Nursing

If you were to ask 10 people what they believe to be the most significant issue facing healthcare today, you might get 10 different answers. Escalating costs? Regulation? Technology disruption?
These and many other topics are worthy of discussion. Not surprisingly, much has been said in the research, within the profession, and in the news about these topics. Whether they are issues of finance, quality, workload, or outcomes, there is no shortage of changes to be addressed.
In this Discussion, you examine a national healthcare issue and consider how that issue may impact your work setting. You also analyze how your organization has responded to this issue.
To Prepare:
Review the Resources and select one current national healthcare issue/stressor to focus on.
Reflect on the current national healthcare issue/stressor you selected and think about how this issue/stressor may be addressed in your work setting.
By Day 3 of Week 1
Post a description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.
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Solution
Healthcare Environment
With new emerging diseases that have proven hard to contain, growth in population, and inflation; the healthcare sector continues to face obstacles despite the several advances that have been made over the years.
A Description of a Healthcare Stressor
One of the biggest national healthcare stressors that have not only affected the third world countries but also the developing countries is the shortage of healthcare workers, especially nurses. Covid 19 has made this situation worse due to the high number of patients affected by the novel virus. The high number of patients was too overwhelming for the doctors and especially nurses who are usually considered as the backbone of a healthcare system (Alshammari, 2020)
How the Healthcare Stressor may Influence the Work Setting.
According to the American Nurses Association (ANA), there are more nursing vacancies in the United States as compared to other professions. Nurses continue to overwork due to the shortage that was brought about by a lack of educators and a high turnover of patients (Haddad LM, 2020). this shortage usually leads to medical errors, high morbidity and mortality rates, patient dissatisfaction, and even burnout syndrome amongst nurses.
How your Health System Work Setting has Responded to the Stressor.
To address the issue of shortage of nurses, the health system has employed several tactics to minimize it. They include; more recruitment of nurses and encouraging more people to take up nursing in school. According to (Li, 2015) most of those nurses recruited to move from developing countries to developed countries a large percentage of them coming from the Philippines.
References.
Haddad, L. M., Annamaraju, P., & Toney-Butler, T. J. (2020). Nursing Shortage. In StatPearls. StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490501/
Li, H., Nie, W., & Li, J. (2015). The benefits and caveats of international nurse migration. International Journal of Nursing Sciences, 1(3), 314-317. https://doi.org/10.1016/j.ijnss.2015.07.006

Attention-Deficit/ Hyperactivity Disorder (ADHD): Treatment in Children and Adolescents
Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your assigned disorder in children and adolescents.
Explain the risk assessment you would use to inform your treatment decision-making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?
Explain whether clinical practice guidelines exist for this disorder and if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.
Support your reasoning with at least three scholarly resources, one each on the FDA-approved drug, the off-label, and a non-medication intervention for the disorder. Attach the PDFs of your sources.
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Solution
Attention-deficit/ hyperactivity disorder is a neurodevelopmental disorder that affects children but can progress into adulthood if not treated early. Affected children have a reduced attention span and may in addition show hyperactivity or not (APA, 2013; Sadock et al., 2015).
Treatment in Children and Adolescents
One FDA-approved drug for treating ADHD in children and adolescents is atomoxetine (Strattera). It is a selective norepinephrine reuptake inhibitor (Stahl, 2017). There are also other medications that are not FDA-approved but used off-label to treat the condition. One of them is bupropion (Wellbutrin). It is a norepinephrine dopamine reuptake inhibitor (Stahl, 2017). A study by Braüner et al. (2016) found that about 32.3% of all psychiatric prescriptions for children and adolescents are off-label. The nonpharmacological interventions that are evidence-based include psychosocial treatments such as parent training, cognitive-behavioral therapy (CBT), and neurofeedback amongst others (Shrestha et al., 2020).
Risk Assessment to be Performed for Treatment Decision
The risk assessment that would be performed to inform the treatment decision would involve finding out the safety profile of especially the non-FDA approved medication. Also, extensive consultations with more experienced colleagues who have used it before will need to be done. For the FDA-approved one, the risk assessment will involve evaluating the possibility of adverse reactions. The benefit of the FDA-approved drug is that it is proven to be efficacious in treating the condition. The risk is that of sedation and reduced appetite (Stahl, 2017). The benefit for the off-label drug is also that it has been shown to reduce ADHD symptoms by anecdotal evidence. The risks however include insomnia, weight loss, and agitation (Stahl, 2017).
Clinical Practice Guidelines
There are indeed clinical practice guidelines for use in guiding the treatment of ADHD in children and adolescents (Wolraich et al., 2019). The guidelines advocate for the use of nonpharmacological interventions as a first step. If results are not achieved, then pharmacological measures are to be added. Off-label prescriptions can be tried if the PMHNP thinks that the characteristics of the child favor a better clinical outcome.
References
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.
Braüner, J.V., Johansen, L.M., Roesbjerg, T., & Pagsberg, A.K. (2016). Off-label prescription of psychopharmacological drugs in child and adolescent psychiatry. Journal of Clinical Psychopharmacology, 36(5), 500–507. https://doi.org/10.1097/jcp.0000000000000559
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.
Shrestha, M., Lautenschleger, J., & Soares, N. (2020). Non-pharmacologic management of attention-deficit/hyperactivity disorder in children and adolescents: A review. Translational Pediatrics, 9(S1), S114–S124. https://doi.org/10.21037/tp.2019.10.01
Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.
Wolraich, M.L., Hagan, J.F., Allan, C., Chan, E., Davison, D., … Earls, M. (2019). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528

Paper Assignment FO
A zero will be given for all Hallmark assignments submitted late.
Concept: Delegation
Case Study
You are working the night shift on a medical unit and have been assigned charge nurse responsibilities. You are working with four RNs, one LPN, and two UAPs. A client becomes pulseless and is not breathing, and the nurse assigned to the client’s care calls a code. The nurse is occupied at this client’s bedside for 1.5 hours until the resuscitation effort is completed, and the client is transferred to the intensive care unit. This nurse also has four other assigned clients. In addition to the nurse assigned to care for the client requiring resuscitation, two of the other nurses working on your unit are assisting in the code.
