Nutritional Supplements As Effective As Full Ward Diet Nursing Essay

Nutritional Supplements As Effective As Full Ward Diet Nursing Essay Pressure ulceration has become a common health issue in hospitalized patients and elderly patients living in a long-term care facility. It can be contributed by various factors such as aging, poor nutrition, immobility, and cognitive impairment. A literature review was conducted based on five published research articles. The aim was to investigate the therapeutic relationship between nutritional support and pressure sores healing. The result indicated significant improvement in pressure ulcer healing. Background Aim of the paper The aim of this study is to critically review current literature in order to evaluate the effectiveness of oral nutritional supplement (ONS) in addition to regular food intake in the prevention and treatment of pressure ulcers. Purpose of the paper The purpose of the study is to evaluate whether nutritional supplement helps cure pressure sores or not. Scope of the paper The study is based on research of a variety of existing research articles, journals, surveys, and clinical trials related to pressure ulcer throughout the global. It mainly focuses on individuals aged 65 and over from different continents. Literature Search Strategy The literature review was designed to assess published studies only. The initial search terms included pressure ulcer, nutrition, elderly, protein, arginine, zinc, vitamin C. The time period of the search covered articles published from 2000 to 2011 in English. The major databases used are CINAHL, Pubmed, and Cochrane Collaboration. An assignment marking guide was used to evaluate methodological quality of selected studies and gather useful information at the same time. Research design, description of intervention, outcome measures, results and author conclusions were included in the marking guide. 2.0 Evaluation of the Literature 2.1 Introduction Pressure ulcers, also referred to as pressure sores, decubitus ulcers or bedsores, are defined as an area of localised damage to the skin and underlying tissue caused by pressure, shear force, friction, moisture, and/or a combination of these factors. (Crowe and Brockbank 2009) It commonly occurs in hospitalized patients and elderly adults living in aged care facilities due to impaired mobility, paralysis and malnutrition. This study only focused on the relationship between malnutrition and pressure ulceration. For elderly people specifically, factors contributing to malnutrition include poor appetite, impaired cognition, depression, dependence on assistance with eating, and medications that cause gastrointestinal upset. (Heyman et al. 2008) Therefore, strategies and nursing interventions for adequate nutritional intake have become essential proportion of care for the elderly not only for pressure ulcer management, but also for their overall well-being. Supplying adequate nutritional supplements have been acknowledged to be beneficial in addition to repositioning and wound dressing since they can provide extra nutrients to strengthen tissue resistance and promote tissue repair. (Posthauer 2006) This review evaluated the clinical evidence supporting the use of ONS is beneficial for the elderly with existing pressure sores as part of their management. Five related article consisted of both clinical trials and literature reviews were selected presenting various perspectives. One of these studies provided Level I evidence while other four provided evidence between Level II and level IV. 2.2 Critical Review Level 1 evidence was provided by a systematic review by Holm, Mesch, and Ove (2007) This study conducted 16 peerà ¢Ã¢â€š ¬Ã¢â‚¬Ëœreviewed articles published between 1995 and 2005, with a combination of qualitative and quantitative analysis of information. General speaking, the reviewer pointed out that pressure ulcer healing for patients aged 65 and over is strongly associated with individuals nutritional status as well as strategies and nursing interventions implemented by healthcare workers when handling pressure ulcers. First of all, it revealed the significance of nutrition for elderly patients with pressure sores in promoting wound healing and preventing deterioration. Meanwhile, it indicated that the use of pressure relieving mattresses and repositioning were the most commonly used measures for pressure area care. It also reported potential factors such as weight loss, dysphagia, catheters and connection to different kinds of monitoring equipment, which might result in prolong ed ulceration. Moreover, the financial impact on the patient and family related to costly treatment was also discussed in this review. When selecting the articles, the reviewer excluded studies that did not comply with the aim of the review or studies contained subjective opinions. It is reasonable to consider this study to be comprehensive and convincing since it provided logical arguments supported with figures and data collected from those 16 published research articles. The limitation of this study was that the articles selected were published from 1995 to 2005, so that the information gathered might not be up-to-date. Although the study demonstrated the connection between nutrition and pressure ulcer healing, it did not involve the role of protein, arginine, vitamin C and zinc in specific. The results of this study were consistent with the setting of this academic paper because they both