RLG100Y1 Lecture : Buddhism

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sapphirewasp325

27 Dec 2011

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Hotbed of ideas where indic traditions emerge. Buddhism seen as a reaction/response to the shramana movement. Buddhism the middle between hinduism and jainism. Started in india, moved to asia, and then to the western world in the. Practice is quite diverse, doctrine is diverse. Uncertain about amount of buddhists in the world. China didn t allow religion due to communism. Centered around the insights, experiences and teachings of its founder siddhartha. Means one who is spiritually aware, awakened. Not the first to have these experiences, not the first buddha. Come from a long line of teachers before him. Siddhartha was known as the sakyamuni means the sage of the sakya clan. Everything we know about the buddha comes from hagiography it is a biography from a person who practices the religion, faith account. Born into a family that is privileged. At the time he is born, many sages come to visit him.

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20 questions: Evidence-based practice or sacred cow?

Miller, Julie BSN, RN, CCRN; Hayes, Denise Drummond MSN, RN, CRNP; Carey, Katherine W.

Author Information

Julie Miller is a staff development educator for critical care at the Trinity Mother Frances Hospitals and Clinics in Tyler, Tex., and president and founder of Paws to Learn in Whitehouse, Tex. Denise Drummond Hayes is senior clinical editor of Nursing2015. Katherine W. Carey is executive editor of Nursing2015.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

DESPITE DRAMATIC ADVANCES in nursing and medical research, many nurses continue to promote outdated nursing practices that have been proven ineffective, unnecessary, and in some cases, downright dangerous. Based on tradition rather than science, these âsacred cowsâ are often revered by nurses and hard to dislodge from practice.

Figure. No caption a...

Last year, Nursing conducted a nationwide survey to gather information about current nursing practice. A total of 2,356 respondents answered 20 true/false questions designed to test nurses' understanding of best practices. The survey instrument was presented in the journal and online.

This article reviews the survey results and provides evidence-based rationales for the correct responses. In cases where the correct response is ambiguous or unsettled, the best available evidence is discussed. The correct answer is highlighted in red. Percentages may not add up to 100 because numbers have been rounded. Not all respondents answered every question.

1. Patients experiencing hypotension and shock should be placed in Trendelenburg position to improve blood flow to the heart and brain.

True: 51% False: 49%

False. Trendelenburg position was originally developed in the 1880s to expose pelvic organs during surgery. Its use was popularized during World War I to treat hypotensive shock. Widespread use was adopted despite numerous calls to stop using it as a method of resuscitation for hypotension.

The Trendelenburg position has been studied for the last 50 years. Most studies show no improvement in cardiac output or BP with its use. Although some anecdotal reports have noted a transient improvement in both cardiac output and BP, those changes usually last less than 10 minutes.

Patients who are placed in Trendelenburg position for hypotension are at risk for experiencing profound hemodynamic compromise, increased intracranial pressure, and altered respiratory mechanics. Additionally, patients who are obese or who have right ventricular failure, pulmonary disorders, or head injuries have been found to suffer adverse consequences from Trendelenburg positioning.

The take-home message here is to stop using Trendelenburg position to manage hypotension and hypotensive shock. If your patient experiences hypotension, position him or her supine with the lower extremities elevated. This position improves venous return to the right heart without causing overwhelming cardiac compromise.

REFERENCES

Bridges N, Jarquin-Valdivia AA. Use of the Trendelenburg position as the resuscitation position: to T or not to T. Am J Crit Care. 2005;14(5):364â368.http://ajcc.aacnjournals.org/content/14/5/364.full.

Johnson S, Henderson SO. Myth: the Trendelenburg position improves circulation in cases of shock. Can J Emerg Med. 2004;6(1):48â49.

Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31(2):38â62.

2. Scrubbing the hub of an I.V. port for a minimum of 15 seconds before accessing a central line has been shown to reduce central line-associated bloodstream infections.

True: 81% False: 19%

Probably true. Although the optimum amount of time for hub disinfection remains to be determined, the suggested time frame ranges from 5 to 15 seconds. The 2014 practice guidelines from The Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and other agencies suggest applying vigorous mechanical friction for no less than 5 seconds before accessing catheter hubs, needleless connectors, or injection ports. Most references recommend 10 to 15 seconds. The guidelines also suggest the use of 0.5% chlorhexidine gluconate in 70% alcohol preparation, 70% alcohol, or povidone-iodine solutions with consideration that the alcohol-chlorhexidine solution may have additional residual activity over alcohol. The guidelines recommend monitoring scrub-the-hub compliance because most access ports remain colonized under conditions of standard practice.

Vigorous mechanical friction technique in scrubbing the hub with alcoholic chlorhexidine, povidone-iodine, or 70% alcohol solution will help reduce the incidence of central line-associated blood stream infections. Current accepted practice is to scrub from a minimum of 5 to 15 seconds.

REFERENCES

The Joint Commission. CLABSI Toolkit and Monograph. 2015.http://www.jointcommission.org/CLABSIToolkit.

Lockman JL, Heitmiller ES, Ascenzi JA, Berkowitz I. Scrub the hub! Catheter needleless port decontamination. Anesthesiology. 2011;114(4):958.

Marschall J, Mermel LA, Fakih M, et al. SHEA/IDSA practice recommendation: strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753â771.http://www.jstor.org/stable/10.1086/676533.

Peel TN, Cheng AC, Buising KL, Dowsey MM, Choong PF. Alcoholic chlorhexidine or alcoholic iodine skin antisepsis (ACAISA): protocol for cluster randomised controlled trial of surgical skin preparation for the prevention of superficial wound complications in prosthetic hip and knee replacement surgery. BMJ Open. 2014;4(5).http://bmjopen.bmj.com/content/4/5/e005424.full.

Simmons S, Bryson C, Porter S. âScrub the hubâ: cleaning duration and reduction in bacterial load on central venous catheters. Crit Care Nurs Q. 2011;34(1):31â35. Ovid Full Text

3. Instilling normal saline solution before endotracheal suctioning improves oxygenation, facilitates removal of secretions, and stimulates coughing to mobilize secretions.

True 35% False: 65%

False. Little research supports the use saline instillation before endotracheal (ET) tube suctioning to improve oxygenation or removal or to thin secretions. In 2010, after reviewing 19 years of literature, the American Association of Respiratory Care published clinical practice guidelines that recommended against the routine instillation of normal saline prior to suctioning. Other studies have demonstrated that normal saline instillation may actually be detrimental by increasing the risk of ventilator-associated pneumonia (VAP) due to bacterial contamination of the saline vials.

Based on current literature and best practice, saline instillation prior to ET suctioning shouldn't be done routinely.

REFERENCES

American Association for Respiratory Care. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55(6):758â764.

Caruso P, Denari S, Ruiz SA, Demarzo SE, Deheinzelin D. Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med. 2009;37(1):32â38.

Rauen CA, Chulay M, Bridges E, Vollman KM, Arbour R. Seven evidence-based practice habits: putting some sacred cows out to pasture. Crit Care Nurse. 2008;28(2):98â123.

4. Auscultating the abdomen while injecting air through a gastric feeding tube is a reliable way to ensure proper tube placement.

True 31% False: 69%

False. Traditionally, auscultation during air insufflation through the feeding tube has been used to verify feeding tube placement at the bedside. To use this method, the clinician instills air into the feeding tube while listening with a stethoscope placed over the stomach. The assumption is that the sound of air entering the stomach confirms that the tube is placed correctly in the stomach. However, research has shown that this assumption is unreliable. The auscultatory method can't detect when the distal end is located in the esophagus or distinguish between gastric and small bowel placement. Misleading findings are known as pseudoconfirmatory gurgling.

In 2012, a safety alert was distributed by the Child Health Patient Safety Organization recommending the immediate discontinuation of the auscultation method for assessment and verification of gastric tube tip placement. When in doubt, obtain a radiograph to determine gastric tube location.

For more discussion and details on confirming feeding tube placement and other enteral feeding guidelines, see âWhat's on the Menu? Delivering Evidence-based Nutritional Therapyâ in this issue.

REFERENCES

Enteral Nutrition Practice Recommendations Task Force: Bankhead R, Boullata J, Brantley S, et al. A.S.P.E.N. enteral nutrition practice recommendations. J Parenter Enter Nutri. 2009;33(2):122â167.

National Association of Childrens Hospitals (NACH), ECRI Institute. Blind Pediatric NG Tube Placements Continue to Cause Harm. Overland Park, KS: Child Health Patient Safety Organization, Inc.; 2012.

