The primacy of vital signs – Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study

BACKGROUND: Registered nurses and midwives play an essential role in detecting patients at risk of deterioration through ongoing assessment and action in response to changing health status. Yet, evidence suggests that clinical deterioration frequently goes unnoticed in hospitalised patients. While much attention has been paid to early warning and rapid response systems, little research has examined factors related to physical assessment skills. OBJECTIVES: To determine a minimum data set of core skills used during nursing assessment of hospitalised patients and identify nurse and workplace predictors of the use of physical assessment to detect patient deterioration. DESIGN: The study used a single-centre, cross-sectional survey design. SETTING and PARTICIPANTS: The study included 434 registered nurses and midwives (Grades 5-7) involved in clinical care of patients on acute care wards, including medicine, surgery, oncology, mental health and maternity service areas, at a 929-bed tertiary referral teaching hospital in Southeast Queensland, Australia. METHODS: We conducted a hospital-wide survey of registered nurses and midwives using the 133-item Physical Assessment Skills Inventory and the 58-item Barriers to Registered Nurses’ Use of Physical Assessment scale. Median frequency for each physical assessment skill was calculated to determine core skills. To explore predictors of core skill utilisation, backward stepwise general linear modelling was conducted. Means and regression coefficients are reported with 95% confidence intervals. A p value < .05 was considered significant for all analyses. RESULTS: Core skills used by most nurses every time they worked included assessment of temperature, oxygen saturation, blood pressure, breathing effort, skin, wound and mental status. Reliance on others and technology (F = 35.77, p < .001), lack of confidence (F = 5.52, p = .02), work area (F = 3.79, p = .002), and clinical role (F = 44.24, p < .001) were significant predictors of the extent of physical assessment skill use. CONCLUSIONS: The increasing acuity of the acute care patient plausibly warrants more than vital signs assessment; however, our study confirms nurses’ physical assessment core skill set is mainly comprised of vital signs. The focus on these endpoints of deterioration as dictated by early warning and rapid response systems may divert attention from and devalue comprehensive nursing assessment that could detect subtle changes in health status earlier in the patient's hospitalisation.

Development of a climate assessment tool for hybrid air conditioner

Australian climate is highly suitable for using outdoor air for free building cooling. In order to evaluate the suitability of hybrid cooler for specific applications, a pre-design climate assessment tool is developed and presented in this paper. In addition to the consideration of the local climate, comfort zone proposed by ASHRAE handbook and specific design of building and operation of hybrid cooler, possible influence from environmental factors (e.g. air humidity and air velocity), as well as personal factors (e.g. activity level and clothing insulation) on occupant’s thermal comfort are also considered in this tool. It is demonstrated that with the input of climatic data for a particular location and the associated design data for a specific application, the developed climate assessment tool is able to not only sort outdoor air conditions into the different process regions but also project them onto the psychrometric chart. It can also be used to estimate the hours for an individual operational mode under various climate conditions and summarize them in a table “Results”.

Entrepreneurial opportunities and the entrepreneurship nexus : a re-conceptualization

The literature on “entrepreneurial opportunities” has grown rapidly since the publication of Shane and Venkataraman (2000). By directing attention to the earliest stages of development of new economic activities and organizations, this marks sound redirection of entrepreneurship research. However, our review shows that theoretical and empirical progress has been limited on important aspects of the role of “opportunities” and their interaction with actors, i.e., the “nexus”. We argue that this is rooted in inherent and inescapable problems with the “opportunity” construct itself, when applied in the context of a prospective, micro-level (i.e., individual[s], venture, or individual–venture dyad) view of entrepreneurial processes. We therefore suggest a fundamental re-conceptualization using the constructs External Enablers, New Venture Ideas, and Opportunity Confidence to capture the many important ideas commonly discussed under the “opportunity” label. This re-conceptualization makes important distinctions where prior conceptions have been blurred: between explananda and explanantia; between actor and the entity acted upon; between external conditions and subjective perceptions, and between the contents and the favorability of the entity acted upon. These distinctions facilitate theoretical precision and can guide empirical investigation towards more fruitful designs.

