Use of intravenous quinine sulfate remains to treat severe malaria - Essay Example

? Evaluating Research for Health Care Introduction My case study is ideally based on the use of intravenous quinine sulfate remains to treat severe malaria. My aim is to give room for the nurse to get a chance to their esthetic and get to know the meaning of caring in their practice by reflecting on the caring efforts. More so I also focus on the value of reflection in knowing and the fulfillment realized by the patients after treatment through the new researched medicine. Further more I will analyze how the empirical, ethical, personal, and aesthetic understanding of nursing has been used in trying to examine how research findings can be integrated into current evidence based practice. Severe malaria is prevalent globally, yet is an uncommon disease posing a challenge to education in nonendemic countries. Severe malaria refers to the malaria with signs of end organ dysfunction, as manifested by comma, pulmonary edema, renal failure, circulatory collapse, or severe anemia. Malaria accounts for over a million deaths per year. A very useful aspect of the severe malaria case management is pre-referral treatment that is administered to patient with severe malaria before they are referred to a health facility as explained by Beauchamp & Childress, (2001 P.78). This is crucial, as most malaria deaths, particularly in Africa, take place outside the hospitals, either in the communities or at a lower level of care. Studies evaluating the role rectal articulate and as a pre-referral treatment have found that these options are highly efficacious. However, the biggest challenge faced in resource-limited settings has been the non-availability of these preparations in health centers. Scenario Background The scenario involved a 35-year old female who complains of fever, vomiting, headache, and malaise within a weak after having visited a friend in Kenya. She has vomited three times a day and has experienced some loose stool. Examining his past medical history, she has had childhood asthma and what he took was the leftover from his son’s recent throat infection. Doing my further research I found that the patient is twenty four weeks pregnant, giving me an opportunity to study about the complications of malaria in pregnancy. This will therefore necessitate a broader differential diagnosis to include preeclampsia, abruptions, and fetal demise with sepsis. She did not take the malaria tablets but instead took her son’s leftovers tablets after becoming sick. She at first presents with a normal mental state of mind but is febrile and ill appearing. She soon becomes obtunded. The laboratory tests clearly reveal that important anion-gap acidosis, but the blood smear is not at present in progress. The objective related critical parts include the following, to identify that the patient is suffering and is in risk and to order the relevant tests for severe malaria and other diseases in the differential diagnosis, to identify the seizure, com, and acidosis as the manifestations of the severe malaria, and more so to remember to look for or treat hypoglycemia. Another thing is to offer supportive care , including the fluids, anticonvulsants and end tracheal intubation as needed to begin on the empiric therapy for severe malaria with the intravenous articulate to identify the complications of the treatment, to also seek for the outside assistance of the malaria care, including consulting those individuals who are specialized. Over the years, the intramuscular quinine has been the first-line treatment for the treatment of malaria. Since the intravenous quinine is not available in the US, guanidine is the only drug of choice. This is a more effective drug than quinine and is less likely to bring about hypoglycemia, but is endemic and hence calls for continuous monitoring. In case of severe malaria with elevated parasitemia, which do not respond clearly to the anti-malarial drugs, an individual may consider an exchange transfusion, although there is no strong clinical evidence to support its issue. Thick and thin bloodstains are the backbone of diagnosis. Even though the thick smear is considerably much sensitive, many centres lack a technician who is skilled in its reading and interpretation and information. In the middle of the night of the or in the weekend, a timely interpretation of a thin smear may be hard as well in smaller hospitals. In addition, a thin smear may yield a false negative in the case s where there is experienced low parasitemia, in specific if the patient was taking malaria prophylaxis tablets, or was even previously treated with some agent that posses an activity against malaria. Therefore, the presumptive therapy ought to be initiated in any serious ill patient who is at high risk of severe malaria. Some other lab findings in malaria that may assist reduce the differential diagnosis include the thrombocytopenia (often common, but in most cases mild). After, the diagnosis has been completed, I often go a step ahead and advice the patient suffering from malaria. This involves the advice regarding the use of the over counter products to relieve symptoms like headache, with the common sense self care reasoning like keeping well hydrated, avoiding irritants like cigarette smoke, driving off the stagnant water sources and sleeping inside a mosquito net if necessary. However, following the problems that the patient brought forward, I was eager to know whether I could incorporate the use of intravenous quinine sulfate remains to lessen the suffering of the patient and if this was a secure and