Respond to at least two of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
Case #7
The Case: The case of physician do not heal thyself
The Question: Does the patient have a complex mood disorder, a personality disorder or both?
The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a difficult patient?
*List three questions you might ask the patient if he or she were in your office:
1. Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down (Hirschfeld, 2002)?
Rationale: This question specifically inquires about whether the client feels they have been their usual self and specifically references their energy levels (Hirschfeld, 2002). These symptoms are important to identify and rule out if a manic episode related to a mood disorder (such as Bipolar I) is occurring. By narrowing down correct symptomologies, the correct and appropriate psychiatric diagnosis can be made, along with the appropriate treatment.
2. Has your mood or behaviors caused major problems in your life like being unable to work; having a family, money or legal troubles; getting into arguments (Hirschfeld, 2002)?
Rationale: This question specifically focuses on how much of a problem the symptoms have been in a client’s everyday life. Mood disorders such as Bipolar I and Bipolar II can significantly impact a client’s life. Patients suffering from a mood disorder, such as Bipolar I, are at a significantly higher risk for suicide, harm to self, or harm to others (Hirschfeld, 2002).
3. How frequently would you estimate that you have experienced racing thoughts or elevated energy in relationship to your mood or fights and have any of these issues occurred during the same period of time (Hirschfeld, 2002)?
Rationale: This particular question addresses if the symptoms that are being experienced, occurred during the same time period, which would be indicative of the diagnosis of Bipolar I mood disorder. This question is important when assessing a client for a mood disorder in those patients who are misdiagnosed may experience rapid cycling or mania (Hirschfeld, 2002).
*Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
According to Stahl (2013), it is essential for healthcare providers to obtain information from not only the client but also from outside sources. Outside sources for a client may include their spouse, parents, or siblings. Information obtained from outside sources may be significantly different than what the client describes and can assist in accurately diagnosing the client (Stahl,2013). Clients that are accurately diagnosed, can then be appropriately treated with pharmacological agents.
-Were there any significant triggering factors related to the client’s first major depression episode at age 23?
These questions can assist in distinguishing between Bipolar Mood Disorders and Borderline Personality Disorder. Bipolar Mood Disorders typically manifest in the early to mid-’20s ( It must be determined if the depression was an initial onset of a hypomanic episode or if it was due to an existing personality disorder.
-What other moods did the client exhibit when they were not in a depressive episode? How long did these moods last?
According to Stahl (2013), individuals often downplay their manic symptomologies and their duration. These episodes and their duration are essential in order to accurately diagnosing a client.
-Does the client have any significant psychiatric history, such as Bipolar I, Bipolar II, or other mood disorders?
According to Stahl (2013), first-degree relatives who also have bipolar disorder can indicate the likelihood that the client also suffers from a bipolar disorder. If the client does have a significant family history of bipolar disorder, any effective treatments, the severity of the condition, and any hospitalizations that occurred should be documented in the client record.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Certain diagnostic tests such as a Complete Metabolic Panel (CMP), Liver Function Tests (LFT’s), Hemoglobin A1c, and a urine specific gravity can be ordered to evaluate the functionality of the client’s kidneys, liver, and the presence/risk of diabetes mellitus. A mood stabilizer such as Lithium may be used to manage the client’s severe fluctuation in moods. Lithium, however, can be severely nephrotoxic. Kidney function tests should be drawn prior to initiating therapy and throughout the course of therapy to assess for kidney dysfunction (Tolliver & Anton, 2015). A urine specific gravity can also indicate the functionality of the kidneys. Antipsychotic medications may be used to treat long-term unstable mood disorders. Antipsychotic medications, both first and second generations, can cause metabolic syndrome. The development of metabolic syndrome can be monitored by obtaining a CMP, LFTs, & Hemoglobin A1C prior to starting medication therapy and then throughout the medication therapy course. According to Stahl (2013), clients taking antipsychotic medications should have lab diagnostic studies done every 3-6 months. A urine drug screen (UDS) should also be done to rule out the illicit substances as the causation of the mood disorder.
It is essential to assess all clients if they have any suicidal ideations. The Columbia-suicide severity rating scale can be used to assess the severity of suicide risk. COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS): This screening tool is used to detect suicidal ideations and their severity. It is scored from 0-5. A score greater than 0 may indicate a need for mental health intervention. A score of 4-5 indicates active suicidal ideation with some intent to act (“Columbia-Suicide Severity,” 2019).
This client should have a full head-to-toe physical assessment completed including a mental status exam, and vital signs. These initial findings can be used as a baseline for the patient and any future assessment changes can be compared to the initial findings (Tolliver & Anton, 2015).
**List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
1. Recurrent major depression with an anxious/dysphoric temperament Most likely diagnosis
According to the DSM V (2013), the client’s symptoms most likely indicate a mood disorder. Due to the limited amount of time with the patient and limited past mania history, a Bipolar mood disorder could be ruled out. The client’s main symptoms present as depressive in nature, with one suicide attempt 40 years ago (Stahl Online, 2018). Recurrent major depression with an anxious/dysphoric temperament, which is also a complex mixed mood disorder, is the most likely diagnosis given the patient’s current symptoms. According to the scenario provided by Stahl Online (2018), the client has been experiencing a mixed dysphoric state with the depression occurring the majority of the time.
2. Bipolar II mixed episode:
Per the client’s history, he has been experiencing symptoms that are consistent with hypomania since the age of 23, such as inflated self-esteem, irritability, and decreased need for sleep (Stahl Online. 2018). Per the DSM 5, Bipolar II is defined as an abnormally elevated or irritable mood with an increased activity that lasts at least 4 uninterrupted days along with at least three behaviors such as inflated self-esteem, decreased need for sleep, increased talking, flight of ideas, racing thoughts, goal-driven activity, and participating in high-risk behaviors (American Psychiatric Association, 2013). Hypomanic episodes should also be noted by those close to the client per the DSM 5. Further interviewing with the client’s family needs to be completed in order to determine if the client exhibited hypomanic episodes.
3. Primarily a cluster B personality disorder (antisocial/histrionic/narcissistic/borderline)
The client’s irritability, anxiety, and past failed relationships may be explained by a cluster B personality disorder, per the DSM 5.
