FAH206H1 Chapter 21: Christopher Mee - Death and Burial

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2 Feb 2012

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Funeral practices were already well developed before the start of the neolithic period as evidenced by the cremation and burial at franchthi cave: not very many neolithic graves excavated. Intramural burial within settlements was not common for adults - most were infants or young. Secondary burial was a regular practice and are also occasionally present within settlements. Inhumation probably sot common practice - so where were most buried: graves must have been quite shallow and have consequently been destroyed or disturbed by later activities. Perhaps death was treated casually: neolithic society relatively egalitarian, therefore burial practices not use to stress status distinctions - evidence of inequality in late neolithic period. Some communities did have complex ritual practices that they observed in both children and adults which may reflect a wider belief system. Funerals probably not as simple as they seem.

Related Questions

Epidemiology

Each of the following paragraphs presents a study objective and the methodology that will be used to evaluate the types of epidemiologic study design. State what is the study design for each study? (24 points â 4 each) (Note: For study design, try to have as detailed design as possible and avoid simply âexperimental studyâ or âobservational studyâ)

c) The following abstract was obtained from PubMed (with modification by XLD).

Lishman H, et al. Exploring the relationship between primary care antibiotic prescribing for urinary tract infections, Escherichia coli bacteraemia incidence and antibiotic resistance. Int J Antimicrob Agents. 2018 Aug 23. [Epub ahead of print].

This study aimed to quantify the association between antibiotic prescribing for urinary tract infections (UTIs) and the incidence/antibiotic susceptibility of UTI-related Escherichia coli bacteraemia in adult women in England. A national study was conducted with data aggregated at the GP practice level. The study population was all adult female patients (18+) with a reported UTI-related E. coli bacteraemia in England (2012-2014). Reports of bacteraemia from the national mandatory surveillance scheme were linked with E. coli blood culture susceptibility data (where available) and the correlation with primary care exposure to trimethoprim and nitrofurantoin was quantified using longitudinal multi-level models. There were 20,274 patients in the study from 5,916 practices. Between 2012-2014, the overall incidence of UTI-related E. coli bacteraemia in the study group did not change significantly (1.3% increase, 95% CI 0.1%-2.7%, p=0.074). However, after adjusting for practice characteristics, UTI-related E. coli bacteraemia incidence increased by 3.0% and 1.5% with each increasing quintile in trimethoprim and nitrofurantoin prescribing, respectively. The incidence of trimethoprim-resistant bacteraemia increased by 4.5% (p=0.032) with each increasing quintile in trimethoprim prescribing and was not associated with nitrofurantoin prescribing. This study demonstrates an association between GP prescribing for UTIs and UTI-related E. coli bacteraemia incidence at the practice level and shows that higher prescribing of trimethoprim is associated with higher incidence of trimethoprim-resistant bacteraemia. Evidence is provided of the importance of prudent antibiotic prescribing in primary care to prevent the development of antibiotic resistance which can put patients at risk of subsequent severe infections.

Study Design: ___________________________

d. The following abstract was obtained from PubMed (with modification by XLD).

Mubarak MY, et al. Hygienic practices and diarrheal illness among persons living in at-risk settings in Kabul, Afghanistan. BMC Infect Dis. 2016 Aug 31;16(1):459.

BACKGROUND: Sustained civil and military conflict, resulting in large numbers of internally displaced persons (IDP), in combination with rapid urbanization has strained public health and sanitation within cities in Afghanistan. In order to examine the association between preventive sanitary behaviors and diarrhea within two high risk settings located within Kabul, Afghanistan, this study aimed to evaluate the prevalence of hygienic practices and diarrheal illness in an IDP camp and an urban slum.

METHODS: In this study, a convenience sample of residents of an IDP camp and an urban slum in Kabul, Afghanistan, was used. Participants were asked to describe their hygienic practices and interviewers independently documented household sanitation. The knowledge and attitudes about and practice of hygienic activities to prevent diarrhea were compared between the two settings.

RESULTS: Two hundred participants, 100 from each setting, were enrolled. Knowledge, attitudes, and practices regarding hygienic activities to prevent diarrhea were greater among the slum dwellers than the IDP. Fewer than half of participants washed their hands with soap before eating or after eating: 31 % of slum dwellers washed before eating compared to 11 % of IDPs (Pâ=â0.0050), and 25 % of slum dwellers washed after defecating compared to 4 % of IDPs (Pâ=â0.0020). The IDPs were more likely to share a latrine (Pâ=â0.0144) and less likely to disinfect their latrine than slum dwellers. Diarrhea in the household within the past 3 months was more common in the IDP camp (54 %) than the slum (20 %) (Pâ=â0.0020).

CONCLUSIONS: Even though certain sanitary and hygienic practices were more common among slum dwellers than IDPs, the lack of hygienic activities in both setting indicates that interventions to change behavior, like increasing the availability of soap and encouraging hand washing, are needed. Any initiative will have to be developed in the context of pervasive illiteracy among persons in these settings.

Study Design: ___________________________

Next Article >

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

1. For each of the following independent situations (a â k),describe the most appropriate course of action that the auditorsshould take.

A. While reviewing audit documentation, Tyson Michaels, apartner at K&O was reviewing working papers as part of thefirmâs system of quality control. Tyson noted that after releasingan audit report related to the financial statements of a publiclytraded client, it does not appear that any tests were conducted toevaluate the need for impairment of the carrying value of theCompany's property, plant, and equipment. These tests are importantwith respect to supporting the audit opinion.

B. Prior to the audit completion date (April 1, 2015), anauditor learned that their audit client Bubbagump Inc., haddeclared a significant dividend payable to its shareholders. Thisdividend was declared on March 14, 2015, to be paid to Bubbagumpâsshareholders of record on May 16, 2015.

