Evidence based practice

5 May 2016

Evidence Based Practice (EBP) is defined as “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external evidence from systematic research” (Gerrish & Lacey, 2010).

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EBP is critically important in today’s clinical settings because of its potential to save both nursing time and healthcare dollars (Gerrish & Lacey, 2010). Using the evidence to guide practice streamlines nursing care. Practices that are not necessary are eliminated, and ineffective practices are replaced with practices that result in the desired outcomes. Using research also decreases the need for trial-and-error methods for finding what works best.

In each case, nursing time is not spent on ineffective procedures or trying numerous interventions before finding the “right” one and nursing time is spent where it can be most effective (Gerrish & Lacey, 2010). This essay will explore the given case study of Mr Armitage using an EBP approach to provide best care for two of his main issues which are type 2 diabetes and obesity. Rationales will be provided as why these issues are the main focus and questions will be developed to guide search strategies.

An outline will be given on finding the evidence: concepts used, databases and included in this section will be a search table. The evidence chosen will be appraised and key findings will be discussed along with the best practice for Mr Armitage and how this practice can be implemented.

Mr. Armitage is a 50-year old male of Aboriginal descent. His major complaints are: Shortness of breath, dizziness, frequent urination, occasional tinnitus. He has a five year history of ill controlled Type-2 diabetes mellitus. This was diagnosed in 2004 after a 2-year hiatus of symptoms that were suggestive of hyperglycemia.

His general state of health is fair; he reports bouts of dizziness, dry mouth, frequent urination, occasional tinnitus, weight gain and slow healing of minor wounds. He is clinically obese with a relative sedate life-style. Mr. Armitage is married and has two adult children, one of whom helps him and his wife with their grocery store business. The Armitages live about an hour from their business and commute daily by automobile. Both report that the commute is, at times, stressful for both.

It appears that the high cholesterol, apnea, hypertension and type-II diabetes that Mr. Armitage is experiencing may have some potential genetic predispositions as well as lifestyle issues. His father died of coronary disease at age 78 and his uncle at age 72. Mr. Armitage reports no allergies, but does admit that he has been unable to remain on a healthy diet (low-glycemic) due to work schedules and pressures (time etc.). He drinks alcohol in moderation and limits sugary sodas, but admits to not drinking enough water during most days.

He sleeps less than 8 hours, but because of frequent urination and apnea, he does not feel that he ever gets enough sleep. His current medical regimen includes an 80mg low dose of aspirin and a statin that he admits to not using regularly. Problems and guiding questions

Using the model of Evidence Based Practice, outlining the chosen issues presented by Mr. Armitage is needed. Evidence for these issues should be primarily scholarly, with the bulk of the materials available from peer-reviewed journals or publications, even Web-Based materials, as long as those materials are written by qualified scholars and/or medical professionals.

Type II Diabetes: II Diabetes, also known as diabetes mellitus, is also called non-insulin-dependent diabetes or adult onset diabetes. It is a medical disorder that, due to a number of factors codependent with the modern world, is characterized by higher than normal blood glucose levels that play havoc with insulin deficiency and resistance.

There is no cure, per se, for the disease, although if managed through exercise and diet it usually diminishes. However, if untreated, Type II Diabetes may become quite serious and require the medication of symptoms in order for the patient to maintain a productive life (Australian Diabetes Society, 2013) Diabetes mellitus type II, formerly called non-insulin dependent diabetes or adult onset diabetes is a metabolic disorder that is medically characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency.

It is initially managed by increasing exercise and dietary modification, but if the condition is unresponsive, medications may be needed. Typically, there is little tendency toward ketoacidosis, but often nonketonic hyperglycemia. Longer-term complications from high blood sugar can increase risks of heart attacks, strokes, amuptation, diabetic reinopathy, and kidney failure.