1. ** 2 Pharmacological Agents: The medications of choice for this client would be those that aim at stabilizing the client’s mood, such as lithium or Lamictal. According to Stahl (2013), Lamictal is a second-line medication therapy that can be used to treat mixed state depression symptoms. The goal dosage of Lamictal would be 200 mg PO Daily. Lamictal dosages need to be titrated up slowly because of the serious side effect known as Steven Johnson’s Syndrome. Dosing Schedule: 25 mg PO daily for 2 weeks-50 mg PO Daily for 2 weeks- 100 mg PO Daily for 1 week-Double dose every week to maintenance at 200 mg Daily PO. Lithium is used for the maintenance treatment for manic-depressive conditions and major depressive disorder (Stahl, 2017). The main goal of treatment with lithium therapy is complete remission of symptoms (Stahl, 2017). The client should have initial kidney function tests done prior to starting therapy and 1 to 2 times a year during therapy. Serum lithium levels should be drawn every 1-2. weeks until the desired serum concentration is achieved, then every 2-3 months for 6 months (Stahl, 2017). After the first 6 months of lithium therapy, stable serum lithium levels should be drawn 1-2 times per year. I would choose Lamictal therapy over lithium therapy due to the lack of lab work needed to maintain and dose Lamictal, compared to lithium.
**Dosing Considerations in Regard to Ethnicity
This particular client’s race was not identified in the case study. According to Prescribing Information (2005), Lamictal had an oral clearance that was 25% lower in non-Caucasians than Caucasians. If this patient were not Caucasian, he would most likely require a lower dose of Lamictal due to the 25% decrease in oral clearance.
**Check Points
12 Week Follow Up:
– The client discontinued his methylphenidate per PMHNP recommendation due to the increased risk of causing the client to have cycling unstable mood states.
-The client started lamotrigine by his local psychiatrist, 400mg PO Daily. I would decrease this dose to 200mg PO Daily per current lamotrigine initiation recommendations (Stahl, 2013).
16 Week Follow Up:
– The client decided to discontinue his lamotrigine because it was making him more depressed and inhibiting his sex life. I would review the patient’s renal function and urinalysis and initiate lithium therapy in order to stabilize his mood. I would prescribe the patient 400mg PO QHS
20, 24, 28 Week Follow Up:
-The client’s lithium levels are 0.4, his dose finally increased to 1800 mg daily. The client unhappy with his lithium therapy due to it negatively affecting his Chron’s disease. The dose is titrated down to 1500mg of lithium and Lamictal therapy is restarted at 25mg and titrated to a max dose of 200mg, which was half of his initial dosage. The hope is that using two mood stabilizers will work together and produce therapeutic effects
– The client restarted methylphenidate therapy against medical advice. The client attested to restarting it because of his low energy and dysphoric mood.
32, 34, & 36 Week Follow Up:
-The client is non-compliant with prescribed medications and therapy and continues to disregard PMHNP recommendations
**Lessons Learned and Ethical Considerations
This case study has taught me to always remember that difficult clients will inevitably be difficult to treat. There will be times when I will need to ask those who have more experience than me for help in deciding the appropriate course of treatment in certain challenging clients. I also learned that treating challenging clients will take time and results may not be observed for a while. It is important to give the specific choice of treatment time to work. One ethical consideration that I took away from this case study is that this patient is a physician, who has taken the liberty of making his own therapeutic decisions in the past. As a provider, I need to monitor and observe this client closely in case he chooses to self prescribe his own medications and disregard his care plan.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
Columbia-Suicide Severity Rating Scale. (2016). Retrieved December 9, 2019, from http://cssrs.columbia.edu/scoring_cssrs.html
Hirschfeld, R. M. (2002). The Mood Disorder Questionnaire (MDQ). Retrieved December 9, 2019, from
SAMHSA website: https://www.integration.samhsa.gov/images/res/MDQ.pdf
Perscribing Information for Lamictal. (2005). Retrieved December 11, 2019, from FDA website:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/
020241s10s21s25s26s27,020764s3s14s18s19s20lbl.pdf
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press
Stahl, S. M. (2017). The prescriber’s guide (6th ed.). New York, NY: Cambridge University Press
Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of
substance abuse. Dialogues in clinical neuroscience, 17(2), 181-190.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518701/
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Post Brandy Ni
/in Uncategorized /by developerRespond by offering one or more additional mitigation strategies or further insight into your colleagues’ assessment of big data opportunities and risks.
Main Post
Big data benefits
Big data is the compilation of insurmountable information gathered. As Milton (2017) suggested, it encompasses everything from “digital technologies, online services, computing devices,” (Milton, 2017). Big data can be used by banks, the stock market, healthcare system, it’s a matter of taking which information is relevant to what. The part of big data that I’m interested in is what can be used to provide personalized healthcare. In the world of nursing, everyone can agree that the electronic health record (EHR) is a great technology. As this technology advances, it is important that it is also standardized and agreed upon across the board. Charting nursing assessments must be consistent in order to make sense of what was observed. This, in turn, will make turning data into useful information easier when it comes to data interpretation. Nurses utilize all this information to come up with a well-thought-out nursing intervention to provide the best patient care possible. The ever-changing EHR, the accumulation of information gathered from patients through advancement in technology, and the continuous improvements in the current technology in healthcare are all great, however, it was designed to lessen the burden on nurses when it comes to charting and documentation. It seems as though, the more improvements and modifications the electronic health system develops, the more time the nurses are to spend on the computers, inputting more data and interpreting results in the hopes of improving patient care, while at the same time not essentially performing “patient care.”
Big data challenge in nursing care
The biggest benefit of big data in healthcare is I believe the organization of the EHR. As a nurse, being in the front line of healthcare, I have observed the real benefits of electronic health records. The organization I work for has multiple hospitals and outpatient centers, and if the physician is part of this organization, he/she can then access all information in the EHR. This current technology is indeed great for everyone involved, patients and clinicians alike, as the information they would need is readily available. My only concern as a nurse is that it somehow takes away from the nurse to patient relationship. As I have observed in nursing practice, charting can become redundant and unnecessary. This simple redundancy in charting is, in fact, a hindrance in a nurse to patient interaction. I would certainly hope that the future modifications of the electronic health record would reduce redundancy and must be more standardized.
