Case Study In Specialty Practice And Epilepsy

Case Study In Specialty Practice And Epilepsy Around fifty million people worldwide suffer from epilepsy, making seizures a common cause for patients to present to emergency departments for treatment (WHO, 2009). They pose for complicated management as the occurrence of further seizures in the ED can result in life threatening complications. A seizure can be defined as à ¢Ã¢â€š ¬Ã‚ ¦ a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of musclesà ¢Ã¢â€š ¬Ã‚ ¦A seizure may be clonic or tonic: focal, unilateral, or bilateral: generalised or partial (Anderson (Ed.), 2002, p. 1554). This case study aims to discuss a patient presenting post seizure activity outlining the presenting and foreseen patient problems including a dependant nursing intervention and its role in seizure management. This paper will discuss the presentation of a sixty-one year old Caucasian male, with a complex medical history. His presentation post a witnessed generalised tonic clonic seizure wi ll be explored including the interventions performed by nursing staff. In this case the prescription of Phenytoin was explored as a dependent nursing intervention that aims to provide symptom relief and cessation of seizure activity by binding to inactive sodium channels to prevent neurons firing and therefore prevent muscle contraction (Aschenbrenner Venable, 2009). Thereafter the paper aims to critically appraise the evidence based literature surrounding its use, discussing its effectiveness in the management of the patient discussed and the evaluation of its use. Any gaps in literature will then be identified outlining suggestions for recommendations to improve current practice. On arrival to the Emergency Department (ED) via ambulance the patient was triaged as a category one and transferred to the resuscitation cubicle for immediate assessment and intervention. He was witnessed by a friend to have full body shaking with eyes closed and was unresponsive for approximately two minutes. The patients history includes alcohol abuse, asthma, epilepsy, heavy smoker and chronic back pain. The patient is generally non-compliant with medications and usually drinks a four litre cask of wine per day of which he has not had for the past three days. The patient was found to be post-ictal following the seizure and remained agitated for some hours after. The patient had multiple problems which include a Glasgow Coma Scale (GCS) of 8-9, agitation, hypertension, and a threatened airway and therefore required a Nasopharygeal airway. He was noted to continue to desaturate on room air. It can be seen that ensuring the patency of the patients airway is essential in first line management to decrease complications such as tissue hypoxia, hypertension and decreased cerebral blood flow. Thereafter an A,B,C,D assessment approach should be undertaken with interventions aiming to cease seizure activity being a priority (Tesoro Brophy, 2010). A seizure that lasts longer than thirty minutes can have devastating effects on the patient; initially causing an increase in autonomic activity which can lead to hypertension, tachycardia, hyperglycemia, and sweating. However if the seizure continues on greater than thirty minutes, then further deterioration can occur. As metabolic demand during a seizure is high, the body is no longer able to compensate for this. As a result cerebral autoregulation is lost, cerebral blood flow decreases, intracranial pressure rises and hypotension occurs (Tesoro Brophy, 2010). Furthermore if the seizure continues on past this time, death and perman ent brain damage can transpire (Rabinstein, 2010). While the management of a patient having a seizure involves multiple interventions, this case study will discuss one dependant intervention being the administration of IV Phenytoin 1gram in 100mls Normal Saline given over thirty minutes. This decision was made by the treating medical officer as the patient was already taking oral Phenytoin, however was likely that a therapeutic dose range was not achieved due to patient non-compliance. The IV route was chosen as the patient could not swallow tablets and therapeutic levels were required immediately for the safety of the patient (Gallop, 2010). While the patient is already on Phenytoin he is therefore assumed not to be allergic to it, however there can be other side effects to this drug when it is given via the IV route. These include local reactions to the IV site, arrhythmias, dizziness and hyponatremia (Gilad, Izkovitz, Dabby, Rapport, Sadeh, Weller Lampl, 2008). While another study also reports adverse effects of hypotension (Aaro nson, Belgado, Spillane Kunisaki, 2010). For the patient involved these side effects were considered minimal compared to the benefit of stopping the seizure. The nursing implications for this medication include regular cardiac and blood pressure monitoring, both during and after the infusion is completed (Gallop, 2010). Numerous studies have been conducted on the use of Phenytoin considering adverse effects, efficacy and in comparison to other antiepileptic drugs. While Phenytoin was used in this case study as the patient was already taking it orally, it was shown to work as the seizure activity ceased. However the study by Zeng, Wang, Xi Yan (2010), illustrate that 39% of patients in their study pulled out due to poor control of seizures. Similar findings were also discovered by Hiba et. al., (2010), who reported less than 40% of patients were seizure free over a twelve month period. Misra, Kalita Patel (2006) also report findings of reduced efficacy of Phenytoin when compared to Sodium Valporate. Ramsay et al., (2010), further substantiates this with more patients