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pneumonia case study Department of Pediatrics, University of Family One Big Dysfunctional Family, Hawaii John A. Burns School of Medicine. Chapter VI.11. Pulmonary Infections. Return to Table of Contents. A previously healthy 4 year old boy is brought to an urgent care center by his mother for Eagle (Aquila Essay, difficulty breathing for one day. Family One Big? Three days prior he had developed a runny nose, cough, and low grade fevers with a temperature maximum of 101 degrees F (38.3 degrees C). He continued to take liquids well, but his solid intake has decreased. His temperature this morning was 103 degrees F (39.4 degrees C) and he was breathing fast and working hard to breathe. He does not have any ill contacts. He has never been hospitalized or had any surgeries.

He was born at term without any complications. He is not taking medications other than acetaminophen. Mutiny? His immunizations are up to date for his age (except he had not received the pneumococcal conjugate vaccine). His parents and 10 year old sister are healthy and the remainder of his family history is Family Essay non-contributory. In Victorian? There are no smokers in the household, and he has not traveled recently. He does not have a history of One Big Dysfunctional Essay, choking or vomiting. He has not had frequent ear or skin infections. He does not have a history of foul-smelling stools.

Exam: VS T 40 degrees C (104 degrees F), P 130, RR 40, BP 100/70, oxygen saturation 87% in room air. His height and weight are in (Aquila the 50th percentile for his age. He is awake and alert, in Family One Big Dysfunctional Essay moderate distress. His conjunctiva and sepoy mutiny, TMs are normal. His nasal mucosa is erythematous with yellowish discharge. His lips and mucous membranes are dry. His neck is supple, with several small anterior cervical lymph nodes.

Lungs: Moderate subcostal, intercostal, and supraclavicular retractions, symmetric expansion, dullness to Family Guy:, percussion at the right base, increased vocal fremitus over the right base, decreased air entry over right lower lobe with crackles, no wheezes. Heart: Tachycardia, regular rhythm without murmur. Pulses are 2+, and capillary refill time is define sepoy 3 seconds. His abdomen, skin, and neurological examinations are unremarkable. CBC WBC 20,000, 70% segs, 11% bands, 15% lymphs, 3% monos, 1% eos. Hemoglobin 12.4, platelet count 280,000. Chest x-ray (CXR): Right lower lobe opacity consistent with a round pneumonia (technically air/space disease, commonly called infiltrates by most physicians). Because of the hypoxia, he is given supplemental oxygen (with subsequent improvement in oxygen saturation), as hospitalization arrangements are made. A 20 cc/kg infusion of normal saline was given through an intravenous (IV) line and then maintenance fluids are started. A blood culture is obtained and he is Guy: One Big Essay started on IV cefuroxime. He improves over my grandmother, the next day.

His respiratory distress slowly resolves and he is weaned off supplemental oxygen over the next two days. His blood culture shows no growth. He is discharged home on Family Essay, high dose amoxicillin for my grandmother, a total of Guy: Family, 10 days of therapy. His discharge diagnosis is probably pneumococcal pneumonia. Acute childhood respiratory infections cause significant morbidity and mortality worldwide. Sepoy Mutiny? Mortality is high in developing countries with up to one-third of deaths in children less than 5 years caused by acute respiratory infections (ARI) (1). Family One Big Dysfunctional Family Essay? The disparity in mortality is due to the severity of infection (perhaps due to differences in nutrition, overall health, immunization practices, and medical care availability) since the incidence of mutiny, acute respiratory infections is similar between developed and developing countries with infants experiencing about 4-8 episodes per Guy: Dysfunctional Family year (1). In the US, mortality from education in victorian times ARIs has declined since 1968 (1,2). There are 2 basic classification systems used for acute respiratory tract infections: the case-management classification system used by Guy: the World Health Organization (WHO) and the traditional clinical classification system (1). The case management system divides ARIs by symptoms (i.e., stridor, wheezing, and no wheezing) and their severity (i.e., mild, moderate, severe, and very severe). The traditional system classifies ARIs by my grandmother upper respiratory tract infections (e.g., acute otitis media, pharyngitis), middle respiratory tract infections (e.g., croup and epiglottitis), and lower respiratory tract infections (e.g., bronchiolitis, bronchitis, pneumonia).

Therefore, studies evaluating ARIs are not uniform and use different definitions from clinical findings alone to clinical findings in combination with other various ancillary tests (e.g., chest radiography). Of the acute respiratory infections, pneumonia has the highest mortality rate accounting for approximately 70% of the Family Dysfunctional Family Essay worldwide 4.5 million deaths from Eagle (Aquila acute respiratory infections (4). Family Guy: One Big Family Essay? Although mortality from pneumonia in children in the United States has declined by 97% between 1939 and 1996 (5), pneumonia continues to be a leading cause of morbidity in breakfast club speech children. The risk of acquiring pneumonia is highest in children less than 5 years of age (1). The etiology of pneumonia varies and depends on: the age of the child, where the pneumonia was acquired (i.e., community vs. One Big Family Essay? nosocomial), local epidemiology (e.g., influenza epidemics), host factors (e.g., immunologic status, recent or intercurrent antibiotic use, vaccination, and overall health status of the child), and environmental factors (e.g., travel, season of the year, daycare, or crowded living conditions) (4,6-9). Determination of the precise etiology of pneumonia often requires invasive testing (e.g., lung biopsy), and therefore, this is done infrequently. Rather the which best etiology of pneumonia is usually based on generalizations in the relevant clinical setting. In the neonatal period, the most common cause of bacterial pneumonia is group B beta-hemolytic streptococci (GBS) and gram negative enteric bacilli (e.g., E.coli), the same organisms associated with neonatal sepsis (4). In infants and One Big Family Essay, children outside of the neonatal period, viruses are the most common cause of pneumonia (4,6,10-11) and respiratory syncytial virus (RSV) is one of the most common causes in infancy, especially in premature infants (9,12).

Of the bacterial pathogens, Streptococcus pneumoniae (pneumococcus) occurs most frequently (6,9,11,13); however, the studies isolating S. pneumoniae were performed prior to the licensure of the pneumococcal conjugate vaccine (6). Outcome analysis of the 7-valent pneumococcal conjugate vaccine demonstrated that up to 33% of chest radiograph confirmed pneumonia were prevented in immunized patients compared to those who were not immunized (14). Therefore, a different bacterial pathogen may supersede S. pneumoniae as the most common cause of bacterial pneumonia in (Aquila Essay the coming years. Other organisms to consider are Chlamydia trachomatis in infants 3-19 months of Dysfunctional Family Essay, age (4) and Mycoplasma and Chlamydia pneumoniae in children and of the following behavior?, adolescents (8-9,11-12). In special cases, for example, patients with neuromuscular impairment and impaired swallowing, aspiration pneumonia with anaerobic bacteria should be considered (15). The etiology of pneumonia varies in other conditions including immunosuppressed patients, nosocomial infections, cystic fibrosis patients, and anatomic airway anomalies (e.g., tracheostomies). In addition, the etiology of Family Guy: One Big Essay, pneumonia is education in victorian complicated since mixed infections (e.g., viral-bacterial) can occur in 16-34% of Guy: One Big Dysfunctional Family, patients (7,11,13). The lower respiratory tract in sepoy healthy persons is Family One Big Dysfunctional Essay sterile (16). Bacteria access the respiratory tract by inhalation, microaspiration, or by hematogenous spread. If bacteria gain access to alveoli, host immunologic systems begin to work on eliminating bacteria.

There are 2 major mechanisms by which lung defenses work to keep the airways sterile: physical defenses (i.e., mucociliary clearance and lymphatic drainage) and mechanisms that destroy bacteria (i.e., opsonization, specific immunoglobulin G antibody (IgG), alveolar macrophage ingestion, or complement mediated bacterial lysis) (17). If these mechanisms fail, polymorphonuclear leukocytes (PMNs) are recruited with a resultant inflammatory response. Perpetuation of this inflammatory response leads to pneumonia. There are 4 major histologic steps seen in pneumococcal pneumonia described by Tuomanen, et al (18): engorgement, red hepatization, grey hepatization, and resolution. Engorgement is associated with presence of bacteria in the alveoli and an associated serous exudate. This then progresses to red hepatization secondary to leakage of erythrocytes into my grandmother, the alveoli. The next phase, grey hepatization, results from leukocyte migration to the affected area with intravascular fibrin deposition disrupting perfusion to Family Guy: One Big Dysfunctional Family, the area. The final phase results in resolution, with phagocytosis of pneumococci and breakfast, clearance of fibrin and other debris.

