Evidence-based Practice in Wound Cleansing

Evidence-based Practice in Wound Cleansing Introduction This essay defines the concept of evidence-based practice and discusses the importance of evidence-based practice for professional practice. The essay also selects an aspect of practice that is relevant to adult nursing, namely the use of water vs. saline for wound cleansing, provides a rationale for choosing that aspect within the context of evidence based practice, and, drawing on practice experience and examples of approbate evidence, discusses the extent to which the aspect of professional practice is informed by different types of evidence. In addition, the essay, with reference to the selected aspect of professional practice, discusses the factors that can hinder, or hinder the implementation of, evidence-based practice. Evidence-based practice is usually taken to mean using â€Å"the current best evidence in making decisions about the care of individual patients† (see Sackett et al., 1996), with a more recent definition being, â€Å"Evidence-based practice requires that decisions about health care are based on best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources† (see Dawes et al., 2005). The importance of evidence-based practice for professional practice In terms of the importance of evidence-based practice for professional nursing practice, offering evidence-based assessments and treatments has become widespread across the nursing profession due to the need for the NHS to be seen to be accountable to their patients as part of the NHS Plan (see Griepp, 1992). In essence, in the context of the NHS Plan and the consequences of this for professional practice, the aim of evidence-based nursing practice is to treat the patient in the best possible way, as dictated by the most up-to-date evidence available, in a timely manner, in order to ensure the highest possible quality of care for that individual patient (Cluett and Bluff, 2000). Within the framework of the NHS, the NHS Plan has meant many changes to nursing practice, including improvements in the delivery of service but mainly placing emphasis on the prompt delivery of evidence-based care and the pro-active involvement of the patient in their own care. As part of this change, which is a sea-change in the way in which the NHS has traditionally viewed care, nursing staff need to commit themselves to lifelong learning and professional development, within an evidence-based practice framework. This evidence-based framework dictates that nursing staff must use the current best evidence when making decisions about patient care, in order to conform to the dictates of their particular guidelines for professional practice. This is especially pertinent considering the need to empower patients through involvement in patient care, under the dictates of the NHS Plan: as Playle and Keeley (1998) argue, patients are no longer passive receivers of care as the NHS now needs to be seen to be accountable to their patients. Offering evidence-based assessments and treatments fulfills the requirements to be accountable to patients through the use of up-to-date research to inform treatment practices, for example (see also Griepp, 1992). Rationale for choosing the use of water vs. saline in wound cleansing This section of the essay discusses an aspect of practice that is relevant to adult nursing, namely the use of water vs. saline for wound cleansing, and provides a rationale for choosing that aspect within the context of evidence-based practice. This aspect practice has been chosen as it is commonly found in nursing practice: many individuals present with wounds at all nursing levels, including AE, community nursing and intensive care, amongst others. The issue thus has widespread importance in nursing practice across many different areas of practice. An analysis of the extent to which the use of water vs. saline for wound cleansing is informed by different types of evidence This section of the essay will now draw on my practice experience, and, using examples of appropriate evidence, will discuss the extent to which the use of water vs. saline for wound cleansing is informed by different types of evidence. Cunliffe and Fawcett (2002) found that nurses are presented with a variety of wound cleansing options, from the products that can be used to cleanse wounds to the dressings that can be used. The work found that this makes it difficult for nurses to make decisions about patient treatment, which means that nursing staff, instead of looking to the literature for advice, turn to the RCN guidelines, which is not an ideal basis for evidence-based practice (Cunliffe and Fawcett, 2002). Betts (2003) found that wound cleansing with water does not differ from wound cleansing with other substances, in terms of wound infection and wound healing (similarly to Gannon, 2007; Hall, 2007 and Griffiths et al., 2001). Fernandez and Griffiths (2008) conducted a systematic review of the literature on the use of water for wound cleansing and found that, whilst saline is usually favoured for wound cleansing, tap water is also a viable alternative, as it does not increase infection and there is some evidence that using tap water actually reduces the risk of infection, even in acute wounds. Their conclusion was that boiled tap water can be used as a wound cleansing agent (Fernandez and Griffiths, 2008), a conclusion also reached by Moscati et al. (2007), O’Neill (2002), Valente et al. (2003), Whaley (2004) and Riyat and Quinton (1997). Thus, the evidence from the research conducted on this subject suggests, overwhelmingly, that tap water is a viable alternative to saline for wound cleansing. The RCN guidelines for wound cleansing still, however, state that saline should be used for wound cleansing. The next section will look at this discrepancy in detail. The factors that facilitate or hinder the implementation of evidence-based practice in wound cleansing This section makes reference to the selected aspect of professional practice in order to discuss the factors that facilitate or hinder the implementation of evidence-based practice. There are many structures designed to support evidence-based nursing practice, including research and development that translates in to best practice guidelines. However, whilst it is clear that nursing staff, under the dictates of the NHS Plan, need to work within an evidence-based care framework, there are no guidelines as to how research is best incorporated in to their practice, in terms of what research should be used or what questions should be asked of that research, and so nursing staff often end up following guidelines that are produced for them, by the NHS. These guidelines are based on current research, and so do provide evidence-based care for patients, in some sense, but following guidelines does not involve nursing staff being directly involved in evidence-based care. As one of the main principles of evidence-based practice is that decisions about care should be based on the best currently available evidence from research, this situation is not ideal. Under a true evidence-based practice framework, nursing staff should be regularly undertaking literature searches themselves, to ensure that they themselves keep up to date with the research, and that they are aware of any new recommendations for nursing practice that are suggested by this research. They should then be implementing these new recommendations. This, however, provides difficulties, in that nurses are bound, by their professional training, to provide the usual standards of care, with the possible implication that, should a nurse try a new treatment method on a patient, following their research on a subject, as part of the evidence-based framework, and this treatment is not successful, the nurse would have let the patient down, under the guidelines provided for their professional practice. This, thus, provides a dilemma for nursing staff, who are bound to work under an evidence-based framework, but who are – in practice reliant on the timely provision of updates to treatment guidelines, which are based on an evidence-based framework but which have not been researched individually by the nursing staff. For example, as has been seen, there are many research publications that show how water can be beneficial in cleansing wounds, but the current recommended practice from the RCN guidelines is that â€Å"irrigation of the wound with saline is usually sufficient† with the provided rationale for this being that, â€Å"cleansing traumatic wounds with saline was associated with a lower rate of clinical infection when compared to tap water (Angeras et al., 1992)†, the RCN guidelines do concede that no clinical trials have been performed comparing tap water and saline water in wound cleansing and, as such, that there is no real evidence-base for these recommendations. Nursing staff working within an evidence-based framework could read the literature supporting water as an effective wound cleanser, and could base their treatment on this literature, which, whilst being within the scope of evidence-based practice, as recommended by the NHS Plan, would go against what they are recommended to do by their professional body. In the example discussed in this essay, therefore, the evidence as provided by the research has not yet been translated in to an up-to-date set of guidelines for nursing staff to follow. It seems, therefore, that patients are not being treated according to the best possible set of treatments according to the research, but, as the RCN guidelines state, there has, as yet, been no clinical trial of wound cleansing with water vs. saline, and so, even if the research suggests tap water is an effective, if not more effective wound cleanser than saline, until a clinical trial has been undertaken testing this, the recommendations for treatme nt will not change. In this case, however, a clinical trial is extremely difficult to imagine, due to the temporary and highly individual nature of wounds, which makes it impossible to provide clinical trial conditions to test water vs. saline as wound cleansing agents. As such, even though the literature suggests that tap water is an effective, if not more effective, wound cleanser than saline, saline will still continue to be used, as this has been used historically, and because no clinical trial has been set up proving the effectiveness of tap water, meaning that tap water cannot be recommended as a wound cleanser, in that it is not recommended in the RCN guidelines for nursing staff. Nursing staff are, however, under the evidence-based practice framework, able to apply, monitor and record wound cleansing using tap water. This approach allows nursing staff to approach the process of evidence-based practice in a series of steps (as recommended by Cluett and Bluff, 2000), within the guidelines provided by the RCN. The first step is defining the research question, based on evidence gained from treating patients in practice, which, in this case would be, â€Å"What is the best way to cleanse a patients wound, using tap water or saline?