leaving the study due to various reasons when compared to that of Topiramate. However, this study then reports that superiority of Topiramate could not be established, with a p value of 0.366. In comparison Gallop (2010), conducted a r eview and found it to be moderately effective for Status Epilepticus (SE) patients and could also be used to prevent early post-traumatic seizures. Turnbull, Howel, Rawlins Chadwick (1985), also report similar findings with efficacy and determined that no statistical difference was found between Phenytoin and Valporate for seizure control, with a p=0.4, both showing similarly good control of seizure activity over a two year period. Several studies have shown a number of adverse effects post the IV administration of Phenytoin in the patient having a seizure. Gallop (2010) and Earnest, Marx Drury (1983), report studies showing burning and pain to the IV site during administration. Tesoro Brophy (2010) also report an adverse effect of pain and oedema to the IV site, however all studies reported pain ceased when the infusion was slowed or diluted further. Other adverse effects were noted by Gilad, et. al., (2008), reporting 12% of patients in the study showed cardiac arrhythmia, vertigo and hyponatremia, however noting a p value 0.035. Further studies show similar findings; Gallop (2010) reports hypotension, bradyarrhythmias and arrest; Aaronson et. al., (2010) shows only hypotension with no statistical difference noted between Phenytoin and Fosphenytoin in terms of adverse reactions. Turnbull et.al., (1985), report on the oral form of Phenytoin and note reactions of rashes, nystagmus, tremor and ataxia. Zeng et. al., (2010), report similar findings with most common reactions being loss of appetite, nystagmus, nausea, fatigue and tremor. Phenytoin was used for the patient to control his seizures as he was already taking its oral form and it was assumed that Phenytoin provided him with good efficacy. However based on the research conducted for this case study, there is no definitive antiepileptic drug that provides excellent efficacy for every patient. A number of studies show several adverse effects relating to Phenytoin and some studies suggest Sodium Valporate as a substitute, which has a limited number of documented adverse reactions. Gilad et. al., (2008) make this suggestion, with 87.8% of patients receiving good seizure control with Sodium Valporate with no recorded side effects, however 88% of patients on Phenytoin also report good efficacy. However other studies, for example Gallop (2010), show good seizure control when administered to patients suffering SE and in post-traumatic seizures. While another study suggests that no superiority was found between Phenytoin and Topiramate in terms of efficacy, however would recommend Topiramate for its reduced number of adverse effects (Ramsay et. al., 2010). While no medication is ever risk free, all adverse effects should be considered and consultation made of whether the risks outweigh the benefits. In this case study the intervention of Phenytoin was decided to be of benefit to the patient, to stop him from having life threatening seizures. While the evidence shows Phenytoin to be of risk to the patient in terms of adverse effects it did stop this patient from seizing while recording no adverse reactions, which suggests good efficacy. The use of Phenytoin, as previously stated, does have its risks, however these can be minimised with recommendations for best practice. Gallop (2010), and Tesoro Brophy (2010), suggest an infusion rate for IV Phenytoin no greater than 50mg/min and monitoring of blood pressure and ECG during and post infusion. Earnest et. al., (1983), make similar recommendations with suggestions of a dilution down to 6.7mg/mL with an infusion rate 40mg/min, with a total dose of 10-15mg/kg, also suggesting regular observations both during and after the infusion is completed. Other studies then suggest a combination of medications. Rabinstein (2010), suggests administration of an antiepileptic drug and also the use of Benzodiazepine. Tesoro Brophy make this same suggestion; stating that Benzodiazepines should be first line and then treat with anticonvulsants. While most studies are able to provide evidence from research carried out, all make the suggestion for further, larger studies, to provide furt her substantiation prior to change of clinical practice. The patient was loaded with IV Phenytoin 1 gram, diluted in 100mls Normal Saline and given over thirty minutes, giving a dilution of 10mg/mL; a slightly higher rate than that suggested by Earnest et. al., (1983), however a slower infusion of 33mg/min, than the suggested 50mg/mL by Gallop (2010), and Tesoro Brophy (2010). The patient was also given Midazolam 3mg in increments for agitation post the seizure, with good effect. The patient at no time became hypotensive or bradycardiac with nil rash, nausea or nystagmus. The patient eventually returned to a GCS 15 and was admitted to the ward for observation. In summary this case study discusses the dependant intervention of Phenytoin administration to a patient that presents to the ED while having a seizure. Various studies report hypotension and bradycardia as life threatening adverse reactions to Phenytoin, however these can be minimised with slow IV infusion. Best practice suggests an infusion rate of 50mg/min with a dilution of 6.7mg/ml. While Phenytoin had good efficacy for this patient, some studies report Sodium Valporate as most efficient, however no antiepileptic drug is found to be superior over all. More research and larger scale studies are recommended prior to application of intervention to clinical practice from the research discussed.