an effective method of treatment. Intravenous articulate is currently in the global market and is recommended for the treatment choice for severe falciparum malaria in adults. Several trials with analysis have been done trying to compare the intramuscular quinine with the intravenous quinine but results have consequently shown that there is no benefit of treatment with the quinine in children with severe malaria. This was evident in Sub-saharan Africa. Therefore, the recently completed study provides conclusive evidence of the superiority of the intravenous artesenuate over the quinine therapy. These observations recently led to the changes in WHO recommendations, with the intravenous artesunate now advocates in preference to quinine for the treatment of severe malaria in children. The most critical issues that will need to be addressed however are the availability of the intravenous artesunate for the patients who need it, especially in resource-limited settings, and its effectiveness in real life settings. Following the identification of the clinical problem, then it ought to be stated as a clinical question. Therefore, to be in a position to make this curious thinking have its place of focus, I used the PICO (P (promise), I (Interventions), C (comparisons), and O (outcome) approach of questioning. Due to this study, I came to ask the following question: Can the intravenous articulate sulfate treat severe malaria? Empirical section: An empirical approach is a theory and a practice for nursing researches that needs additional development, further use, and refinement. As an orientation and method, phenomolgy holds promise for nursing science in that it can compliment traditional approaches and accomplish its own contributions towards development of human care knowledge and advancement of the human heart and science of nursing. This section represents knowledge that is obtained by either direct or indirect observation or measurement. It represents knowledge that is publicly verifiable, objective, and factual and a research based. This empirical section gives room for the objective measurement that yields evidence that can be replicate by multiple observers. A previous patient under my care in intensive care had a low potassium level since the morning blood work. The medical staff had already made their rounds on the day. I went over my orders and there were no new orders in regards to potassium replacement. I called the physician to make sure they were aware of the results. The doctor accidentally studied the results and then called for replacement of potassium. The intervention for this patient was the potassium got replaced from my phone call to the physician and the understanding of the of the laboratory results. Rossworm together with Labaree (1990) suggested that the synthesis of research findings from the relevant literature is a crucial step in hypothesis testing, where the primary and the secondary research findings can allow for the integration of robust evidence into clinical application. This is intrinsic to how the gained empirical knowledge is applied to the practice. The control trials are peaces of primary research where they are quantitative, comparative, control experiments in which investigators study two or more interventions in a series of fellows who receive them in a random order. On the other, a systematic review is a peace of secondary research and it entails the structured writing review that addresses a question that is answered by analysis of existing evidence. It is good to be aware that not all the published research is reliable; consequently, any research evidence ought to be appraised. An appraisal tool is a tool used to assist the practitioners in evaluating research presented in a randomized trial and chosen to reflect the focused question. The first thing to put into consideration is whether the researchers have answered the question in study. This assists the reader to distinguish whether the study is of relevance to their specific line of inquiry. The researchers involved here therefore have a task to show how the intravenous quinine sulfate is indeed the efficient treatment of severe malaria. To prove this a random survey study is undertaken where ten patients are administered with the intravenous quinine and another ten are administered with the intramuscular quinine the common medicine and both patients are suffering from malaria. Then another set of fifty individuals who had earlier suffered from malaria are recruited and given a questionnaire to answer on the effectiveness of the drugs they were administered to. Persons with defined long-term conditions and those taking immune-suppressive drugs together with the pregnant women were all included in the research. The average age of the subjects was 30 years of age and all in all their was an equal number of men and women in the study. All the subjects recruited were given the identical protocols and explanations of dosing instructions and malaria assessment questionnaires. Therefore, where the difference comes in is whether they received intravenous quinine or intramuscular quinine. The patients were administered with a liquid substance containing guanidine, citric acid, and disaccharide molecules containing 0.35, 5.6, and 66mg/ml respectively, prepared from a cinchona tree. The quinine drug was made to look, taste, and smell the same as the cinchona extract but contained none of the active ingredients. Both groups were given instructions to take ten doses of the liquid on the first day of the symptoms and four doses per day on the subsequent days for a week. The participants