Critically discuss this case study in terms of the problematic nature of this patient’s pharmacological management. Outline some pharmacokinetic changes in the geriatric population that may affect drug disposition.

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Pharmacological management

Mrs. A is a 71 year old widow with CHF and osteoarthritis who has recently been exhibiting quite unusual behavior. Her daughter is concerned about her mother’s ability to remain independent and wishes to pursue nursing home admission arrangements. She fears the development of a dementing illness. Over the last two to three months Mrs. A has become confused, easily fatigued and very irritable. She has developed disturbing obsessive/compulsive behavior constantly complaining that her lace curtains were dirty and required frequent washing. Detailed questioning revealed that she thought they were yellow-green and possibly moldy. Her prescribed medications are:

  • Furosemide 40 mg daily in the morning
  • Digoxin 250 micrograms daily
  • Paracetamol 500 mg, 1-2 tablets 4-hourly PRN
  • Piroxicam 20 mg at night
  • Mylanta suspension, 20 ml PRN
  • Coloxyl 120 mg, 1-2 tablets at night

Assignment Questions

  1. Critically discuss this case study in terms of the problematic nature of this patient’s pharmacological management.
  2. Outline some pharmacokinetic changes in the geriatric population that may affect drug disposition.
  3. Outline how changes in renal and hepatic function may affect treatment strategies.
  4. In the drug regimen presented above – discuss potential side effects and potential interactions, if any?

Your response should include a discussion of the problems of polypharmacy as it is related to this case study and the assessment/management and educational strategies which could have been implemented to improve the outcome of Mrs. A.

 

Analyze the case study provided and determine what symptoms support the diagnosis of asthma. Identify the treatment provided in the emergency department and determine what additional therapies are needed to mitigate the asthma symptoms and return the client to wellness.

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Purpose of Assignment:

This assignment will help the student evaluate of a respiratory disorder, which, if untreated, can be a serious condition. Students need to understand respiratory complications and how it can impact ventilation and respiration is important to the study for maintaining homeostasis in the body.

Competency
• Evaluate pathophysiologic alterations that affect the neurologic and respiratory systems.

Content:
J.S. is a 42-year-old man who lives in the Midwest and is highly allergic to dust and pollen and has a history of mild asthma. J.S’s wife drove him to the emergency room when his wheezing was unresponsive to his fluticasone/salmeterol (Advair) inhaler. J.S. was unable to lie down, and began to use accessory muscles to breathe. J.S. is immediately started on 4 L oxygen by nasal cannula and intravenous (IV) D5W at 75 mL/hr. A set of arterial blood gases is sent to the laboratory. J.S. appears anxious and says that he is short of breath.

Vital signs
BP = 152/84 HR = 124 bpm RR = 42 Temp = 100.40F
ABGs
pH = 7.31 PaCO2 = 48 HCO3 = 26 PaO2 = 55

Instructions:
Investigate the pathophysiology of asthma and the clinical manifestations of the disease. Analyze the case study provided and determine what symptoms support the diagnosis of asthma. Identify the treatment provided in the emergency department and determine what additional therapies are needed to mitigate the asthma symptoms and return the client to wellness.

  • Do you have any concerns with the numbers above?
  • Identify what may be causing (etiology) J.S. to have an exacerbation of asthma.

Prepare a 3-5 page paper outlining the causes of asthma, the symptoms that the client presents and the management of the disorder. Use at least one scholarly source to support your findings. Examples of scholarly sources include academic journals, textbooks, reference texts, and CINAHL nursing guides. Be sure to cite your sources in-text and on a References page using APA format.

Read a selection of your colleagues’ responses from Week 9 and respond to at least two of your colleagues on two different days who were assigned a different patient case study, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology.

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Colleagues’ responses

Read a selection of your colleagues’ responses from Week 9 and respond to at least two of your colleagues on two different days who were assigned a different patient case study, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples.

 Case study

HH is a 68 yo M who has been admitted to the medical ward with community-acquired pneumonia for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, which include ceftriaxone 1 g IV qday (day 3) and azithromycin 500 mg IV qday (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements. He is not tolerating a diet at this time with complaints of nausea and vomiting.