Review the case study and write an essay (suggested length of 2–3 pages, excluding title page and reference page) in which you do the following:
Discuss what tasks could you delegate to the UAPs?
The LPN working on the unit is a new graduate and has been employed for only 4 weeks. How would you collaborate with this nurse when delegating tasks for completion?
Discuss how you will maintain the safety of the other clients on your unit while three nurses are occupied with the client requiring resuscitation?
Explain how might effective delegation to other team members contribute to care of the clients on the unit? (Remember, this is not a question about the patient that is coded, but how you will handle the unit while you are short staffed).
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Solution
Delegation
Delegation is the process whereby a registered nurse or delegator directs another person, the delegate, to perform nursing activities and tasks involving patient care (Barrow & Sharma, 2021). Registered nurses must decide whether to delegate and understand which tasks can be delegated, the competence of the delegate, and the level of supervision necessary (Barrow & Sharma, 2021). Delegation decisions are challenging in nursing practice and require appropriate considerations to improve patient care outcomes. Factors that necessitate delegation include increased patient care complexity and nursing shortages (Barrow & Sharma, 2021). This means that delegation in the healthcare sector is unavoidable but requires a thorough understanding by involved parties to avoid lawsuits and deliver safe and effective care. Thus paper discusses tasks that can be delegated to UAPs, how to collaborate with the LPN to delegate duties, and ensure patient safety during the delegation process.
Delegation to UAPs
Nursing tasks can be performed by other healthcare team menders, such as unlicensed assistive personnel (UAPs). UAPs provide effective care both through clinical work like vital signs monitoring, mouth care, and turning, and nonclinical work like keeping the environment orderly (Wagner, 2016). In this case, I would delegate the three clinical tasks to the UAPs to assist in providing care to the coded patient in the intensive care unit. However, I would follow the legal parameters defined by the scope of practice established by professional nursing organizations like the ANA and the state to ensure patient safety (Wagner, 2016). RNs are accountable for delegation decisions and the adequacy of nursing care provided to the client or healthcare customer. Thus, the UAPs will perform these tasks under the supervision of the RN.
Collaboration with LPN in Task Delegation
Collaboration in nursing practice is vital as it helps promote patient safety and better patient outcomes. In cases of emergencies in the facility, collaboration is crucial in meeting the patients’ complex needs (Jowsey et al., 2020). In this case, the newly graduated LPN will perform tasks as taking and monitoring vitals and administering medications under the supervision of the RN (Jowsey et al., 2020). The RN should thoroughly explain the tasks to be completed the how they should be performed while supervising the LPN to enhance patient safety and outcomes.
Patient Safety Concerns
As a charge nurse, I would do rounds and communicate with the other patients to ensure they feel safe and comfortable. I would instruct the UAPs to keep the environment orderly and the LPN to take and monitor patients’ vitals and ensure medications are taken on time under my supervision as a charge nurse (AHRQ, 2021). This will provide a safe environment for the patients, thus promoting patient outcomes.
Impact of Effective Delegation to Patient Outcomes
Effective delegation is crucial in leadership and helps create workload balance between management and staff. Delegators or nurses in charge should assign tasks with the understanding that they are responsible for the outcomes of the activities the individual the task is delegated to perform (Walker et al., 2021). Thus, the nurse in charge should critically consider individuals’ competencies, the scope of practice, and competencies before delegating tasks to provide a sense of safety to patients and promote patient outcomes. Moreover, effective communication and teamwork will promote a better work environment where all employees and staff members are committed to patient safety and outcomes by delivering high-quality and timely care (Walker et al., 2021). Patients are satisfied when they receive high-quality care from caring staff and in a caring environment.
References
AHRQ. (2021, April). Nursing and patient safety. https://psnet.ahrq.gov/primer/nursing-and-patient-safety
Barrow, J. M., & Sharma, S. (2021). Five rights of nursing delegation. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519519/
Jowsey, T., Foster, G., Cooper-Ioelu, P., & Jacobs, S. (2020). Blended learning via distance in pre-registration nursing education: A scoping review. Nurse education in practice, 44, 102775. https://dx.doi.org/10.1155%2F2020%2F5057084
Wagner, E. A. (2018). Improving patient care outcomes through better delegation-communication between nurses and assistive personnel. Journal of nursing care quality, 33(2), 187-193. https://www.nursingrepository.org/bitstream/10755/612249/3/Wagner_Manuscript2016.pdf
Walker, F. A., Ball, M., Cleary, S., & Pisani, H. (2021). Transparent teamwork: The practice of supervision and delegation within the multi?tiered nursing team. Nursing Inquiry, e12413. https://doi.org/10.1111/nin.12413

Define CAM.
Describe the patient who uses CAM the most.
List some common misconceptions about CAM.
Identify methods of including the use of CAM in patient education.
Discuss the safe use of CAM.
List ways in which conventional medicine and CAM can be integrated.
Define ethical theories, ethical principles, and values.
Provide examples of ethical issues in patient education and compliance, and describe ways in which an effective professional/patient relationship and a poor health professional/patient relationship can impact these issues.
Explain what is meant by “ethical patient education practices”.
Explain the purpose of informed consent.
Discuss what factors determine the patient’s ability to give informed consent.
Compose a sample informed consent form.
Discuss the process of communication to use with the patient and the family when obtaining informed consent.
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Solution
Complementary and Alternative Medicine
Complementary and Alternative medicine (CAM) involves implementing strategies, practices, and products that are not part of the standard medical care to help enhance the health and wellness among patients (Brewer et al., 2019). These therapeutic approaches have become more common among patients since it plays a significant role in the healthcare sector. The increased use of CAM approaches in the future might become an essential part of all healthcare systems.
A large number of patients are using complementary and Alternative Medicines. For example, approximately 46% of the population is expected to use one or more CAM approaches during treatment in the UK. Reviews show a prevalence use of CAM among specific clinical populations like diabetes, asthma, and stroke patients. Research also shows that females of middle age have been prevalent in using CAM. Those using CAM approaches are usually experiencing more than one medical condition.