Patient Safety Authority. Confirming feeding tube placement: old habits die hard. PA PSRS Patient Saf Advis. 2006;3(4):23â30.

5. Before initiating enteral nutrition, pH testing of gastric tube aspirate is a reliable way to ensure that the tube is properly placed in the stomach.

True: 51% False: 49%

False. Gastric pH testing doesn't reliably confirm correct placement of a gastric tube. It's true that gastric fluid is usually acidic with a pH less than or equal to 5.5, and respiratory secretions are almost always alkaline with a pH greater than or equal to 6.0. But several conditions can affect the pH of these aspirates. For example, gastric pH will rise temporarily when the patient is receiving enteral feedings or certain medications, such as a proton pump inhibitor.

Guidelines from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend radiographic confirmation for any blindly inserted gastric tube (small or large bore) before its initial use for instillation of medications or feedings in adults. Marking the tube at the exit site with an indelible marker after radiographic confirmation is also recommended.

In 2014, A.S.P.E.N. affirmed that abdominal radiographs or chest radiographs that include the abdomen are most reliable for confirmation of gastric tube tip location. This recommendation extends to the pediatric population. Methods for ongoing verification of gastric tube placement include assessing the external tube length for changes.

REFERENCES

American Association of Critical-Care Nurses. Practice Alert. Verification of feeding tube placement (blindly inserted).http://www.aacn.org/wd/practice/docs/practicealerts/verification-feeding-tube-placement.pdf?menu=aboutus.

American Society for Parenteral and Enteral Nutrition. Researchers call for upgrade in guidelines and technology for placement of nasal feeding tubes in pediatric patients. News release. May 21, 2014.

Enteral Nutrition Practice Recommendations Task Force: Bankhead R, Boullata J, Brantley S, et al. A.S.P.E.N. enteral nutrition practice recommendations. J Parenter Enter Nutri. 2009;33(2):122â167.

Irving SY, Lyman B, Northington L, Bartlett JA, Kemper C. Nasogastric tube placement and verification in children: review of the current literature. Crit Care Nurse. 2014;34(3):67â78.http://ccn.aacnjournals.org/content/34/3/67.full.

Patient Safety Authority. Confirming feeding tube placement: old habits die hard. PA PSRS Patient Saf Advis. 2006;3(4):23â30.

National Association of Children's Hospitals (NACH), ECRI Institute. Blind Pediatric NG Tube Placements Continue to Cause Harm. Overland Park, KS: Child Health Patient Safety Organization, Inc.; 2012.

6. Continuous aspiration of subglottic secretions helps prevent ventilator-associated pneumonia (VAP).

True: 29% False: 71%

True. Numerous studies and evidence-based guidelines recommend continuous or frequent intermittent drainage of subglottic secretions using an ET tube with a dorsal lumen above the cuff in adult patients. The 2014 SHEA/IDSA guidelines for reducing VAP recommend using ET tubes with subglottic suctioning ports in patients expected to require mechanical ventilation for at least 48 hours. As reported in the guidelines, a meta-analysis of 13 randomized controlled trials showed that use of ET tubes with subglottic drainage reduced VAP rates by 55%, reduced mechanical ventilation duration by 1.1 days, and shortened ICU length of stay by 1.5 days.

REFERENCES

American Association of Critical-care Nurses. VAP Practice Alert. Ventilator associated pneumonia. 2008.http://www.aacn.org/wd/practice/docs/practicealerts/vap.pdf.

Ampel NM. Intermittent subglottic suction to prevent ventilator-associated pneumonia. NEJM Journal Watch. [e-pub October 27, 2010]

Deem S, Treggiari MM. New endotracheal tubes designed to prevent ventilator-associated pneumonia: do they make a difference. Respir Care. 2010;55(8):1046â1055.

Klompas M, Branson R, Eichenwald EC, et al. SHEA/IDSA practice recommendation. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(8):915â936.

Lacherade JC, De Jonghe B, Guezennec P, et al. Intermittent subglottic secretion drainage and ventilator-associated pneumonia: a multicenter trial. Am J Respir Crit Care Med. 2010;182(7):910â917.

Speroni KG, Lucas J, Dugan L, et al. Comparative effectiveness of standard endotracheal tubes vs. endotracheal tubes with continuous subglottic suctioning on ventilator-associated pneumonia rates. Nurs Econ. 2011;29(1):15â20, 37.

7. Checking gastric residual volume before initiating enteral feeding is necessary to assess gastric emptying and reduce aspiration risk.

True: 78% False: 22%

Probably false. More research is needed about the frequency and significance of gastric residual volume (GRV) measurements. Historically, elevated GRV has been used as a measure of tolerance to enteral tube feedings, but the evidence doesn't support measuring GRV as a single tool for evaluating enteral feeding tolerance or for preventing aspiration. Elevated GRV when combined with other patient assessment data such as nausea, vomiting, abdominal distension, sepsis, use of sedation, or the addition of vasopressors does show worsening patient outcomes. Research shows that measuring GRV doesn't correlate with aspiration risk and interferes with nutritional support.

All patients fed enterally should be assessed for aspiration risks, such as hemodynamic instability, sepsis, altered level of consciousness, and mechanical ventilation. Nurses must assess beyond GRV for other measures of intolerance, such as abdominal distension, nausea, vomiting, and abdominal pain. The 2009 A.S.P.E.N. practice guidelines for enteral feeding recommend the following strategies for preventing aspiration:

* Ensure that the feeding tube is in the proper position before initiating feedings.

* Keep the head of bed (HOB) elevated 30 to 45 degrees during administration of enteral feedings.

* If possible, utilize a large-bore sump tube for the first 24 to 48 hours of enteral feeding and evaluate GRV using at least a 60-mL syringe.

* Assess GRV every 4 hours during the first 48 hours in patients receiving gastric tube feedings. After the enteral feeding goal rate is achieved and/or the sump tube is replaced with a soft, small-bore feeding tube, GRV monitoring may be decreased to every 6 to 8 hours in noncritically ill patients. However, every-4-hour measurements are recommended in critically ill patients.

* If GRV is greater than 250 mL after a second GRV measurement, consider the addition of a promotility agent in adults.

* For GRV greater than 500 mL, hold enteral nutrition and reassess patient tolerance with an established algorithm including physical assessment, GI assessment, evaluation of glycemic control, minimization of sedation, and consideration of a promotility agent.

* Consider placement of a feeding tube below the ligament of Treitz when GRV measurements are consistently more than 500 mL.

REFERENCES

Enteral Nutrition Practice Recommendations Task Force: Bankhead R, Boullata J, Brantley S, et al. A.S.P.E.N. enteral nutrition practice recommendations. J Parenter Enter Nutri. 2009;33(2):122â167.

Flynn Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31(2):38â62.

Seres D. Nutrition support in critically ill patients: enteral nutrition. UpToDate. 2015.http://www.uptodate.com.

8. Continuous enteral nutrition should be stopped before a patient is turned or repositioned.

True: 59% False: 41%

False. The evidence doesn't support the practice of holding tube feedings when lowering the HOB or repositioning patients for routine care. In fact, research shows that it's not only unnecessary, it's detrimental. In one study, 30% of 45 critically ill patients received inadequate calories because feedings were suspended during nursing care.

Best practice is to minimize interruptions in enteral feedings. Don't suspend feedings for short periods when the HOB needs to be lowered for nursing care. Although feeding should be stopped for procedures requiring the HOB to be lowered for a prolonged period, it should resume immediately when the procedure is complete. Follow your facility's enteral nutrition protocol to ensure that patients receive their prescribed calories.

REFERENCES

Enteral Nutrition Practice Recommendations Task Force: Bankhead R, Boullata J, Brantley S, et al. A.S.P.E.N. enteral nutrition practice recommendations. J Parenter Enter Nutri. 2009;33(2):122â167.

Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31(2):38â62.

McClave SA, Saad MA, Esterle M, et al. Volume-based feeding in the critically ill patient. J Parenter Enteral Nutr. [e-pub June 18, 2014]

Metheny N. Turning tube feeding off while repositioning patients in bed. Crit Care Nurse. 2011;31(2):96â97.

Stewart ML. Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice. Crit Care Nurse. 2014;34(4):14â22.