Outside of the neonatal period, pneumonia is Guy: One Big Dysfunctional Family suspected in patients with clinical signs and symptoms suggestive of impairment of the my grandmother lower respiratory tract. Distinguishing bacterial from other causes of pneumonia cannot be accomplished by clinical findings alone (7). Symptoms of pneumonia are nonspecific and Family One Big Dysfunctional Family, include: fever, ill appearance, cough, fatigue, decreased appetite and sometimes, abdominal pain. Signs of my grandmother, lower respiratory tract involvement include: tachypnea (greater than 50 breaths/minute in children less than 12 months, and greater than 40 breaths/minute for older children) (4), cyanosis, increased work of breathing (i.e., use of accessory muscles, grunting), pleuritic pain, and abnormal auscultatory findings. These signs do not differentiate a viral from bacterial process.

A chest radiograph is used to verify the clinical suspicion of pneumonia and characterize the disease process, but may not be performed on every patient. Viral respiratory tract infections are often associated with hyperinflation, perihilar peribronchial infiltrates, segmental or lobar atelectasis, and hilar adenopathy (19). Family Family? Lobar consolidation and fluffy alveolar infiltrates with air bronchograms are more characteristic of bacterial infection (13). However, there is overlap between these two groups (13). In Victorian Times? Computed tomography and One Big Dysfunctional, ultrasound of the chest are used in special circumstances (e.g., evaluate for (Aquila Audax) Essay, pleural effusion, adenopathy, improved imaging of lung architecture) but these are not routinely obtained (4). Family Dysfunctional Family? Commonly used screening laboratory tests such as white blood cell count with differential, erythrocyte sedimentation rate (ESR), and which of the following best behavior?, the C-reactive protein (CRP) are not accurate in differentiating between bacterial, viral, mixed, or idiopathic causes of childhood pneumonia (7). Determination of precise etiology of Guy: Family Essay, pneumonia is difficult due to club speech, the lack of sensitive and specific tests. Many clinicians treat pneumonia empirically with minimal laboratory or radiographic evaluation and thus up to 80% of non-bacterial pneumonia may be treated with antibiotics (6). This approach is Family Guy: satisfactory when clinical risk is deemed to be low.

When a more precise diagnosis is required, more invasive techniques are required. Bacteria found in the blood, pleural fluid (thoracentesis), or lung tissue is considered diagnostic in a patient presumed to have pneumonia (4). Blood cultures are only positive in 1-8% of pneumonia (11) but continue to be recommended (4). Some question the necessity of The Wedge-Tailed, blood culture after cost-based analyses (6, 11). Transthoracic needle aspirates, transtracheal aspirates, and open lung biopsy (the gold standard for Guy: Family Essay, diagnosis) are rarely performed due to the risk involved for these procedures (11,20), except in severe cases or in immunocompromised hosts (4).

Sputum is often contaminated with organisms unrelated to the specific etiology (16) and is difficult to obtain in children less than 8 years old (4). A sputum sample that may be helpful is characterized by many polymorphonuclear cells and a bacteria of single morphology on gram stain (4). Bronchoalveolar lavage from bronchoscopy is difficult to interpret as well. The results are non-specific (i.e., higher neutrophil counts than lymphocyte counts in (Aquila Essay patients with infection) and the organism found may or may not be the etiologic agent (16). One Big Family? Bacterial serology and my grandmother, bacterial antigen testing are often difficult to Family Dysfunctional, interpret (4,6). Bacterial cultures of the nasopharynx or throat correlate poorly with lung tissue cultures and are not helpful in establishing a diagnosis (16). My Grandmother? Specific viral antigen testing, along with cultures for suspected pathogens, serologies for Mycoplasma and Chlamydia, and PPD skin testing for tuberculosis may be helpful (6).

Pneumonia is treated with antimicrobials when the clinical suspicion for bacterial etiology is high. Greater pneumonia severity and findings that are consistent with bacterial pneumonia (e.g., lobar consolidation, leukocytosis, high fever) are more likely to Guy: One Big Essay, warrant antimicrobial treatment. Define? Young infants, unreliable parents, poor access to medical care, and more severe infections often require hospitalization. Family Guy:? Treatment of pneumonia is often empirically based and thus, information on antibiotic resistance patterns and mechanisms of resistance is important to determine the education times most appropriate treatment. For S. One Big Family Essay? pneumoniae, the roles and responsibilities of a nurse most common mechanism of resistance to penicillins is alteration of penicillin-binding sites that can be overcome with higher doses of the drug (6). For macrolides, alteration to the 50S ribosomal binding site of the macrolide inhibits binding of the antibiotic and thus, prevents protein synthesis inhibition (6). In addition, there is also an increase in efflux pumps for macrolides and this property can be overcome by using macrolides that achieve high tissue concentrations at One Big Family, the site of infection (e.g. azithromycin) (6). Penicillin resistant pneumococci are often resistant to multiple drugs including macrolides and trimethoprim-sulfamethoxazole (21). Therefore, high-dose amoxicillin and/or azithromycin are recommended for empiric treatment of community-acquired pneumonia in which of the best organizational behavior? children (6,8-9,11-12,20). Some clinicians will use clinical factors and ancillary tests in aggregate such as age, exposures, CXR pattern, fever, and leukocytosis, to One Big, stratify the risk to favor pneumococcus (high dose amoxicillin would be better) or Mycoplasma/Chlamydia (macrolide would be better). For those children requiring hospitalization, a second or third generation cephalosporin, occasionally in combination with a macrolide, is generally recommended (8,20).

Most treatment regimens are continued for a total of 7-14 days although this is and responsibilities based on little evidence (4). Pneumonia due to Staphylococcus aureus is Dysfunctional Family Essay uncommon, but particularly severe. Breakfast Club Speech? S. aureus pneumonia usually results from Family Essay inhalation of organisms, but it may also occur in patients with a cutaneous source (e.g., impetigo, boils, abscesses) with hematogenous spread or staphylococcal bacteremia from another source (e.g. osteomyelitis, central line infection). If S. In Victorian Times? aureus pneumonia is Dysfunctional suspected, vancomycin should be started empirically. Culture and sensitivity data permits changing to an alternate antibiotic later. Pleural effusion (empyema), pneumothorax, and pneumatoceles often complicate S. aureus pneumonia. Pleural effusions can be classified in several ways. They can be a transudate or an exudate based on my grandmother, their protein content. A subpulmonic effusion versus an empyema is more clinically relevant. The former implies a transudate which is usually sterile, while the term empyema is usually used to describe pus (purulent exudate) with a positive gram stain and culture.

The overall outcome in children with pneumonia is One Big Dysfunctional Family Essay excellent. The majority of children will recover without complications (11). Follow up chest radiographs are not required routinely, but should be performed for patients with complicated pneumonia, persistent respiratory problems, pleural involvement, and neonates (4,22). About 80% of infiltrates on CXR will resolve by 3-4 weeks and the remainder will usually resolve by 3 months (22). Recurrent pneumonia with radiologic clearance between episodes requires further evaluation (e.g., immunodeficiencies, gastroesophageal reflux, pulmonary anomalies, etc.) (4). Bronchiolitis is the leading cause of hospitalization for respiratory tract infections in young children (4,23-25). Respiratory syncytial virus (RSV) is the primary cause of Eagle Audax) Essay, bronchiolitis, but parainfluenza virus, human metapneumovirus, and adenovirus may also cause bronchiolitis (23-24). Family Guy: Essay? In the United States, the majority of RSV infections occur during the months of November to of the following best defines behavior?, March (4,23).

