This assignment contains three parts, as identified and described below. Please include three subheadings in your paper that clearly identifies each part. In a 1,000-1,500-word paper, include the following:

Part 1:
1.Read and review the Eliza intake document.
2.Assess how you would handle the psychosocial assessment based on the information provided.
3.Assess how you would use the Level 01 Cross-Cutting Measure (CCM-1), in addition to what specific questions would need to be answered by the end of the psychosocial assessment.

Part 2:
1.Review the completed psychosocial assessment for Eliza.
2.Provide an assessment related to client symptomology, a DSM and ICD diagnosis based on client assessment.
3.Provide the initial treatment goals and plan. Include common community principles and approaches as appropriate for the client.

Part 3:
1.Determine what Level 02 Cross-Cutting Measure (CCM-2) you would utilize in future sessions based on the information provided.
2.Identify one additional assessment outside of those provided by the APA that would measure what the future counselor is attempting to assess based on treatment goals/plan.

Prepare two educational handouts (two pages each), one for community members and patients and one for health care providers, that provide information about common bacteria or viruses and how to reduce the risk of infection.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:


Competency 1: Evaluate scholarly nursing literature that supports evidence-based nursing practice.
Identify timely evidence-based data needed to explain a potential health threat.
Apply evidence-based research to a health care initiative.
Competency 2: Explain ways to promote safe, quality, evidence-based care to populations and communities in health care environments.
Apply evidence-based research to a health care initiative.
Explain the factors that can adversely affect the health of individuals.
Describe evidence-based preventative measures to increase safety.

This Case Study is an assignment for my BSN course.
Please:
Type the case study using APA format. The case study must include:
1.Purpose/Goal of the case study. For example: To better understand assessment of chest pain in an elderly female experiencing an MI.
2.Learner objectives for the case study (at least three). For example: Upon completion of this case study the learner will be able to differentiate, identify, state, describe, etc...
3.A scenario or introduction to the case study including age, gender, race, etiology, medical history, medications that would affect assessment, and any other pertinent data relevant for the assessment of condition.
4.A brief cultural/social/family history and physical exam that emphasizes findings relevant to the case study.
5.Highlight what are the significant findings/assessments the nurse should consider when caring for the client in this case study. This should include a discussion of the developmental/wellness or disease topic which correlates your client's clinical picture with the literature.
6.Must have at least 6 references other than your text. These should be cited throughout the discussion portion of your paper. (Note: journal articles must be current - not more than 5 years old).

*This should be about a client whose care you have been involved in. Please protect confidentiality. Remember no patient identifiers.
*The purpose(s) of this assignment are to explore assessments that are being done throughout the nation, to network/share findings/resources that may be new in this area, and to develop your abilities in professional writing.

RUBERIC:
Purpose goal of study 10
Learner objectives 10
Scenario or introduction 20
Cultural/social/family history and physical exam 30
Significant findings/assessments considered in care of patient/literature review 40
Minimum of six references cited in paper 10
APA format 30
THANK YOU SO MUCH!!

I accidentally hit journal review only instead of research paper. The paper is a literature search paper.
Also,
Specific PICO question should read at the end diarrhea "or" yeast infections not "and"

A. Shape Your Clinical Question in PICO Format (30 points)
Your original clinical question and the specific rationale for its choice with an analysis of the question by the PICO components:
1. Present your clinical question and shape it according to PICO format (Week 2 Lesson).
2. Clinical question should relate to a patient population of interest to you. State why you chose this population and justify the relevance of the topic to nursing practice.
B. Search for Studies Relating to PICO Question (150 points)
Search Medline, CINAHL and Google Scholar for evidence relating to your PICO formatted question from III. A. above.

1. Present the results of your search for evidence to answer the PICO formatted question in the following 3 venues: (150 points divided as follows):
Medline -- Week 3 Lesson (50 points)
CINAHL -- Week 4 Lesson (50 points)
Google Scholar Week 5 Lesson (50 points)
2. Include a thorough description of each step of the search strategy in each database together with a rationale for choice of search terms. The citations in these searches may primarily consist of abstracts and some citations may appear in all 3 databases.
3. Use search strategies learned in this course either in the lessons or in the tutorials associated with each database.
4. At no time should full text or local holdings be used as limits on the searches.
5. Present 1 3 studies in each database; choose different articles in each database.
6. In each database, search for systematic reviews on the topic. Include search strategies/terms to find systematic reviews if different from B. 2 above. Cochrane Library may also be used as source for systematic reviews.
7. Include total number of studies found about the clinical question (a systematic review counts as one article) in each database at conclusion of final search.

C. Analyze the 1 3 Studies Found in Each Database (120 points divided as follows):
Medline (40 points)
CINAHL (40 points)
Google Scholar (40 points)
Include a complete description and analysis of each study produced by search in each database. The analysis of each article should include:
Type of study research, expert opinion, case study, etc
Quantitative or qualitative?
Population studied
Setting for the study
Kinds of interventions
Summary of results (if available in the abstract)
Relevance to PICO question
Evaluate strength of evidence

D. Pick Two (50 points)
Select two articles (a systematic review counts as one article) from all of the results that you analyzed in C. that best address your PICO question.
Justify the selection and state why these 2 studies constitute the best evidence. State any criteria of study validity used to select the 2 best articles.
The two articles may contradict one another.

IV. Presentation (50 points divided as follows)
1. APA Format (30 points)
APA format must be followed for: title page, running head, page margins, font, page numbers and reference citations.
2. Standard English grammar and usage (10 points)
3. Checked for typos (10 points)

This is the Walden University mission statement?a laudable and challenging academic goal. In this Application Assignment, you will relate the Walden vision and mission to your own academic and professional goals to becoming a scholar-practitioner in the field of clinical research administration. You will also have the opportunity to assess skills and experiences needed for success in the Walden Masters of Clinical Research Administration program.

To prepare for this Assignment:

Consider what Walden?s vision, mission, and outcomes mean to you. Think about how they relate to why you are here and what you want to accomplish.
Consider your personal and professional goals and how these goals intersect with your academic interests and selected field of study.
Reflect on the mission of Walden University.
Consider how specialized learning and the attainment of an advanced degree will help you meet your career and personal life goals, as well as help you become a scholar-practitioner who effects social change
With this in mind, write a 2- to 3-page paper that includes the following:

Explain in your own words what transformations (professional goals) you hope to effect for yourself and society with your advanced degree.
Based on your professional goals, identify at least three aspects of the goals that will have an impact on your role as a developing scholar-practitioner. Elaborate on how you believe these aspects are particularly relevant to your studies at Walden.



Below, is my statements of purpose essay. you can use connection from there, thanks

Assignment Below
1) Scenario: You are working for a community mental health agency that serves male adolescents aged 14-16 who have received a diagnosis of conduct disorder. You have been asked by your director of clinical training to answer the following questions (choose only one):
a) What individual treatment modes have been found to be effective (best practices, evidence-based) for treating this population?
b) What group treatment modes have been found to be effective (best practices, evidence-based) for treating this population?
c) What family treatment modes have been found to be effective (best practices, evidence-based) for treating this population?
2) Using database searches (e.g., EBSCO), locate at least three resources that provide information to answer your question. Some keywords to try for the search are highlighted in the question (best practices, evidence-based).
3) Your assignment response will consist of two sections:
a) Submit an annotated bibliography with an entry for each of your resources. Include the references in proper APA format. Write a brief summary highlighting the theory, treatment, intervention, and research methodology discussed in each resource. Use the additional materials for this module to help you in creating your annotated bibliography. There is no minimum required word count or length for your bibliography; however, you should conduct enough research to write the assigned paper for Module 1 (see below), and even more importantly, to write your final research proposal.
b) Based on your readings, write a paper (750-1,000 words) in which you prepare an answer to your question, citing the resource(s) you used for your answer. Note any gaps in information, special considerations, etc., that you found limited your ability to answer your question. Use standard essay format in APA style, including an introduction, conclusion, and title page. An abstract is not required.

REFERENCES BELOW and Lecture NOTES
http://gcumedia.com/digital-resources/mcgraw-hill/2011/research-design-and-methods_a-process-approach_ebook_8e.php
http://www.library.cornell.edu/olinuris/ref/research/skill28.htm
http://owl.english.purdue.edu/owl/resource/614/01/

