Read a selection of your colleagues’ responses 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.

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Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

Patients today are much sicker than they used to be. The advanced practice nurse needs to manage all comorbidities in the plan of care. In this post, I will discuss the patient’s health care needs and a recommended treatment plan, including pharmacotherapeutic choices. Also, I will present an education strategy to assist the patient in managing their disease conditions. The patient has a history of hypertension, myocardial infarction, hyperlipidemia angina, and diabetes type two. Her needs center around the management of these comorbidities. Also, I noticed that her serum creatinine is on the high end of the range if not outside of it. This fact is not surprising considering her diabetes. The case reports that she was doing well until about a month ago. It was tempting to consider adding another medication to the regimen. However, I believe that either the metoprolol is not high enough to manage her current disease state or she has been missing doses, and I am leaning toward the latter. If withdrawn suddenly, the drug can increase the incidence and intensity of anginal attacks. Metoprolol is the first-line drug for stable angina and should be working (Rosenthal & Burchum, 2018).  

A review of her current drug therapy appears appropriate. Aspirin, simvastatin, and metformin are competent choices, and the doses are adequate. My plan would include an assessment of how she takes medication at home and manages them before making any changes. If this were in order, I would increase the metoprolol to 75 mg twice a day and set a follow-up appointment in two weeks. I prefer to increase the dose of metoprolol first before adding any new drug because of polypharmacy considerations, and the drug does not require renal adjustment (Epocrates, 2019). This fact is beneficial to consider because she has diabetes. Assuming that the patient has missed doses over the last month, the priority is to determine why. Costa et al. (2015) recommend explaining how to take medication, discussing reluctance to take drugs, and a conversation about the patient’s beliefs and knowledge about their health and treatment. I believe that this is a great strategy to use with the patient. Medication adherence is troubling and particularly so with the elderly who have multiple medications and conditions. I think it is essential for the patient and provider to be partners in the plan of care. The patient must agree to it and fully understand their conditions and the purpose of each medication. 

 

                                          References

Costa, E., Giardini, A., Savin, M., Menditto, E., Lehane, E., Laosa, O., … Marengoni, A. (2015). Interventional tools to improve          medication adherence: review of literature. Patient Preference And Adherence, 9, 1303–1314. doi:10.2147/PPA.S87551Epocrates. (2019). Metoprolol Tartrate Adult Dosing. Retrieved from https://online.epocrates.com/drugs/25501/metoprolol-        tartrate/Adult-DosingRosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO:        Elsevier.

 

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Respond to at least two of your colleagues who selected a different factor than you, in one of the following ways:

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Share insights based on your own experience and additional research.

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Cardiovascular Alterations

It is essential to understand the typical structure and function of the cardiovascular system because alterations occur. Some changes can be pathologic and others not. Alhadheri (2005) states that 50 to 90 percent of children have a benign or functional murmur. In this post, I will explain how I would diagnose and prescribe treatment for the patient in the scenario, including how genetics impacts the diagnosis and treatment.

Diagnosis and Treatment

Making a proper diagnosis is necessary before allowing the teenager to engage in sports. The patient had no significant family history of cardiac death and an unremarkable medical history. The lack of patient medical history leads me to conclude that the problem is not acquired, but congenital. The physical assessment is not enough information to definitively determine the etiology of the murmur. It would be wise to run additional tests to rule out a pathological murmur. Appropriate tests include a chest x-ray, electrocardiogram, blood work, and echocardiogram (Alhadheri, 2005). The patient is asymptomatic, so I would order an echocardiogram looking for structural abnormalities. I suspect that the patient has mitral regurgitation based on the location and description of the sound in the scenario. Hammer and McPhee (2019) state that a murmur can be heard best at the apex of the heart with mitral regurgitation. Another possibility is coarctation of the aorta, but this is unlikely because the patient does not have diminished blood pressure nor pulses in the lower extremities. If mitral regurgitation is the case, the treatment may be surgical intervention. Either way, I would refer the patient for treatment to a pediatric cardiologist knowing that it is outside of my scope. A registered nurse practitioner is required to make a referral to a physician for a patient condition that is beyond their knowledge or experience (Arizona State Board of Nursing, 2018, p. 46).