Different Styles of Learning Essay

Different styles of learning were the topic of conversation this week during a class discussion. We were asked by our instructor to first discover and talk about what our personal styles of learning are and share what helps us be successful in a learning environment. Next we were tasked to discover what our actual learning abilities were against a few online brainteasers. The information given by these sites have given me a chance to step back and ask myself what and how different styles of learning affect me. With that said, I personal believe that these sites should be used as a generic scale and not a basis of what students true learning potential are. One of the first steps of understanding what kind of student you are is to pin point what your ability to learn is and use your strong points to help push you through your goals. I have learned from this subject that there are several types of learning styles, Visual, Auditory and Kinesthetic. Through a short test I completed I learned that I am 46% Auditor, 29% Visual and 25% kinesthetic (Advanogy. com, 2004). From the questions that were asked and the results I received I believe that is test is correct on its calculation. I feel like I learn more accurately under the guidance of a teacher. The second test I took also indicated that I rated highest in aural learning ability (Bixler, 2010). Based on these results from the two web sites. I agree that I prefer to learn by listening and that written tests can slow me down because I tend to read every question to myself. (Advanogy. com, 2004) Motivation and foundation are the two keys I believe in for styles of learning. Motivation â€Å"is a psychological feature that arouses an organism to act towards a desired goal and elicits, controls, and sustains certain goal-directed behaviors† Wikipedia (2013). What the definition of motivation doesn’t state is how to get it, and sustain it. In my opinion motivation maybe gained though a few different avenues, such as hardship, prenatal encouragement/guidance and the will to overcome bad life decisions and raise above family, peers and others expectation of you. Without motivation I would not be able to continue through this our any other course I am pursuing. Second, foundation is the ground that builds an object. Without a proper foundation an object cannot stand new obstacles and will most likely fail. Now what I’m referring to is foundation of education. Foundation is one of the keys to a student’s ability to become successful in a learning environment. This is most likely passed down through the leaders of the student’s family. Some of my keys of foundation are; organization skills, importance of building character, compassion and setting feasible short term and long term goal. I unfortunately was not given the best educational opportunity growing up; my parents have always let their children figure out their problems and give little to no guidance. This situation left my education to the wayside, but I will not let that excuse continue to affect my family or myself. I have learned throughout my years in the Coast Guard that you cannot change your past but that you can change your future. To fully understand what different learning styles are, you first have to go out and find them. They cannot found on Internet based test or even someone’s opinion. You must seek the information from qualified educators and bust your tail to better your understanding of a subject.