Lecture 1
Introduction
Profession: "A calling requiring specialized knowledge and often long and intensive preparation, including instruction in skills and methods as well as in the scientific, historical, or scholarly principles underlying such skills and methods..." (Webster, 1968, p. 1811). In addition to skills, competencies, and professional standards, professions are typically characterized by a set of basic theories, foundation knowledge, and processes for ongoing collection and assessment of knowledge. Research methods provide basic philosophies and tools for continuing acquisition and critique of such knowledge.
The Role of Research in Professional Counseling
In a time of emphasis on evidence-based practice(King & Heyne, 2000), it is even more important for mental health professionals to be able to locate and critically review the professional literature that presents evaluation of both theory and clinical practice. In addition, practitioners should be able to evaluate their own clinical practice to ensure that their methods are appropriate and effective. In fact, the Council for Accreditation of Counseling and Related Educational Programs (n.d.)?the training accreditation arm of the American Counseling Association?has identified the following as knowledge that should be developed in the course of training in the profession:
The importance of conducting research
Various types of research methods
The use of technology and statistical methods
The roles of research in program evaluation and modification
Using research to improve counseling effectiveness
Ethical and legal issues in conducting research
What Is Evidence-Based Practice?
Evidence-based practice generally refers to clinical activities and treatment protocols that are supported by systematic evaluation?in other words, research. Excellent resources on evidence-based practices for mental health professionals include edited collections by Stout and Hayes (2004), Roberts and Yeager (2004), and The Center for School Counseling Outcome Research (Carey & Dimmit, 2006). Professional journals and books are filled with reports of such research and preferred research designs to establish the level of evidence that have been identified (e.g., Chambless & Ollendick, 2001).
In practice, mental health professionals should be able to review the literature to seek information about the efficacy of various treatment options for specific disorders and client populations, apply this information in their own choices of service, and evaluate the progress and outcomes of their own treatment activities through single case designs and more structured experimental designs.
The Goals of Research
In general, any given research project will seek to fulfill one or more of the following goals:
Describing a phenomenon
Explaininga phenomenon (theory building, modeling)
Predicting events related to phenomenon (predictions generated from theories, models)
Controlling variables to affect a phenomenon
Describe
One goal of research is accurate portrayal of a phenomenon. Observation with description is often a first step in gathering better information about an incident, process, individual, etc. The information can become the basis for theory building. Various observational techniques might be used here, from naturalistic observation to more structured ways of collecting, coding, and counting information.
Qualitative research is frequently useful in gathering details about processes, such as how people are experiencing a phenomenon. Qualitative refers to focusing on features that are less understood in numbers. For example, while one may be able to count the exact wavelength of red light or count the number of red balls in a basket, this is not the same as studying the qualitative experience of seeing redness. Redness would be the quality of the experience. Diaries, folk stories, photo albums, newspaper reports, contents of speeches, open-ended responses in interviews and focus groups, and therapy session notes are but a few of the sources of information for qualitative research. Content analyses of the materials seek to identify common themes and relationships.
Quantitative research is also a tool for observing and describing a phenomenon. Quantitative refers to measuring and counting. Most phenomena can be counted in some way. Even the example from above regarding the experience of perceiving redness can be quantified. Early researchers of sensation and perception asked individuals to report when they first saw or experienced events such as color, and were able to devise measurement scales for these perceptual phenomena. They realized that experiences such as seeing a color are the result of much more than the simple wavelength of light?in fact, that they are very individualized processes.
Mixed-methods approaches might use a combination of qualitative and quantitative methods to gather basic information about a phenomenon. Examples are interviews, which allow respondents to describe their thoughts, needs, feelings, and behaviors in their own words, and a survey, which asks questions about these areas but in a structured question-and-answer format (e.g., "Use a scale from 1-5 to indicate the level of agreement with the following statement.") related to thoughts, needs, feelings, and/or behaviors. For example, a researcher might collect information in a clinical interview about new widow's experiences with depression and administer a quantitative measure, such as the Beck Depression Inventory.
Explain
Gathering and describing observations can give researchers pieces of a puzzle. The next step is to build on these pieces through inductive reasoning in order to develop an explanation for these observations. This is theory or model building. For example, Freud's psychosexual theory of personality development was built on the observations he collected from his patients, while Piaget's theory of cognitive development was based on his observations of his own young children. In addition, trait theories of personality are based on factor analyses of numerous types of measures of attitudes, aptitudes, and behaviors (Schultz & Schultz, 2008).
Co-relational methods allow researchers to study quantitative relationships between phenomena (e.g., the correlation between level of poverty and alcohol abuse rates) and these correlations can then be used to create explanatory models via statistical methods such as path analyses, factor analyses, discriminant analyses, and regression analyses. Literature reviews and meta-analyses also allow researchers to integrate existing thoughts and research findings on a particular topic. For example, Avants and colleagues have used path analysis (Avants, Margolin, & McKee, 2000) and regression analysis (Avants, Margolin, Warburton, Hawkins, & Shi, 2001) to try to explain treatment adherence patterns among individuals in methadone maintenance programs. Prendergast, Podus, Finney, Greenwell, and Roll (2006) conducted a meta-analysis to integrate findings about the usefulness of contingency management in the treatment of substance use disorders.
Good theories offer general principles to explain already observed events and relationships, but also generate testable predictions (hypotheses) about future events. Good theories are also economical or parsimonious, meaning they are explained in the most forthright manner and without unnecessary complexity. Theories ultimately rise or fall on their ability to be tested and to predict from their explanations.
Predict
It is important to test whether and how explanatory theories and models hold up in actual practice. This level of experimental research identifies predictions?that is, hypotheses?that would be made from a given line of explanation, and then devises designs that adequately test these hypotheses. The validity of these tests of hypotheses depends heavily on the quality of the research design. Previous co-relational research might suggest that there is a relationship between two variables, but it does not demonstrate cause and effect. For example, it might be observed that people who are depressed also express negative thinking; that is, the more depressed a person is, the more negative the beliefs, expectations, and interpretations he or she expresses. However, while there is a strong correlation here, it is difficult to know which factor is the cause and which is the effect. In other words, is negative thinking caused by depression, or is depression caused by negative thinking?
Abela, Brozine, and Seligman (2004) designed a study to test whether there was a cause-effect relationship between attribution style and later experiences of hopelessness depression in reaction to life stressors. Although they did not manipulate the person's attribution style (the independent variable, which is a subject variable that the person brought with him or her), the researchers measured it in advance as a predictor of later behavior. This type of directional prediction strengthens the argument that A must cause B. However, the problem is that investigators may not be able to rule out other confounding variables that might be equally as important or more important in causing B. For example, perhaps individuals who think negatively do so as an outcome of earlier depression, which could mean that depression predicts depression and that the thinking style is just an aftereffect of earlier depression. Perhaps these individuals are more likely to behave in ways that cause more negative stressors in their lives and feel more hopeless about their chances of not having negative outcomes in their lives. By contrast, those who do not think in a generally hopeless way may be able to see that bad things in their lives come along, but not as a consequence of their own choices. This would support greater hope that things could change in the future.
The true experiment involves the manipulation of the independent variable, which the researcher hypothesizes to be the cause, so he or she can observe what happens to the dependent variable, which the researcher hypothesizes to be the effect. In a simple experiment, Croft and Walker (2001) manipulated people's beliefs about Monday work days, and then observed their moods on subsequent work days. One group (A) was given information that supported the belief that people are more blue on Mondays, while the other group (B) was given information that this is not true. The hypothesis was that the more a person believe he/she will have the blues (negative affect) on Monday, the more likely he/she will be blue on that day (and more so than on other days of the week). That is, group A should then report more negative affect on Mondays than those in group B. In reality, the researchers found that both groups still reported more negative affect on Mondays, but that those in group A reported less positive affect on Mondays. Here, negative beliefs had more to do with decreasing the positive than increasing the negative. This kind of information may then be used to adjust the underlying theory about the relationship between beliefs and moods.
Control
Finally, once people believe there is a demonstrated relationship between an independent variable (cause) and dependent variable (effect), they may wish to manipulate the independent variable in order to control outcomes (dependent variable). An example of this might be the use of certain types of treatment to control symptoms. Background research demonstrates the effectiveness of a treatment mode for a particular client group. Researchers build on this by then using the treatment to affect outcomes.
Beginning a research process
Ideas for research projects may come from any number of sources. For example, one may simply be curious about something and want to know more using a systematic method. Alternatively, one may wish to gather data to assess a need, or to evaluate a program or intervention, in order to provide recommendations for treatment, program, or policy decisions. One might seek to identify risk factors for certain behaviors. One might wish to compare one form of intervention with another, or to compare the effectiveness of one type of treatment for different types of clients. Sometimes ideas for research projects are self-generated, while at other times they are requested or required by others (e.g., a class assignment).
Whenever someone begins a research project, it is important to collect information that is already known about the problem or target phenomenon. Information may exist on any or all of the four stages of the scientific method: observation, explanation (i.e., theories, models), prediction, and control. It is the researcher's responsibility to build upon previous work, not to start from scratch.
Step 1: Review of the Scientific Literature
Sources usually include scholarly books, articles in professional journals, and possibly unpublished manuscripts, such as papers delivered at professional conferences or dissertations. Sometimes something published in a less scholarly source can be of use. For example, a newspaper or magazine might contain an article on a topic and provide the names of researchers or theorists. One could then go to professional resources to track down the works by these researchers or theorists.
Whenever possible, primary sources?that is, those written by the original authors?are preferred over secondary sources, which contain secondhand reports and interpretations of the original work. Textbooks are a type of secondary source that should guide one toward finding the primary sources. Electronic databases such as PsycInfo and PsycArticlesprovide useful tools for searching a very large collection of publications (and some unpublished works) to find resources that pertain to a topic. In addition, e-mail addresses of authors are often provided in articles (or through Internet searches) and may be used to contact the authors directly to gather information. Reference lists within articles or books may also be used to gather references for more background information.
Creating an annotated bibliography is a good strategy while collecting and reviewing information. An annotated bibliography is an ongoing series of notes about all the materials that are read and reviewed in the process of researching the topic. Not all of the resources will be used in the final research proposal or report. However, they can serve as the source of background information.
It is important to write the reference for each item in correct APA format, with all of the necessary information recorded in order to access the source quickly when transferring the reference to the research proposal or report. Also, it is useful for researchers to use keywords that may help them organize the various items as they go.
Some create annotated bibliographies using Excel spreadsheets or other software to allow organization of and searching within the information that is collected. An example of an annotated bibliography and resources on annotated bibliographies can be found in the Overview section of this module.
Note that this step may lead to a dead end. Sometimes the review of the literature may convince a researcher that it is not a useful path to follow for a project. Perhaps there is too little known to build on, or, at the other extreme, it is a huge area that would be difficult to boil down to one project. If this is the case, repeat Step 1 with a new idea for review.
Step 2: Writing Introduction and Literature Review for Research Proposal
Research should be purposeful. Before collecting any data, it is important to state clearly the question or problem to be addressed. For example, the question might be, "How do military spouses who are recently widowed cope with grief?" Another question might ask whether a grief group for spouses who are recently widowed could be a viable new service to offer at an outpatient center. If such a group already exists, the question might be whether it has had any positive effects. Another question might be whether a peer support group for these recently widowed spouses is as effective as, more effective than, or less effective than a professionally facilitated grief group or individual treatment.
After stating the question or problem of interest, the next step is to present a review of relevant literature that can provide background knowledge on the question. Here, theories and prior research can be summarized. Key terms should be defined for the reader. Attention can also be given to operational definitions, measurement techniques, and research designs previously used to gather information. Limitations and gaps in information can be pointed out.
The review should be logical and not scattered. It should guide the reader toward expecting what the particulars of this new research project will be, such as the hypotheses.
Conclusion
Research plays an integral role in the development and maintenance of a profession. Members of the profession, including professional counseling, are expected to have a basic understanding of the research that supports theory and practice, to apply evidence-based practice as appropriate, and to be able to systematically gather information and evaluate services they provide.
Research activities help us to describe, explain, predict, and control phenomena, including those relevant in clinical practice. The ability to conduct a good review of the professional literature is a key skill underlying any research project.
References
Abela, J.R.Z., Brozina, K., & Seligman, M.E.P. (2004). A test of integration of the activation hypothesis and the diathesis-stress component of the hopelessness theory of depression. British Journal of Clinical Psychology, 43(2), 111-128
Avants, S. K., Margolin, A., & McKee, S. (2000). A path analysis of cognitive, affective, and behavioral predictors of treatment response in a methadone maintenance program. Journal of Substance Abuse, 11(3), 215-230.
Avants, S. K., Margolin, A., Warburton, L. A., Hawkins, K. A., & Shi, J. (2001). Predictors of nondherence to HIV-related medication regimens during methadone stabilization. American Journal of Addictions, 10(1), 69-78.
CACREP. 2001 Standards. Retrieved November 10, 2008, from http://www.cacrep.org/2001Standards.html.
Carey, J.C., & Dimmitt, C. (2006). Resources for school counselors and counselor
educators: The Center for School Counseling Outcome Research. Professional School Counseling, 9(5), 416-420.
Chambless, D.L., & Ollendick, T.H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.
Croft, G.P., & Walker, A.E. (2001). Are the Monday blues all in the mind? The role of expectance in subjective experience of mood. Journal of Applied Social Psychology, 31(6), 1133-1145
King, N.J., & Heyne, D. (2000). Promotion of empirically validated psychotherapies in counselling psychology. Counselling Psychology Quarterly, 13(1), 1-12.
Prendergast, M., Podus, D., Finney, J., Greenwell, L., & Roll, J. (2006). Contingency management for treatment of substance use disorders: A meta-analysis. Addiction, 101(11), 1546-1560.
Schultz, D. P., & Schultz, S. E. (2008). Theories of personality. New York: Cengage.
Webster, N. (1968). Webster's third new international dictionary (Unabridged). Springfield, MA: Merriam-Webster.
copyright 2009. Grand Canyon University. All Rights Reserved.