focused on patients aged 65 and over. In addition, this article is relevant to the PICO que stion since it talked about the importance of nutrition among elderly patients and its relationship with pressure sores management. The goal of the research paper by Heyman et al. (2008), which provides level III evidence, was to examine the effects of oral nutritional supplements enriched with protein, arginine, vitamin C and zinc in dietary management of pressure ulcers and chronic wounds. This open multicentre trial was conducted among 61 institutional care facilities in Belgium and Luxembourg for a nine-week period and 245 participants, with a mean age of 80, were selected randomly with no exclusion criteria. Each patient received three servings of ONS per day accompanied with standard pressure area care. The result was a 60% reduction in pressure ulcer area after nine weeks. The primary limitation of this study was that it neither attempted to blind nor carry out randomized controlled trials. Hence, factors affecting pressure ulcer healing other than malnutrition had not been eliminated which reduced the reliability of the result. Another limitation was that the exudate levels were not measured objectively, and ruler was used to measure the size of the wound instead of planimetry. All these factors might lead to inaccurate outcomes. Nevertheless, the result of this study was supported by three other studies. These studies indicated that ONS enriched with arginine, zinc and antioxidant vitamins helps accelerate pressure ulcer healing rates. (Benati et al. 2001; Desneves et al. 2005; Soriano et al. 2004) The study by Cereda et al. (2009) aimed to evaluate the effectiveness of a disease-specific nutritional treatment enriched in protein, arginine, zinc, and vitamin C compared to full ward diet for enhancing the rate of pressure ulcer healing. It was a twelve-week randomized controlled trial which provided level I evidence. It involved 28 elderly subjects with Stage II, III, and IV pressure ulcers of recent onset from four residential care facilities in Italy. Participants were divided into two groups and both groups received exactly same amount of daily nutritional support. However, one of the groups was provided with standard full ward diet while the other group was administered a 400-mL oral supplement or specific enteral formula enriched with protein, arginine, zinc, and vitamin C in addition to the standard diet. The result reflected that there was a 72% decrease in pressure ulcer area after 12 weeks of receiving ONS. This study concluded that disease-specific nutritional support is feasible and beneficial in promoting the healing of pressure ulcers. Furthermore, a secondary research article written by Crowe and Brockbank (2009) investigated the role of nutrition in the prevention and treatment of pressure ulcers. The function and mechanisms of protein, arginine, and micronutrients in wound healing process had been discussed respectively in this study. It also cited a variety of existing studies to support its arguments. The study concluded that high-protein oral nutritional supplements played an essential role in minimizing the incidence of pressure ulcers in susceptible elderly patients. The role of arginine, vitamin C and zinc in pressure ulcer healing, on the other hand, was not very clear stated by Crowe and Brockbank due to limitation in sample size and heterogenous study design of current studies. Although some studies reported that arginine, Vitamin C and zinc can promote muscle and collagen synthesis which increase the strength of the wound and help the body maintain a healthy immune system (Fleishman 2005), confirmatory studies are needed to support current clinical evidence. The major down side of this study was absence of critical analysis of information gathered from clinical trials used. Nevertheless, nutritional support was considered to be beneficial and effective in enhancing pressure ulcer healing after all. In addition, the conclusion that nutritional supplement rich in protein speeded up pressure ulcer healing rate was consistent with another study by Breslow et al. (1993) Breslow et al. (1993), another level III evidence, investigated 28 malnourished elderly patients living in residential care facility with existing pressure sores for eight weeks. It aimed to evaluate the impact of dietary protein on healing of pressure ulcers in malnourished patients. The result indicated that participants who received supplemental nutritional formulas containing 24% protein displayed a faster rate of wound healing in contrast to those received formulas containing 14% protein. Therefore, it was reasonable to believe that supplemental protein aided in pressure ulcer healing process. However, because of the time of this study being conducted, the novelty and reliability of the information provided might be doubted. Based on the findings of this review, additional nutritional supplement enriched with protein, arginine, vitamin C and zinc had been proved to be effective in promoting pressure ulcer healing. The implementation of specialised nutritional support was recommended for elderly patients suffering from chronic pressure ulcers. Moreover, patients having difficulty swallowing, cognitive impairment are at risk of malnourishment so nutritional supplement should be considered despite of no existing pressure ulcer. (Cereda et al.2009) Besides, although nutritional supplementation aided the wound to