Clinical decision-making in senior nursing students in Iran

Clinical decision-making is the basis for professional nursing practice. This can be taught and learned through appropriate teaching and clinical experiences. Unfortunately, it has been observed that many graduates are unable to demonstrate suitable clinical decision-making skills. Research and study on the process of decision-making and factors influencing it assists educators to find the appropriate educational and clinical strategies to teach nursing students. To explore the experience of nursing students and their view points regarding the factors influencing their development of clinical decision-making skills. An exploratory qualitative approach utilizing grounded theory methods was used; focus group interviews were undertaken with 32 fourth year nursing students and data were analysed using constant comparative analysis. Four main themes emerged from the data: clinical instructor incompetency, low self-efficacy, unconducive clinical learning climate and experiencing stress. The data indicated that students could not make clinical decisions independently. The findings of this study support the need to reform aspects of the curriculum in Iran in order to increase theory-practice integration and prepare a conductive clinical learning climate that enhances learning clinical decision-making with less stress.     

Normal wound healing in mice deficient for fibulin-5, an elastin binding protein essential for dermal elastic fiber assembly

Extracellular matrix proteins play a critical role in dermal wound healing by mediating matrix-cell interactions and re-establishing the dermal architecture and environment. Fibulin-5 is an elastin-binding protein essential for elastic fiber development in vivo, and it has recently been shown to inhibit angiogenesis in vitro. Here, we use mice deficient for the fibulin-5 gene (fbln5) to examine the role of fibulin-5 and the effect of the loss of elastic fibers in dermal wound healing. Fbln5 is upregulated in the granulation tissue 14 days after full-thickness wounding in wild-type mice, before the formation of elastic fibers. Although wounded fbln5(-/-) skin showed enhanced neovascularization compared to the wild-type skin, no difference in the rate of wound closure was observed between mutant and wild-type mice. In addition, a breaking strength test revealed that there was no difference in breaking stress or strain between wild-type and fbln5(-/-) wounded skin. These results suggest that fibulin-5 and elastic fibers are not directly involved in short-term wound healing. Clearly, the long-term effect of the absence of fibulin-5 on the function and integrity of regenerated skin needs to be further addressed.     

Induction of nitric oxide synthase is a key determinant of progression to pulmonary injury in experimental pancreatitis

BACKGROUND: The immunomodulatory potential of nitric oxide provides prospective strategies to attenuate inappropriate inflammatory reactions. This study tested the hypothesis that inhibition of nitric oxide synthase (NOS) reduces end-organ injury in pancreatitis. METHODS: Pancreatitis was induced in male Sprague-Dawley rats by intraperitoneal (i.p.) injection of 20% L-arginine (500 mg/100 g of body weight). Animals were randomized into four groups of 45: Pancreatitis without intervention; pre-treatment with i.p. aminoguanidine (AMG) (50 mg/kg), an isoform-specific inhibitor of inducible NOS; post-treatment with AMG (50 mg/kg); and controls. Pancreatic and pulmonary pathology, neutrophil infiltration (myeloperoxidase activity), endothelial permeability (bronchoalveolar lavage, wet:dry weight ratio), NOS expression, and concentrations of pro-inflammatory cytokines (tumor necrosis factor-alpha; interleukin-6) were assessed. RESULTS: Inhibition of iNOS significantly reduced end-organ injury. Pancreatic and pulmonary injury scores were markedly attenuated in the AMG treatment groups compared with no intervention (p < 0.05). Increased endothelial permeability (2,411.1 +/- 47.9) and neutrophil sequestration (1.99 +/- 0.01) were manifest in the untreated animals compared with AMG pretreatment (1,286.8 +/- 35.1 and 1,548.0 +/- 0.1; p < 0.05). In addition, a significant reduction in inflammatory cytokine concentrations was observed (p < 0.05). CONCLUSIONS: Inhibition of inducible NOS encourages a more benign immunologic profile, minimizing the deleterious effects of unrestrained neutrophil sequestration subsequent to pancreatitis.     

No rest for the wounded: early ambulation after hip surgery accelerates recovery

BACKGROUND: Level 3 evidence-based guidelines recommend first walk after hip fracture surgery within 48 h. Early mobilization is resource and effort intensive and needs rigorous investigation to justify implementation. This study uses a prospective randomized method to investigate the effect of early ambulation (EA) after hip fracture surgery on patient and hospital outcomes. METHODS: Sixty patients (41 women and 19 men; mean age 79.4 years) admitted between March 2004 through December 2004 to The Alfred Hospital, Melbourne, for surgical management of a hip fracture were studied. Randomization was either EA (first walk postoperative day 1 or 2) or delayed ambulation (DA) (first walk postoperative day 3 or 4). Functional levels on day 7 post-surgery, acute hospital length of stay and destination at discharge were compared. RESULTS: At 1 week post-surgery, patients in the EA group walked further than those in the DA group (P = 0.03) and required less assistance to transfer (P = 0.009) and negotiate a step (P = 0.23). Patients in the EA group were more likely to be discharged directly home from the acute care than those in the DA group (26.3 compared with 2.4%) and less likely to need high-level care (36.8 compared with 56%). A failed early ambulation subgroup had significantly more postoperative cardiovascular instability and worse results for all outcome measures. CONCLUSION: EA after hip fracture surgery accelerates functional recovery and is associated with more discharges directly home and less to high-level care.     

Extended deepithelialization to secure double-breasted closure of the skin

Double-breasted closure of the skin is achieved by deepithelialization of 1 edge of a wound and advancement of the opposite edge over this deepithelialized area. Such closure may prevent contamination or exposure of the implant in cases where immediate breast reconstruction with prosthetic material is obtained after skin sparing mastectomy. The deepithelialization routinely extends as far as the incision to be closed and, consequently, the skin suture at the end of the incision immediately overlies thedeep suture or implant in cases where the implant is not fully covered by muscle. To prevent contamination or exposure of the implant when suture infection or wound dehiscence occurs in these cases, we extend the deepithelialization beyond and around the limit of the skin incision. This allows for complete and secured double-breasted closure of the entire wound and lessens the risk of implant contamination or exposure.