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A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms.  She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms.  She had felt well until 1 month ago and she presented to her gynecologist for her annual gyn examination and to discuss her symptoms.  She has a history of ASCUS about 5 years ago on her pap, other than that, Pap smears have been normal. Home medications are Norvasc 10mg qd and HCTZ 25mg qd. Her BP today is 150/90.  She has regular monthly menstrual cycles. Her LMP was 1 month ago.

 

This patient appears to be active in her health maintenance, her blood pressure is elevated during this visit.  She does have a History of HTN, and she is currently on Norvasc 10mg every day and HCTZ 25mg QD, Blood pressure elevation may be related to her fear of a cancer diagnosis, stress, but it is not a reason to change her current medication regime immediately. My follow up questions will be

  1.  what does her gynecologist recommend?
  2.  is complaint with her prescribed medication?
  3. Did she take her medication prior to her visit?
  4. What are her blood pressure readings at home?

Reviewing this question can give me a better understanding on measures and steps to take in treating this patient. It also appears this patient may be entering the early phases of menopause. Natural menopause typically begins at about age 51 to 52 years, with 95% of women entering menopause between the ages of 45 and 55 years. (Rosenthal & Burchum, 2018) If so, it would be the very early stages of menopause, as she continues to have regular menstrual cycles. At this stage, prescribing of hormone replacement would not be indicated. If her symptoms were more severe, she could be considered for the start of SSRIs or SNRIs. Escitalopram is the recommended SSRI for treating moderate to severe hot flashes. It does have a risk of sexual dysfunction that would need to be monitored. It would not influence her hypertension. The SNRI that is recommended is venlafaxine. I would recommend the escitalopram first because of the risk of dose-dependent diastolic hypertension since she is currently being treated for hypertension. The North American Menopause Society developed a tool that can be used for women with menopausal symptoms who are ages 45 years and older. (Manson et al., 2015) Unfortunately, since she is not having moderate to severe hot flashes, it would be appropriate to monitor the symptoms and prescribe nothing to treat the current state. Her blood pressure is elevated and should be addressed. If she is entering menopause, she will be at a higher risk of developing more cardiovascular disease. Hypertension in older women is not being treated aggressively enough because of a large proportion, especially those most at risk for stroke and heart disease by age does not have enough blood pressure control. (Wassertheil-Smoller et al., 2000)

My initial education would start with her dietary regimen and weight controlled. If she is entering menopause, she will be at a higher risk of developing more cardiovascular disease. Hypertension in older women is not being treated aggressively enough because of a large proportion, especially those most at risk for stroke and heart disease by age does not have enough blood pressure control. (Wassertheil-Smoller et al., 2000) Due to her history of hypertension and currently being on medications, I would continue with her current medication and do a 24-hour ambulatory monitoring to validate her blood pressure reading. If I must change her medication, due to the readings being elevated after 24 hours monitoring, I will change the Norvasc to Metoprolol. Although CCBs are appropriate to treat her hypertension, it is not working as well as would be desired. Metoprolol, a beta-blocker, blocks cardiac beta-1 receptors; it reduces heart rate, the force of contraction, and the conduction velocity through the AV node (Rosenthal & Burchum, 2018) Because of this it is essential to teach the patient to monitor for bradycardia and orthostatic hypotension.

 

References:

https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.113.02148

Rosenthal, L., & Burchum, J. (2018). Lehnes Pharmacotherapeutics for Nurse Practitioners and Physicians Assistants. Elsevier Health Sciences.

Manson, J. E., Ames, J. M., Shapiro, M., Gass, M. L., Shifren, J. L., Stuenkel, C. A., & Schnatz, P. F. (2015). Algorithm and mobile app for menopausal symptom management and hormonal/non-hormonal therapy decision making: a clinical decision-support tool from The North American Menopause Society. Menopause, 22(3), 247-253.

Wassertheil-Smoller, S., Anderson, G., Psaty, B. M., Black, H. R., Manson, J., Wong, N., & Lasser, N. (2000). Hypertension and its treatment in postmenopausal women: baseline data from the Women’s Health Initiative. Hypertension, 36(5), 780-789.

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The pharmacokinetics and pharmacodynamics of medications play an integral role in diagnosing and treating injuries, illnesses, conditions, and disorders. With psychiatric disorders, understanding these medications processes is as important due to the complexity of mental illness and intricacies of the brain. Anxiety disorder is the most common health problem in the United States and involves an uncomfortable feeling of fear, uneasiness, and apprehension (Kavan et al., 2019). For this week’s discussion, we are analyzing Generalized Anxiety Disorder (GAD) and its different treatment methods.

