By B. Makas. Conway School of Landscape Design. 2018.
If you wish to pursue any of these in more depth discount zestril 2.5 mg without a prescription, useful re- ferences are included at the end of this chapter discount 5 mg zestril visa. Quantitative research generates statistics through the use of large-scale survey research zestril 10mg line, using methods such as questionnaires or structured interviews. If a market re- searcher has stopped you on the streets, or you have ﬁlled in a questionnaire which has arrived through the post, this falls under the umbrella of quantitative research. This type of research reaches many more people, but the con- tact with those people is much quicker than it is in quali- tative research. Qualitative versus quantitative inquiry Over the years there has been a large amount of complex discussion and argument surrounding the topic of re- search methodology and the theory of how inquiry should proceed. Much of this debate has centred on the issue of qualitative versus quantitative inquiry – which might be the best and which is more ‘scientiﬁc’. Diﬀerent meth- odologies become popular at diﬀerent social, political, historical and cultural times in our development, and, in my opinion, all methodologies have their speciﬁc strengths and weaknesses. At the end of this chap- ter references are given if you are interested in following up any of these issues. Certainly, if you were to do so, it 16 / PRACTICAL RESEARCH METHODS would help you to think about your research methodology in considerable depth. Deciding which methodology is right for you Don’t fall into the trap which many beginning (and ex- perienced) researchers do in thinking that quantitative re- search is ‘better’ than qualitative research. Neither is better than the other – they are just diﬀerent and both have their strengths and weaknesses. What you will ﬁnd, however, is that your instincts probably lean you towards one rather than the other. Listen to these instincts as you will ﬁnd it more productive to conduct the type of re- search with which you will feel comfortable, especially if you’re to keep your motivation levels high. Also, be aware of the fact that your tutor or boss might prefer one type of research over the other. If this is the case, you might have a harder time justifying your chosen methodology, if it goes against their preferences. EXAMPLES OF QUALITATIVE RESEARCH METHODOLGIES Action research Some researchers believe that action research is a re- search method, but in my opinion it is better under- stood as a methodology. In action research, the researcher works in close collaboration with a group of people to improve a situation in a particular setting. The researcher does not ‘do’ research ‘on’ people, but instead works with them, acting as a facilitator. There- fore, good group management skills and an under- standing of group dynamics are important skills for HOW TO DECIDE UPON A METHODOLOGY / 17 the researcher to acquire. This type of research is pop- ular in areas such as organisational management, com- munity development, education and agriculture. Action research begins with a process of communica- tion and agreement between people who want to change something together. Obviously, not all people within an organisation will be willing to become co-researchers, so action research tends to take place with a small group of dedicated people who are open to new ideas and willing to step back and reﬂect on these ideas. The group then moves through four stages of planning, acting, observing and reﬂecting. This process may hap- pen several times before everyone is happy that the changes have been implemented in the best possible way. In action research various types of research meth- od may be used, for example: the diagnosing and eval- uating stage questionnaires, interviews and focus groups may be used to gauge opinion on the proposed changes. Ethnography Ethnography has its roots in anthropology and was a popular form of inquiry at the turn of the century when anthropologists travelled the world in search of remote tribes. The emphasis in ethnography is on describing and interpreting cultural behaviour. Ethnographers im- merse themselves in the lives and culture of the group being studied, often living with that group for months on end. These researchers participate in a groups’ activ- ities whilst observing its behaviour, taking notes, con- ducting interviews, analysing, reﬂecting and writing 18 / PRACTICAL RESEARCH METHODS reports – this may be called ﬁeldwork or participant ob- servation. Ethnographers highlight the importance of the written text because this is how they portray the cul- ture they are studying.