9. Kinetic and continuous lateral rotation therapy reduces the risk of ventilator-associated pneumonia.

True: 74% False: 26%

True. Continuous lateral rotation therapy (CLRT) has been shown to reduce the prevalence of VAP in appropriately selected patients. Most studies agree that intervention with CLRT should be initiated within 48 hours of when the patient meets criteria for benefiting from CLRT. Criteria used to identify patients who will benefit from this intervention include a ratio of arterial oxygen tension to fraction of inspired oxygen (Pao₂/Fio₂) less than 300 mm Hg or the need for increasing levels of positive end-expiratory pressure and Fio₂ to maintain oxygenation. Research shows that CLRT can reduce the incidence of VAP, shorten ventilation time, and shorten length of stay. Study results are mixed regarding the best degree of lateral rotation.

REFERENCES

Hansen-Flaschen J, Siegel MD. Acute respiratory distress syndrome: clinical features and diagnosis in adults. UpToDate. 2015.http://www.uptodate.com.

Staudinger T, Bojic A, Holzinger U, et al. Continuous lateral rotation therapy to prevent ventilator-associated pneumonia. Crit Care Med. 2010;38(2):486â90.

Swadner-Culpepper L. Continuous lateral rotation therapy in progressive mobility in critical care. Crit Care Nurse. 2010;30(2):S5âS7.

10. Benzodiazepines such as lorazepam are a first-line treatment for insomnia, agitation, and delirium in older adults.

True: 14% False: 87%

False. According to the Pain, Agitation, Delirium (PAD) guidelines published in 2013 by the American College of Critical Care Medicine, âelderly patients are significantly more sensitive to the sedative effects of benzodiazepines. Benzodiazepines can cause respiratory depression and systemic hypotension, especially when administered in conjunction with other cardiopulmonary depressants, particularly opioids.â In addition, hepatic impairment, common in older adults, reduces clearance of benzodiazepines. The Beers criteria strongly recommend against use of benzodiazepines in older adults citing the high quality of evidence supporting this position.

Agitated patients should be promptly assessed to identify underlying causes, such as pain, hypoxemia, delirium, or alcohol withdrawal, and treated accordingly. Besides pain control, recommended first-line strategies to manage agitation and promote sleep in older adults include grouping nursing interventions to minimize interruptions, controlling noise and light in the environment, and minimizing stimuli at night to promote normal sleep-wake cycles. The PAD guidelines also recommend using progressive mobility to reduce the incidence of delirium in adult ICU patients. Nonbenzodiazepine medications are recommended to reduce the incidence of delirium in all adults on mechanical ventilation.

REFERENCES

Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263â306.

2012 AGS Beers criteria for potentially inappropriate medication use in older adults.http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf.

11. The routine use of hyperventilation to reduce increased intracranial pressure (ICP) is considered a standard of care.

True: 19% False: 81%

False. Routine use of hyperventilation isn't recommended due to the risk of cerebral ischemia from reduced partial pressure of arterial carbon dioxide (Paco₂).

Research shows that mechanical ventilation can rapidly reduce ICP due to vasoconstriction and a reduction in intracranial blood volume; however, the effects are temporary (24 hours or less). Therapeutic hyperventilation is an option for managing ICP in certain urgent situations but isn't indicated on a chronic basis, particularly in patients with acute stroke or traumatic brain injury (TBI).

Limiting the use of hyperventilation has been shown to improve 3- and 6-month outcomes for patients with TBI. Most patients with severe TBI have elevated ICP. In the past, hyperventilation has been used routinely to reduce ICP associated with severe TBI, but numerous studies have documented cerebral ischemia and poor outcomes in patients managed with routine hyperventilation.

The most recent guidelines for severe TBI published in 2007 advise avoiding hyperventilation in the first 24 hours following TBI, when cerebral blood flow is often already reduced. These guidelines also recommend that hyperventilation be used only as a temporizing measure for increased ICP. When it is used, either jugular venous oxygen saturation or brain tissue oxygen tension levels should be monitored to assess oxygen delivery.

REFERENCES

Bullock MR, Povlishock JT. Guidelines for the management of severe traumatic brain injury. Editor's Commentary. J Neurotrauma. 2007;24(suppl 1):S1âS106.

Smith ER, Amin-Hanjani S. Evaluation and management of elevated intracranial pressure in adults. UpToDate. 2015.http://www.uptodate.com.

12. Visitors should be restricted for patients with TBI to prevent spikes in ICP.

True: 30% False: 70%

Probably false. The literature is mixed and limited with regards to visitation and its effect on ICP. What is known is that with patients who have elevated ICP, appropriate interventions include maintaining a quiet, low-stimulation environment. Visitors who can maintain this type of an environment may be beneficial to the care of the patient. A gentle, soothing tone of voice and calming touch are also important.

For the nursing profession, the impact visitors may have on a patient's ICP is an area requiring further study. However, the American Association of Critical-Care Nurses recommends open visiting policies in the ICU because the evidence shows that âthe unrestricted presence and participation of a support person can enhance patient and family satisfaction, because it improves the safety of care.â

REFERENCES

American Association of Critical-Care Nurses. Practice Alert. Family presence: visitation in the adult ICU. 2011.http://www.aacn.org/WD/practice/docs/practicealerts/family-visitation-adult-icu-practicealert.pdf.

Hendrickson SL. Intracranial pressure changes and family presence. J Neurosci Nurs. 1987;19(1):14â17. Ovid Full Text

13. To reduce aspiration risk, healthy preoperative adults who are undergoing elective procedures should be N.P.O. after midnight.

True: 67% False: 33%

False. Current anesthesia guidelines suggest that the traditional N.P.O.-after-midnight protocol should no longer be implemented. Studies comparing GRV and gastric pH in patients who were N.P.O. from clear liquids for 2 to 4 hours to that of patients who were N.P.O. for more than 4 hours showed higher GRV and lower pH values in the patients who'd been N.P.O. for more than 4 hours. Studies also have shown that when N.P.O. overnight is compared with N.P.O. for 6 hours after a light meal (toast), results are equivocal regarding gastric volumes.

Current anesthesia guidelines and literature for healthy adults provide recommendations for fasting from solids and clear liquids. For clear liquids, the minimum fasting period can be shortened to 2 hours prior to elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. For a light meal, the minimum fasting period can be shortened to 6 hours before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. For patients who consume a meal that includes fatty or fried foods, the recommendation is a minimum fasting period of 8 hours or more prior to elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. (These recommendations don't apply to women in labor.)

REFERENCE

Apfelbaum JL, Caplan RA, Connis RT, et al. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495â511.

14. Unless contraindicated, the HOB should be elevated 30 to 45 degrees to prevent ventilator-associated pneumonia.

True: 87% False: 13%

True. Guidelines and studies support elevating the HOB to 30 to 45 degrees as a measure to prevent aspiration leading to VAP and hospital-acquired pneumonia.

HOB elevation is a simple, low-cost intervention that doesn't cause harm, whereas supine positioning predisposes the patient to aspiration. The SHEA/IDSA guidelines recommend placing endotracheally intubated patients in the semirecumbant position unless contraindicated.

REFERENCES

American Association of Critical-Care Nurses. Practice Alert. Ventilator associated pneumonia. 2008.http://www.aacn.org/wd/practice/docs/practicealerts/vap.pdf.

American Association of Critical-Care Nurses. Implementing the ABCDE Bundle at the Bedside.http://www.aacn.org/wd/practice/content/actionpak/withlinks-ABCDE-ToolKit.content?menu=practice.

Centers for Disease Control and Prevention. FAQs about ventilator-associated pneumonia.http://www.cdc.gov/HAI/pdfs/vap/VAP_tagged.pdf.

File Jr. TM. Risk factors and prevention of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia in adults. UpToDate. 2015.http://www.uptodate.com.

Institute for Clinical Systems Improvement. Health care protocol: prevention of ventilator-associated pneumonia. 2011.https://www.icsi.org.

Klompas M, Branson R, Eichenwald EC, et al. SHEA/IDSA practice recommendation. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol. 2014;35(8):915â936.

15. Wet-to-dry gauze dressings promote healing in clean granulating chronic wounds.

True: 41% False: 59%

False. In chronic wounds with an adequate blood supply, a moist environment supports healing. Wet-to-dry dressings don't maintain a moist environment when they dry out. In addition, removing a dried dressing also removes newly deposited granulation tissue from the wound bed and is painful for the patient. In general, wet-to-dry dressings should be avoided for clean granulating chronic wounds.