Recruitment and Selection Process

Referencing should be provided in Harvard Style referencing. The word count limit for this assignment is 2500 words excluding references. (Index is not required for this assignment). The assignments shou-ld be completed in Font Tlpe: Time New Roman with Size 12 and double spacing between lines. For Office Use Ouly Result Deliverer Internal Verifier Name & Signature Date -J#E+ E‚ ¬EgEl :ffis3 rysi! l tr ri : , † l,lorrorl. r'r†r,r Course: HNC/HND Diploma in Business Unit 14 Working with and Leading People Assessment Decision Form To be tilled in by the Assessors & Verifier Assessors CommentInternal VerifierJModerator Comment: Any Action to be taken By Assessor: Exam Board Committee (EBC) Review: fflE ir-:;-:;: i, r' Managerrre:nt large national you have recently been appointed io the Human Resource Department of a staff of non managerial retailer, with specific responsluility for recruitment assistant for its Bradford branch and you The company is wanting to recrui t a full,time sales advise the senior management team of have been asked to prepare all relevant-oocumentation, they must observe and take part in the any legal, regulatory'and ethical considerations ecruitment Process.TASK that you comprete and encrose the following: rn order to full meet this brief you shourd ensure 1 ‘Abriefstaiementfortheseniormanagementteamoutliningthediffere- ncesandmerits your recommendations for the processes with between internal and external recruitment most suitable method' 2. A Job description correct format and person specification for the Job using the They could include some or all of the following: Job description . Job title o Department and location of Post . Broad terms of Job o Responsible to whom .Scope of Post Education and qualifications r Name of compiler and approver . Date of issue Person specification . Job title and reference number . Essential and desirable attributes r Physical characteristics required r Attainments and qualificat ion . Previous experience . Generalintelligence . Special aptitudes r Temperament and Personality . Hobbies and interests . Personalcircumstances ffln Miuragern-ient TASK 2 You must produce a briefing sheet for the senior management team to guide them on aspects of law relating to recruitment and selection of candidates. This should include:Sex Discrimination Act 1995197 Race Relations Act 1992 Equal payAct 1970 Disability Discrimination Act 1997 and 2005 Employment Act 2002 National Minimum Wage (current levels) Data Protection Act 1998 Immigration, Asylum and Nationality Act 2006 Employment Equality (Sexual Orientation) ‘Religion or Belief) (Amendment) Regulations 2007 Any other relevant Acts (if any) There should also be a section on ethical issues such as: asking candidates the same questions guidelines for interviewers who are related to candidates gender and ethnic balance on interview panels TASK 3In pairs you will be interviewing a prospective candidate who has submitt ed a completed application form. For this task you wili need to complete and enclose the following: 1. Prepare a list of questions 2. to ask the interviewee based on their completed application form. Conduct the interview and write a brief statement afterwards to analyse how you contributed to the selection process. What went well and what could have been improved? fflG In order to achieve Pass Grade Evidence on page Tasks staff To include Job description, person specification, interview questionsAssess the impact of legal, regulatory and ethical considerations tn the reernifment and seleetion orocess 5 Take part in the selection Process 4. Evaluate own contribution to the selection process All Tasks 1 – 4 should be completed In order to achieve Merit Grade Effective Judgements have been shown in tasks 1 -4 In order to achieve Distinction Grade A critical reflection is evicient on tasks 1-4 Assessor's Feedback on Outcome Criteria LO 1. t. z Assessment Criteria )repare documen tation to select and recruit a new member of staff assess the impact of legal, egulatory and ethical considerations to the recruitment Assessor's Comments take part in the selection process evaluate own contribution to tfre selection process lvlanzrgement Learning outcomes LOI recru itment, selection and retention Be able procedures Assessment criteria for pass The learner has to: 1. prepare documentation to select and recruit a new member of staff I-. 2 assess the impact of legal, regulatory and ethical considerations to the recruitment and selection process 1. 3 take part in the selection process 1. 4 evaluate own contribution to the selection process .

Caffeine Addiction Essay - 1312 Words

Although it is not scientifically proven, everyone has an addiction. It may be a mild addiction or it may be a strong one. For me, I am addicted to caffeine. Every morning, I visit the snack bar and order an ice coffee. When I arrive Ms. Margaret, the employee for the snack bar, says â€Å"the usual?†. Immediately, she would pour me a full cup of ice coffee and say â€Å"you like it black right?†. Her actions prove my love for coffee. Every day, I consume three cups of coffee at most- one in the morning, one in my free blocks, and one in the afternoon. Without coffee, many of the times, I noticed that I am unable to focus and concentrate on my work. I tend to feel agitated and many of the times tired without it. Coffee is significant for me because†¦show more content†¦Eventually, he disregards Cathleen’s warning as he â€Å"grabs the bottle and pours a drink, adds ice water and drinks† (2052). When he hears someone approaching, â€Å"he puts the glass hastily on the tray and sits down again, opening his book† (2052). Edmund’s action displays his severe addiction to alcohol as he deceives Cathleen and secretly drinks when his family members are not present. His addiction is further portrayed during lunch. Edmund dully says â€Å"Did I hear you say, let’s all have a drink? (2057) despite the criticism from Tyrone. When Tyrone stops him by mentioning Doctor Hardy, Edmund says â€Å"to hell with Doctor Hardy! One isn’t going to kill me† (2057). His response to Tyrone implies his strong addiction towards alcohol, even up to the point where he would overlook his parents. Edmund’s remark â€Å"Well, what’s wrong with being drunk?† (2087), proves his love for alcohol. Several times, he vehemently approves Tyrone’s offer of a drink and continues to drink despite being drunk. He says â€Å"Enough is not as good as a feast† (2085) as he continues to pour a big dr ink. 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