A strategy that I believe has the potential to lighten this growing issue is charting by exception. I surmise, charting by exception will give nurses a little less time to spend on the computer and more time at the bedside. This will improve patient morale and satisfaction if they actually interact more with their nurses instead of having the nurse stare at a computer screen while talking to them.
Big data risk
An information security breach is I believe the biggest threat with the use of big data. Protected health information or PHI, if stolen can wreak havoc in an individual’s life. According to Milton (2017), “big data, by design, are intended to reveal unforeseen connections between data points.” (Milton, 2017). Patient privacy must be protected at all times, confidentiality is essential and must never be compromised. I surmise the information security we currently have is really hard to break however, I also assumed that was the case with credit companies like Equifax, even big banks like J.P. Morgan Chase. If hackers can hack through those, it’s only a matter of time for them to hack through health records.
References
Arora, A., Garg, S., & Khanduja, V. (2017). Applications of big data in real world: It’s not what you know, it’s what you do with what you know. International Conference on Computing, Communication and Automation, 159-163.
Delaney, C. W., & Westra, B. (2017). Big data: Data science in nursing. Western Journal of Nursing Research, 39(1), 3-4.
Henley, S. J. (2014). Mother lodes and mining tools: Big data for nursing science. Nursing Research, 63(3), 155.
Milton, C. L. (2017). The ethics of big data and nursing science. Ethical Issues, 30(4), 300-302.
Needleman, J. (2013). Increasing acuity, increasing technology, and the changing demands on nurses. Nursing Economic$, 31(4), 200-202.
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Post Brandy Nursing Informatic
/in Uncategorized /by developerRespond to the post bellow, offering additional/alternative ideas regarding opportunities and risks related to the observations shared.
Initial Post
I am currently a home telehealth nurse for a large VA hospital. I worked bedside for 17 years prior my current position. Unlike the inpatient setting, the technology and advancement made for the telehealth programs within the VA are impressive and evolving rapidly.
Technology Trends and Risk
An obvious trend within the VA system is the expansion of technology within the telehealth program. A large percentage of the veterans live in rural areas. At the time, home telehealth technology is limited to monitoring patients with chronic diseases through platforms via PC, a device to manually enter readings daily, mobile apps, and manually entering readings through a phone number. The VA is now trending toward video assisted monitoring with home telehealth. There are physician’s offices and community-based clinics are already using this technology. The primary challenge with this technology is the accessibility of reliable signal strength to patients in rural areas. An additional struggle is difficulty with these veterans working with this technology.
Data Safety
The VA medical system has an adequate privacy and security protection as it relates to data safety and information sent through telemedicine modalities. The VA has a dedicated department that strictly monitors all data activity. Despite the security in place there are risk, specifically with telehealth transmission of personal health information. These risks include accidental transmission of household information and activities including personal interactions with family members or indicators when the patient may not be home (Hall & McGraw, 2014).
Patient Care
Patient care benefits of telemedicine are endless. These benefits include less travel time, real time monitoring of medication changes, monitors patients with chronic condition like COPD and CHF closely to prevent or address acute episode (McGonigle & Mastrian, 2018). This cuts down on office visits and travel time. More importantly, healthcare management is achieved sooner improving overall patient outcomes. Patient’s rely heavily on monitoring from home creating a potential risk. Often these patients with chronic care management are not compliant with transmitting information or information is sent inconsistently making it difficult to assist with achieving overall goals.
Legislation
Telehealth technology allows providers to treat remotely defined by state-by-state licensure (Milstead & Short, 2019). The benefit of state regulation is the ability to closely monitor practice and outcomes on a state level. The federal government is considering nationalizing the regulations for telehealth. This presents a dilemma as physicians practicing telehealth will require multi state licenses.
I believe the most promising healthcare trends impacting healthcare technology and nursing practice is the advancement of telemedicine. The ability to remotely monitor patients and maintain a consistent record provide information for time sensitive diagnosis and treatment. The impact this has on nursing is profound. Nurses will be responsible not only for monitoring but for teaching these patients how to manage these problems themselves. The nurse’s consistent communication allows for education not only with medication but with diet, exercise, weight loss and overall prevention. Telehealth is a promising tool to the new culture of preventative healthcare. While patients are in the program, they can interact and learn about their disease process and exacerbation prevention. Telehealth is a win win.
References
Hall, J. L., & McGraw, D. (2014). For Telehealth to Succeed, Privacy and Security risks must be Identified and Addressed []. Health Affairs, 33(2). https://doi.org/https://doi.org/10.1377/hlthaff.2013.0997
McGonigle, D., & Mastrian, K. G. (2018). Nursing Informatics and the Foundation of Knowledge (4 ed.). Burlington, MA: Jones & Bartlett Learning.
Milstead, J. A., & Short, N. M. (2019). Health Policy & Politics A Nurse’s Guide. Burlington, MA: Jones & Bartlett Learning Books.
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Post Brandy
/in Uncategorized /by developerRespond to this post with a positive response :
Ask questions to help clarify the scenario and application of data, or offering additional/alternative ideas for the application of nursing informatics principles.
Main Post
The development of the electronic medical record (EMR) has been a pivotal advancement within nursing and to the delivery of healthcare. I have been a nurse for 19 years. While the electronic medical record was difficult to embrace in the beginning, it has proven to be a reliable and necessary tool. EMR has evolved over time impacting delivery of care and improving outcomes including time sensitive acute care patient scenarios resulting in positive outcomes (Sweeney BSN, 2017). The availability of viewing labs and health records simultaneously allows nurses and critical care team members, i.e. pharmacist and intensivist, the ability to make safe time sensitive decisions for patients.
As a critical care nurse, things can go bad quickly at the bedside. For example, a patient arrives to the ED in an acute CHF exacerbation. Lab work, radiologic studies and a baseline of vital signs are crucial to fast and effective care. If this patient is established in the system, baseline lab values, previous radiologic test for comparison and possibly even notes from a specialist i.e. cardiology/nephrology are available while waiting on new test to arrive and stabilizing the patient. This information is available to the entire team instantaneously through his/her EMR. EMR has allowed physicians, nurses and other medical team members to make safe and effective decisions producing favorable and effective outcomes. For example, knowledge of the patient’s renal function or availability to notes from his/her renal physician will direct the ED physician to the appropriate treatment. This could potentially avoid possible long-term effects to this patients’ kidneys and provides insight to treatment options that have worked well for this patient in the past. The Agency for Healthcare Research and Quality (AHRQ) supports this with study results noting fewer medication errors, improved quality of care with and cost savings as a result of fewer medical errors from utilizing the EMR (“Electronic Health Reporter,” 2018).