The land hoarding and land inspector dilemma in China : an evolutionary game theoretic perspective

China has experienced considerable economic growth since 1978, which was accompanied by unprecedented growth in urbanization and, more recently, by associated rising urban housing and land banking issues. One such issue is that of land hoarding - where real estate developers purchase land to hold unused in the rising market for a future lucrative sale, often several years later. This practice is outlawed in China, where land use is controlled by increasingly strengthened Government policies and inspectors. Despite this, land hoarding continues apace, with the main culprits being the developers and inspectors working subversively. This resembles a game between two players - the inspector and the developer - which provides the setting for this paper in developing an evolutionary game theory model to provide insights into dealing with the dilemmas faced by the players. The logic and dilemma of land banking strategy and illegal land banking issues are analysed, along with the land inspector’s role from a game theory perspective by determining the replication dynamic mechanism and evolutionary stable strategies under the various conditions that the players face. The major factors influencing the actions of land inspectors, on the other hand, are the costs of inspection, no matter if it is strict or indolent, conflict costs, and income and penalties from corruption. From this, it is shown that, when the net loss for corruption (income from corruption minus the penalties for corruption and cost of strict inspections) is less than the cost of strict inspections, the final evolutionary stable strategy of the inspectors is to carry out indolent inspections. Then, whether penalising developers for hoarding is severe or not, the evolutionary strategy for the developer is to hoard. The implications for land use control mechanisms and associated developer-inspector actions and counteractions are then examined in the light of the model's properties.

The performance of diversified emerging market equity funds

We investigate the performance of globally diversified emerging market equity funds during the first decade of the twenty-first century. A vast majority of these funds do not outperform the market benchmark even before transaction costs. The systematic risk of most of the funds is similar to that of the market benchmark portfolio, which may suggest that they aim to offer diversification benefits rather than seeking superior risk-adjusted returns through active management. We do not find any evidence of market timing ability amongst these funds. Finally, whilst we detect persistence in performance, this result is driven mainly by the poorly performing funds.

A method to evaluate the response of the coronary circulation of perfused rat heart to adenosine

Exogenous adenosine causes a monophasic dilation of the coronary vessels in paced, perfused rat heart preparations. Because levels of endogenous adenosine in paced hearts may mask the presence of high potency adenosine receptors, we have developed a method to measure coronary vascular responses in a potassium-arrested heart. Hearts from adult male, Wistar rats were perfused at a constant flow rate of 10 mL/min in the nonrecirculating, Langendorff mode, using Krebs-Henseleit buffer. After 30 min, coronary perfusion pressure was 44 +/- 1 mmHg (mean +/- SEM). Hearts were then perfused with a modified Krebs-Henseleit buffer containing 35 mM potassium. Coronary perfusion pressure increased by 84 +/- 3 mmHg. Adenosine-induced reductions in coronary perfusion pressure were expressed as a percentage of the maximal increase in pressure produced by modified Krebs-Henseleit buffer from the equilibration level. A concentration-response curve for adenosine (n = 6) was biphasic and best described by the presence of two adenosine receptors, with negative log EC50 values of 8.8 +/- 0.3 and 4.3 +/- 0.1, representing 29 +/- 3 and 71 +/- 3%, respectively, of the observed response. Interstitial adenosine sampled by microdialysis during potassium arrest was 25% of the concentration found in paced hearts. Endogenous adenosine in nonarrested hearts may obscure the biphasic response of the coronary vessels to adenosine.

Managing moose harvests by the seat of your pants

Moose populations are managed for sustainable yield balanced against costs caused by damage to forestry or agriculture and collisions with vehicles. Optimal harvests can be calculated based on a structured population model driven by data on abundance and the composition of bulls, cows, and calves obtained by aerial-survey monitoring during winter. Quotas are established by the respective government agency and licenses are issued to hunters to harvest an animal of specified age or sex during the following autumn. Because the cost of aerial monitoring is high, we use a Management Strategy Evaluation to evaluate the costs and benefits of periodic aerial surveys in the context of moose management. Our on-the-fly "seat of your pants" alternative to independent monitoring is management based solely on the kill of moose by hunters, which is usually sufficient to alert the manager to declines in moose abundance that warrant adjustments to harvest strategies. Harvests are relatively cheap to monitor; therefore, data can be obtained each year facilitating annual adjustments to quotas. Other sources of "cheap" monitoring data such as records of the number of moose seen by hunters while hunting also might be obtained, and may provide further useful insight into population abundance, structure and health. Because conservation dollars are usually limited, the high cost of aerial surveys is difficult to justify when alternative methods exist. © 2012 Elsevier Inc.

Monitoring does not always count

The gross under-resourcing of conservation endeavours has placed an increasing emphasis on spending accountability. Increased accountability has led to monitoring forming a central element of conservation programs. Although there is little doubt that information obtained from monitoring can improve management of biodiversity, the cost (in time and/or money) of gaining this knowledge is rarely considered when making decisions about allocation of resources to monitoring. We present a simple framework allowing managers and policy advisors to make decisions about when to invest in monitoring to improve management. © 2010 Elsevier Ltd.

