Clinical Reasoning And Decision Making In Nursing Nursing Essay

Clinical Reasoning And Decision Making In Nursing Nursing Essay All nurses use clinical judgement to make decisions while caring for patients. These decisions have an effect on the actions of the healthcare professional and the delivery of health care the patient receives Jones and Beck (1996). Its the nurses responsibility to make clinical decisions based on their learnt knowledge and skills. Simple decisions such as, would a bed pan or commode be more appropriate? To making quick, on the spot decisions, such as what steps to take if a patient began to rapidly deteriorate. Nurses rely on sound decision making skills to maintain positive outcomes and up to date care. Orme and Maggs (1993) identified that decision-making is an essential and integral aspect of clinical practice. Nurses are accountable for their decisions, therefore it is crucial that they are aware of how they make these decisions Muir (2004). This essay will discuss two decision making models, factors that may improve or interfere with clinical reasoning and decision making in pat ient centred care and how they vary across the different fields of nursing. The decision making models that will be discussed are Risk Analysis and Evidence Based. Risk assessment plays a major part in the process of supporting patients and it greatly helps to maintain safety in hospital settings. Its main purpose is not only to identify potential risks but also remove and prevent them. Assessment is considered to be the first step in the process of individualised nursing care Neno and Price (2008). Risk analysis provides information that is vital in developing a plan of action that can help improve personal health. It has the potential to decrease the severity of chronic conditions, helping the individual to gain control over their health through self-care RCN (2004). Not only is risk analysis for the patients safety but its also there to ensure staff safety Kavaler and Spiegel (2003). It is imperative that nurses use suitable risk assessment tools as a guide to enable them to make effective decisions. Once the tool has been implemented, using the gathered information and using their own clinical judgement, the nurse will then be able to provi de the right safety precautions for patients Holme (2009). There are many different types of risk assessment tools available for patients and staff within the clinical setting. For patients there is the Waterlow score risk of pressure sores and ulcers, the MUST tool Malnutrition Universal Screening Tool, FRAT Falls Risk Assessment Tool and Pain Assessment Tools are only to name a few and they are commonly used in clinical practice. Staff have Infection Control Assessments and Discharge Risk Assessments only to name a couple but they should be kept up to date and reassessed regularly Daniels (2004). The pressure ulcer risk assessment/prevention policy tool, is frequently used in clinical practice. Pressure risk-assessment tools have been described as the backbone of any prevention and treatment policy Waterlow(1991). The Department of Health set annual targets for an overall reduction of pressure ulcers by 5-10% over 1 year (DoH, 1993), so it is vital that nurses accurately determine which patients are at risk of developing pressure ulcers. A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction or a combination of these EPUAP (1998). The intention of the Waterlow pressure sore risk assessment is to recognise service users who are highly at risk of developing pressure sores, to avoid them becoming worse and/or even developing them at all, to serve as an early predictive index before the development of pressure damage Nixon and McGough ( 2001). It is imperative that patients are assessed using this tool, especially patients with Intrinsic risk factors such as restricted mobility and /or are confined to their bed for long periods of time, patients with poor nutrition, elderly patients, patients with underlying health conditions such as diabetes and patients who are urinary incontinent and bowel incontinent are also highly at risk of developing pressure sores, this due to the moisture, moist skin can be weak and susceptible to breakdown Andrychuk (1998). Accordi ng to the NICE clinical guideline 29 (2005) pressure ulcer grades should be recorded using the European Pressure Ulcer Advisory Panel Classification System. There are four stages that pressure ulcers are graded at and it is down to the nurses own clinical judgement to decide what stage the ulcer is. Depending on the grade of the pressure sore, it will depend on the type of mattress that will be needed. There are factors to be considered before selecting a mattress for the patient which include, making sure the mattress does not elevate the patient to an unsafe height and to ensure the patient is within the recommended weight range for the mattress NICE (2005). Using their learnt skills, experiences and own clinical knowledge, nurses have to decide what dressings should be used in the treatment of pressure ulcers. They have to take into consideration the grade of the sore, any manufacturers indications for use and contraindications, previous positive effects of certain dressing and preference for comfort or lifestyle reasons Bouza et al (2005). Specially designed dressings and bandages can be used to speed up the healing process and help protect pressure sores such as hydrocolloid and alginate dressings which will be used at the nurses digression NHS Choices (2010). Nurses should always be aware of any potential risk factors that may worsen or add to the development of pressure ulcers when using any pressure risk assessment tool. The nurse will have to decide the frequency of re-positioning the patient, implementing a turning chart to keep times and dates documented and to communicate to other members of staff what time the patient needs turning. This involves moving the patient into a different position to remove or redistribute pressure from a part of the body Walsh and Dempsey (2010). By analysing the evidence on the effectiveness of repositioning this can