Nurses have contributed to the evolution of the EMR and applications centered toward favorable outcomes. The role of the informatic nurse has changed with the evolution of healthcare redefining roles and forms, it is not consistent and will change as healthcare evolves (Nagle, Sermeus, Junger, & Bloomberg, 2017). Nurses will continue to play a profound role in the development of EMR and other tools available to provide safe and effective patient care.
References
How Nurses Are Using Health Informatics to Improve Patient Care. (2018). Retrieved from https://electronichealthreporter.com/nurses-using-health- informatics-improve-patient-care/
Nagle, L. M., Sermeus, W., Junger, A., & Bloomberg, L. S. (2017). Evolving Role of the Nursing Informatics Specialist []. Forecasting Informatics Competencies for Nurses in the Future of Connected Health, 212-221. https://doi.org/doi:10.3233/978-1-61499-738-2-212
Sweeney BSN, N, J. (2017). Healthcare Informatics [Entire issue]. Online Journal of Nursing Informatics (OJNI), 21(1). Retrieved from https://www.himss.org/library/healthcare-informatics
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Post Britan Policy
/in Uncategorized /by developerRespond to this post with a positive response :
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Use references
EXAMPLE OF A REFERENCE:
If you cannot locate a doi number, this is how the reference should look:
Quelly, S. B. (2017). Characteristics Associated with School Nurse Childhood Obesity Prevention Practices. Pediatric Nursing, 43(4). Retrieved from https://www.pediatricnursing.net/issues/17julaug/abstr5.html
Main Post
In order to reform the healthcare system, strong leadership is needed to make that transformation and that leadership needed comes from all levels within an organization. Nurses need leadership skills and to be full partners with other health professionals in the efforts to redesign the health care system. It is crucial for nursing research and practice to develop improvements in care based on best evidence-based practices. Nurse leaders must be able to interpret new research findings and incorporate those into practice and education in order to advocate for policy change. Nurses are vital in identifying problems in the work environment, executing a plan for improvement, tracking it over time, and adjusting as needed to establish the best possible outcomes.
From the information in box 7.3, “Research Priorities for Transforming Nursing Leadership,” one of the topics is the identification of skills and knowledge most critical to leaders of healthcare organizations. This is important to me as I further my education to pursue a career in advanced nurse practitioner. The unique position that advanced nurse practitioners are in is they still posses the qualities of a nurse such as communication skills, attention to detail, empathy, emotional stability, problem-solving skills, and respect but are specialized to diagnose illnesses and conditions, interpret diagnostic tests, provide counseling, and prescribe medication as needed. According to the article in the Journal of Professional Nursing, Reforming health care means fixing escalating costs, providing accessibility and quality care to patients, and addressing personnel shortages in various health disciplines. Nurse practitioners are in a position to utilize their skills and knowledge to increase those shortcomings in various health disciplines and to provide high-quality more cost-effective care.
It is essential for nurses to possess leadership skills to be able to contribute to patient safety and quality of care effectively. These skill sets include being able to work in a team, knowledge of the healthcare delivery system, and holding themselves and others accountable. Collaboration amongst all levels within an organization has been proven to demonstrate more significant results with patient outcomes, cost, and job satisfaction. Education and self-confidence are essential attributions in a leader to advocate for needed changes in health care.
References
Archibald, M. M., & Fraser, K. (2013). The Potential for Nurse Practitioners in Health Care Reform. ScienceDirect, 29(5), 270-275. Retrieved from https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/pii/S8755722312001883?
Barnes, H., Maier, C. B., Sarik, D. A., Germack, H. D., Aiken, L. H., & McHugh, M. D. (2016, May 13). Effects of Regulation and Payment Policies on Nurse Practitioners’ Clinical Practices. Medical Care Research and Review, 74(4). Retrieved from https://journals-sagepub-com.ezp.waldenulibrary.org/doi/full/10.1177/1077558716649109?
Shaughnessy, M., Griffin, M. Q., Bhattacharya, A., & Fitzpatrick, J. J. (2018, November). Transformational leadership practices and work engagement among nurse leaders. The Journal of Nursing Administration, 48(11), 574-579. https://doi.org/10.1097/NNA.0000000000000682
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Post Britney Evidence Based Practice
/in Uncategorized /by developerRespond to the Main post bellow, in one or more of the following ways:
Ask a probing question, substantiated with additional background information, and evidence.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own review of the literature in the Walden Library.
Validate an idea with your own experience and additional sources.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Initial post
An intervention program to promote health-related physical fitness in Nurses
Nursing is a very stressful profession and has become more demanding in recent years. (Kuo, H.-W, 2009, P. 1404) With nursing being increasingly demanding and strenuous it is important for the nurse to take care of themselves. Regular exercise can help maintain a healthier lifestyle. This will always be beneficial not only to the nurse working with the patients but for the patients as well to have a healthy example of a current lifestyle.
In this study 90 nurses were chosen. These nurses came from five different hospitals. They were separated into two groups experimental and controlled. Experimental groups are those who are being exposed to a variable to receive an outcome. (Steadmans Medical Dictionary, 2002) Controlled group is not being exposed to this variable. In this case the variable is exercise on the treadmill for three months. Nurses were exposed to treadmill exercise for three months to see what type of results they obtained compared to those who were not active. This study demonstrates that the development and implementation of an intervention program can promote
health-related physical fitness of nurses. (Kuo, H.-W, 2009, P. 1404)
I do think this is very relevant to our practice because the nurses are benefiting in a health manner. The extent to which results are consistent over time and an accurate representation of the total population under study is referred to as reliability. (Golafshani, 2003)It is important as healthcare workers to live a healthy lifestyle so that when we educate our patients they are able to see an example. It also helps nurses be able to release stress in a healthy way and reduces the risk of many disease. Staying active will help with patient care when it comes to taking care of our patient at the bedside and will help us keep our energy for longer periods of time since most of the day we are on your feet.
