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Abstract
For a short-term purpose the feeding tubes can be introduced through the nasal cavity of the patient known as the nasogastric tubes when surgery and treatment of some patients affect their ability to eat their food properly. This type of tube is known as Percutaneous Endoscopic Gastrostomy tube or PEG tube. The PEG tubes offer great comfort to the patients and complications, like displacement of the tubes, are less frequent in them. The PEG tubes reduce stress and pain of both the patients and their family members as it not only optimizes the fluid and nutritional intake of the patients but also decreases the risk of choking. The use of PEG tubes sometimes does not improve the quality of life of the patients. PEG tubes cause some local wound infection and also gastric erosions. (Fletcher, 2005) PEG tubes cause less discomfort than the nasogastric tubes and the rate of blockage or displacement of the nasogastric tubes are reduced. (Fletcher, 2005) Thus, in the context of the impact of PEG feeding on patients and carers daily lives it is important to evaluate the success result of the method and its use under specific cases. Alongside, it would be seen whether it is possible to reduce the discomfort of the patients using the PEG. The impact of PEG tubes has been very positive for their basic survival. However, it is relevant to find the amount of survival results due to the use. Furthermore, the success results of PEG in such specified cases like dysphagia would also be evaluated. Moreover, it is required to understand and evaluate the amount of discomfort and causalities recorded due to this problem and ultimately decipher a method to negate this problem in future. Thus, the research would work in view to understand the experiences of patients with a PEG and to examine patients views of having a PEG.
Introduction
Surgery and treatment of some patients affect their ability to eat their food properly. Thus, a feeding pipe or tube needs to be inserted in them so that they can meet their everyday nutritional needs. (Bandura, 2005) For a short-term purpose the feeding tubes can be introduced through the nasal cavity of the patient known as the nasogastric tubes. It can also be surgically inserted into them through their stomach by a process called gastronomy. However, if the patient requires using the tube for a longer time then the tube is directly placed in the stomach through the abdominal wall. This type of tube is known as Percutaneous Endoscopic Gastrostomy tube or PEG tube. It was introduced in 1980s as an alternative to gastronomy tubes that were surgically placed and nasogastric tubes. (Bandura, 2005) Their main advantage is that they are not painful and also cannot be easily seen under normal clothes. If they are not being used then we can simply tape them onto the patient so that it does not move under the clothes making it cosmetically suitable. (Bandura, 2005)
It has been confirmed that the PEG tube is comparatively free from any immediate or long-term serious complications as compared to other alternatives, like open gastronomy. (Stainton, 1999) The patients and the caregivers believe that the PEG tubes have not only helped them in the feeding process but also it has extended the survival of the patients. (Stainton, 1999) It has been found to be a safe and an effective process. (Stainton, 1999) The PEG tubes offer great comfort to the patients and complications, like displacement of the tubes, are less frequent in them. (Stainton, 1999) A PEG tube can be used from six months to over a year and does not need to be replaced frequently. (Stainton, 1999) Since it is made out of Silicon, which is an inert nonmetallic element, local reactions or regular complications do not occur. (Stainton, 1999)
The PEG tubes have immensely helped patients who cannot maintain their nutrition level through oral intake, as they cannot eat properly and on time. (Border, 2002) The patients can tolerate them better than the nasogastric tubes as they are easy to use. (Border, 2002) Aspiration pneumonia, which is mainly associated with various swallowing disorders, is reduced with the use of PEG tubes. (Border, 2002) They are also very cost effective and have a better life expectancy. (Border, 2002)
Major Literature
Swallowing problems bring about episodes of choking, spillage of food, the requirement of preparing special meal for the patients, extends time of eating and fatigue due to chewing and respiratory problems. (Cook, 1998) It also causes malnutrition in the patients. (Cook, 1998) All these contribute in creating a dislike towards eating and the person suffering from neurological disorders becomes afraid of mealtimes. (Cook, 1998) Thus, the use of PEG tubes helps the patients by directly sending the food to their gastrointestinal tract or stomach. (Cook, 1998) It not only optimizes the fluid and nutritional intake of the patients but also decreases the risk of choking. (Cook, 1998) The PEG tubes reduce stress and pain of both the patients and their family members. (Cook, 1998)
