

Introduction to the influence of school on personality
To register high success rates, research methods in education require the schools and schooling process has direct effects on children’s personality, and educational attainment. The Schools provide the primary school children with basic knowledge to build on disciplines such as geography, history, science, mathematics, language, etc. The primary schools provide the children an opportunity to have formal education and training. Not only the cognitive aspects of personality are enhanced, the social skills and self-management are shaped in the primary schools (Diaz-Guerrero, 2017). Indian schools provide a uniform educational opportunity to all children and only a few schools provide individual attention to the students. The indirect effects on the student’s development are contributed by the quality of the curriculum, the peer group, the teacher’s involvement in development, the social environment of the school, etc. The children’s cognitive abilities, the personality traits, and the motivational inclination also work as the mediating factors in their development.

Three levels of Personality
Before we explore factors influencing Research methods in education and their effects on student personality, an understanding of the scope and dimensions of personality is necessary. For almost several decades, the behavioral scientists were struggling to formulate an appropriate definition of personality and also were trying to enumerate the components of personality. The recent personality researches have achieved a fair degree of success in ordering the personality elements in a coherent manner (McAdams, et al, 2004). Some researchers have proposed to view personality in three levels. The first level of personality is comprised of the traits of a person i.e. the dispositional factors of a person. The traits are considered as the core of a person’s personality. The traits may include friendliness, emotional stability, being organized, outgoing, talkative, moody, etc. and are enduring characteristics of a person. The traits of a person are considered as biologically determined patterns of responses. The second level of Personality is the adaptation characteristics which refer to the patterns of responses to the contexts of time, place and roles. The adaptation mechanisms of a person are manifested as characteristic motives, social interactional orientation, relational styles, coping strategies, defense mechanisms, interests, values, etc. Traits are deeper aspects of personality which are not readily observable or recognizable, but the adaptation characteristics are observable in action and more recognizable. The third level of personality is the social and psychological identity they carry along as they move in the world i.e. integrative life stories or narrative self-identity. These narratives are sum total of a person’s experience with the world and own perceptions about the self. Students carry their stories with them (their self-concept, self-esteem and life narrative) as much as they carry their traits. A school is likely to influence the adaptation characteristics and the life narrative of a person.

Framework to assess School influence on personality
It is likely that there are many factors of a school that has potential to contribute with respect to the shaping of the personality of students. In order togain a comprehensive picture of Research methods in education and the factors of influence are classified into three broad categories i.e. people, processes, and place in a school. These categories are likely to have overlapping influence on the students. Some the subfactors of each of these categories are discussed briefly here. The contexts of Indian schools are considered as much as possible to explain the influences.

People factors
In a positively functioning school, the human relationships and interactions are very significant. Among the three broad factors of influence on the learners, people factor is very vital. Along with cognitive development, social skills development is also critical for the students to succeed in a career. The social relationships in a school, especially the friendship groups and a teacher’s attitudes towards the school, teaching, and students have a profound influence on the primary school students of a school (Pena, 2000).

Friendships and relationships in school
The researchers, practitioners, teachers, parents, and students themselves attach significance to friendships and relationships in a school. The day to day experiences is enhanced by the fun of interactions and feeling of belongingness. Students who have a healthy relationship with peers are found to be enjoying learning tasks and are likely to overcome the barriers to learning (Hughes, & Kwok, 2007). A male parent from India once commented that a school is a place where social time has to be utilized to form deep friendships and intellectual relationships.

Research methods in education surveys conducted on Indian schools have indicated that the students, teachers and the parents are aware of the significance of social relationships and encourage their children to form a friendship with students of different grades. Student respondents saw this in terms of friendships with their classmates or students from different grades, and their relationships with teachers. Previously, due to cultural norms the parents and other guardians were reluctant to go to their children’s school;now many parents actively participate in the school programs and encourage a positive relationship with teachers and school management. Due to this shift in parental attitude, many schools are able to run community programs successfully. In a village school in Uttar Pradesh, India, the attendance rate of parent teacher’s association members is 125%, i.e. along with parents, the grandparents of primary school children also attend the parent teachers meeting. Participation in community function is part of Indian culture and people do not hesitate to visit their children’s’ school.

In many private schools in India, especially run by Christian missionaries, there are multi-grade houses such as daffodils, lotus, shamrock, etc. in which every child will belong to any of these houses. Students belonging to a house is required to wear a colored band, tie, tee shirt or cap common to all members of a house and complete with students of other clubs in school sports events, exhibitions, shows, etc. This multi-grade clustering of students promotes relationship development and extends the bonding to the student’s respective families. The social interactions in school bring out the personality traits of a student and help them to acquire appropriate adaptation characteristics and form healthy self-concept.

Teacher’s attitudes
A teacher’s interaction with a student is critical information of his or her personality. The effect of positive attitudes and attributes has far-reaching consequences for the students. Most parents, students, and teachers have agreed about this factor. Once a student from India said” teachers must not be strict and impose on the students regarding marks, projects and other activities. The teacher can help the students learn without being too critical; the attitude of the teachers matter most in school” (Hughes, & Kwok, 2007).

Many urban schools have recognized the importance of teachers who encourage; interact with positivity and who are innovative in teaching and kindles fun in class. Students like teachers who are friendly and have a sense of humor. Once during a parent-teacher meeting, a parent suggested that recruitment and selection of teachers must meet the criteria of good attitudes towards students. The teachers’ personality, attitude, and skills must match the profile of the available teaching role. Teachers who have “I teach – you listen “attitude can have a negative effect on the personality of the students. Many teachers in India are not liked by the primary students as the teachers are showing high handedness.

A solution to the issue of teacher-student attitude, the practitioners are recommending to create a sense of family in the school premises. The second recommendation is to set priorities regarding, personality, attitude and ethics of the prospective teaching candidates during the recruitment and selection of teachers. The selection procedure for primary teachers needs to be rigorous as the teacher can have a profound influence on the students’ personality.

Infusing positive values
There is a practice in India to fill the walls of the schools with statements, quotes, and sayings of great men. Many of these statements infuse values among the students. Most of the statements are focused on common values of integrity, education, commitment, appreciation, respect, cooperation, knowledge, altruism, tolerance, independence, creativity, diversity, etc. Mostly these sayings are colorful representations of underlying values, the wall messages are meant to remind the students, but are also influencing all in the school. Many contemporary issues are also presented on the walls as values (Wall, 2018). For example, global warming, environmental protection etc. are represented on the walls and posters. These displays are significant in shaping the personality of the students, epically the value education.

Process factors
Teaching and learning functions are basic processes in a school. The teaching and learning methods in a class to a large extent determine the interest in learning and classes. Effective learning and teaching methods can help the learners to gain nonacademic skills too. The teacher’s classroom management can affect the student’s feeling of freedom to express themselves and be creative in their approach. Two of the process factors are discussed here. i.e. types of disciplines and learner freedom that can influence the personality of the students.

Type of discipline used
Most students in primary schools prefer to have positive discipline in school and classroom rather than being exposed to physical and emotional punishment (Osher, Bear, Sprague, & Doyle, 2010). Presence of these kinds of punishment is disliked by the students and can have a long-lasting effect on the personality of the students. One of the most hated teacher behaviors by the primary students in India is the frequent comparison of students with each other for example the achievements, behaviors, appearance, etc. Instead of motivating the students, the comparison creates an erosion of self-confidence and development of hatred towards the teacher.

