RLGA01H3 Chapter Notes - Chapter 3: Sanzen, Hinayana, Nonkilling

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25 Oct 2012

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49 days in the immovable spot: buddha founded an order of monks and nuns, challenged the deadness of. Infinite it is drawn to: buddha was determined to clear the ground from corruption that truth might find new life, buddha preached a religion devoid of authority. and do not accept what they hear by report. He wanted to abolish the brahmin caste. Brahmanic rites as superstitious petitions to ineffectual gods. No god or gods could be counted on, not even the buddha himself. Buddha considered the notion that only brahmins could attain enlightenment as ridiculous. Buddha doesn"t believe reincarnation because once gone, they will always be gone: buddha preached a religion devoid of the supernatural. Buddha condemned all forms of divination, soothsaying and forecasting as low arts. Morbidity of decrepitude/elderly: fear of financial dependence, fear of being unloved and unwanted and fear of protracted illness and pain. Five skandas or life components (painful): body, sensations, thoughts o.

Related Questions

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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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 Most Stressful Conditions
How can effective choices be made when there is no time, when your employees, your company, and your community are in imminent danger? Decision making under these conditions takes on a different character, as shown in the response of Sidley Austin Brown & Wood to the tragic events of September 11, 2001.
The giant law firm was formed in May 2001 when Brown & Wood merged its Wall Street financial law offices with those of Chicago-based Sidley & Austin, corporate law specialists, creating the nationâs fourth-largest practice, with 1,400 lawyers worldwide. Many of the firmâs lawyers are headquartered in New York City, with 600 formerly housed at 1 World Trade Center on floors 52 to 57 and another 100 seven miles away in midtown Manhattan. On September 11, the first plane struck overhead. Workers noticed the explosionâs tremors and the smell of jet fuel. Director of Administration John Connelly asked workers to evacuate, helping the frightened and confused employees to the stairs. Being unaware of the extent of the danger, Connelly and others went from floor to floor to ensure that everyone was safely out, then left the building just as it collapsed. Only one company employee perished in the attack.
In the aftermath, with damaged facilities and workers in shock, Sidley Austin employees faced the most trying circumstances of their careers. When their attempts to contact the midtown building failed because cell phone towers had been destroyed, many employees walked to the site. At the midtown location, partner Alan S. Weil anticipated the need for additional office space and called his landlord, who granted immediate leases on two floors and also got another law firm to gibe up two newly leased floors. By the end of the day, hundreds of desks, computers, and cell phones were arriving, and contractors were installing computer cables. âItâs just amazing what you can get in New York overnight,â says partner Thomas R. Smith Jr. According to New York writer John Schwartz, âThe normal rules of business engagementâdeliberate negotiation, adversarial wrangling and jockeying for advantageâwere swept away. The infamously in-your-face New York attitude was nowhere to be found.â
The partnershipâs directors were supposed to meet in Los Angeles on September 12 but were stranded elsewhere as airlines ceased operations. The executives used conference call to begin âissue-spotting,â according ti Thomas Cole, partner. He explained, âThe lawyers who assembled that day and in the days thereafter were people who had spent their entire working lives engaged in solving complex problems for clients.
â¦But that was under normal conditions. Would we succeed under the most stressful conditionsâ¦?â Issues involving people, insurance, and communications were complex; for example, the people issue covered such items as payroll continuity, trauma counseling, and safety and security. The organization pulled togetherâstaffers from the Chicago headquarters drove all night to assist. When the firmâs backup data tapes needed transport from a New Jersey warehouse to Chicago, the storage companies offered to have their employees drive overnight because no planes were flying. Dennis J. OâDonovan, head of the firmâs technology section, says, â[Disaster recovery seminars] always prepare you for the worstâpeople not being available, people not being cooperative; the opposite has happened.â
On September 17, firm employees met, and partner Charles W. Douglas told the crowd, âThe assets of the law firm are not the desks in the offices, the woodwork thatâs on the walls or the paintings that are hung in the corridors. The assets of the law firm are its people.â Smith agreed, saying, âBeing able to keep the business going is great, but itâs the people that count.â Employees and partners at Sidley Austin have taken on the added work with few complaints; many say that work is therapeutic. The lawyers have completed many financial deals on time, believing that itâs their patriotic duty to continue working as before. Employees claim that the tragedy drew them closer together, creating intimate friendships. Others are still suffering from stress, and some may choose paid disability leave, Nancy L, Karen, chief information officer, says the firm has learned a lot about crisis conditions. âWe ought to be able to recover in less than a say next time,â she says, adding with a nervous laugh, âGod forbid!â Perhaps Thomas Cole best askedâ¦if the disaster has been a setback to the full realization of the anticipated benefits of our merger. I answer that â[b]because of the way few have risen to this challenge together, the most important yet most elusive goal in any merger integration, namely the creation of a true partnership, occurred overnight.â

References: âAbout Sidley,â âOur Offices,â âOur Practices,â Sidley Austin Brown & Wood website. www.sidley.com

Case Questions
1. Using the rational approach to decision making, describe the ways in which these crisis conditions affected each step of the decision-making process.

2. Based on your answer to question 1, what are some potential problems that firm should be aware of when they must make decisions during a crisis? What are some steps that firms can take to avoid those problems or to minimize their negative impact?

3. Due to the extraordinary circumstances in New York City during and just after September 11, many individuals and firms changed their behavior, acting more altruistically and ethically. In your opinion, why did this occur? Do you think the change is likely to endure for a long time, or is it only temporary?

RLGA01H3 Chapter Notes - Chapter 3: Sanzen, Hinayana, Nonkilling

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