There are some difficulties that arise from using PEG tubes too. Almost 71% of the patients using them complain of vomiting, 54% have leakage around the insertion area, 46% have had infections and 33% have had diarrhea. (Roy, 2001) They also suffered from disturbed and delayed sleep cycles, lose their ability to move freely and go out, restrict their choice of clothes, missed being capable of eating and drinking and sometimes even develope negative attitude towards their caregivers and family members. (Roy, 2001) The use of PEG tubes sometimes does not improve the quality of life of the patients. (Roy, 2001) Studies (Roy, 2001) are still being done to determine the genuine nutritional gain of the patients. Also both the patients and their caregivers need to make emotional and psychological adjustments. (Roy, 2001) PEG tubes cause some local wound infection and also gastric erosions. (Roy, 2001) Some patients even died after the process mainly due to aspiration pneumonia. (Roy, 2001) But most of the patients completely recover within a few weeks. (Roy, 2001) Some other complications due to the PEG tubes are hemorrhage, benign pneumo peritoneum, gastric perforation, infection of the stoma site and gastric fistula. (Roy, 2001)
PEG tubes are an alternative to surgically produced gastrostomy and were mainly developed to avoid operation by using anesthesia for those patients that are old and frail. (Edelman, 2005) Most patients are not comfortable with nasogastric tubes, as they need to be re-inserted frequently creating unnecessary stress for the patients. (Roy, 2001) The patients not only need extra attention for this but they also need radiography while replacing the feeding tubes. (Roy, 2001) Thus, the patients, their caregivers and family members accept the PEG tubes as a better option when compared to the nasogastric tubes. (Edelman, 2005) PEG tubes cause less discomfort than the nasogastric tubes and also the rate of blockage or displacement of the nasogastric tubes are reduced. (Edelman, 2005) PEG tubes do not interfere with the patients rehabilitation programs and the caregivers need to give lesser nursing time to the patients as feeding them becomes easier. It shows terrific improvement in the nutritional status of the patients too. (Edelman, 2005) All these elements prove that PEG is an important instrument of care however, it is to be seen the actual amount of its success rate and there should be a better evaluation of its overall use. Alongside, the amount of discomfort and causalities recorded due to PEG would also be taken into account. Thus, the research would work in view to understand the experiences of patients with a PEG and to examine patients views of having a PEG.
Research questions and aims
Nowadays a huge number of people suffer from oral cancer and due to the damage of their esophageal or oral tissues maintaining their weight and receiving proper nutrition becomes very difficult. It is also helpful for patients with dysphagic strokes. (Fletcher, 2005) They have difficulties with swallowing their food and some of them suffer from certain neurological indications, like motor neuron disease. (Fletcher, 2005) The impact of PEG tubes has been very positive for their basic survival. (Fletcher, 2005) However, it is relevant to find the satisfaction amount of survival results due to the use.
The secondary research aim and objective is relevant to the first one. This is because Dysphagia shows symptoms of lowered aspirations, which cannot be cured by altering diet plans. Also if dysphagia becomes very severe, then it is unsafe to eat through the mouth and a feeding tube is the only alternative. (Madhav, 2006) Thus, it is important to find the satisfaction amount of patients in the success results of PEG in such specified cases.
Nevertheless, in order to cope up with the negative affects of the PEG tubes both the patients and the caregivers need properly planned social support and the help of healthcare professionals. A PEG tube is very convenient as it makes mealtime pleasurable for the patient and their family members. The patients need to be strong and avoid serious complications to take place. They should not let weight loss problems, weaknesses and nutritional deficiency cause discomfort and frustration in themselves. (Mukherjee, 2004) Thus, the third objective or aim is to understand and evaluate the amount of discomfort and causalities recorded due to this problem and ultimately decipher a method to negate this problem in future.