REFERENCES

Ayello EA, Baranoski S. Nursing2014 survey results: wound care and prevention. Nursing2014. 2014;44(4):34. Ovid Full Text

Jones KR, Fennie K, Lenihan A. Evidence-based management of chronic wounds. Adv Skin Wound Care. 2007;20(11):591â600.

16. When preoperative hair removal is necessary, it should be performed with a surgical clipper rather than a razor.

True: 89% False: 11%

True. Preoperative shaving of surgical sites is no longer the standard of care. Shaving a site the night before surgery significantly raises the risk of a surgical site infection (SSI) compared with use of depilatory agents, clipping hair immediately before surgery, or no hair removal at all. Shaving produces microscopic cuts that invite infection, and depilatories may produce hypersensitivity reactions. Some studies indicate that all methods of hair removal increase the risk of SSIs compared with no hair removal.

The current standard is to avoid hair removal unless the hair will interfere with the surgery. If hair removal is indicated, it should be performed with electric clippers immediately before the procedure.

REFERENCES

Anderson DJ, Podgorny K, BerrÃos-Torres SI, et al. SHEA/IDSA Practice Recommendation. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605â627.

Institute for Healthcare Improvement. How-to guide: prevent surgical site infections. 2012.http://www.ihi.org.

Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31(2):38â62.

17. To clean the skin of patients with fecal incontinence, use a no-rinse bathing/perineal cleaning product rather than soap and water.

True: 63% False: 37%

True. Cleaning the skin with soap and water is irritating and can damage skin due to mechanical friction and alkalinity of soap. No-rinse bathing products, which are pH balanced, gently reduce the amount of residual bacteria colonized on the skin. Ensuring the skin remains moisture-free is also a strategy known to help reduce the incidence of pressure ulcer development. Frequent linen changes and using a moisture barrier are best practices to help reduce moisture.

REFERENCES

Estilo ME, Angeles A, Perez T, Hernandez M, Valdez M. Pressure ulcers in the intensive care unit: new perspectives on an old problem. Crit Care Nurse. 2012;32(3):65â70.

Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31(2):38â62.

18. By diverting feces into a collection bag, rectal tubes can help prevent perianal tissue damage in critically ill patients with fecal incontinence.

True: 75% False: 25%

False. The use of rectal tubes is a tradition that many nurses ascribe to; however, it's the least safe procedure for managing fecal incontinence. Mushroom-shaped catheters or traditional urinary catheters with a balloon are likely to damage the rectal vault and sphincter. Best practice for managing fecal incontinence includes assessment of the cause of the diarrhea/incontinence and the use of fecal collection devices such as rectal pouches/bags.

Assess and manage the cause of the patient's diarrhea. If a collection device is needed, use a rectal pouch or bag, not a rectal tube.

REFERENCE

Makic MB, VonRueden KT, Rauen CA, Chadwick J. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31(2):38â62.

19. Evidence-supported indications for inserting an indwelling urinary catheter include major trauma, bladder irrigation, and comfort care for terminally ill patients.

True: 78% False: 22%

True. According to current guidelines from the Healthcare Infection Control Practices Advisory Committee, appropriate indications for indwelling urinary catheterization include:

* treating acute urinary retention or obstruction

* accurate measurement of urinary output in critically ill patients

* aiding healing of open sacral or perineal wounds in incontinent patients

* selected perioperative situations, such as urologic surgery

* multiple traumatic injuries such as pelvic fractures

* patient comfort at end of life, if needed.

Insertion of indwelling urinary catheters is inappropriate for caregiver convenience or patient comfort except during end-of-life care. Catheters should be inserted only when absolutely necessary and removed as soon as they're no longer needed to reduce the risk of catheter-associated urinary tract infections (CAUTIs). Consider alternatives such as intermittent catheterization and external catheters for males who can cooperate with treatment.

REFERENCES

APIC Implementation Guide: guide to preventing catheter associated urinary tract infections. 2014.http://apic.org/Resource_/EliminationGuideForm/6473ab9b-e75c-457a-8d0f-d57d32bc242b/File/APIC_CAUTI_web_0603.pdf.

Dumont C, Wakeman J. Preventing catheter-associated UTIs: survey report. Nursing2010. 2010;40(12):24â30. Ovid Full Text

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for the prevention of catheter-associated urinary tract infections, 2009.http://www.cdc.gov/hicpac/cauti/001_cauti.html.

Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009.http://www.cdc.gov/hicpac/cauti/001_cauti.html.

Lo E, Nicolle LE, Coffin SE, et al. SHEA/IDSA Practice Recommendation. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(5):464â479.

20. To reduce the risk of catheter-associated urinary tract infections, nurses should perform routine meatal care with soap and water during daily bathing.

True: 83% False: 17%

True. Best practices support using soap and water to clean the meatal surface around the catheter during daily routine catheter care. Cleaning the meatal surface with antiseptic solutions while a catheter is in place is ineffective for preventing CAUTI and not recommended.

For the initial discussion post, refer to the above article by Miller, Drummond and Carey:

Miller, J., Drummond Haye, D., & Carey, K. W. (2015). 20 QUESTIONS: Evidence-based practice or sacred cow? Nursing, 45(8), 46-55. doi:10.1097/01.NURSE.0000469234.84277.95

Question:

1) Choose one (1) nursing practice discussed in the article that is considered a âsacred cowâ and is not supported by the evidence.

2) Imagine that you are the RN responsible for changing practice on a nursing unit. Develop a plan you could implement to change nursing practice on your unit for the âsacred cowâ you have chosen. Provide specific details for the plan you develop.