Most students in primary schools prefer to have positive discipline in school and classroom rather than being exposed to physical and emotional punishment (Osher, Bear, Sprague, & Doyle, 2010). Presence of these kinds of punishment is disliked by the students and can have a long-lasting effect on the personality of the students. One of the most hated teacher behaviors by the primary students in India is the frequent comparison of students with each other for example the achievements, behaviors, appearance, etc. Instead of motivating the students, the comparison creates an erosion of self-confidence and development of hatred towards the teacher.

Learner freedom, engagement, and creativity
Successful research methods in education require for self-confidence and learning freedom. Some parents in India feel that the schools discourage self-initiatives of the students and suppress their academic freedom. The opportunity for expression of creativity is curtailed, which can lead to stunted thinking skills and personality. One of the parents in India has disclosed that his child is afraid to talk about new ideas and suggestions because the school environment discourages making mistakes and ridicules impractical ideas. The western education, on the other hand, allows the students to explore their ideas and tolerates the mistakes done by the students. However, many schools in India have begun to recognize the significance of making mistakes and facing failures. Now mistakes and failures are considered as a natural part of learning. The current education directs the attention of the students towards mistakes and encourages them to improve their performance and master it in cycles of learning. Too much critical comments on the mistakes of students make them cynical.

Mats and O’Brien (2014) suggests that allowing students to make mistakes in the classroom removes the fright out of the students and creates an environment that is safe to try out new and creative things. The teacher can have creative dialogues with the students who propose different ideas and suggestions. By acknowledging their viewpoints, the teacher can shape their personality and avoid the guilt feeling among the students. Another important aspect of learner freedom is the freedom to ask questions of the teacher. An effective tutor must allow and encourage the students to ask questions and should not hesitate to say ‘I do not know’ when an answer is not known to the teacher.

Place factors
Schools have tremendous potential to provide a positive environment to the students. The place factors can have wider and all-encompassing influence on shaping the personalities of the students.

School vision and philosophy of education and leadership
Many school authorities in India are not aware of the benefits of having a written vision for a school and do not invest towards research methods in education which can enhance learning. Some of the private schools especially funded by successful industrialists have a school vision and mission published in the school premises. The school visions, punch lines, logos, slogans, mottos, etc. with direct reference to the outcomes of the educational process have the potential to create a positive feeling among the students and parents. They can even feel proud of their educational institution. A reputed school can influence the third level of personality i.e. life narrative of a student. Students, who are studying in a school that is grounded in strong philosophy and vision, are likely to feel proud of their school and have a positive personality.

Control systems and beliefs of the school management
One of the most frequently observed factors of an unsafe school environment is the presence of bullying in the school campus. As most schools in India accommodate large sections of students, it is likely that some students may have an inclination for bullying. But, it is the responsibility of the school management to control the bullying and harassment behavior in the school campus (Skinner, Wellborn, & Connell, 1990). If negative behaviors such as bullying, harassing, etc. are not controlled in the campus, the victims are likely to experience traumatic experiences, and their personality may be damaged. The psychological effect of bullying may be heightened fear, abnormal anxiety, development of low self-esteem, lack of interest in school activities, etc. Continued exposure to bullying can have serious damage to the self-concept and personality of the students. The control systems and the approach to running a school can have an influence on the personality of the students who are influenced by the school environment.

Some Causes of poor personality development in India
One of the factors that contribute to poor personality development among primary school children in India is related to the interactions between a school and the stakeholders in the community (Karande, &Kulkarni, 2005). Schools whose functioning is misaligned are likely to create a poor environment for the school students and can have a devastating effect on the personality of the students. The second critical factor that contributes to poor personality development is the negative school atmosphere.The feelings of indifference, apathy, lack of ownership of the educational process, etc., are the components of the bad school atmosphere. The third factor of negative influence on the students is the negative teacher attitudes expressed in behaviors of strictness, unkindness, unfairness, lack of support, insincerity, etc. teachers lack the interest towards performing research methods in education and developing strategies to communicate theories. Without practical examples to demonstrate theories many students find themselves lacking the desired understanding. When these teacher behaviors are present, the students are likely to develop maladjustment with school and the peers. Another related factor that contributes adversely to the personality of the students is the discordant relationship with the school community.

Schools that house bullies, delinquents, etc. have an aura of dismal mood, lack of smiles among the school community, lack of care, absence of empathy, etc. Most such schools are run by government administration; the researchers have reported that students who join such schools are belonging to an economically backward community.

Conclusion
There is sufficient evidence to propose that quality of education – as substantiated by the objective assessment has an influence on the development and shaping of the personality among children. By having best practices in schools, the speed with which the communities can become stronger and healthier entities is established by the literacy drives in India (Jayaram, 2017). Years of education and acquisition of cognitive skills, social skills, self-concept, have economic and social payoffs. It is important for the schools not only to impart education through cognitive exercises but also the overall development of personality of students.

Two powerful conclusions can be drawn based on the information gathered from this document. First, the impact of a school has far-reaching consequence, when schools are governed by visionary based management and teaching strategies aimed at overall development of the personality of the students. Second, many of the influences of schooling are indirect, which means that the effect of education is mediated through the cognitive development, value education, personality enhancement of the students, etc. this makes it important to infuse practical research methods in education so as to benefit all stakeholders.

Reference List
Indra, C. T. (2017). Introduction. In Language, Culture, and Power (pp. 21-39). Routledge India.

Mitra, S. (2018).Re-Assessing “trickle-down” Using a Multidimensional Criteria: The Case of India. Social Indicators Research, 136(2), 497-515.

Ghosh, S.C. (1989), Education Policy in India since Warren Hastings, NayaPrakashan, Calcutta, 23-26.

Diaz-Guerrero, R. (2017). Personality development of Mexican school children: A research project. Revista Interamericana de Psicologia/Interamerican Journal of Psychology, 4(3 & 4).

McAdams, D. P., Anyidoho, N. A., Brown, C., Huang, Y. T., Kaplan, B., & Machado, M. A. (2004). Traits and stories: Links between dispositional and narrative features of personality. Journal of Personality, 72(4), 761-784. Pena, D. C. (2000). Parent involvement: Influencing factors and implications. The Journal of Educational Research, 94(1), 42-54.

Hughes, J., & Kwok, O. M. (2007). Influence of student-teacher and parent-teacher relationships on lower achieving readers’ engagement and achievement in the primary grades. Journal of educational psychology, 99(1), 39.

Wall, T. (2018). 23 Infusing ethics in leadership learning and development. Leading Beyond the Ego: How to Become a Transpersonal Leader.

Osher, D., Bear, G. G., Sprague, J. R., & Doyle, W. (2010). How can we improve school discipline?. Educational Researcher, 39(1), 48-58.

Skinner, E. A., Wellborn, J. G., & Connell, J. P. (1990). What it takes to do well in school and whether I’ve got it: A process model of perceived control and children’s engagement and achievement in school. Journal of educational psychology, 82(1), 22.

Karande, S., &Kulkarni, M. (2005). Poor school performance. The Indian Journal of Pediatrics, 72(11), 961-967. Jayaram, N. (2017). Compulsory Primary Education as a Human Right: Prospects and Challenges. NATIONAL HUMAN RIGHTS COMMISSION INDIA.

 

Effects Pediatric Transplant in Children Literature Review

 

Question

Task: What the impact of Pediatric transplants that help children live longer, more normal lives?

Answer

Title: The following report presents a systematic review of the impact of pediatric transplants on the quality of life of children and the prospects for their long lives.