Several misconceptions about the use of CAM are perceived in treating and enhancing wellness. First, CAM is an unscientific method as compared to the implementation of standard medical care. This is because it does not use mainstream medicine since it integrates evidence-based approaches. Secondly, some believe that it is ineffective, which is one of the major misconceptions held about CAM approaches. Some CAM approaches have been perceived to be wrong, and it specific worth treating and promoting a patient’s health. Lastly, CAM is expensive. People believe that paying a therapist is more costly than visiting a health facility. This is not the case since some of the therapies done in CAM, such as relaxation, guided imagery, and self-management therapy, can be conducted by individual patients.
There are different methods where the use of CAM can be included in patient education. They include the biologically based method, which involves using medicines and supplements derived from herbs for dietary deficiency and supplementing nutrients in the body (Brewer et al., 2019). Manipulative and body-based therapies are methods that incorporate the use of massage and other activities that stretch the body’s structural parts. Lastly is the mind-body interventions that focus on also healing the mind and spirit like yoga, meditation, and guided imagery.
CAM approaches are safe for patient use if they serve the intended purpose and do not worsen a situation. To ensure the safe use of CAM, practitioners involved should clearly understand the approaches and when they should be applied. Some approaches should be used with caution among different clinical populations. For example, cancer patients can implement less harmful and painless approaches to help cope with side effects of the chemotherapy, such as fatigue.
A perceptible trend towards the combination of complementary and alternative medicines approaches and conventional medicine practices is happening in the healthcare sector. This is usually a combination of convectional primary medical care and CAM practices. There can also be a focus on open communication between patients and service providers that promotes openness and comfort to patients.
Ethical theories are a set of principles used to account for moral practices to be used by nurses when facing specific issues. Ethical principles in nursing refer to practices that nurses must adhere to regarding justice, compassion, liability, fidelity, and authenticity (Kiljunen et al., 2017). Ethical values are standards that serve to differentiate between good and evil, right or wrong, and what is morally right.
Several ethical challenges in the healthcare sector may involve patients, leaders, and health practitioners. These issues include patient privacy and confidentiality, end-of-life issues, and relationships (Kiljunen et al., 2017). A positive effect of professional/patient relationships towards ethical issues is that patients can actively engage with their practitioners and share any critical detail that may help inpatient care. A poor professional/patient relationship affects ethical issues since a patient might feel that sharing personal details might jeopardize their confidentiality and privacy.
Ethical patient education practices refer to proper methods in which patients make informed decisions regarding compliance, concordance, and acceptance of preferred treatment. This is whereby patients believe that after discussing with a service provider, guided with principles and openness, honesty, and acceptance, they can choose the treatment they most prefer.
Informed consent is a process in which a patient acquires education about the risks, interests, and alternatives of a given approach or alternative. With this, a patient can relate to any particular medication or treatment as opposed to controlled substances. Its purpose is to ensure that the treatment objectives are well articulated, the patient is aware of the risk involved, and that alternative treatment methods are considered.
Factors that determine a patient’s ability to provide informed consent include age, where the patient is of legal age to make a decision. Secondly is mental stability, where the patient should have a clear mind through the decision process.
Research Study Title God’s callings after retirement
Study Type Project
Purpose Identify different callings that a person can engage in after retirement.
Goals Narrow to two practices to engage after retirement
Risks What are some of the challenges participants likely to encounter?
Advantage What benefits will the callings were chosen have to the participants?
The communication process used while obtaining informed consent from patients and family include:
Developing an effective rapport with the patient.
Getting consent for a discussion.
Preparing and engaging the patient’s family.
Acquiring information about the patient’s insights.

References
Brewer, N., Turrise, S., Kim-Godwin, Y., & Pond, R. (2019). Nurses’ Knowledge and Treatment Beliefs: Use of Complementary and Alternative Medicine for Pain Management. Journal Of Holistic Nursing, 37(3), 248-259. https://doi.org/10.1177/0898010118822212
Kiljunen, O., Välimäki, T., Partanen, P., & Kankkunen, P. (2017). Multifaceted competence requirements in care homes: Ethical and interactional competence emphasized. Nordic Journal Of Nursing Research, 38(1), 48-58. https://doi.org/10.1177/2057158517712084
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NURS 6521
To Prepare
Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
Think about a personalized plan of care based on these influencing factors and patient history in your case study.
By Day 3 of Week 1
NURS 6521
Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.
By Day 6 of Week 1
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
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Use the “Community Teaching Work Plan Proposal” resource to complete this assignment. This will help you organize your plan and create an outline for the written assignment.
After completing the teaching proposal, review the teaching plan proposal with a community health and public health provider in your local community.
Request feedback (strengths and opportunities for improvement) from the provider.
Complete the “Community Teaching Experience” form with the provider. You will submit this form in Topic 5.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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Solution
Community Teaching Work Plan Proposal: Stroke Prevention
Community health nursing is premised on preventive education and health promotion. The most preferred type of prevention in this is primary prevention. This type of prevention aims to prevent the occurrence of disease in the first place by educating the community about the correct behavioral attitudes and practices that will keep them healthy. The purpose of this paper is to present a community teaching work plan proposal for the primary prevention of stroke.
Teaching Plan Summary
The topic for this teaching plan is stroke prevention through an educational intervention. The community members will be taught about what stroke is and what they need to do to prevent themselves from suffering from it. This project will teach the educators who are nurses and nurse assistants with direct patient contact who will then go into the community and teach about stroke prevention. The location of the teaching exercise will be Mansfield Medical Associates premises and the estimated duration of the exercise will be 25 minutes. The cost of the exercise is estimated to be about USD 80. This will cater to the resources required for the exercise. These include materials like pamphlets, supplies, snacks, and equipment such as a computer and overhead projector for PowerPoint presentations.
Focus for Community Teaching
This involves the topic selection and the focus for community teaching in this exercise is the primary prevention of strokes. The goal of the exercise to be specific will be:
To educate the population of patients and the community on what stroke is and its consequences.