Numerical investigation of plant tissue porosity and its influence on cellular level shrinkage during drying

Dried plant food products are increasing in demand in the consumer market, leading to continuing research to develop better products and processing techniques. Plant materials are porous structures, which undergo large deformations during drying. For any given food material, porosity and other cellular parameters have a direct influence on the level of shrinkage and deformation characteristics during drying, which involve complex mechanisms. In order to better understand such mechanisms and their interrelationships, numerical modelling can be used as a tool. In contrast to conventional grid-based modelling techniques, it is considered that meshfree methods may have a higher potential for modelling large deformations of multiphase problem domains. This work uses a meshfree based microscale plant tissue drying model, which was recently developed by the authors. Here, the effects of porosity have been newly accounted for in the model with the objective of studying porosity development during drying and its influence on shrinkage at the cellular level. For simplicity, only open pores are modelled and in order to investigate the influence of different cellular parameters, both apple and grape tissues were used in the study. The simulation results indicated that the porosity negatively influences shrinkage during drying and the porosity decreases as the moisture content reduces (when open pores are considered). Also, there is a clear difference in the deformations of cells, tissues and pores, which is mainly influenced by the cell wall contraction effects during drying.

The effect of a meteorological tower on its top-mounted anemometer

The wind-speed at a site can be measured by installing anemometers on top of meteorological (met) towers. In addition to other sources of error, accelerated airflow, or speed-up, around the top of met towers can cause incorrect anemometer measurements. We consider a particular example where an anemometer was located only 2 tower diameters above the met tower. Using a standard computational fluid-dynamics package, we found the maximum error for this configuration to be 2% of the wind-speed. We conclude that a top-mounted anemometer should be located at the windward side of its met tower, raised 5 diameters above the top. This will reduce speed-up error to less than 1%.

7-point Subjective Global Assessment is more time sensitive than conventional Subjective Global Assessment in detecting nutrition changes

Background: It is important for nutrition intervention in malnourished patients to be guided by accurate evaluation and detection of small changes in the patient’s nutrition status over time. However, the current Subjective Global Assessment (SGA) is not able to detect changes in a short period of time. The aim of the study was to determine whether 7-point SGA is more time sensitive to nutrition changes than the conventional SGA. Methods: In this prospective study, 67 adult inpatients assessed as malnourished using both the 7-point SGA and conventional SGA were recruited. Each patient received nutrition intervention and was followed up post-discharge. Patients were reassessed using both tools at 1, 3 and 5 months from baseline assessment. Results: It took significantly shorter time to see a one-point change using 7-point SGA compared to conventional SGA (median: 1 month vs. 3 months, p = 0.002). The likelihood of at least a one-point change is 6.74 times greater in 7-point SGA compared to conventional SGA after controlling for age, gender and medical specialties (odds ratio = 6.74, 95% CI 2.88-15.80, p<0.001). Fifty-six percent of patients who had no change in SGA score had changes detected using 7-point SGA. The level of agreement was 100% (k = 1, p < 0.001) between 7-point SGA and 3-point SGA and 83% (k=0.726, p<0.001) between two blinded assessors for 7-point SGA. Conclusion: The 7-point SGA is more time sensitive in its response to nutrition changes than conventional SGA. It can be used to guide nutrition intervention for patients.

Cord blood vitamin D and neurocognitive development are nonlinearly related in toddlers

Background Little is known about the relation between vitamin D status in early life and neurodevelopment outcomes. Objective This study was designed to examine the association of cord blood 25-hydroxyvitamin D [25(OH)D] at birth with neurocognitive development in toddlers. Methods As part of the China-Anhui Birth Cohort Study, 363 mother-infant pairs with completed data were selected. Concentrations of 25(OH)D in cord blood were measured by radioimmunoassay. Mental development index (MDI) and psychomotor development index (PDI) in toddlers were assessed at age 16–18 mo by using the Bayley Scales of Infant Development. The data on maternal sociodemographic characteristics and other confounding factors were also prospectively collected. Results Toddlers in the lowest quintile of cord blood 25(OH)D exhibited a deficit of 7.60 (95% CI: −12.4, −2.82; P = 0.002) and 8.04 (95% CI: −12.9, −3.11; P = 0.001) points in the MDI and PDI scores, respectively, compared with the reference category. Unexpectedly, toddlers in the highest quintile of cord blood 25(OH)D also had a significant deficit of 12.3 (95% CI: −17.9, −6.67; P < 0.001) points in PDI scores compared with the reference category. Conclusions This prospective study suggested that there was an inverted-U–shaped relation between neonatal vitamin D status and neurocognitive development in toddlers. Additional studies on the optimal 25(OH)D concentrations in early life are needed.