†. The next step would be to search for and to read all the relevant literature, and then to decide, on the basis of that literature, what the best treatment options are for the patient. This would, as has been seen, overwhelmingly suggest that tap water is the best treatment option, but the RCN guidelines would suggest that saline is the best treatment option. The nurse would thus be obliged to use saline but could apply, monitor and record wound cleansing using tap water, as part of the evidence-based framework they are encouraged to follow. Evaluation of the care provided and the processes through which the care was decided upon and administered would constitute the third and final step of the evidence-based framework (as given by Cluett and Bluff, 2000), which would gather all the relevant information and then would evaluate the results of this treatment in terms of finding a better solution for wound cleansing. This step-by-step approach to evidence-based practice allows for gradual improvements in the delivery of patient care through a process of gathering evidence of best practice. As has been seen, however, often nursing staff are not encouraged to follow this pathway as they are obliged to be bound by the guidelines for treatment provided by their professional body, the RCN, which, in this case, recommends a treatment option that seems outdated, according to the current research. Conclusion As shown by the appraisal of evidence for the use of tap water vs. saline as a wound cleanser, evidence-based practice in a nurses working life can be hindered by their professional guidelines, which, in this case, have not been updated based on the findings of current research. Whilst evidence-based practice facilitates best treatment practice for patients (as dictated by the NHS Plan) through the step-by-step approach outlined by Cluett and Bluff (2000), in this case, this facilitation is not enabled through the failure of the RCN to update their guidelines. Angeras M.H. et al. (1992). Comparison between sterile saline and tap water for the cleaning of acute traumatic soft tissue wounds. European Journal of Surgery, 158; 6-7: 347-50. Betts, J. (2003). Review: wound cleansing with water does not differ from no cleansing or cleansing with other solutions for rates of wound infection or healing. Evidence Based Nursing 6, pp.81. Cluett, E. and Bluff, R. (eds.), 2000. Principles and Practice of research in midwifery. Bailliere Tindall. Cormack, D., 2000. The research process in nursing. Oxford: Blackwell Science. Cunliffe, P.J. and Fawcett, T.N. (2002). Wound cleansing: the evidence for the techniques and solutions used. Professional Nursing 18, pp.95-99. Dawes, M. et al., 2005. Sicily statement on evidence-based practice. BMC Medical Education 5, pp.1-2. Fernandez, R. and Griffiths, R. (2008). Water for wound cleansing. Cochrane Systematic Syst Rev 23, pp. CD003861. Gannon, R. (2007). Wound cleansing: sterile water or saline? Nursing Times 103, pp.44-46. Goldenberg, M.A., 2006. On evidence and evidence-based medicine: a commentary on common criticisms. CMAJ 163(7), pp.837-841. Griepp, m.E, 1992. Undermedication for pain: an ethical model. Advances in Nursing Science 15. pp.44-53. Griffiths, R.D. et al. (2001). Is tap water a safe alternative to normal saline for wound irrigation in the community setting? Journal of Wound care 10, pp.407-411. Guyatt, G. et al., 2004. Evidence-based medicine has come a long way. BMJ 329, pp.990-991. Hall, S. (2007). A review of the effect of tap water vs. normal saline on infection rates in acute traumatic wounds. Journal of Wound Care 16, pp.38-41. Hinchiff, S. et al. (2003). Nursing practice and health care. Hodder Arnold. LoBiondon-Wood, G. Haber, J. (2006) Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. St. Louis. Mosby. Moscati, R.M. et al. (2007). A multicenter comparison of tap water vs. saline for wound irrigation. Acad Emerg Med 14, pp.404-409. NLH (2006). What is the evidence-based method of wound cleansing either with tap water or normal saline? Available from http://www.clinicalanswers.nhs.uk/index.cfm?question=2518 [Accessed 20th March 2008]. O’Neill, D. (2002). Can tap water be used to irrigate wounds in AE? Nursing Times 98, pp.56-59. Patel, S. and Beldon, P. (2003). Examining the literature on using tap water in wound cleansing. Nursing Times 99, pp.22-24. Riyat, M.S. and Quinton, D.N. (1997). Tap water as a wound cleansing agent in AE. J Accid Emerg Med 14, pp.165-166. Sachine-Kardase A, et al. (1992). Study of clean versus aseptic technique of tracheotomy care based on the level of pulmonary infection. Noseleutike 31(141), pp.201-11. Sackett et al., 1996. Evidence-based medicine: what it is and what it isn’t. BMJ, 312, pp.71-2. Salami, A.A. et al. (2006). A comparison of the effect of chlorohexidine, tap water and normal saline on healing wounds. Int J Morph 24, pp.673-676. Valente, J.H. et al. (2003). Wound irrigation in children: saline solution or tap water? Ann Emerg Med 41, pp.609-616. Watret L., Armitage M.A. (2002). Making Sense of Wound Cleansing. Journal of Community Nursing, 16(4), pp.27, 29-32, 34. Whaley, S. (2004). Tap water or normal saline for cleansing traumatic wounds? Br J Comm Nurs 9, pp.471-478.