Obstruction may also occur by contamination from material in the mouth zestril 2.5 mg sale, nasopharynx 2.5mg zestril visa, oesophagus best zestril 10 mg, or stomach—for example, food, vomit, blood, chewing gum, foreign bodies, broken teeth or dentures, blood, or weed during near-drowning. Laryngospasm (adductor spasm of the vocal cords) is one of the most primitive and potent animal reflexes. It results from stimuli to, or the presence of foreign material in, the oro- and laryngopharynx and may ironically occur after cardiac resuscitation as the brain stem reflexes are re-established. Recovery posture Patients with adequate spontaneous ventilation and circulation who cannot safeguard their own airway will be at risk of developing airway obstruction in the supine position. Turning Airway patency maintained by the head tilt/chin lift the patient into the recovery position allows the tongue to fall forward, with less risk of pharyngeal obstruction, and fluid in the mouth can then drain outwards instead of soiling the trachea and lungs. Spinal injury The casualty with suspected spinal injuries requires careful handling and should be managed supine, with the head and cervical spine maintained in the neutral anatomical position; constant attention is needed to ensure that the airway remains patent. The head and neck should be maintained in a neutral position using a combination of manual inline immobilisation, a semi-rigid collar, sandbags, spinal board, and securing straps. The usual semi-prone recovery position should not be used because considerable rotation of the neck is required to prevent the casualty lying on his or her face. If a casualty must be turned, he or she should be “log rolled” into a true lateral Airway patency maintained by jaw thrust position by several rescuers in unison, taking care to avoid rotation or flexion of the spine, especially the cervical spine. If the head or upper chest is injured, bony neck injury should be assumed to be present until excluded by lateral cervical spine radiography and examination by a specialist. Further management of the airway in patients in whom trauma to the cervical spine is suspected is provided in Chapter 14. Casualties with spinal injury often develop significant gastric atony and dilation, and may require nasogastric aspiration or cricoid pressure to prevent gastric aspiration and tracheobronchial soiling. Vomiting and regurgitation Rescuers should always be alert to the risk of contamination of the unprotected airway by regurgitation or vomiting of fluid or solid debris. Impaired consciousness from anaesthesia, head injury, hypoxia, centrally depressant drugs (opioids and recreational drugs), and circulatory depression or arrest will rapidly impair the cough and gag reflexes that normally Medical conditions affecting the cough prevent tracheal soiling. It occurs more G Bulbar and cranial nerve palsies commonly during lighter levels of unconsciousness or when G Guillain-Barré syndrome cerebral perfusion improves after resuscitation from cardiac G Demyelinating disorders arrest. Prodromal retching may allow time to place the patient G Motor neurone disease in the lateral recovery position or head down (Trendelenburg) G Myasthenia gravis tilt, and prepare for suction or manual removal of debris from the mouth and pharynx. Regurgitation is a passive, often silent, flow of stomach contents (typically fluid) up the oesophagus, with the risk of 26 Airway control, ventilation, and oxygenation inhalation and soiling of the lungs. Failure to maintain a clear airway during spontaneous ventilation may encourage regurgitation. This is because negative intrathoracic pressure developed during obstructed inspiration may encourage aspiration of gastric contents across a weak mucosal flap valve between the stomach and oesophagus. Recent food or fluid ingestion, intestinal obstruction, recent trauma (especially spinal cord injury or in children), obesity, hiatus hernia, and late pregnancy all make regurgitation more likely to occur. During resuscitation, chest compression over the lower sternum and/or abdominal thrusts (no longer recommended) increase the likelihood of regurgitation as well as risking damage to the abdominal organs. Gaseous distension of the stomach increases the likelihood of regurgitation and restricts chest expansion. Inadvertent gastric distension may occur during assisted ventilation, especially if large tidal volumes and high inflation pressures are used. This is particularly likely to happen if laryngospasm is present or when gas-powered resuscitators are used in Sellick manoeuvre of cricoid pressure conjunction with facemasks. The cricoid pressure, or Sellick manoeuvre, is performed by an assistant and entails compression of the oesophagus between the cricoid ring and the sixth cervical vertebra to prevent passive regurgitation. It must not be applied during active vomiting, which could provoke an oesophageal tear. Choking Asphyxia due to impaction of food or other foreign body in the upper airway is a dramatic and frightening event. In the conscious patient back blows and thoracic thrusts (the modified Heimlich manoeuvre) have been widely recommended. If respiratory obstruction persists, the patient will become unconscious and collapse. The supine patient may be given further thoracic thrusts, and manual attempts at pharyngeal disimpaction should be undertaken. Visual inspection of the throat with a laryngoscope and the use of Abdominal thrust Magill forceps or suction is desirable.