Abstract: The effectiveness of pediatric transplants has been responsible for providing a better chance at life to many children. The background of the following review was based on identification of the specific factors that contributed to the quality and longevity of life for recipients of pediatric transplants. The following research presented a literature review through critical reflection on various academic journals that comprised of references to the impacts of pediatric transplantation.

The results derived from the literature were presented on the grounds of inferential review and the discussion was based on thematic analysis that provided insights into three distinct factors that were responsible for influencing the quality of life of children post-transplantation (Azeka, Saavedra & Fregni, 2014). The use of qualitative studies in the report was helpful for drawing credible outcomes from the thematic analysis. Furthermore, it is essential to focus on the ethical concerns addressed in conducting the research.

Introduction: As per Green et al., (2007), organ transplantation has been the major cause of transforming the lives of many people including children along with adults suffering from organ failure. One of the first examples of pediatric transplantation could be identified in the kidney transplant between identical twins to address the issue of rejection due to MHC incompatibility (Green et al., 2007).

Solid organ transplantation has turned out to be a promising factor for improving patient survival rates as well as sustainability of the allograft survival alongside reducing the detrimental consequences arising from immunosuppression. The primary rationale of the report is vested in identification of the impact of pediatric transplants in extending as well as improving the quality of life for children (Glotzbach, May & Wray, 2018).

The objectives of the report could be highlighted with respect to the PICO framework that represents the participants, interventions, comparisons and outcomes of the study. The participants in the study were accounted to be children in the age group of 6-12 years. The interventions were accounted as the occurrence of transplants in a period larger than but not limited to 6 months before the study. As per Kim & Marks (2014), the comparisons or control factors would be derived from focused ethnographic studies that can be used to compare the different outcomes of the pediatric transplantation interventions (Kim & Marks, 2014). The outcomes of the study would be inclined towards identification of the factors that are responsible for influencing the quality of life after pediatric transplants. The structured report for presenting a literature review would follow the PRISMA framework by highlighting the methods, results, and discussion of the review alongside the ethical implications followed for the research.

Literature review: As per Liberati et al (2009), the instances of patient survival after transplantation have improved over the course of the last decade. One of the examples to validate this statement could be presented in the form of the 5-year survival rate through deceased donor renal transplantation which has increased to 96% in the period ranging from1996-2007 as compared to 91%in the era of 1987-1995 (Liberati et al., 2009).

The improvements have been primarily observed in the peri-operative period and the primary factors which can be considered responsible for the improvements are identified in improved procurement of donors, advanced HLA testing methods, improved techniques for micro-anastomosis and surgical techniques as well as matching schemes. HLA typing has been improved substantially through direct DNA sequencing thereby contributing to the precision in outcomes that is supported by the favourable implications of flow cytometric bead-based technology for detection of HLA antibodies (Parmar, Vandriel & Ng, 2017). Flow cytometry also facilitates favourable implications for predicting the alloimmune responses prior to transplantation that contribute to effective virtual crossmatching. The technology is also liable to provide the functionality of detecting alloantibodies that are formed de novo after transplant.

On the other hand, it is essential to understand that transplantation in the case of infants has to be associated with special emphasis owing to various factors such as incompatibility of donor and recipient size as well as congenital heart disease for cardiac transplants, biliary atresia in case of liver transplants and congenital deficiencies identified in the urinary tract and kidney for renal transplants (Schulte et al., 2016). The cases of transplantation in infants have also been associated with concerns of reduced allograft and patient survival rates. As per Todaro et al (2000), in the case of deceased donor transplants, the overall patient survival rate for children at 3 years was found to be 93% that is comparatively lesser than older children having transplants which are estimated in the range of 96-99% (Todaro et al., 2000). It is also imperative to observe that the survival rate does not depict any substantial differences in the case of living donor transplants. Furthermore, it has been estimated that infants surviving the period immediately post the operation are more likely to show favourable results similar to that of older children. The increased availability of organs has been identified in context of the ABO blood group barrier.

According to the reports from the Paediatric Heart Transplant Study database comprising of 931 cases of ABO-incompatible cardiac transplants for recipients below the age of 15 months, there were limited instances of rejection and minimal differences in mortality rates (Vandekerckhove et al., 2016). One study in a small single-centre on pediatric liver transplants for the weight range less than 5 kg, the survival rates were comparable to ABO-compatible transplants. The prospects of successful survival among infants are found to be influenced by the factors of higher acceptance for ABO mismatches alongside the implications of a less-developed immune system in infants. In the case of older children, the outcomes of the antibody removal through rituximab or plasma exchange are responsible for moderation of blood group antibody levels to reasonable amounts often aimed at a dilution ratio of 1:8 (Yadav et al., 2017).

Implications of growth: The chronic conditions for which the children are subject to paediatric transplants are responsible for limited growth as compared to other children before the transplantation. On the other hand, post effects of transplantation have depicted references to promising growth. Data obtained from NAPRCTS suggest prominent indications towards the higher extent of catch-up growth depicted by children subject to pediatric transplantation prior to the age of six years. Another study has also depicted evaluation of outcomes over the course of 3 years post renal transplantation for children under the age of 5 years that suggest better growth in the corticosteroid-free regimen (Glotzbach, May & Wray, 2018).

The corticosteroid-free regimen was found to be responsible for higher safety, lower blood pressure and inhibition of cholesterol levels. Therefore, these factors implied prominently towards the emphasis on early withdrawal of corticosteroids in cases when complete withdrawal is not possible in transplants without complexities (Parmar, Vandriel & Ng, 2017). The application of recombinant human growth hormone has been subject to various controversies and one of the foremost criticisms is presented in the form of increased probabilities of PTLD.One of recently provided Cochrane update emphasizes on the fact that treatment of infants with growth hormone was responsible for increased velocity of increase in height.

On the other hand, the application of the recombinant human growth hormone has been associated with limitations of costs in resource-deficient countries (Vandekerckhove et al., 2016). However, these limitations could be balanced through improving calorie intake as well as nutrition that lead to promising growth outcomes in recipients. Another significant aspect to be noted in context of the growth of recipients of pediatric transplants is the minimal instances of delay in puberty albeit with the concerns of delay in bone age and accomplishing final height.

Quality of life: Despite the contribution of pediatric transplants in the resolution of chronic conditions, the recipients are found to depict underlying chronic health issues throughout the course of their life. This emphasizes on the requirement of focusing the objectives of transplantation on improving the quality of life as well as longevity (Glotzbach, May & Wray, 2018). Therefore it can be inferred that the introduction of a holistic approach on behalf of the multi-disciplinary team for transplantation as well as the support of psychologists, social workers, and primary care physicians would be mandatory for improving the quality of life following the transplantation.

These factors are responsible for addressing the concerns of attention problems, improving long-term relationships with other children and reducing absenteeism at school as well as improvement in academic performance. Transition to adolescence is also another significant factor to be considered with respect to the quality of life of pediatric transplantation recipients (Vandekerckhove et al., 2016).

The period of adolescence is responsible for the limited compliance with immunosuppression thereby contributing to the loss of the functioning graft. This requires the prominent focus on the requirements of additional support for young recipients to enable a flexible transition to surgeons, physicians and multi-disciplinary teams. The transition could be supported by moderating the process according to the needs of the recipient rather than focusing on the service specifications. The support that is provided to adolescents should involve appropriate training of the personnel such as surgeons, pharmacists, and physicians as well as the multi-disciplinary team members and psychosocial teams.