Yuan, S.-C., Chou, M.-C., Hwu, L.-J., Chang, Y.-O., Hsu, W.-H., & Kuo, H.-W. (2009). an intervention program to promote health-related physical fitness in nurses. Journal of Clinical Nursing, 18(10), 1,404–1,411.
Experimental Group.” Dictionary.com, Steadmans Medical Dictionary, 2002, www.dictionary.com/browse/experimental-group.
Golafshani, N. (2003). Understanding Reliability and Validity in Qualitative Research. The Qualitative Report, 8(4), 597-606. Retrieved from https://nsuworks.nova.edu/tqr/vol8/iss4/6
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Post Britney
/in Uncategorized /by developerPost a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.
Main Post
Week 1 Advanced Health Assessment
Initial Post
My patient: 38-year-old Native American pregnant female living on a reservation
Each patient you meet you will have different techniques and ways of going about communication with them depending on their culture and beliefs. It is important to understand what is important to them. Ask yourself what do they value most? You want to be able to connect with them to get an accurate history to provide care. The nursing assessment includes gathering information concerning the patient’s individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. (Jamieson H,2019)In my situation with my patient being of the Native American decent livening on a reservation whom is pregnant I can already assume she does not have much interaction with the outside world such as those outside the reservation. She mainly probably stays with those who live around her and live off the land with little unhealthy habits since nature is very important in this culture.
My interview techniques to obtain a health history would need to be based on her lifestyle. I need to make sure I am wording them correctly so that she can understand what I am needing from her. Certain health information that is important to us may not be pertinent to the patient. I need to target my questions towards her lifestyle. The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient. (Gray LC,2018) I also need to base a lot of my question on the fact she is pregnant. I need to ensure she Is healthy not only for herself but for the baby. I may have to redirect and reword my question multiple times to obtain accurate information. With this patient living on a reservation I need to ask about her diet and environmental factors since my way of life Is different than hers I need to first understand how she lives. The cultural competency assessment will identify factors that may impede the implementation of nursing diagnosis and care. (Dunham M,2018)I then need to focus on potential health risk based on first this patient age. This patient is 38 years old and is pregnant. This is automatically a high-risk pregnancy due to her age. 35 is considered geriatric pregnancy. This increase the risk for many health concerns for her and the baby. Also, her living situation can at time be difficult for her and baby depending on what type of reservation she lives on. I need to ensure she has quick access to medical care and is receiving the proper supplements. Many native American cultures believe in herbal and home remedies which can sometimes be harmful or interact with other medications. Some questions that need to be asked I order to obtain an accurate health history are the following: Do you have any allergies to medication?Is this your first child? If not, how many children do you have, and did you have a C-section?
What medication including herbal supplements are you taking?Have you ever had any major surgeries?Have you ever been hospitalized for any reason including mental health reasons? What is your family history?Have you been having any complications that you have noticed or concerns?
References
Jamieson H, Abey-Nesbit R, Bergler U, Keeling S, Schluter PJ, Scrase R, Lacey C. Evaluating the Influence of Social Factors on Aged Residential Care Admission in a National Home Care Assessment Database of Older Adults. J Am Med Dir Assoc. 2019 Mar 26;Gray LC, Beattie E, Boscart VM, Henderson A, Hornby-Turner YC, Hubbard RE, Wood S, Peel NM. Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care. Health Serv Insights. 2018 Dunham M, MacInnes J. Relationship of Multiple Attempts on an Admissions Examination to Early Program Performance. J Nurs Educ. 2018 Oct 01;57(10):578-583.
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Post Brittan
/in Uncategorized /by developerRespond to this post with a positive response :
Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Use references
Main Post
The burden of mental illness in the United States is among the highest of all diseases, and mental disorders are among the most common causes of disability (HealthyPeople.gov, 2014). Many people with a variety of mental disorders are disadvantaged because of poor access to health care. Poor access to care can be due to several reasons, and those reasons range from lack of employment and insurance to knowledge deficiencies surrounding mental conditions and the need to get help. Several factors can play into this, such as the behavior of an individual. Individual determinants include stress, coping mechanisms, risk-taking behaviors, and openness. Another factor is social environment determinants. These determinants include access to good education and a supportive network of people, access to employment for income, and community dynamics. A third factor is physical environment. Physical environment determinants include access to parks and safe sidewalks for physical activity to relieve stress, supportive house environment with no violence, residential crowding, home conditions, and exposure to toxins at certain developmental stages. Lastly, genetic factors play a significant role in a person’s susceptibility to mental health issues. Disorders such as depression, schizophrenia, and autism are known to run in families through DNA transmission.
In overlooking the five population determinants, the ones that most standout when it comes to mental health are access to healthcare and social environment determinants. According to an article in Social Solutions, more than half of Americans living with a mental health condition receive no treatment. These barriers to health access are due to financial burdens, lack of mental health providers, mental health education and awareness, the social stigma that surrounds mental health conditions, and racial barriers. Early screenings, accurate diagnoses, and appropriate treatment for mental illnesses can help to alleviate suffering from both patients and those close to the individual.
The social determinants of health, defined as those conditions in which people are born, grow, live, work, and age that impact health and well-being are known to have major influences on diverse health outcomes (Shim et al., 2014, p. 23). Prevention at a population level will have the most significant impact. Providing health equity across a populational level regardless of economic or social status will play a crucial role when considering all five determinants of health.
According to the Centers for Disease Control and Prevention (2012), epidemiologic data provides enough evidence to direct swift and effective public health control and prevention measures. Mental health effects people of all ages. Data in HealthPeople.gov (2014), states that approximately 20% of children are affected within their lifetime and about 83% of adults have some type of mental illness. Epidemiologic data is gathered to analyze the health status of a population living in an environment and then utilize that information to outline potential health impacts and quantify them. This information is then used as a direct link to policy-making decisions.
References
Centers for Disease Control and Prevention. (2012). Lesson 1: Introduction to epidemiology.
Retrieved December 17, 2018, from https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section1.html
Gulis, G., & Fujino, Y. (2015). Epidemiology, population health, and health impact assessment. Journal of Epidemiology, 25(3), 179-180. https://doi.org/
HealthyPeople.gov. (2014). Mental health. Retrieved December 17, 2018, from https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Mental-Health/determinants
Kindig, D., Asada, Y., & Booske, B. (2008). A population health framework for setting national and state health goals. JAMA, 299(17), 2081–2083. Retrieved from https://jamanetwork-com.ezp.waldenulibrary.org/journals/jama/fullarticle/181830
Laureate Education (Producer). (2012). Population health. Baltimore, MD: Author.
