NURS-FPX4030 Assessment 3 Example
PICO(T) framework and Type 1- Diabetes
Population, intervention, comparison, outcome, and time comprise the PICOT framework (McEwen & Wills, 2017). The aspect of time is not always applicable and only does when need be. The use of the PICOT framework helps in improving the specificity and conceptual clarity of clinical problems. In studies, PICOT is used to formulate questions in evidence-based practice. These questions should entail every element of the PICOT framework. It helps design research and identifies the key concepts that need to be an article or a study that ensures high quality of findings.
Use of the PICO(T) Approach when Caring for Patients with Type 1 Diabetes
The question addresses how self-monitoring of blood glucose is not as effective as the use of glucose monitoring technologies to provide better HbA1c for type one diabetic patients. The question to be analyzed in this paper is: In patients with type 1 diabetes and uncontrolled blood glucose levels, how does continuous use of glucose monitoring technologies compared to self-monitoring of blood glucose provide better HbA1c control.
The study population is patients with type-1 diabetes with uncontrolled blood sugar levels. The intervention suggested is monitoring technologies over the convectional finger stick method (DiMeglio et al., 2018). The comparison is to find the most effective intervention by monitoring blood glucose levels using monitoring technologies and the convectional finger stick method. The outcome is to determine if continuous monitoring technology lowers the HbA1c. In this case study, there are no time frames decided on.
Identification of Source Evidence
Dexcom CGM
The PICOT compares continuous glucose monitoring methods and self-monitoring of blood glucose. Dexcom is a quintessence of a technology used in the continuous monitoring of blood glucose, a device used by diabetic patients to provide a real-time look at blood glucose levels for 24 hours. The Dexcom G6 is an automated applicator that uses a comfortable sensor inserted just beneath the skin and a Dexcom G6 mobile app to provide a simple and one-touch method for glucose measurement. The mobile app displays glucose information, triggering alerts and alarms that notify the patient of the glucose levels.
There are customizable alarms and alerts for low and high blood glucose levels for ease of interpretation. The data can then be translated into graphs, patterns, and trends that are simple to interpret and useful, especially when determining progress over a month or over a specific time period. Continuous glucose monitoring technologies outperform self-monitoring of blood glucose, which does not provide a continuous reading throughout the 24 hour period and does not provide trends, patterns, or statistics.
The use of the Dexcom G6 is justified by the technology’s ability to empower patients to make more informed decisions about their conditions’ management. This is accomplished by sending real-time glucose monitoring to the patients’ smart phones. Compared to self-monitoring of blood glucose, studies show that the technology has a beneficial effect on lowering HbA1C and reducing the frequency of hypoglycemia.
Closed-loop Insulin Delivery
People with type 1 diabetes benefit from an emerging technology that is used for both therapeutic and monitoring purposes. The closed-loop Insulin delivery is a medical device that works in conjunction with a glucose monitor and an insulin pump. Wireless communication allows for automated data transfer between components without the need for human intervention. This device allows for continuous blood glucose monitoring. This is the foundation of the technology’s use, and when compared to self-glucose monitoring, it is superior in terms of lowering HBA1C and lowering the frequency of hypoglycemia. NURS-FPX4030 Assessment 3 Example
Findings from Articles
According to Roz et al. (2020), glycemic controls improved with the use of Dexcom G6 RT-CGM continuous glucose monitor. Also, it helped reduce the fear of hyperglycemia and improve the quality of life in patients. The use of continuous glucose monitors (CGM) cuts health-related costs as opposed to self-monitoring blood glucose (SMBG). Continuous technology monitoring was associated with reduced levels of HbA1c as compared to self-monitoring. Type 1- diabetes patients who use continuous glucose monitor spend little to nothing on costs associated with long-term diabetes-related complications, as the intervention has a cost-effective disease management option.
A randomized parrel-group control involving twenty-two type one diabetes mellitus was conducted to find which method was most effective. According to Helmi & Hussain, (2021 NURS-FPX4030 Assessment 3 Example), the result collected from using both interventions were equivalent making both interventions equally important in the study. However, detecting hypoglycemia proved to be more effective with a continuous glucose monitoring system in children.
The article focused on whether there are clinical benefits associated with the adoption of a real-time continuous glucose monitoring system in type one diabetes (Styles et al., 2021). The study found that using this significantly lowered hemoglobin A1C compared to interventions associated with the non-use of technology devices (Styles et al., 2021). Also, CGMS reduced the chances of patients with type-1 diabetes getting hospitalized for hypoglycemia. Patients are better able to have glycemic control instead of using other interventions.
Relevance of Findings from Articles
All the three articles discussed above were chosen because they support the research into the study’s PICO(T) question. The three articles are reliable because they use credible sources, thus making the result valid and applicable to my PICOT question. Its main aim is to find if the use of the continuous glucose monitoring system lowers the HbA1c instead of using self-monitoring blood glucose.
