NR 439 Week 1: Role of Research and the Importance of the Searchable Clinical Question
Week 1 Case Study
A 57‑year‑old female presented with a 13 year history of diabetes. Due to the failure of oral hypoglycemic agents (OHAs) in controlling her sugar levels, for the last 3 years, she was treated with biphasic insulin aspart 30/70. She was a very frequent flier, a regular swimmer and socially very active, and this led her to have irregular meals. Hence, she often go into frequent hypoglycemia and during the last 6 months the patient’s average blood glucose level during fasting were 170 mg/dL and postprandial glucose levels varied from 230 to 280 mg/dL. Even after high sugar levels, she fortunately had normal kidney functions. Patient was able to afford an insulin pump, so she was put on one. With the pump, her blood glucose was in control and patient was happy. However she soon realized the limitation of carrying it everywhere she went.
These were the true feelings of a patient who was very active while she was on an insulin pump. The physician, after discussing with the patient, started her on insulin degludec and lifestyle modification, especially the diet component. Patient understood these problems and followed the diet. She followed the dietary modification and over 2 months of time, fasting blood glucose was 110 mg/dL, post meals values were around 180 mg/dL. She had only one episode of minor hypoglycemia which was due to delayed meal. The doctor later reduced degludec from 44 U to 40 U and blood glucose was still improving without any episode of hypoglycemia in the last 3 months. The outcome of this case is that with this therapy and dietary modification, a desired level of blood glucose can be achieved, without hypoglycemic risk.
This case study reminds me of many patients that I take care of while working at a local Medical surgical/Ortho floor at a local hospital. Almost daily I have at least one or more patients with Diabetes. I always assess and educate on how much the patient and family knows about Diabetes and risk factors.
Does the patient lifestyle interferes with her Diabetes, does she eat adequate meals, and is she compliant with medications?
The PICOT format is a way to develop a clinical question that lends itself to searching for evidence.
P= Population of Interest: Patient hospitalized frequently with hypoglycemic episodes.
I= Intervention of Interest: Patient teaching and education with home medication regimen, keeping scheduled doctor visits to stay updated, and eating 5 to 6 small meals per day to help prevent hypoglycemic episodes.
C= Comparison of Interest: Compare the treatment and discharge planning and teaching prior to current hospitalizations.
O= Outcome of Interest: Compliance of recommended treatment and follow through with discharge instructions and plan.
T= Time: Goal 30 days with no readmissions to the hospital for the same medical diagnosis-Diabetes.
For the patient to be successful she needs adequate and reliable resources to refer to in order to stay compliant and understand clearly on what are expected to prevent hypoglycemic episodes and frequent hospital visits. I f she has a friend or family member that would be willing to take part of her pal of care, it probably would motivate her to stay on track.
Reference:
www.cdc.govLinks to an external site.
Kumar, S. (2015). Type 1 diabetes mellitus-common cases. Indian Journal Of Endocrinology & Metabolism, 19S76-S77. doi:10.4103/2230-8210.155409
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Along the way, you’ll explore nursing research and its evolution from Florence Nightingale’s time until today.
You’ll build on knowledge gained in the informatics course as you choose a significant clinical issue, formulate a searchable clinical question, and search for research-based evidence.
This process lays the groundwork for a PICOT assignment that you’ll complete during the course as you discover sources of evidence for your own EBP. Nursing research critically advances our profession through the development of evidence upon which our practice standards are based. To determine what the best evidence is, a nurse needs to look at how the information was collected, how rigorous the methods used to develop the evidence was, and what source was used to share the evidence.
The Course Outcomes (CO) we will apply in our first week include:
Examine the sources of evidence that contribute to professional nursing practice.
Recognize the role of research findings in evidence-based practice.
Read the assigned case study and formulate searchable, clinical questions in the PICO(T) format. There are several potential questions that could be asked. Identify if the focus of your question is assessment, etiology, treatment, or prognosis. Remember to integrate references.
There are many possibilities for the research question. Make sure that you also Identify the focus of each question and explain WHY. Don’t forget to give the “P”, “I”, “C”, “O” AND T
You may want to review the lesson from Week One
According to CCN 2017 week 1 lesson, evidence can form the basis of best practices for the nursing process (assessment, diagnosis, planning, implantation and evaluation). As we consider the who, what, where, when, why and how of the situation, we begin to formulate a clinical question that addresses these queries. The PICOT format is a way to develop a clinical question that leads itself to searching for evidence. PICOT is an acronym for:
P= Population of interest
I= Intervention of interest
C= Comparison of interest
O= Outcome of interest
T Time
The case study of a 57 year old female with a 13 year history of diabetes who presented to the hospital due to failure of oral hypoglycemic agents (OHAs) in controlling her sugar levels, for the last 3 years, and was using biphasic insulin aspart 30/70 for treatment. She is a regular swimmer and socially very active, which led to her to have irregular meals and so often goes into frequent hypoglycemia. Her lifestyle, eating habits, and the use of biphasic insulin are the contributing factors of her uncontrolled diabetes and hypoglycemia. In addressing this case study, I will formulate the PICOT as follows:
P= 57 year old female with 13 years history of diabetes
I=Teaching regarding diabetic management
C=No teaching regarding diabetic management
O=Improvement in diabetic management and reduction of diabetic crisis
T=Daily monitoring of fasting blood-sugar and postprandial blood-sugar levels x 3 months and monitoring HA1C levels every 3 months. Assessment of knowledge about diabetic management.