at least 2 paragraphs per prompt: in-text citations and APA style bibliography

Describe the Masters prepared nurses role as:
1.researcher.
2.collaborator.
3.clinician.
4.consumer advocate.
5.manager of systems.
6.consultant.
7.change agent.
8.in improving healthcare delivery and outcomes.?
9.Identify effective communication strategies for interacting with other healthcare professionals.?
10.Identify strategies for working in collaborative and interdependent relationships.?
11.Describe negotiation skills for the Masters prepared nursing role.?
12.Differentiate Master's prepared nursing roles of nurse practitioner, clinical nurse specialist, nurse anesthetist, and certified nurse-midwife.
13.Describe the masters-prepared nurses role as advocate for the nursing profession.
14.Describe the masters-prepared nurses role and responsibility in professional activities.
15.Describe the masters-prepared nurses role in maintaining continued competence.
16.Describe the masters-prepared nurses leadership role within the profession.
17.Describe the masters-prepared nurses role as a professional role model.?
18.Compare the concepts of personal values, societal values, professional values, organizational values, and moral values.?
19.Recognize the role of emotions in ethical decisions.?
20.Identify the importance of personal values and patient values.?
21.Identify the implications for nursing care of values conflict.

How we can benefit from nursing research in our clinical areas. We do just implement clinical procedures or changes to clinical areas without doing research to validate what we are doing.

I need a scholarly article related to the role of WOC/ET Nursing (BSN level that has completed Wound, Ostomy, Continence Nurse Education program at accredited facilty)about venous stasis leg ulcers. The topic MUST relate to the role of WOC/ET Nursing. It should include prevalence, etiology, prevention, assessment, care, treatment by the WOC/ET nurse in different settings including acute care, long term care, and home care. The topic (venous stasis ulcers) must be well researched, referenced and presented in a clear, concise, well-organized format. Ideas must be supported with references to literature and research. A minimum of 5 of the minimum 15 required literature references must be from the Journal of WOCN. The article must reflect an understanding of the topic. It must include a comprehensive and current bibliography (no more than 5 years old). The content must be summarized. It must include identified areas for future research. The paper must be written at a professional level (BSN RN CWOCN).

Extrapolate strategies you propose are useful to close the theory-practice gap in nursing. Must use 3 specific articles plus 2 more of your choosing for a total of 5 references. This is for a master's degree Nursing Theory Course. The paper is to be between 3-5 pages in length in APA format.

The three articles that must be incorporated into this paper I have uploaded are:

Mind the gap: philosophy, theory, and practice by Derek Sellman, Nursing Philosophy, 2010, 11, pp.85-87;

Integrating Evidence-Based Practice With Educational Theory in Clinical Practice for Nurse Practitioners: Bridging the Theory Practice Gap by Rona F. Levin Research and Theory for Nursing Practice: An International Journal, Vol. 24, No.4, 2010, p. 213-216; and

Closing the theory-practice gap: a model of nursing praxis by Gary Rolfe, Journal of Clinical Nursing, 1993; 2: p. 173-177.

Purpose: To demonstrate ability to identify a clinical or population health problem, outline it in a PICO format, access relevant medical literature, analyze and synthesize that literature, and distill meaningful information for addressing the clinical or population health problem.
Format:
o Topic areas:
? All areas of health and medicine are viable.
? Topics relevant to current courses in clinical medicine, CABS, pharmacology, clinical reasoning, etc. are fine, but can?t be same product (no cut and paste).
o 10-pages, double spaced.
o Space allocation guidelines:
? Statement of problem (1 page; 5 %)
? PICO analysis (1 page; 25 %)
? Review of Literature: (6 pages; 35%)
? Mixture of primary and secondary sources.
? Organized in a structured format, perhaps by strength of design, relevance to the patient population or clinical problem, or other organizing concept.
? Analyzed according to characteristics of internal validity (i.e., study design, research methods, etc.), and external validity (i.e., how well does it apply to your target population/problem, etc.).
? Synthesized by criteria for causality or other organizing format.
? Application: (2 pages; 25%)
? How does this evidence from the literature interface with your understanding from personal experience, expert opinion of clinician colleagues, or clinical practice guidelines?
? What is your clinical decision and why?
o Citations and references in APA style (10%)

PICO question format
"In adult patients with bacteremia and bacterial pneumonia, does adjunctive measurement of pro-calcitonin level improve patient outcomes such as early diagnosis, reduction in morbidity/mortality compared with standard diagnostic methods?"
PICO stands for:
?Population/ Patient Problem: Who is your patient? (Disease or Health status, age, race, sex)
ICU patients admitted with bacterial sepsis and or pneumonia
?
Intervention: What do you plan to do for the patient? (Specific tests, therapies, medications)
adjunctive measurement of pro-calcitonin level

?Comparison: What is the alternative to your plan? (ie. No treatment, different type of treatment, etc.)
?standard methods of treatment for septic shock and pneumonia

Outcome: What outcome do you seek? (Less symptoms, no symptoms, full health, etc.)
improved patient outcomes such as early diagnosis, reduction in morbidity/mortality compared with standard diagnostic methods.

grading criteria
Guidelines for Evidence-base Paper:
1. The paper must be typed, double-spaced, and referenced using formal APA format.
2. The length of the paper will be 15(fifteen) - 20 (twenty) pages.



6. To prepare the reader for your analysis of the issue, the paper must include (but not limited to) the following elements:
a. Introduction to the issue
b. Relevance of the issue to clinical practice
c. Effectiveness of Evidence
d. Critique, Synthesis and Analysis of Evidence
e. Discussion
f. Conclusion-Brief summary of an answer to your PICO question

Grading Rubric for Evidence Based Paper:
Introduction of the Issue 10%
Relevance of the Issue 5%
Effectiveness of Evidence 15%
Critique, Synthesis & Analysis of Evidence 25%
Discussion 15%
Conclusions 10%
Use of available evidence-based references 10%
Use of correct grammar 5%
Use of APA format or format for the appropriate journal 5%

The length of the paper is to be no longer than four (4) pages excluding title page and reference page. Extra pages will not be read and will not count toward your grade.
APA format is required. Include a title page and a reference page. The body of the paper should have four sections with these headings:

a. Introduction
b. Summary of the Article
c. Evaluation of the Article
d. Conclusion

The Introduction is the first part of the body of the paper. It should be one paragraph that include:
Author(s) full name,
Article title
Journal name
Date of publication
The Summary is the second part of the body of the paper. It should include:
Focus of the article
Health assessment procedure and rationales discussed
Health assessment tools and/or strategies discussed
Evaluate the article. Include a full one- to-two page critique that answers all of the following questions:
What was done well and what could have been improved in the article?
Did this article interest you? If so, explain why. If not, explain this reaction.
Was the health assessment strategy beneficial? Could you adopt it in your practice?
Was the health assessment strategy explained clearly?
Should more research articles be written about this area of health assessment?
What population or individuals would benefit the most from information reported in this article?
Identify the main ideas and major support points from the body of your report. Omit minor details. Summarize the benefits of proper assessment for the patient.

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quality improvement activities
Requested Writers
Explain

? What are quality improvement activities in nursing practice (such as ongoing consideration, use and review of practice in relation to practice outcomes, standards and guidelines and new developments, case review activities , clinical audits, etc.)
? Why quality improvement activities in nursing practice is important
? Why nurses need ongoing facility accreditation
? How can nurses participate in quality improvement activities (such as seeks feedback from a wide range of sources to improve the quality of nursing care, participates in case review activities, participates in clinical audits, etc.)
Other elements:
Reference in APA format.
Direct quote is not allowed.

Topic: Bipolar Disorder: How Bipolar Disorder effects the routine life of a person in Work, Family, Friends.

Thesis Statement to be used: "Bipolar disorder is an intricate physiological and psychological disorder that can control, tamper, and falsify a person's thoughts and actions in their daily life."