According to Roz et al., (2020), the first study was chosen because it provides a comparative study based on the two interventions. Additionally, it was ideal as it supports the hypothesis made by the PICOT question. It is significant as it answers the PICOT question. The PICOT questions seek to find the two interventions: CGMS or SMBG, which lowers the HbA1c, which this article addresses.
Article two focuses on type-1 diabetes in children. This allows me to get another perspective based on another demographic in the same population. The article is scholarly, and peer-reviewed (Helmi & Hussain, 2021). Therefore, making the study results accurate, reliable, and high quality. The report compares CGMS and SMBG, which my PICOT question focuses on; hence I can apply the analysis in the article to answer my PICOT question. Similar to the third article, CGMS proves to be effective in lowering HbA1c improving glycemic control and safe time reducing risks of being hospitalized because of issues of hypoglycemia (Styles et al., 2021).
Conclusion
The article analyzed in this study proposes that the participants of the study showed improved glycemic controls when they used CGMS for all ages, from older adults to children, as opposed to SMBG. Although CGMS is an expensive intervention upon first investment, it has a lot of advantages for patients. All articles recommend using this intervention, especially for patients with type 1 diabetes.
NURS-FPX4030 Assessment 3 Example References
DiMeglio, L. A., Evans-Molina, C., & Oram, R. A. (2018). Type 1 diabetes. Lancet, 391(10138), 2449–2462. https://doi.org/10.1016/s0140-6736(18)31320-5
Muhd Helmi, M. A., Bachok, N., & Hussain, S. (2021). Continuous glucose monitoring system versus self-monitoring blood glucose in type 1 Diabetes Mellitus children: A randomised controlled trial (RoSEC). Malaysian Journal of Paediatrics and Child Health, 27(2), 51–68. https://doi.org/10.51407/mjpch.v27i2.152
McEwen, M., & Wills, E. M. (2017). Theoretical basis for nursing (5th ed.). Wolters Kluwer Health.
Roze, S., Isitt, J., Smith-Palmer, J., Javanbakht, M., & Lynch, P. (2020). Long-term cost-effectiveness of Dexcom G6 real-time continuous glucose monitoring versus self-monitoring of blood glucose in patients with type 1 diabetes in the UK. Diabetes Care, 43(10), 2411-2417
Styles, S., Wheeler, B., Boucsein, A., Crocket, H., de Lange, M., Signal, D., Wiltshire, E., Cunningham, V., Lala, A., Cutfield, W., de Bock, M., Serlachius, A., & Jefferies, C. (2021). A comparison of Freestyle Libre 2 to self-monitoring of blood glucose in children with type 1 diabetes and sub-optimal glycaemic control: A 12-week randomised controlled trial protocol. Journal of Diabetes & Metabolic Disorders, 1-9.
Seers, K., Rycroft-Malone, J., Cox, K., Crichton, N., Edwards, R. T., Eldh, A. C., … & Wallin, L. (2018). Facilitating implementation of research evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Implementation Science, 13(1), 1-11.
Assessment 3 PICO(T) Questions and an Evidence-Based Approach
Evidence-based Approach: Clinical Inquiry
The current paradigm of nursing practice is based on clinical and scientific evidence to make clinical decisions and improve patient care. Evidence-based practice (EBP) promotes high quality in health care. Therefore, a nursing workplace environment should create and embrace a culture of evidence-based practice (McIntosh et al., 2022). The initial steps in EBP include clinical inquiry. Clinical inquiry sets the stage for the quest for literature and clinical evidence to answer clinical problems (Mick et al., 2022). This paper aims to describe a practice issue, present a clinical inquiry for this clinical problem, and discuss the findings of selected sources to answer this clinical question.
Practice Issue
Hypertensive disorders in pregnancy form a significant portion of incidence rates of maternal mortalities nationally and worldwide. The most common hypertensive diseases in pregnancy that have a higher risk of maternal mortality are preeclampsia and eclampsia. Preeclampsia occurs when the maternal blood pressure exceeds the upper limits after 20 weeks of gestation. Otherwise, hypertensive disease can be referred to as chronic hypertension. Various strategies have been used by practitioners to prevent these conditions in pregnancy.
The United States Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG) have recommended the use of aspirin among those with moderate to severe risk of preeclampsia in pregnancy (Van Doorn et al., 2021). However, the use of aspirin in pregnancy, especially after 19 weeks, is also controversial as various items of literature have reported renal problems in the fetus related to nonsteroidal anti-inflammatory drugs (NSAIDS) use, a drug class to which aspirin belongs. This adverse effect has been associated with daily doses above 100mg (Short et al., 2021). Doses below 80mg are considered relatively safe.
