Critical Analysis of Protocol Term Paper

Critical Analysis of Protocol

You will critically analyse your chosen protocol, in the form of a 2500 word academic essay. You should focus on evaluating the relative strengths and
weaknesses of the research and evidence described in the protocol, using the guiding questions (BELOW) as the basis for your appraisal. Please note that you
should not just present a question and answer format – you must write this in an academic essay style so that your analysis based on the guiding questions
flows as an integrated piece of work.
You are expected to justify comments and analysis with reference to literature.
You are trying to determine the strengths and limitations of the protocol, including the evidence which underpins the protocol and in so doing its relevance to your practice, in the same way, that you would review research or opinion based article to determine its strengths or limitations in supporting your discussion.

Protocol to be analysed
GUIDELINE: Initiation of Patient Controlled Epidural Analgesia (PCEA) and Assessment of Motor and Sensory Response in Hip and Knee Surgery Patients Post Combined Spinal Epidural Anesthesia
Department of Nursing
Population/Specialty-Based Clinical Guideline
PTU/PACU

PURPOSE
To provide a guideline for the timely initiation of Patient Controlled Epidural Analgesia (PCEA) based on the assessment of motor function and sensory
response in hip and knee surgery patients post combined spinal-epidural anesthesia.

DEFINITIONS
Combined Spinal-Epidural Anesthesia (CSE): A type of regional anesthesia that combines the benefit of both spinal and epidural anesthesia. The spinal
component gives a rapid onset of a predictable block. The epidural indwelling catheter component provides access for the administration and titration of anesthesia and analgesia (Mulroy, 2002)
CSE allows for a minimal dose of spinal anesthetic of a short duration and allows of the addition of epidural reinforcement of anesthesia and /or
administration of analgesia (Bali, Sharma & Gupta, 2007)
Patient Controlled Epidural Analgesia (PCEA): A method for patient self administration of narcotic-analgesia and a low dose of local anesthetic agent through an epidural catheter via a dedicated programmable infusion pump (Standl et al, 2003; Block et al, 2003).
Sensory Response Level (Dermatome): The dermatome is the area of the skin supplied by the sensory nerve and approximately corresponds to the myotome (Waxman, online).

It may also be assessed to evaluate the extent of spinal blockade and its resolution (Mulroy, 2002).
Motor Function (Myotome): The muscle and its nerve comprise a myotome. Each muscle in the body is supplied by a particular level of the spinal cord and its corresponding spinal nerve. The initiation and resolution of the spinal blockade of anesthesia is determined by evaluating the motor function of the lower extremities (Smet, Vlaminck & Vercauteren, 2017).

PROCEDURE:
Upon Arrival
1. Positioning Patient;
a. If patient is hypotensive, keep HOB flat.
b. If blood pressure in normotensive range (or other BP parameters defined by anesthesiologist) and other vital signs are stable, place patient in semi
fowlers (HOB @ 30 degrees) unless contraindicated by surgeon or anesthesiologist.
c. Initiate comfort measures and orient patient to Recovery area.

GUIDLINE: Initiation of Patient Controlled Epidural Analgesia (PCEA) and Assessment of Motor and Sensory Response in Hip and Knee Surgery Patients Post Combined Spinal Epidural Anesthesia
2. Assess and document patient’s level of consciousness to determine the level of sedation and anesthesia, vital signs (blood pressure, heart rate, and respirations), oxygen saturation via pulse oximetry, body temperature.
Monitor and document every 15 minutes per protocol.
3. Assess pain level
a. Using the Pain Management Guideline for patients who respond verbally and follow commands.
b. Refer to Pain Assessment Tool for Non-Cognizant Adults.
4. If pain present and no motor movement has occurred, follow physician orders.
5. Access of the epidural catheter and document condition of dressing;
a. Transparent dressing intact, notify anesthesia immediately if not intact.
b. If displaced, bloody, or leakage present, notify physician.
6. Motor Function:
a. Assess and document both lower extremity movements.
b. Motor function is assessed by asking patient to move lower limbs especially the unaffected side, since movement of the unaffected limb usually occurs sooner than the affected limb.
c. Assess every 15 minutes per xxx until meets xxx discharge criteria.
d. Document dermatome level before transferring patient to the floor.
7. The assessment indicator for the resolution of CSE anesthesia and initiation for PCEA is any movement of either lower extremity. This is due to the
relatively low dose of local anesthetic in the PCEA that is routinely used in post hip and knee surgery patients. Thus, the low dose of medication is
unlikely to cause motor and sensory blockade and interfere with the resolution of CSEA (Patel, Sadoughi & Zadeh 2010).
8. Sensory Response
a. For assessment of dermatome level, use alcohol prep to assess “cold” and “wet” sensation (Bourne, Campbell, Mushambi & May, 1997).
b. Assess the non affected area first (for example chest or upper arm) then the affected area.
c. Assess every 15 minutes per xxx until meets xxx discharge criteria.
With the return of any movement of either lower extremity: Prepare to initiate PCEA
1. Two RNs verify medication with physician order
a. Confirm settings on infusion pump are entered correctly per order
b. Co-signatures of RNs are entered on the paper record
c. Label tubing “PCEA”
2. Assess and document vital signs (blood pressure, heart rate, and respirations), oxygen saturation via pulse oximetry, body temperature to ensure
hemodynamic stability.
3. Assess and document the integrity of the epidural catheter transparent dressing and report presences of excessive leakage or displacement at site.
4. If hemodynamically stable, initiate PCEA per physician’s order.