help to reduce patient suffering and improve their quality of life, lighten the work load of staff and help reduce the financial burden on the health service Luoa and Chub (2010). In paediatric nursing, a child is to be assessed within six hours of being admitted and then reassessed daily. Most paediatric pressure ulcer risk assessment scales were developed using clinical experience, or by modifying adult scales Bedi (1993). The Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale was developed using detailed paediatric inpatient data Willock et al (2008). It is a clinical tool designed to help nurses assess the risk of a child developing a pressure ulcer, it uses a scoring system that takes things like mobility, equipment, haemoglobin levels and temperature into account and guides the nurse as to what interventions need to be put in place, such as what type of mattress or dressings will be needed. In learning disability and mental health nursing, a range of pressure sore assessment tools are used such as the Norton, Braden and Waterlow risk assessment scales, these are mainly used for patients who are not very mobile as in the adult field. Nursing is more concentrated on their patients psychological health OTuathail and Taqi (2011). It is the nurses duty to provide the best possible care for their patients and this involves using Evidence-based practice. EBP enables the nurse to make decisions about patient care based on the most current, best available evidence. It allows the nurse to provide high quality care to patients based on knowledge and research Rodgers (1994). Principles of evidence-based practice and the crucial elements involved in the process are explained by Cleary-Holdforth and Leufer (2008) in five steps. Steps are there to equip nurses with the necessary knowledge and skills to use evidence-based practice effectively and to make positive contributions to patient outcomes. The five steps Ask, Aquire, Appraise, Apply, Analysis and Ajust are to simply guide healthcare professionals in making effective clinical decisions when problem solving. Early Warning Score (EWS) is an evidence based method. Carberry (2002) identifies that the purpose of EWS is to provide nursing and medical staff with a physiological score generated from recordings of vital signs. NICE Clinical Guideline 50 (2007) suggests that physiological track and trigger systems should be implemented to monitor all adult patients in acute hospital settings, providing guidance on the standardization of EWS. Physiological signs that should be monitored and recorded are heart rate, blood pressure, respiratory rate, oxygen saturation, temperature and level of consciousness. Vital signs should be recorded upon admission, at regular intervals during a patients stay and also before, during and after certain procedures Castledine (2006) and the frequency of monitoring, if abnormal physiology is detected should increase. EWS uses a scoring system 0, 1, 2, and 3 and colour codes white, yellow, orange and red, number 3 and the colour red being the highest risk indicators Morris and Davies (2010). Nurses should adapt to following guidelines the Early Warning Score offers, to help make clinical decisions that are best for their patients. Factors that may improve or prevent effective decision making while using the EWS could be down to capability, knowledge and ignorance. If health care professionals are well able and confident in recording and documenting patients vital signs, then any changes can be observed and prevented or dealt with quickly. The EWS implementation adds automated alerts hours before a rapid response would be initiated and can decrease treatment delays by up to three hours Subbe et al (2003). It only takes one nurse to lack competence when using the EWS, therefore putting patients lifes at risk. Early Warning Score is also used in the Mental Health and Learning Disability fields of nursing although it may not be used as often as in Adult nursing, it is imperative that patients who are physically or mentally unwell, require monitoring of their vital signs in an acute setting. Nurses may have to use their knowledge to improvise different ways of obtaining vital signs from some patients with learning disabilities or mental health problems, such as turning it into a game or distracting them especially if they lack the mental capacity and are unwilling to comply Hardy (2010) Medication can have serious effects on a patients health. Indications of these effects may be noticed in their EWS, combined with the knowledge and clinical judgement of health care professionals NIMH (2008) . If the EWS tool is not used as it should be in these fields then it will be hard for the health care professionals to obtain the needed evidence to make accurate clinical decisions. In the child field of nursing a similar tool to the EWS is used called PEWS, Paediatric Early Warning Scores. There are currently four PEWS charts used within the NHS for different age groups, 0-11months, 1-4 years, 5-12years and 13-18 years, the difference being the ranges for childrens vital signs NHS (2013). A key factor that may hinder accurate PEWS scoring could be due to the fact the child is scared when it comes to checking their vital signs, also very young children can be unwilling or fidgety Kyle (2008), this is where the nurse would have to use their knowledge to overcome such problems. The nurse could make it fun for the child, explain the equipment and what they are going to do and why. It is vital that the nurse gains consent from the childs parent before carrying out any procedure. It is important that the family play an important role in the care of the child DOH (2001). I have learnt various things while researching into the chosen decision making models and methods. I have been made aware of potential risk factors that may arise while using both tools in all fields of nursing and what could be done to prevent them. I feel confident in looking out for any risks involving the EWS and Pressure ulcer risk assessment tools while out in practice and believe that using these tools correctly can ultimately save lives.