Thus, the research aim would be:
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to understand the experiences of patients with a PEG
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to examine patients views of having a PEG
Perspective and Methodology
One of the primary ways in which Qualitative methodology is defined is in terms of its difference from the so-called pure sciences such as physics, chemistry, biology etc. Its use of theory and methodology is, therefore, closely related to this distinction. Academics of marketing often emphasize what too many of us are utterly obvious, that there is no certainty in the study of marketing sciences. This is because marketing not only deals with fiscal variables but also it deals with humanity, which is inherently transient. Taking this element of transience into consideration marketing scientists has to use not just quantitative but also qualitative methods of study. (Watson, 2006)
A Qualitative method of study differs from the usual quantitative methods (used in the study of pure sciences) in the sense that it tends to be far more subjective. This is in sharp contrast to the methods used in pure sciences which are exclusively objective. (Watson, 2006) The research methods for marketing are a combination of both quantitative and qualitative methods. Being open to qualitative methods of study also allows social scientists to incorporate non-quantitative data (i.e. non-numerical data, such as words, images, gestures, impressions etc.) in their study. (Watson, 2006) Since human beings tend to operate in terms of such data and not in terms of the terminology used in ordinary sciences this broader outlook is far more applicable in the study of social sciences. (Silverman, 2001) In keeping with the methodology employed in marketing research the theories too are formulated and used keeping in mind that they are not necessarily applicable to all conditions. Human events are most likely to influence the rules which define the basic theories of a related subject. Success in the field of nursing research can therefore be achieved if and only if it is understood that the subject has no space or opportunity for watertight methodologies or theories. (Silverman, 2001)
It can always be stated that Qualitative research is a process that includes interpretative paradigm under the measures of theoretical assumptions and the entire approach is based on sustainability that is depended on peoples experience in terms of communication. (Burns, 2001) It can also be mentioned that the total approach is because reality is created on the social formulations. It can also be mentioned that the basic target of qualitative research is instrumented towards social context under normal circumstances where it would be possible to interpret, decode and describe the significances of a phenomenon. (Burns, 2001) The entire process is operational under the parameter of interpretative paradigm that can minimize illusion and share subjectivity under contextualization, authenticity and complexity of the investigation. (Burns, 2001)
The basic advantages of qualitative measures are multifold. Firstly, it presents a completely realistic approach that the statistical analysis and numerical data used in research based on quantitative research cannot provide. Another advantage of qualitative measures is that it is more flexible in nature in terms of collected information interpretation, subsequent analysis and data collection. It also presents a holistic point of view of the investigation. Furthermore, this approach of research allows the subjects to be comfortable thus be more accurate as research is carried on in accordance to the subjects own terms. (Bowling, 2005) you need to relate this to your topic and state which type of qualitative research you will use and why its strengths and weaknesses. Thus, as the research would work in view to understand the experiences of patients with a PEG and to examine patients views of having a PEG, qualitative method would be used.