sangriatermite542

THE BEVERAGE BATTLEFIELD In 2007, the President and CEO of Coca-Cola asserted that Coke has had a rather rough run in India; but now it seems to be getting its positioning right. Similarly, PepsiCoâs Asia chief asserted that India is the beverage battlefield for this decade and beyond. Even though the government had opened its doors wide to for- eign companies, the experience of the worldâs two giant soft drinks companies in India during the 1990s and the beginning of the new millennium was not a happy one. Both companies experienced a range of unexpected problems and difficult situations that led them to recognize that competing in India requires special knowledge, skills, and local expertise. In many ways, Coke and Pepsi manag- ers had to learn the hard way that âwhat works hereâ does not always âwork there.â âThe environment in India is challenging, but weâre learning how to crack it,â says an industry leader. THE INDIAN SOFT DRINKS INDUSTRY In India, over 45 percent of the soft drinks industry in 1993 con- sisted of small manufacturers. Their combined business was worth $3.2 million dollars. Leading producers included Parle Agro (hereafter âParleâ), Pure Drinks, Modern Foods, and McDowells. They offered carbonated orange and lemon-lime beverage drinks. Coca-Cola Corporation (hereafter âCoca-Colaâ) was only a distant memory to most Indians at that time. The company had been pres- ent in the Indian market from 1958 until its withdrawal in 1977 fol- lowing a dispute with the government over its trade secrets. After decades in the market, Coca-Cola chose to leave India rather than cut its equity stake to 40 percent and hand over its secret formula for the syrup. Following Coca-Colaâs departure, Parle became the market leader and established thriving export franchise businesses in Dubai, Kuwait, Saudi Arabia, and Oman in the Gulf, along with Sri Lanka. It set up production in Nepal and Bangladesh and served distant markets in Tanzania, Britain, the Netherlands, and the United States. Parle invested heavily in image advertis- ing at home, establishing the dominance of its flagship brand, Thums Up. Thums Up is a brand associated with a âjob well doneâ and personal success. These are persuasive messages for its target mar- ket of young people aged 15 to 24 years. Parle has been careful in the past not to call Thums Up a cola drink so it has avoided direct comparison with Coke and Pepsi, the worldâs brand leaders. The soft drinks market in India is composed of six product seg- ments: cola, âcloudy lemon,â orange, âsodaâ (carbonated water), mango, and âclear lemon,â in order of importance. Cloudy lemon and clear lemon together make up the lemon-lime segment. Prior to the arrival of foreign producers in India, the fight for local dominance was between Parleâs Thums Up and Pure Drinksâ Campa Cola. In 1988, the industry had experienced a dramatic shakeout fol- lowing a government warning that BVO, an essential ingredient in locally produced soft drinks, was carcinogenic. Producers either had to resort to using a costly imported substitute, estergum, or they had to finance their own R&D in order to find a substitute ingredient. Many failed and quickly withdrew from the industry. Competing with the segment of carbonated soft drinks is an- other beverage segment composed of noncarbonated fruit drinks. These are a growth industry because Indian consumers perceive fruit drinks to be natural, healthy, and tasty. The leading brand has traditionally been Parleâs Frooti, a mango-flavored drink, which was also exported to franchisees in the United States, Britain, Portugal, Spain, and Mauritius. OPENING INDIAN MARKET In 1991, India experienced an economic crisis of exceptional se- verity, triggered by the rise in imported oil prices following the first Gulf War (after Iraqâs invasion of Kuwait). Foreign exchange reserves fell as nonresident Indians (NRIs) cut back on repatria- tion of their savings, imports were tightly controlled across all sec- tors, and industrial production fell while inflation was rising. A new government took office in June 1991 and introduced measures to stabilize the economy in the short term, then launched a fun- damental restructuring program to ensure medium-term growth. Results were dramatic. By 1994, inflation was halved, exchange reserves were greatly increased, exports were growing, and foreign investors were looking at India, a leading Big Emerging Market, with new eyes. The turnaround could not be overstated; as one commentator said, âIndia has been in economic depression for so long that ev- erything except the snake-charmers, cows and the Taj Mahal has faded from the memory of the world.â The Indian government was viewed as unfriendly to foreign investors. Outside invest- ment had been allowed only in high-tech sectors and was almost entirely prohibited in consumer goods sectors. The âprinciple of indigenous availabilityâ had specified that if an item could be obtained anywhere else within the country, imports of similar items were forbidden. As a result, Indian consumers had little choice of products or brands and no guarantees of quality or reliability. Following liberalization of the Indian economy and the dis- mantling of complicated trade rules and regulations, foreign investment increased dramatically. Processed foods, software, engineering plastics, electronic equipment, power generation, and petroleum industries all benefited from the policy changes. PEPSICO AND COCA-COLA ENTER THE INDIAN MARKET Despite its huge population, India had not been considered by for- eign beverage producers to be an important market. In addition to the deterrents imposed by the government through its austere trade policies, rules, and regulations, local demand for carbonated drinks in India was very low compared with countries at a simi- lar stage of economic development. In 1989, the average Indian was buying only three bottles a year, compared with per-capita consumption rates of 11 bottles a year in Bangladesh and 13 in Pakistan, Indiaâs two neighbors. PepsiCo PepsiCo entered the Indian market in 1986 under the name âPepsi Foods Ltd. in a joint venture with two local part- ners, Voltas and Punjab Agro.â As expected, very stringent condi- tions were imposed on the venture. Sales of soft drink concentrate to local bottlers could not exceed 25 percent of total sales for the new venture, and Pepsi Foods Ltd. was required to process and dis- tribute local fruits and vegetables. The government also mandated that Pepsi Foodâs products be promoted under the name âLehar Pepsiâ (âleharâ meaning âwaveâ). Foreign collaboration rules in force at the time prohibited the use of foreign brand names on products intended for sale inside India. Although the requirements for Pepsiâs entry were considered stringent, the CEO of Pepsi-Cola International said at that time, âWeâre willing to go so far with India because we want to make sure we get an early entry while the market is developing.â In keeping with local tastes, Pepsi Foods launched Lehar 7UP in the clear lemon category, along with Lehar Pepsi. Marketing and distribution were focused in the north and west around the major cities of Delhi and Mumbai (formally Bombay). An aggres- sive pricing policy on the one-liter bottles had a severe impact on the local producer, Pure Drinks. The market leader, Parle, pre- empted any further pricing moves by Pepsi Foods by introducing a new 250-ml bottle that sold for the same price as its 200-ml bottle. Pepsi Foods struggled to fight off local competition from Pure Drinksâ Campa Cola, Dukeâs lemonade, and various brands of Parle. The fight for dominance intensified in 1993 with Pepsi Foodâs launch of two new brands, Slice and Teem, along with the introduction of fountain sales. At this time, market shares in the cola segment were 60 percent for Parle (down from 70 percent), 26 percent for Pepsi Foods, and 10 percent for Pure Drinks. Coca-Cola In May 1990, Coca-Cola attempted to reenter India by means of a proposed joint venture with a local bottling company owned by the giant Indian conglomerate, Godrej. The gov- ernment turned down this application just as PepsiCoâs application was being approved. Undeterred, Coca-Cola made its return to India by joining forces with Britannia Industries India Ltd., a local pro- ducer of snack foods. The new venture was called âBritco Foods.â Among local producers, it was believed at that time that Coca- Cola would not take market share away from local companies be- cause the beverage market was itself growing consistently from year to year. Yet this belief did not stop individual local produc- ers from trying to align themselves with the market leader. Thus in July 1993, Parle offered to sell Coca-Cola its bottling plants in the four key cities of Delhi, Mumbai, Ahmedabad, and Surat. In addition, Parle offered to sell its leading brands Thums Up, Limca, Citra, Gold Spot, and Mazaa. It chose to retain ownership only of Frooti and a soda (carbonated water) called Bisleri. FAST FORWARD TO THE NEW MILLENNIUM Seasonal Sales Promotionsâ2006 Navratri Campaign In India the summer season for soft drink consumption lasts 70 to 75 days, from mid-April to June. Dur- ing this time, over 50 percent of the yearâs carbonated beverages are consumed across the country. The second-highest season for consumption lasts only 20 to 25 days during the cultural festival of Navratri (âNavâ means nine and âratriâ means night). This tra- ditional Gujarati festival goes on for nine nights in the state of Gujarat, in the western part of India. Mumbai also has a significant Gujarati population that is considered part of the target market for this campaign. As the Regional Marketing Manager for Coca-Cola India stated, âAs part of the âthink localâact localâ business plan, we have tried to involve the masses in Gujarat with âThums Up Toofani Ramjhat,â with 20,000 free passes issued, one per Thums Up bottle. [âToofanâ means a thunderstorm and âramjhatâ means âletâs dance,â so together these words convey the idea of a âfast dance.