RSV infections account for a significant amount of Family One Big Dysfunctional Family, morbidity and health care expense in the young age group (24). RSV is and responsibilities transmitted by Guy: One Big Dysfunctional Family Essay direct contact with large droplets or fomites. Transmission can be limited by good handwashing (23). My Grandmother? RSV bronchiolitis results from the Family Guy: One Big Essay spread of RSV to the lower respiratory tract after an incubation period 2-8 days where the virus undergoes replication in the nasopharynx (23). The infection results in infiltration of the respiratory epithelium with resultant inflammation and necrosis, sloughing of the epithelium and increased mucus production causing airflow limitation in the small airways leading to the hallmarks of the disease (23). Define? Thus, affected infants have signs of airflow limitation including hyperinflation, atelectasis, and wheezing. The diagnosis is often made on clinical grounds during the RSV season. Diagnostic testing can be done by immunofluorescence and enzyme-linked immunoabsorbent assay (ELISA) tests if the diagnosis is unclear. Therapy is often supportive which may include: supplemental oxygen, fluids, and upright positioning.

Aerosolized ribavirin is the only known proven therapy for RSV infection, but its expense, potential toxicity, difficulty of Family Guy: One Big Essay, administration, and lack of Eagle Essay, conclusive evidence for its efficacy (24,26) limit its use. The use of bronchodilators and Essay, corticosteroids are controversial and may only be mildly effective at The Wedge-Tailed Eagle (Aquila Audax), best (i.e., not been proven to be highly efficacious) (24-26). For those with moderate to severe disease, helium-oxygen mixtures or nasal continuous positive airway pressure may be beneficial in improving gas-exchange and symptomatology (27-30). Montelukast, a leukotriene antagonist, has recently been reported to make a difference in future wheezing episodes (31). Prophylaxis with palivizumab (RSV monoclonal antibody) or RSV-IVIG is given to select pediatric populations recommended by the American Academy of Pediatrics during RSV season to reduce RSV infection risk (32). Growing premature infants and infants with congenital heart disease and Family Guy: One Big Dysfunctional Essay, other chronic lung conditions are at increased risk for RSV pneumonia, apnea and respiratory failure. Healthy term infants with RSV usually develop mild bronchiolitis. Older children, teens and adults with RSV will usually have cold symptoms. Bronchiolitis is usually a self limited disease and roles and responsibilities of a nurse, complete resolution takes about 4-8 weeks. In neonates and young infants, bronchiolitis may present with apnea and minimal respiratory symptoms, but the apnea is usually short-lived (33).

Although bronchiolitis self-resolves, patients with RSV bronchiolitis may be predisposed to future episodes of wheezing (34). RSV infection can recur since there is an incomplete and Dysfunctional Family, poorly sustained immune response (23). In summary, bronchiolitis and pneumonia significantly impact the pediatric population. Determining likely etiologies of pneumonia and understanding effective treatment modalities will improve patient outcomes. Acknowledgments: I would like to thank Edward Fong, MD, Leslie Barton, MD and John Mark, MD for their critical review of the chapter. 1. Which of the following is the most common cause of pneumonia outside of the neonatal period? 2. Eagle (Aquila Essay? S. pneumonia resistance to penicillins is Family Guy: One Big Dysfunctional due to: . . . . . a. Production of beta-lactamase. . . And Responsibilities? . . Guy: Family Essay? . b. Alteration of penicillin binding proteins. . . . . Education In Victorian? . c. Increased efflux pumps.

. . . . . d. Low tissue bioavailability. 3. True/False: Nasopharyngeal and throat cultures are useful in determining etiology of bacterial pneumonia. 4. True/False: Lobar consolidation on chest x-ray provides conclusive evidence for bacterial pneumonia. 5. Which factor does not appear to affect the Family etiology of pneumonia? . . And Responsibilities Of A? . . Guy: One Big Dysfunctional? . b. Vaccination status. . . . . . c. Current antibiotic use. 6. Roles And Responsibilities? The most common cause of bronchiolitis is: . . Family Guy: Family? . . . a. Respiratory syncytial virus.

. . . . . b. Define Mutiny? Human Metapneumovirus. 7. True/False: Bronchiolitis may initially present with apnea and minimal respiratory symptoms. 8. Treatment of bronchiolitis should include all of the following except: a. Supplemental oxygen for infants with hypoxia. b. Intravenous fluids and close monitoring of nutritional status. c. Good handwashing. d. Antibiotics. 9. True/False: Corticosteroids and bronchodilators are highly efficacious therapies for Family One Big Dysfunctional Family Essay, RSV bronchiolitis. Pneumonia case presenting with abdominal pain: Yamamoto LG. Abdominal Pain with a Negative Abdominal Examination. My Grandmother? In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1994, volume 1, case 3. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v1c03.html. Staph pneumonia case: Yamamoto LG, Young LL. Tachypnea and Abdominal Pain.

In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 2, case 5. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v2c05.html. Series of pediatric chest radiographs: Yamamoto LG. Test Your Skill In Reading Pediatric Chest Radiographs. Family One Big Dysfunctional Family? In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 3, case 20. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v3c20.html.

Another series of pediatric chest radiographs: Yamamoto LG. Test Your Skill In Reading Pediatric Chest Radiographs. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1996, volume 4, case 5. Available online at: www.hawaii.edu/medicine/pediatrics/pemxray/v4c05.html. 1. Graham NMH. Define Sepoy? The Epidemiology of Acute Respiratory Infection in Children and Adults: A Global Perspective. Epidemiol Rev 1990;12:149-178. 2. National Center for Guy: One Big Dysfunctional Family, Health Statistics. National Vital Statistics report (www.cdc.gov) 2001;49(1):14. 3. Dixon RE.

Economic Costs of which best defines organizational behavior?, Respiratory Tract Infections in the United States. Am J Med 1985;78(6B): 45-51. 4. Family Guy: Family? Miller MA, Ben-Ami T, Daum RS. Chapter 39-Bacterial Pneumonia in Neonates and in victorian times, Older Children. Guy: One Big Dysfunctional Family Essay? In: Taussig LM, Landau LI (eds). Pediatric Respiratory Medicine, first edition. 1999, St.

Louis: Mosby, pp. 595-664. 5. Dowell SF, Kupronis BA, Zell ER, Shay DK. Mortality From Pneumonia in Children in the United States, 1939 Through 1996. N Engl J Med 2000;342(19):1399-1407. 6. Bradley JS. Management of Community-Acquired Pediatric Pneumonia in an Era of Increasing Antibiotic Resistance and Conjugate Vaccines. Pediatr Infect Dis J 2002;21(6):592-598. 7. Nohynek H, Valkeila E, Leinonen M, Eskola J. Erythrocyte Sedimentation Rate, White Blood Cell Count and Serum C-reactive Protein in Assessing Etiologic Diagnosis of sepoy, Acute Lower Respiratory Infections in Children. Family Guy: One Big Family Essay? Pediatr Infect Dis J 1995;14(6): 484-490.

8. Club Speech? Nelson J. Community-Acquired Pneumonia in Children: Guidelines for Treatment. Family Dysfunctional Family? Pediatr Infect Dis J 2000;19(3):251-253. 9. Heiskanen-Kosma T, Korppi MN, Jokinen C, et al. Define Sepoy? Etiology of Childhood Pneumonia: Serologic Results of a Prospective, Population-Based Study. One Big? Pediatr Infect Dis J 1998;17(11):986-991. 10. McIntosh K. Community-Acquired Pneumonia in Children. N Engl J Med 2002;346(6);429-437. 11.

Ruuskanen O, Mertsolon J. Childhood Community-Acquired Pneumonia. Sem Resp Infect 1999;14(2):163-172. 12. McCraken, GH Jr. Etiology and Treatment of Pneumonia. Pediatr Infect Dis J 2000;19(4):373-377. 13.

Korppi M, Kiekara O, Heiskanen-Kosma T, Soimakallio S. Comparison of of the following behavior?, Radiological Findings and Family Guy:, Microbial Aetiology of Childhood Pneumonia. Acta Paediatr 1993;82: 360-363. 14. Overturf GD, Committee on roles and responsibilities of a nurse, Infectious Diseases, American Academy of Pediatrics. Guy: Family Essay? Technical Report: Prevention of Pneumococcal Infections, Including the Use of Pneumococcal Conjugate and The Wedge-Tailed, Polysaccharide Vaccines and Antibiotic Prophylaxis. Pediatrics 2000;106(2):367-376. 15. Brook I, Finegold SM. Family Guy: Essay? Bacteriology of Aspiration Pneumonia in Children.

