Analytical study of care quality and moral distress in clinical situations and patient care

Objective: Nursing profession conventionally meets a high standard of ethical behavior and action. One of the ethical challenges in nursing profession is moral distress. Nurses frequently expose to this phenomenon which leads to different consequences such as being bored by delivering patient care that decline care quality and make it challenging to achieve health purposes. This study was conducted to investigate the association between the aspects of moral distress and care quality.Methods: In this descriptive–analytical study, 545 nurses of intensive and cardiac care units and dialysis and psychiatric wards were recruited by census sampling. Three questionnaires, Sociodemographics, Moral Distress Scale, and Quality Patient Care Scale, were distributed among the participants and collected within 9 months. Data analysis was conducted by descriptive statistics, analysis of variance, and the least significant difference in SPSS 13.Results: Investigating moral distress domains(ignoring patient, decision-making power, and professional competence) and care quality domains(psychosocial, physical, and communicational) demonstrated that in being exposed to moral distress, ignoring patient had no effect on psychosocial domain(P=0.056), but decision-making and professional competence of moral distress had positive effect on psychosocial, physical(bodily), and communication domains of care quality.Conclusions: Because moral distress domains are effective on patient care quality, it is recommended to enhance the knowledge of nurses, especially beginners, about moral distress, increase their strength alongside standardizing nursing services in decisionmaking domains, improve the professional competence, and pay attention to patients.

CT examination, clinical situation and experimental characteristics of infants with intracranial hemorrhage induced by delayed vitamin K deficiency

BACKGROUND: Delayed vitamin K deficiency is characterized by acute onset, severe illness and high fatality rate. 33%-50% survivors accompany with other various nervous system sequelas. Therefore, diagnosis and treatment of intracranial hemorrhage in time become a key factor for improving healing rate and reducing fatality rate and incidence of sequela. OBJECTIVE: To investigate the clinical situation, experimental characteristics, CT examination and terminative characteristics of infants with intracranial hemorrhage induced by delayed vitamin K deficiency. DESIGN: Case analysis. SETTING: Department of Pediatrics, Zhongshan Hospital Affiliated to Xiamen University. PARTICIPANTS: A total of 17 infants with intracranial hemorrhage induced by delayed vitamin K deficiency aged 1-3 months including 11 boys and 6 girls were selected from Department of Pediatrics, Zhongshan Hospital Affiliated to Xiamen University from January 1994 to December 2005. All infants had drowsiness, rejective milk, spiting milk, gaze of both eyes, tic, coma, full anterior fontanelle, high muscular tension and cerebral hernia, etc. Experimental examination demonstrated that infants had anemia at various degrees; prothrombin time and partial thromboplastin time were prolonged; platelet count was normal. CT examination indicated that screenages of subarachnoid hemorrhage, subdural hematoma, cerebral parenchyma hemorrhage and intraventricular hemorrage were changed. Hemorrhage was stopped by the application of vitamin K. All patients provided informed consent. METHODS: ① Clinical situation and physical sign of infants were observed after hospitalization and scanned with rapid spiral CT scanning system. The thickness and average space of layers were 8-10 mm and the scanning time was 5 s with window width of 30-80 Hu and window position of 28-35 Hu. ② After hospitalization, four items of blood coagulation was measured with Futura meter and biochemical indexes of blood, such as serum calcium, serum alkaline phosphatase, total bilirubin, direct bilirubin and indirect bilirubin, were detected with Roche Modular PPI automatic biochemistry analyzer. ③ After hospitalization, infants were given 5-10 mg vitamin K1 for 3-5 days, and then, they were transfused with 10-15 mL/kg fresh plasma or whole blood for 1-3 times and received other relative therapies. Therapeutic effects were evaluated based on clinical diagnosis and criteria. MAIN OUTCOME MEASURES: ① Clinical situation, physical sign and CT examination; ② results of experimental examination; ③ treatment and termination. RESULTS: A total of 17 infants with intracranial hemorrhage were involved in the final analysis. ① Clinical situation, physical sign and CT examination: All infants had pale facial expression and full or bossing anterior fontanelle. Among them, 13 infants had drowsiness or dysphoria, 12 rejective milk or emesis, 11 tic, 13 injection site hemorrhage, 2 gastrointestinal hemorrhage, 3 cerebral hernia, 11 high muscular tension and 6 cervical rigidity. CT examination demonstrated that most infants (88%, 15/17) had subarachnoid hemorrhage; 10 (59%, 10/17) had subdural hematoma; 8 (47%, 8/17) had cerebral parenchyma hemorrhage; few had intraventricular hemorrhage. In addition, results of CT examination also indicated that 17 infants had intracranial hemorrhage. Hemorrhage sites of 12 infants were equal to or more than 2, which was accounted for 70% (12/17); meanwhile, partial cases accompanied with a large area of focus of cerebral infarction or cerebral hypoxia-ischemia lesion. ② Results of experimental examination: There were 6 infants with elongation of prothrombin time, 5 with partial elongation of prothrombin time, 4 with decrease of serum calcium (1.69-2.25 mmol/L), 3 with increase of serum alkaline phosphatase, 3 with increase of total bilirubin, 3 with increase of direct bilirubin, and 3 with increase of indirect bilirubin. ③ Treatment and termination: After treatment, 12 infants were cured well, 3 improved, 1 given up and 1 died. Later, ten infants received CT re-examination at 3 months after treatment. The results indicated that 3 infants had simple subarachnoid hemorrhage and 4 had subarachnoid hemorrhage accompanying with subdural hematoma. Their focuses were absorbed well and not show as obvious sequela. One infant had subdural hematoma accompanying with subarachnoid hemorrhage, cerebral parenchyma hemorrhage, intraventricular hemorrage and cerebral hypoxia ischemia, and then, after hematom absorption, obvious cerebral malacia focus, hydrocephalus, brain atrophy and inferior accumulating fluid of dura mater were observed; 2 had subdural hematoma accompanying with subarachnoid hemorrhage and cerebral hypoxia ischemia, and then, after bleeding absorption, brain atrophy was changed remarkably; changes of hydrocephalus were observed in one infant. CONCLUSION: ① Symptoms of pale facial expression, full or bossing anterior fontanelle, drowsiness and dysphoria are observed in infants with delayed vitamin K deficiency . ② Experimental indexes demonstrate that prothrombin time and partial prothrombin time are prolonged, and numbers of infants having decrease of serum calcium are in the third place. ③ Poly-intracranial hemorrhage is a notable characteristic of CT examination. Partial infants who have poly-intracranial hemorrhage always accompany with cerebral hypoxia-ischemia lesion or cerebral infarction. Clinical situation and prognosis of infants who have a large area of intracranial hemorrhage and cerebral hypoxia-ischemia changes are poor; however, those of infants who have simple subarachnoid hemorrhage or combination of subarachnoid hemorrhage with subdural hematoma are well. ④ Effect of vitamin K on this kind of disease is well.