Methods
Access, Ethical issues
It is true that the case was ultimately dismissed in favour of the defence and the testing methods were not withdrawn but it was stated that the tests and performances should be more clearly and homogenously defined and incorporated. However, it should be stated that though this particular case was dissolved by the Court Litigation in favour of the methods it can be sated that there are still many critics of the intelligence tests and its use of determination of classifying students into groups as this was clearly an example of Educational Discrimination where the Black Students suffered the most. This is not only an aspect of Legal Problems but also attached to ethical considerations too. (Kar, 2006) The Testing Problems and the Test Bias tend towards Racial Discrimination and the most affected part of it is the children of the Minority Groups. It may be an issue that the Minority Group Children may be intellectually inferior to their white counterparts but it is no logical or ethical solution to regard it as mild or serious Mental Retardation. It is not only the African Americans that are affected but a wide range of Mexican Americans are affected by these covert Intelligence Tests. This scenario cannot be termed as an ideal background of Equal Education system and Elementary Education in general is suffering for this issue. It can be well stated that a complete Educational Diagnosis is need for the issue in order to find the cure. (Roberts, 2007)
However, from an ethical point of view it should be noted that a tool relating to social science could hardly be neutral in any sense because it depends too much on the social structure and demands a specific form of socio cultural background dependence for success. (King, 2006) In this respect it can be stated that classification tests like the intelligence tests cannot be completely neutral and thus the covert methods like the Stanford-Binet Intelligence Scale and the Wechsler Intelligence Scale for Children can only be modified to bridge the gaps among the cross cultural variations but can hardly be eradicated as these test in this context deals with the aspects of society and the society of the United States is completely a confluence of multiple cultural backgrounds. So there would be patients and participants from different cultures and these variables would be taken into account. (King, 2006)
From the ethical point of view, it can be stated that the classification on the basis of intelligence should be banned but then compromising on such grounds would surely give rise to mediocrity and would surely bring down the national level of quality in terms of education. The best possible ethical aspect in this context would be the proper appointment and use of a school psychologist who would look over the actual aspects of individual skills and abilities by concentrating on person-to-person behavioural assessments. Thus with closer assessment of the school psychologists it would be possible to illustrate the individual capacities in the illumination of implications that are chiefly socio political. In such manner, the basic concept of the intelligence test or the perspective of the elements of intelligence would not be misused. (Sen, 2006) Intelligence and education level of the patients are vital part of the research because it is seen that people with different level of intelligence and education react differently to discomfort or physical and mental uneasiness. (Sen, 2006)
It should be stated that the Legal and Ethical Considerations in relation to covert Tests and Measurements in research should always be devoid of Test Bias or biased Educational Legislations. The student rights should always be honoured and practiced and this would be directed towards openness in terms of social influence and activated towards better position of the Elementary Secondary Education methods and systems. The School Psychologists, the administration should work in simultaneous measures with the Intelligence Tests as these are tested and found to be quite useful for the benefit of the state and the society in the long run. Thus, it could well be stated that the issue that gave rise to the alleged educational discrimination could well be directed towards the eradication of racism in the future. (Lamb, 2004)
There are specific exceptions to the rule. Apparently, there are situation when the utilitarian perspective should be taken into consideration that would be more relevant in the context of the given situation. Act Utilitarianism represents all ethical theories where the goal is maximization of some measure of goodness. These are outcome-oriented ethics where goodness is measured by its results. In other words, Utilitarianism is a doctrine that confirms whether or not actions have been useful or beneficial to a large group, once applied. (Deb, 2006)
It is important to understand that the concept related to the aspects of zero tolerance developed from the viewpoint that has its base in the parameters that actually rose as a classical utilitarianism reaction. From the parameters of Act Utilitarianism it should be remembered that Mill placed his argument that the there is much pain in the penal system and it tend to affect an individual by a large margin and the aspects of penal consequences should be taken into consequences while evaluating the entire process of proposed activity, in this case covert research methods. Take for example if a situation when it is important to understand the basic psyche of the general population of a given enemy state over a specific issue. Under such condition, an overt operation of research is not possible thus; it is well relevant to use covert research method, as it is beneficial for the nation as a whole. (Anand, 2006)
It would be relevant to mention that both overt and covert methods are beneficial and permissible for the purpose of research. The basic rationale behind this though process lies in the fact that, in general sense, a research is directed towards the greater goodness of the society in the long run and thus for a short run period it would be acceptable to allow a covert action. However, the dilemma remains that it is important to evaluate the need of the research that justifies the cause of using a covert operation in a given research. (Podolski, 2006)
Factors that manage approval of studies such as this one in regard to impact of PEG use and abuse on professional level would include the verifiable reports of discrimination or mismatch by agencies including senior workers, administrator and fellow employees. The rise in differences and such provide a very thorough glance into the behaviour of subjects. Reactions can also be generated that behaviour in the use of impact of Peg paradox is affected by their ready knowledge of self-positioning along with related facts and figures. The researcher may find that the hypotheses made in the progression of the research would indeed have been validated through responses from the selected population. This further approves the necessity for further study and research into methods toward equilibrium in the environment relating to impact of Peg.