Alibaba: Competing in China and Beyond Essay

1. Introduction In this paper, we will talk about the most successful and famous e-commerce company in China: Alibaba Group about its competition strategies and its future moving. Alibaba Group was founded by Ma Yun (Jack) and the other 17 people in 1999 in Hangzhou. Jack wants to make the Internet become a universal, safe and reliable tool that would benefit the public. Alibaba Group now is holding by private, it has more than 70 offices in Greater China, Singapore, India, the United Kingdom and the United States, with more than 20,400 employees. 2. History and Development of Alibaba In 1999, Alibaba was formally established in Hangzhou and it financed from Softbank, Goldman Sachs, Fidelity Investments and other U.S. investment agencies for about 25 million dollars. Three years later, Alibaba’s B2B become profitable. In 2003, China’s first personal e-commerce site Taobao was established by Alibaba, in the same time, it also published the online payment system-Alipay to support their B2B and C2C business. In 2005, Alibaba established a strategic partnership with Yahoo USA; meanwhile, it was in charge of Yahoo China. In 2007, Alibaba founded the business management software company: Ali Software, and Alibaba.com Limited IPO in  Hong Kong Stock Exchange. In 2009, Alibaba Cloud Computing established, later in 2010, Taobao Mall started an independent domain name Tmall.com and it became Alibaba’s B2C service website which is focus on quality goods sales. In 2012, Alibaba Group has completed the initial share buyback and restructure the relationsh ip with Yahoo, while, Alibaba.com Limited officially delisted from the Hong Kong Stock Exchange. Chart 2.1 Overview of Alibaba Group 3. Alibaba’s competition advantages 3.1 Biggest market share of E-commerce in China We can see from the charts, till the end of 2013, Alibaba has owned the biggest market share in B2B, B2C, C2C and online-payment service. It has already became the top one e-commerce company in China. Chart 3.1.1 China B2B Market in 2013 Chart 3.1.2 China B2C Market in 2013 Source: http://www.chinainternetwatch.com/ Chart 3.1.3 China C2C Market Share Chart 3.1.4 China Online Payment Market Share Source: www.NBweekly.com & http://www.chinainternetwatch.com/ 3.2 The largest B2B, B2C and C2C website Alibaba is the world’s largest provider of online trading, and the world’s largest business forum. To December 31, 2012, the platform had around 500 million registered users and more than 2.8 million supplier storefronts, and  its websites are available in English, Simplified Chinese, Korean and other languages. It provides professional services for the global business. 3.3 The visibility is very strong Depends on its Propaganda efforts, almost all over the world have their ads now. 3.4 Better function Alibaba’s site speed, reasonable softwares, and good service attracted entrepreneurs of all ages around the world. 3.5. Others Also Alibaba had a high reputation in the Asia Pacific region and it always keep innovation, for example, in 2013 it officially published its online chat App called â€Å"LaiWang†. 4. The Movement of IPO (Initial Public Offering) 4.1 Background On March, 2014, Alibaba Group Holding Ltd. announced the company will do IPO in New York Stock Exchange; the estimated time will be in quarter three of 2014. The IPO scale is considered to be between $150~200 billion (USD) (Chen, 2014). If the plan is actually executed, it will be one of the biggest IPO scales in the history. To do IPO, from the obvious perspective, it is for arranging the global market. However, it has been 15 years since Alibaba was founded in 1999, why the company decided to do IPO now? What is the reason behind and trigger this movement? It is worth to look into the meanings behind and analyze the reasons. There are two major reasons behind this huge action. One is keeping the control right inside the partnership; the other is competing with the main and biggest competitor Tencent in China. 4.2 Maintaining the control right The first reason is to maintain the control right inside the partnership. For the founder of Alibaba, the core idea of managing the firm is to keep the company culture and the innovation power. Based on this idea, he developed the special partnership structure for the firm. The special partnership structure is meaning CEO needs to be chosen from Alibaba’s partners. And, to  become the partner, the staff needs to be the core manager in the department and work in Alibaba group at least five years. The meeting of choosing partners will run one time per year, the nominee needs to get at least 75% votes from the existing partners, then he/she can become the partner. Now the boards of directors are formed by 2 seats of Alibaba, 1 seat of Softback and 2 seats of Yahoo. It is dangerous for the founder and managers that they can be replaced or take away the control right suddenly. The shareholding structure of Alibaba now is around Yahoo has 23%, Softbank has 31.9%, the founder has 7.4% and managers/other shareholders have 37.7%. According to the agreement between Yahoo  and Alibaba in 2012, if Alibaba can do IPO before in the end of 2015, then Alibaba can repurchase the half of holding shares which Yahoo takes now, also Yahoo will give up one seat in board of directors. Therefore, doing IPO is not just a simple global strategy, more with the implicit intention behind. 