GUIDLINE: Initiation of Patient Controlled Epidural Analgesia (PCEA) and Assessment of Motor and Sensory Response in Hip and Knee Surgery Patients Post Combined Spinal Epidural Anesthesia
5. Continue to assess and monitor vital signs, pain level, and adverse responses to PCEA every 15 minutes.
a. If hypotension occurs as a result of any pain medication administered,
notify physician and monitor vital signs more frequently.
b. Assess for adverse responses such as respiratory depression, nausea, vomiting, pruritis, local anesthetic toxicity, urinary retention/incontinence,
hallucinations, and dense/high block. If any occur, notify physician.
c. If pain is unrelieved while receiving PCEA, administer prn pain medication orders per xxx orders to initiate “Clinician Dose” of xxx per order set. The
patient’s pain level dictates which medication and dose to administer, (See Physician order set).
d. If unrelieved pain continues, notify MD for additional orders until acceptable level of pain control has been achieved.
e. Following initiation of the PCEA, the local anesthetic agent( e.g. Bupivicaine) may adversely spread to the intrathecal space causing motor weakness or worsening sensory blockade (Bourne, Campbell, Mushambi & May, 1997; Patel, Sadoughi & Zadeh 2010).
6. Continue to assess and document every 15 minutes
a. Both lower extremity movement and sensory response
b. Pain level
c. Vital signs
7. Continue monitoring and documentation until patient meets criteria for discharge from xxx
a. Hemodynamically stable one hour following initiation of PCEA
b. Resolution of CSEA has occurred as demonstrated by dorsi-flexion of the unaffected foot.
LOC- Awake and alert.

RELATED RESOURCES
Adult Pain Management Nur-Hs G1006

REFERENCES
Bali, A., Sharma,J.,Gupta, S.D. (2017). Combined spinal epidural anesthesia. JK Science, 9(4), 161-163.
Block, B.M., Lui,S.S.,Rowlingson, A.J., Cowan, A.R.,Cowan, J.A., Wu, C.L.

(2003). Efficacy of postoperative epidural analgesia, a meta-analysis. JAMA, 290(18), 2455-2463.

Bourne,T.M.,Campbell, F.,Mushambi, M.C.,M.C.,May, A.E.(1997) Patients’ assessment of sensory levels during epidural analgesia in labor. International Journal of Obstetric Anesthesia,6,239-241.

Mulroy, M.F., (2002). Regional Anesthesia, An Illustrated Procedural Guide (3rd ed), Philadelphia, PA: Lippincott Williams & Wilkins.

Patel, N.,Sadoughi,A.,Zadeh,B.(2010). Anesthesia Dept.Santa Monica/UCLA
Smet,I.,Vlaminck,E.,and Vercauteren,M.(2007).Randomized controlled trial of patient controlled epidural analgesia after orthopaedic surgery with sufentanil and ropivacaine 0.165% or levobupivacaine 0.125%. British Journal of Anesthesia, 1-5. Doi:10.1093/bja/aem309,1-5.