heal, it was not an entire part of pressure ulcer management. In order to prevent and treat pressure sores quickly and effectively, it is essential to combine nutritional support with wound management, use of pressure-relieving devices as well as repositioning techniques. (Heyman et al. 2008) 3.0 Evaluation of the Main Research Article 3.1 The study overview The study, Benefi ts of an oral nutritional supplement on pressure ulcer healing in long-term care residents, by Heyman et al. (2008) aimed to investigate the effects of combine oral nutritional supplement high in protein, arginine, vitamin C and zinc with standard care on the healing of pressure ulcers in nursing home residents compare to standard care solely. This nine-week trial was conducted in Luxembourg and Belgium and 245 patients with grade II-IV pressure ulcers were involved. During the study, participants were provided with the ONS daily for nine weeks, in addition to their normal diet or enteral feed. Standard pressure care was provided to each patient. Pressure ulcer area (mm2) and condition were assessed after three and nine weeks. (Heyman et al. 2008) Patients received 200ml ONS per daily which contained 46g protein,6.9g arginine, 575mg vitamin C, 87mg vitamin E and 21mg zinc. The result indicated that there was a remarkable decrease in pressure ulcer area, with 53%, at the end of the trial. Complete wound closure occurred after three and nine weeks in 7% and 20% of the pressure ulcers respectively. 3.2 Type of article and level of evidence This article is a quantitative primary research article because all the data was collected by the authors themselves by performing a clinical trial. It is a case control study rather than a randomized controlled trial since it involved large number of subjects so that the randomness and suitability of participants selected diminished. Nevertheless, the study demonstrated comparison by monitoring changes of conditions and improvements of the wound. The pressure ulcer area was measured three times throughout the trial: at the beginning, after three weeks, and at the end. Therefore, this study provided level III evidence. (The Royal Melbourne Hospital 2009) 3.3 The study design This was an open multicenter case-control study, in which 245 patients with different grades of pressure ulcers participated. Three servings of oral nutritional supplements were provided for every patient and wound healing process was monitored and assessed by measuring pressure ulcer area using rulers. Patient medical history and characteristics of existing wounds were gathered to be baseline information at the beginning of the trial. All measurements were performed by a single practitioner at each center in order to minimize subjectivity of data collected. (Heyman et al. 2008) 3.4 Statistical analysis Data are expressed as mean  ± standard deviation. Data were statistically analysed using ANOVA. Pressure ulcer data were log-transformed using a mixed-effects model to compare changes in pressure ulcer area over time. SGS Life Science Services Clinical Research (Bierges-Wavre, Belgium) performed the data entry, verification and statistical analysis. (Heyman et al. 2008) 3.5 Outcomes/Results for Nurse and Patient During the study period, the average intake of the ONS recorded was 2.3  ± 0.56 servings per day. After three weeks, the mean pressure ulcer area decreased from 1580  ± 3743mm2 to 1103  ± 2999mm2 and further reduction displayed to 743  ± 1809mm2 at the end of the trial, a 53% decrease compared to baseline. Additionally, Complete wound closure occurred after three and nine weeks in 16 (7%) and 49 (20%) of the pressure ulcers respectively. There was also a remarkable decline in exudates levels. At baseline, they were reported as mild, moderate and severe in 54 (33%), 61 (25%) and 32 (13%) of the pressure ulcers respectively, while after nine weeks this had reduced to 81 (22%), 34 (14%) and 10 (4%) respectively.(Heyman et al. 2008) Also, the oral nutritional supplements were accepted by most of participants. Eight out of ten patients did not complain about being given three servings per day and roughly 80% of the patients drank more than half of the ONS at each serving. On the o ther hand, in ten health practitioners involved in this study, nine of them expressed that they would use ONS as part of their pressure ulcer management regimen. (Heyman et al. 2008) 3.6 Limitations and Gaps Although the study involved large number of participants which roughly reflect the nursing-home population of Luxembourg and Belgium, there was no excluded criteria when selecting the participants. As a consequence, various factors such as medical history of diabetes or peripheral vascular disease can prolong wound healing and influence the outcome of the study. 3.7 Recommendations for Further Research The essentiality of conducting further studies has been pointed out to evaluate whether the implementation of oral nutritional supplements is cost-effective and suitable for all patients with pressure ulcers. 4.0 Conclusion Based on the findings from studies provided above, it is reasonable to consider the use of oral nutritional supplements enriched with protein, arginine, vitamin C and zinc as an effective and beneficial intervention in pressure ulcer management. Nevertheless, it is important to administer the ONS combined with other interventions including appropriate wound management and regular repositioning to promote pressure ulcer healing.