In extreme cases, circulation of limbs is affected; as is loss of hearing, eyesight and cognitive ability (Inzuccian, S., et al., 2012). Recent studies have shown that there is now a global consequence of obesity – and the resulting diabetes and other problems as not just a medical issue but a true social, cultural and economic problem.

In fact, since 1999 there is a clear relationship between the consumption of certain foods and type-II diabetes, leading to the epidemic spreading from the developed world into the developing world, largely as a result of globalization, advertising, and availability of processed foods (Bagchi & Preuss, 2013). Obesity- One need only look at a sampling of billboards, magazine and television ads, or local grocery store aisles to see that in Australia, one of the most egregious issues facing the public health paradigm is obesity and the link between being overweight and unhealthy. Both scholars and public health professionals agree that there is a true link between food and health.

Daily, we are besieged with advertisements for diet fads and pills, new products promising low fat or low calorie offerings, all designed to support Australia’s need for a quick fix to the burgeoning problem of obesity (Fumento, 2008). Are there negatives to healthful eating? Certainly none that are medical – but, in our society of fast food, it is more expensive to eat right, fresh vegetables, hormone free meat, low sugar beverages all are a bit more expensive that the high-carbohydrate, fast foods so popular (Robbins, 2008).

The Australian Public Health community is alarmed that there is a clear epidemic of obesity in the country, one of which shows no reversing. This is defined as a condition in which excess weight or body fat contributes to potentially negative effects for the person.

There are also numerous health risks; heart disease, cirrhosis of the liver, arthritis, diabetes (most especially those overweight), and numerous other aches and pains that keep Australians out of work, and at far more risk of developing chronic cardiovascular and other diseases.

Alarmingly, 25% of Australian children are obese, and 3 in 5 adults are now considered obese. In Australia, over 30% of indigenous populations and those living in remote areas are obese as opposed to major cities (Australian Government, 2011). An estimated 280 Australians develop diabetes daily; with a 2005 study showing that 1.7 million had Type-2 diabetes diagnosed and that likely another 1 million were undiagnosed.

The total financial cost for this was estimated at over $10 billion dollars annually with $4 billion lost in productivity. A reduction in type-2 diabetes will not only result in cost savings, but in increasing the health of all Australians (Diabetes in Australia, 2010). In addition, the cost burden of obesity is staggering and it is expected to increase.

Demographically, it is moving from an adult disease to a pandemic across the entire age spectrum without regard to ethnicity or demographic/psychographic modifiers. While there is no single effective approach to the disease; we suggest a multistage approach in which a combination of lifestyle and dietary modification/exercise, legislation aimed at prevention in children, and exercise/healthy lifestyles at work to be an appropriate response to the issue.

Each intervention alone (counseling, diet, or exercise) may be somewhat appropriate, but the combination will prove to be the most efficacious. In fact, over 14 million Australians are currently obese or overweight, and if the trend continues, by 2025 over 80% of all Australian adults will be obese with obesity and related issues becoming the leading cause of premature death (Obesity in Australia, 2012)

Locating the evidence
Commercial organisations that develop evidence-based practices include the Cochrane Collaboration (http://www.cochrane.org), the Joanna Briggs Institute for Evidence Based Nursing & Midwifery (http://www.joannabriggs.edu.au.ezproxy.ecu.edu.au), and the Sarah Cole Hirsh Institute for Best Nursing Practices Based on Evidence (http://www.hirshinstitute.com). Each of these organizations offers a variety of services and products to facilitate and enhance evidence-based practice.

Appraising the evidence
In order to use EBP effectively involves both complex and conscientious decision-making which utilizes clinical characteristics and situations that
are individualized for the patient in combination with a questioning approach to the scholarly management of the issues at hand.

Collaboration based on evidence is important, as is vetting and understanding source materials. In the case of our evaluation of Mr. Armitage’s issues, sources were primarily used that were medical or scholarly in nature and as current as possible (See Figures 1 and 2).