Method: The study was executed through a critical review of existing studies related to pharmaceutical interventions for controlling hyepertension. The critical review of the literature was conducted with references from sources such Journal of pediatric psychology, Pediatric transplantation, transplantation (Vandekerckhove et al., 2016).

Results: The structured report on the research question pertaining to quality of life of children after pediatric transplants was reflective of various aspects involved in the transplant regimen as well as with the behavioral and psychosocial implications for children (Parmar, Vandriel & Ng, 2017). The survival rates for children undergoing pediatric transplants were found to be influenced by the limited development of immune system and higher resistance to ABO mismatches.

The review also suggested that the use of appropriate levels of nutrition and sustainable medication were responsible for contributing to the growth of recipients after the transplants. Furthermore, the results derived from the review also emphasized on the crucial nature of transitioning to adolescence that can influence the longevity and quality of life for children following pediatric transplants.

The paper identified different factors that influence quality of life of children after pediatric transplants. The factors which were recognized from the research imply the nature and amount of nutrition provided to children, psychosocial support and effectiveness of change in treatment approaches according to age. Analysis of the findings also showed that the longevity of infants undergoing pediatric transplants was improved naturally by the lack of a completely developed immune system

Discussion: The systematic review of the literature available on the subject of the impact of pediatric transplants on the longevity and quality of life of infants was responsible for presenting distinct themes. The foremost theme was identified in the form of opportunities for favourable environment post-transplantation. The specific aspects to be considered in this theme were reflective of the favourite activities of the students at school, visiting places and unfavourable aspects of school among which the findings reflected on visiting places and participating in activities (Kim & Marks, 2014). The review depicted minimal restrictions for the activities desired by children in certain cases while the impact of the chronic conditions were also responsible for inducing limitations on activities such as horse riding and pursuit of a career in the army.

The second theme identified in the case of the impact of transplants on the quality of life of children was related to the involvement with family and friends that involve particular references to the emphasis on support from friends. The studies have depicted formidable references to the impact of psychosocial support from the immediate social circle in the adaptability of children to the concerns of post-transplantation. Some instances of parents supporting children through taking care of their medications and providing them with appropriate advice on dealing with the events after the transplantation can be accounted as a prolific factor that determines the betterment of quality of life of pediatric transplant recipients (Vandekerckhove et al., 2016). The interaction of children with family and friends were also associated with the concerns of bullying and consistent mockery that can be reflective of detrimental outcomes that can lead to detrimental consequences for children to cope with the effects post-transplantation.

The final theme identified in the systematic review was related to the experience of being a recipient of pediatric transplant that was primarily associated with the impact of the transplantation, medical issues experienced by the child and the transplant regimen. This theme also presented formidable references to the factors such as care of the body, underlying health problems and the effectiveness of the transplant team. It was found that the acceptance of children for the transplants as a significant experience in their lives could be accounted as a notable influence on the quality of life of individuals. Majority of qualitative studies have implied that the negative impact of the transplantation was observed only for a limited period of time and was particularly associated with the emphasis on cognitive maturity (Glotzbach, May & Wray, 2018).

The aspect of taking care of body after the transplant was profoundly associated with negative experiences particularly in terms of medical management. The concerns that were identified in this context were reflective of the fear and pain of removing pressure dressing, intravenous lines, phlebotomy and limitations on mobility which are attributed as primary reasons for affecting the quality of life of recipients after pediatric transplants (Vandekerckhove et al., 2016). The continuation of medication was also found to be a noticeable aspect that contributed to the quality of life after the transplant and was associated with varying behavioural implications among the recipients. The moderation of caloric intake as well as nutrition in complement with the medication results in setbacks for quality of life of children.

Ethical concerns: The sources of information selected for the systematic review were obtained from journals and qualitative studies conducted in context of the impact of pediatric transplants. Therefore the ethical concerns have been addressed properly for this research report.

Conclusion: The systematic review presented above could thus be associated with the conclusion that the quality and longevity of life of children undergoing pediatric transplants was dependent on psychosocial factors such as support from the immediate social circle as well as the factors of nutrition and calorie intake apart from the quality of treatment provided to the children.

References

Azeka, E., Saavedra, L. C., & Fregni, F. (2014). Clinical research in pediatric organ transplantation. Clinics, 69, 73-75.

Green, A., McSweeney, J., Ainley, K., & Bryant, J. (2007). In my shoes: children’s quality of life after heart transplantation. Progress in Transplantation, 17(3), 199-208.

Glotzbach, K., May, L. and Wray, J., (2018). Health-related quality of life and functional outcomes in pediatric cardiomyopathy. Progress in Pediatric Cardiology.

Kim, J. J., & Marks, S. D. (2014). Long-term outcomes of children after solid organ transplantation. Clinics, 69, 28-38.

Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P., … & Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. PLoS medicine, 6(7), e1000100.

Parmar, A., Vandriel, S. M., & Ng, V. L. (2017). Health?related quality of life after pediatric liver transplantation: A systematic review. Liver Transplantation, 23(3), 361-374.

Schulte, F., Wurz, A., Reynolds, K., Strother, D., & Dewey, D. (2016). Quality of Life in Survivors of Pediatric Cancer and Their Siblings: The Consensus Between Parent?Proxy and Self?Reports. Pediatric blood & cancer, 63(4), 677-683.

Mental Health Nursing

Question

Task : By week 6 you should be in a group. To complete this task, you and your group will need to do the following:

Hints and tips for assessment one

• Read the case study several times before doing anything else – ensure you have a good understanding of the client’s history, possible contributory factors, family situation, employment, current presentation, actual and potential risks to self, family and others.
• Carefully consider the search terms and keywords in your literature search.
• Use journal search engines such as: Scopus, ProQuest or Google Scholar. With key words / terms such as: mental state examination; low mood; depression in males; post-partum depression for males; mood and new fathers; depression and medical staff; anxiety in males; depression or anxiety among Chinese migrants; Stress Vulnerability Model; mental health recovery.
• Try to have most of your references from research papers or policy papers.
• Websites such as: Department of Health; Mental Health Commission; Reach Out; Beyond Blue; Black Dog can be helpful as long as properly referenced in your work.
• There is no need for an essay introduction nor conclusion in your work for assessment one.
• You are required to use an academic writing style throughout your work using literature to support you.
• Please number each of your answers, 1,2,3, so the marker is clear which of your answers relates to which question.
• Each question is marked out of 10 and each answer should be 500 words. Avoid using 600 words for one answer and 400 words for another question, as this will reduce your opportunity for higher marks.
• Make sure each question relates back to the client in the case study and incorporates literature.
• Your work should extend more than description or discussion but should move towards critical analysis. One way to do this is to compare and contrast the ideas in the literature. For example: what are the similarities and differences from different pieces of research or noted in policy.
• It’s fine to use a few sub-titles if that helps you to structure your work.
• You should have one reference list which includes all the references from the 3 questions.
• An APA reference list must be included with your work. Your work should include at least 10 different pieces of literature, no more than 5 years old unless it is seminal work.
• Ensure you avoid cutting and pasting text. This will result in review under the Misconduct policy. It can also reduce your overall mark of your work.