were then asked to complete a symptom log for the same time each day. More so, they were asked to log what symptoms they had fro a list of thirteen common cold symptoms. I also personally accessed all the participants, if the symptoms on the third day and eighth day using similar severity. I in addition took time to determine the white blood cell count. Six of the participants were not accounted for at the end of the end of research, two from the intravenous group and four from the intramuscular group. It is evident that the data from these subjects was withdrawn from the research due to either concomitant relief medication, discontinuation of treatment or incomplete data submission. However, intent to treat data from this subject was presented in the end. The groups were randomized using a computer program and the research development coordinator offered investigators with a sealed envelop containing in it the treatment codes. Randomization codes were not broken only until all when all the data had been analyzed. In addition, the participants were not aware which category they fell into, whether that of the intravenous quinine or the intramuscular quinine. Information for the two populations was analyzed under unseen conditions. Intentions to treat (ITT)(where subject data is analyzed regardless of the adherence) and per protocol (PP)( where only information from subjects who adhere to the protocol are analyzed) analysis was include in the results of the trial. The research was done over a period of three months in the months of June, July, and August. This is the exact periods where this malaria is usually prone to the individuals. The statistical interpretation of results was that the self-assessed total daily symptoms scores were lower in the intravenous quinine and therefore the authors made a conclusion that the early intervention with the standardized preparation of the quinine was in association with the decrease in the average severity and duration of the severe malaria. Nonetheless, the overall reduction in the severity and duration, figures of 15.8% (in the ITT group) and 26.4% (in the PP group) should be critically appraised for significance to the evidence based practice. Whereas there was a statistically better result in the PP group than the ITT group, Hollis and Campell(1999) advocate readers critically get access of the reported intention to treat analysis as it is in most cases inadequately described and inadequately applied. Another research was done in the months of January, February, and March. The researchers wanted to study the efficacy of the summer season in comparison with the winter season. Therefore, what was done is that twenty participants received the intravenous quinine and thirty others received the intramuscular quinine. Sixty other participants who had early symptoms of severe malaria were recruited from the student population in the community. Their happened to be an exclusion criteria that possessing symptoms of the severe malaria longer than thirty hours, those at present taking antibiotics, those with undefined long term conditions and the pregnant women. The average age of the participants was eighteen years, and the ratio of males to females was 1:4. The treatment arms were provided with active capsules with 40% Cinchona plant leaves and 30% Cinchona roots. The other groups were given capsules that had 399 mg of the intramuscular guanidine. Both groups were instructed to take four capsules six times daily in the first twenty-four hours and the rest three times daily, until the symptoms have disappeared, for at least ten good days. The outcome results were defined as severity and duration of self-reported symptoms. It was concluded that with at least fifty participants, there was eighty percent power to detect a benefit of two days duration and a two-point severity reduction. Durations of the symptoms were assessed from the time of enrolment to the research until the participant answered NO when asked if he or she was still sick at this moment. The randomization design was that the participants had to get 50% chance of receiving intravenous quinine or intramuscular quinine and more so the identically designed bottles and capsules were labeled using a random number generator. The length of the study was precisely two and half months, which was done towards the end of the winter. This is a short season of research, however the prevalence of the severe malaria is less during such spring months and due to this the researches may not have had many more recruits even if then trial would go on for some time. Whilst this was a community-based research, there are some disadvantages to the general findings. The results of the research were that there was no important statistical difference in duration of severity of malaria in those using this preparation of intravenous quinine or intramuscular quinine. After the research, it was found out that there was no important statistical difference in the duration or the severity of malaria in those individuals using this preparation of cinchona plant. According to Greenhalgh (2006 p.78), the object of their view was to access if there is truth that intravenous quinine preparations are indeed more effective than intramuscular quinine or more effective than no treatment or even similarly effective to other treatments in the prevention and treatment of severe malaria. A research on the medical databases using Quinine as the main word was conducted as well as a study on the bibliographies and existing reviews. The manufactures and the investigators were more so contacted for the relevant