Ht: 5’8” Wt: 89 kg

Allergies: Penicillin (rash)

 

David

Individuals with comorbidities can present with challenges when trying to manage the many medical symptoms when their health begins to deteriorate. For patient HH, who has PMH of COPD, HTN, hyperlipidemia, and diabetes is now having to manage newly acquired pneumonia. Comorbidities contribute decisively to the risk of dying from pneumonia in the hospital, regardless of their type or origin (Hespanhol & Bárbara, 2020) His medical needs will require hospitalization for monitoring of respiratory distress given the diagnoses of pneumonia and history of COPD. Provide optimal care to minimize stress on the respiratory system allowing for rest and recovery with supplemental oxygen.

To combat the infection, the patient is to finish out the prescribed empiric antibiotic regiment of Ceftriaxone and Azithromycin that is specific to the patient who is allergic to Penicillin that can take up to 10 days. Initial treatment of Community-acquired pneumonia (CAP) is usually empirical, because the microbial etiology cannot be predicted on the basis of clinical presentation (Wongsurakiat & Chitwarakorn, 2019). With the patient showing improvement and deceased oxygen requirement there will be a time to switch the patient from IV antibiotic therapy to antibiotics to be given orally. Continued monitoring of other heath related factors will be addressed and provided with care as needed. As needed medication can prescribed such as Zofran IV to combat the nausea and vomiting that perhaps is related to the current antibiotic regiment. Due to the antibiotics having disrupted the gut balance, a probiotic can be prescribed to help restore the guts normal PH balance and prevent for episodes of nausea and vomiting.

Educational needs will be provided during stay in the hospital and upon discharge with educational materials to help patient better understand heath related illness and management of health. Given the history of COPD and the likeliness of continued development of health-related issues due to compromised health, its imperative that the patient is understanding of medication regiment set for discharge and the need for follow up by primary health care provider. Medication non-adherence is a complex process determined by many modifiable and unmodifiable determinants which can be categorized into five dimensions (socio-economic, patient-related, therapy-related, condition-related, and health system–related) (González-Bueno et al, 2022). Resources for outpatient services, connection with social services and other social concerns to be addressed to help manage both physiological and psychological health needs.

 

GE

Infections and Hematologic Systems

The patient’s health needs are particular and include a need for antibiotics, IV fluids, and pain relief. Mr. HH is also at risk for complications from his underlying medical conditions, so close monitoring is warranted. He needs to be as comfortable as possible and have as little pain as possible. The patient also needs to be able to eat and drink without difficulty. In addition, Mr. HH needs to be able to take his antibiotics without vomiting (Jacobs, 2017). Lastly, he needs to be able to urinate without difficulty. According to Gallagher et al. (2016), the best treatment regimen for Mr. HH would be a ceftriaxone and azithromycin combination. This regimen is effective in treating community-acquired pneumonia. The patient should also be given IV fluids and pain relief. The IV fluids will help to keep the patient hydrated, and the pain relief will help to manage any discomfort the patient may be experiencing (Gallagher et al., 2016). The patient should be closely monitored for any complications from his underlying medical conditions.

Prabhu et al. (2016) found that patients with community-acquired pneumonia (CAP) often require significant lifestyle changes to improve their prognosis. A patient education strategy that could be recommended for Mr. HH is creating a personalized plan of care that considers their Previous Medical History (PMH). For example, Prabhu et al. (2016) explain that a CAP patient with HTN and hyperlipidemia may need to change their diet and exercise regimen, while a patient with COPD may require lifestyle modifications such as increased rest and reduced smoking. Many resources are available to help patients understand and follow their personalized PMH care plan, such as patient education leaflets or books.

Describe your interest in pursuing your degree at Chaminade University of Honolulu, and any related extracurricular activities that have prepared you for your educational goals.

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Personal Statement

Describe your interest in pursuing your degree at Chaminade University of Honolulu, and any related extracurricular activities that have prepared you for your educational goals. Your statement should be between 250-300 words. Feel free to use the text box below or upload feature.

Describe in 300 to 500 words what challenges you may face while a nursing student and how you plan to overcome those challenges.

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Nursing students challenges

Nursing students face many challenges academically, personally, and professionally while enrolled in a rigorous nursing curriculum.

Describe in 300 to 500 words what challenges you may face while a nursing student and how you plan to overcome those challenges.

 

Write a one-page Letter of Recommended Improvement’ identifying a potential area in the practice setting (or system) and suggesting a potential solution. Write a one-page paper reflecting on their experience in the community focusing on personal vocational discernment.

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Letter of Recommended Improvement

This assignment focuses on vocational exploration and fulfilling a civic responsibility by helping to meet healthcare needs in our community. Students will complete eight (8) of their practice hours at a non-profit organization in Florida.