Waxman SG, “Chapter 5. The Spinal Cord”.(n.d.) Waxman SG: Clinical Neuroanatomy,26e. Retrieved from
http://www.accessmedicine.com/content.aspx?aID=5271677&searchStr=spinal+cord#5271677

Standl,T.,Burmeister,M.,Ohnesorge,H.,Wilhelm,S.,Striepke,M.,Gottschalk,A.,Horn,E.,Esch,J.(2003).Patient-controlled epidural analgesia reduces analgesic requirements compared to continuous epidural infusion after major abdominal surgery. Canadian Journal of Anesthesia. 50(3). 258-264.

Guiding questions and points to help you critically appraise a protocol Notes / bullets (for completion by student

What topic does the protocol address?
What are the component parts of protocol?
Were there aspects of the protocol which you found unclear, and if so, why?
What were the different types of evidence which were used to develop the protocol (e.g. research studies; systematic reviews; government policies; grey
literature)
Where does the evidence that underpins the protocol fit in a hierarchy of evidence?
Evaluate the key pieces of evidence which were used to develop the protocol looking at, for example:
• how current the evidence is
• the relevance of the evidence
• the quality of the research carried out
Evaluate the strength of the body of evidence used to develop the protocol (i.e. taken all together, does the evidence support the aims and outcomes of the
protocol?)
How much confidence can be placed in the evidence which underpins the protocol?
What are the practice guidelines and requirements you can identify in the protocol?
What are the implications of these findings for your own practice?

References must not be more than 5 years old

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Stress of step-parents physically and psychologically

stress of step-parents physically and psychologically

For this paper, you will need to review the theories and research on the topic step-parenting –stress of step-parents physically and psychologically. (the
focus of the paper should be on parents/parenting- not on children.)

You will also include a research section on community services/interventions linked to this parenting issue. This paper should be like reviews in major journals (e.g., Child Development).

You should outline the major theories, discuss important methodological issues in the research area, review research findings, discuss community
connections, draw conclusions, and suggest directions for future research.
(a) Are the most important theories described?
(b) Are the strongest studies on the topic cited (i.e., recent studies- 2000s to the present- as well as the most important)?
(c) Are the research findings integrated (or do you simply describe one study after another)?
(d) Did you discuss research involving community resources/services/interventions linked to your parenting topic?
(e) Have you cited problems with the methods (how the researchers studied the topic or collected their information) involved with the theories and research
you discuss?
(f) Do the conclusions of the paper offer original and valuable insights about the topic?

You must integrate what you learn from your independent reading for the paper with what you have learned. This integration must be shown in the way listed below.;

First, you must refer at least once in your paper to statements in the textbook (Igner, J. J., & Gerhardt, C. (2014). Parent-child relations: An introduction to parenting (10th edition).

The textbook must then be included in the reference list (not included in your ten references). This is the only textbook that can be used for the paper.

Paper criteria.
Sections:
I. Introduction
• Introduce your paper and present some background information (what and how you plan to discuss the issues in the rest of your paper). <br />
• Discuss why this paper is important and describe the focus on parents and/or parenting.
• End this section by discussing the plan of the paper (e.g., First I will discuss…, Next, I will discuss…).

II. Body
• Longest section of the paper, bulk of points are assigned here.
• Discuss the major issues involved with your paper (using lecture materials, outside research articles, and your text/course reading).
• Present research-based evidence to support the issues as you discuss them.
• Must describe a research theory or explanation for the findings presented on your topic.
• Include research on community services/resources linked to this parenting issue (e.g., community interventions that have worked or not worked).
• Be as specific as possible. Provide details and examples of what you are discussing in your paper and make sure your ideas flow from one idea to the next.;
• Critique the studies (methodological issues) – provide criticisms of the way the data was collected or limitations of the research you found (e.g., did not
use a diverse sample, research focuses on only mothers).
• Keep the focus on parents and parenting (not children).

III. Summary and Conclusions;
• Summarize the major points in your paper.
• Make some conclusions about your assignment and discuss how you came to these conclusions.
• Summarize the findings of your paper and discuss whether or not your views coincide with the data or information that you have presented.
• Suggest areas for future research (these suggestions should be carefully thought out- not “more research needs to be done”).