published and unpublished studies. The review team identified fourteen control trials that tested quinine in human beings. Four of these studies did not meet the inclusion criteria, and six because of the mythological inadequacies and the rest since they did not reflect the focused question, therefore only four studies were reviewed. All the included studies were assessed independently by two other authors for eligibility, trial quality and extracted information. Two studies had a relation completely to prevention, which I had not considered as part of my question. Three other trials focused on self-treatment at the beginning of symptoms and four trials randomized and treated participants who presented with severe malaria symptoms. The results of this research were not combined into a quantities analysis. This is mainly because of several quinine preparations used in the trial, the approach of some of studies differed, with some self-treatment, and others treatment themselves, the outcome measures were dissimilar in the trials and the presentation of the results in most cases included insufficient detail to give room for the effect size estimation. The presentation of the results was broken down into three distinct categories. Watson et al (2006 p,132) says that, the prevention trials with a quinine therapy control, treatment of self-treatment trials with no comparisons and treatment or self-treatment with a quinine therapy comparison. Following these defined categories, results for every study are discussed separately in relation to the preparation used and the statistical significance of the conclusions of the study. Nevertheless, the table format characteristics for every research gave additional data concerning the author’s conclusion and the reviewer’s conclusion of each trial. This information clearly suggests that their authors and the reviewers conclusion agreed that there was statistically significant improvement in severity and duration scores in four trials and no statistical difference in the three trials and more so a discrepancy flanked by the authors’ and the reviewer’s conclusions in the two trials. Therefore, the results of this systematic review conclude that whereas the preparations based majorly on the aerial sections of the cinchona plant might have beneficial effects on the severe malarial symptoms in adults, if started early as explained by (Craig & Smyth, 2007 p.324). To understand better the empirical section, I recognize the high-risk groups for malaria. Any traveler to an endemic surrounding should be considered in high risk of malaria. Immigrants originally from the malaria prone countries are at particularly high risk since they are much less likely to take malaria prophylaxis when they travel to visit the relatives abroad. The travel history is crucial to identify the susceptible patient, as any travel to the tropics constitutes a risk. According to Cronin & Rawlings-Anderson (2004 p.66), the aesthetical component of the theory is much in relation to my creativity. Whenever I worked in homecare, I had to be I had to be creative at times. On one incident, I remember administering intravenous fluids over four hours in the home. The medical equipment company did not drop off an intravenous pole. I used my creativity and looked through out the home to find something the intravenous fluids on. I used a wire hunger and the curtain rod to administer the fluids to the patient. The intervention was the patient successfully received the fluids they needed through my creativity. Ethics-The moral component of Nursing This ideally presents ethical knowledge as being more than just knowing the ethical codes of the discipline, but also includes all the voluntary deeds that can be judged as right or wrong in connection with the care and treatment of illness and the promotion of health. Moral choice furthermore, ought to be made in relation to the particular situation and the context in which they happen. In my patient scenario I was asked to if, I thought that intravenous quinine worked at the treatment of the severe malaria and lessen its symptoms. According to Brettle, (2004 p.130), Evolution of nursing roles and the rise in emphasis on evidence-based practice raises the need for nurses to be autonomous moral decision makers when dealing with the uncertainty. So when considering the question, and the decision in the quest to recommend intravenous quinine or not it is significant to consider the four common prima facie principles of respect for autonomy, beneficence, non-malfeasance, and justice. Part of respect for autonomy concerns giving practitioners communicating well with their patients, which includes giving patients adequate information about any proposed intervention or recommendation of treatment and finding out if the treatment is accepted to the patient or not. The principles of beneficence and non-munificence can be considered together with the aim of making sure that the net benefit over the harm as explained by (Closs & Cheater, 2000 p.88). To make considerations to these principles we call for empirical information concerning the probabilities of the several harms and benefits that may result from the proposed health care interventions. It is hard to make conclusions concerning the benefits of the reviewed research, as there were benefits shown in the usage of one specific formulation of intravenous quinine. Non-malefinence can be demonstrated through side effect of and adverse event data supplied in the investigation lessons. In both the RCTs and the systems review it is clearly sated that the side effect profile was the same