Acceptable Use Policy (AUP) Definition Essay

E-mail All messages composed, sent, received, or stored on the e-mail system are and remain the property of the company. They are not the private property of the employee. Personal e-mail accounts are not to be used on the company’s computer system. The e-mail system is not to be used to send offensive, sexually suggestive, obscene, lewd, demeaning, or disruptive messages. This includes, but is not limited to, messages that are inconsistent with the company’s policies on equal employment opportunity, anti-discrimination, and anti-harassment (including sexual harassment). Moreover, the e-mail system is not to be used to solicit or proselytize for commercial ventures, religious or political causes, or other non job-related solicitations. The Company reserves and intends to exercise the right to review, audit, intercept, access, disclose, and use all messages created, received, or sent over its e-mail system for any purpose. The contents of e-mail may be disclosed and used by the company to protect its rights and/or property without the permission of the employee, in the company’s discretion. The confidentiality of any message should not be assumed. Even when a message is erased, it is still possible to retrieve and read that message. Further, passwords for security do not guarantee confidentiality. All passwords must be disclosed to the company or they are invalid and cannot be used. Employees not involved in maintenance or operation of the company’s e-mail system are not authorized to retrieve or read any e-mail not sent to them. Any exception to this policy requires the approval by senior management of the company. Internet The company’s computer network, including its connection to the Internet, is to be used for business-related purposes. Any unauthorized use of the Internet is strictly prohibited. Unauthorized use includes, but is not limited to, connecting, posting, or downloading pornographic material; engaging in computer â€Å"hacking† and other related activities; attempting to disable or compromise the security of information contained on the company’s computers; or otherwise using the company’s computers in a manner which interferes with their business purpose. Employees should not send highly confidential information through the Internet without encryption. Anything  sent through the Internet passes through a number of different computer systems, all with different levels of security. The confidentiality of messages may be compromised at any point along the way. Because postings placed on the Internet may display the company’s address, make certain before posting information on the Internet that the information reflects the standards and policies of the company. Under no circumstances should information of a confidential, sensitive, or otherwise proprietary nature be placed on the Internet. Information posted or viewed on the Internet may constitute published material. Therefore, reproduction of information posted or otherwise available over the Internet may be done only by express permission of the author. Offensive, sexually suggestive, obscene, lewd, demeaning, or disruptive messages are prohibited. This includes, but is not limited to, messages that are inconsistent with the company’s policies on equal employment opportunity, anti-discrimination, and anti-harassment (including sexual harassment). Use of the company’s e-mail/Internet system from a personal or company-owned computer through company-owned connections are subject to the same policies that apply to use from within company facilities. computers Due to the sensitive nature of computers and the software contained therein, all employees provided with computers may not download, install, alter, or delete any software, programs, and information (i.e., e-mails, spread sheets, databases, Microsoft Word, or other word processing documents) contained on company computers without the express authorization of the company. The company reserves the right to inspect or review its computers and the information contained therein at any time without notice or consent. Any employee who violates the company’s e-mail/Internet/computer usage policy shall be subject to discipline, up to and including employment termination. Reference â€Å"Internet Acceptable Usage Policy Guidelines .† OSA. http://www.osa.state.ms.us/downloads/iupg.pdf (accessed April 17, 2014). â€Å"Table of Contents.† 9781449692438.