As described by (Rosenthal & Burchum, 2021), GAD is a condition characterized by uncontrollable worrying regarding several activities such as work or school performance. GAD has physical manifestations such as hypervigilance, tension, apprehension, poor concentration, difficulties with sleep, and somatic manifestations such as trembling, muscle tension, restlessness, palpitations, tachycardia, sweating, and clammy hands.

Treatment Methods

There are many different treatment methods for GAD, which can be pharmacological and nonpharmacological therapies. With mild cases of GAD, nonpharmacological therapies can be used and may be the only treatment needed; however, pharmacological therapies may be needed when the symptoms are severe or disabling (Rosenthal & Burchum, 2021). The main course of pharmacological therapies to treat GAD includes anxiolytic medications such as Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs), and Benzodiazepines. SSRIs are usually the first line of therapy for anxiety and include This drug class includes Fluoxetine (Prozac, Eli Lilly), Sertraline (Zoloft, Pfizer), Citalopram (Celexa, Forest), Escitalopram (Lexapro, Forest), Fluvoxamine (Luvox, Solvay), Paroxetine (Paxil, GlaxoSmithKline), and Vilazodone (Viibryd, Forest); and these medications work on anxiety by inhibiting the serotonin transporter and desensitizing postsynaptic serotonin receptors in the brain (Bystritsky et al., 2013). SNRIs work by inhibiting the serotonin and norepinephrine transporters and include medications such as Buspirone (Buspar), Duloxetine (Cymbalta), Desvenlafaxine (Pristiq, Pfizer), and Venlafaxine (Effexor) (Bystritsky et al., 2013). Lastly, Benzodiazepines are often used for short-term treatment due to their high risk for dependence and abuse potential and other risk factors with high use such as potential withdrawal fatalities, impaired cognition and coordination, potentially lethal overdose when mixed with alcohol or opioids, and inhibition of memory encoding, which can disturb concomitant psychotherapy (Bystritsky et al., 2013). Different Benzodiazepines include Alprazolam, Chlordiazepoxide, Clorazepate, Diazepam, Lorazepam, and Oxazepam (Rosenthal & Burchum, 2021).

References

Bystritsky, A., Khalsa, S. S., Cameron, M. E., & Schiffman, J. (2013). Current diagnosis and treatment of anxiety disorders. P & T: A Peer-Reviewed Journal for Formulary Management, 38(1), 30–57. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173/

Kavan, M. G., Elsasser, G. N., & Barone, E. J. (2009). Generalized Anxiety Disorder: Practical Assessment and Management. American Family Physician, 79(9), 785–791. https://www.aafp.org/afp/2009/0501/p785.html

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

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 Anxiety is one of the most common mental disorders. The effects of anxiety disorder can be detrimental if not properly addressed. Several medications are available for the treatment of generalized anxiety disorder (GAD). Escitalopram is a selective serotonin reuptake inhibitor used in the treatment of GAD (Strawn et al., 2020). The medication causes an increase in serotonin levels in neuronal synapses by preventing the re-uptake of serotonin into the presynaptic terminals (Strawn et al., 2020). It is administered orally and absorption completes after 4-5 hours (Strawn et al., 2020). It is eliminated in the urine. 

     Diazepam is another treatment option for GAD. It is a long-acting benzodiazepine used to treat anxiety disorder. It causes anxiolytic, sedative, muscle- relaxant, anticonvulsant and amnestic effects (Dhaliwal et al., 2020). All  of these effects result from the action of an inhibitory neurotransmitter in the central nervous system called gamma-aminobutyric acid or GABA (Dhaliwal et al., 2020). It is taken orally and absorbed from the gastrointestinal tract. Its peak plasma concentration is 1 – 1.5 hours and is excreted mainly in the urine (Dhaliwal et al., 2020).

     The third treatment option is Alprazolam, a triazolobenzodiazepine, used to treat anxiety disorder. It binds GABA type-A receptors (GABAARs) to enhance their inhibitory effect on neurotransmission, specifically in the brain (Dangkoob et al., 2015). Alprazolam has similar effects as Diazepam such as drowsiness, slowed reaction time and amnestic effects (Gussone, 2021). It is administered orally and rapidly absorbed in the gastrointestinal tract (Dangkoob et al., 2015). Alprazolam is also mainly eliminated in the urine.   

References

Dhaliwal, J. S., Rosani, A., & Saadabadi, A. (2020). Diazepam. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK537022/

Dangkoob, F., Housaindokht, M. R., Asoodeh, A., Rajabi, O., Zaeri, Z. R., & Doghaei, A. V. (2015). Spectroscopic and molecular modeling study on the separate and simultaneous bindings of alprazolam and fluoxetine hydrochloride to human serum albumin (HSA): With the aim of the drug interactions probing. Spectrochimica Acta Part A: Molecular and Biomolecular Spectroscopy, 137, 1106-1119. https://doi.org/10.1016/j.saa.2014.08.149

Gussone, F. (2021). Anxiolytics: use, side effects, and risks. Mental Health.