Question 1

• You are asked to think about the mental health status of the client making reference to the Mental State Examination.
• Make sure you think about the Mental State Examination (MSE) here and not the overall mental health assessment structure. You will learn more about this in session 2. We want you to think about the present state / presentation of the client in terms of the components of the Mental State Examination such as: appearance and behaviours, affect, mood, thought form, thought content, perception, judgement and insight for example.
• We also want to see that you can think about the client’s presentation with reference to the DSM V. You can do this by thinking about the specific criteria for diagnoses. Show that you can consider the criteria and how they may be relevant for this particular client in the case study. For example: you might want to suggest the client has depression or anxiety so show you have considered the criteria for depression or anxiety which are relevant and how.
• We are expecting that you will have more literature other than the MSE and DSM V for question 1. You should also use other research papers.
• It’s a good idea to aim for 250 words for the Mental State Examination (MSE) and 250 words for the DSM V sub section.
• 4 marks MSE, 4 marks DSM V, 2 marks for references)

Question 2

• Asks you to show your understanding, using literature, of the Stress Vulnerability Model. It would be reasonable to use 100 words for this as the maximum marks for this is 2.
• You are also asked to think about 2 contributing factors where you should make reference to the case study and literature.
• You should use 200 words to identify and discuss, critically analyse the literature for each contributing factor.
• A good way to think about contributing factors are possible stressors which could have impacted on how a person thinks, feels and behaves. For example: having a new baby could be a contributory factor as it creates change in the couple’s relationship; may change the time a person has for themselves and their hobbies; may challenge a person’s sense of self; may increase anxiety; lack of sleep as a result of caring for a new baby can result in changes to a person’s energy and mood.
• (2 marks for Stress Vulnerability Model, 3 marks for each contributing factor, 2 marks for references)

Question 3

• Question 3 asks you to show your understanding of the mental health recovery model / theory and to relate the recovery principles of respect, empowerment and hope to the client in the case study.
• Ensure you relate your answer to the client in the case study and include relevant literature.
• Recommended use of words – 125 words for recovery model / theory and 125 words for each of the principles – respect, empowerment and hope.
• To help direct your thoughts for this question, you might want to ask ‘how can the health professional show respect or exercise a respectful to the client in this particular case study and how could this support his recovery?’ You might want to consider how his family can show a respectful attitude towards the client to better support his recovery or how could his employee be respectful give his current situation to support the client. Thinking about the wider community approach to mental health concerns may also be helpful here. i.e. how can the language used by members of the community support his recovery. ie non-stigmatising language. How can a health professional facilitate self-respect for the client?
• You may want to ask these questions in relation to empowerment ie. how can a health profession, family, employer and the wider community offer greater empowerment to the client to support his recovery? How can this be helpful and why?
• Also, how can hope be helpful for the client, particularly given his current presentation and concerns for self and possible self-harm and suicide? How can a family member, employer and community members support greater hope for this client and why?
• (2 marks for recovery orientated mental health theory and practice, 2 marks each for factors, 2 marks for references)

Answer

Answer 1: The mental health condition of the patient is described below-
Mental status examination or MSE is one of the effective assessment process in mental health practice. It helps to observe and describe the mental status of a person in an effective manner. It helps to understand the attitude, thought process, mood and affect, speech, cognition and perception of a person with mental illness (Fernando & Henskens, 2014). In this case it has been found through the mental status examination that, mood and affect of Chung has been affected due to the excessive pressure of work, lack of time for family, inquiry of the drug error and poor health condition (). Tearful eyes, flat mood, minimum eye contact, restricted affect and purposeful speech have been identified during the session of MSE. Concern for his wife’s health condition, long shift in workplace and less time for his wife and new born daughter have made him anxious. Stress due to such situation has affected his physical health as well. Symptoms such as palpation, weight loss, loss of appetite, chest pain and breathlessness have been found. Such poor health condition and mental depression have led to the consequence of sleeplessness. The mental state examination has also indicated that dramatic change in the thought process of the patient has occurred (Wiger & Mooney, 2014). According to the description of the patient, he has started to think himself uselessness due to his mistake in the workplace. Such failure in the professional life and private life has led to the thought of suicide. In this regards he has thought about overdose of medication as well. Such mental condition of the patient has indicated his hopeless and helpless situation.

DSM 5 or Diagnostic and Statistical Manual for mental illness helps to differentiate between different mental disorders. It provides effective diagnostic criteria that helps to identify the mental status of a person (Brown & Barlow, 2014). Chung has been found to be speak purposefully and his affect has become restricted. In addition, lack of interest in eye contact and looking at the floor while speaking have indicated lack of interest in communication. The feelings of guilt and regret due to the drug error in the workplace and providing less time to the family have led to the consequence of depression and anxiety. Such situation has affected his physical health, thus he has been experiencing chest pain, breathlessness and palpitation. Due to the effect of poor mental health his physical health has affected. The DSM 5 has identified the severe health condition of Harriett, wife of Chung, as the cause of his mental distress (American Psychiatric Association, 2013). Furthermore, DSM 5 has identified anxiety as the cause of insomnia for the patient (Brown & Barlow, 2014). It has been found that due to severe anxiety and depression the patient has been thinking about suicide as well. Considering such facts identified by the diagnostic criteria of DSM 5 it can be said that the client has been suffering from anxiety disorder and depression as well (Regier et al., 2013).

Answer 2: Two main factors contributing to the development of the patient’s mental health are as follows-
One of the most effective tools for recognizing the potential factors that are responsible for the mental illness is stress vulnerability model. The contribution of stress in the development of mental disorder has been identified by the stress vulnerability model. The model has differentiated such factors into protective factor, vulnerability factor and environmental factor (Calvete, Orue & Hankin, 2015). In this case, use of stress vulnerability model would help to recognize the main factors that has contributed to the poor mental status of Chung. The stress vulnerability model has considered stress and having new baby as the vulnerability factors for the client (McEwen & Morrison, 2013).

It has been found that, stress occur due to the inability of a person to cope up with his or her thought during the vital time of life (Calvete, Orue & Hankin, 2015). In case of Chung, stress has contributed to his severe mental condition in an effective manner. Excessive pressure from his workplace has been identified as the main cause of his stress. On the other hand, the client’s wife has been suffering from infection in the surgical site and pain as well, since the birth of their daughter. During such vital time he has failed to provide adequate time and care to his wife. Furthermore, the human resource department of the hospital has started an inquiry due to the drug error. He has been experiencing regret and guilt due to such situation. Together such situations have contributed to the development of stress within Chung. Increase in the stress level has led to the development of psychotic symptoms within the client (Chukhraev et al., 2017). Beside the mental health, the increasing stress has affected the physical health of the client as well. Thus, he has been experiencing the thought of heart attack and suicide. Such level of stress has made him hopeless and helpless as well.

Another responsible factor that has contributed to the poor mental contribution of the Chung is having new baby. The incident of having new baby brings dramatic changes in the life of the couple. It changes the lifestyle, hobbies, self-sense, time management and the relationship as well. Such changes sometimes lead to the consequence of anxiety disorder (Thoits, 2013). In case of Chung it has been found that, after giving the birth to the baby girl, Harriett has been suffering from severe infection and pain. In such condition adequate care and support from Chung is expectable. However, due to pressure of the accident and emergency department of the hospital Chung has failed to spend adequate time with his family. He has been experiencing regret and guilt. Such mental condition has affected his mood, thus, tearful eyes, restricted affect, lack of eye contact, purposeful speech and less interest in communication has been found. Such situation has led to severe depression as well. Thus, having new baby can be considered as a responsible factor for the development of mental distress and poor mental health of the client.

