NR 451 Week 2 Discussion The Clinical Question

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The Clinical Question

Your capstone change project begins this week when you identify a problem that you judge needs to experience a change in order to produce better patient outcomes

• Formulate a significant clinical question that will be the basis for your capstone change project

• Relate how you developed the question

• Describe the importance of this question to your clinical practice

• Define meta-analysis.and explain how this relates to evidence -based practice (EBP)
• Describe what a research-practice gap is

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For this weeks’ discussion topic, I have chosen the review on skin to skin contact between newborn and mother. My clinical question is as follows,” Could SSC be used as treatment for tachypnea as opposed to tachypnea being criteria to interrupt SSC within the transition period? I developed this clinical question, because there has been a significant increase in admission to NICU for newborn tachypnea since protocol for SSC has been adopted in the labor and delivery area. This is unfortunate, as once admitted to the NICU, we have standard orders for high flow cannula, IVF initiation both of which require extended time to wean and discontinue these interventions. Very often, we see the tachypnea as very intermittent, with no work of breathing or other symptoms of distress, and resolves quickly after separation from mom. This of course, causes stress for both infant and mother due to separation. In addition, a NICU admission and care is much more expensive than normal newborn care. This places additional cost and financial burden of the organization as staffing is necessary due to higher census. Also, additional financial concerns become the responsibility of the family/insurance provider. Do not misunderstand, if an infant is experiencing increased work of breathing, or other signs of distress, a NICU admission is definitely needed for closer observation as well as clinical support such as temperature regulation, glucose and volume management, oxygen supplementation, etc., however, as stated above, many times within an hour or two these newborns have stabilized and often still remain in NICU setting after mom goes home. There seems to be a gap between criteria for the transitioning infant as opposed to the normal newborn and compromised intensive care neonate protocol. If allowing the infant to remain with mom utilizing skin to skin contact, it has been suggested that this can facilitate stabilization of temperature, glucose metabolism, heartrate and respiration within the first 24 hours of life. In our hospital setting, if an infant is breathing over 60, it is taken to NICU for observation. If after six hours the infant has not self-resolved, it becomes a NICU admission with standard admission orders initiated. If protocol could include using SSC as intervention for mild tachypnea, absent of any other respiratory or distress symptoms, with close observation during the process for signs and symptoms of declining condition, this could decrease the number of mother /infant dyads being separated, as well as decrease NICU admissions for non-critical care. The “transition area” had been staffed and “run” by mother-baby until August 1,2017, when NICU took over, however, no policy changes have been made as far as how these infants are managed. I would like to take this idea to our unit council which is made up of physicians, management, and nursing staff to identify the gap and facilitate change of some type for this patient population. I feel change will bring about both improved patient satisfaction and outcome, as well as be a cost containment advantage. I have a personal thought on why we are seeing the increase for tachypnea. It is very common now to have induction as well as caesarean deliveries, both of these scenarios increase the amount of lung fluid that an infant has to reabsorb from the lung. When infants are placed on mothers’ chest immediately after delivery, the amount of crying and stimulation is decreased as opposed to older practice when nursing staff stimulated infants at the warmer for 30-60 seconds post-delivery. I feel this lack of stimulation decreases the “opening up” of alveoli that infants previously had when taken by nursing staff to warmer and vigorously stimulated to cry for 30-60 seconds. My observation is that if an infant is crying vigorously the mothers’ generally console to stop the infants from crying. If the SSC is started initially after birth, and the infant lacks a period of good crying to increase pulmonary pressure to facilitate fluid redistribution, it is compensatory to increase respiration rate. So, are we actually setting up these infants to fail by initiating SSC but “punishing” them for a compensatory response to increase lung fluid retention? Should slightly higher respiratory rates with no signs of distress be acceptable in the initial transition time? Now this is just my general thought process, I have conducted no research or study. So, I am very excited about this project as it will definitely help me in determining what evidence, what practices are being used in other facilities with improved outcome.