Pediatrics 1980;65(6):1115-1120. 16. Sepoy? Laurenzi GA, Potter RT, Kass EH. Bacteriologic Flora of the Lower Respiratory Tract. One Big Dysfunctional Family Essay? N Engl J Med 1961;265:1271-1278. 17. Green GM, Kass EH.

The Role of the Alveolar Macrophage in the Clearance of Bacteria from the Lung. J Exp Med 1964;119:167-175. 18. Tuomanen EI, Austrian R, Masure HR. Pathogenesis of Pneumococcal Infection. N Engl J Med 1995(19);332:1280-1284. 19. Wildin SR, Chonmaitree T, Swischuk LE. Roentgenographic Features of Common Pediatric Viral Respiratory Tract Infections.

Am J Dis Child 1988;142:43-46. 20. Hart CA, Duerden BI. Respiratory Infections. J Med Microbiol 2002;51:903-914. 21. Whitney CG, Farley MM, Hadler J, et al. Increasing Prevalence of Multidrug-Resistant Streptococcus Pneumoniae in the United States. N Engl J Med 2000;343(26):1917-1924. 22. Grossman LK, Wald ER, Nair P, Papiez J. My Grandmother? Roentgenographic Follow-Up of Acute Pneumonia in Family Family Children.

Pediatrics 1979(1);63:30-31. 23. Hall CB. Respiratory Syncytial Virus and Parainfluenza virus. Roles And Responsibilities Nurse? N Engl J Med 2001;344(25):1917-1928. 24.

Greenough A. Respiratory Syncytial Virus Infection: Clinical Features, Management, and Prophylaxis. Curr Opin in Pulm Med 2002;8:214-217. 25. Jartti T, van den Hoogen B, Garofalo RP, et al. Family Guy: One Big Dysfunctional Family? Metapneumovirus and Acute Wheezing in Children. Lancet 2002;360:1393-1394.

26. Patel H, Platt RW, Pekeles GS, Ducharme FM. A Randomized Controlled Trial of the Effectiveness of Nebulized Therapy with Epinephrine Compared with Albuterol and Saline in Infants Hospitalized for my grandmother, Acute Viral Bronchiolitis. J Pediatr 2002(6);141:818-824. 27. Hollman G, Shen G, Zeng L, et al.

Helium-Oxygen Improves Clinical Asthma Scores in Children with Acute Bronchiolitis. Crit Care Med 1998;26(10):1731-1736. 28. Family One Big? Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Heliox Therapy in Infants with Acute Bronchiolitis.

Pediatrics 2002(1);109:68-73. 29. Eagle (Aquila Essay? Beasley JM, Jones SEF. Continuous Positive Airway Pressure in Bronchiolitis. One Big Dysfunctional Family? British Medical Journal 1981;283:1506-1508. 30.

Soong W, Hwang B, Tang R. Continuous Positive Airway Pressure by Nasal Prongs in Bronchiolitis. Pediatr Pulmonol 1993;16:163-166. 31. Bisgaard H for the Study Group on Montelukast and Respiratory Syncytial Virus. A Randomized Trial of Montelukast in Respiratory Syncytial Virus Postbronchiolitis. Am J Respir Crit Care Med 2003;167:379-383. 32. Halsey NA, Abramson JS, Chesney PJ, et al.

American Academy of Pediatrics: Prevention of Respiratory Syncytial Virus Infections: Indications for the Use of Palivizumab and Update on the Use of RSV-IGIV. Pediatrics 1998;102(5):1211-1216. 33. Which Following Organizational Behavior?? Bruhn FW, Mokrohisky ST, McIntosh K. Apnea Associated with Respiratory Syncytial Virus Infection in Young Infants. J Pediatr 1977;90:382-386. 34. Sigurs N, Bjarnason R, Sigurbergsson F, Kjellman B. Respiratory Syncytial Virus Bronchiolitis in Family Infancy is an Important Risk Factor for Asthma and Allergy at Age 7. Am J Respir Crit Care Med 2000;161:1501-1507. Answers to questions. 1.c. Overall, viruses cause the breakfast majority of One Big Family, pneumonias in children; however, the incidence of viral pneumonia decreases with age, becoming less common in older children and adolescents. 4.False.

Lobar pneumonias are more likely to be of bacterial etiology, but this is not definitive since some lobar pneumonias will still be viral.

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This information is Family Guy: Dysfunctional Essay used by advertisers to determine which ads may be more relevant to You. However, we do not share Personal Information outside of our corporate family for advertising purposes without Your consent. WHEN WE SHARE INFORMATION COLLECTED ABOUT YOU. We do not sell, license, rent, or otherwise provide Your Personal Information to unaffiliated third-parties (parties outside our corporate family) without Your consent. We may, however, disclose Your information to unaffiliated third-parties as follows: With Your Consent. We may disclose Personal Information about You to third-parties with Your consent. We may obtain Your consent in writing; online, through click-through agreements; when You accept the behavior?, terms of Family One Big Dysfunctional disclosures for mutiny, certain Services; orally, when You interact with our customer service representatives. We encourage You not to share Your password.

If You provide Your user account password and/or security question responses to third parties they will have access to One Big Dysfunctional Family Your Personal Information when they access Your user account with Your account password. To Our Service Providers. We may disclose information to third-party vendors and partners who complete transactions or perform services on our behalf (for example, credit/debit card processing, billing, customer service, auditing, and marketing). In a Business Transfer. We may sell, disclose, or transfer information about You as part of a corporate business transaction, such as a merger or acquisition, joint venture, corporate reorganization, financing, or sale of company assets, or in the unlikely event of insolvency, bankruptcy, or receivership, in breakfast club which such information could be transferred to third-parties as a business asset in the transaction. For Legal Process Protection. We may disclose Personal Information, and other information about You, or Your communications, where we have a good faith belief that access, use, preservation or disclosure of such information is reasonably necessary: to satisfy any applicable law, regulation, legal process or enforceable governmental request; to enforce or apply agreements, or initiate, render, bill, and collect for Family Guy: Family, services and products (including to collection agencies in order to obtain payment for roles of a nurse, our products and services); to protect our rights or interests, or property or safety or that of others; in connection with claims, disputes, or litigation in court or elsewhere;

to facilitate or verify the appropriate calculation of Guy: One Big taxes, fees, or other obligations; or. in an emergency situation. We may provide information that does not identify You personally to my grandmother third-parties for marketing, advertising or other purposes. HOW WE STORE AND PROTECT THE INFORMATION COLLECTED ABOUT YOU. Protecting Your Information. We use a variety of One Big Dysfunctional Essay physical, electronic, and which of the best behavior? procedural safeguards to protect Personal Information from unauthorized access, use, or disclosure while it is under our control. Unfortunately, no data transmission over Family Guy: Family the internet can be guaranteed to be completely secure.

As a result, although we will utilize such measures, we do not guarantee You against the loss, misuse, or alteration of roles and responsibilities Personal Information under our control, and You provide Personal Information to us at Your own risk. You should always take care with how You handle and Dysfunctional Family disclose your Personal Information and should avoid sending Personal Information through insecure e-mail, social networks or other internet channels. Retention and Disposal. We retain information only for as long as we have a business or tax need or as applicable laws, regulations and/or government orders allow. When we dispose of sepoy mutiny Personal Information, we use reasonable procedures designed to Guy: Family Essay erase or render it unreadable (for example, shredding documents and wiping electronic media). PRIVACY POLICY UPDATES. How We Communicate Changes to This Policy. We may update this Policy at any time to The Wedge-Tailed Eagle (Aquila Audax) Essay provide updates to Family Dysfunctional or clarification of our practices. Define Mutiny? If we make changes we may provide You with additional notice (such as adding a statement to the homepage of our Website or sending You a notification).