While completing the hours, students will assess the site for potential areas for improvement. The student will write a one-page Letter of Recommended Improvement’ identifying a potential area in the practice setting (or system) and suggesting a potential solution. The student will also write a one-page paper reflecting on their experience in the community focusing on personal vocational discernment. The correct APA 7th Edition Format must be applied throughout the papers.

 

Identify the probable diagnosis and what data support your decision. Describe the pathogenesis for the diagnosis. What data are inconsistent with your diagnosis? What diagnostic tests would you order, if any, and how would you treat this patient?

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Directions
All students should complete Part 1, choose two (2) cases of your preference. All students should complete Part 2. Note: All case studies are provided as a learning tool for students who wish to have them.

Part 1 – Choose 2 of the 5 cases
The following activity includes several case presentations of edema. Make a diagnosis for each case, remembering the following questions:

Is the edema acute/sudden or chronic (e.g., duration, progression)?
Is it unilateral or bilateral? Is the edema generalized or localized?
Is it pitting or nonpitting?
Is it dependent?
In addition to edema, what other characteristics are associated with the edema (e.g., redness, pain)?
What is the pertinent past or coexisting medical history? What medications is the patient taking?
You may want to refer to chapter 3 and chapter 4 to help determine the diagnosis.

Case 1

45-year-old Mrs. Rodriguez is complaining of intermittent mild bilateral feet/ankle swelling for the past 2 months, but it is worse on her right leg. She denies leg pain, but she does describe her legs as feeling heavy at times and reports standing for long periods worsens the swelling. She notes her veins are getting larger in her legs. For the past 8 months, she has been experiencing intermittent numbness in her feet and reports her left knee has been achy. She is a server at a busy restaurant and sometimes works 10-hour days. She denies any fever, warmth, erythema, or trauma.

Past medical history: obesity (BMI 31); type 2 diabetes mellitus.
Medications: metformin.
Physical examination: vital signs are within normal limits; exam is unremarkable except for bilateral tortuous veins in both lower extremities, which are worse on the right leg, and decreased sensation in both feet.
Note: Assume history and examination is within normal limits if not listed.

Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?

Case 2

68-year-old Mr. Quincy is complaining of left leg swelling for the past 2 weeks. The swelling started while he was on a cruise. The swelling is intermittent and below the knee to his foot. He describes a cramplike pain in his left calf. Lately, both legs have been cramping while walking, but it resolves when he sits. He denies any fever, warmth, erythema, or trauma.

Past medical history: iliofemoral deep vein thrombosis of his left leg after he had left hip replacement for osteoarthritis 9 months ago; treated with rivaroxaban for 6 months; stable angina; obesity (BMI 31); dyslipidemia.
Social history: quit smoking 4 years ago but resumed one-fourth pack per day 1 year ago.
Medications: simvastatin; aspirin; metoprolol.
Note: Assume history and examination is within normal limits if not listed.
Physical examination: vital signs are within normal limits; right leg is within normal limits except hairless, shiny skin; left leg has 1+ pitting edema in the pretibial area and foot; mild pain with left calf compression and one small tortuous vein on the medial aspect of his calf; left leg is also hairless and shiny. A venous duplex Doppler ultrasound of his left leg was done and reveals no deep vein thrombosis.

Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?

Case 3

85-year-old Mrs. Delaney has bilateral ankle and foot swelling for the past 3 weeks; she states her feet hurt and her shoes feel tight and describes this swelling as the first occurrence; she denies fever, erythema, warmth, or trauma.

Past medical history: aortic valve replacement; hypertension; dyslipidemia; osteoporosis.
Medications: amlodipine; benazepril; atorvastatin; alendronate sodium; aspirin.
Physical examination: vital signs within normal limits; exam unremarkable except for grade 1 systolic ejection murmur at the left sternal border, second intercostal space with no radiation, and mild (< 1+) pitting edema bilateral ankles and feet.
Note: Assume history and examination is within normal limits if not listed.

Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?

Case 4

78-year-old Mr. Smith is complaining of increased swelling in his lower legs for the past 3 weeks. He states it worsens when his legs are hanging down and gets a bit better when he elevates them. The swelling started about a week after he left the hospital for an episode of pneumonia. He states his legs occasionally swell, especially when he eats too much salt, and the last time it happened was about 8 months ago. He reports taking a water pill for a while but not lately. He noted that he feels like he has put on a few pounds this week and feels a bit more tired and short of breath. He has had to sleep propped up with two pillows. He denies leg pain, fever, warmth, or trauma.