â] There are a number of [retail] on-site activities too, such as the âbuy oneâget one freeâ scheme and lucky draws where one can win a free trip to Goa.â (Goa is an independent Portuguese- speaking state on the west coast of India, famed for its beaches and tourist resorts.) For its part, PepsiCo also participates in annual Navratri cel- ebrations through massive sponsorships of âgarbaâ competitions in selected venues in Gujarat. (âGarbaâ is the name of a dance, done by women during the Navratri festival.) The Executive Vice President for PepsiCo India commented: âFor the first time, Pepsi has tied up with the Gujarati TV channel, Zee Alpha, to telecast âNavratri Utsavâ on all nine nights. [âUtsavâ means festival.] Then there is the mega offer for the people of Ahmedabad, Baroda, Surat, and Rajkot where every refill of a case of Pepsi 300-ml. bottles will fetch one kilo of Basmati rice free.â These four cities are located in the state of Gujarat. Basmati rice is considered a premium quality rice. After the initial purchase of a 300-ml bottle, consumers can get refills at reduced rates at select stores. The TV Campaign Both Pepsi-Cola and Coca-Cola en- gage in TV campaigns employing local and regional festivals and sports events. A summer campaign featuring 7UP was launched by Pepsi with the objectives of growing the category and building brand awareness. The date was chosen to coincide with the Indiaâ Zimbabwe One-Day cricket series. The new campaign slogan was âKeep It Coolâ to emphasize the product attribute of refresh- ment. The national campaign was to be reinforced with regionally adapted TV campaigns, outdoor activities, and retail promotions. A 200-ml bottle was introduced during this campaign in order to increase frequency of purchase and volume of consumption. Prior to the introduction of the 200-ml bottle, most soft drinks were sold in 250-ml, 300-ml, and 500-ml bottles. In addition to 7UP, Pepsi Foods also introduced Mirinda Lemon, Apple, and Orange in 200-ml bottles. In the past, celebrity actors Amitabh Bachchan and Govinda, who are famous male stars of the Indian movie industry, had en- dorsed Mirinda Lemon. This world-famous industry is referred to as âBollywoodâ (the Hollywood of India based in Bombay). Pepsiâs Sponsorship of Cricket and Foot- ball (Soccer) After India won an outstanding victory in the IndiaâEngland NatWest One-Day cricket series finals, Pep- siCo launched a new ad campaign featuring the batting sensation, Mohammad Kaif. PepsiCoâs line-up of other cricket celebrities includes Saurav Ganguly, Rahul Dravid, Harbhajan Singh, Zaheer Khan, V.V.S. Laxman, and Ajit Agarkar. All of these players were part of the Indian team for the World Cup Cricket Series. During the two months of the Series, a new product, Pepsi Blue, was marketed nationwide. It was positioned as a âlimited edition,â icy-blue cola sold in 300-ml, returnable glass bottles and 500-ml plastic bottles, priced at 8 rupees (Rs) and Rs 15, respectively. In addition, commemorative, nonreturnable 250-ml Pepsi bottles priced at Rs 12 were introduced. (One rupee was equal to US 2.54 cents in 2008.) In addition to the sponsorship of cricket events, PepsiCo has also taken advantage of World Cup soccer fever in India by featur- ing football heroes such as Baichung Bhutia in Pepsiâs celebrity and music-related advertising communications. These ads fea- tured football players pitted against sumo wrestlers. To consolidate its investment in its promotional campaigns, PepsiCo sponsored a music video with celebrity endorsers includ- ing the Bollywood stars, as well as several nationally known crick- eters. The new music video aired on SET Max, a satellite channel broadcast mainly in the northern and western parts of India and popular among the 15â25 year age group. Coca-Colaâs Lifestyle Advertising While Pepsiâs promotional efforts focused on cricket, soccer, and other athletic events, Coca-Colaâs India strategy focused on relevant local idioms in an effort to build a âconnection with the youth market.â The urban youth target market, known as âIndia A,â in- cludes 18â24 year olds in major metropolitan areas. Several ad campaigns were used to appeal to this market seg- ment. One campaign was based on use of âgaanaâ music and bal- let. (âGaanaâ means to sing.) The first ad execution, called âBombay Dreams,â featured A. R. Rahman, a famous music director. This approach was very successful among the target audience of young people, increas- ing sales by about 50 percent. It also won an Effi Award from the Mumbai Advertising Club. A second execution of Cokeâs south- ern strategy was âChennai Dreamsâ (Chennai was formerly called Madras), a 60-second feature film targeting consumers in Tamil Nadu, a region of southern India. The film featured Vijay, a youth icon who is famous as an actor in that region of south India. Another of the 60-second films featured actor Vivek Oberoi with Aishwarya Rai. Both are famous as Bollywood movie stars. Aishwarya won the Miss World crown in 1994 and became an in- stant hit in Indian movies after deciding on an acting career. This ad showed Oberoi trying to hook up with Rai by deliberately leaving his mobile phone in the taxi that she hails, and then calling her. The ad message aimed to emphasize confidence and optimism, as well as a theme of âseize the day.â This campaign used print, outdoor, point-of-sale, restaurant and grocery chains, and local pro- motional events to tie into the 60-second film. âWhile awareness of soft drinks is high, there is a need to build a deeper brand connectâ in urban centers, according to the Director of Marketing for Coca- Cola India. âVivek Oberoiâwhoâs an up and coming star today, and has a wholesome, energetic imageâwill help build a stronger bond with the youth, and make them feel that it is a brand that plays a role in their life, just as much as Leviâs or Ray-Ban.â In addition to promotions focused on urban youth, Coca-Cola India worked hard to build a brand preference among young people in rural target markets. The campaign slogan aimed at this market was âthanda matlab Coca-Colaâ (or âcool means Coca-Colaâ in Hindi). Coca-Cola India calls its rural youth target market âIndia B.â The prime objective in this market is to grow the generic soft drinks category and to develop brand preference for Coke. The âthandaâ (âcoldâ) campaign successfully propelled Coke into the number three position in rural markets. Continuing to court the youth market, Coke has opened its first retail outlet, Red Lounge. The Red Lounge is touted as a one-stop- destination where the youth can spend time and consume Coke products. The first Red Lounge pilot outlet is in Pune, and based on the feedback, more outlets will be rolled out in other cities. The lounge sports red color, keeping with the theme of the Coke logo. It has a giant LCD television, video games, and Internet surfing facilities. The lounge offers the entire range of Coke products. The company is also using Internet to extend its reach into the public domain through the Web site www.myenjoyzone.com. The com- pany has created a special online âSprite-itudeâ zone that provides consumers opportunities for online gaming and expressing their creativity, keeping with the no-nonsense attitude of the drink. Coca-Colaâs specific marketing objectives are to grow the per- capita consumption of soft drinks in the rural markets, capture a larger share in the urban market from competition, and increase the frequency of consumption. An âaffordability plank,â along with introduction of a new 5-rupee bottle, was designed to help achieve all of these goals. The âAffordability Plankâ The purpose of the âaf- fordability plankâ was to enhance affordability of Coca-Colaâs products, bringing them within armâs reach of consumers, and thereby promoting regular consumption. Given the very low per- capita consumption of soft drinks in India, it was expected that price reductions would expand both the consumer base and the market for soft drinks. Coca-Cola India dramatically reduced prices of its soft drinks by 15 percent to 25 percent nationwide to encourage consumption. This move followed an earlier regional action in North India that reduced prices by 10â15 percent for its carbonated brands Coke, Thums Up, Limca, Sprite, and Fanta. In other regions such as Rajasthan, western and eastern Uttar Pradesh, and Tamil Nadu, prices were slashed to Rs 5 for 200-ml glass bottles and Rs 8 for 300-ml bottles, down from the existing Rs 7 and Rs 10 price points, respectively. Another initiative by Coca-Cola was the introduction of a new size, the âMini,â expected to increase total volume of sales and ac- count for the major chunk of Coca-Colaâs carbonated soft drink sales. The price reduction and new production launch were announced together in a new television ad campaign for Fanta and Coke in Tamil. A 30-second Fanta spot featured the brand ambassador, ac- tress Simran, well-known for her dance sequences in Hindi mov- ies. The ad showed Simran stuck in a traffic jam. Thirsty, she tosses a 5-rupee coin to a roadside stall and signals to the vendor that she wants a Fanta Mini by pointing to her orange dress. (Fanta is an orangeade drink.) She gets her Fanta and sets off a chain reaction on the crowded street, with everyone from school children to a traditional ânaniâ mimicking her action. (âNaniâ is the Hindi word for grandmother.) The director of marketing commented that the company wanted to make consumers âsit up and take notice.