Management of ICU Delirium

Management of ICU Delirium 1. Introduction In the critical care setting, haemodynamic failure is recognised by monitoring the patient’s blood pressure and pulse and treatment may involve fluid resuscitation or the use of inotropic agents (Webb Singer, 2005). In respiratory failure, the patient’s respiration rate and oxygen saturations are closely monitored and ventilatory support is sought (Cutler, 2010). Just like the heart and lungs, the brain can acutely fail in critical illness. An acute disturbance in brain function is recognised as delirium (Page Ely, 2011). Historically, delirium was accepted by the medical and nursing community as an inevitable consequence of the ICU experience (Shehabi et al., 2008). More recently, delirium is beginning to gain acceptance as a serious condition in the adult intensive care unit (ICU) and early identification and timely treatment is essential so as to reduce the detrimental effects on patient outcomes (Arend Christensen, 2009 Boot, 2011). Nurses are well-positioned to not only detect discrete fluctuations in levels of consciousness but to also minimise modifiable risk factors and to prompt doctors to review the critically unwell adult (Page Ely, 2011). However, there is a growing recognition that delirium in the ICU is misunderstood and underreported by health professionals and hence continues to cause cognitive dysfunction in affected patients (Wells, 2010). This introduction discusses delirium in adult patients hospitalised in the ICU; specifically nurses’ knowledge, attitudes, beliefs and current practices regarding ICU delirium, and presents the literature review problem, question and the aim and objectives. The literature has used numerous terms interchangeably to describe cognitive impairment in the ICU. There are references to ICU psychosis (Justice, 2000), ICU syndrome (Granberg-Axà ¨ll, 2001), acute confusional syndrome (Tess, 1991), and acute brain failure (Lipowski, 1980; cited in Page Ely, 2011, p. 6). The multiplicity of terms in the literature may explain why the condition has not received the degree of prioritisation it deserves (McGuire et al., 2000). The above expressions are gradually being superseded by a more widely accepted expression termed ‘ICU delirium’ (Boot, 2011). Criteria set by the ‘Diagnostic and Statistical Manual of Mental Disorders’ (DSM-IV; American Psychiatric Association, 2000) describes delirium as a disturbance of consciousness (i.e. limited awareness of surroundings) and cognitive fluctuations (e.g. a memory deficit); the onset is over a short period of time and the syndrome is a consequence of a physiological condition. There are three subtypes of delirium; namely: hypoactive, hyperactive and mixed delirium. Page Ely (2011) provide data on the prevalence of delirium: One in five adult patients hospitalised in the ICU develop delirium. A higher incidence occurs in ventilated patients (four out of five patients). A considerable body of research is dedicated to the investigation of the adverse effects of delirium on patient outcomes. A prospective cohort study by Girard (2010) concludes that the duration of delirium in ventilated patients in the ICU is an independent predictor of cognitive impairment up to 1 year following discharge. This conclusion has far-reaching implications for the growing population of patients who are concerned about the preservation of cognitive function following hospitalisation during a period of critical illness. Similarly, Ouimet et al., (2007) used a prospective study design to conclude that delirium increased the risk of mortality in a population of 820 patients admitted to the ICU for a period of more than 24 hours. In addition to this, delirium was associated with an extended period of hospitalisation. The implementation of preventative measures, early recognition tools and the timely delivery of treatment may prove useful in the preservation of cognitive funct ion in affected patients (Boot, 2011). Although there are several assessment tools available for ICU patients, the National Institute for Health and Clinical Excellence (NICE, 2010) recommends the use of the Confusion Assessment Method for the ICU (CAM-ICU; Ely et al., 2001). The tool has high validity for detecting the delirious non-intubated patient (Ely, et al., 2001); however the symptoms of hypoactive delirium such as lethargy and drowsiness are not always recognised by the CAM-ICU (McNicoll et al., 2005). The topic of this review was selected based on observations made in clinical practice; for example, it was witnessed that very few delirium assessments were being performed in the ICU and subsequent conversations with critical care nurses reinforced the perception that approaches to delirium monitoring in the ICU are inconsistent. In an attempt to address this clinical problem, the topic of ICU delirium was selected as the main focus of inquiry for the present research. So as to construct a relevant and well framed review question it was necessary to explore the literature pertaining to this clinical problem. In a telephone-based questionnaire study conducted in the Netherlands (Van Eijk et al., 2008) it was concluded that 7% of the ICUs surveyed in this nationwide study routinely practiced delirium monitoring using a validated tool such as the CAM-ICU; despite the presence of international guidelines that advocate delirium assessment practices. Ely et al., (2001) states that very few institutions routinely practice delirium monitoring despite well-documented adverse effects associated with the syndrome. The implications of this are that timely diagnosis and the implementation of management strategies are prevented (Ista et al., 2014). Boot (2009) proposes that nurses in the ICU may not have the appropriate level of knowledge to guide nursing practice. On the contrary, Wells (2012) states that a lack of knowledge may not fully explain why nurses do not engage in delirium monitoring and that the reason lies with the barriers to delirium as identified by Devlin et al., (2008) such as difficulties in assessing intubated patients. An alternative explanation is that nursing practices are based on the deep-rooted belief that delirium is an expected consequence of critical illness (Boot 2009). Undoubtedly, a lack of scientific attention given to the topic of ICU delirium may have contributed to a lack of general awareness (Page and Ely, 2011). In recent years, there has been a growing recognition in the literature and clinical practice that a change in attitude is required, which may need to be supported by educational efforts. Prior to introducing a change in attitude; it is first necessary to understand why so many nurs es are failing to incorporate screening into their routine practice (Wells, 2010). In an attempt to gain an improved understanding of the perceived barriers, beliefs, current practices and knowledge levels of critical care nurses, Devlin et al., (2008) identified nurses’ responses regarding delirium monitoring in the ICU using a questionnaire design. One of the main findings from this study was that nurses who did not routinely practice delirium monitoring were unaware that the syndrome was underreported and that delirium is characterised by fluctuating symptoms such as levels of consciousness. The study’s findings bring to attention a severe deficit in nurses’ knowledge relating to questions about delirium in the ICU. Mention should be made here of an important limitation of the study, that is, the results are only representative of 331 nurses in the Massachusetts area of North America. By employing a systematic search strategy to identify similar research, a synopsis of the level of support required to alleviate the clinical problem will be c reated (Aveyard, 2010). There appears to be no published evidence of an attempt to produce a systematic review that has explored critical care nurses’ responses in relation to delirium and delirium monitoring in the ICU. In light of this, the present review will explore this gap in research evidence at the level of a literature review in which a selected body of literature will be critically appraised. 1.1 The Review Question ‘What knowledge, practices and attitudes do critical care nurses have about delirium and its assessment in the ICU?’ 1.2 Aim and Objectives The aim of this review is to critically appraise primary research studies to reveal the knowledge, practices and attitudes of critical care nurses regarding delirium in the ICU and its assessment, whilst identifying implications and recommendations for clinical practice. The following objectives describe the individual steps that will be undertaken as part of this review: To employ a systematic search strategy to retrieve primary research articles that are relevant to the research question as specified above, through the use of inclusion and exclusion criteria. To use appropriate databases and hand searching techniques to identify additional articles that are relevant to the research question and that meet the inclusion and exclusion criteria. To critically appraise the selected research articles using a validated appraisal tool so as to establish their research quality and reliability. To extract the findings from the selected articles so as to effectively answer the research question. To draw conclusions from the findings whilst discussing the limitations of the review and implications and recommendations for clinical practice. Word count 1447 References American Psychiatric Association. (2000) Diagnostic and statistical manual mental disorders. 4th ed. Washington DC: Author. Arend, E. Christenson, M. (2009) Delirium in the intensive care unit: a review. Nursing in Critical Care, 14 (6): 145-154. Aveyard, H. (2010) Doing a literature review in health and social care. A practical guide. 