4.3 Rising competition The second reason is to compete with Tencent in China. Alibaba is the biggest B2B and B2C e-commerce company in China; it has leading position for past years. However, the situation has changed in recent 3~4 years, more and more users access the internet including buying goods and services via cell phones. It is the benefit access for the competitor Tencent to grab the market from Alibaba. Especially, Tencent just bought a large stake of JD.com (Gittleson, 2014). JD.com is the second biggest e-commerce site in China and in B2C market; it is also the second place right behind Alibaba. The competition intention with Alibaba is obvious. The recent competitions between two parties can refer the below Table 4.3.1. Both companies also start to make acquisitions in small areas and ready for a head-to-head competition (Gittleson, 2014). Tencent doesn’t need to worry about the money since the company did IPO right early in 2004 in Hong Kong Stock Exchange; the stock price is HK$578 on 18th, March, 2014 which is 156 times more compared to 10 years ago (Yu, 2014). Hence, Alibaba needs to find the money  support and start this† one of the most expensive competitions in online history.† said by Kim Gittleson from BBC news. Main business E-commerce platforms in B2B, B2C and C2C markets. (Taobao, TMall, Alipay) Instant message platform. (QQ, WeChat) Recent Competitions 1. During Chinese New Year, Tencent launched a mobile payment service that users can send or receive the money of red packet on line; it gave a warning to Alibaba’s Alipay (Gittleson, 2014). 2. The competition in mobile app for calling taxis (Alibaba’s Kuaidi v.s. Tencent’s Didi). The app not only can call cabs but also can tip for the ride. It is estimated that both parties pay more than $3 billion to subsidize it (Tong, 2014). 3. In the end of 2013, Alibaba launched one messaging application called â€Å"LaiWang† and tried to compete with Tencent’s â€Å"WeChat† 5. Conclusion As we can find out from the previous chapters, Alibaba is a market leader and dominance Chinese e-commerce markets over ten years. Due to its large market share, innovation power and strong website function, no one is able to challenge its leading positions. However, in recent years, internet users start to change their using ways via the booming mobile phones. It benefits another giant company Tencent to penetrate Alibaba’s existing markets. Even though Alibaba has the first-mover advantages in the market, the competition from Tencent doesn’t stop even getting aggressive. From the IPO movement of Alibaba, it can see Alibaba take this competition serious and doesn’t want to lose. Two giants battle for the leading place. The tough and expensive competition with Tencent just started. But, now Alibaba not only need to concern about the domestic competition but also need to make careful actions in global markets due to the IPO. The future of Alibaba is becoming more uncertain since the global markets are adding into the plan and the sever competition keeps going on. 6. References 1. Bidwai, S.V. (2010) Case Analysis Alibaba: Competing in China and Beyond. 2. Chen, Copper (2014) Super IPO, what’s the meaning for Alibaba (translated). Business Next. Retrieved from: http://www.bnext.com.tw/article/view/id/31942. 3. China Internet Watch 2013. For Charts 3.1.1, 3.1.2 & 3.1.4. Retrieved from: http://www.chinainternetwatch.com/. 4. Gittleson, Kim (2014) Tencent and Alibaba Battle for Internet Dominance in China. BBC News. Retrieved from: http://www.bbc.com/news/business-26540666. 5. Southern Weekly. For Charts 3.1.3. Retrieved from: http://www.NBweekly.com. 6. Tong, Frank (2014) Alibaba’s Founder Talks about Its IPO and Competition. Internet Retailer. Retrieved from: http://www.internetretailer.com/2014/03/18/alibabas-founder-talks-about-its-ipo-a nd-competition. 7. Walraven, Piet (2009) A Brief History (and Future) of Alibaba.com. TechNode. Retrieved from: http://technode.com/2009/01/22/a-brief-history-and-future-of-alibabacom/. 8. Wang, Guo-An & Lim, Yong-Taek (n.g) Research in China’s Alibaba’s Development. 9. Yu, Sophie (2014) A Tale of Two Internet Leaders: Tencent vs Alibaba. China Business. Retrieved from: http://www.scmp.com/business/china-business/article/1452041/tale-two-internet-l eaders-tencent-vs-alibaba.