Ah, Wilderness - Significance of the plays title Essay -- Ah Wildern

Ah, Wilderness - Significance of the play's title The title of the play, Ah, Wilderness, by Eugene O'Neill, plays a significant role in the understanding of the play. The "wilderness" is used as a metaphor for the period in a male's life when he is no longer a boy, but not yet a man. This play tells the story of the coming-of-age of Richard, and the evolution he undergoes while becoming a man. The "wilderness" used in the title is a metaphor for the years between childhood and manhood. Life, for a man, is like the woods. When one is a boy, he is in a clearing. Everything told by adults is taken as truth, and because of this trust the truth is clear. As one enters the in-between years, the truth is no longer as clear. The developing mind begins to question the notions held by those in control, parents in particular. This period is like a wilderness one must wander through. When one exits the woods, things once again become clear. One no longer feels the need to wander aimlessly through the darkness, and one usually returns to the truths instilled by parents. Richard begins the play as a boy on the verge of manhood. A studious youth, just beginning to sow the seeds of rebellion, he at first feels no need to rebel against things close at hand. This soon changes with a visit to his father from Richard's girlfriend's father. Richard has been sending poetry to Muriel, his girlfriend, and her father sees the subject matter of this poetry as inappropriate. Unbeknownst to Richard, Muriel has been coerced into writing a letter to him breaking off the relationship. Richard feels so heartbroken he rebels against everything. This moment is the point in which Richard enters the "wilderness." The perfect opportunity to prov... ...uneasy side glances, and steels himself for what is coming." Richard has come back around to his prior ways of thinking. He now states "(His head down humbly.) I know I was a darned fool" (844). Richard, in the course of the play, makes the transition from boyhood to manhood. As with most young men, Richard enters the "wilderness", a metaphor for the stage of rebellion, and exits with no lasting scars. Richard's father, like most parents, realizes that Richard has walked out of the wilderness and states, " . . . I don't think we'll ever have to worry about his being safe--from himself--again. And I guess no matter what life will do to him, he can take care of it now" (845). This statement shows the necessity of the wilderness to the evolution of man, and the importance of a father's understanding during this important stage of development. Ah, Wilderness - Significance of the play's title Essay -- Ah Wildern Ah, Wilderness - Significance of the play's title The title of the play, Ah, Wilderness, by Eugene O'Neill, plays a significant role in the understanding of the play. The "wilderness" is used as a metaphor for the period in a male's life when he is no longer a boy, but not yet a man. This play tells the story of the coming-of-age of Richard, and the evolution he undergoes while becoming a man. The "wilderness" used in the title is a metaphor for the years between childhood and manhood. Life, for a man, is like the woods. When one is a boy, he is in a clearing. Everything told by adults is taken as truth, and because of this trust the truth is clear. As one enters the in-between years, the truth is no longer as clear. The developing mind begins to question the notions held by those in control, parents in particular. This period is like a wilderness one must wander through. When one exits the woods, things once again become clear. One no longer feels the need to wander aimlessly through the darkness, and one usually returns to the truths instilled by parents. Richard begins the play as a boy on the verge of manhood. A studious youth, just beginning to sow the seeds of rebellion, he at first feels no need to rebel against things close at hand. This soon changes with a visit to his father from Richard's girlfriend's father. Richard has been sending poetry to Muriel, his girlfriend, and her father sees the subject matter of this poetry as inappropriate. Unbeknownst to Richard, Muriel has been coerced into writing a letter to him breaking off the relationship. Richard feels so heartbroken he rebels against everything. This moment is the point in which Richard enters the "wilderness." The perfect opportunity to prov... ...uneasy side glances, and steels himself for what is coming." Richard has come back around to his prior ways of thinking. He now states "(His head down humbly.) I know I was a darned fool" (844). Richard, in the course of the play, makes the transition from boyhood to manhood. As with most young men, Richard enters the "wilderness", a metaphor for the stage of rebellion, and exits with no lasting scars. Richard's father, like most parents, realizes that Richard has walked out of the wilderness and states, " . . . I don't think we'll ever have to worry about his being safe--from himself--again. And I guess no matter what life will do to him, he can take care of it now" (845). This statement shows the necessity of the wilderness to the evolution of man, and the importance of a father's understanding during this important stage of development.