2nd ed. London: Open University Press. Boot, R. (2012) Delirium: a review of the nurse’s role in the intensive care unit. Intensive and critical care nurses, 28 (3): 185-189. Cutler, J. (2010) Critical care nursing made incredibly easy. London: Lippincott Williams Wilkins. Devlin, J. W., Fong, J.J. Howard, E.P. et al. (2008) Assessment of delirium in the intensive care unit: nursing practices and perceptions. American Journal of Critical Care, 17 (6): 555-566. Ely, E.W., Inouye, S.K. Bernard, G.R. et al. (2001) Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). The Journal of the American Medical Association, 286: 2703-2710. Girard, T.D., Jackson, J.C. Pandharipande, PP. et al. (2010) Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38 (7): 1513-1520. Granberg-Axà ¨ll, A., Bergdom, I. Lundberg, D. (2001) Clinical signs of ICU syndrome/delirium: an observational study. Intensive Critical Care Nursing, 17 (2): 72-93. Ista, E., Trogrlic, Z. Bakker, J. (2014) Improvement of care for ICU patients with delirium by early screening and treatment: study protocol of iDECEPTIVE study. Implementation Science, 9: 143. Justice, M. (2000) Does ICU psychosis really exist? Critical Care Nurse, 20: 28-39. Lipowski, Z. J. (1980) Acute brain failure in man. Springfield , IL: Charles C Thomas. McGuire, B., Basten, C. and Ryan, C. et al. (2000) Intensive care unit syndrome, a dangerous misnomer. Archives of Internal Medicine, 160 (7): 906-909. McNicoll, L., Pisani, M. Ely, E. (2005) Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. Journal of the American Geriatrics Society, 53: 495-500. National Institute for Health and Care Excellence (NICE) (2010) Delirium: diagnosis, prevention and management [online]. Available from: https://www.nice.org.uk/guidance/cg103 [Accessed 13 January 2015]. Ouimet, S., Kavanagh, B.P. and Gotfried, S.B. et al. (2007) Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine, 33 (1): 66-73. Page, V. Ely, E. W. (2011) Delirium in critical care (core critical care). Cambridge, UK: Cambridge University Press. Shehabi, Y., Botha, J. A. and Ernest, D. et al. (2008) Sedation and delirium in the intensive care unit: an Australian and New Zealand perspective. Anaesth Intensive Care, 36 (4): 570-578. Tess, MM. (1991) Acute confusional state in critically ill patients: a review. Journal of Neuroscience Nursing, 23: 398-402. Van Eijk, M.M., Kesecioglu, J. Slooter, A. J. (2008). Intensive care delirium monitoring and standardised treatment: a complete survey of Dutch intensive care units. Intensive and Critical Care Nursing, 24 (4): 218-221. Webb, A.R. Singer, M. (2005) Oxford Handbook of Critical Care. 2nd ed. Oxford UK: Oxford University Press. Wells, L. G. (2010) Why don’t intensive care nurses perform routine delirium assessment? A discussion of the literature. Australian Critical Care, 25 (3): 157-161. 1

Conceptualizing a New Product or Service Division of an Existing Business Essay

The success of an organization depends on the strategic plan. In the plan, it will define the mission, vision, ad value statements. The strategic plan is designed to assist the organization with its strengths, weaknesses, opportunities, and threats. The SWOT analysis will help develop a strong strategic plan and map out the direction to follow to achieve an organizational vision and goal. The purpose of this paper is to cover the mission, vision and core value of De Von’s Printing. Define the guiding principles and strategic direction. Then introduce and identify the customer’s needs and how it achieves competitive advantage. Mission De Von’s is classified as a full service printing provider for standard and custom invitation, web design, and web support. The company’s clientele are individuals and organizations of any size or nature. The services offered to the clientele ranges from standard to custom. De Von’s center its dedication and customer appreciation around the skills of displaying the most outstanding customer service to each customer that the company serve. The company’s mission statement is to provide the customer with the highest quality product and service in a timely manner, and provide each customer with a competitive price. We will be honest, give professional advice and provide friendly customer service. Our goal will be to meet and exceed full expectation. The mission statement is a written declaration of an organization’s core purpose and focus that normally remains unchanged over time. Properly crafted mission statements (1) serve as filters to separate what is important from what is not, (2) clearly state which markets will be served and how, and (3) communicate a sense of  intended direction to the entire organization (â€Å"Mission Statement†, 2014). Vision De Von’s vision statement is to be a leader in the Printing industry. The way the company will display and honor the statement is to use innovative work practice with a self-improvement of the culture, to evaluate the new technology that will add value, and being socially responsible. We commit to our principles, product and service, ad clientele. The vision statement is an aspirational description of what an organization would like to achieve or accomplish in the mid-term or long-term future. It is intended to serves as a clear guide for choosing current and future courses of action (â€Å"Vision Statement†, 2014). Core Value The company’s core values are to discipline and respect the commitment that was developed, ownership to the goals, and take accountability and responsibility for our actions, uphold the trust, sensitivity, and professional conduct, and have a