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Clinical question after PICOT format:
- Etiology and assessment: Does lifestyle (irregular meals )and biphasic insulin aspart 30/70 causes hypoglycemia on the female.
Treatment and Prognosis: With lifestyle modification(regular meals), teaching on diabetic management and insulin degludec help in controlling the ladies diabetes by maintaining her blood-sugar levels and HA1C within normal limits?
References
CCN (2017). Week 1 Lesson. NR-439 RN Evidence-Based Practice. Online lesson. Downers Grove, IL: DeVry Education. Group.CCN (2016).
“The PICO(T) format is a way to develop a clinical question that lends itself to searching for evidence. PICO(T) is an acronym for
P = population of interest
I = intervention of interest
C = comparison of interest
O = outcome of interest
T = time”. (Lesson, week 1)
“Research is used as evidence in the evaluation and determination of best nursing practices. Nurse researches use a variety of methods to generate new knowledge or summarize existing study results”. In one of the given scenarios, we will try to generate new knowledge about the effects of the new medication. (Houser. 2018).
I chose the scenario about a 6 year old boy.
P=a 6 year old type 1 diabetic boy.
I=Using the new medication-Degludec/injection tresiba.
C=Standard IV insulin basal bolus therapy.
O=The diabetes type 2 stable control was achieved, with no reported hypoglycemic reaction, and diet compliance was achieved.
T=3 months.
My question is in assessment. Assess if the new medication can control diabetes type 2 with no episodes of hypoglycemia for 3 months.
According to the text, a 6 year old type 1 diabetic boy experienced the side effects from the standard IV insulin basal bolus therapy that he is usually getting. According to S. Kumar. (2015) “Tight glycemic control in type 1 diabetes mellitus patients is associated with the risk of hypoglycemia”. The major side effect in this study, were two severe hypoglycemic reactions. The other inconveniences were frequent blood glucose monitoring, severe anxiety, depression and frustration of the client and his parents. Our assessment is based on the results that we get over the period of three months, after the client and his parents agree to start the new medication Degludec. As we can see, the client’s blood glucose level has become stable, client demonstrates diet compliance, no hypoglycemic reactions were reported over the period of three months. The client can monitor his blood sugar level only once a day. The client is happier in his life, no anxiety or depression were reported. We conclude that the new medication Degludec can definitely control diabetes type 2 with no episodes of hypoglycemia for at least three months.
References:
Chamberlain College of Nursing. (2017). Week 1: Introduction to Evidence-Based Practice: Basic concepts.
Houser, J. (2018). Nursing research: Reading, using, and creating evidence (4th ed.). The importance of research as evidence in nursing. What is nursing research? pp.5.
Kumar, S. (2015). Type 1 diabetes mellitus-common cases. Indian Journal of Endocrinology& Metabolism, 19, S76-S77. Retrieve fromhttp://proxy.chamberlain.edu:8080/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=102354944&site=eds-liv
According to this week’s lesson, “Evidence can form the basis of the best practices for the nursing care process, including assessment diagnosis, planning, implementation, and evaluation” (CCN, 2016). Today, there is a push for better healthcare, better delivery, and better technology. Our profession is constantly looking for the best practice and look to Evidence Based Practice to guide us in the right direction. At my currently position I do not have a large hand in changing the care we deliver. As new ideas come across based on EBP our unit (L&D) take them to the manager for further review. These ideas are then passed to Perinatal Committee before being implemented into our unit.
Looking at the case study for this week evidence is gathered about Mary to provide the best practice for her nursing care. “Finding and developing significant problems for nursing research is critical to improving processes and outcomes for patients, nursing staff, organizations, and communities” (Houser p. 77). Clinical questions that could be asked regarding Mary’s case study would be:
- Does physical activity and diet effect blood sugars in diabetic patients? This questions focuses on treatment ad prognosis. As nurses we are aware how diet and physical activity effects diabetic patients. This question can be used in reference to treatment and prognosis as an education tool for Mary and her risks in regards to her lifestyle choices.
P- Diabetic patients
I- Does diet and physical activity effect blood sugars
C- Diet and physical activity vs sedentary lifestyles in diabetic patients
O-Improve diet and physical activity to improve blood sugars in diabetic patients
T- No time noted.
- For patients with co-morbidity does the use of discharge programs reduce the risk of hospital readmission rates compared to no discharge programs? This question focuses on treatment of Mary. Hospital discharge programs and f/u would potentially decrease hospital readmission by addressing s/s in a timely fashion and addressing additional educational needs.
P- Patients with co-morbidity
I- Does discharge programs decrease hospital readmission rates with patients with co-morbidity?
C-hospital readmission rates without discharge programs.
O- To decrease hospital readmission with hospital discharge programs and patient f/u.
T- No time noted.
References:
Chamberlain College of Nursing. (2017). NR439 Evidence- Based Practice: Week 1 Lesson. Downers Grove IL: Online Publication
Houser, J. (2018). Nursing research: Reading, using, and creating evidence (4rd ed.).