Cylinder Deactivation Variable Engine Displacement

What is cylinder deactivation? It is a method used to create a variable displacement engine that is able to supply the full power of a large engine under high load conditions as well as the fuel economy of a small engine for cruising. The Case for Cylinder Deactivation In typical light load driving with large displacement engines (e.g. highway cruising), only about 30 percent of an engine’s potential power is utilized. Under these circumstances, the throttle valve is only slightly open and the engine has to work hard to draw air through it. The result is an inefficient condition known as pumping loss. In this situation, a partial vacuum occurs between the throttle valve and the combustion chamber—and some of the power that the engine makes is used not to propel the vehicle forward, but to overcome the drag on the pistons and crank from fighting to draw air through the small opening and the accompanying vacuum resistance at the throttle valve. By the time one piston cycle is complete, up to half of the potential volume of the cylinder has not received a full charge of air. Cylinder Deactivation to the Rescue Deactivating cylinders at light load forces the throttle valve be opened more fully to create constant power, and allows the engine to breathe easier. Better airflow reduces drag on the pistons and the associated pumping losses. The result is improved combustion chamber pressure as the piston approaches top dead center (TDC) and the spark plug is about to fire. Better combustion chamber pressure means a more potent and efficient charge of power is unleashed on the pistons as they thrust downward and rotate the crankshaft. The net result? Improved highway and cruising fuel mileage. How Does it All Work? In a nutshell, cylinder deactivation is simply keeping the intake and exhaust valves closed through all cycles for a particular set of cylinders in the engine. Depending on the design of the engine, valve actuation is controlled by one of two common methods: For pushrod designs—when cylinder deactivation is called for—the hydraulic valve lifters are collapsed by using solenoids to alter the oil pressure delivered to the lifters. In their collapsed state, the lifters are unable to elevate their companion pushrods under the valve rocker arms, resulting in valves that cannot be actuated and remain closed.For overhead cam designs, generally a pair of locked-together rocker arms is employed for each valve. One rocker follows the cam profile while the other actuates the valve. When a cylinder is deactivated, solenoid controlled oil pressure releases a locking pin between the two rocker arms. While one arm still follows the camshaft, the unlocked arm remains motionless and unable to activate the valve. By forcing the engine valves to remain closed, an effective â€Å"spring† of air is created inside the deactivated cylinders. Trapped exhaust gasses (from previous cycles before the cylinders were deactivated) are compressed as the pistons travel on their upstroke and then decompressed and push back on the pistons as they return on their down stroke. Because the deactivated cylinders are out of phase, (some pistons traveling up while others are traveling down), the overall effect is equalized. The pistons are actually just going along for the ride. To complete the process, fuel delivery for each deactivated cylinder is cut-off by electronically disabling the appropriate fuel injection nozzles. The transition between normal operation and deactivation is smoothed by subtle changes in ignition and camshaft timing as well as throttle position all managed by sophisticated electronic control systems. In a well-designed and executed system, the switching back-and-forth between both modes is seamless—you really don’t feel any difference and have to consult the dash gauges to know that its happened. Read more about cylinder deactivation at work in our review of the GMC Sierra SLT flex-fuel, and see the instant fuel economy it generates in the GMC Sierra test drive photo gallery.

10 Habits Of Happy People - 1179 Words

10 Habits of Happy People! Do you know this? Somewhere within each of us, there exists a supreme self who is always at eternal peace. This means, however difficult or dire your situation is, there always is a source in your own self to derive solace from. In other words, each one can and has to find his/her peace from within. This peace is real and cannot be affected by outside circumstances. Happiness results from the possession or attainment of what one considers good, the supreme of which is peace. It could also be said, while pleasure, which is broadly considered as happiness, is something derived from outside, joy arises from within. Happy people always carry peace with them. Peace makes your heart beautiful and in turn makes your physical self beautiful too. We shall now examine the 10 habits of Happy People. 1. Live in the present The tested and accepted truth is, living one day at a time is the key to happiness. When you procrastinate and put until tomorrow what you could have done today as well, you run the risk of dying leaving a job undone. The best day in a week, a month or a year is TODAY. Happiness lies in enjoying a day’s work and loving deadlines. If you stand on an island of opportunities, but think another land is greener you are the loser. There is no other land; there is no other life but this. There is no other day but today. 2. Thank Heavens for each second What all you have right this second? 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