The immunophenotypic changes and clinical effectiveness after treatment of cancer patients with infusion of human peripheral blood lymphocytes stimulated by anti-CD28 and anti-CD80 monoclonal antibodies in combination with radiotherapy and chemotherapy

To investigate the changes on the immunopbenotypes and the clinical effects of treatment of the late cancer patients with infusion of human peripheral blood lymphocytes stimulated by anti-CD28 and anti-CD80 monoclonal antibodies in combination with radiotherapy and chemotherapy, 42 patients with late cancers were collected for study, among which 22 patients were treated with infusion of stimulated lymphocytes in combination with radiotherapy and chemotherapy. The immunological treatment procedure was given twice per week, and one course of treatment consisted of 8 times of giving infusion of lymphocytes. Another 20 patients were selected for control group, in which only radiotherapy and chemotherapy were given without lymphocyte infusions. Flow cytometry was used to examine the immunophenotypes and the clinical symptoms were observed before and after treatments. It was found that the numbers of the CD3^ ＋ , CD4^＋ cells increased, while those of the CD8 ^＋ cells decreased, with an increase of CD4/CD8 radios, but no significant difference existed in case of 22 patients treated with lymphocyte infusion as well as with radiotherapy and chemotherapy. Fifteen patients out of these 22 cases （68.18%）, the immunophenotypes changed obviously with increased numbers of CD3^ ＋ , CD4^ ＋ cells in comparison with those before treatment, and the number of CD95^ ＋ cells was increased after treatment. The PS value in this group of patients decreased after treatment. In comparison with 20 cases in the control group, the immunophenotypes showed no differences before and after treatment. While the PS value decreased obviously. Seven out of the 22 cases （31.83 % ） treated with lymphocyte infusions as well as with radiotherapy and chemotherapy illustrated no major changes in their i mmunophenotypes, compared with the situation before treatment, but the PS value also decreased. In case of treatment with lymphocyte infusions in combination with radiotherapy and chemotherapy, the alteration of phenotypes was reversely correlated with the changes of clinical grades. Although there were 7 cases showing no major alterations of the immunological phenotypes, but their correlation was still evident. In the control group, neither alteration of immunophenotypes nor changes in clinical grades was found. It is concluded that immunotherapy in combination with radiotherapy and chemotherapy can relieve the side effects induced by radiotherapy and chemotherapy and also enhance the therapeutic efforts.