â A NEW PRODUCT CATEGORY Although carbonated drinks are the mainstay of both Cokeâs and Pepsiâs product line, the Indian market for carbonated drinks is now not growing. It grew at a compounded annual growth rate of only 1 percent between 1999 and 2006, from $1.31 billion to $1.32 billion. However, the overall market for beverages, which includes soft drinks, juices, and other drinks, grew 6 percent from $3.15 billion to $3.34 billion. To encourage growth in demand for bottled beverages in the Indian market, several producers, including Coke and Pepsi, have launched their own brands in a new category, bottled water. This market was valued at 1,000 Crores.1 Pepsi and Coke are responding to the declining popularity of soft drinks or carbonated drinks and the increased focus on all beverages that are non-carbonated. The ultimate goal is leader- ship in the packaged water market, which is growing more rapidly than any other category of bottled beverages. Pepsi is a signifi- cant player in the packaged water market with its Aquafina brand, which has a significant share of the bottled water market and is among the top three retail water brands in the country. PepsiCo consistently has been working toward reducing its dependence on Pepsi Cola by bolstering its non-cola portfolio and other categories. This effort is aimed at making the company more broad-based in category growth so that no single product or category becomes the key determinant of the companyâs market growth. The non-cola segment is said to have grown to contribute one-fourth of PepsiCoâs overall business in India during the past three to four years. Previously, the multinational derived a major chunk of its growth from Pepsi-Cola. Among other categories on which the company is focusing are fruit juices, juice-based drinks, and water. The estimated fruit juice market in India is approximately 350 Crores and growing month to month. One of the key factors that has triggered this trend is the emergence of the mass luxury segment and increasing consumer consciousness about health and wellness. âOur hugely successful international brand Gatorade has gained momentum in the coun- try with consumers embracing a lifestyle that includes sports and exercise. The emergence of high-quality gymnasiums, fitness and aerobic centres mirror the fitness trend,â said a spokesperson. Coca-Cola introduced its Kinley brand of bottled water and in two years achieved a 28 percent market share. It initially produced bottled water in 15 plants and later expanded to another 15 plants. The Kinley brand of bottled water sells in various pack sizes: 500 ml, 1 liter, 1.5 liter, 2 liter, 5 liter, 20 liter, and 25 liter. The smallest pack was priced at Rs 6 for 500 ml, while the 2-liter bottle was Rs 17. The current market leader, with 40 percent market share, is the Bisleri brand by Parle. Other competing brands in this segment include Bailley by Parle, Hello by Hello Mineral Waters Pvt. Ltd., Pure Life by NestlÃ©, and a new brand launched by Indian Railways, called Rail Neer. CONTAMINATION ALLEGATIONS AND WATER USAGE Just as things began to look up for the American companies, an environmental organization claimed that soft drinks produced in India by Coca-Cola and Pepsi contained significant levels of pes- ticide residue. Coke and Pepsi denied the charges and argued that extensive use of pesticides in agriculture had resulted in a minute degree of pesticide in sugar used in their drinks. The result of tests conducted by the Ministry of Health and Family Welfare showed that soft drinks produced by the two companies were safe to drink under local health standards. Protesters in India reacted to reports that Coca-Cola and Pepsi contained pesticide residues. Some states announced partial bans on Coke and Pepsi products. When those reports appeared on the front pages of newspapers in India, Coke and Pepsi executives were confident that they could handle the situation. But they stumbled. They underestimated how quickly events would spiral into a nationwide scandal, misjudged the speed with which local politi- cians would seize on an Indian environmental groupâs report to attack their global brands, and did not respond swiftly to quell the anxieties of their customers. The companies formed committees in India and the United States, working in tandem on legal and public relations issues. They worked around the clock fashioning rebuttals. They com- missioned their own laboratories to conduct tests and waited until the results came through before commenting in detail. Their ap- proaches backfired. Their reluctance to give details fanned con- sumer suspicion. They became bogged down in the technicalities of the charges instead of focusing on winning back the support of their customers. At the start, both companies were unprepared when one state after another announced partial bans on Coke and Pepsi products; the drinks were prevented from being sold in government offices, hospitals, and schools. Politicians exploited the populist potential. In hindsight, the Coke communications director said she could see how the environmental group had picked Coca-Cola as a way of attracting attention to the broader problem of pesticide contami- nation in Indian food products. âFringe politicians will continue to be publicly hostile to big Western companies, regardless of how eager they are for their investment,â she said. Failing to anticipate the political potency of the incident, Coke and Pepsi initially hoped that the crisis would blow over and they adopted a policy of silence. âHere people interpret silence as guilt,â said an Indian public relations expert. âYou have to roll up your sleeves and get into a street fight. Coke and Pepsi didnât un- derstand that.â Coca-Cola eventually decided to go on the attack, though in- directly, giving detailed briefings by executives, who questioned the scientific credentials of their productsâ accusers. They directed reporters to Internet blogs full of entries that were uniformly pro- Coke, and they handed out the cell phone number for the director of an organization called the Center for Sanity and Balance in Pub- lic Life. Emphasizing that he was not being paid by the industry, Kishore Asthana, from that center, said, âOne can drink a can of Coke every day for two years before taking in as much pesticide as you get from two cups of tea.â The situation continued to spin out of control. Newspapers printed images of cans of the drinks with headlines like âtoxic cocktail.â News channels broadcast images of protesters pouring Coke down the throats of donkeys. A vice president for Coca- Cola India said his âheart sankâ when he first heard the accusa- tions because he knew that consumers would be easily confused. âBut even terminology like P.P.B.âparts per billionâis difficult to comprehend,â he said. âThis makes our job very challenging.â PepsiCo began a public relations offensive, placing large ad- vertisements in daily newspapers saying, âPepsi is one of the safest beverages you can drink today.â The company acknowledged that pesticides were present in the groundwater in India and found their way into food products in general. But, it said, âcompared with the permitted levels in tea and other food products, pesticide levels in soft drinks are negligible.â After all the bad press Coke got in India over the pesticide content in its soft drinks, an activist group in California launched a campaign directed at U.S. college campuses, accusing Coca- Cola of India of using precious groundwater, lacing its drinks with pesticides, and supplying farmers with toxic waste used for fertilizing their crops. According to one report, a plant that produces 300,000 liters of soda drink a day uses 1.5 million liters of water, enough to meet the requirements of 20,000 people. The issue revolved around a bottling plant in Plachimada, India. Although the state government granted Coke permission to build its plant in 1998, the company was obliged to get the lo- cally elected village councilâs go-ahead to exploit groundwater and other resources. The village council did not renew permission in 2002, claiming the bottling operation had depleted the farmersâ drinking water and irrigation supplies. Cokeâs plant was closed until the corporation won a court ruling allowing them to reopen. The reopening of the plant in 2006 led students of a major Mid- western university to call for a ban on the sale of all Coca-Cola products on campus. According to one source, more than 20 cam- puses banned Coca-Cola products, and hundreds of people in the United States called on Coca-Cola to close its bottling plants be- cause the plants drain water from communities throughout India. They contended that such irresponsible practices rob the poor of their fundamental right to drinking water, are a source of toxic waste, cause serious harm to the environment, and threaten peo- pleâs health. In an attempt to stem the controversy, Coca-Cola entered talks with the Midwestern university and agreed to cooperate with an independent research assessment of its work in India; the univer- sity selected the institute to conduct the research, and Coke fi- nanced the study. As a result of the proposed research program, the university agreed to continue to allow Coke products to be sold on campus. In 2008 the study reported that none of the pesticides were found to be present in processed water used for beverage produc- tion and that the plants met governmental regulatory standards. However, the report voiced concerns about the companyâs use of sparse water supplies. Coca-Cola was asked by the Delhi-based environmental research group to consider shutting down one of its bottling plants in India. Cokeâs response was that âthe easiest thing would be to shut down, but the solution is not to run away. If we shut down, the area is still going to have a water problem. We want to work with farming communities and industries to reduce the amount of water used.â The controversies highlight the challenges that multinational companies can face in their overseas operations. Despite the huge popularity of the drinks, the two companies are often held up as symbols of Western cultural imperialism. QUESTIONS 1. Timing of entry into the Indian market brought different results for PepsiCo and Coca-Cola India. What benefits or disadvantages accrued as a result of earlier or later market entry? ? 2. âGlobal localizationâ (glocalization) is a policy that both companies have implemented successfully. Give examples for each company from the case. ? 3. Which of the two companies do you think has better long- term prospects for success in India? ? (Please answer the three questions with 300-350 words each, thank you so much).