To educate about the recognition of a stroke through its signs and symptoms.
To educate on what to do in terms of behavioral practices to reduce the risk of suffering a stroke.
The need for this education on stroke prevention is informed by the fact that statistics for stroke in the DFW area show that the incidence remains high. The approach is expected to be successful as it did when stroke mortality numbers came down following the teaching that EMS should be called early for intervention.
Epidemiological Rationale for the Topic: The Statistics
Stroke is currently the fifth leading cause of death in the United States, accounting for about 42.3 deaths per 100,000 persons. It is also a major cause of disability especially for the elderly above the age of 65 years (Hammer & McPhee, 2018). In absolute terms, about 795,000 persons in the US are affected by stroke every year according to the Centers for Disease Control and Prevention or CDC (CDC, 2021). Stroke is also the number three killer in the state of Texas, costing it about USD 5.3 billion in 2017 alone (AHA, 2017). The mortality in the North Texas area has gone down in recent years, but the prevalence still remains high with a 4.4 ranking placing the county among the 17 with the most strokes. Among the 17 counties, North Texas falls in the middle in terms of stroke rate between the lowest rate of 2.8% and the highest of 6.6%.
Teaching Plan Criteria
The nursing Diagnosis
The nursing diagnosis is the second stage in the five-step nursing process of assessment, diagnosis, care planning, intervention, and evaluation (Toney-Butler & Thayer, 2020). The nursing diagnoses for stroke include the following:
Risk of ineffective cerebral tissue perfusion related to impaired blood flow within the brain.
Impaired verbal communication is related to hypoxia of the speech (Broca’s) area in the brain.
Impaired physical mobility is related to hypoxia of the motor area in the brain.
Readiness for Learning and Learning Theory to be Used
The nurses and medical assistants being professionals have shown a lot of maturities and emotional intelligence. These are essential for readiness to learn. The learning theory chosen is constructivism. It states that learners will actively construct information or knowledge rather than just take it in passively. Thus the learners will be encouraged to think critically and act instead of being fed information.
Healthy People 2020 Goal and Relation to Alma Ata’s ‘Health for All’ Global Initiatives
The HP2020 objective for heart disease and stroke is to prevent, detect, and manage risk factors. Prevention is through health education and promotion. The relationship to the Alma Ata Declaration is that ‘Health for All’ can only be achieved if the risk factors for stroke are also checked.
Table: Develop Behavioral Objectives (Including Domains), Content, and Strategies/Methods
Behavioral Objective and Domain Content Strategies/ Methods
Learners will be asked to name the risk factors they know about stroke (cognitive domain) The educators will pose the question to the learners verbally Oral interaction during the lecture with those who want to try answering raising their hands.
Learners will be given a hypothetical situation that they will be asked to present a solution to (cognitive and affective domains) The educators will give each learner a hypothetical case Case presentation by the learners.
A dummy will be placed and each learner will be required to demonstrate what they need to do in the event that they suspect a stroke (psychomotor domain) Each learner will be given a chance to show what they can do and the educators will supervise and award marks/ grade competence The use of a dummy for demonstration.
The educators will do simulation for the learners to copy and emulate (psychomotor domain) Educators will demonstrate skills and competencies needed in stroke prevention and management The use of lectures, simulations, and demonstrations.
Creativity
This will be applied in the teaching methodologies by way of vivid graphics in the presentation. Also, case presentations will be accompanied by screen animations that will enable learners to grasp the content faster.
Planned Evaluation of Objectives
Assessing what the learners know before giving them the presentation. This will be evaluated by way of an initial short written pre-test that each learner will be gauged with.
Assessing whether the learners have understood the content. This will be evaluated by giving a post-test but also by asking the learners random questions.
Planned Evaluation of Goal, Lesson, and Teacher
The evaluation of the overall goal will be done by way of a community survey after the educators have been sent to educate patients within the community. The survey will be administered to a representative sample and it will show whether they now know how to prevent stroke or not. The lesson’s effectiveness will be evaluated by the scores that the learners will get in the post-test. As for the teacher, the same test will show whether they were effective in their approaches or not by the scores that the learners will get.
Potential Barriers During Teaching
The potential barriers that may arise during teaching include scarcity of time, lack of enough experience of some of the learners, and distraction by mobile gadgets. Handling these will require setting ground rules before starting, such as switching off mobile phones. Also, time can be managed by not wasting time on matters that are not directly related to the subject at hand.
Therapeutic Communication
The lecture will be started with an interesting anecdote aimed at capturing the attention of the learners. Random questioning will be used to determine if there is active listening. Active listening will be applied to tailor the presentation to the audience by repeating some points if it is determined that active listening is wanting. The conclusion of the presentation will be by way of a summary of all the salient points. The non-verbal communication techniques to be used include gestures and facial expressions.
References
American Heart Association [AHA] (2017). Texas fact sheet. https://www.heart.org/-/media/files/about-us/policy-research/fact-sheets/quality-systems-of-care/quality-systems-of-care-texas.pdf
Centers for Disease Control and Prevention [CDC] (August 2, 2021). Stroke. https://www.cdc.gov/stroke/index.htm
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 7th ed. McGraw-Hill Education.
Toney-Butler, T.J. & Thayer, J.M. (2020). Nursing process. https://www.ncbi.nlm.nih.gov/books/NBK499937/#:~:text=The%20nursing%20process%20functions%20as,planning%2C%20implementation%2C%20and%20evaluation.&text=Assessment%20is%20the%20first%20step,data%20collection%3B%20subjective%20and%20objective.

A nurse is taking care of an 85-year-old woman in a hospital-based skilled nursing facility. In the report, the nurse is told the patient has not been breathing well for the past 2 days. She has been lethargic, her skin is warm and dry, and she has a decreased urine output. The following laboratory findings were returned from the laboratory immediately after the morning report:
Blood Chemistries
Na: 147
Cl: 110
K: 4.0
Arterial Blood Gases
pH: 7.33
PCO2: 48
HCO3: 27
PO2: 96
Urinalysis
Urine Specific Gravity: 1.040
Address the following:
Identify each of the abnormal laboratory findings in the above results. Specify how they differ from a normal range and identify what condition each abnormality indicates.