Strawn, J. R., Mills, J. A., Schroeder, H., Mossman, S. A., Varney, S. T., Ramsey, L. B., … & DelBello, M. P. (2020). Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. The Journal of Clinical Psychiatry, 81(5), 0-0. https://www.psychiatrist.com/jcp/depression/escitalopram-in-adolescents-with-gad/

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Response (1Page) with 2 References required

First Post

As a Travel Nurse Case Manager, a significant part of the role is discharge planning, and there are often times the patient’s requests are unable to be met. After a patient’s hospital stay, it may be that the care team suggests a short-term rehab placement which firstly may not be what the patient wants. Secondly, even if they agree, the facility they want to go to is unavailable for either insurance reasons or bed availability. 

There was recently a situation like this in the current assignment. The patient is an 86-year-old male and his wife and 86 year old. They did not have immediate family to help take care of decisions. Both patient and wife were adamant the patient is going home even though rehab has been recommended. Due to COVID 19 precautions, Case Managers (CM’s) speak with patients via telephone, but this patient is profoundly deaf. Hoffmann et al., 2014 state that there must be a connection between evidence-based decisions and involving the patient, and in this situation, there were definitely some barriers to care. Following hospital protocol to follow the patient’s request discharging to the home would be an unsafe discharge and likely to end in readmission. The CM called the wife and discussed with her but felt that the wife was potentially not understanding the severity of the patients’ weakness (he had fallen the day prior with Physical therapy).

When delivering evidence-based medicine, it is essential to consider all factors, including patients’ requests. The patient’s safety is paramount, and although this CM arranged home health care and home Physical therapy, she still did not feel it would be enough to prevent a readmission. The day of discharge approached, but no one could get hold of the wife, and a wellness check had to be undertaken by the local Sheriff’s office, who found her to be safe but with what was possibly the early onset of dementia. 

With this new information, if there was any doubt, the patient should not be discharged home before there was none now. The CM went to the patient’s bedside with appropriate PPE and decided to speak directly with the patient. Even though the patient had a hearing aid, it was still necessary to communicate using a notepad. The CM explained that she wanted the patient to get a bit stronger before he went home to his wife and felt that it would be safest for him and his wife because his wife would probably find it challenging to look after him on her own. The patient and CM had a friendly discussion on keeping him safe and getting him home quickly but without incident, and the patient agreed to rehab. Luckily, in this case, the hospital had an inpatient rehab attached to the hospital, and the patient was able to transfer there the next day, and he had Medicare who covers the costs. 

Similar to The Ottawa Hospital Research Institute (2019). decision aid the CM speaks with the patient on admission and asks specific questions which help determine the discharge plan. These questions cover who is at home to help, before admission do they need durable medical equipment such as cane, walkers etc.? It is from this conversation the CM and the patient develop a plan.

Hoffmann et al. (2014) state evidence-based medicine should begin and end with the patient, and whilst I strongly agree, I feel sometimes the patient’s wishes get overlooked. It is a balancing act in case management between the patient’s wishes, insurance, and bed availability. Occasionally, patients do have to go home with home health due to lack of bed availability in facilities, especially in the current climate of COVID 19.  Melnyk and Fineout-Overholt, 2019 recognize that patient-centered care must involve the patient, and I do feel there is always a way to work things out with the patient. Usually, it is how something is presented to the patient that makes the difference in outcome.

 

 

 

References

 

Melnyk, B., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Wolters Kluwer.

Hoffmann, T. C., Montori, V. M., & Del Mar, C. (2014). The Connection Between Evidence-Based Medicine and Shared Decision Making. JAMA, 312(13), 1295. https://doi.org/10.1001/jama.2014.10186

The Ottawa Hospital Research Institute (2019). Patient decision aids. Retrieved from Patient Decision Aids – Ottawa Hospital Research Institute (ohri.ca)

 

 

 

 

Second Post (1 Page with 2 reference)

 

Throughout the years working as a nurse, I have experienced several cases that require the employment of patient preference and values. These aspects usually affect the entire treatment plan. Precisely, Nurses do all they can to save lives and keep everyone healthy (Upshur, 2016). Through practical experience, nurses have learned the art of acting realistically and the cognitive ability to realize when the patient has reached a high end.