Past medical history: anterior wall myocardial infarction 2 years ago; hypertension; heart failure with reduced ejection fraction; dyslipidemia.
Social history: 1 pack a day smoker for 30 years—quit 2 years ago.
Medications: sacubitril/valsartan; metoprolol; rosuvastatin; aspirin (which he forgets to take).
Physical examination: vital signs — temperature 98.5°F; pulse 70 beats per minute, respirations 22 per minute; blood pressure 150/80 mmHg; pulse oximeter 96%; weight increase of 5 pounds in 1 month; cardiovascular exam remarkable for an S3 gallop; lungs with bibasilar fine inspiratory crackles; bilateral lower extremities pretibial to feet with 2 + pitting edema; and mild pain when depressing skin.
Note: Assume history and examination is within normal limits if not listed.

Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?

Case 5

40-year-old Mr. Jason is complaining of right leg swelling, pain, erythema, and warmth for the past 2 days. The swelling started after he accidentally cut the front of his leg with a pocketknife while fishing.

Past medical history: hypertension.

Medications: amlodipine.

Social history: drinks four to five beers on the weekends and has smoked one or two cigarettes a day for the last 15 years (he states he is trying to quit).
Physical examination: temperature 100°F; pulse 88 beats per minute; respirations 18 per minute; blood pressure 140/92 mmHg; examination unremarkable except for edematous anterior right leg with open linear wound approximately 1-inch long; wound with scant purulent drainage; and area is warm and tender with blanching erythema that extends 3 inches around the wound.
Note: Assume history and examination is within normal limits if not listed.

Activity

Identify the probable diagnosis and what data support your decision.
Describe the pathogenesis for the diagnosis.
What data are inconsistent with your diagnosis?
What diagnostic tests would you order, if any, and how would you treat this patient?

Part 2:
Students are to complete Part 2

A 70-year-old woman was recently treated for pneumonia with antibiotics. After 1 week on antibiotics, she started developing severe diarrhea of 6–7 loose, watery stools per day. The diarrhea has been present for 3 days. She also has a decreased appetite, feels nauseous, and has not been drinking a lot of fluids. She feels very weak and dizzy. She lives alone, so she called 911 and was brought to the emergency department. She is diagnosed with diarrhea, presumptive Clostridium difficile.

Patient medical history: Clostridium difficile 2 years prior.
Physical examination: temperature 99.0°F; pulse 100 beats per minute; respirations 24 per minute; and blood pressure 90/50 mmHg, which dropped to 70/40 mmHg when seated. Examination unremarkable except for dry mucous membranes and generalized mild abdominal tenderness with palpation.
Laboratory findings reveal:
Chemistry panel: sodium 135 mEq/L; potassium 3.4 mEq/L; chloride 100 mmol/L; HCO3- 12 mEq/L; blood urea nitrogen 40 mg/dL.
Creatinine: 1.2 mg/dL.
ABG: pH 7.22, PaO2 85 mmHg, PaCO2 20 mmHg, HCO3- 12 mEq/L.

Activity

Analyze the ABG and determine the acid–base disturbance.
Calculate the compensation response and determine if it is appropriate.
This item is optional. Calculate and interpret the anion gap.
Discuss the diagnosis.
Develop a treatment plan.

Explain at least three functional considerations to take into account when implementing an EHR. Explain the regulatory considerations for implementing EHRs. Explain interoperability. Why is interoperability important?

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Implementing Electronic Health Records

In this writing assignment, you will be writing a one- to two-page paper explaining the implementation of electronic health records.

Step 1 Reflect on your involvement with the implementation of electronic health records (EHRs) in the clinical setting (either as a practicing nurse or as a student in the clinical setting).

If you have not used an EHR, think about how you might implement an EHR in your practice setting. Answer the questions in Step 2 using this hypothetical EHR system.

Step 2 Address the following topics in your paper:

Explain at least three functional considerations to take into account when implementing an EHR.
Explain the regulatory considerations for implementing EHRs.
Explain interoperability. Why is interoperability important?
Explain data integrity. Why is data integrity important?
Explain why the security of data is important when implementing an EHR.
Explain the legal concerns surrounding the implementation of EHRs.
Cite any sources in APA format.