Can someone revise this essay
state and better Thesis statement

In traditional grading, letter grades report thenumber of point earned in a subject but not
about what students have learned. Getting rid of traditionalgrading should be replace with a
standard base grading where student's content knowledge shouldinstead be considered. Does
grade diminish students' interest or eliminate the opportunity forself evaluations? Should
students have a variety ways to show what they know and learned, aswell as a chance to relearn
lessons? The answers should be resounding yes. Conversely, theobjective of learning is
compromised. For instance, traditional grading has manydisadvantages; however, there are
various alternatives method that can take students' knowledge intoaccount.
According to Stephen Covey, âmany students procrastinate and thensuccessfully cram
for testsâthey might cram to get the grades and degrees they needto get good or better jobs,
even if they fail to get a good general educationâ (Corey, 2010).This statement speaks about the
separation that exists within our society when it comes to gradesand content knowledge. For
instance, if good grades are achieved, one can simply assume that agood education has been
given and important knowledge has been learned. Regrettably, thisdoes not always happen. In
fact, it is very unlikely. In reality, grades are usually based oninformation which has nothing to
do with standard knowledge or knowledge to be acquired. However, itis just a way to stamp the
students with numbers; where the ones with the higher numbers getto move on academically,Simon2
while the ones with lower numbers are being put on academicprobation or even kicked out of
school. As far as one can see the correlation with traditionalgrading to be âsort ofâ Charles
Darwinâs survival of the fittest theory, which states that âtheones that are the most fit for the
environment survivesâ. This method is problematic in our societybecause it discriminates or
marginalizes against those that are not good test-takers or unableto meet the traditional grading
threshold.
Some may say that the effect of traditional grading on students arewidespread and
students who perform well in school may tend to view assessmentsand grading evidence of
their success. In contrast, not all students are a good test takerbecause the other who do poorly in
school or received a lower grade view assessment as evidence oftheir failures. However,
traditional grade should change because not all students accept thetraditional grade as new
challenges; instead these students feel hopeless and seek theeasiest option like giving up or fail
into a negative cycle.
Another disadvantage of traditional grading it that that studentsbecome discouraged after
they receive a poor grade or when they get to the point where theydo not believe they can
receive a passing grade. As a result, they develop low self-esteemsand at times become very
depressed. Additionally, some students have complained that thetraditional grading system or
the way in which it is done have not been a positive experience forthem. Furthermore, there are
times when the students really know the materials, but due to lackof test-taking skills perform
poorly in the class. Currently, âmost current grading practices aregrounded in tradition, rather
than research on best practice. Teachers continue to average scoresto calculate grades; combine
indicators of achievement, behavior, and progress into a singlegrade; and grade on the curve,Simon3
despite evidence showing the detrimental consequences of thesepracticesâ (Jung & Gusky,
2011). In other words, the traditional grading hinders studentsâlearning and therefore suppresses
them to move on academically.
Next, Grade is one of the most common cause of cheating in school.It can be the
difference between multiple things getting into college or thepressure from parents about getting
a good grade cause student to cheat. If the sole reason forengaging in an academic task is to get
a good grade, then it is probably easy for students to justify theact of cheating.To alleviate this
growing problem, the ministry of education or teacher shoulddeveloped several propositions to
help grades become a more accurate reflection of studentsâknowledge and suppose, will not only
help improve the relevant of studentsâ grades, but also theirattitudes towards grades and their
ability to do well in their course.
Away from studentsâ attitude, grades help determine studentsâ livesafter high school. In
addition, colleges often look at GPA, grades, and high-stakes testscores in an effort to find
higher students will be successful on their institution.Unfortunately, many schools discovered
that the grades students earn in their courses often are not goodpredictors of how well they will
perform on those exams. This dissimilarity reveals a hidden truththat grades have not been
reliable indicators of what students know or able to do. Byexample, when parents taught
children to talk and count; the did not receive a grade.The did itbecause is was a mirth and if
they failed to pronounce words however, parents keep working withthe children until they
learned it the proper way.
If colleges are depending on grades and GPA to determine who getsaccepted to their
school. In fact reliable data should be provided on the students sothe school can make informSimon4
decision to whom they allow on their campuses. In firstproposition, teachers should accept late
work from students and give them descriptive written and verbalfeedback on their assignments.
In other words, several arrangement must be made for the studentsconsidering the many
different learning methods that are available.The feedback beinggiven to students have been
more evaluate in the traditional system than it is descriptive.Accepting late work is a step in the
right direction as evidenced because giving a student zeros are notgood motivation for students.
Feedback, accepting late work, giving purposeful work, and thepercentage of a failing grade are
all aspects which should be most likely to improve in propositionin an effort to give students
more accurate grades.
The current grading system is due for a major change. Considerablytoo often it forces
teachers to take into account factors other than the studentâsknowledge when assigning grades.
In the article written by Jeanetta Jones Miller (2014), entitledâWhat the Researchers Say about
Gradesâ, states âthe difference between failure and the honor rolloften depends on the grading
policies of the teacher. In order to reduce the failure rate,schools do not need a new curriculum,
a new principal, new teachers, or even new technology. They justneed a better grading system.â
With the traditional grading system, however, students can earn apassing grade simply by
turning in work.
Another proposition is to implement a Standards-based grading whichis more accurate
than grades that are based on traditional grading systems thatincorporate a mixture of academic
performance, extra credit, behavior, and work habits,â (Proulx,Spencer, & Westerberg, 2012).
Standards-based grading is a better way to show what standardsstudents have been able to
master over the course of the school year. In addition, manyresearchers believe standards-basedSimon5
grading is fairer for students' report cards because achievement ismore accurately represented in
relation to learning expectations or standards.Grades shouldaccurately portray the studentsâ
learning in their classrooms. Nevertheless, there is no consistentset of criteria to base grades.
This means the interpretation of grades can vary from one person tothe next and takes away the
credibility of grades.
Studentâs grade should, ideally, represent how well they know thematerial; it should not
reflect behavior in class or many other non-academic basedcriteria. This should be the base of
how teachers grade so all interpretations, no matter who is lookingat them, can begin with the
same understanding. However, concerning grading practices showsthat it is greater than
expected number of factors that are used in determining studentgrades. âWhile traditional tests
and quizzes are almost always considered, other factors includeevaluations of class
participation, homework, projects, answer question asked byprofessor, notebook reviews, labs
and lab reports, effort, neatness, behavior and attendance, as wellas a teacher's personal
assessment of a student's traits and personal characteristicsâ(Corey 2010). It is difficult to
distinguish what qualifies as academic and what qualifies asbehavioral. However, most teachers
will not be able to agree 100% on where these actions belong and ifstudents should be graded on
these actions or not.
If a grade reflects what students have learned, we must notpenalize students' grades over
behavioral issues,â Teachers need to focus on what the students arelearning, not outside
influences. ââ¦traditional end-of-course grades are the finalproducts of many factors, including
quizzes, homework, behavior, and attendance, with standards basedgrading nothing but mastery
matters. Standards-based grades account for non academic elementsvery minimally or not atSimon6
all,â (Spencer, 2012) which helps the grade reflect actual studentlearning. When grading
systems differentiate between practice and mastery, students havemore incentive to master the
skills necessary because there is nothing there to cushion theirgrade. This motivates students to
move from easy concepts to more difficult concepts and rewards themâfor ultimately obtaining
knowledge, no matter how longâ it takes, (Spencer, 2012)
In addition, some might argue about how to evaluate other areas ofschool such as
homework and other nonacademic standard. Homework assignment needsto be thoughtful and
productive, not busywork. Furthermore, if the purpose of homeworkis to give students extra
practice, it is important to remember that not all students learnthe same way. Professor or
teacher should differently their teaching; so it makes sense thento offer a variety of homework
assignments as well. Traditionally, âhomework grades do notaccurately express student
understanding,â (Spencer, 2012). Homework does not necessarily meanthat it needs to be graded
along with behavior, attendance, notebooks, and group work.Assigning homework can be
important as long as it helps to improve the studentsâ learning,but it does not necessarily need a
grade. A zero in the grade book can take a studentâs grade downsignificantly. A zero is âseldom
an accurate description of a student's achievement and skew averagegrades dramatically.â Many
teachers claim to use zeros as a way to motivate students when, infact, âresearch indicates the
opposite. however, most students are discouraged by zeros and tendto give up. More students to
become discouraged and give up once a zero or a lower grade isentered as their grade for the
assignment.
Contrary to many opinion, traditional grading has adverseconsequences on students
motivation. Some students get motivated to do some tasks for theinherent enjoyment whileSimon7
others may have the motivation to do some assignments because ofthe result outcome or they
do not have any other choices to prove their content ofknowledge.
There is no advantage to using zeros for grading. A zero in thegrade book discourages students
from trying to master needed skills and does not accurately measuretheir knowledge. Low
scores often have a similar effect as a zero for students. They seetoo many low grades on
assignments, and they begin to find themselves less motivated andless likely to continue trying
their best. Many argue that grades should be indicators of academysuccess ; although, grades do
not reveal what a student know or studentâs knowledge according toERIC (U.S. Dept. of
Education) journal.
For instance low grades marks as punishments. Instead of promptinggreater effort, low
grades more often cause students to withdraw from learning orclasses. Students should be given
an opportunity to relearn and redo an assignment they earned a lowscore on. This shows that the
student has not mastered an important skill they are expected tolearn. Several zeros or low
scores often result in a failing grade. In a typical grading scale,90-100 would equal an âAâ
grade; this is a range of ten points. An âFâ could be anywhere from0 points to 59 points; giving
a 59 point spread compared to ten. In other words, âwhile theintervals representing most grades
are typically 10 points or less, the interval for an "F" istypically 60 points or more,â (Carey &
2010).To conclude ,for the benefit of students, teacher and inbetter learning for the society;
those reasons prove that students knowledge should take intoaccount first not the letter grading
In proposition, the traditional grading system needs to bereconsidered and it needs to change.

Work Cited
Carey, T., & Carifio, J. (2010). A Critical Examination ofCurrent Minimum Grading Policy
Dinnen, J., & Collopy, R. (2009). An analysis of feedback givento strong and weak
student writers. Reading Horizons, 49, pp. 239-256.
Darwin & the banking industry. (Charles Darwin'ssurvival-of-the-fittest theory) (The
Banking Industry) July, 1991, Vol.80(7), p.10(5)
Guskey, T. (2000). Grading policies that work againststandards...and how to fix them.
National Proulx, C., Spencer-May, K., & Westerberg, T. (2012).Moving to Standards-Based
Grading.
Tierney, R., Simon, M., & Charland, J. (2011). Being fair:Teachers' interpretations of
principles for standards-based grading. The Educational Forum,75(3), pp. 210-227.
ERIC (U.S. Dept. of Education) Elementary School Journal, 2011,Vol.112(1), p.61-82

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