You should refer to Family Guy: One Big Family Essay this Policy often for the latest information and the effective date of breakfast speech any changes. This web site is owned and Guy: One Big Dysfunctional Essay operated by Viatta Business Ltd . A Partner is an roles and responsibilities nurse individual who refers customers. A Referral is an individual who requests a service via the Guy: One Big Family, referral link given by a Partner. With the my grandmother, first order, a Referral acquires a 15% discount on Guy: One Big Dysfunctional Essay, the order, while a Partner receives $50 to education times the Referral Balance. With further purchases, a Partner earns 5% of the Referrals total order price. All money earned with the Referral Program is stored on your Referral Balance.

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5 Tips for Creating a Photo Essay with a Purpose. Family Guy: One Big Family. As a photographer, you are a storyteller. The nouns are your subject matter; the verbs are the roles nurse, color and contrast that keep the story moving. A cast of characters all working together to get your point across. Instead of Guy: Dysfunctional Family proper grammar, you ensure proper exposure.

Instead of my grandmother spelling errors, you watch for tack-sharp focus. For those times when the story is Family Guy: One Big Dysfunctional Essay, especially important and meaningful, or for when one image doesn’t say it all, there is the photographic essay. With blogging and social media, photo essays are more popular than ever: humorous or emotionally relevant, sparking debate or encouraging compassion, each with a story to tell. I’ve mentioned before that taking on roles, a photo project is Family Dysfunctional Family, one of my favorite ways to Essay, reignite my love for photography, but beyond that, it’s a great way to One Big Family Essay, get your message across and have your work seen by a larger group. A photo essay is intriguing; it’s something to talk about after people hear that you’re a photographer and want to know about the glitz and glamour of it all. It’s the mutiny, perfect thing to tell them after you’re done going on and on about all of the red carpets, the celebrities, the Family Family, fame, and in victorian times, the fortune. It also can be extremely satisfying and kick-start your creative wonderment. By definition, a photographic essay is Family, a set or series of photographs intended to tell a story or evoke emotions. Of The Following Defines Organizational. It can be only images, images with captions, or images with full text. In short, it can be almost anything you want it to Family Guy: One Big Dysfunctional Essay, be.

Which is where I struggle mostwhen the The Wedge-Tailed (Aquila Audax) Essay, options are limitless. In this freelance world we live in, I love a little guidance, a little direction. Ideally, someone to tell me exactly what they want and promise to be thrilled with whatever I produce, for my fragile artist ego can’t take any less. While I continue my quest for that, I offer you these 5 tips for creating your own, completely without bounds, photographic essay: Each time I’ve had a very specific concept in mind before I started shooting, it’s never been the end result. An example: for a hot minute, I offered a “day in the life” session to my clients. One Big. I was photographing so many of the same clients year after year that I wanted to times, be able to offer them a different spin on the portrait sessions I was doing for them. I asked a long-time client if her family could be my guinea pigs for this and told them that we could do whatever they wanted. We went out for ice cream, had a mini dance party in their living room, and One Big Dysfunctional Family, I photographed a tooth that had been lost that very morning.

Then, very last, I photographed the two young daughters with notes they had written, which to my grandmother, be honest, I’m not even sure how they had come about. I rushed home after the Family One Big Essay, session and my grandmother, edited those last note pictures first just because they were so different from Family One Big Family Essay what I usually shoot, and posted them on my personal Facebook page the heading Notes Girls Write . Within minutes a dear friend, and fellow photographer, commented that this was big. Define. Bigger than just the two pictures. She and I would spend the Guy: Dysfunctional, next year working on a photo essay that became a blog, that in turn became a book entitled Notes Girls Write . We photographed hundreds of roles and responsibilities of a nurse women of Guy: One Big Family Essay all ages with their notes, each one later expressing having their portrait taken with their own words was an extremely powerful moment for them. Breakfast Club Speech. Beyond my beautiful children, the fact that I can make a bed with hospital corners like no one’s business, and the award I won in the 4th grade for “Most Patient”, Notes Girls Write is one of Family Guy: Dysfunctional Family Essay my proudest accomplishments. It evolved on its own, starting from a few similar photographs that struck a cord in viewers and becoming a large and powerful project, one of the biggest markers in my career so far. TIP: Don’t be so set in your idea that your project can’t outgrow your original concept. Your images will guide you to your end result, which may end up being different than you originally envisioned it. 2) If you think there’s something there, there’s likely something there. For the last year I have been a “foster mom” with a dog rescue group.

Volunteers transport dogs that would otherwise be put down from overpopulated shelters, or seized from terrible situations, to education in victorian, my area, where dog adoption rates are much higher. These dogs live in foster homes while they receive medical care and One Big Essay, basic training so that they can be adopted out to loving homes. Club. It’s incredibly rewarding. Especially when I had hardwood floors. I knew from the first time I met the transport van I wanted to document what it looked like: a van full of dogs that just narrowly escaped death arriving to temporary homes where they will experience a level of Guy: Family love and care which they’ve likely never known. I tear-up every time I see it. I am also put to work every time I am there, so taking photos while holding onto a 100 pound German Shepard is tough. It’s going to take me several trips to organizational, have enough images to Dysfunctional Essay, do anything with, but that’s fine. I have no idea what I will be doing with these photos. I know they will find a home somewhere: maybe with the rescue group to (Aquila Audax), raise awareness, or to help bring in volunteers, or maybe they will do nothing more than document my own story with volunteering, or perhaps something more. I’m not sure yet, but the Family One Big, point is in victorian times, that I have the Family Family Essay, images, ready for their time, whenever that is.

TIP: If you think there is something to it, there likely is. Even if it’s just a personal passion project. Take photos until you find the direction or purpose and save them until your essay takes shape. You may not end up using all, or any of the images, but in continuing to take photographs, your project will be defined. I’m the “World’s Worst Over-Shooter”. Need one image? Let me take a hundred so we know we have it.

Luckily for my bad habit, the photographic essay needs over shooting. Whether you know what your plan is, or have no idea want your end result will look like, the more coverage you have, the better. This is one of the few times I push my luck and in victorian, ask my subjects to work for me until they never want to Family One Big, see me again (I only club speech photograph people though, so if you are photographing mountains or something, you have the added advantage of Essay not pushing people until they cry or yell). Don’t be shy. Shoot everything you know you don’t need, just in case you need it. Should your end product need supporting images or take a different direction than you originally thought, you’ll be ready. Take advantage of digital (if that’s how you shoot) and fill a memory card. You may end up trashing everything, or you may not.

I had no idea that my Notes Girls Write project would span for as long as it did, but because I didn’t turn down anyone who was interested in the very beginning I ended up with some shots that told complete stories and expanded on club, the original concept. TIP: Think big. Guy: One Big Dysfunctional Family. If you are shooting an essay where mountains are your subject matter, see the mountain in pieces and roles of a, photograph the surrounding trees, rocks, and whatever else. This will save you having to return to the beginning of the project for supporting shots, or having to Family Dysfunctional Essay, reshoot if your essay takes a different turn than you planned. 4) Ask for help with image selection. I struggle with this oneI let my personal feelings get involved. Throughout our Notes Girls Write project I was constantly picking images based on following best defines organizational, my personal feelingsthe subjects that I had connected with more, and Family Family Essay, the girls that I knew were most interested in the project. My Grandmother. This is where it is so helpful to Family Guy: One Big Dysfunctional Family Essay, have someone else help. Someone who has no personal feelings towards the images and will help you pick based only on the strength of the image and my grandmother, not your own feelings. Even if people were not involved as subjects, you tend to have personal feelings toward images that the general public may not see the power behind. Guy: Dysfunctional Family. I recently photographed several dozen sexual assault survivors as part of a photographic essay for a victim advocacy’s annual gallery show.

This event is meant to put faces on the survivors and Eagle (Aquila Audax), raise awareness, and has been a large local event for years. I was thrilled to Family Guy: Dysfunctional Essay, be selected to be the speech, exclusive photographer, though this was one of the hardest projects I’ve ever taken on. The photo sessions themselves, whether five minutes or 30, were extremely emotional for the survivors and in the time I spent with them, I often learned a lot about their journey and experience. This made it difficult for me to pick which final images would be used for the show, based only on Guy: One Big Family Essay, the power of the my grandmother, image and Guy: Dysfunctional, not my personal feelings. In the my grandmother, end several select friends helped me narrow each survivor’s images down, and the subjects themselves selected which would be the Guy: One Big Family, final image used, as ultimately this is their story.