Spectroscopy

Spectroscopy (stopped flow method)Spectroscopy:It is the analysis of the electromagnetic radiation emitted, absorbed, or scattered by molecules. It is used to analyze materials and to monitor changes in concentration in chemical kinetics. Since photons act as messengers from atoms, the atomic spectra can be used to obtain detailed information about electronic structure and molecules. The energy of a molecule can change because of electronic transitions, and it can make transitions between its rotational and vibrational states. They are more complicated than atomic spectra and can give more information about electronic energy levels and about bonds length, strength, and angels (1).Stopped-flow technique:The solutions are mixed very rapidly and forced from syringes into a mixing chamber designed to ensure that the flow is turbulent and that complete mixing occurs very quickly. Behind the chamber, there is an observation cell fitted with a plunger that moves back as the liquids flood in and comes up against a stop after a certain volume. Filling the chamber corresponds to a sudden creation of an initial sample of the reaction mixture. The reaction then continues in the thoroughly mixed solution and is monitored spectrophotometrically. After a very short time of the flow, the flow is stopped suddenly when the observation cell is filled by an opposing piston which is linked to a sensing switch that triggers the measuring device (2). Small volumes of solutions are used, and the kineticequations for modeling the reactions are equivalent to those used inconventional methods in which concentration and time are measured.It is useful to study fast reactions that have half-lives as short as a few milliseconds. It is appropriate for studying biochemical reactions, such as studying enzymes. ? Formation of Peroxynitrite Peroxynitrite, an inorganic molecule of biological interest, is the product of the combination reaction between nitric oxide (?NO?^†¢) and superoxide (O_2^(†¢-))(4).?NO?^†¢+ O_2^(†¢-) ? ?ONOO?^-Increasing sensitivity can potentially allow the reaction to be measured, to be studied by slowing down the reaction rate through the use of lower concentration of reactants.the rate of the isomerization reaction depends little on the pressure ‘high pressure slows down the rate of reaction'(3). With the stopped-flow technique a value of 6.5 is found at millimolar phosphate concentrations, while at 0.5 M phosphate the value is 7.5The kinetics of decay do not follow first-order kinetics when the pH is larger than the pKa.The kinetics of the decay of hydrogen peroxynitrite are not very pressure-dependent: from stopped-flow experiments up to 152 MPa the rate of the isomerization reaction depends little on the pressure. Materials:Deionized water.Buffers, which are saturated with argon immediately before use, from salts and acids.Freshly prepared peroxynitrite.Prepration: Peroxynitrite was prepared by a modification of biomimetic synthesis of nitrogen monoxide with solid potassium superoxide. In Brief, 30% mol nitrogen monoxide was added to 100% mol solid potassium superoxide that was stirred with sand under argon in a 100-mL Erlenmeyer flask. Laser Flash Photolysis: the following reactions could take place:(i) Isomerization: cis and trans- peroxynitrite: (ii) Photodissociation: (iii) Photoionization: Reactions 3-6 can be neglected and for spectroscopic reasons reactions 8 and 9 must be abandoned.Under the assumption that we observed the reverseof reaction 7. The global analysis gives a rate constant of (1.5-2.0) Ãâ€" ?10?^10 M^(-1) S^(-1). Conventional second-order analysis at 25 different wavelengths and 4 different laser intensities resulted in a value of (1.6 ( 0.2) Ãâ€" 1010 M^(-1) S^(-1).The rate constant for reaction 7 of 1.6 Ãâ€" ?10?^10 M^(-1) S^(-1) is higher than those reported by other workers. These rate constants were measured under experimental designs that involve reaction cascades to arrive at the reactants. The rapid one-step production of superoxide and nitrogen monoxide reported herein has the advantage of allowing measurement of the recombination rate not complicated by other processes.The high rate constant has important consequences for the generation of peroxynitrite in vivo. Under normal in vivo conditions, the concentrations of nitrogen monoxide and superoxide dismutase are on the order of 1 Ãâ€" ?10?^(-8) and 5 Ãâ€" ?10?^(-6) M, respectively, whereby superoxide dismutase scavenges 98-99% of all superoxide, and consequently very little peroxynitrite is formed. Near an activated macrophage the nitrogen monoxide and superoxide concentrations may be 100 times higher, and the ratio of superoxide reacting with nitrogen monoxide to superoxide reacting with superoxide dismutase becomes 3:2. While considerations based on homogeneous solution kinetics do not necessarily apply to the inhomogeneous milieu inside or outside a cell, they do indicate that peroxyitrite formation is likely.According to the mechanism we can represent the rate law as:Rate = k [?NO?^†¢][O_2^(†¢-)]In addition to the determining step, a second-order curve was obtained which proves that the overall order of this reaction is 2.

Dna Sequences Using Polymerase Chain Reaction - 1605 Words

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