Directions: You must include at least 10 relevant journal articles in your paper. All articles must be empirical* and recent (written within the last 5 years unless the citation is linked to an author whose work is seminal to your topic). This paper should be written in a scholarly fashion, strictly adhering to APA standards. Do not express your own opinion.
You should use the following guidelines in constructing your research paper:
Abstract page.
Introduction should define and discuss the importance of your topic.
The body of the paper should organize the topic in a meaningful way and critically review the current empirical knowledge base relevant to your topic.
A conclusion section should include a discussion of practice/policy implications/recommendations and future research directions.
Reference page should list at least 10 primary empirical sources.
Follow APA Publication Manual organization and style guidelines

Direction Cont':
1. Do not use personal pronouns or your opinions in your research paper. (I, you, they, we, your, etc).
2. Do not use your opinions in the research paper.
3. Do not use contractions.
4. Do not overuse a word, even if its the topic!
5. Do not use footnotes.
6. Do not end a sentence with a preposition.
7. Do not use casual terms, such as kids, a lot of.
8. Do not use too many quotes or too long a quote; I want your ideas!
10. Regarding numbers: 1 ??" 10, use numerals; 10+ use words.
11. Avoid using strong verbs, such as, proves, causes, determines. Try something like, suggest.
12. Use correct punctuation. Quotation marks are outside commas and periods. Use commas around however and therefore.
13. Use correct noun/pronoun agreement:
Person---who (not that)
Persons----they (incorrect)
13. Avoid he/she by using the plural: people/they
Sentence Structure
14. Do not submit run on, wordy sentences.
15. If you submit a group of words that is not a sentence, you will
lose 10 points.
16. Effect/Affect
These words can be confusing; which to use?
Affect: is a VERB; to influence (The drug affected the disease.)
Effect: anything brought about by an agent; a result; (The drug had a positive effect on the disease.)
17. References in the reference list MUST be cited in the paper.
18. References cited in the paper MUST be listed in the reference section.
19. Do not submit your annotated bibliography as your reference list; check APA .
20. Use academic journals and one or two books may be used if critical to the paper.
21. Use correct APA style.


References to be used:

Lichtenstein, P., Yip, B., Bjrk, C., Pawitan, Y., Cannon, T., Sullivan, P. & Hultman. C. (2009). Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. The Lancet, 373(9659), 234-39.

Merikangas, R., Akiskal, H., Angst, J., Greenberg, P., Hirschfield, R., Petukhova, M. & Kessler, D. (2007). Lifetime and 12-Month Prevalence of Bipolar Spectrum Disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry 64(5), 543-52.

Miklowitz, D. (2007). The Role of the Family in the Course and Treatment of Bipolar Disorder. Current Directions in Psychological Science, 16(4), 192-6.

Miller, I., Keitner, G., Ryan, C., Uebelacker, L., Johnson, S. & Solomon, D. (2008). Family Treatment for Bipolar Disorder: Family Impairment by Treatment Interactions. Journal of Clinical Psychiatry, 69(5), 732-40.

Moreno, C., Laje, G., Blanco, C., Jiang, H., Schmidt, A. & Olfson, M. (2007). National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth. Archives of general psychiatry, 64(9), 1032-9.

Muller, D., de Luca, V., Sicard, T., King, N., Strauss, J. & Kennedy, J. (2006). Brain-derived neurotrophic factor (BDNF) gene and rapid-cycling bipolar disorder. The British Journal of Psychiatry, 189, 317-23.

Pandey, G., Rizavi, H., Dwivedi, Y. & Pavuluri, M. (2008). Brain-Derived Neurotrophic Factor Gene Expression in Pediatric Bipolar Disorder: Effects of Treatment and Clinical Response. Child & Adolescent Psychiatry 47(9), 1077-85.

Phillips, M., Travis, M., Fagioloni, A. & Kupfer, D. (2008). Medication Effects in Neuroimaging Studies of Bipolar Disorder. American Journal of Psychiatry 165, 313-20.

Post, R. & Leverich, G. (2007). The Role of Psychosocial Stress in the Onset and Progression of Bipolar Disorder and its Comorbidities: The Need for Earlier and Alternative Modes of Therapeutic Intervention. Focus 5, 73-97.

Strakowski, S., DelBello, M., Fleck, D., Adler, C., Anthenelli, R., Keck, P., Arnold, L. & Amicone, J. (2007). Effects of Co-occurring Cannabis Use Disorders on the Course of Bipolar Disorder After a First Hospitalization for Mania. Archives of General Psychiatry, 64(1), 57-64.


Customer is requesting that (FreelanceWriter) completes this order.

1. What is the process for evidence-based medicine? What role does technology play in EBM? What challenges does management face with the implementation and use of EBM?


2. Clinical Decision Support Systems
What are the critical success factors for selecting and implementing a CDSS? What are the key business requirements for a CDSS; provide an example from your experience, the Internet, or the text? What are the key technical requirements for a CDSS; provide an example from your experience, the Internet, or the text?

The purpose of this project is to help you to develop the skills of a practitioner-researcher and to be able to evaluate the effectiveness of your own clinical work. For your course project, you will select a single case (individual client) at your clinical internship. During the course of your internship, you will develop a proposal to conduct an evaluation of the interventions used for a present or future case or group. You must format the proposal as an empirical research proposal, including introduction, literature review, methodology, and appendices. This is a proposal, not a project you must actually implement. The client is fictional and should have anxiety and substance abuse issues.
I have attached the first part of the project that should help you in completing the second half. The client can be completely fictional. Please contact me assap with any questions. Thank you so much.
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A capstone project paper identifying the issue of inadequate staffing in nursing which relates to the QSEN competency of safety and teamwork and collaboration.
Clinical Integration Paper/Capstone Project (175 points possible):
Learning Objectives: In writing this 10-12 page clinical integration paper, the senior nursing student will:
1. Describe a nursing or patient care concern, issue, or problem encountered during the senior level clinical experience.
2. Identify one or more of the QSEN competencies referring to the specific knowledge, skills, or attitudes and behaviors for that particular competency (ies).
3. Analyze the significance of the concern for nursing practice in relation to the one or more QSEN competencies. (From different perspectives, what and why is it important to explore this concern or issue?)
4. Complete a review of the literature related to the nursing or patient care concern and the associated QSEN competency.
5. Provide a case exemplar from your clinical experience that exemplifies the nursing or patient care concern and its related QSEN competency(ies).
6. Synthesize the nursing implications from recent literature to the specific concern or issue and include implications for these three areas:
a) Practice- What did you determine was the best or preferred nursing practice for this concern, providing rationales and evidence?
b) Education- What are the current guidelines for educating staff about patient care or nursing practice related to this concern or issue, providing rationales and evidence?
c) Research- What are the priorities for further study, from a nursing clinical or professional perspective?

Each student will write a paper relating a nursing care concern, issue, or problem, encountered during the senior clinical experience, to a particular QSEN competency (ies). The paper must include a selected case or exemplar that illustrates the clinical concern or issue.

Cultural Health Promotion Plan Paper

This is an INDIVIDUAL assignment based on community data and the Healthy People 2010/2020 National Objectives.

DUE DATE: July 6, 2010 by 10:00 p.m. with late submission policy application to this assignment.
Complete the paper according to APA 6th Edition Guidelines as a word processed document. The paper must be submitted electronically via course Web Courses Assignment function.

The paper is limited to a MAXIMUM of Ten (10) pages (including the title page and references pages; NO Abstract is needed for this assignment). Do not exceed the ten page limit as only ten pages will be read and graded! The paper must double spaced in font size 12. Include Title Page with a running head and a page number according to APA Sixth Edition format. Page one begins on the title page. References using APA format are included in the total page count.

The Cultural Health Promotion Plan paper topics are derived from the work that was previously identified by faculty, students, and other pertinent resources in the community. The problems/needs/risks are drawn from Community Data/Healthy People 2010/2020.

1. Each student will select ONE problem/need/risk from the list provided by Dr. Ark. The list is located in Web Courses Course Web Site on a separate Discussion Board. The problem/need/risk is written in the four-part community diagnosis format. The student should not alter the diagnosis.

2. Develop a cultural health promotion plan as if the plan would be implemented for a target group within any community, not particular to your assigned Community Nursing Coalition. Writing the plan paper assignment will aid in the development of the program planning and evaluation skills that you will use in the development of the senior project in Public Health Nursing Clinical in the last semester of the Basic BSN Program ?" the topic area of your paper is not necessarily the topic area for the community intervention plan in the Public Health Nursing clinical, however the skills you learn in this course will prepare you for the important service-learning work in the community during the last semester of the program. RN-BSN students conduct a teaching project/evaluation in NUR 4604L Community/Public Health Nursing Practicum.


3. Submit the plan paper by the due date and time.







Here are thoughts to guide the development of the paper regarding health variations by cultural heritage:

Cultural Diversity refers to the differences among people based upon shared ideology and valued sets of beliefs, norms, customs, and meanings evidenced in way of life (ANA, 1996, Position Statement on Cultural Diversity). This diversity is expressed in various ways. Diversity in history, beliefs, practices, and opportunities not only exist among cultural groups, but also typically exist across a wide continuum within the group. Health behaviors are influenced by culture and cultural values as well as by socioeconomic status.

In this assignment, students develop a health promotion plan for a cultural group living in the United States, not necessarily in your CNC community location. You are to learn as much as you can about the cultural norms and patterns and how these norms and patterns influence health practices. The purpose of this assignment is for the student to develop a deeper understanding and sensitivity regarding the role of culture in life of the client and in nursing through the examination of a cultural/ethnic group.

Thoughts to consider as you develop the paper:

Health and Culture: The nurse must recognize that members of various cultures define health differently. Individuals may define themselves or others in their group as healthy even though the nurse identifies symptoms of disease. Cultural priorities of the client may differ from that of the nurse.

Culture and Healing: Individuals and families in various cultural groups may also use traditional healing systems, sometimes called lay or folk-healing systems, with or without allopathic (modern) medicine. In addition to seeking help from the nurse as a health care provider, clients may also seek help from traditional or religious healers. Most nurses have experienced clients who combine medical care with prayer. Nurses need to be sensitive to, respectful of and nonjudgmental regarding patients health beliefs and practices in order to maximize patient outcomes.

Health status of all clients is influenced by the interaction of physiological, cultural, psychological, economic and societal factors. Diversity within and among groups necessitates data collection activities and programs that are tailored to meet the unique health care needs of different subgroups.

Health beliefs are translated into health care practices, which then affect health status. What constitutes appropriate care for specific health conditions may be guided by cultural and social class expectations held by members of the culture.

Health Information and Education:
Planning health education programs requires identifying and building on cultural strengths and ensuring sensitivity to cultural factors. Meeting the language and cultural needs of each identified minority group, using minority specific community resources to tailor educational approaches, and developing materials and methods of presentation that are at the educational level of the target population are essential considerations in the planning process. Health programs should be sustainable over a long period of time and accountable to the clients.