to the intramuscular quinine and following that, there is a low probability of harm from taking the intravenous quinine. Justice calls for individuals to be treated equally and within the context of the health care. Therefore the principle f justice can be applied to the scenario from a perspective of, it is reasonable to recommend a treatment that some individuals will be in a position to pay for? As intravenous quinine is a non –prescription remedy and it is more so fair to let the people pay for a treatment. Personal Knowledge Personal knowledge is necessary to understand the meaning of the health in terms of personal well-being and involves the interactions, relationships, and transactions flanked by the nurse and the patient. More so, it refers to any encounter with an individual or event, which brings a chance for personal understanding and these calls for openness, heightened awareness and the questioning frame of mind. In addition, personal knowing is the discovery of the self-and –other arrived at through reflections, synthesis of perceptions and connecting with what is familiar by an individual. Following this personal knowledge, a model for structured reflection ways of understanding that gives room for the practitioners to focus on the development of the self-awareness by putting in consideration their thoughts and emotions concerning particular situations or encounters. Therefore what I thought and felt about on the reflection of the consultant was that, although I was no in a position to give the old lady she needed exactly, I took much of my time trying to exp-lore how her symptoms were affecting her and was open to her requirement of something to make her recover quickly. According to Aveyard & Sharp, (2009 p.90), In doing this, I felt I became closer to the patient’s perspective, gained insight into her health beliefs and values, and came up with a therapeutic relationship with the patient. Aesthetics- The art of nursing This pattern of knowing is concerned with the creativity and the art of nursing and is viewed through the approach and action of nurses when taking care of the patients. In addition, it may be a perception of a specific clinical situation that involves interpretation of the information in order to respond appropriately. It is more so, suggested that empathy and intuition are the main skills in this process and that reflection is a device used to detect whether desired outcomes were made. Furthermore, Carper (2006 p.45) argues that, aesthetic understanding draws upon the empirical, ethical and personal aspects of understanding, and that bringing together all these perspectives into the consultation gives room to the holistic practice, where the patient is given the desired care, treatment if is in need and information tailored to them as persons. I am in a position to empathize with all the patients, who have presented their suffering of severe malaria. This is because I have had many myself, and understand clearly how It can hinder well-being and the ability to function to the later of one’s abilities and I would definitely take a treatment if somebody told me that their was an evidence to show that it would make one feel better faster. However, my motive during the consultations is to offer safe and effective evidence-based care and advice, together with being intuitive and empathetic practitioner, which is recognizable as bringing a nurse once from novice to an expert. 2589 words Recommendations for practice Based on my study, and the systematic review, I could want to let the patients know that, presenting early with severe malaria, calls for one to use the preparations based primarily on the aerial parts of the Cinchona tree. It is imperative that, this might minimize the severity and the duration of their symptoms by say 30%, if they adhere to the similar regime of dosing like the ones used in the trials, however it is significant to be informed that preparations of this manner may not be available throughout the Universe. It is also worth to note that Cinchona tree products are not the same an differ greatly and the overwhelming majority of them have not been certified in the clinical trials and due to this may not give same results if tested in my patient population as enumerated by Dawes et al (2005 p.140). Therefore, because of the critiquing research papers regarding the effectiveness of intravenous quinine for the treatment of severe malaria, I have made a conclusion that even though there is a little harm in consuming this drug, there is also a little proven advantage and consequently, I will go on giving you my usual advice regarding symptom control and self-care. However, incase a patient wants to know about the same question again, I will now be in a position to present the relevant research to be in a position to make their own choices as to whether to take the drug or not. Conclusion I have tabled a review of research in regard to the effectiveness of Intravenous quinine as a treatment for the severe malaria and hoe the considerations of the empirical understanding on this subject has helped shaped my evidence-based practice for the future as stated by Holland & Rees (2010 p340) . I have in addition acknowledged the understanding of the other four fundamental patterns of knowing is important to the awareness of the of the complexity and diversity of the nursing understanding and that the reflective practice gives room for the practitioners to meet the health challenges of the future, by blending science and art through nursing theory, practice and research. 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