Describe the theory. Provide 3 examples of how the theory applies to current practice. Provide 3 positive patient outcomes resulting from utilizing the theory.

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Putting It All Together

Create a PowerPoint presentation that addresses each of the following points/questions. Be sure to completely answer all the questions for each bullet point. Use clear headings that allow your professor to know which bullet you are addressing on the slides in your presentation. Support your content with at least two (2) sources and the textbook using APA citations throughout your presentation. Make sure to cite the sources using the APA writing style for the presentation. Include a slide for your references at the end. Follow best practices for PowerPoint presentations related to text size, color, images, effects, wordiness, and multimedia enhancements. Review the Signature Assignment rubric criteria for this assignment.

This week, you will develop a PowerPoint presentation reviewing the theories from each module. Select one theory from each module (1-8) and answer the following questions. You should have 2-4 slides per theory with a total of 8 theories discussed.

Describe the theory.
Provide 3 examples of how the theory applies to current practice.
Provide 3 positive patient outcomes resulting from utilizing the theory.
Explain 3 benefits to nursing satisfaction when utilizing the theory.
Describe two barriers to using the theory in practice and at least one method for overcoming each barrier (support methods with sources).
Support from literature clearly noted throughout.
The PowerPoint presentation should include at least two outside references and the textbook. The presentation should contain 2 to 4 slides per theory, for a total of 16 to 32 slides.

Describe the pathophysiology of PDA and why the history of PDA is significant in this scenario. What risk factors place Vivi Mitchell at a greater risk for the development of bronchiolitis? What are the characteristic signs/symptoms of bronchiolitis?

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Purpose of Assignment

The goal of creating a nursing concept map is to create a plan of care for a child with bronchiolitis. The nursing interventions would reflect the underlying respiratory syncytial virus with patent ductus arteriosus (PDA) history.

Competency

Apply the foundations of pediatric nursing when caring for clients with health alterations.

Scenario

You are working in a large urban pediatric clinic after-hours.

A mother brings her 6-month-old daughter, Vivi Mitchell, to the clinic for rhinorrhea, congestion, fever, and cough. Upon assessment, you identify the child has wheezing upon auscultation and on inspection, you identify retractions.

  • The child is in less than 10th percentile of weight and has a cardiac history of Patent Ductus Arteriosus (PDA).
  • Born at 36 weeks gestation.
  • Mother states this child doesn’t go to day care but her two other children ages 2 and 3 do attend daycare.
  • T- 102.1 HR 140 RR 40 BP 83/58 Pulse ox 96%
  • A swab for respiratory syncytial virus (RSV) is positive.

Doctor orders – Nasal bulb suction and saline drops PRN, Tylenol 15mg/kg Q4 PRN for fever, Albuterol nebulizer in office and push po fluids as tolerated.

After the albuterol neb treatment, respirations are 36 and oxygen saturation is 100%. Wheezing has diminished. Mom is an ER nurse and the doctor feels comfortable that she has a nebulizer at home and can return to pediatric afterhours or ER if needed.

Client is discharged with these orders:

  • methylprednisolone 0.4 mg/kg oral BID for 3
  • Albuterol Q4 hours for 24 hours, then Q 6 hours for 24 hours, and Q6 as needed.
  • Call if needed prior to the Q4 dose.
  • Manage fever with Tylenol and continue hydration and nasal bulb suction Q6 while awake.
  • Return for re-evaluation in 3 days
Instructions

In a two to three-page APA formatted paper, provide reponses for these questions and requests for information:

Criteria:
  1. Describe the pathophysiology of bronchiolitis and identify the most common organism causing this infection. What laboratory testing can confirm your suspicion?
  2. Describe the pathophysiology of PDA and why the history of PDA is significant in this scenario.
  3. What risk factors place Vivi Mitchell at a greater risk for the development of bronchiolitis?
  4. What are the characteristic signs/symptoms of bronchiolitis?
  5. Vivi Mitchell been prescribed the following medications; acetaminophen, albuterol nebulizer, corticosteroids. Provide the rationale for why each medication has been included as part of her medical management and explain any potential contraindications related to these medications.
  6. You are designing Vivi Mitchell’s plan of care. Identify two priority nursing diagnoses to include in your plan. For each nursing diagnosis, identify two SMART goals, and two interventions for each goal.
  7. What short and long-term possible complications should the nurse anticipate?
  8. What client education is appropriate for Vivi Mitchell as she is discharged from the after-care clinic?