Final Term Paper Grading Protocol:
_____ Description of topic and background information, explanation of why topic is important, overview of how it will be presented;
(5 points)
_____ Discussion of major theories or explanation for findings;
(5 points)
_____ Discussion of major issues integrated with research articles, textbook, and classroom discussion (10 points)
_____ Discussion of research involving community services and/or resources linked to topic in parenting (5 points)
_____ Critique of studies (cite problems with methods) (5 points)
_____ Summary and conclusions (summarize major points, make conclusions with valuable insights, suggest areas of research) (5 points)

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A Comparison of Physicians and Emergency

Fathering, Class, and Gender:A Comparison of Physicians and Emergency

write a 4-5 page reaction (excluding cover/reference). These should include a brief summary, your own ideas/thoughts, and integration of the chapter (Chapter 10 in Our Social World: Introduction to Sociology, Third Edition Media Update by Jeanne H. Ballantine and Keith A. Roberts. .

All papers should include a cover page with your name, date, my name, chapter, and article title. A reference page should also be included.

Use at least three (3) quality references Note: Wikipedia and other related websites do not qualify as academic resources.

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Source Evaluation Essay about Smoking

You need to take one of the sources you are considering using in your research paper (Essay 3) and evaluate it to see if it
holds up as a credible and reputable source. The following list applies to print sources (books, magazines, journals, newspapers and Electronic Databases like Proquest). You can only use a print source for this assignment.

In your introduction, you will explain what your research topic is briefly being as specific as possible about what it is you intend to prove. Then you will
introduce the source that you intend to evaluate (For example: “One source I’m considering for my research paper is a book titled War and Victory by Robert S. Thompson.” Then you will end the introduction with a sentence that explains that you need to evaluate the source in order to establish that it is a credible source that can be used in your research paper.

You will follow the book’s list of evaluation criteria from Chapter 8, section B. The first one is Author’s Credentials. That involves proving through
research that the authors are credible and worthy of being put in your paper. You can verify their credibility through education (what degree do they have and where did they get it), Affiliations (Do they belong to any prestigious groups or organization), or publication (What other articles or books have they
published).

The next section is Appropriate Focus. It is about comparing the aspect of the issue that you will be looking at and comparing it to the aspect of the issue
that the source is looking at. Not just that they are both about the same big general topic, but are they both focused on the same narrow point that you will
be making in your research paper. Explain your focus. Explain their focus, and then explain how well they compare. If you have a book, only a chapter or
section may match, but that may be enough to be useful Sufficient Coverage is where you evaluate whether the source goes into enough detail and provides enough quality information to be useful to your research.

Some sources have very little information while some have page after page. What kind is yours? In this section you will also be required to quote from the
source to show the reader on bit of information you’ve found in this source that you intend using in your final research paper.

The next section is either Reputable Publisher or Respected Periodical. You will only do one of these. If you have a book, you will do research on the
publishing house to be sure it is a reputable company. You can do this by going to the webpage of the publishing house and looking at when they were founded, what kind of books they publish and have they won any awards for their publications. If you have a periodical (magazine/journal/newspaper) then you would research the reputation and history of the publication. You would also look at the founding date, the type of material produced, and the awards won along with things like the size of the staff, reputation of contributors, what organization runs the publication, etc. Anything you can use to prove it is reputable. You can make up for a weak author with an excellent publisher.

Publication Date is about whether your source is the type that needs the most recent information and if this source is recent enough to be useful. A source
may pass everything else, but if it fails badly here it might be useful. You might have a topic where time isn’t so important. Explain that and give us the
publication date.

Supplementary Materials is the next aspect to evaluate. Your book gives a long list of what is considered to be supplementary materials. Check and see if any are in your book/article and explain which ones are present in this section. If there are no supplementary materials, explain that and say whether you think it hurts the source’s credibility much.

Writing Style is simply how clean and understandable the source’s author is. Do they use easy to understand vocabulary, nice examples and explain complicated
ideas clearly? Or do they use highly technical language or complex vocabulary, explain nothing and make life difficult for their reader. In this section you
will provide your second quote from the source. This time it is simply to show the writer a small example of the writer’s style to support your claims.

Your conclusion should review all these tests and talk about which one it passed and which it failed. You should explain whether you intend to use it in your
Work Cited Page. Your MLA work cited page will contain the source you are evaluating and any sources you used to establish the credibility of the author or publisher/periodical. There should really be three citations at the most. Use the sample essay at the end of Chapter 14 and follow the format of the Works Cited page you see on pages 206 and 207.

Source Evaluation Essay about Smoking

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The Soldiers War Essay Paper Available

The Soldiers War Essay topic:

1. Did the First World War soldiers on the Western Front share a basic experience of the war?

2. Explain the similarities and differences (between the allies and the German forces– including their allies who served with them) on the western front.