Shim, R., Koplan, C., Langheim, F. J., Manseau, M. W., Powers, R. A., & Compton, M. T. (2014). The social determinants of mental health: An overview and call to action. Psychiatric Annals, 44(1), 22-26. Retrieved from http://m3.wyanokecdn.com/94bb6a43efb278e9eb152cdaf4e17b9a.pdf
Social Solutions. (n.d.). Top 5 barriers to mental healthcare access. Retrieved December 17, 2018, from https://www.socialsolutions.com/blog/barriers-to-mental-healthcare-access/
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Post Camille
/in Uncategorized /by developerRead a selection of your colleagues’ responses and respond on two different days who selected a different type of diabetes than you did. Provide recommendations for alternative drug treatments and patient education strategies for treatment and management.
Main Post
Type 1 diabetes which is sometimes called juvenile or insulin-independent is when the pancreas produces little to no insulin. It can be seen as an autoimmune disease because the immune system mistakenly attacks the insulin-producing beta cells of the pancreas (Diabetes UK The Global Diabetes Community, 2019). Since these patients are not producing enough insulin, they are insulin-dependent for the rest of their lives, and most patients wear an insulin pump (Mayo Clinic, 2018). Type 1 is normally diagnosed during pediatric years or people younger than the age of 30 (Diabetes UK The Global Diabetes Community, 2019).
Type 2 diabetes which is also called adult-onset or non–insulin-dependent diabetes, is different from type 1 because in type 2 the body loses the ability to respond to insulin (Thompson & Romito, 2018). This causes the body to become insulin resistant because the body is not using insulin in the right way (Thompson & Romito, 2018). The pancreas soon becomes overworked and makes less insulin leading to insulin deficiency. Type 2 diabetes can be treated with insulin and medications, it can also be prevented if caught early and by lifestyle modifications such as in food, diet, and behaviors. Type 1 diabetes is not preventable (Diabetes UK The Global Diabetes Community, 2019).
Gestational diabetes (GDM) occurs during pregnancy. A hormone made by the placenta in the womb keeps the body from using insulin the way it should (Cedars-Sinai, 2019). Glucose builds up in the body and is not absorbed by cells leading to this disorder. GDM normally goes away after the birth of a baby. Women who are overweight are more prone to developing this disorder, and their children are at an increased risk of developing type 2 diabetes (Cedars-Sinai, 2019). Making sure to get blood work done routinely, sticking to proper diet, exercise, medications, and insulin injections can control and prevent developing GDM (Cedars-Sinai, 2019).
I selected Aspart (Novolog) insulin pen as the drug of choice for GDM. To prepare this drug I would show the pregnant patient how to administer this drug. First, I would instruct the patient to check their blood sugar pre-meals. If the blood sugar is above 150, right before their meal then the patient should follow the range dose of insulin to give that is prescribed to the patient. If the patient plans of eating all of their food then the patient will be told to give the required dose 15 minutes before or after the meal (University of Iowa Hospitals & Clinics [UIHC], 2019). If the patient only eats half then wait till after the meal to administer insulin.
The patient will be told that in pregnancy the best place to administer insulin is in the abdomen because this is where insulin gets absorbed the fastest in the bloodstream (UIHC, 2019). It should be injected at least 2 inches away from the belly button. To use the pen I would instruct the patient to remove the cap of pen and clean with alcohol, apply needle, prime the pen by selecting 2 units making sure to see drops so you know its working right. After this, select the appropriate dose needed for the patient, point the pen towards the abdomen site and push down to inject (UIHC, 2019). The dietary considerations would consist of a balance of legumes, sweet potatoes, salmon, eggs, fruits, broccoli, green leafy vegetables, fish liver oil. Berries, whole wheat products, and lean cooked meats (Cedars-Sinai, 2019). The patient would be told to stay away from processed, sugary, and fried foods.
A short term effect that may not be talked about with GDM is the cost. On average women living with GDM spend up to two-thousand dollars more than women living without GDM (Xu et al., 2015). This is related to the cost of medications, frequent doctor visits, and symptoms of hyperglycemia that the patient experiences. This is why making sure to take insulin, following a proper diet, and exercise program can help decrease these cost and prevent developing type 2 diabetes in the long-term for patient and child. If the patient develops type 2 diabetes after pregnancy this can lead to obesity, stroke, and heart attack if not properly controlled (Diabetes UK The Global Diabetes Community, 2019). It is clear that following and living a balanced diet regardless of the type of diabetes diagnosed with can help control, and prevent detrimental effects on the body and allow to live a satisfying life.
References
Cedars-Sinai. (2019). Gestational Diabetes. Retrieved from https://www.cedars-sinai.org/health-library/diseases-and-conditions/g/gestational-diabetes.html
Diabetes UK The Global Diabetes Community. (2019). Differences Between Type 1 and Type 2. Retrieved from https://www.diabetes.co.uk/difference-between-type1-and-type2-diabetes.html
Mayo Clinic. (2018). Type 1 Diabetes. Retrieved from https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011
Thompson, E., & Romito, K. (2018). Diabetes: Differences Between Type 1 and 2. Retrieved from https://www.mottchildren.org/health-library/uq1217abc
University of Iowa Hospitals & Clinics. (2019). Insulin use during pregnancy. Retrieved from https://uihc.org/health-topics/insulin-use-during-pregnancy
Xu, T., Danielli, L., Yu, K., Ma, L., Silva Zolezzi, I., Detzel, P., & Fang, H. (2015). The short-term health and economic burden of gestational diabetes mellitus in China: a modelling study []. BMJ Open, 7(12). Retrieved from https://bmjopen.bmj.com/content/7/12/e018893
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Post Casey 19222135
/in Uncategorized /by developerRespond to the post bellow (positive comment), using one or more of the following approaches:
Ask a probing question, substantiated with additional background information, and evidence.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own review of the literature in the Walden Library.