According to Van Doorn et al. (2021), many guidelines recommend the use of aspirin before or at 16 weeks of pregnancy. Because of the risk and benefits documented about aspirin and preeclampsia in pregnancy, a quality, evidence-based clinical decision is required to ensure maternal and fetal care is safe before administering aspirin to pregnant mothers at risk of preeclampsia. This evidence-based project sets out to consolidate clinical evidence-based literature that documents high-quality findings about aspirin use and preeclampsia prevention.
Clinical Inquiry
A clinical inquiry was formulated in a PICOT format to guide the literature search for the above clinical practice issue. The PICOT question stated as follows: among pregnant women with moderate to high risk of preeclampsia (P), does the use of aspirin (I) reduce the incidence of preeclampsia (O) as compared with no use of aspirin (C) when administered before 16 weeks of gestation (T)? The population in this clinical inquiry is pregnant women at risk of preeclampsia. This population included pregnant mothers who had preeclampsia in the previous pregnancy or pregnancies, those younger than 20 years, older than 35 years, have obesity, have a chronic disease such as diabetes mellitus, hypertension, or renal disease, who have a family history of preeclampsia, and multifetal pregnancies.
A mother with moderate risk for preeclampsia has a body mass index (BMI) greater than 35, has multifetal pregnancies, is older than 39 (≥40) years, has been nulliparous, has a pregnancy interval of more than 10 years, or has a positive family history of preeclampsia. Severe risk cases involve a combination of two or more of the moderate factors listed above (Fox et al., 2019). In intervention, prophylactic use of aspirin involves the use of low-dose aspirin (LDA), including doses between 75 mg and 150mg daily (Poon et al., 2021). This intervention is usually implemented after 12 weeks of gestation until parturition.
Literature Search Strategy
The literature search was done from three sources: The Cochrane Library, PubMed, and ScienceDirect databases. These sources have a reputation for providing quality and credible nursing and allied health resources, including journals, books, reports, reviews, and editorial articles. Search terms used in the literature search were aspirin, preeclampsia, preterm preeclampsia, and moderate preeclampsia. Additional search filters were applied to return results that included research articles only published within the last five years. Resources were manually selected based on their level of evidence in the hierarchy. Priority was given to systematic reviews and meta-analyses because they provide the highest level of research evidence (Melnyk & Fineout-Overholt, 2018). Four resources were selected for this evidence-based project.
Evidence Synthesis
Choi & Shin (2021) conducted a systematic review and meta-analyses study that involved 35 placebo-controlled randomized trials (RCTs). In their study, Choi & Shin compared maternal and neonatal outcomes of mothers at risk of preeclampsia who received low-dose of aspirin (LDA) and those who received a placebo. This study found that LDA, when imitated before 20 weeks of gestation, reduces preeclampsia incidence without risk of bleeding. Specific outcomes improved by LDA were preterm birth, intrauterine growth retardation (IUGR), and neonatal mortality.
A systematic review by Van Doorn et al. (2021) evaluated LDA impacts on preterm preeclampsia and gestational eclampsia. Their study included a meta-analysis of 23 RCTs. This study found that LDA of doses higher than the currently recommended doses of 81mg daily produced higher reductions in preeclampsia incidence. The maximum used doses were ups to 150mg daily. However, the incidence of gestational age hypertension reduced significantly with all diseases between 81mg and 150 mg. Therefore, LDA reduces preeclampsia and gestational age hypertension. However, controversy still exists in the set optimal dose of LDA for this population.
Short et al. (2021) conducted a multisite double-blinded, placebo-controlled randomized trial in different low and middle-income countries. This study included 5943 nulliparous pregnant women in the intervention (81mg LDA) and 5936 nulliparous pregnant women in the placebo group. Short and colleagues found that LDA (81mg) is a well-tolerated and safe medication that reduces the risk of preterm preeclampsia. A significant safety risk reported was hives and rashes, which were significantly higher in the intervention group. The use of LDA did not significantly impact the risk of unexpected emergency medical visits due to preeclampsia. The participants in this study received 81mg from 6 to 36 weeks of gestation.
Duley et al. (2019) conducted a systematic review and meta-analysis of 77 RCTs to assess the impact of antiplatelet agents that included aspirin and dipyridamole among pregnant women at risk of preeclampsia in terms of maternal and fetal or neonatal outcomes. This study found that LDA reduces preeclampsia incidence, risk of preterm births, reduce risk of low birth weight, and perinatal mortality. This systematic review graded this evidence as high-quality evidence considering the sources used.