Data collection
In the context of qualitative method operations, communication relates to inter personnel office communication such as phone, documents, memos, email, FAX and voicemail. (Robson, 2002) These communicative systems could be termed as formal communication system. (Robson, 2002) There are also other forms of communication and it could be termed as informal communication. Informal communications could be defined as taking place synchronously in face-to-face settings. Questionnaire data produce estimates of between 25% and 70% of time being spent in face-to-face interaction, with these figures depending on job type. Similarly, and again, depending of the industry formal communication system may occupy about 54% to about 91% of the time spent on an average. Obviously, it could be stated that formal communication are usually well planned and structurally sound. (Robson, 2002) On the other hand, informal communications are, revealed in studies, brief, unplanned, and frequent. Informal communication supports a number of different functions: the execution of work-related tasks; co-ordination of group activity; transmission of culture and social functions such as team building. (Robson, 2002) This statistics would help to use the questioner in a better and effective manner so that the responses are gathered in a more lucid and effective manner.
Its importance is shown by research into scientific collaboration demonstrating that physical distance is a strong predictor of whether scientists will co-publish, because people who are physically collocated are more likely to communicate frequently and informally. (Creswell, 2003) Questionnaire studies also suggest that physical proximity supports frequent opportunistic conversations, which are vital to the planning and definitional phases of projects. (Creswell, 2003) Other questionnaire studies support the effects of proximity and hence informal communications on social and cultural knowledge. Researchers are more likely to be familiar with, and to respect the work of colleagues who sit close to them. Thus to understand the experiences of patients with a PEG and to examine patients views of having a PEG it is important to follow these aspects for better and effective data gathering results.
The two main types of prototype system that have been built both involve synchronous audio and video. The first provides a permanently open link between the commons areas of two geographically separated sites, with the aim of facilitating unplanned conversations between workers at the two locations. Commons area connections have been moderately successful in promoting brief social interactions. However, there was evidence that briefly seeing someone over the video link was less likely to promote an extended interaction, than an equivalent face-to-face sighting.
The second class of system for remote informal communications involves Desktop video, either point-to-point or between multiple locations. (Denzin, 2003) Some of these systems provide additional visual information about the communication status of the call recipient, using a glance feature. (Denzin, 2003) Here callers can check the availability of their recipient, by opening a visual link for a few seconds, prior to initiating the conversation.(ref) An eventuation of one such system showed, however, that it does not effectively replicate face-to-face interaction. (Denzin, 2003) However, if face-to-face interaction is not possible, this method would be very helpful for gathering information.
Research communications also raise numerous questions for interaction theories. Research conversations are mainly opportunistic, so how do participants co-ordinate and initiate them, given that they are unanticipated? Given the situation that the subjects are mostly ailing and sick. There are also often time lags between business interactions: how do people maintain and re-establish context, given such lags? Finally, business communications often occur between frequent interactions who often share large amounts of background knowledge. Thus, collection of sheets would need very intricate approach by the researcher.
However, it should be taken into contention that to obtain such goals in finding legitimate and verified answers substantial and thorough research should be operated in a far larger scale. For example, for interactions away from desk, the first and foremost variable required is to find out the exact location of occurrence. Thus, regular visits to the hospitals are absolutely needed. Next, it should be looked into whether there are enough variables on the structural properties, examining how conversations are opened and closed and the ways that participants introduce and agree on conversation context. Another test prediction is about frequency. Frequent interaction should share background context as well as being familiar with each other. We therefore expected frequent interactions to show less formality in opening and closing interactions as well as reduced need for context setting. (Fowler, 2002) This would make it possible to get the perfect insight the issues of the research.