Paper Guidelines
Format the paper according to APA Sixth edition guidelines; you will have Level 1 and Level 2 Headers in this paper.


Insert a Title Page

Then, page two (repeat title of paper on page two)

Community Diagnosis

State the community diagnosis addressing the problem/need/risk that you selected from the approved list for this paper. Be sure to include the in text cite for Healthy People 2010 in your References list.
First address the
Aspects of Cultural Assessment

Ethnic/racial identity How does the group identify itself in terms ethnicity and racial background? What is the range of interaction outside of the cultural group? Are recreational, educational, and other social activities within the ethnic reference group, the wider community, or both?
History and Value Orientation How are values derived? What is the historical experience of the group that may have impacted values?
Language-communication process What languages are spoken in the home? And by whom? What language is preferred when speaking to outsiders? Do second and third generations in the U.S. speak the language of their grandparents?
Health Belief and Practices What are the traditional health beliefs? How common are these beliefs and practices within this group? To what extent are folk healing practices and practitioners used? Is access to care and equality of care an issue for this group?
Religious Beliefs Religious articles & practices, how spirituality is defined. Remember that Religious Beliefs and Spirituality are different concepts.
Spirituality How is spirituality defined? Remember that Religious Beliefs and Spirituality are different concepts.
Lifecycle events Which life cycle events are important to the culture? What are the customs associated with births, coming of age, marriage, and death?
Nutritional Behavior/Diet Are there restrictions? Are there common practices?


Review of Literature on the Health Problem

Complete a review of the literature highlighting the health problem and the target group. Be sure to use headers to organize this section of the paper. Students must use the Maurer & Smith textbook and optional use of other textbooks from the first semester courses as references. You may use literature from Allied Health however you must have THREE evidence-based nursing references (nursing literature/nursing journals) published within the last five years included in your in text citations within the paper and on the list of references. In other words, include cites in the boy of the paper and the full citations of all sources in the References section of the paper according to APA format. Remember that not all journals listed in the CINAHL database are nursing journals.

You should answer these questions in the review of literature ?" these three categories are headers:
Why is this diagnosis a health problem for this target group?
What are the current nursing interventions for this problem?
What interventions have been successful and what interventions have NOT been successful?

Planning

Plan Title
Give the plan a title ?" this title must be consistent on the title page, on the second page, and here.

Short Term Goal
List one short term goal with the time frame of the final semester (15 week 45-hour clinical) in the BSN program. Remember that education is a strategy not an outcome or goal.

Measurable Objectives
Write three measurable, time specific learner objectives. State the learning domain for each of the three objectives; you should write in the domains of Cognitive; Affective; and/or Psychomotor. Remember that in order to have an effective program intervention, you would not have all three of the objectives in the cognitive domain, nor would you necessarily have one objective for each of the domains.
Objectives Summary
Consider all of the objectives together; write two paragraphs (maximum) addressing these areas:
The Objectives are: (1.) Specific; (2.) Measurable; (3.) Reasonable/Feasible; (4.) Fit with a community-based setting; and (5.) Easily understood by clients.

Budget
Create a Brief Budget (must be in Table format according to APA)
Determine a budget for the project.
Time: Consider $14.00/hour for the student nurse rate (remember that you will have a 45-hour clinical course in which to complete the project ~ you may have other student nurses assisting you on the project).
Materials: while brochures may be donated - in kind - there is still a cost.
List other resources needed for the project.
Be sure to total out the amount of the project using the Table format guidelines in the APA manual.

Intervention
Health Promotion Strategies/Methods
Describe in detail the strategies/methods for each of the three objectives. Remember to use headers throughout this section to clearly articulate the intervention. You should list Objective One, then describe the primary and secondary prevention strategies; then, Objective Two, describing the primary and secondary prevention strategies; then, Objective Three, describing the primary and secondary prevention strategies. Explain the rationale for selecting the strategies/methods. Remember that you are writing strategies at the levels of Primary Prevention & Secondary Prevention levels, and not Tertiary Prevention level strategies in this paper.

Evaluation
Use three headers
Objective One
Objective Two
Objective Three
The text in paragraph form will follow each of the headers as displayed above. In the text, tell the reader how the outcomes of each objective are measured/assessed at both the primary and secondary level of prevention. Remember that an evaluation is based on objectives. An evaluation is the appraisal of the effects of activities and/or program interventions. An evaluation is conducted in order to determine the relevance, progress, efficiency, effectiveness & impact of program activities.

References
Formatted according to APA Sixth edition guidelines

There are faxes for this order.

APA Format with abstract. Discussion 4-6 pages with footnotes and citations within text, but a specific # wasn't listed. References required are:(3)Peer reviewed data based articles and (2)Peer reviewed articles. Introduction of topic. Background and significance of problem to include affect of alteration on individual, family, and community. Social and cultural considerations. Trends in management: Historical and current. Evidence based nursing practice information to include: Assessment/Diagnosis, Expected outcomes, Interventions: Therapeutic Relationships, Psychopharmacology, Milieu management, and Evaluation. This is a nursing research paper for my ADN-RN Psychology class.

Im Requesting for "FreelanceWriter" to write this essay Thank you.


Below are 5 questions in parenthesis with some of the texts book answers below. Please use your experience to write an essay, APA style from the 5 answers to the questions using your experience. Thank you

1. (Explain the four phases of emergency planning (i.e. mitigation, preparedness, response, recovery) in detail. Practically speaking, which phases do you think most emergency managers spend time thinking about? Which phases should they spend the most time thinking about? How, if at all, has 9-11 changed where the emphases should lie?)

Mitigation

Mitigation is the cornerstone of emergency management. It's the continuing effort to lessen the impact disasters have on people and property. Mitigation is defined as "sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects." ----
Through effective mitigation practices we can ensure that fewer people and communities become victims of natural disasters. Mitigation can take many forms. It can involve such actions as:----

promoting sound land use planning based on known hazards
Buying flood insurance to protect your belongings
Relocating or elevating structures out of the floodplain
Securing shelves and hot water heaters to walls
Developing, adopting and enforcing building codes and standards
Engineering roads and bridges to withstand earthquakes
Using fire-retardent materials in new construction
Developing and implementing a plan in your business or community to reduce your susceptibility to hazards-----

Mitigation links include:---
FEMA Mitigation Division
Protect Your Property, Home or Business From Disaster ---
National Flood Insurance Program ----

Preparedness----
Preparedness takes the form of plans or procedures designed to save lives and to minimize damage when an emergency occurs. Planning, training, and disaster drills are the essential

elements of preparedness. These activities ensure that when a disaster strikes, emergency managers will be able to provide the best response possible. Disasters are caused by gale force winds, floods, releases of deadly chemicals, fire, ice, earthquakes and other natural and man-made hazards. When disaster strikes, the best protection is knowing what to do. Preparedness links include:---

Preparedness --

Response & Recovery---
Response is defined as the actions taken to save lives and prevent further damage in a disaster or emergency situation. Response is putting preparedness plans into action. Response activities may include damage assessment, search and rescue, fire fighting, and sheltering victims.---

Recovery is defined as the actions taken to return the community to normal following a disaster. Repairing, replacing, or rebuilding property are examples of recovery.----
Local and State governments share the responsibility for protecting their citizens from disasters, and for helping them to recover when a disaster strikes. In some cases, a disaster is beyond the capabilities of the State and local government to respond.---

The Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288, as amended (the Stafford Act) was enacted to support State and local governments and their citizens when disasters overwhelm them. The Disaster Process and Disaster Aid Programs explains the disaster declaration process and provides an overview of available assistance.--

There are individual assistance programs (an overview of individual assistance programs) that assist people and businesses following a disaster and help you get back on your feet. Public Assistance Programs provides supplemental federal disaster grant assistance to help state and local governments and certain private non-profit organizations rebuild.--

The four phases of emergency planning are mitigation, preparedness, response and recovery.
There are seven categories that makeups the Mitigation phase. The Federal assistance programs,
there are numerous federal programs available to assist local officials in the mitigation
phase of their emergency management plans. Specialize training programs provided by the
Federal Emergency Management Agency, the U.S. Fire Administration, the Federal Bureau of
Investigation, the Departments of Justice, Health and Human Services and Defense and Energy.
Many of these programs are provided free of charge or for limited cost, to local government
officials. Second the Mitigation phase deals with U.S. Homeland Security Advisory Thomas Ridge,
the Director of the Office of Homeland Security, set forth a national system of advising all levels of government-federal, state, and local as well as the American people of the risk of terrorist threats. A color corded system low green, guarded blue, elevated yellow, high orange and severe red. This alerting system spells out protective measures suited to each warning category.--

The Third category is Threat assessment, to asses the threat of terrorist acts by individuals or groups within their jurisdiction, cities and counties must work with state and federal agencies---

Building design and physical structures, Municipal and county building codes, Nonstructural
safety measures, Pedestrian and vehicular evacuation routes.---

The fourth category deal with Building design and physical structures to improve public safety. Certain types of construction are more likely to withstand a terrorist attack than others. High-quality sprinkler systems and new fireproof roofing materials can reduce the chance of fire. The selected placement of steel and concrete barriers around public buildings is frequently used to restrict vehicular access.----

2 ( Explain in detail the process of risk analysis? In light of the readings and your own experience, how would you define risk? How would you weigh it? If you were the city manager or police chief in a small town with limited resources, how much effort would you put into risk analysis? Would you simply "eyeball" risk and give it your best guess, or would you be inclined to conduct an actual assessment? )
The four parts of risk assessment. The particular procedure necessary for such an analysis of local law enforcement jurisdictions can be readily accomplished by dividing the risk assessment process into four individual arts: (1) external general, (2) external specific, (3) internal general, and (4) internal specific. The first three categories generally measure the acquired risk; the last measures the institutional ability to minimize that same risk. Overall, the risk ascribed by this analysis is weighted not only by the terrorists operational abilities but also by those of the local agency. The categories are as follows:--

External general- The first variables are of a general nature that is not related to any specific circumstances within the jurisdiction. They refer to external factors that can create a climate conducive for contemporary guerrilla activity in the world and may lead to the injection of the activity into a local jurisdiction if relevant targets exist. (Factor are Geopolitical, Economic, Ideological, and Guerrilla).----

External specific- These are events in the world that have a specific relationship to the jurisdiction in question. These variables focus on question regarding the general environment and its conduciveness to immediate guerrilla group formation and operations. Weather: Is the current weather conducive to supporting a campaign of terrorism likely to hinder a counter terrorist operation? Population demographics: and Target access viability: are roads and airfields available and rivers navigable? ----

Internal general- These are the events within a jurisdiction that have a general relationship to the formation of terrorist groups within the area. Increased activism, New local organization, Initiating violence, Increased ordnance and Politically motivated intelligence gathering .---

Internal specific- These are the variables that represent th counter terrorist ability specific to the jurisdictions resources. Expertise: what is the level of training in the areas necessary for the creation of an effective crisis management operation? A survey of all personnel regarding their relevant knowledge must be conducted. Training, Preparation and Liaison---

3 (How important to a community or an agency is an emergency plan? If you were crafting or revising such a plan for your own agency or community, what components would you make sure were present in the plan and why? What would you do to ensure knowledge of the plan's provisions?)