TIP: All creative work is personal, and looking at photographs we take ourselves is (Aquila Audax), incredibly hard to do with clear eyes. We see the mistakes, the personal feelings, the shot that could have been better. It’s impossible to always set these aside so when working on a project that is incredibly important to you, or large in Family scale. Have others help you decide what images to use for which of the organizational behavior? your final pieces. Bring in Family Dysfunctional Family people who are interested in photography and people that aren’t. People that know about your subject matter and and responsibilities of a, people that don’t understand it at all. But above all, bring in people who will be honest and Family Essay, not tip-toe around your feelings. Lastly, also bring a thick skin. 5) Tell your story, in fact shout it from the breakfast club speech, rooftops if you can. Maybe your original idea for your photographic essay was to post it on your blog.

Awesome, nothing wrong with that, but are you sure it can’t be more? Shop it around, who can it help? Does this benefit a group, an organization, or a person? Could it inspire people? If you feel passionately about the photos, chances are that someone else will too. Your photographic eye doesn’t stop when your shooting is Family Dysfunctional Essay, done. If you felt compelled to take the time to organizational, create a photographic essay, there are likely “readers” for your story. TIP: This isn’t the time to be humble. Taking on a photo essay is a large endeavour. While there’s nothing wrong with having it be something you only did for your own personal growth, showing it around can be helpful both in experience and longterm benefit.

Post it on social media, find appropriate places your essay could be displayed, and Family Guy: One Big Family Essay, think about how it helped you. Every single photo essay I have done has led to an outstanding connection, or more work, and there is nothing wrong with getting those things along with the personal gain of speech accomplishing something you’re proud of. The ideas are truly for a photographic essay are limitless. Truly. Guy: One Big Family. Want a few more ideas for projects, try these?

Have you ever done a photographic essay? What is in victorian, your experience? Share with in the comments if you have, or have considered it. If you haven’t, what are you waiting for? Read more from our Tips Tutorials category. Lynsey Mattingly photographs families, kids, couples, and other groups of people who, for One Big Essay whatever reason, kind of like each other. Her portrait work has been featured in People Magazine, Us Weekly, BBC Magazine, and on of a nurse, national TV including CNN, Oprah, and Ellen, but most importantly, in the personal galleries of clients across the country. One Big Family. Her photography can be viewed at www.lynseymattingly.com or on Facebook.

Excellent post Lynsey. I suffer from the same challenges as you in roles tip #4. I get caught up in my personal meaning behind some of my pictures. Family One Big Dysfunctional. Apparently, others feel the same way. http://www.picture-power.com/my-most-powerful-picture.html. Roles And Responsibilities. I have an idea for a photo essay I wanted to pursue, this article helped grow it further. Thank you. Wonderful article. I liked the picture for #3. This is the main reason why I think a blog is a much more interesting format than a photo sharing site such as flickr or 500px to show your work; for me, the Family Guy: One Big Dysfunctional Family Essay, images are just part of the story, but the words and define mutiny, texts can help define them, giving them context and body.

For me, an Guy: One Big Family Essay, image rarely works alone and my grandmother, usually comes in a set with a particular rhythm and flow; what precedes and what follows is a very important element of each capture, as well. One example from my blog, a short walk that I took recently along a humble neighborhood in Bangkok: I think the Family Guy: Family, issue in Tip #4 is common to all creative endeavors: We all get too close to the material. In a previous life, I was a writer and editor, but when it came time for define sepoy me to Family One Big Family, edit my own stuff, I had somebody else look at it. We have too much of ourselves tied up in the work to be objective sometimes. Wonderful article, thank you #128578; some of the examples are awesome and best defines organizational behavior?, thought-filling. Thank-you for Family One Big Dysfunctional Essay telling me about breakfast club speech, this!! It pretty much rocks. I am so glad that I came across this article this morning. I am no pro photographer but just someone who loves capturing images to Guy: Dysfunctional Essay, share. I have been asked to volunteer my time to sepoy, capture a group of students in Beijing, who would be traveling to Xian, the home of the terracotta warriors, to One Big Family Essay, help out in a orphanage just 2 weeks from now. I have never done this before.

They are not expecting much. Just pictures for the event. However, I wanted to tell a story. A story of these volunteers as well as the orphans and education in victorian times, I have been struggling over Family Guy: One Big Dysfunctional Essay, the past week of whether is that what I should do. After reading this article, I know that I am on the right path and hopefully help not to take pictures of people, but take pictures of the story behind the people. Thank you again very much. Define Sepoy Mutiny. This is my first opportunity to use my hobby for a good cause, and I am very excited about it. Thank you again for this great article. Really good points and very motivational to get me on a riveting photo essay again. I did attempt one such photographic essay which I titled #8220;The World of Family Guy: One Big Essay Weeds.#8221; Would appreciate a few visits with any helpful comments or critiques. It#8217;s over at one of my grandmother my blogs and can be found here: http://thegoldenumber.blogspot.com/2013/07/the-world-of-weeds.html. you have some beautiful images there, but I would keep the focus similar. the shift in focus from 1, 2, 3 and 5 is Family One Big Family, radical.

5 the green plant on nurse, the corner and then 7 seems another sudden change. The drain-pipe is beautiful because the eye follows the path of the pipe and so tightly focused. Family One Big Dysfunctional Essay. It seems to define, be erratic because you have the wonderful still life of dried plants against nearly solid backdrops like walls and then sudden change to green plants that don#8217;t seem to have the same focus.. but the dried plants and wall work, the drain beautiful and interesting. Dysfunctional Essay. The green plants against walls work well with dried plants because they have similar conceptual style. Overall, is interesting group and sepoy mutiny, should be developed some more. I recently completed my first photo essay as an eBook. It took me a long time to figure out how to work with iBooks Author, but it was a great platform to construct such a vehicle to display digital photographs in Family Guy: One Big a meaningful way.

Unfortunately, it only publishes to iBooks, which translates, effectively, to having the of the best defines, eBook only on Family Guy: One Big Dysfunctional Essay, iPads. Photo essays in black and white. This post inspired me to my grandmother, start my website of photo essays. My current ongoing series is about a band I went on tour with and the different things I learned and encountered: http://www.quietandconstant.com/on-tour-with-lemuria-part-1/ I recently made a photo essay which was published in a mainstream web portal so I#8217;m quite happy about Family, that. I agree that sometimes, photographs have to be put in context by using words to string them together. The Wedge-Tailed Eagle. Also believe that any subject can be turned into Family Guy: One Big Essay a photo essay.

The Photo Essay is a piece where its the photographer#8217;s voice through and through. Landscape Photography Tips. Photo Composition Tips. Beginner Photography Tips. 2006 - 2017 Digital Photography School, All Rights Reserved / Disclaimer. Thanks for subscribing! DPS NEWSLETTER Guaranteed for 2 full months Pay by PayPal or Credit Card Instant Digital Download. DPS NEWSLETTER All our best articles for The Wedge-Tailed Eagle Audax) Essay the week Fun photographic challenges Special offers and Guy: One Big Dysfunctional Essay, discounts.

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?Critique of a Research Article Essay. This paper presents a critique of a qualitative research article titled: Perceived support from healthcare practitioners among adults with type 2 diabetes (Oftedal et al, 2010) (appendix 1). To enable the critique of this article the Caldwell critiquing tool (2005) will be utilized. (Appendix 2) Research critiquing is a valuable skill, to gain as it enables student nurses to develop and improve knowledge and skills and also adheres to the NMC code of conduct (NMC, 2008). Polit and Family Guy: One Big Dysfunctional Family Essay, Beck (2006) emphasis the ability to analyse research enables individuals to gain knowledge.

A great importance of research is that it introduces improvements and changes into practice based from my grandmother evidence based practice (EBP). According to Pioneer David Sacklett (2000). EBP can be defined as the integration of the One Big Family best research evidence and clinical expertise, and patient values (Sacklett,2000). This article was selected as diabetes is becoming an which of the following best defines organizational, international epidemic affecting all healthcare professions (WHO,2012). First point of interest to a reader is the title; giving clear indication of the subject (Polit and Family Guy: One Big Dysfunctional Family Essay, beck, 2012). It should grab the club speech attention of a reader as discussed by Parahoo (2006).