The best statistical method would be to interview long well formulated day-to-day working procedure at a specific and well-selected location. This is because once the researcher is visiting a specific location, a hospital in this context, it is logical to complete all the tasks formulated beforehand to make the job easier and effective. Throughout the procedure, it should be noticed whether there are specific variables within the testable population or not. The variables would include race and ethnicity. This is because researches proved that people of different race react differently to mental and physical discomfort. (Punch, 2000) These variables would be extremely important while evaluating the basic data in the final stages where the adjustments would be made to the formulated data in accordance to the observations. However, it is important to completely take into account the aspects of fundamental variables of an individual such as ethnicity, religious belief or positive support from the discomfort level structure of the patient. (Punch, 2000)
Data analysis
All these variables are considered as very relevant and important features of the statistical method and it is to be seen if these aspects are fundamentally acceptable in practical world and it could well be mentioned that service, especially health service industry, are a very relevant manifestation of the social dimensions. As a result, if the test is carried out in a proper manner with proper calculations of the population involved then there is no reason that the results would be both logical and true at the end consideration. Though it is a qualitative method, opinions of the patients would be recorded and formulated to ascertain visible trends related to the research issue.
As descriptions of statistical methods that will be used it could be stated that in order to isolate the results for this particular study, a survey questionnaire done would have been utilized and the opinions of the patients would be recorded. These questionnaires would be delivered to potential stakeholders and retailers along with the administrators of different health organizations to get the general view of the administration about the issue of using PEG. The results were divided into these same categories to ensure validity and reliability. General information in regard to identifiers was utilized in order to ensure that there would be no bias. This information provided the researcher with a more clarified view of perceptions in regard to the impact of PEG. (Gerrish, 2006)
Timetable
The total dissertation procedure would take 11 months. Literature Review would take three months, it would be followed by Conduct Interviews/Collect data, and it would take two months. Transcribe of Interviews would take another two months followed by Analyse Data would take one month. The Draft Final Report would be in one week and Feedback in another one month followed by Submitting Final Report. There would be an additional month to counter any unforeseen circumstances that may suspend the work.
However, it should be mentioned there are certain limitations of the study. A number of people (usually senior administrators) may also insist that the consumers have no contribution to the issue. Many of them may think that patients come into the working formulation only during the healing scenario and never in the development plan of the formulation procedure. As a result they do not use the requisite strategic techniques or adaptive methods that need to be exercised while developing a study such as this. However, it creates a void in the test as this limitation can be overcome by taking the subject into better mode of confidence. However, at the same time, it should also be noted that there are certain limitations regarding the methodology of the interview aspect. (Morse, 2002) It could be mentioned that past history has shown that it is not always people revealing a context in a survey or interview holds much truth in the long run in general sense. This is one variable that is able to corrupt any well-formulated strategically set formulations. (Morse, 2002) However, this again is a possibility and not the general rule. At any case it should be noted that all steps would be taken with utmost care so that such variables are not allowed to upset the basic test of patient segmentation beyond a certain permissible limit. (Morse, 2002) If all these parameters are well implemented there could be no reason why a long-term strategy for operation in a full-length penetration and procedure cannot be established. (Morse, 2002)
Budget and likely funding sources
The funding in this case would be kept to a minimum. It would be seen that no extra cost is incurred during the process. It would also be taken into consideration that no extra equipments and fancy gadgets would be used. The fundamental cost would be centred around the travelling mode that would be necessary during the interviewing procedure. It should be mentioned that this travelling would be in and around the vicinity of the working area and thus the cost would be minimized. The research and the evaluation would be done in house and thus, no extra cost would be incurred. The total cost of a project would include costs of travel, ($500) tapes, ($400), transcription ($400) and paper ($100) or $1400 in total.
Dissemination of results
Results would be based on reflection that should be put into consideration and implemented always. In instances where officials are to be deployed to work in the community, they should not misuse the power and authority bestowed on them. This is because some officers by virtue of being in possession of power and authority; they can continue acting in a coercive manner towards the community. This may damage the public order, which in the first place they were supposed to maintain. Officials should not take positions and start protecting their active supporters even when they are on the wrong since this can lead to bad perception of the officials by the public. This paper would be published in eminent journal to convey the re
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