The emergency plans of cities and counties should include preparedness procedures for all types of likely disasters. These plans should detail the technical expertise that might be needed in the event of a terrorist attack, required resources, and the proper procedures to request assistance from neighboring jurisdictions as well as higher levels of government. Increasing emphasis must be placed on the interaction of local, state, and federal officials . Cities and counties with sites that might be prime targets of terrorists such as nuclear power plants and busy ports, should include these sites in local emergency plan. Early-warning public notification systems, a key feature of a local governments response to an emergency is prompt notification of the public (citywide sirens). Training for local government employees is very essential for preparedness. --

4 (What role, if any, should emergency managers play in ensuring emergency medical care for a mass-casualty incident? In other words, what can emergency managers and disaster planners do to facilitate such care? In what ways may public safety agencies or infrastructure agencies (such as the utility companies or public works) play a role in effectively responding to mass casualties?)

Public officials in the jurisdiction where a natural or man-made disaster occurs should establish a clearinghouse to coordinate assistance to victims and their families. The Federal Emergency Management Agency, state governments, Red Cross, and other nonprofit organizations frequently offer this type of assistance. By providing a centralized location for assistance information, a local government will be able to speed up the process of restoring order after a disaster. ---

Local government officials may need to make arrangements for temporary morgues. Local mortuaries must also be put on alert to handle the additional deaths from mass-casualty---
After a disaster, citizens expect local public officials to restore public infrastructure (sewer water lines electricity est.) in a timely manner. City and country officials should take prompt action to merit citizens trust in this regard.---

Because a terrorist bombing can cause a large number of seriously injured persons, prehospital care systems play a critical role in managing the emergency medical response to this kind of mass casualty event. The quality of prehospital emergency medical response will affect the quality of all subsequent clinical care activities, and it may directly affect patient mortality and morbidity rates. The complexity and scope of a mass casualty event caused by an explosion requires that prehospital emergency medical care systems address the following issues:---

Recognition of specific hazards associated with a terrorist bombing, such as secondary devices, environmental hazards (e.g., toxins, fires) and structural instability. --

Effective communication with acute care medical resources and emergency management resources. --

Expedient patient triage to match available resources with patient needs.---

In the United States, the majority of emergency medical service (EMS) systems are organized and coordinated at the local level. Nationwide, this results in an incredibly diverse prehospital emergency medical care system that is often markedly different in operational and clinical approaches among jurisdictions. According to the Institute of Medicine, EMS systems are challenged by the following key issues: insufficient coordination, response time disparities, inconsistent quality of care, lack of disaster readiness, divided professional identity, and limited evidence base for the profession.--

5(What makes for a good emergency manager or disaster planner? What personal attributes would contribute to the success of such an official? Also, what kind of resources and support must be available to multiply the effectiveness of the emergency management function in an agency or community? To what degree do you think those resources are available to the emergency management profession today? )

Emergency manager are Committed to Helping Make Families and Communities Safer From the Ravages of Natural Hazards and Terrorist attack--

Emergency manager Mission, protects communities by coordinating and integrating all activities necessary to build, sustain, and improve the capability to mitigate against, prepare for, respond to, and recover from threatened or actual natural disasters, acts of terrorism, or other man-made disasters.--

Those individuals and departments assigned emergency responsibilities will participate in developing and maintaining current Standard Operating Procedures and checklists for the support of the EOC. Elements of these procedures include:---

Provision to support, maintain, staff, direct and control University resources during the time of a major disaster. --

Specific emergency actions that will be assumed by staff and designated successors during emergency situations. --

Circumstances under which successor emergency authorities would become effective, and when they would be terminated. --

Current department personnel notification/recall rosters procedures and the means to implement. This should include a communication system to implement call-out rosters for personnel assigned to the EOC, support functions and field response team. ---

Establishment of a system for communication to the EOC, Public Safety dispatch and Physical Plant dispatch/work order control center, and to manage organizational resources, response field personnel and maintain contact with the EOC during emergencies. --

Developing mutual aid and other support agreements with appropriate local and state agencies, vendors, and "sister" departments within the CSU system. ---

Reporting of damage assessment information (casualties, damage observations, evacuation status, radiation levels, chemical exposure, etc.) to the EOC during an emergency.

Support of cleanup and recovery operations following disasters.

Training of assigned response staff and campus volunteers to augment the performing of emergency functions.

Together with this research paper I need a draft before as well.
I will sent you the three articles , and from the book " Clinical Handbook of Psychological Disorders 3rd edition edited by David H. Barlow you have to use the chapter 2 for post traumatic tress disorder to write the first three sections of the paper.

In the draft for this research paper I need a summary of 1 experiment in an APA style.


The organization of this research paper must be:



1. Introduction: Describe the symptoms of the disorder that you are studying, the epidemiology of the disorder, and common contextual features. That is, does the disorder commonly co-occur with other disorders? Is it more likely in certain social-environmental settings? (20 pts)
2. Theoretical Conceptualization: Describe how the psychotherapy that you have chosen conceptualized the disorder. Give a detailed description of the theoretical conceptualization of the disorder that you are researching (30 pts).
3. Give a detailed description of intervention you are researching. Describe the treatment components. What are the hypothesized mechanisms for change? How many sessions does the treatment take? How does the treatment unfold over the course of treatment? How does a therapist measure change? How does the therapist end therapy? Use the case example in the book to describe the components of the intervention. (30 pts)
4. Review 3 experiments have been done on the effectiveness of the therapy. Describe the studies. Organize your summary according to the standardized organization of research articles (Introduction, Methods [subjects, research design, and statistics], Results, Discussion).Discuss the strengths and weaknesses of different research designs and how different studies have built on each other (50 pts).
5. Discussion: Summarize the findings regarding the efficacy of the intervention. What are next steps that need to be taken in developing the treatment? What is your opinion about the efficacy of the treatment and the quality of the research? (20 pts)

the article with topic " A randomized trial of cognitive therapy and i maginal exposure in the treatment of chronic posttraumatic stress disorder is the one that I want the summary in the draft paper to be worked with.


There are faxes for this order.

Organizational Analysis
Select an organization for a case study and organizational analysis. Use the Fourteen Forces of Magnetism* as a guide to assess the organization. In a 1800 2500 word paper, determine if the organization has structures in place to for recruitment, retention, and support of a qualified workforce and to support the professional practice of nursing.
a. Content should:
1) Provide an overview of the organization:
a) Location
b) Size
c) Age
d) unusual history
e) image
f) sub-unit configuration
2) Describe the consistencies and the inconsistencies between the intent of each force of the fourteen forces of magnetism and the current state of the organization.
3) Synthesize the assessment to identified strengths and weaknesses
4) Support conclusions based on the analysis of the organizations position to recruit, retain, and support a qualified workforce and to support the professional practice of nursing.
5) Reference: *Bliss-Holtz, J., Winter, N., Scherer, Elaine M. An invitation to Magnet accreditation. Nursing Management. 35(9):36-42, September 2004.

Multiple Sclerosis

A.) Following an introduction of theb topic to be covered, the non-diseased or normal condition and/or body system(s) involved should be described in full detail. Here the student should adequately describe the normal anatomy and/or physiology, with emphasis on normal mechanisms, so that explanation of abnormal is based upon the reader understanding normal.
b.) The known or suspected cause of the condition should be explained, describing the mechanism of the condition and how the condition develops or how it differs from the normal anatomical or physiological condition (i.e. sequence how the condition develops from a previous normal condition). Make sure to cover anatomical, physiological, genetic, molecular, or any other mechanisms that cause the disease to develop.
C.) A brief explanation of the prevalence(total number of cases normally occuring in a population) and incidence (number of new cases that occur annually in the population)of the condition is important, as it helps keep a perspective on the significance of the disease. Here the student should provide total numbers and/or percentages of people affected in the U.S. population, or North American population, or even in the world population. Any differences by race, gender, age, etc. should also be described when such statistical data are available.
D.) The student should also describe the clinial signs (an objective finding that can be observed and/or measured by another person), symptoms (subjective findings observed by the patient) and lesions (micro or macrscopic physical or chemical changes) that accompany the condition. This description should be more than a mere listing of symptoms, clinical signs, and lesions, but should include a brief explanation of the mechanism how or why such symptoms, signs, and lesions occur.
E.) Explain how the diagnosis is generally made, including description of any unique or specific diagnostic tests, is another critical component. Obviously symptoms are the reason people seek medical attention, but the reader needs to know how the medical team sifts through edical history,physical exam findings, standard diagnostic tests and any high tech and unique diagnostic tests to reach a diagnosis. In this section be sure to briefly explain the mechanisms of such diagnostic procedures and the meaning or significance of the results. Simply listing clinical signs or mentioning tests that are performed without explaination of mechanisms and manings of results is not sufficient. Also, many diagnostic tests are used to rule out conditions, and this concept needs to clear the reader where pertinent.
F.) Successful surgical, medical or any other type of treatment that either ease the condition, cure the patient, or prevent the condition should be explained, including a description of the mechanism(s) of how and why such treatments work. Here, even if there are older generation treatments that provide limited bnefit, they should also be described if said treatments are still in common usage. If there are numerous medications, for example, they should be desribed in groups based upon their mechanisms of action. In describing classes of medications or treatments, for example, be sure to describe the goal of said treatment and the mechanism of action that seeks to fulfill the goal.
G.) Since many diseases do not have cures and many are far from fully understood, there should be a discussion of the current theories or direction(s) of medical research on the disease, giving attention to the mechanisms that are being investigated, such as into discovering the genetic, physiologic or biochemical cause of the condition, approaches to prevent or cure the condition, or surgical or technologically advanced approaches to correct the anatomy or physiology of te condition, etc. Be sure to cite a minium of two to three examples of researchers' ongoing or recent work and findings (dont just mention something like thanks to all the research, theres hope in the future).
H.) The report should have a minimum of 10 references. At least 3 of the 10 must come from scientifically reviewed medical journals. Try to find more known sources make sure there is credibility (New England Journal of Medicine). Also, the student must not use any source older than 2001.
I.) Cite in MLA format-give credit where credit is due and be sure, however, not to overuse quotes.