What specific electrolyte disturbance does the patient have?
What clinical manifestations would the nurse expect to see with this electrolyte abnormality presented above?
If the patient had an increase in her potassium level, for what clinical manifestations would the nurse monitor?
What blood gas abnormality is seen in this patient? Discuss the rationale for your answer.
What are the three major mechanisms of pH regulation?
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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Solution
Laboratory Findings
The blood chemistries show elevated sodium and chloride levels with normal potassium levels. A high sodium level above 143mEq/l is hypernatremia. Causes of hypernatremia are severe dehydration from acute volume loss or diarrhea. The chloride levels for this patient are 110, which is slightly higher than the normal value of 106. This is a sign of hyperchloremia. Causes of hyperchloremia are metabolic acidosis, dehydration, excessive salt intake, and electrolyte imbalance. The potassium level is within the normal value.
Arterial blood gases show slightly low PH levels, higher bio-carbonate, elevated partial pressure of carbon dioxide, and normal oxygen saturation. PH of 3.3 is a sign of metabolic acidosis. Slightly elevated bio-carbonate and partial pressure of carbon dioxide level is a result of electrolyte imbalance or dehydration. Changes in arterial blood gases indicate electrolyte imbalance (Pin-On, et al, 2018). The urine-specific gravity elevated. It is an indication of mild dehydration.
Patient Electrolyte Imbalance
The patient suffers from hypernatremia and hyperchloremia due to the elevated sodium and chloride, increased partial pressure of carbon dioxide, decreased PH, and elevated bio-carbonate.
Clinical Manifestation Of The Electrolyte Imbalance
Electrolyte imbalance in elevated sodium and chloride levels presents with lethargy, confusion, seizure, numbness of extremities, tingling sensation, sweating, tachycardia, tachypnea, oliguria, dry oral mucosa, dry axillae, abnormal skin turgor, abnormal speech, irritability, weight loss, and generalized weakness.
High Potassium Levels
Hyperkalemia is elevated potassium levels greater than 5.5mEq/l. Causes of hyperkalemia are destruction of red blood cells, excessive potassium supplement use, severe dehydration, and adrenal deficiency (Hunter, et al, 2019). Clinical presentation includes muscle paralysis, dyspnea, palpitations, chest pain, paresthesia, nausea, and vomiting. The nurse should monitor the heart rate to check for bradycardia due to the heart block. They should also monitor the respiratory rate. The patient has tachypnea due to respiratory muscle weakness.
Blood Gas Abnormality
The blood gas abnormality in this patient is metabolic acidosis due to low PH, slightly elevated bio-carbonate, and partial pressure of carbon dioxide level. Acidosis is the build-up of acid levels in the blood due to severe dehydration. The cause of metabolic acidosis in this patient is hyperchloremia and hypernatremia. Hyperchloremia causes the loss of sodium bicarbonate due to severe dehydration.
Three mechanisms of PH regulation
Mechanisms of PH regulation are chemical buffer, respiratory system, and urinary system. Chemical buffer regulates the PH levels by increasing the concentration of hydrogen in elevated acid levels. The H+ ion binds to the hydrogen reducing the carbon dioxide levels. The respiratory system helps in acid-base balance by regulating the carbon dioxide is in the blood (Venn, et al, 2019). During respiration, there is rapid hyperventilation that decreases the carbon dioxide in the blood thus reducing the bicarbonate in the blood. The renal system helps in regulating the PH by absorbing more acids and producing bicarbonate when needed.
References
Hunter, R. W., & Bailey, M. A. (2019). Hyperkalemia: pathophysiology, risk factors and consequences. Nephrology Dialysis Transplantation, 34(Supplement_3), iii2-iii11.
Pin-On, P., Saringkarinkul, A., Punjasawadwong, Y., Kacha, S., & Wilairat, D. (2018). Serum electrolyte imbalance and prognostic factors of postoperative death in adult traumatic brain injury patients: A prospective cohort study. Medicine, 97(45).
Venn, A. A., Tambutté, E., Caminiti-Segonds, N., Techer, N., Allemand, D., & Tambutté, S. (2019). Effects of light and darkness on pH regulation in three coral species exposed to seawater acidification. Scientific reports, 9(1), 1-12.

NURS 6521N Advanced Pharmacology Week 6 Alzheimers Disease
Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.
According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”
Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.
SUBJECTIVE
During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so you perform a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.
MENTAL STATUS EXAM
Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When you asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.
Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)
Advanced Pharmacology Nurs 6521
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Solution
Advanced Pharmacology Nurs 6521
Introduction
The case study focuses on Mr. Akkad a 76-year-old Iranian man who was diagnosed with major neurocognitive disorder due to Alzheimer’s disease (presumptive). The MMSE score for the client was 18/30 indicating moderate dementia. This paper, therefore, aims to make three decisions on the mediations to prescribe to the client. In addition, the ethical considerations likely to affect communication and the treatment plan for the client will be discussed.
Decision Point One
The first pharmacological agent that was selected for the client is to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks. The rationale for selecting rivastigmine is due to the medication’s efficacy in treating dementia and Alzheimer’s Disease. According to Su et al (2015), pathological changes associated with dementia of Alzheimer type include deficits in cholinergic neuronal pathways. Accordingly, the rivastigmine works by enhancing the cholinergic function by stopping the breakdown of acetylcholine. This improves the synaptic transmissions within the brain and thus improves memory as well as other cognitive functions (Kandiah et al, 2017). Because the client has dementia of Alzheimer type, he has low quantities of acetylcholine in the brain and thus rivastigmine will improve the symptoms the client is manifesting. Additionally, Birks et al (2015) explain that FDA recommended that the initial dose should be 1.5 mg BID and if the client does not experience significant side effects and tolerates the initial dose well after taking rivastigmine for two weeks, the dose should be increased to 3 mg BID.