Postural drainage with a small percussive cup discount 10 mg zestril free shipping, or vibration buy generic zestril 10 mg online, placing the most atelectatic lung segments upward can be helpful purchase 10mg zestril with amex. Glycopyrrolate (Robinul) is difﬁcult to use well; often the beneﬁt of drying secretions is undermined by increased thickness of secretion that makes the overall situation worse. Infants often beneﬁt from aerosolized bronchodilator treatments during times of increased respiratory distress. Many infants with SMA 1 are more comfortable and breath more slowly and effectively in a Trendelenberg position and on their side or even prone. This position is advantageous given the relative imbalance between chest wall weakness and diaphragmatic strength: in the upright position the increase in thoracic volume created by diaphragmatic contraction is undermined by chest wall collapse, but in the Trendelenberg position the forces to collapse the chest wall are diminished. Finally, the distress of severe dyspnea can be blunted by use of aerosolized nar- cotics. This includes the risk of suppression of respiratory drive, but in my experience there is little evidence that delivered in the following manner that induced respiratory depression is a major concern. Instead, the delivered dose appears to be partially Therapy for Spinal Muscular Atrophy 197 adjusted by the diminished respiratory volumes. This is placed in a standard nebulizer and directed to the mouth and nose with enough air- ﬂow to last approximately 10 min (usually about 6 L=m). Repeated dosing is possible every 30–60 min observing for effect and the absence of apparent respiratory depres- sion. This does not have to be used only in the terminal stages, though I tend to conﬁne its use to more severe episodes. Parents do not have to be worried that use of this commits the infant to an immediately terminal course, as I have frequently had the experience with infants recovering from severe dyspnea to their prior level of compromised respiratory function. Care for Children Not in Palliative Care Those with different levels of weakness due to SMA have varying treatment concerns. Those with the mildest forms of SMA have chieﬂy orthopedic problems, with deformities of feet and spine of paramount concern. With increasing levels of weakness, respiratory care assumes proportionately greater importance. At all levels there are nutritional, therapy, and parenting issues to be followed. In children who sit only with effort, the development of scoliosis is virtually inevitable; for those stronger it remains a high risk. In contrast to orthope- dic scoliosis, children with SMA develop scoliosis with a broad curve that initially appears slowly, but once established can progress rapidly as the deforming force of gravity increases with the degree of curvature. Use of a light weight rigid jacket brace (thoraco-lumbo-sacral orthosis or TLSO) can be very useful to slow the rate of progression, particularly when begun relatively early in the course. Thus, children with SMA at risk for scoliosis need to have careful and frequent assessment for the development of mild degrees of curvature. Unfortunately TLSO braces are uncom- fortable, expensive, and need to be adjusted frequently, but the alternative of cata- strophic scoliosis is life threatening or life limiting. The TLSO is fashioned to maintain supportive pressure on the pelvic rim and must below the axilla (which sup- ports at about T7) on the concave side and broadly over the trunk on the convex side of the curve; some looseness of ﬁt can be afforded in the anterior–posterior dimension to maximize room for thoracic expansion. It should be worn full time whenever the child is upright; since it is intended to counter the deforming force of gravity it can be removed when the child is recumbent or in water. The overall goal of TLSO support is to maintain as straight and ﬂexible a spine a possible for as long as possible to improve the outcome with operative spinal fusion. This operation (discussed in Chapter x) is more successful in the long run if done as close as possible to, or after, the onset of skeletal maturity. Dislocation of the hips is common in the nonambulatory or limited ambulatory patient. As surgical ‘‘correction’’ often increases pain and immobility in the long term, thus operative approaches should be approached with caution.
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