Write a research paper on Renal Artery Stenosis. In writing the paper defines renal artery stenosis, the cause of the disease, the risk factors, the symptoms and manifestations of the disease and possible treatments. Then discuss in detail the relation of this pathology with Renal artery occlusion, Fibromuscular dysplasia. Then discuss the role of ultrasonography diagnosis methods in detecting the disease. Here discuses the benefits and limitations of these techniques and then use the information to analyze the role played by Color Doppler Sonographic features in excluding pathology.
In writing the paper you can use the following materials and other sources including, medical journals. But make sure that each quotations and parenthetical citations are matched with proper references. And other peoples works are given credits. You can back your writing with limited quotations in small paragraph forms with no more than one for the entire paper.
Use a case study if possible.
Here I have cut and paste you information some of the information I found from the internet. So if you decide to use them make sure you give credit to the writers.

The Paper should follow APA style and have reference list of no more that five.
********************
Alternative Names Return to top
Renal artery occlusion; Stenosis - renal artery; Occlusion - renal artery; Fibromuscular dysplasia (FMD)
Definition Return to top
Renal artery stenosis is a narrowing or blockage of the artery that supplies blood to the kidney. It is caused by atherosclerosis, fibromuscular dysplasia of the renal artery wall, or scar formation in the artery. (See also atheroembolic renal disease.)
Causes Return to top
Renal artery stenosis is caused when atheroembolic renal disease results in narrowing of the renal artery. Fibromuscular disease, a condition more common in young women in which fibrous tissue grows in the wall of the renal artery and narrows it, is a second cause. It may also be caused when scar tissue forms in the renal artery after acute arterial obstruction or traumatic injury to the kidney.
Renal artery stenosis often causes hypertension (high blood pressure) with no other signs of its presence, and it is usually discovered in investigation for the cause of hypertension that is difficult to control. Renal artery stenosis is, in fact, among the most common causes of secondary (caused by another condition) hypertension. The disorder may also be discovered when a bruit (loud whooshing sound) over the kidney is noted on examination with a stethoscope (auscultation). Auscultation is a method used to listen to the sounds of the body during a physical examination.
Information Return to top
Auscultation is usually performed by listening through a stethoscope. Health care providers routinely listen to a patient's lungs, heart, and intestines to evaluate the frequency, intensity, duration, number, and quality of sounds.
Health care providers also use auscultation to listen to the heart sounds of unborn infants. This is not performed with a stethoscope, but with sound waves. This is called a Doppler ultrasound. It can also be used to hear pulses in the hands and feet.
Related topics:


In the elderly, renal artery stenosis is most commonly associated with atherosclerotic disorders, including atherosclerotic heart disease. Atherosclerotic plaque deposits within the renal artery and causes it to become stenosed (narrowed).
Fibromuscular dysplasia is a congenital disorder involving thickening of the arterial wall and is a cause of renal artery stenosis in younger adults, particularly women 20 - 40 years old.
Renal artery stenosis may cause chronic renal failure if it affects both renal arteries or if the high blood pressure associated with this condition is prolonged or severe.
Symptoms Return to top
There are usually no symptoms.
Exams and Tests Return to top
The blood pressure may be high, and there may be a history of high blood pressure that doesn't respond to medication or is difficult to control. A bruit may be heard on examination with a stethoscope (auscultation) over the kidney.
A radionuclide renogram may show decreased blood flow. The value of radionuclide scanning is increased if the test is done twice: once after a dose of captopril and once without the captopril.
An MRI, kidney CT scan, or kidney ultrasound may indicate a decreased size of the kidney, and/or a decrease in blood flow through the artery because the artery has become narrow.
Renal arteriography shows the exact location of the stenosed (blocked) area.
This disease may also alter the results of the following tests:
Urine specific gravity
Urine concentration test
Renal perfusion scintiscan
Treatment Return to top
The treatment varies depending on the extent and severity of the symptoms. If the stenosis results in failure of a kidney, the second kidney may take over filtering and urine production for the body. Surgical repair of the stenosed area may be possible.
A balloon angioplasty (a radiographic procedure during which a balloon-tipped catheter is threaded through the artery) or a stent placement across the stenosis may be an alternative to surgery to open the stenosed area.
Antihypertensive medications may be needed to control high blood pressure.
Outlook (Prognosis) Return to top
Renal artery stenosis may cause eventual failure of the kidney if it progressively blocks the artery. This may result in chronic renal failure if there is only one functional kidney or if both renal arteries are affected.
Renal hypertension caused by renal artery stenosis may be difficult to treat. Surgical or balloon catheter repair often successfully opens the stenosed area. However, stenosis may recur.
Possible Complications Return to top
Hypertension
Malignant hypertension
Chronic renal failure
When to Contact a Medical Professional Return to top
If your history indicates a high risk for renal artery stenosis, make an appointment to see your health care provider. However, decreased urine volume may be an emergency symptom indicating renal failure.
Prevention Return to top
Some cases of renal artery stenosis may be prevented by avoiding smoking.
Update Date: 12/9/2005

Alternative Names Return to top
Renal disease - atheroembolic; Cholesterol embolization syndrome; Atheroemboli - renal; Atherosclerotic disease - renal
Definition Return to top
Atheroembolic renal disease (AERD) is an inflammatory reaction in the small blood vessels of the kidneys.
Causes Return to top
AERD is linked to atherosclerosis. Atherosclerosis is a common disorder of the arteries. It occurs when fat, cholesterol, and other substances build up in the walls of arteries and form hard substances called plaque.
In AERD, cholesterol crystals from plaque break off and move to the kidneys and into the blood stream. Once in circulation, the crystals get stuck in tiny blood vessels called arterioles. There, they cause an intense inflammatory response. The result is organ damage due to decreased blood supply. Acute kidney failure is possible if the reaction is severe.
Atherosclerosis of the aorta is the most common cause of AERD. The cholesterol crystals may also break off during cardiac catheterization or aortic surgery.
In some cases, AERD may occur without a cause.
The risk factors for AERD are the same as risk factors for atherosclerosis.
Symptoms Return to top
AERD may not cause any symptoms. Symptoms that may occur include:
Foot pain, ulcers on the feet, or blue toes
Pain in the abdomen, nausea, or vomiting
Pancreatitis or hepatitis (rare)
Strokes or blindness
Flank pain and blood in the urine (rare)
Uncontrolled high blood pressure
Kidney failure may result in the following:
Nausea or vomiting
Loss of appetite
Weight loss
Decreased or no urine output
Swelling
Decrease in sensation
Skin pigment changes
Dry itchy skin
Drowsiness, confusion, lethargy
Exams and Tests Return to top
The doctor will perform a physial exam. Swelling may affect the entire body. An eye exam may show particles in the small arteries of the retina.
The doctor will listen to your lungs and heart with a stethoscope. Abnormal sounds may be heard. For example, a loud whooshing sound called a bruit may be heard over the aorta or renal artery.
Blood pressure may be high. There may be multiple ulcers of the skin of the lower feet.
Tests that may be done include:
Abdominal CT scan
Abdominal MRI
Abdominal x-ray
Chem-7 or chem-20
Complete blood count
Kidney biopsy
Kidney function tests including BUN and creatinine
Kidney or abdominal ultrasound
Renal arteriography
Serum complement
Serum lipids
Urinalysis
Treatment Return to top
Medicines may be used to treat high blood pressure and lower lipid and cholesterol levels.
Other treatments for kidney failure or complications may be needed.
Your doctor may tell you to reduce fats and cholesterol in your diet. If you have kidney failure, you may need to restrict protein, salt, and fluids, or make other dietary changes.
Your doctor may also recommend other lifestyle changes such as increased exercise or weight loss. Stopping smoking is extremely important.
Outlook (Prognosis) Return to top
The outcome varies but is generally poor. The disorder slowly gets worse over time. Lifestyle changes may help slow progression of the disease.
Possible Complications Return to top
Acute renal failure
Chronic renal failure
High blood pressure
Blood clots to other location of the body -- brain, intestine, legs
When to Contact a Medical Professional Return to top
Call your doctor if you have:
A decrease in urine output or no urine production
Blood in the urine
Severe abdominal pain or leg pain
Unexplained ulcers on your legs or feet
Toes that turn purple and occur with foot pain
Prevention Return to top
You can alter the factors that increase your risk of getting this disease. You should lose weight if you are obese, decrease or stop smoking, and follow your doctor's recommendations to control diabetes or high blood pressure. Reducing fats, especially saturated fats, in your diet may help to reduce serum lipid levels.
Update Date: 5/15/2007


Reference


Medical Encyclopedia
Atheroembolic renal diseasehttp://www.nlm.nih.gov/medlineplus/ency/article/000480.htmllustrations