Containerization, Unitized Cargo and Cargo Containers

ONCEPT OF CONTAINERIZATION The conteainerization is a physical distribution method that uses a container as a way of tranporting the cargo. Is an inter-modal system of transporting the general cargo or product in lots. With containerization goods are moved easier from one place to another with the help of the containers which can be loaded intact onto the container ships, trucks, railroad cars and planes. Nowadays, containerization is the innovative key in the field of logistics that helps to organize cargo in an efficient, better and save way.Benefits of containerization If you visit a port, you would notice that all shipping containers are very similar in form. The introduction of containerization has revolutionised the way cargo is handled. The standardization of container sizes, shapes, and forms lowered freight charges and costs. Containerization also improved cargo security. First, the box effectively hides whatever cargo from the casual viewer. Next, the container doors are se aled upon closing. The doors also prevent the cargo from falling out the back of the box.Finally, uniformly sized shipping containers reduce railway cargo problems that are caused by incompatible rail measures in different countries, making trans-shipment between different measure trains faster and easier. When transporting goods to an international location, there are many container ships that run regular routes to a variety of destinations. This helps the customer to receive the order in less time. CONTAINERIZED CARGO LOSS CONTROL—CONTAINERIZED CARGO The use of intermodal containers for the transport of a great variety of cargo has become increasingly popular in recent years. Intermodalism is a oncept that embraces the movement and transfer of standardized cargo containers by sea, air and surface. It has greatly reduced cargo handling, particularly in Door-to-Door shipments.The development of specialized containers with a wide range of types, sizes and configurations permit s containerization of most cargo. Undamaged arrival of the complete shipment at destination is the first objective of the shipper. In committing goods to containerized transport, the shipper can reduce losses by: * Select the proper container service. * Selecting the right type of container for the goods in question. Inspecting the container to ensure proper accommodation and protection of goods. * Packaging goods to withstand the hazards of the â€Å"toughest leg of the journey. † * Stowing and securing goods in the container to prevent damage to the goods, container ? and transport vehicle. * Properly describing and documenting the container contents, locking and sealing the ? container and recording container and seal numbers on all shipping documents. * Timely unloading at destination. Intermodal variations ?The popular intermodal container, adaptable to carriage by truck, railcar, and some other, is the most common form of containerization.The considerations governing pr eparation and storage of the cargo in these containers are no longer applicable to other methods of cargo transport. Cargo Containers? 1. End Loading, Fully Enclosed— The basic intermodal container with end doors, suitable for general cargo not requiring environmental control while enroute. 2. Side Loading, Fully Enclosed— Equipped with side doors for use in stowing and discharge of cargo where it is not practical to use end doors, as when the container must remain on a railcar while cargo is placed in or removed from the container. 3.Open Top—Used for carriage of heavy, bulky or awkward items where loading or discharge of the cargo through end or side doors is not practical. Most open top containers are equipped with fabric covers and are often termed â€Å"soft† or â€Å"rag† top containers. Some open top versions are fitted with removable hatch-type panel covers or detachable full metal roof. 4. Ventilated—Equipped with ventilating ports on ends or sides, and used for heat generating cargo or cargo requiring protection from condensation (sweat) damage. Versions with powered air-circulating fans are available.Vents are normally fitted with baffles to prevent entry of sea or rain water. 5. Insulated—For cargo that should not be exposed to rapid or sudden temperature changes. Available in ventilated or non-ventilated versions. Some carriers provide containers with heating systems for special applications. 6. Refrigerated—Insulated and equipped with a built-in refrigeration sys-tem, powered by direct electrical connection or by diesel or gasoline generator. It is used primarily for foods or other commodities requiring a temperature con-trolled environment. 7. Liquid Bulk—Tank-type containers for carriage of liquids.Some have been designed to high level specifications for carriage of certain hazardous materials. 8. Dry Bulk—Designed for carriage of bulk cargo such as dry chemicals and grains. 9. Flat Rack—Available in a variety of sizes and models, the flat racks are used for lumber, mill products, large, heavy, bulky items, machinery and vehicles. Some are equipped with removable sides. 