In this case, 75% of all sources consulted were from 2011-2013. In terms of type of material, the quality of Internet based web-sites has considerably improved. WebMD, The Mayo Clinic and others have practicing clinicians write materials that may be in lay-language, but are sourced appropriately. For our overview, scholarly and statistical sources made up 92% of sources; the other 2% knowledgeable lay source materials written by medical professionals but without peer-reviewed citations.

Various databases were invaluable at finding current studies and using specific search terms to delineate needed information: PubMed, Questia, Joanna Briggs Institute and the Cochrane library. The documents in this overview were chosen for both their relativity to the issues at hand and how current they were.

Implementing the evidence
The key findings from the articles used to answer guiding questions were

Evaluation
The implementation of this practice can be evaluated by

Conclusion

More than ever, the modern nurse must be a multitasking professional with superior communication skills. Accentuating dialog is Evidence Based Practice. This model helps the professional focus on implementing practices that are based largely on evidence.

While it acknowledges that there are clearly times for the use of intuition, it also asks that there be an ongoing focus of curiosity about the best evidence that will guide appropriate decision-making. EBP has a direct relationship to the quality of the learning organization for most nurses. However, recent research shows that there is not enough EBP used in most clinical organisations, and that nurses would relish improving the quality and quantity of knowledge through EBP in their daily duties.

Using EBP as a primary paradigm of care, instruction, learning, and day-to-day activities is critical for not only the profession, but for the continued improvement of care and professionalism within the clinical environment. Not only does the mindset improve patient outcomes, it also helps the nurse actualize and grow within their career – providing options for intellectual and personal achievement (Hall & Roussel, 2013).

To place this evidence into practice requires cooperation of nursing staff. For instance, incorporating EBP into the clinical setting can be difficult at times since it involves change management. However, some of the ways to incorporate this mind-set are: Reference EBP – Reference ECP in topic areas as much as possible.

This should be done in a non-threatening manner designed to inform, not show off. For example, if one were working on a case of mouth infection on patients with breathing tubes, one could say, “There was a recent study on this that found 2-3 rinses with saline and X was effective in reducing infection by almost 80%.” During weekly or regular meetings, assign each person under your charge to present one EBP article or method that has relevance to the unit. Use EBP in staff assessments, goal setting, and personal growth programs.

Encourage use of EBP into grand rounds, educational programs, journal clubs, new staff orientation, and all training session (Melnyk, B., et al., 2012). In the case of Mr. Armitage, using current EBP source materials will allow for a dual natured approach to his medical issues.

On one hand, medical professionals have the tools to utilize the most current and effective treatment and lifestyle changes; and on the other, Mr. Armitage, again through EBP sources, has the opportunity to take some personal responsibility for his healthcare. .

References

Australian Bureau of Statistics. (2013, January). Future Population Growth and Aging. Retrieved from abs.gov.au: http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/4102.0Main+Features10March%202
009 Australian Diabetes Society. (2013, January). Diabetes in australia. Retrieved from diabetessociety.com.au: http://www.diabetessociety.com.au. Australian Government. (2011, June). Overweight and Obesity. Retrieved from AIHW: http://www.aihw.gov.au/overweight-and-obesity/ Bagchi, D., & Preuss, H. (Eds.). (2013).

Obesity: Epidemilogy, Pathophsyicology and Prevention. New York: Taylor and Francis. Bakris, G., & Baliga, R. (2013). Hypertension. Oxford and New York: Oxford University Press. Diabetes in Australia. (2010, June). Retrieved from diabetesaustralia.com: http://www.diabetesaustralia.com.au/Understanding-Diabetes/Diabetes-in-Australia/ Don’t Blame Your Genes. (2009, September 3). Retrieved from The Economist: http://www.economist.com/node/14350157?story_id=14350157 Egan, B., et al. (2013).

Blood Pressure and Cholesterol Control in Hypertensive Hypercholesterolemic Patients. Circulation, 128(2), 29-41. Gerrish, K., & Lacey, A. (2010). The Research Process in Nursing (6thed.). Oxford, United

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