quality orientation and purpose of excellence. The core values are a company’s ethical and moral compass and decision making foundation. They are the ideals and ethics that management holds dear. They drive decision making in that they are constantly referred to in the decision making process. That is, when in a tough spot, the answer needs, first and foremost, to be consistent with the company values. They are generally for both internal and external consumption. They tell those in the company how things are done and those outside the company why they want to be associated with this company. Corporate values are best when they are few in number but high in meaning and lived daily (â€Å"Mission, Vision, and Value†, 2013). Guiding Principles The company’s core value is developed around the certainty that the standard and custom printing is a way to produce quality invitations for the clients. This makes it easier for those that do not wont cheap printing and looking for a professional look. De Von’s Printing guiding business principles are committed to follow is: a. Listen and communicate b. Leadership c. Courtesy and respectful d. Exceed customer expectation e. Excellence f. Share knowledge g. Simple process h. Team work i. Participate and contribute to activities The company has beliefs that the custom printing will target a huge segment of clients, who are in need of quality printing. The management team wants to serve a competitive price depending on the design. Organization’s Strategic Direction De Von’s objectives for the future are to achieve the goals in the strategic plan to expand on the growth for the company. Once the achievement has been accomplished, the management team would review the profit made and look at other opportunities in the printing industry such as screen printing. De Von’s future goal is to add to the partnership network with the competitors such as Paramount Printing. The executive and management team has discussed the advancement plan of the objectives. The objectives would include connect with web designers and screen printing organizations, communicate, and advertise the new service. Produce a partnership with local competitors by advertising workshops or seminars, and use a recruitment method to reach out to master printers. Use social media, such as Facebook, Twitter, and Instagram, to advertise and promote the product and service. The strategic plan solely depends on the mission, vision, and core values. The mission statement identifies the company and who it supports; the clientele, employees, and investors. The mission statement recognizes the proficiency within the industry. The clients realize that De Von’s Printing is committed with customer satisfaction, focus, and outstanding abilities. The vision statement summaries how the company wants to succeed by providing outstanding products and service to the clients. De Von’s vision is to become one of the popular printing companies in the area and through the United States. This shows that the company is committed to accomplishing and achieving excellence to the clients, staff and investors. It also shows that the ownership has motivation to be the best it can be and be loyal to  the goals for the company to expand. The core values of De Von’s Printing are correspondingly as impertative as the mission and vision statement of the organization’s strategic plan. Lastly, the value of integrity shows that cl ients and employees can trust the company to do what is right for not only clients, employees, and shareholders, but for the community and society as well. The Customer Needs and Achieved Competitive Advantages De Von’s top priority is to be able to meet the customer’s needs. The company has developed a strong communication method. This method has allowed the management team to utilize his or her listening skills. Once the communication and listening plan was put in place, they were able to understand what the clients were looking for in a product and services. There are three steps the team would need to follow in order to bring satisfaction to the clients. The steps would be Listen, Process, and Deliver. The team took the steps and developed a plan. The first step is Listen. Team A took the information from the clients and was able to understand what he or she was trying to achieve. Team B had the Process step. They reviewed the multiple solutions that were available and then were able to decide the best one for each individual or organization. In the Process step, the team used the advanced solution instead of the cheaper one. The last step is the deliver. This step Team C set a method for the clients to follow through, and establish a way for the client to meet the request of the customers by providing on time service, and a committed competitive price. De Von’s focus is to remain in an advance stage of bring competitive with the competitors. The management team and executive leaders have put in place ways to stay competitive in the Printing Industry. An incentive and training program was put in place to provide positive resources for the employees. Conclusion De Von’s Printing has a strong