10. Auto — Used for carriage of vehicles and available in enclosed or open versions.? 11. Livestock — Configured for the nature of livestock carried; containers are available for transporting poultry, cattle and other livestock.Also, transport boxes can be loaded onto flats. 12. Controlled Atmosphere—-These systems carry a cylinder of liquid nitrogen and carbon dioxide. Through computer-based controls, the atmosphere within the container can be maintained at preset levels to meet requirements of commodity carried. Used mainly in the transport of produce to extend the post-harvest and storage life. 13. High Cube—These containers are used for high volume/low weight cargo and can greatly increase the cubic area available for cargo stowage. High cube contai ners are in heights to 9. 5 feet and to lengths of a maximum of 48 feet. 4. Garment—With special tie downs and internal ceiling fittings, this container can handle hanging garments. UNITIZED CARGO It a system used to transport goods that are packaged in small volumes, can be consolidated or grouped into a single large volume (container), making sure that those godos are not easily destroyed. At the same time, it facilitates the handling and loading cargo or unloading of it. Unitarization It is the aggrupation of shipment in the corresponding type of package that is over a pallet and secure from damages to manipulate transport and warehouse as a whole unit of load.One of the first attempts of unitarizing the cargo is within the pallet, that is about placing the shipment over a platform, which is constructed with a variety of materials. Actually, pelleting and containerizing are the most common modalities of unitarizing the cargo. Unitarized cargo is composed of individual arti cles such as boxes, packages and other elements are originally separated and then grouped together as pallets or containers. In other words unitarization is the merchandise ready to be transported. There are some norms that have been developed to facilitate this process.For example, one is the ISO 3394 that ha to do with the size and dimensions of the boxes and pallets. Another norm is ISO 7000 that has to do with the code bars in the merchandize. Unitarization in containers is very important because it helps to maintain and preserve the merchandise in good conditions, is easier to transport it and it helps to save space in all the process of storage. And, when unitarizing cargo, in international markets, is very important to be informed of the rules and techniques that are followed by the Country for doing packing.Advantages of unitarization Optimization of time when manipulating the cargo in warehouses, cargo terminals, and in the unload of cargo in ports. It facilitates the recep tion and control in the delivery of merchandise. Well use of space and reduction of damages when the merchandise is handled. Simplifies the management of inventory and improves the identification of products. It provides multiple use in the process of production, goods transportation, international transportation, in the storage and warehousing.

William Shakespeare s Macbeth - 1242 Words

In 16th century England, life was far different than it is today in regards to entertainment. The Elizabethans’ favourite past time was watching theatrical performances mostly delivered by William Shakespeare. During the Golden Age of England, theatre was at its pinnacle, influencing classical English culture and starting a catalyst that would ripple through amphitheatres throughout Europe. Since drama’s debut in Ancient Greece, the dimensions of comedy and tragedy have never been explored until William Shakespeare expanded them to include the themes, motifs and gothic elements relevant during his time. Shakespeare wrote these plays for more than entertaining; he attempted to transcend universal themes and messages that still resonate with audiences today. One of these plays was Macbeth, a tragedy that voices the ambition of a young, kind and righteous man and how it ultimately leads to his downfall and destruction. Shakespeare incorporates into this tragedy a couple of gothic elements that fascinated humanity with the grotesque, the unknown, and the frightening, inexplicable aspects of the universe and the supernatural. In Macbeth however, these elements are complexly weaved with only three of the characters- the three witches. The three witches are acutely significant as they establish the atmosphere of the play, orient the plot and are the architects of the various themes in the play. Shakespeare attempted to deliver certain messages or main ideas to the audience,Show MoreRelatedWilliam Shakespeare s Macbeth 1363 Words   |  6 PagesMacbeth is without a doubt one of the most captivating plays, in my opinion written by William Shakespeare. Throughout this play there is definitely a numerous amount of things that can catch your attention, whether it is a trio of witches appearing, committing murder, or keeping secrets. 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