Question 3: The recovery of the patient would be facilitated by recovery-oriented practice and with hope, respect and empowerment in the following manner-
Study has revealed that recovery oriented mental health practice is one of the most effective evidence based practice that facilitates the recovery of the patient with mental illness. The principles of recovery oriented practice include uniqueness of individual, real choice, attitudes and rights, dignity and respect, partnership and communication and evaluating recovery. The one dimensional approach of recovery oriented mental health practice focuses on the retaining hope, identify the strength and weakness of the patient and personal autonomy. In this way recovery oriented practice helps to provide a purposeful and meaningful life through inducing positive sense of self (health.gov.au, 2018). Thus, in this case utilising the principles of recovery oriented practice would facilitate the patient and foster the recovery in an effective manner.

Hope is one of the most effective elements that could be used in the treatment of mental disorder. Inducing hope in the mental health recovery encourage the patients to expect that their condition could be improved. Thus, could inspire them to contribute in the recovery process effectively (Slade et al., 2014). In case of Chung, due to the situation of life, depression and excessive stress he has become hopeless. Introducing hope could help to reduce the level of stress, depression and anxiety. Inducing hope in the recovery process would help to improve the mental health by increasing family support. Hope of improvement in the career and future would help the patient to participate effectively in the treatment and could lead to faster recovery (Abraham et al., 2016).

Respect is another vital element that helps to improve the recovery of the patient with poor mental health (Moran & Russo-Netzer, 2016). In case of Chung, he has been experiencing thought of failure in both the professional life and private life. Thus, inducing respect in the recovery process could help the patient to manage his illness in an effective manner. Respect in the workplace could help to improve professional skill thus, could reduce the guilt of drug error. Furthermore, respect from the family for his contribution in providing care to his wife and daughter even after long working shift could help him to get rid of regression of spending less time with family. In this way the patient could establish personal goal and with respectful treatment he could achieve successful health outcomes (Le Boutillier et al., 2015).

Finally it is important to introduce empowerment in the recovery of mental illness. Empowerment needs to be implemented in the individual level and in society as well. Involve in the self-decision, contribution in wider community, self-reliance and dignity are the four important dimensions of including empowerment in recovery (Moran & Russo-Netzer, 2016). Empowerment could help Chung to resolve the issue of powerlessness. Hence, empowerment could help to improve self-determination. Empowerment in the control, influence and level of choice over the events of life could help the client to understand the significance of life and live a meaningful life. Through empowerment the client could establish social networks, thus, could enhance the social support. In this way, empowerment could help Chung to recover from his psychotic disorder (Slade et al., 2014).

References:
Abraham, K. M., Nelson, C. B., Ganoczy, D., Zivin, K., Brandfon, S., Walters, H., … & Valenstein, M. (2016). Psychometric analysis of the Mental Health Recovery Measure in a sample of veterans with depression. Psychological services, 13(2), 193.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5L)-Lifetime Version: Client Interview Schedule 5-Copy Set (Treatments That Work).

Calvete, E., Orue, I., & Hankin, B. L. (2015). A longitudinal test of the vulnerability-stress model with early maladaptive schemas for depressive and social anxiety symptoms in adolescents. Journal of Psychopathology and Behavioral Assessment, 37(1), 85-99.

Chukhraev, N., Vladimirov, A., Zukow, W., Chukhraiyeva, O., & Levkovskaya, V. (2017). Combined physiotherapy of anxiety and depression disorders in dorsopathy patients. Journal of Physical Education and Sport, 17(1), 414.

Fernando, D. I., & Henskens, F. A. (2014, November). A case-based reasoning approach to mental state examination using a similarity measure based on orthogonal vector projection. In Artificial Intelligence (MICAI), 2014 13th Mexican International Conference on (pp. 237-244). IEEE.

health.gov.au (2018). Department of Health | Principles of recovery-oriented mental health practice.. Retrieved from http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-i-nongov-toc~mental-pubs-i-nongov-pri

Le Boutillier, C., Chevalier, A., Lawrence, V., Leamy, M., Bird, V. J., Macpherson, R., … & Slade, M. (2015). Staff understanding of recovery-orientated mental health practice: a systematic review and narrative synthesis. Implementation Science, 10(1), 87.

McEwen, B. S., & Morrison, J. H. (2013). The brain on stress: vulnerability and plasticity of the prefrontal cortex over the life course. Neuron, 79(1), 16-29.

Moran, G., & Russo-Netzer, P. (2016). Understanding universal elements in mental health recovery: a cross-examination of peer providers and a non-clinical sample. Qualitative health research, 26(2), 273-287.

Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. American journal of psychiatry, 170(1), 59-70.

Slade, M., Amering, M., Farkas, M., Hamilton, B., O’Hagan, M., Panther, G., … & Whitley, R. (2014). Uses and abuses of recovery: implementing recovery?oriented practices in mental health systems. World Psychiatry, 13(1), 12-20.

Thoits, P. A. (2013). Self, identity, stress, and mental health. In Handbook of the sociology of mental health (pp. 357-377). Springer, Dordrecht.

Wiger, D. E., & Mooney, N. B. (2014). Mental Status Exam. The Encyclopedia of Clinical Psychology, 1-5.

Clinical Scenario Assignment: Pathophysiology and Pharmacology in COPD

 

Question

Background to Clinical Scenario:Robert is a 51 year old man who lives with his wife in regional Victoria. He has been admitted to your ward from the Intensive Care Unit (ICU), where he had a 3 day stay for an acute exacerbation of COPD, caused by community acquired pneumonia. He required several days of non-invasive ventilation whilst in ICU. Robert tells you his wife (Jill) was very frightened when he was admitted to ICU, and he doesn’t want ‘to put her through that anymore’. He would like some help to understand and manage his COPD. Robert said he was diagnosed with COPD about 18 months ago by his GP, but admits he was sick for ‘a while’ before that. He is a current smoker, and has smoked for about 40 years. He has unsuccessfully attempted to quit on more than 5 occasions. Robert worked for many years on his chicken farm, but now finds he becomes breathless very easily and Robert and Jill have had to hire a farm helper. Robert’s medications include:

Salbutamol 2 – 4 puffs PRN
Budesonide/Efomoterol fumarate dehydrate 2 puffs daily
Metoprolol 25mg daily
Aspirin SR 100 mg daily

Pathophysiology
1.1 Describe the pathophysiology of COPD. Include in your answer the two disease processes contained in the umbrella term ‘COPD’ and how they develop.
Robert has been diagnosed with a severe exacerbation of COPD, caused by Community Acquired Pneumonia.

1.2 Explain the term ‘acute exacerbation of COPD’. What factors put patients like Robert at high risk for exacerbations of COPD? What else may contribute to an exacerbation of COPD?

1.3 Describe the pathophysiology of pneumonia. Include in your answer the differences between Community Acquired, Hospital Acquired and Health Care Associated Pneumonia.

Pharmacology
The Respiratory Physician who reviewed Robert in ICU suggested some changes to his current inhaler regime. The physician suggested that Robert cease his Budesonide/Efomoterol fumarate dehydrate, and commence on Tiotropium 2 puffs daily.

2.1 For each of the three inhalers (Salbutamol, Budesonide/Efomoterol fumarate dehydrate and Tiotropium), describe the
Mechanism of action in COPD
Contraindications and Adverse Reactions
Nursing Considerations and Patient Education Points
Include in your answer why the respiratory physician might have changed Robert’s medication regime.

Robert was diagnosed with Community Acquired Pneumonia, and Streptococcus pneumoniae was cultured from his sputum.

2.2 Identify three antibiotics that could be used to treat Streptococcus pneumoniae in Robert’s case. For each antibiotic, describe the
Mechanism of action
Contraindications and Adverse Reactions
Nursing Considerations and Patient Education Points

Psychosocial issues
3.1 Discuss three evidence-based interventions to help Robert manage his COPD.