Selection of this decision expected that the cognitive performance, behavior, function, as well as the ability to conduct activities of daily living for the client, would improve. This is because the efficacy of Exelon (rivastigmine) in treating has been demonstrated in several studies (Kandiah et al, 2017).
However, the expected outcome and the actual outcome of the first decision were different. This is because there was no symptom improvement as the son reported and also there was no change in the MMSE score. The lack of symptom improvement can be attributed to the low dose of rivastigmine prescribed to the client. The low dose of rivastigmine did not avail adequate levels of acetylcholine in the brain that could have led to symptom improvement (Kandiah et al, 2017).
Decision Point Two
The second decision that was selected is to have the rivastigmine dose increased to 4.5 mg orally BID. The reason for increasing the dose is because evidence indicates that an increased dose of rivastigmine has higher efficacy for people with Alzheimer’s Disease (Stahl, 2014). Evidence has shown that the efficacy of rivastigmine is dose-dependent when it comes to symptoms such as activities of daily living, cognitive functions, and global functioning. Therefore, it is expected that an increased dose will be more effective (Su et al, 2015).
The decision to increase the dose to 4.5 mg orally BID hoped that the cognitive function and other symptoms for this client would improve. It was also expected that the client would tolerate the higher dose well (Birks et al, 2016).
The actual outcome of the selected decision and the expected outcome were relatively similar. This is because the client manifested slight symptom improvement as evidenced by his attendance to religious service with the family. This shows that the increased dose of rivastigmine led to symptom improvement for the client, however slight (Kandiah et al, 2017). Moreover, as anticipated, the client tolerated the increased dose well as he did not report any side effect with the higher dose.
Decision Point Three
The last decision was to have the rivastigmine dose increased to 6 mg orally BID. As aforementioned, higher dose of rivastigmine increases the amount of acetylcholine within the brain and thus increases the efficacy of the medication (Sadowsky et al, 2015).
The decision to increase the dose to 6 mg orally BID hoped that there will be notable symptom improvement for the client, especially with the cognitive functioning and the capacity to carry out activities of the daily living. A study performed by Su et al (2015) showed that the administration of higher doses of rivastigmine to people with Alzheimer’s disease led to better symptom improvement especially symptoms such as cognitive functioning and the capacity to carry out activities of daily living. Since cholinesterase inhibitors like rivastigmine can only improve symptoms and not reverse the generative process, it will be important to educate the client and the son as well about how the medication works (Stahl, 2014).
Another expectation was that the client would still tolerate the increased dose of rivastigmine and thus will not experience significant side effects.
Ethical Considerations
Ethical considerations applicable to this client involve capacity determination, the ability of the client to make treatment decisions, and informed consent as well. In regard to capacity determination and the ability to make treatment decisions, symptoms of Alzheimer’s disease and dementia such as impairment in the cognitive functioning may hamper the ability of the client to understand and make treatment decisions (Fields & Calvert, 2015). In addition, it will be important for the PMHNP to explain to the client and the son about all the available treatment choices in order to enable them to make an informed decision (Fields & Calvert, 2015).
Conclusion
The initial medication that was selected is Exelon (rivastigmine) 1.5 mg. This is because the medication works by improving the cholinergic function and thus improves symptoms like cognitive functioning. With this decision, the client did not report any symptom improvement. Therefore, the second decision was to increase the dose of rivastigmine to 4.5 mg and the client showed some symptom improvement as he started attending religious functions with the family. The last decision was also to increase the dose to 6 mg orally BID. The increased dose aimed to increase the efficacy of the medication because higher-doses of rivastigmine are associated with increased efficacy. The ethical considerations applicable to this client encompass capacity determination, the ability of the client to make treatment decisions, and the informed consent.
References
Birks J, Chong L & Grimley J. (2015). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews. 9(2).
Farlow M, Grossberg G, Sadowsky C, Meng X & Somogyi M. (2013). A 24-Week, Randomized, Controlled Trial of Rivastigmine Patch 13.3 mg/24 h Versus 4.6 mg/24 h in Severe Alzheimer’s Dementia. CNS Neurosci Ther. 19(10): 745–752.
Fields L & Calvert J. (2015). Informed consent procedures with cognitively impaired patients: A review of ethics and best practices. Psychiatry and Clinical Neurosciences. 1(69): 462–471.
Kandiah N, Pai M, Looi I, Ampil E, Park K, Karanam A & Christopher S. (2017). Rivastigmine: the advantages of dual inhibition of acetylcholinesterase and butyrylcholinesterase and its role in subcortical vascular dementia and Parkinson’s disease dementia. Clin Interv Aging. 1(12), pp: 697–707.
Sadowsky C, Micca J, Grossberg G & Velting D. (2014). Rivastigmine From Capsules to Patch: Therapeutic Advances in the Management of Alzheimer’s Disease and Parkinson’s Disease Dementia. Prim Care Companion CNS Disord. 16(5).
Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Su J, Liu Y, Liu Y & Ren L. (2015). Long-term effectiveness of rivastigmine patch or capsule for mild-to-severe Alzheimer’s disease: a meta-analysis. Expert Rev Neurother.
15(9):1093–1103.

Instructions
Discussion: Pharmacokinetics and Pharmacodynamics
As an advanced practice nurse assisting physicians in the diagnosis and treatment of disorders, it is important to not only understand the impact of disorders on the body, but also the impact of drug treatments on the body. The relationships between drugs and the body can be described by pharmacokinetics and pharmacodynamics.
Pharmacokinetics describes what the body does to the drug through absorption, distribution, metabolism, and excretion, whereas pharmacodynamics describes what the drug does to the body.
When selecting drugs and determining dosages for patients, it is essential to consider individual patient factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. These patient factors include genetics, gender, ethnicity, age, behavior (i.e., diet, nutrition, smoking, alcohol, illicit drug abuse), and/or pathophysiological changes due to disease.
For this Discussion, you reflect on a case from your past clinical experiences and consider how a patient’s pharmacokinetic and pharmacodynamic processes may alter his or her response to a drug.
To Prepare
• Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
• Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
• Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
• Think about a personalized plan of care based on these influencing factors and patient history in your case study.