Validate an idea with your own experience and additional sources.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
Main post
In order to improve patient outcomes and ensure appropriate decision making, it is essential that evidence-based practice (EBP) be incorporated into patient clinical experiences (Polit & Beck, 2017). EBP should be a priority in this current day and age of healthcare. Patient healthcare decisions should be designed according to the most up to date available clinical evidence. This clinical evidence should be focused on safe and efficient patient care. In many facilities, my own included, EBP is encouraged to be incorporated into daily clinical practice. Unfortunately, the practical process and resources that are necessary for achieving EBP are frequently not available or successful (Aitken et al., 2011). In order to improve and increase EBP utilization in healthcare, nurse-led EBP programs have been put in place. My current institution is currently trialing a nurse-led EBP in the ICU. This program consists of 3 nurses that complete daily rounds in the ICU to evaluate the efficacy of specific protocols or products such as oral care on ventilated patients being completed every 2 hours.
According to Cullen & Adams (2012), nurse-led research is increasingly recognized as an essential pathway to effective and practical was of improving patient outcomes. The dissemination of EBP should be a top priority. Effective dissemination strategies provide a pathway for knowledge to be shared and inspire further innovations. In order to disseminate EBP findings, my institution uses its website to post the most current and up to date clinical findings. The healthcare staff members are expected to review newly posted information on a weekly basis. When it comes to instituting an excellence-focused culture in healthcare, nursing research and EBP are required along with the integration of a professional practice model (Aitken et al., 2011). In order to achieve this great feat, nurses and all healthcare staff alike need to be encouraged to participate in scholarly activities (Aitken et al., 2011). Healthcare institutions should also have readily available resources for nurses and staff members to investigate the most current EBP methods.
Aitken, L. M., Hackwood, B, Crouch, S., Clayton, S., West, N., Carney, D., & Jack, L. (2011). Creating an environment to implement and sustain evidence-based practice: A developmental process. Australian Critical Care, 24(4), 244–254.
Cullen, L., & Adams, S. L. (2012). Planning for implementation of evidence-based practice. Journal of Nursing Administration, 42(4), 222–230.
Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer.
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Post Casey 19465791
/in Uncategorized /by developerRespond to at least two of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
Case #7
The Case: The case of physician do not heal thyself
The Question: Does the patient have a complex mood disorder, a personality disorder or both?
The Dilemma: How do you treat a complex and long-term unstable disorder of mood in a difficult patient?
*List three questions you might ask the patient if he or she were in your office:
1. Has there ever been a period of time when you were not your usual self and thoughts raced through your head or you couldn’t slow your mind down (Hirschfeld, 2002)?
Rationale: This question specifically inquires about whether the client feels they have been their usual self and specifically references their energy levels (Hirschfeld, 2002). These symptoms are important to identify and rule out if a manic episode related to a mood disorder (such as Bipolar I) is occurring. By narrowing down correct symptomologies, the correct and appropriate psychiatric diagnosis can be made, along with the appropriate treatment.
2. Has your mood or behaviors caused major problems in your life like being unable to work; having a family, money or legal troubles; getting into arguments (Hirschfeld, 2002)?
Rationale: This question specifically focuses on how much of a problem the symptoms have been in a client’s everyday life. Mood disorders such as Bipolar I and Bipolar II can significantly impact a client’s life. Patients suffering from a mood disorder, such as Bipolar I, are at a significantly higher risk for suicide, harm to self, or harm to others (Hirschfeld, 2002).
3. How frequently would you estimate that you have experienced racing thoughts or elevated energy in relationship to your mood or fights and have any of these issues occurred during the same period of time (Hirschfeld, 2002)?
Rationale: This particular question addresses if the symptoms that are being experienced, occurred during the same time period, which would be indicative of the diagnosis of Bipolar I mood disorder. This question is important when assessing a client for a mood disorder in those patients who are misdiagnosed may experience rapid cycling or mania (Hirschfeld, 2002).
*Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
According to Stahl (2013), it is essential for healthcare providers to obtain information from not only the client but also from outside sources. Outside sources for a client may include their spouse, parents, or siblings. Information obtained from outside sources may be significantly different than what the client describes and can assist in accurately diagnosing the client (Stahl,2013). Clients that are accurately diagnosed, can then be appropriately treated with pharmacological agents.
-Were there any significant triggering factors related to the client’s first major depression episode at age 23?
These questions can assist in distinguishing between Bipolar Mood Disorders and Borderline Personality Disorder. Bipolar Mood Disorders typically manifest in the early to mid-’20s ( It must be determined if the depression was an initial onset of a hypomanic episode or if it was due to an existing personality disorder.
-What other moods did the client exhibit when they were not in a depressive episode? How long did these moods last?
According to Stahl (2013), individuals often downplay their manic symptomologies and their duration. These episodes and their duration are essential in order to accurately diagnosing a client.
-Does the client have any significant psychiatric history, such as Bipolar I, Bipolar II, or other mood disorders?
According to Stahl (2013), first-degree relatives who also have bipolar disorder can indicate the likelihood that the client also suffers from a bipolar disorder. If the client does have a significant family history of bipolar disorder, any effective treatments, the severity of the condition, and any hospitalizations that occurred should be documented in the client record.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Certain diagnostic tests such as a Complete Metabolic Panel (CMP), Liver Function Tests (LFT’s), Hemoglobin A1c, and a urine specific gravity can be ordered to evaluate the functionality of the client’s kidneys, liver, and the presence/risk of diabetes mellitus. A mood stabilizer such as Lithium may be used to manage the client’s severe fluctuation in moods. Lithium, however, can be severely nephrotoxic. Kidney function tests should be drawn prior to initiating therapy and throughout the course of therapy to assess for kidney dysfunction (Tolliver & Anton, 2015). A urine specific gravity can also indicate the functionality of the kidneys. Antipsychotic medications may be used to treat long-term unstable mood disorders. Antipsychotic medications, both first and second generations, can cause metabolic syndrome. The development of metabolic syndrome can be monitored by obtaining a CMP, LFTs, & Hemoglobin A1C prior to starting medication therapy and then throughout the medication therapy course. According to Stahl (2013), clients taking antipsychotic medications should have lab diagnostic studies done every 3-6 months. A urine drug screen (UDS) should also be done to rule out the illicit substances as the causation of the mood disorder.