Answer

1. Pathophysiology
1.1 Pathophysiology of COPD: Chronic obstructive pulmonary disease (COPD) is a progressive disorder with emphysema (alveolar destruction) and bronchial fibrosis in variable proportions. Inhalational particles such as allergens and chronic bacterial infections generate inflammatory response resulting COPD (A. Bhat and Panzica, 2015). The inflammatory cells are responsible for COPD are a type of white blood cells which include macrophages and neutrophil granulocytes. People having COPD due to smoking have Tc1 lymphocyte involvement. These inflammatory factors produce chemotactic factor in cell.

The factors which are responsible for lung damage are-

1. Due to tobacco smoke, free radicals are generated which results in oxidative stress
2. Discharge of inflammatory cells
3. Proteases damage the connective tissue of lungs

The term umbrella characterizes the chief persistent disorders of lungs e.g emphysema and chronic bronchitis.

Emphysema- It is a disorder of lungs which is responsible for shortness of breath because of over-inflation of air-sacs present in lungs (Sharafkhaneh, Hanania and Kim, 2008). It comes under umbrella term COPD because in emphysema cessation of airflow occurs due to inappropriate exchange of air on person breathing because air sacs are present in lungs. It develops due to cigarette smoking, air pollution, deficiency of an enzyme known as alpha-1-antitrypsin.

Chronic Bronchitis (CB) – It is explained as the generation of persistent cough and release of sputum from last 3 months to 2 consecutive years. It is comes under the umbrella term of COPD because in CB inflammation and lots of mucus get accumulated in bronchi. It is developing because of smoke inhalation, infections occur due to microorganism, and activation of inflammatory cell of mucin gene transcription which oversecrete the mucus by goblet cells and hence restrict airflow pathway (Kim and Criner, 2013).

1.2 Acute exacerbation of COPD: An acute exacerbation of COPD is explained as incidents described by damaged respiratory symptoms of person which is away from regular day-to-day changes and hence result in alteration in medication (Garvey and Ortiz, 2012).

In patients like Robert exacerbations of COPD get high by various factors-

1. As continuous smoking and especially in older age causes lung destruction which leads to high risk of acute exacerbation.
2. Streptococcus pneumonia virus worsens the condition of COPD and leads to acute exacerbation of COPD.
3. Working in chicken farm, there may be presence of influenza virus which also increases the chances of exacerbation of COPD.

Acute exacerbation is life threatening and leads to negatively affect the treatment of disease. It is started by infection of microorganisms or pollutants. It retards the quality of life, accelerates death rate, and increases lung function damage specifically among hospitalized patients. In acute exacerbation, air entrapment and lung hyperinflation becomes negligible which leads to poor expiratory air flow and accelerate dyspnoea.

1.3 Pathophysiology of pneumonia: It is defined as an inflammatory condition that affects the small air sacs known as alveoli which are present on lungs which leads to abnormal high body temperature and shortness of breath. It is mainly produced by toxic agent like bacteria, viruses and rarely caused by fungi, parasites, certain medications and due to autoimmune diseases.

The pathophysiology is mostly the same, regardless of causative agent.

In this, microorganism invades into the lung with inhalation although microorganism can enter into the lung through the systemic circulation also if any other body part is infected. Mostly, microorganism resides in upper respiratory tract and breath into the alveoli in continuous manner. On reaching in the alveoli, microorganism moves between the gaps and between the adjacent alveoli through linked pores. Due to this, immune system gets activated. It triggers the leukocytes for attacking microorganism to the lungs. The helpful microorganism (neutrophils) invades harmful microorganism and also releases cytokines (Cilloniz and Ignacio, 2016). Hence as a result, cytokines result boost up the immune system which leads to abnormal rise in body temperature, restlessness, chills. Lung damage occur due to attack of microorganism on it and due to production of cytokine in response to immune system, fluid gets leaked into the alveoli which results in impaired oxygen transportation. In addition to damage to lungs, if there is attack of viral organism, it can affect other organs of body also. On bacterial attack, it mostly travel from the lungs to the surrounding blood vessels which result in ill health like septic shock which leads to hypotension results in multiple damage of body parts including brain, kidney, heart.

Community-acquired pneumonia- it is acquired in community. The main difference between community-acquired pneumonia and hospital acquired pneumonia (HAP) is that persons having HAP resides in hospital from long term or recently admitted in hospital. CAP involves less multidrug-resistant bacteria (W. Pletz and G. Rohde, 2016).

Health care–associated pneumonia (HCAP) – It is an infection associated with current exposure to the healthcare system which includes hospitals, nursing home, and dialysis centre.

Hospital-acquired pneumonia- It is acquired in hospital. It is due to the presence of pathogen in the hospital or it may be acquired due to the other patient’s illness. It mostly occurs after the admission of 2-3 days in hospital. It consists of higher risk of multi-drug resistant bacteria.

2. Pharmacology
2.1 Salbutamol
M.O.A- It causes bronchodilatation through ?2 adrenergic receptors stimulation. These receptor are mainly present in bronchial smooth muscle of lungs. Activation of ?2 receptors causes increased in cAMP formation in bronchial muscle cells which results in relaxation of these smooth muscles cells and reduction of airway blockage by decreasing intracellular ionic calcium concentrations. When cAMP level gets increased then it also retards production of many bronchoconstrictor factors e.g allergic histamine, leukotriene from the mast cells in the airways (Ullmann and Caggiano, 2015).

Contraindication- It is contraindicated in persons having hypersensitive reaction like urticaria, angioedema, in patients having cardiac tachyarrhythmias.

Adverse effect- Tremor in skeletal muscle specially in hands, nervousness, headache, tachycardia, palpitation, muscle cramp, hypokalemia, chest discomfort are adverse effect of salbutamol.

Nursing consideration and patient education points-

1. In the patients who suffer from cardiovascular abnormalities, it should be used carefully.
2. If patient is using both tablets and inhaler at one time, monitor the patient for toxicity.
3. If patient is doing exercise, tell him to take inhaler before 15 minutes to workout to avoid exercise-provoked bronchospasm.
4. The patient should know about the danger of paradoxical bronchospam. If it happens patient should cease the administration of drug immediately.
5. Patient should know how to use inhaler properly. Nurses should properly educate the patient about it.
6. If patient is using the steroid inhaler also, then he/she should use bronchodilator first and after that wait for 5 minutes for using steroid.
7. Between puffs of inhaler there should be gap between 2 minutes.
8. To avoid the dry mouth after inhalation, nurses should teach the patient to wash the mouth with water after using each inhalation.
9. The patient should be informed about noxious taste of salbutamol.

Budesonide-
M.O.A- it retards the activity of broad area of inflammatory cells which includes eosinophils, T lymphocytes, macrophages, mast cells, neutrophils (Iborra, 2014).

Contraindication- It is contraindicated in nasal ulcers and in presence of infections. In the initiative medical care of status asthmatics budesonide is contraindicated. The patients who suffers from hypersensitivity of budesonide, it is contraindicated in these patients.

Adverse effect- Ankle edema, hirsutism, nausea, rhinitis, arthralgia.