By Day 3 of Week 1
Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.
Learning Resources
Required Readings
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
• Chapter 1, “Prescriptive Authority” (pp. 1–3)
• Chapter 2, “Rational Drug Selection and Prescription Writing” (pp. 4–7)
• Chapter 3, “Promoting Positive Outcomes of Drug Therapy” (pp. 8–12)
• Chapter 4, “Pharmacokinetics, Pharmacodynamics, and Drug Interactions” (pp. 13–33)
• Chapter 5, “Adverse Drug Reactions and Medication Errors” (pp. 34–42)
• Chapter 6, “Individual Variation in Drug Response” (pp. 43–45)
American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767
American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults by American Geriatrics Society, in Journal of the American Geriatrics Society, Vol. 67/Issue 4. Copyright 2019 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing via the Copyright Clearance Center.
This article is an update to the Beers Criteria, which includes lists of potentially inappropriate medications to be avoided in older adults as well as newly added criteria that lists select drugs that should be avoided or have their dose adjusted based on the individual’s kidney function and select drug-drug interactions documented to be associated with harms in older adults.
Drug Enforcement Administration. (n.d.-a). Code of federal regulations. Retrieved February 1, 2019, from https://www.deadiversion.usdoj.gov/21cfr/cfr/1300/1300_01.htm
This website outlines the code of federal regulations for prescription drugs.
Drug Enforcement Administration. (n.d.-b). Mid-level practitioners authorization by state. Retrieved May 13, 2019, from http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html
This website outlines the schedules for controlled substances, including prescriptive authority for each schedule.
Drug Enforcement Administration. (2006). Practitioner’s manual. Retrieved from http://www.legalsideofpain.com/uploads/pract_manual090506.pdf
This manual is a resource for practitioners who prescribe, dispense, and administer controlled substances. It provides information on general requirements, security issues, recordkeeping, prescription requirements, and addiction treatment programs.
Drug Enforcement Administration. (n.d.-c). Registration. Retrieved February 1, 2019, from https://www.deadiversion.usdoj.gov/drugreg/index.html
This website details key aspects of drug registration.
Fowler, M. D. M., & American Nurses Association. (2015). Guide to the code of ethics for nurses with interpretive statements: Development, interpretation, and application (2nd ed.). American Nurses Association.
This resource introduces the code of ethics for nurses and highlights critical aspects for ethical guideline development, interpretation, and application in practice.
Institute for Safe Medication Practices. (2017). List of error-prone abbreviations, symbols, and dose designations. Retrieved from https://www.ismp.org/recommendations/error-prone-abbreviations-list
This website provides a list of prescription-writing abbreviations that might lead to misinterpretation, as well as suggestions for preventing resulting errors.
Ladd, E., & Hoyt, A. (2016). Shedding light on nurse practitioner prescribing. The Journal for Nurse Practitioners, 12(3), 166–173. doi:10.1016/j.nurpra.2015.09.17
This article provides NPs with information regarding state-based laws for NP prescribing.
Sabatino, J. A., Pruchnicki, M. C., Sevin, A. M., Barker, E., Green, C. G., & Porter, K. (2017). Improving prescribing practices: A pharmacist?led educational intervention for nurse practitioner students. Journal of the American Association of Nurse Practitioners, 29(5), 248–254. doi:10.1002/2327-6924.12446
The authors of this article assess the impact of a pharmacist?led educational intervention on family nurse practitioner (FNP) students’ prescribing skills, perception of preparedness to prescribe, and perception of a pharmacist as a collaborator.
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Solution
NURS 6521 week 1: Pharmacokinetics and Pharmacodynamics
Scenario
P.K, a 23-year-old Caucasian American female, presented to the emergency clinic with severe stomach pain and vaginal bleeding. She has a history of bipolar illness and is obese. Although she did not seem pregnant at the time of admittance, there was speculation that she was. Sadly, she was unable to recall her LMP. She was found to be pregnant after a pregnancy test, and she was sent for an ultrasound to determine the size of the fetus.
Further testing was performed, such as a cervical exam to determine the rate of contraction and the best timing for delivery. The contractions ranged from 5 to 7 minutes apart. When the patient’s history was taken, it was noted that she had a history of substance abuse, with her favorite drug being Desoxyn, which she had used one hour before her admittance to the emergency room. After some time in the emergency room, her contractions became closer, ranging from three to five minutes apart. Her pain level was 10/10, and she was admitted to the labor and delivery unit for ongoing care.
Pharmacokinetic Process
When taken orally, Desoxyn is quickly absorbed into the bloodstream. This absorption peaks in blood plasma and lasts for about 6 hours after administration. Desoxyn can cross the blood-brain barrier more rapidly than other stimulants. The kidney eliminates Desoxyn, with speed substantially controlled by urinary pH; when administered orally, roughly 55 percent of the dosage is excreted into the urine unchanged, whereas, with IV-dose, only around 45 percent is excreted in the urine unchanged (Markowitz & Patrick, 2017). Besides, the plasma half-life of Desoxyn is 5 to 30 hours. When this drug is injected into the body of pregnant women, the likelihood of preeclampsia, preterm rupture of membranes, and preterm deliveries escalate. And once the baby is born, Desoxyn side effects such as lethargy, heart and brain abnormalities may still present.
Pharmacodynamic Process
Desoxyn is a full agonist of trace amine-associated receptor 1, a G protein-coupled receptor that modulates catecholamine systems in the brain. The trace amine-associated receptor is triggered cAMP generation, and either entirely blocks or reverses the dopamine, norepinephrine, and serotonin transporters’ transport routes. The binding of Desoxyn to trace amine-associated receptor activates the transporter phosphorylation via protein kinase A and protein kinase C signaling, eventually culminating in the internalization of monoamine transporters (Prakashet al., 2017). Desoxyn has also been shown to elevate intracellular calcium, which is linked to DAT phosphorylation via a Ca2+/calmodulin-dependent protein kinas-dependent signaling pathway, resulting in dopamine efflux.