A good title should contemplate all aspects of the Family Guy: One Big Family Essay above, also considering Polit and Becks (2012) thoughts on the title being with a 15 word limit. My Grandmother. This title is very clear to the reader, in relation to Family Dysfunctional Essay, the subject under study being short, concise and use of good language. Appropriate selection for a research paper relies highly on validity and reliability, which can be shown via credentials of authors. Working statues within health studies and behavioural research within university of roles nurse Stavanger clearly quoted against each of the authors. This article has clearly labelled, educational status and working status of all authors. Willis (2007) believes that an authors academic background can give validity and credibility within the research itself. Education held by authors was MSc, PhD, RNT being of an Family Guy: Dysfunctional Family, university level (Oftedal et al, 2010). Further interest to a reader commences from the information shown within an abstract.

This has to hold enough information for it to of a nurse, show a brief understanding of the study in place. Holloway and Wheeler (2010) recommend a clear, concise summary of the research and how it should be implemented. Burns and Grove (2007) mention good abstracts convey findings and Family Dysfunctional, capturing attention of a reader. A benefit to this article is club speech, that it is clear, readable and structured with subheadings providing a deeper structured understanding. The introduction of this article evidently outlines the Family Guy: rationale for the study; with reference of findings from other relevant studies completed.

Holloway and Wheeler (2010) declare authors have to provide awareness of their subject and reasons for their study. Eagle Audax) Essay. Suggestions made indicated that it is paramount for study for the improvements to be made, emphasising on the rise in statistics from the condition (Oftedal et al, 2010). Within the article, there is Family Guy: Family, no clear indication of of the defines behavior? a literature review. Although, through reading this it has become apparent that it has been included within the background section. Polit and Family One Big, Beck (2012) discuss a literature review being a summary of previous research. The Wedge-Tailed Eagle (Aquila. Explanations are given within reference to other studies such as Schilling et al (2002) which has shown to lack empirical evidence. However, Thorne and Paterson (2001) look at aspects, but indicate more research can be done. The purpose of a literature review is essential as it gives more emphasis on why the study is important; for instance lack of previous research on Family Dysfunctional, the subject. Within this article has an disadvantage, because there is no clear stating of a literature review, which would in some circumstances confuse a reader. Research referenced within the mutiny article was between the years 1992-2008; mentioning the need for Family Dysfunctional Family Essay, further research (Oftedal et al, 2010).

A purpose for an article is to generalise there aims, informing subject under study stating what is likely to in victorian times, be achievable from the One Big study; Polit and mutiny, beck (2012) emphasis this being an importance. The aim is Family Guy: Dysfunctional Family, clearly sub headed giving the reader clear positioning within the report, it is short and concise with relevant information; indicating the subject of study and what is desired. The aim being perceived support from healthcare and different attributes, that influence peoples self-management of the disease (Oftedal et al, 2010). The study is complete by using participants. Ethical issues have a vast importance relating to the validity and credibility of the research. Approval of ethical committees is exceptional, including reference. Legal rights and ethical aspects for of the following best defines organizational behavior?, all research methods have to be considered (Holloway and Wheeler, 2002; Moule 2011; Strubert, 2011). The study appears to have been approved by Norwegian regional committee for medical and health research ethics, social science data services all having reference provided.

Implications can be studied at length but four rights are paramount in research: the right not to Guy: One Big Dysfunctional, be harmed, the right of sepoy mutiny full disclosure, the right to One Big Dysfunctional Family, self-determination and the right to privacy, anonymity and breakfast speech, confidentiality (ICN, 2012). Guy: Dysfunctional Family. It is apparent from the study that informed consent was gained from participants, as an roles and responsibilities of a nurse, invitation was sent, and approval from participants was gained. Family Guy: Family Essay. The right to withdraw was shown as two participants never contributed from initial approval. Methodology is discussed by Parahoo (2007) simply as a plan that describes, how, when and where data is to be collected and analysed. This article does not visibly show methodology but it is an interchangeable term such as research design is present. An advantage from the article is that further reading and comprehension is not necessary as it obviously indicates this research as interpretive and descriptive qualitative design (Oftedal et al, 2010). Holloway and Wheeler (2002) state it gives an understanding of human experiences, giving an advantage to this research as it is what they wish to achieve. Additionally, Holloway and Wheeler (2010) discuss, how roots with philology and the human science, especially in history, centring the way humans related to their subjective reality and attaching a meaning. to it. Approach taken solely on world life context rather than individuality; allowing more of an understanding of human experiences at a whole.

This type of research allows authors to gain characteristics within this field. Usage of the data is to develop theories and identify problems with current practice (Burns and in victorian times, Grove, 2007; Gerrish and Lacey, 2010). Outcomes achieved five themes, namely: an empathetic approach, practical advice and information, involvement in decision making, accurate and Family Dysfunctional Essay, individualised information and on-going based support (Oftedal et al, 2010). These are gained via interpretive and descriptive qualitative design, as it focusses more natural environments rather than cause and effect which is quasi-experimental. This concept being noticeably identified via the research, this was conducted. Details of the participants can be found within the article visibly labelled participants. Breakfast Club Speech. A participant enables the One Big Dysfunctional researcher to conduct the study; Burns and of the organizational behavior?, Grove (2012) suggest participants are selected due to experience, knowledge and views related to Family Essay, the study in the progress aiding the researcher to gain accurate information.

Within this article, the type of sampling which has been declared is purposive sampling; Parahoo (2006) suggests that this type of sampling conducted is chosen because it provides more reliable and valid data as it is represented by participants diagnosed with the condition. Furthermore the participants, who were invited to take part, were recruited via referrals, from local organisations relating to diabetes such as learning and coping. Ability to Audax) Essay, speak Norwegian and be within an age bracket of Guy: Dysfunctional Family 30-65 allows the data to be more accurate. As discussed, sampling was purposeful; therefore it emphasises the reliability. The sample size used for this research was 19 participants recruited from 3 organisations, unemployed to reduce bias. Education Times. Mixed gender, aged 30-65 and all participants had the Family Guy: Dysfunctional Essay condition for a minimum of education in victorian one year. Although, purposive sampling is used it does not indicate which strategy; for instance, Patton (2002) allocates more than 12 for qualitative research, Polit and Beck (2012) note there being no fixed rules for Dysfunctional, sample size, although Morse (2000) mentions how much broad the scope, reflects in the sample size. My Grandmother. This research has an advantage as it focussed on participants whom are diabetic.

However limitations being restricted are age group, and metabolic generalisation. For example: participants within the study all had the controlled blood glucose levels, there was no sample members who shown uncontrolled or unstable diabetes. Data collection from the research conducted was presented within a table. Collected via focus groups, consisting of 6-7 person per session, participants were interviewed at Guy: One Big Dysfunctional Essay the workplace of the authors and mixture of genders per group. Although as mentioned by Polit and Hungler (1997) advantage being that it increases dialogue; disadvantage being an decrease for those not comfortable voicing within a group.

As it has it pros and cons we can establish that all participants had type 2 disease therefore would not have much influence on responses. Limits of time, and for 2 sessions was placed by researchers. The authors recommended time for reflection between sessions. The models used, were identified with the data collection section being expectancy-value and social support theory for questions within the in victorian focus groups. Family. All the participants spoke one language; Norwegian which is an advantage to others as it is easier to transcribe. The focus groups explained in data analysis was audiotaped and transcribed verbatim, creating auditability. The analysis was as stated Qualitative content analysis in nursing research: Concepts, procedures and club, measures to achieve trustworthiness (Graneheim and Guy: One Big, Lundman, 2004; Oftedal et al, 2010, p1503). Club. Processes took place for this study, unmistakably shown as coding to breakdown text into parts; identifying patterns within the data (Burns and Guy: One Big Dysfunctional, Grove, 2006; Holland and Rees, 2010). After identifying codes, this enables the themes to be developed which was interrelated as findings of the study.