It is essential to assess all clients if they have any suicidal ideations. The Columbia-suicide severity rating scale can be used to assess the severity of suicide risk. COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS): This screening tool is used to detect suicidal ideations and their severity. It is scored from 0-5. A score greater than 0 may indicate a need for mental health intervention. A score of 4-5 indicates active suicidal ideation with some intent to act (“Columbia-Suicide Severity,” 2019).
This client should have a full head-to-toe physical assessment completed including a mental status exam, and vital signs. These initial findings can be used as a baseline for the patient and any future assessment changes can be compared to the initial findings (Tolliver & Anton, 2015).
**List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
1. Recurrent major depression with an anxious/dysphoric temperament Most likely diagnosis
According to the DSM V (2013), the client’s symptoms most likely indicate a mood disorder. Due to the limited amount of time with the patient and limited past mania history, a Bipolar mood disorder could be ruled out. The client’s main symptoms present as depressive in nature, with one suicide attempt 40 years ago (Stahl Online, 2018). Recurrent major depression with an anxious/dysphoric temperament, which is also a complex mixed mood disorder, is the most likely diagnosis given the patient’s current symptoms. According to the scenario provided by Stahl Online (2018), the client has been experiencing a mixed dysphoric state with the depression occurring the majority of the time.
2. Bipolar II mixed episode:
Per the client’s history, he has been experiencing symptoms that are consistent with hypomania since the age of 23, such as inflated self-esteem, irritability, and decreased need for sleep (Stahl Online. 2018). Per the DSM 5, Bipolar II is defined as an abnormally elevated or irritable mood with an increased activity that lasts at least 4 uninterrupted days along with at least three behaviors such as inflated self-esteem, decreased need for sleep, increased talking, flight of ideas, racing thoughts, goal-driven activity, and participating in high-risk behaviors (American Psychiatric Association, 2013). Hypomanic episodes should also be noted by those close to the client per the DSM 5. Further interviewing with the client’s family needs to be completed in order to determine if the client exhibited hypomanic episodes.
3. Primarily a cluster B personality disorder (antisocial/histrionic/narcissistic/borderline)
The client’s irritability, anxiety, and past failed relationships may be explained by a cluster B personality disorder, per the DSM 5.
1. ** 2 Pharmacological Agents: The medications of choice for this client would be those that aim at stabilizing the client’s mood, such as lithium or Lamictal. According to Stahl (2013), Lamictal is a second-line medication therapy that can be used to treat mixed state depression symptoms. The goal dosage of Lamictal would be 200 mg PO Daily. Lamictal dosages need to be titrated up slowly because of the serious side effect known as Steven Johnson’s Syndrome. Dosing Schedule: 25 mg PO daily for 2 weeks-50 mg PO Daily for 2 weeks- 100 mg PO Daily for 1 week-Double dose every week to maintenance at 200 mg Daily PO. Lithium is used for the maintenance treatment for manic-depressive conditions and major depressive disorder (Stahl, 2017). The main goal of treatment with lithium therapy is complete remission of symptoms (Stahl, 2017). The client should have initial kidney function tests done prior to starting therapy and 1 to 2 times a year during therapy. Serum lithium levels should be drawn every 1-2. weeks until the desired serum concentration is achieved, then every 2-3 months for 6 months (Stahl, 2017). After the first 6 months of lithium therapy, stable serum lithium levels should be drawn 1-2 times per year. I would choose Lamictal therapy over lithium therapy due to the lack of lab work needed to maintain and dose Lamictal, compared to lithium.
**Dosing Considerations in Regard to Ethnicity
This particular client’s race was not identified in the case study. According to Prescribing Information (2005), Lamictal had an oral clearance that was 25% lower in non-Caucasians than Caucasians. If this patient were not Caucasian, he would most likely require a lower dose of Lamictal due to the 25% decrease in oral clearance.
**Check Points
12 Week Follow Up:
– The client discontinued his methylphenidate per PMHNP recommendation due to the increased risk of causing the client to have cycling unstable mood states.
-The client started lamotrigine by his local psychiatrist, 400mg PO Daily. I would decrease this dose to 200mg PO Daily per current lamotrigine initiation recommendations (Stahl, 2013).
16 Week Follow Up:
– The client decided to discontinue his lamotrigine because it was making him more depressed and inhibiting his sex life. I would review the patient’s renal function and urinalysis and initiate lithium therapy in order to stabilize his mood. I would prescribe the patient 400mg PO QHS
20, 24, 28 Week Follow Up:
-The client’s lithium levels are 0.4, his dose finally increased to 1800 mg daily. The client unhappy with his lithium therapy due to it negatively affecting his Chron’s disease. The dose is titrated down to 1500mg of lithium and Lamictal therapy is restarted at 25mg and titrated to a max dose of 200mg, which was half of his initial dosage. The hope is that using two mood stabilizers will work together and produce therapeutic effects
– The client restarted methylphenidate therapy against medical advice. The client attested to restarting it because of his low energy and dysphoric mood.
32, 34, & 36 Week Follow Up:
-The client is non-compliant with prescribed medications and therapy and continues to disregard PMHNP recommendations
**Lessons Learned and Ethical Considerations
This case study has taught me to always remember that difficult clients will inevitably be difficult to treat. There will be times when I will need to ask those who have more experience than me for help in deciding the appropriate course of treatment in certain challenging clients. I also learned that treating challenging clients will take time and results may not be observed for a while. It is important to give the specific choice of treatment time to work. One ethical consideration that I took away from this case study is that this patient is a physician, who has taken the liberty of making his own therapeutic decisions in the past. As a provider, I need to monitor and observe this client closely in case he chooses to self prescribe his own medications and disregard his care plan.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author
Columbia-Suicide Severity Rating Scale. (2016). Retrieved December 9, 2019, from http://cssrs.columbia.edu/scoring_cssrs.html
Hirschfeld, R. M. (2002). The Mood Disorder Questionnaire (MDQ). Retrieved December 9, 2019, from
SAMHSA website: https://www.integration.samhsa.gov/images/res/MDQ.pdf
Perscribing Information for Lamictal. (2005). Retrieved December 11, 2019, from FDA website:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/
020241s10s21s25s26s27,020764s3s14s18s19s20lbl.pdf
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press
Stahl, S. M. (2017). The prescriber’s guide (6th ed.). New York, NY: Cambridge University Press
Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of
substance abuse. Dialogues in clinical neuroscience, 17(2), 181-190.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518701/
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