C. Pat Colt completed the December 31, 2014, audit of Manningand issued an unmodified opinion on Manning's financial statementsdated March 15, 2015. Colt's opinion was released, along withManning's financial statements, on March 21, 2015. During a reviewof Manning's first quarter 10-Q in late April, Colt became aware ofthe company's settlement with a customer over a product warrantylawsuit; this case had been settled on March 17, 2015. AlthoughColt had received the necessary letter from Manning's attorneys,the letter arrived prior to the settlement of the case and did notmention this development. After reviewing the information relatedto the settlement, Colt does not believe that the settlement ismaterial to Manning's financial condition or results of operationsand believes the opinion on Manning's financial statements is stillsupportable.

D. During a PCAOB inspection, it was determined that WKRP, LLPhad not adequately documented their rationale for not observing thephysical inventory count in its audit of King Manufacturing. Thisdiscovery occurred over a full year after the audit report releasedate. Lebron McWhiney, the lead engagement partner conceded thatthe inventory observation had not occurred and alternativeprocedures were not available due to the clientâs accounting recordretention policies. In discussions with the PCAOB investigatorsLebron noted that the rationale, although not documented, was thatKingâs year-end inventory is quantitatively immaterial, at just 1%of total assets.

E. Drew Allison is conducting the audit of Anderson Inc. as ofDecember 31, 2014. At the beginning of the evidence gathering,Allison becomes aware that one of Anderson's major customers(Jones) is experiencing significant financial difficulties. Jonesnormally accounts for 5 percent of Anderson's net sales. Afterperforming the necessary procedures, Allison believes that $2.8million of Jones's receivable balance will ultimately becomeuncollectible. Allison further believes this amount is material toAnderson's financial condition and results of operations.

F. Charles Carmelo is completing the December 31, 2014, audit ofNugget Company. As part of the final procedures, Carmelo hasrequested representations from Nugget's management regarding theirassertion as to the fairness of the financial statements and otherimportant matters addressed by professional standards on February5. Because Nugget's management is attending an analyst briefing inthe upcoming week, Carmelo receives these signed representationsdated February 9, 2015. Because Carmelo had already completed allof the important procedures he released his auditorâs report, datedFebruary 5, 2015, with the financial statements on February 6.

G. Gruden LLP, was auditing Raider Company for the year endedDecember 31, 2014. Gruden plans on completing the audit by February17, 2015. On January 17, 2015, Gruden LLP learned that RaiderCompany activated a portion of its line of credit on January 5,2015, by borrowing $2.5 million. This additional obligationincreased Raider Company's long-term liabilities by 10 percent.

H. Cameron Alta completed the December 31, 2014, audit of SaxeCompany on February 10, 2015. Saxe is planning to release itsfinancial statements, along with Alta's opinion on these financialstatements and internal control over financial reporting, onFebruary 17, 2015. On February 12, 2015, a flood in one of Saxe'swarehouses located in the Gulf Coast region destroyed more than $10million of inventory. The extent to which this loss is recoverablethrough Saxe's insurance is unlikely, Alta believes that this losscould have a material impact on Saxe's financial condition andresults of operations.

I. During the audit of Glomco, Angel Myron identified a numberof misstatements. These misstatements are not material in dollaramount, do not appear to represent any discernable pattern, and donot represent fraudulent activity. As a result, Myron has decidedthat Glomco's financial statements do not need to be adjusted toreflect the effect of these misstatements.

J. Crismus and Stori, LLP is auditing Frozen Pole Desserts (FPD)for the year ended December 31, 2014. On February 9, 2015, theaudit partner in-charge Ralphy, learned of the following eventsduring his meeting with FPD's chief operating officer. A classaction lawsuit was brought against FPD by some of its formeremployees for workplace discrimination. An attorney on behalf of aclass of employees filed the lawsuit on January 10, 2015. Theletter from FPD's attorneys suggested that the amounts are notestimable and the likelihood of a negative outcome cannot bedetermined at this time.

K. Following the completion of the 2014 audit (including therelease of the audit report) of Blankenship Corporation, bySeeanSee, Muzik, and Fakdurry, LLC (SMF). Reese Jill, SMFâs auditpartner met with the manager on the audit engagement to conduct apostmortem on the engagement and identify how changes inBlankenship's operations noted during the most recent audit mayaffect future audits. During this review, Jill became aware thatBlankenship's process for evaluating potential impairment ofgoodwill related to an acquisition made by Blankenship during themost recent year had been considered and calculated by the auditteam, but for unknown reasons the adjustment had not been proposedto the client. Thus, the impairment had not been properly disclosedor accounted for in the financial statements. Jill believes thatthe results of the procedure is important in supporting the opinionon Blankenship's financial statements and notes that Blankenshipâsmanagement would probably be receptive to adjusting thefinancials.

Required: Unless otherwise noted, assume that each scenarioaffect (are material) to the Companyâs financial statements, andthere are persons who continue to rely on the financial statements.For each of the preceding items, determine:

I. whether the event described should be classified as:

A. Subsequent Event

B. Subsequently Discovered Event

C. Omitted Procedure

D. None of the above

II. what actions the auditor should take after the firm'squality review identified these issues:

1) Disclosure in financial statements

2) Adjustment to and/or disclosure in the financialstatements

3) No further action is necessary (specific auditprocedures)

4) Determine if alternative procedures are available, if so takeaction 5, if procedures are not available, withdraw the auditorâsreport

5) Perform procedures related to the item and revise theauditorâs report date if necessary

6) Perform procedures related to the items and if facts wouldresult in revision of auditorsâ report or financials, then notifyindividuals relying on financials and issue revised financialswhich provide disclosure of facts

7) Not applicable

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