method of maintaining a positive strategic plan. The mission, vision, and values were properly evaluated and developed with a smooth path of organization. The mission statement identifies the company and who it supports; the clientele, employees, and investors. The vision statement gives a view of where the company has set out for the future and in what direction they plan to be. The core values are a guide  that helps the company to meet the goals that are set. De Von’s management team has realized that their biggest competitive advantage will be the clientele and the employees. . Reference â€Å"Mission Statement†, (2014). Retrieved from http://www.businessdictionary.com/definition/mission-statement.html#ixzz35ZMkiGFn â€Å"Vision Statement†, (2014). Retrieved from http://www.businessdictionary.com/definition/vision-statement.html#ixzz35aW3DgZb â€Å"Mission, Vision, and Value statement†, (2013). Retrieved from http://www.bellevuechamber.org/links/pdf/mission_vision_and_values_template.pdf

Meaning to Human Life Essay

Is there any meaning to human life? After listening to the first two lectures I gathered what I felt to be Professor Amrbosio’s definitions of the hero and the saint. I took notes and after going back through and reading them it helped me to put a few things together. He asks the question about whether or not human existence is meaningful or absurd. We live in a hostile and deadly environment so we try to find our purpose and meaning so we have some sense of security. It is a defense mechanism. Why is there so much evil in this world? We have the good and the bad. The good being our loving parents and the soldiers who put their lives at risk to defend our freedom and our lives. But then you have the bad and the evil such as the homeless people and the terrorist attacks and the holocaust. It is unfair how there are so many people with nothing and living on the streets when there are just as many people who have much more then they need to survive. The hero and the saint represent traits that can and will be inherited and passed on across different cultures and over time. The hero and the saint are metaphors that humans have used to search for the meaning of life. With the hero, reality is formed and driven by the struggle of humans. They believe in honor and self-esteem along with self-fulfillment and admiration. They always run up against bad things and they believe the good guys will come in last. The Saint believes that reality is made up of our personal and loving relationships. These relationships are based around unconditional trust. They feel like humans really have no goal but they have a purpose. Love and gratitude define them. Some people say life is a wrong turn and it’s down a dead end street. Saints and heroes show us ways we can share and participate in living every day and still asking our questions about life. The best we can do is to live the most meaningful life. Make every day count and always tell the ones you love how much you love them because you never know when it could be the last time that you are able to tell them. Sometimes you just have to trust that our life has a purpose.

Analysis Of Henrik Ibsen s A Doll House Essay - 981 Words

Gender expectation and stereotypes are common in the United States today, although many men and women are working hard to alert them. According to our traditional stereotypes, men are strong and dominant, while women are weak and submissive. There are moments in the person’s life when men do not appreciate their wives and go across their limits. This view sounds a lot like what Henrik Ibsen wrote about in his play, A Doll House. Ibsen presented gender roles through social roles, identity and marriage. This factors affect how the characters in the play are viewed by society. Althouth gender roles have changed over time and males and females have become more equal, a certain label behavior which is accepted by men to women are still exist. Today we live in times of rapid change and of course change of the relationship between men and women’s in all spheres of society. Gender equality an important trend in all around the world in recent years. Gender relation is discussed through the portrayal of struggle of ideological power between the men and the women. Ibsen in 18th century, in his play focuses on social and ideological aspects, through how women are perceived, especially what as reflected through marriage of social values and duties of both men and women. In the play, men are seemingly in the dominant position, they manipulate their power to control the women. As appeared in A Doll House, men are in ideologically and a financially higher position over women,Show MoreRelatedAnalysis Of Henrik Ibsen s A Doll House 1823 Words   |  8 PagesA Doll House is a play that was written by Henrik Ibsen in 1879. Nora Helmer is a wife and mother who secretly loaned money to save her husband’s, Torvald, life. Torvald views and treats Nora has a doll and she goes along with it. As conflict comes and goes Nora decides that her current life is not what she wants for herself. 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