Furthermore, data management requires clear processes to ensure methodological rigour and credibility of the findings (Burns and Grove, 2007). According to Polit and Beck (2006) a reader should consider if the data is adequate, to which of the behavior?, be published in a clear and efficient manner. This article has appropriately labelled correctly making it readable and understandable. The results gained from the data analysis, is clearly drawn within the Guy: Family article under the breakfast speech findings section; providing the established themes, creating an understanding for the reader of how and Guy: Dysfunctional, why they found referenced themes. Define Sepoy. Polit and Beck (2013) discuss how a reader should notably find limitations within the study. this article presents a limitation section outlining a discussion of how it affects the Family One Big Dysfunctional results and further addresses possible queries that can be made such as, different attributes that can be found from people without stable metabolic ranges as it was limited to acceptable metabolic levels (Oftedal et al, 2010). The impact of results found can construct towards EBP. Additionally, the authors have discussed implications for practice within the following best organizational behavior? study. This advantage is a favourable point as it leads the reader of the implications and how it can be implemented.

It focuses hugely on Guy: One Big Dysfunctional, how beneficial it is when it comes to practice. According to transferability of The Wedge-Tailed (Aquila Essay these findings it becomes apparent that type 2 diabetes is a worldwide increasing problem. Results can be transferrable to any country to improve better care for Guy: Essay, those with type 2 diabetes. The study was conduct in Norway, although it is based within another country the of the organizational prevalence is still applicable in the UK. Guy: One Big Family Essay. Holloway and Wheeler (2010) discuss the meaning of transferability as findings of one context that can be transferred to similar situations or participants diabetes is a worldwide known disease (WHO, 2012) it can be transferred.

Polit and Beck (2013) reference that for the generalisation of the study; it has to my grandmother, be valid and reliable for this to take place. The role of a nurse becomes paramount within this section. Family Guy: Essay. Whether the results can be implemented by a nurse in practice, such as supporting patients in a better manner and referring if needed for define sepoy, more education, giving more individualisation to self-management programmes as discussed within the article (Oftedal et al, 2010). In relation to the conclusion within the article it clearly sums up the findings and Guy: One Big Dysfunctional Essay, how it can be implemented within practice. It states that further research is necessary before definite conclusions can be retained. Transferability of the research to other chronic illness similar to type 2 diabetes was also mentioned. Define Mutiny. Burns and Grove (2010) express that the findings and Guy:, the meaning of the research should be placed within the education in victorian times conclusion. The assignment has explored the significance within research and EBP, transferability of research and recommendation have an importance in this. Overall, this article was clear with good use of words, presentation was greatly achieved, allowing the reader to Family One Big Family Essay, be more focussed. It discussed within itself the limitations, recommendations and the need for further research for this to become meaningful. Recommendations can be viewed as knowledge and implemented within practice from this study.

Also showing that evidence based practice does start from research; it is roles, shown that studies are required in some circumstances to gain more knowledge to improve services. Burns, N, Grove, S K (2006) Understanding nursing research: Building an evidence based practice 4th ed Elsevier Saunders, United States of America. Burns, N, Grove, S K (2007) Understanding nursing research: Building an evidence-based practice. 5th ed. Elsevier Saunders, United States of Family Guy: Family Essay AmericaCaldwell, K., Henshaw, L., and Taylor, G. (2005) Developing a frame-work for critiquing health research, Journal of health, social and envi-ronmental issues, 6(1), pp45-53. [accessed via: https://eprints.mdx.ac.uk/2981/1/Developing_a_framework_for_critiquing_health_research.pdf] [accessed 20/05/2013] Cutcliffe, J. and Ward, M. (eds.) (2007) Critiquing nursing research. 2nd ed.

London: Quay Books. Gerrish, K and Lacey, a (2010) The reseach process in nursing 6th Ed Blackwell publishing: Oxford. Graneheim, UH. Roles And Responsibilities Of A Nurse. Lundman, B. (2004). Qualitative content analysis in nursing.

research: Concepts, procedures and Family One Big Family, measures to achieve trustworthiness. Nurse Education Today, 24, pp. 105-112. [accessed via: http://www.nurseeducationtoday.com/article/S0260-6917(03)00151-5/abstract][accessed 20/05/2013] Holland, K. and Rees, C. (2010) Nursing: evidence-based practice skills. New York: Oxford University Press. Holloway, I, Wheeler, S (2002) qualitative research in nursing 2nd ed. Blackwell publishing: Oxford. Holloway, I, Wheeler, S (2010) qualitative research in nursing and healthcare 3rd ed.

Blackwell publishing: Oxford. ICN (international council of nurses) (2012) ethical guidelines for nursing research. Geneva ; ICN [accessed via http://www.icn.ch/images/stories/documents/publications/free_publications/Code_of_Ethics_2012.pdf] accessed 20/05/2013. Morse, Janice, M. (2000). Determining sample size. Qualitative Health Research, 10(1), 3-5. Education. [accessed via http://qhr.sagepub.com/content/10/1/3.extract] accessed 20/05/2013. Moule, P, Hek, J (2011) Making sense of reseach; an Family One Big Dysfunctional Family Essay, introduction for breakfast club, health and social care practioners. Family Essay. 4th ed. In Victorian. Sage publications: London.

Nursing Midwifery Council (2008) The code: standards of conduct, performance and ethics for nurses and midwives. London: Nursing and Midwifery Council. Oftedal, B, Karlsen, B, Bru E. (2010) Perceived support from healthcare practioners among adults with type 2 diabetes. Journal of advanced nursing, vol 66, issue 7, pp1500-1509. Blackwell publishing [accessed via http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2010.05329.x/abstract] [accessed on 01/03/2013]

Patton, M Q (2002): Qualitative Research Evaluation Methods, Sage: Thousand Oaks. Parahoo, K. (eds.) (2006) Nursing research: principles, process and issues. 2nd ed. Basingstoke: Palgrave Macmillan. Polit, D.F. and Beck, C.T. (eds.) (2012) Nursing research: generating and assessing evidence for nursing practice. One Big Essay. 9th ed. Philadelphia: Lippincott Williams and Wilkins. Polit, D.F. and Beck, C.T. (eds.) (2006) Essentials of nursing care: methods, appraisal and Eagle (Aquila, utilization. 6th ed.

Philadelphia: Lippincott Williams and Wilkins. Polit, D.F. and Beck, C.T. (eds.) (2010) Essentials of One Big Dysfunctional Essay nursing research: appraising evidence for nursing practice. 7th ed. Philadelphia: Lippincott Williams and Wilkins. Polit, D.F. and Beck, C.T. Following Best Organizational. (eds.) (2013) Essentials of nursing research: appraising evidence for nursing practice. 8th ed. Philadelphia: Lippincott Williams and Wilkins. Polit,D F, Hungler, B P (1997) Essentials of nursing research; methods, appraisal and utilization. Guy: One Big Family. 4th Ed, Lippincott- Raven, Philadelphia: New York.

David L. Sackett (2000). Which Of The Following Organizational. Evidence based medicine; how to Family One Big Dysfunctional Family, practice and teach EBM. Volume 2 Edition, 2, Churchill Livingstone: University of Michigan. Schilling L.S., Grey M. Knafl K.A. (2002) The concept of selfmanagement of mutiny type 1 diabetes in children and adolescents: an. evolutionary concept analysis. Journal of Advanced Nursing 37(1), 8799.accessed via: .http://www.ncbi.nlm.nih.gov/pubmed/11784402 [Accessed 20/05/2013] Streubert, H J, Carpenter, D R (2011) Qualitative research in nursing: advancing the humanistic imperative 5th Ed, Wolter Kluwer Lippincott Williams Williams:London. pp56-59. Thorne S.E.

Paterson B.L. (2001) Health care professional support for Family Guy: Family Essay, self-care management in chronic illness: insights from of the best defines diabetes research. Patient Education and One Big, Counseling 42(1), 8190.Accessed via: http://www.ncbi.nlm.nih.gov/pubmed/11080608 [Accessed 20/05/2013] WHO. (2012) About WHO [online]. World Health Organization. Available from: http://www.who.int/about/en/ [Accessed 17th December 2012]. Willis, J, W. (2007) Foundations of qualitative research. Thousand Oaks, California: Sage. University/College: University of Arkansas System.

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