Personalized Plan of Care
When a patient with a history of substance abuse arrives in the labor and delivery room, the very first line of therapy is to discover whatever illegal substance they are currently using. It is vital to consider this since pain control is the most challenging task for these people owing to their high tolerance for illicit medications. It is also essential to guarantee that there are orders for volume expanders are if the patient has suffered extreme fluid loss as a result of Abruption. The NICU and social programs must be included in the care plan prepared with the OB care provider (Fallettaet al., 2018).
References
Falletta, L., Hamilton, K., Fischbein, R., Aultman, J., Kinney, B., & Kenne, D. (2018). Perceptions of child protective services among pregnant or recently pregnant, opioid-using women in substance abuse treatment. Child abuse & neglect, 79, 125-135.
Markowitz, J. S., & Patrick, K. S. (2017). The clinical pharmacokinetics of amphetamines utilized in the treatment of attention-deficit/hyperactivity disorder. Journal of child and adolescent psychopharmacology, 27(8), 678-689. https://www.liebertpub.com/doi/abs/10.1089/cap.2017.0071
Prakash, M. D., Tangalakis, K., Antonipillai, J., Stojanovska, L., Nurgali, K., & Apostolopoulos, V. (2017). Methamphetamine: effects on the brain, gut and immune system. Pharmacological research, 120, 60-67. https://www.sciencedirect.com/science/article/abs/pii/S1043661816312002

Assessing and Treating Clients With Pain
Required Media
Laureate Education (2016a). Case study: A Caucasian man with hip pain [Interactive media file]. Baltimore, MD: Author
Note: This case study will serve as the foundation for this Assignment.
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/07/mm/complex_regional_pain_disorder/index.html
To prepare for this Assignment:
• Consider how to assess and treat clients requiring therapy for pain and sleep/wake disorders.
ACTUAL ASSIGNMENT
PLEASE Addressed each of the following bullets with a subtopic, include references; in-text citation in each paragraph. Please use my articles and any additional one should come from USA and must be within last five years only that is from 2014 to 2018. Please do not begin a paragraph with author name(s) (PLEASE USE parenthetical/in-text citations) Thanks
The Assignment
Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
• Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
o Include how ethical considerations might impact your treatment plan and communication with clients.
Case Study: A Caucasian Man with Hip Pain
BACKGROUND
This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was ”all in his head.” He further reports that his physician believes he is just making stuff up to get ”narcotics to get high.”
SUBJECTIVE
The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said ”there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states ”I said ’no,’ there is no need for a wheelchair, I can beat this!”
The client reports that he used to be a machinist where he made ”pretty good money.” He was engaged to be married, but his fiancé got ”sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”
He reports that he does get ”down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states ”you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”
During the client interview, the client states ”oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. ”It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states ”if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is ”sparingly” because he does not like the side effects of feeling ”sleepy” and constipation. He also reports that the medication makes him ”loopy” and doesn’t really do anything for the pain.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.
Diagnosis:
Complex regional pain disorder (reflex sympathetic dystrophy)
Decisions Made and Outcomes (Needed to formulate the paper)
Choices for Decision 1: Select what the PMHNP should do:
1. Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
2. Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
3. Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed.
My decision: Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
Outcome: RESULTS OF DECISION POINT ONE:
• Client returns to clinic in four weeks
• Client comes into the office to without crutches but is limping a bit. The client states that the pain is ”more manageable since I started taking that drug. I have been able to get around more on my own. The pain is bad in the morning though and gets better throughout the day”. On a pain scale of 1-10; the client states that his pain is currently a 4. When asked what pain level would be tolerable on a daily basis, the client states, ”I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.”. When questioned further, the PMHNP asks what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 4?”. The client states that since using this drug, I can get to a point on most days where I do not need the crutches. ” The client is also asked what would need to happen to get his pain from a current level of 4 to an acceptable level of 3. He states, ”If I could get to the point everyday where I do not need the crutches for most of my day, I would be happy.”
• Client states that he has noticed that he frequently (over the past 2 weeks) gets bouts of sweating for no apparent reason. He also states that his sleep has ”not been so good as of lately.” He complains of nausea today.
• Client’s blood pressure and pulse are recorded as 147/92 and 110 respectively. He also admits to experiencing butterflies in his chest. The client denies suicidal/homicidal ideation and is still future oriented
Choices for Decision 2: Select what the PMHNP should do:
1. Continue with current medication (Savella) but lower dose to 25 mg twice a day
2. Discontinue Savella and start Lyrica (pregabalin) 50 mg orally BID
3. Discontinue Savella and start Zoloft (sertraline) 50 mg
My decision: Continue with current medication (Savella) but lower dose to 25 mg twice a day.
Outcome: RESULTS OF DECISION POINT TWO:
• Client returns to clinic in four weeks
• Client comes to office today with use of crutches. He states that his current pain is a 7 out of 10. ”I do not feel as good as I did last month.”
• Client states that he is sleeping at night but woken frequently from pain down his right leg and into his foot
• Client’s blood pressure and heart rate recorded today are 124/85 and 87 respectively. He denies any heart palpitations today
• Client denies suicidal/homicidal ideation but he is discouraged about the recent slip in his pain management and looks sad.
Choices for Decision 3: Decision Point Three Select what the PMHNP should do next:
1. Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME
2. Discontinue Savella and start tramadol 50 mg orally every 6 hours. Client may increase to 100 mg orally every 6 hours if pain is not adequately controlled
3. Reduce Savella to 12.5 mg orally BID and start Celexa (citalopram) 10 mg orally
My decision: Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME
Outcome: Guidance to Student
Guidance to Student
The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid-similar analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.
References/Resources
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
• Chapter 10, “Chronic Pain and Its Treatment”
Stahl, S. M., & Ball, S. (2009a). Stahl’s illustrated chronic pain and fibromyalgia. New York, NY: Cambridge University Press.
To access the following chapter, click on the Illustrated Guides tab and then the Chronic Pain and Fibromyalgia tab.
• Chapter 5, “Pain Drugs”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
National Institute of Neurological Disorders and Stroke. (2016). Pain: Hope through research. Retrieved from http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_2