Relevance of the Findings
The presented findings have an essential value in preventive maternal, neonatal, and fetal health. Maternal and child health nursing aims to prevent maternal, prenatal, and childhood deaths and improve the quality of life of pregnant women, postpartum mothers, neonates, and children. Maternal bleeding and hypertensive disorders in pregnancy and the peripartum period are among the top causes of maternal mortality and morbidity. Therefore, a prevention strategy needs to prevent preeclampsia and not risk hemorrhage. These findings presented the outcomes of the administration of outcomes on maternal health, fetal health, and neonatal outcomes.
The synthesized resources have presented the dosage and timing of aspirin administration to prevent preeclampsia and poor neonatal outcomes. Therefore, these findings can be used to formulate guidelines, policies, and programs to prevent preeclampsia in pregnant women at risk of developing this hypertensive disorder. More importantly, to this EBP project, these findings provide clinical answers to my clinical inquiry by addressing the population, intervention, comparison, outcomes, and timeframe.
Conclusion
Preeclampsia causes maternal and fetal/neonatal mortality and morbidity nationally and worldwide. This evidence-based approach has presented evidence that supports the use of LDA in the prevention of preeclampsia, among other causes of maternal and neonatal mortality and morbidity. This project started with the formulation of a clinical inquiry that led to a selection of four high-level evidence sources that included three systematic reviews and meta-analyses and one RCT.
The currently recommended dose for LDA is 81mg daily before 12 weeks throughout the pregnancy period. The synthesized evidence supported the use of this intervention in preeclampsia prevention. The safety issue of concern presented was related to the risk of bleeding, especially with high doses. Nevertheless, the benefits of this intervention went beyond the prevention of preeclampsia and included improvement in fetal outcomes. Therefore, compared with no use of LDA, low-dose aspirin reduces the risk and incidence of preeclampsia and improves fetal and maternal outcomes when started before 16 weeks of gestation.
References
Choi, Y. J., & Shin, S. (2021). Aspirin prophylaxis during pregnancy: A systematic review and meta-analysis. American Journal of Preventive Medicine, 61(1), e31–e45. https://doi.org/10.1016/j.amepre.2021.01.032
Duley, L., Meher, S., Hunter, K. E., Seidler, A. L., & Askie, L. M. (2019). Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database of Systematic Reviews, 2019(10). https://doi.org/10.1002/14651858.CD004659.pub3
Fox, R., Kitt, J., Leeson, P., Aye, C. Y. L., & Lewandowski, A. J. (2019). Preeclampsia: Risk factors, diagnosis, management, and the cardiovascular impact on the offspring. Journal of Clinical Medicine, 8(10), 1625. https://doi.org/10.3390/jcm8101625
McIntosh, K., Collins, J., & Mick, J. (2022). Promoting a culture of clinical inquiry in nursing. Nursing, 52(9), 31–35. https://doi.org/10.1097/01.NURSE.0000854000.91255.f6
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Lippincott Williams and Wilkins.
Mick, J., Ceasar, S., Collins, J., Giegerich, C. A., Gilroy, H., Holub, M., Rittenhouse, C., & Thayer, V. B. (2022). EBP activities to develop a culture of clinical inquiry in healthcare organizations. Nursing, 52(10), 50–55. https://doi.org/10.1097/01.NURSE.0000872472.81240.bb
Poon, L. C., Magee, L. A., Verlohren, S., Shennan, A., von Dadelszen, P., Sheiner, E., Hadar, E., Visser, G., Da Silva Costa, F., Kapur, A., McAuliffe, F., Nazareth, A., Tahlak, M., Kihara, A. B., Divakar, H., McIntyre, H. D., Berghella, V., Yang, H., Romero, R., … Hod, M. (2021). A literature review and best practice advice for second and third-trimester risk stratification, monitoring, and management of pre-eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics): Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics). International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics, 154 Suppl 1(S1), 3–31. https://doi.org/10.1002/ijgo.13763
Short, V. L., Hoffman, M., Metgud, M., Kavi, A., Goudar, S. S., Okitawutshu, J., Tshefu, A., Bose, C. L., Mwenechanya, M., Chomba, E., Carlo, W. A., Figueroa, L., Garces, A., Krebs, N. F., Jessani, S., Saleem, S., Goldenberg, R. L., Das, P. K., Patel, A., … Derman, R. J. (2021). Safety of daily low-dose aspirin use during pregnancy in low-income and middle-income countries. AJOG Global Reports, 1(1), 100003. https://doi.org/10.1016/j.xagr.2021.100003
Van Doorn, R., Mukhtarova, N., Flyke, I. P., Lasarev, M., Kim, K., Hennekens, C. H., & Hoppe, K. K. (2021). Dose of aspirin to prevent preterm preeclampsia in women with moderate or high-risk factors: A systematic review and meta-analysis. PloS One, 16(3), e0247782. https://doi.org/10.1371/journal.pone.0247782
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