Grading Rubric Guidelines

Performance Category	10	9	8	4	0
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic decisions.	Provides relevant evidence of scholarly inquiry clearly stating how the evidence informed or changed professional or academic decisions Evaluates literature resources to develop a comprehensive analysis or synthesis. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion	Provides relevant evidence of scholarly inquiry but does not clearly state how the evidence informed or changed professional or academic decisions. Evaluates information from source(s) to develop a coherent analysis or synthesis. Uses some valid, relevant, reliable outside sources to contribute to the threaded discussion.	Discusses using scholarly inquiry but does not state how scholarly inquiry informed or changed professional or academic decisions. Information is taken from source(s) with some interpretation/evaluation, but not enough to develop a coherent analysis or synthesis. Little valid, relevant, or reliable outside sources are used to contribute to the threaded discussion. Demonstrates little or no understanding of the topic.	Discusses using scholarly inquiry but does not state how scholarly inquiry informed or changed professional or academic decisions. Information is taken from source(s) without any interpretation/evaluation. The posting uses information that is not valid, relevant, or reliable	No evidence of the use of scholarly inquiry to inform or change professional or academic decisions. Information is not valid, relevant, or reliable
Performance Category	10	9	8	4	0
Application of Course Knowledge – Demonstrate the ability to analyze, synthesize, and/or apply principles and concepts learned in the course lesson and outside readings and relate them to real-life professional situations	Posts make direct reference to concepts discussed in the lesson or drawn from relevant outside sources; Applies concepts to personal experience in the professional setting and or relevant application to real life.	Posts make direct reference to concepts discussed in the lesson or drawn from relevant outside sources. Applies concepts to personal experience in their professional setting and or relevant application to real life Interactions with classmates are relevant to the discussion topic but do not make direct reference to lesson content	Posts are generally on topic but do not build knowledge by incorporating concepts and principles from the lesson. Does not attempt to apply lesson concepts to personal experience in their professional setting and or relevant application to real life Does not demonstrate a solid understanding of the principles and concepts presented in the lesson	Posts do not adequately address the question posed either by the discussion prompt or the instructor’s launch post. Posts are superficial and do not reflect an understanding of the lesson content Does not attempt to apply lesson concepts to personal experience in their professional setting and or relevant application to real life	Posts are not related to the topics provided by the discussion prompt or by the instructor; attempts by the instructor to redirect the student are ignored No discussion of lesson concepts to personal experience in the professional setting and or relevant application to real life
Performance Category	5	4	3	2	0
Interactive Dialogue Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts a minimum of two times in each graded thread, on separate days. *(5 points possible per graded thread)*	Exceeds minimum post requirements Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts three or more times in each graded thread, over three separate days. Replies to a post posed by faculty and to a peer Summarizes what was learned from the lesson, readings, and other student posts for the week.	Replies to each graded thread topic posted by the course instructor, by Wednesday, 11:59 p.m. MT, of each week, and posts a minimum of two times in each graded thread, on separate days Replies to a question posed by a peer Summarizes what was learned from the lesson, readings, and other student posts for the week.	Meets expectations of 2 posts on 2 different days. The main post is not made by the Wednesday deadline Does not reply to a question posed by a peer or faculty	Has only one post for the week Discussion posts contain few, if any, new ideas or applications; often are a rehashing or summary of other students’ comments	Does not post to the thread No connections are made to the topic
	Minus 1 Point	Minus 2 Point	Minus 3 Point	Minus 4 Point	Minus 5 Point
Grammar, Syntax, APA Note: if there are only a few errors in these criteria, please note this for the student in as an area for improvement. If the student does not make the needed corrections in upcoming weeks, then points should be deducted. Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition	2-3 errors in APA format. Written responses have 2-3 grammatical, spelling, and punctuation errors. Writing style is generally clear, focused, and facilitates communication.	4-5 errors in APA format. Writing responses have 4-5 grammatical, spelling and punctuation errors. Writing style is somewhat focused.	6-7 errors in APA format. Writing responses have 6-7 grammatical, spelling and punctuation errors. Writing style is slightly focused making discussion difficult to understand.	8-10 errors in APA format. Writing responses have 8-10 grammatical, spelling and punctuation errors. Writing style is not focused, making discussion difficult to understand.	Post contains greater than 10 errors in APA format. Written responses have more than 10 grammatical, spelling and punctuation errors. Writing style does not facilitate communication. The student continues to make repeated mistakes in any of the above areas after written correction by the instructor
	0 points lost				-5 points lost
Total Participation Requirements *per discussion thread*	The student answers the threaded discussion question or topic on one day and posts a second response on another day.				The student does not meet the minimum requirement of two postings on two different days
Early Participation Requirement *per discussion thread*	The student must provide a substantive answer to the graded discussion question(s) or topic(s), posted by the course instructor (not a response to a peer), by Wednesday, 11:59 p.m. MT of each week.				The student does not meet the requirement of a substantive response to the stated question or topic by Wednesday at 11:59 pm MT.

Also Read: NR 451 Week 1 Discussion Types of Nursing Models and Frameworks of EBP