3. Look at how these opposing groups of soldiers interpreted their experiences. What was similar or different? Why?

4. Illustrate important points with historical examples and evidence (rather than only citing the authoritative view of a historian).

5. Essay Requirements: All info directly taken from a source, even though re-worded must be footnoted. All direct quotes must be, ?quoted?and footnoted. The essay must be done in Chicago Style. Include a bibliography at the end. No page number on title page. 2500 words?this is a fourth year level essay.

6. This paper needs to be a comparative paper. It must discuss a given topic by comparing the history of that topic for two countries. Comparison implies discussing similarities and differences. A comparative paper should strive for even coverage of each country, but this is a goal, not an absolute necessity. This depends upon how much info is in sources for each side. This paper can also have a transnational approach must consider its given topic in multiple national settings.

7. Mandatory Sources?Please stick to these sources: Note the underlined books and articles were used in class, and would be good to include. Also sources from the other choices provided by the instructor are listed below.

Charles Yale Harrison, Generals Die in Bed (Annick Press, 2014 [1930]) [Course Book]
Joe Lunn, Male Identity and Martial Codes of Honor: A Comparison of the War Memoirs of Robert Graves, Ernst Junger, and Kande Kamara,
The Journal of Military History 69, 3 (July 2015): 713-735 [Library E-Resources]
The Canadian Letters and Images Project, https://canadianletters.ca/index.php
Desmond Morton, When Your Number’s Up: The Canadian Soldier in the First World War Antoine Prost,
In the Wake of War: les anciens combatant and French Society Richard Holmes,
Tommy: The British Soldiers on the Western Front,
1914-1918 Robert Graves, Goodbye to All That Ernst Junger,
Storm of Steel Donald Fraser. The Journal of Private Fraser, 1914-1918,
Canadian Expeditionary Force Winter,
Jay. The Legacy of the Great War, Ninety Years On (University of Missouri Press, 2015).

Note: If you can find scholarly sources that are better than what the instructor has suggested, feel free to include them, as long as I can access the sources from my home computer. The above sources were chosen from the instructor.

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Local Community Health Care Issue

Resource: Article Review Grading Criteria on the student website Review two to three news articles to determine a local community health care issue. Examples include swine flu, asthma, and teenage pregnancy.

Write a 350- to 700-word paper answering the following questions:

How long has it been a problem?
How has it affected the community?
How has the community responded?

Format your paper consistent with APA guidelines.

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Cognitive Psychology Research Paper

Cognitive Psychology

Critically discuss and evaluate the crossmodal interference in attention. Answer these questions within the essay.

1. Auditory stimuli and visual perception compete for resources (selective attention). When and why is one of them dominant over the other (overrule the other, i.e. get more resources or being prioritized over the other)? Link to Stroop interference.

2. When auditory and visual stimuli compete for attention, how does the decision-making process operate in relation to which stimuli to allocate resources to? Link to Stroop interference.

3. When auditory, visual and semantics are competing for attention, how are the cognitive processes operating and how is the resources for processing being allocated? An example if this is when driving a car (visual attention), talking on the phone (auditory) and the conversation over phone (semantics).

4. Does the theory of executive function has any relationship to question number 1, 2 and 3?

5. How is the reaction time and accuracy in decision making to allocate cognitive resources when auditory, visual and semantic perception is competing for attention? (No waffling and I need the internet link to each reference)

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Debate on Children and Childhood

Debate on Children and Childhood – is Childhood Disappearing

Reading should include Neil postman book – Postman N (1994) the disappearance of childhood, New York.

The reading is needed in order to answer the question which is, is childhood disappearing. the essay should also have a vast amount of reading and it is an essay and I want debates for and against but I have a stand which I have written at the end.

This essay should focus on the social construction of childhood in history, has there always been a childhood, has society ideas about children always been the same. where did our ideas of childhood come from difficulty in comparing childhoods

Cyberkids (is technology raising our children)
is childhood disappearing as Postman argues (main focus)

What is the state of contemporary childhood of concern at the current time? how do these debates impact upon early childhood practice?

MY STAND ON THIS ESSAY
Personally i do not believe childhood is disappearing but i believe our idea of childhood is what is changing, children are no longer free to do what
children are meant to do which is play and explore their surroundings but there are all these laws limiting children and media playing on parents paranoia and making them hide their children indoors and limiting their social development to when they are only at school. And when they get home technology takes over and its either television so is the media and technology raising our children.

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