Nursing consideration and patient education points-

1. Nurses should check patient history like nasal infections, nasal surgery etc.
2. Nurses should teach the patients that they do not cut, crush or chew capsule, it should be swallowed completely.
3. Nurses should motivate the patient to compete the drug therapy of 8 weeks.
4. Nurses should monitor the patients for adverse effect of drug like acne, hirsutism, buffalo hump. If this effect occurs then dosage regimen should be decreases.
5. Nurses should teach the patient if they forget to take a capsule a day, then on the next day take the drug at regular time.
6. Nurses should advise the patient to not to take grapefruit juice with this drug.
7. Nurses should aware the side effect of drug to the patients like dizziness, headache, and nausea.
8. If patient feel chest pain, ankle swelling, respiratory infection during the treatment of this drug, he/she should immediately reported.

Tiotropium-
M.O.A- it is a quaternary ammonium compound which is badly absorbed across cell membranes which leads to reducing its effect to the airways after inhalation. There are three types of muscarinic receptors in human airways i.e. M1, M2 and M3. M1 and M3 trigger the release of acetylcholine from vagal nerve endings and hence results in bronchoconstriction.. Tiotropium antagonize the two receptor and results in potent bronchodilation (Halpin, 2016).

Contraindication- it is not used for remedial therapy for acute COPD. If after its administration, hypersensitive reactions like urticaria, swelling of lips, toungue, throat, itching occurs then its therapy should be stop immediately. Tiotropium powder should not be used in eyes because dryness of eyes can be occurring by using it which leads to irritation in eyes. In elderly males having prostatic hypertrophy- urinary retention can occur.

Adverse effect- Dry mouth, throat infection, urinary retention, palpitation, increased risk of heart attacks, constipation, acute angle closure glaucoma.

Nursing consideration and patient education points-

1. 1) Do not take the capsule by mouth. Take them only by oral inhalation by Handi Haler device.
2. 2) Use only one capsule at a time.
3. 3) The drug should not be administered for acute bronchospasm although it should be used be used for maintenance remedy of COPD.
4. 4) Nurses should monitor the patient for hypersensitive reactions like angioedema and paradoxical bronchospasm.
5. 5) This medicine should be used in same manner as prescribed by doctor for patient.

Respiratory physician might have changed Robert’s medication regime because the role of inhaled corticosteroid in the management of COPD is still uncertain (Qureshi and Sharafkhaneh, 2014).

Levofloxacin-
M.O.A- It inhibits the enzyme bacterial DNA gyrase. This enzymes nicks double stranded DNA due to which negative supercoiling occur nicked end get resealed. In gram positive bacteria it inhibits the enzyme topoisomerase IV which nicks and separates daughter DNA strand after DNA replication (J. Aldred and J.kerns, 2014).

Contraindication- It is contraindicated in patients with known hypersensitivity to levofloxacin Cardiovascular collapse, hypotension, angioedema may occur.

Adverse drug effect- Hepatotoxicity, peripheral neuropathy, prolongation of QT interval, blood glucose disturbances, hypersensitive reaction, tendon rupture, crystalluria, photosensitivity.

Nursing consideration and patient education points-

1. Nurses should administer the patient for previous sensitivity reaction like rashes, urticaria.
2. Nurses should examine the patient for possible drug induced adverse reaction.
3. Nurses should monitor the patient for hypersensitivity and thrombophlebitis in routine manner.
4. Nurses should advise the patient to take lots of fluid while taking drug
5. Nurses should teach the patient to report if any joint pain, sore throat, itching, occurs.
6. Patients should be advised to use sunscreen or avoid sun exposure to prevent photosensitivity.

Ceftriaxone
M.O.A- It is bactericidal in nature and inhibits bacterial cell wall synthesis (Leyenaar, 2014).

Contraindications- Hypersensitivity, crystalline material was observed in lungs and kidney, prolongation of prothrombin time.

Adverse effect-

Nursing consideration and patient education points-

1. Patient should monitor for renal and hepatic function.
2. If hypoprothrombinemia occur, then vitamin K should be given.
3. Patient should be assess for thrombophlebitis.
4. Patient should advise to take the dug with food.
5. Nurses should teach to the patient that they have to avoid alcohol while taking the medication and afterward 3 days on completion of course

Vancomycin- M.O.A- It is a glycopeptides antibiotic. It acts by preventing the synthesis of bacterial cell wall. It attached to the peptidoglycan units by terminal dipeptide D-ala-D-ala sequence and hence avoid its cross-linking to form the cell wall of bacteria (Kalil, 2010).

Contraindication- Rapid i.v injection has caused chills, fever, urticaria and intense flushing known as Red man syndrome.

Adverse effect- Systemic toxicity, skin allergy, fall in B.P, kidney damage.

Nursing consideration and patient education points-

1. Nurses should assess renal function.
2. If red man syndrome occurs during administration of drug, then give antihistamine to patient.
3. Nurses should avoid extravasations during therapy because necrosis can be occur due to it.
4. Patient should be taught if symptom of superinfection, sore throat, fever occur then he/she should be consult to doctor.

Psychosocial issues

1. 1) Inhaled bronchodilators- ?2 agonists which are short-acting inhalation and anticholinergic drugs treat the COPD. Salbutamol act by triggering the release of cAMP (J, 2001).
2. Formoterol which is long acting ?2 inhalation also recommended for treatment of acute exacerbation of COPD in cumulative manner (Qureshi and Sharafkhaneh, 2014).
3. 3) Antibiotics- there are evidence which supports the need of antibiotics in exacerbation of COPD when there are also signs of bacterial infection. Antibiotics decrease the danger of short-term mortality by 77%.

References-
A. Bhat, T. and Panzica, L. (2015). Immune Dysfunction in Patients with Chronic Obstructive Pulmonary Disease. Annals of the American Thoracic Society.

Cilloniz, C. and Ignacio, M. (2016). Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns. International Journal of Molecular Sciences.

Cilloniz, C. and Ignacio, M. (2016). Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns. International Journal of Molecular Sciences.

Cilloniz, C. and Ignacio, M. (2016). Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns. International Journal of Molecular Sciences.

Iborra, M. (2014). Long-term safety and efficacy of budesonide in the treatment of ulcerative colitis. Clinical And Experimental Gastroenterology.

J. Aldred, K. and J.kerns, R. (2014). Mechanism of Quinolone Action and Resistance. ACS.

J, M. (2001). Safety of formoterol Turbuhaler at cumulative dose of 90 microg in patients with acute bronchial obstruction. Eur Respir J.

Kalil, A. (2010). Treatment of hospital-acquired pneumonia with linezolid or vancomycin: a systematic review and meta-analysis. BMJ.

Kim, V. and Criner, G. (2013). Chronic Bronchitis and Chronic Obstructive Pulmonary Disease. American Journal of Respiratory and Critical Care Medicine.

Leyenaar, J. (2014). Comparative Effectiveness of Ceftriaxone in Combination with a Macrolide Compared with Ceftriaxone Alone for Pediatric Patients Hospitalized with Community Acquired Pneumonia.

Overington, J. (2014). Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions. Journal Of Throacic disease.

Qureshi, H. and Sharafkhaneh, A. (2014). Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Therapeutic Advances in Chronic Disease.

Sharafkhaneh, A., Hanania, N. and Kim, V. (2008). Pathogenesis of Emphysema. American Thoracic Society.

Ullmann, N. and Caggiano, S. (2015). Salbutamol and around. Italian Journal of Pediatrics.

Van Rensburg, D. (2010). Efficacy and Safety of Nemonoxacin versus Levofloxacin for Community-Acquired Pneumonia. Antimicrobial agents and chemotherapy.

W. Pletz, M. and G. Rohde, G. (2016). Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000 Research.