Carotid stenosis, X-ray of the left artery



Carotid stenosis, X-ray of the right artery



Enlarged view of atherosclerosis



Prevention of heart disease



Developmental process of atherosclerosis



Angina




Atherosclerosis



Cholesterol producers



Coronary artery balloon angioplasty - series


Alternative Names Return to top
Arteriosclerosis; Hardening of the arteries; Plaque buildup - arteries
Definition Return to top
Atherosclerosis is a condition in which fatty material collects along the walls of arteries. This fatty material thickens, hardens, and may eventually block the arteries.
Atherosclerosis is a type of arteriosclerosis. The two terms are often used to mean the same thing.
Causes Return to top
Atherosclerosis is a common disorder of the arteries. It occurs when fat, cholesterol, and other substances build up in the walls of arteries and form hard substances called plaque.
Eventually, the plaque deposits can make the artery narrow and less flexible. This makes it harder for blood to flow. If the coronary arteries become narrow, blood flow to the heart can slow down or stop, causing chest pain (stable angina), shortness of breath, heart attack, and other symptoms.
Pieces of plaque can break apart and move through the bloodstream. This is a common cause of heart attack and stroke. Blood clots can also form around the plaque deposits. Clots block blood flow. If the clot moves into the heart, lungs, or brain, it can cause a stroke, heart attack, or pulmonary embolism.
Risk factors for atherosclerosis include:
Diabetes
High blood pressure
High cholesterol
High-fat diet
Obesity
Personal or family history of heart disease
Smoking
The following conditions have also been linked to atherosclerosis:
Cerebrovascular disease
Kidney disease involving dialysis
Peripheral vascular disease
Symptoms Return to top
Symptoms usually do not occur until blood flow becomes slowed or blocked. If this happens, you may have chest pain or leg pain, depending on which artery is involved. Sometimes symptoms occur only with activity.
Exams and Tests Return to top
A health care provider will perform a physical exam and listen to the heart and lungs with a stethoscope. Early atherosclerosis can create a whooshing or blowing sound ("bruit") over an artery.
Tests that may be used to diagnose atherosclerosis or complications include:
Ankle/brachial index (ABI)
Arteriography
Cardiac stress testing
CT scan
Doppler study
Intravascular ultrasound (IVUS)
Magnetic resonance arteriography (MRA)
Treatment Return to top
Your doctor will probably suggest a low-fat diet, weight loss if you are overweight, and exercise.
There are many different medicines used to treat atherosclerosis. Blood thinners may be given to prevent clot formation. Medications may be also recommended to lower cholesterol and to keep your blood pressure at a healthy level.
Atherosclerosis can lead to coronary heart disease (CHD). If you have CHD that does not cause symptoms, you can be treated with either medicine or angioplasty with stenting. Recent studies show that medicine and angioplasty with stenting have equal benefits. Angioplasty with stenting does not help you live longer, but it can reduce angina or other symptoms of coronary artery disease.
Angioplasty with stenting, however, can be a life-saving procedure if you are having a heart attack
Some people may need a procedure called an endarterectomy to remove plaque build up.
See also:
Coronary artery bypass surgery
Minimally invasive heart surgery
Outlook (Prognosis) Return to top
Everyone starts to develop some amount of atherosclerosis as they grow older. In some people, the condition can cause complications such as a heart attack or stroke.
Possible Complications Return to top
Coronary artery disease
Damage to organs (such as the kidneys, brain, liver, and intestines)
Heart attack
Stroke
Too little blood to the legs and feet
Transient ischemic attack (TIA)
When to Contact a Medical Professional Return to top
Call for an appointment with your health care provider if you are at risk for atherosclerosis, especially if symptoms occur.
Talk to your doctor before starting a new exercise plan, especially if you have been diagnosed with coronary artery disease or if you have ever had a heart attack.
Prevention Return to top
The following lifestyle changes can help prevent atherosclerosis:
Eat a low-fat, low-cholesterol, and low-salt diet.
Eat fish. Adding fish to the diet at least twice a week has been shown to be helpful. Do not fry the fish, as this destroys the benefit.
If you don't like to eat fish, try a fish oil supplement.
Exercise 30 minutes every day. If you are overweight, you should get 60 to 90 minutes of exercise a day.
Lose weight if you are overweight.
Stop smoking.
Mild to moderate consumption of alcohol or wine (1-2 drinks per day) may also reduce the risk of cardiovascular events. Too much alcohol, however, does more harm than good.
If you have one or more risk factors for heart attack or stroke, ask your doctor if you should take aspirin every day. Aspirin can help some people reduce the risk of heart disease and stroke.
Work with your doctor to bring the blood pressure into the normal range. This may require medication. Follow your doctor's recommendations for treatment and control of diabetes and other diseases.
Do not take hormonal replacement therapy, folic acid supplements, vitamin C or E, or antioxidants to decrease the risk of heart disease or troke. These methods have not been proven to prevent these conditions.
References Return to top
Boden WE, O'rourke RA, Teo KK, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med. 2007 Mar 26; [Epub ahead of print].
Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007; Published online before print February 19, 2007.
Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed. St. Louis, Mo: WB Saunders; 2005:921-935.
Update Date: 3/30/2007

Background: Specialists have known for a long time that renal artery stenosis (RAS) is the major cause of renovascular hypertension and that it may account for 1-10% of the 50 million people in the United States who have hypertension. Apart from its role in the pathogenesis of hypertension, RAS is also being increasingly recognized as an important cause of chronic renal insufficiency and end-stage renal disease. In older individuals, atherosclerosis (ATH) is by far the most common etiology of RAS. As the renal artery lumen progressively narrows, renal blood flow decreases and eventually compromises renal function and structure.
With the increase in the elderly population and the possible increase in prevalence of RAS and ischemic nephropathy, clinicians dealing with renovascular disease (RVD) need noninvasive diagnostic tools and effective therapeutic measures to resolve the problem successfully. This review explores the natural history of this disorder, the value of a variety of invasive and noninvasive diagnostic procedures, and the consequence of allowing the artery to remain obstructed versus reversing renal artery occlusion.
Pathophysiology: In patients with ATH, the initiator of endothelial injury is not clear; however, dyslipidemia, hypertension, cigarette smoking, diabetes mellitus, viral infection, immune injury, and increased homocysteine levels may contribute to endothelial injury. In the atherosclerotic lesion site, endothelium permeability to plasma macromolecules (eg, low-density lipoprotein [LDL]) increases, turnover of endothelial cells and smooth muscle cells increases, and intimal macrophages increase. When atherogenic lipoproteins exceed certain critical levels, the mechanical forces may enhance lipoprotein insudation in these regions, leading to early atheromatous lesions.
Renal blood flow is 3- to 5-fold greater than the perfusion to other organs because it drives glomerular capillary filtration. Both glomerular capillary hydrostatic pressure and renal blood flow are important determinants of the glomerular filtration rate (GFR).
In patients with RAS, the chronic ischemia produced by the obstruction of renal blood flow produces adaptive changes in the kidney that are more pronounced in the tubular tissue. These changes include atrophy with decreased tubular cell size, patchy inflammation and fibrosis, tubulosclerosis, atrophy of the glomerular capillary tuft, thickening and duplication of the Bowman capsule, and intrarenal arterial medial thickening. In patients with RAS, the GFR is dependent on angiotensin II and other modulators that maintain the autoregulation system between the afferent and efferent arteries and can fail to maintain the GFR when renal perfusion pressure drops below 70-85 mm Hg. Significant functional impairment of autoregulation, leading to a decrease in the GFR, is not likely to be observed until arterial luminal narrowing exceeds 50%.
Frequency:
In the US: Studies suggest that ischemic nephropathy may be responsible for 5-22% of advanced renal disease in all patients older than 50 years.
Mortality/Morbidity:
The consequences of RAS are hypertension, which may be particularly difficult to control or may require multiple antihypertensive agents (with increased adverse effects), and progressive loss of renal function (Ischemic Nephropathy).
In addition, the discovery of atherosclerotic RVD frequently occurs in the setting of generalized vascular disease (ie, cerebral, cardiac, peripheral), with the co-morbidity associated with disease in those vascular beds. Thus, any therapeutic intervention for RAS should logically take into account the underlying prognosis associated with these co-morbidities.
Race:
RVD is less common in African American patients. The incidence rate in 2 studies of patients with severe hypertension was 27-45% in white persons compared to 8-19% in African American persons.
Sex:
While the incidence of atherosclerotic RVD is independent of sex, Crowley et al showed that female sex (as well as older age, elevated serum creatinine level, coronary artery disease, peripheral vascular disease, hypertension, and cerebrovascular disease) is an independent predictor of RVD progression.
Age:
In 1964, Holley et al reported data from 295 consecutive autopsies performed in their institution during a 10-month period. The mean age at death was 61 years. The prevalence rate of RAS was 27% of 256 cases identified as having history of hypertension, while 56% showed significant stenosis (>50% luminal narrowing), and, among normotensive patients, 17% had severe RAS (>80% luminal narrowing). Among those older than 70 years, 62% had severe RAS.
Another similar autopsy study reported similar results, with 5% of patients older than 64 years showing severe stenosis; this figure increased to 18% for patients aged 65-74 years and 42% for patients older than 75 years.





CLINICAL Section 3 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography


History: Patients with documented or possible renovascular hypertension may experience progressive azotemia as a consequence of the renal ischemia and/or the persistence of significant hypertension. Refractory hypertension (ie, poor control of blood pressure despite treatment with 3 or more antihypertensive agents) may occur.
Physical: The strong association of RVD with generalized ATH indicates that any typical findings associated with cerebrovascular (eg, carotid bruits, old cerebrovascular accident, transient ischemic attack), cardiovascular, or peripheral vascular disease occur frequently in patients with RVD. Abdominal bruits are highly specific for RVD when heard over the flank and are back-and-forth in nature (ie, present during both systole and diastole).
Patients with ischemic RVD present with one or more of the following clinical, historical, or diagnostic scenarios:
Azotemia occurs in patients with peripheral vascular occlusive disease, carotid or coronary artery disease, and other signs of ATH.
Sudden worsening of hypertension or renal function may occur.
Acute renal failure or decreased renal function after antihypertensive therapy, especially with ACE inhibitors or angiotensin receptor blockers, may occur; an increase in serum creatinine levels of more than 15% in this setting is strongly suggestive of a high incidence of RVD.
Unexplained renal insufficiency may develop in elderly patients.
Congestive heart failure may occur with poor control of hypertension and renal insufficiency in the absence of a significant decrease in ejection fraction (the so-called flash pulmonary edema).
Causes: Risk factors associated with ischemic renal disease (IRD) are as follows:
Hypertension: Of patients with IRD, 35% can be normotensive.
Advanced age: Numerous cases occur in persons aged 60-69 years. Incidence increases in persons older than 70 years.
Renal insufficiency
Extrarenal ATH
Diabetes mellitus
Smoking
http://www.emedicine.com/med/topi c2001.htm