In some cases, prior conditions of patients are considered in decision-making. According to Melynk & Fineout-Overholt, (2018), clinicians must use evidence-based practice and operate in the patient’s best interest. This may include using judgment to assist patients in deciding. I recently had an 82-year-old male patient who had developed issues with the gall bladder and urgently needed surgery. Up until eight months ago, the patient could walk up to 9 miles. The surgeon using his judgment, perceived that the patient was bound to benefit significantly from the surgery since he was very active. The patient went in for cholecystectomy and unfortunately developed an ileus while in the Hospital. Several surgeries were performed, and he was sent home with a sludge drain and living on Total Parenteral Nutrition (TPN). Nine months later, the patient developed further problems with His drain that led to an intra-abdominal abscess. As time went by, the patient’s health continued to deteriorate, and he came back for several more abdominal surgeries that came along with sepsis and acute respiratory distress syndrome (ARDS).

Through the entire ailment process, the Nursing staff and other medical staff were very transparent to the family after several months of the most intense desperate measure to save his life, including the use of several pressers and maxed out vent settings. To seek options, palliative care options were discussed between the family and the medical staff to determine the course of action. The family never seemed to lose hope, even when things never seemed to get better. A section of the family members perceived that as torture to the patient and proposed euthanasia which some fiercely refused. Finally, the family decided to withdraw from palliative care. Once the decision was made, the patient died within a short time. Had shared decision-making involving patient decision aid been used earlier in the disease process, the outcome may have been different. The decision to die or continue with treatment ultimately rests on the surrogate and the patient (Ottawa Hospital Research Institute, 2016). There is nobody who can comfortably make this decision. Clinicians admit and witness patients die and, in some cases, live wishing they would have done more or better for a particular patient to survive. To mitigate this, I believe that clinicians should have intense training to enable them effectively and efficiently communicate to facilitate treatment decisions. As healthcare professionals, we have a crucial role in shared decision-making. We offer evidence-based decisions and treatment while considering patients’ goals, values, and preferences (Carhuapoma & Hollen, 2018). They also help people involved in decision-making by making explicit decisions to be made. They complement rather than replace.

 

 

References

Upshur, R. (2016). Unresolved issues in Canada’s law on physician-assisted dying. The Lancet, 388(10044), 545-547.

Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th Ed.). Philadelphia, PA: Wolters Kluwer Carhuapoma, L. R., & Hollen, P. J. (2018).

The Use of Decision Aids for End-of-Life Surrogate Decision Making for Critically-ill Stroke Patients: A Systematic Review. STROKE, 49. Retrieved from: https://doi.org/10.1161/str.49.suppl_1.TP360

Ottawa Hospital Research Institute. (2016). Advance Care Planning: Should I Stop Treatment That Prolongs My Life? Retrieved from https://decisionaid.ohri.ca: https://decisionaid.ohri.ca/docs/das/OPDG.pdf

 

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Three professional nursing organizations that interest me are the Association of Surgical Technologist (AST), the Association of periOperative Registered Nurses (AORN) and the Society of Perioperative Assessment and Quality Improvement (SPAQI). AST is an organization that is geared to supporting intraoperative practices of Surgical Technologists and Surgical Assistants. Their purpose is to enhance knowledge and skillset with national guidelines established through a partnership with AORN and American Nurses Association (AST, 2020). Members are required to be certified in their profession and pay a yearly fee of $80. This organization aligns with my goals in the perioperative environment because it holds key components to patient safety with team members that are in integral part of surgical services. Prior to becoming a Registered Nurse, I functioned as a Certified Surgical Technologist. This organization was a wonderful asset to my knowledge base as I practiced my skill and developed a sense of inquiry in the perioperative realm. AORN is an organization that supports best practice measures with a focus on surgical attire, technique, cleaning methods/ practices and preventable measures for surgical site infections (AORN, 2020). Their purpose is to protect the surgical patient and team and aligns with the specialty that is near and dear to my heart, as I find this to be an amazing asset to my day-to-day questions for best practice in patient care. Often times my team will also access articles and resources provided by AORN to support new initiatives and improve processes. The last organization that interests me is the Society of Perioperative Assessment and Quality Improvement. This organization seeks to engage and create a culture of collaboration and innovation between members of the perioperative team through educational opportunities and evidence-based practice measures (SPAQI, 2020). My worldview is to improve patient outcomes and staff satisfaction. SPAQI can assist with my goals through their innovative techniques for partnerships and patient care measures.

 

 

References

 

Association of perioperative Registered Nurses (AORN). (2020). AORN membership: Join the

community. https://www.aorn.org/

Association of Surgical Technologist (AST). (2020). https://www.ast.org/

Society for Perioperative Assessment and Quality Improvement (SPAQI). (2020).

https://www.spaqi.org/web/index.php

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