Genetics

Genetics could impact the diagnosis. There is a high incidence of congenital heart defects with trisomies 13 and 18, Turner syndrome, and Down syndrome (Huether & McCance, 2017). The diagnosis could be a ventricular septal defect instead. However, I do not think the treatment would change if genetics were a factor. Usually, surgery is the intervention when the problem is pathological regardless of origin. 

References

Alhadheri, S. A. (2005). Children with Heart Murmurs…When to be Concerned?. Retrieved from https://apcardio.com/wp-content/themes/advancedpedia/pdf/Heart_Murmurs.pdf

Arizona State Board of Nursing. (2018, May 23). Rules of the State Board of Nursing. Retrieved June 24, 2019, from https://www.azbn.gov/media/2880/ruleseffectivemay232018.pdf

Hammer, G. D., & McPhee, S. J. (2019). Pathophysiology of disease: An introduction to clinical medicine (8th ed.). New York, NY: McGraw-Hill Education.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.

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Respond  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.

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

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When conducting research, it is necessary that the researcher not only know how to find the sources needed to answer the question that they have created but also how to analyze that information to understand which research design was used. Doing so will allow the researcher to provide the evidence needed to support or reject the question being asked. Quantitative research is the investigation of phenomena that lends themselves to precise measurement and quantification, often involving a controlled design (Polit & Beck, 2017). This discussion will look at two different quantitative studies and the qualities that make them so. 

Sleep Apnea Study Number One

 This study by Boulos et al.(2017) looks at the effectiveness of using home sleep apnea testing (HSAT) as a means of detecting obstructive sleep apnea (OSA)  in stroke or transient ischemic attack (TIA) inpatients and outpatients. OSA can negatively impact poststroke functional recovery and by using HSAT these patients can be screened and diagnosed for OSA sooner and improve their poststroke functional and motor recovery (Boulos et al., 2017).

The question being asked is therapeutic in nature. The design of the study is listed under the methods section as a single-center prospective observational study. An observational study means that the researchers do not intervene by manipulating the independent variable  (Polit & Beck, 2017). The independent variable within this study would be that all participants have had a stroke or TIA. Prospective designs are studies that begin with a presumed cause and look forward in time for its effect (Polit & Beck, 2017). Within this study, OSA was the presumed cause in a delay of functional and motor recovery for those patients who suffered a stroke or TIA. This design method was appropriate for the group being used. A control group would not have helped to validate the use of HSAT in stroke recovery since those within that group would not be suffering from the same effects. The use of t-tests, Wilcoxon rank sum-test, and multivariate logistic regression were used to analyze the data (Boulos et al., 2017). The results demonstrated that the use of HSAT in the poststroke or TIA population was effective at expediting the diagnosis and treatment of OSA (Boulos et al., 2017). 

Sleep Apnea Study Number Two

The second study is similar to the first in that it evaluated patients with acute ischemic stroke for the prevalence of sleep apnea and compared the functional outcomes of patients with and without sleep apnea at the 3rd month after an acute ischemic stroke (Nair et al., 2019). The type of question being asked is an etiology in that it looks to see if OSA is a risk factor for stroke. The design of the study is under the methodology section and is listed as a prospective observational study. This type of study is also known as a cohort design and as stated by Polit & Beck (2017), it is the strongest design for etiology questions when randomization is impossible. This method study is appropriate in that no manipulation was done to the independent variable (stroke). Randomization would not be appropriate for this particular study as the only treatment option would be the use of Continuous Positive Airway Pressure (CPAP) and the use of such treatment was not evaluated.

Questionnaires such as the sleep disordered Questionnaire, Berlin Questionnaire, and Epworth sleepiness scale were used to diagnose sleep apnea in the patients being evaluated and the results divided the group into those who had sleep apnea and those who did not. The two groups were then compared using Barthel scores at baseline and at 3 months. Using repeated measure of ANOVA, the results showed a significant difference with an improved functional gain in patients in the no sleep apnea group demonstrating that sleep apnea is associated with an increased risk of ischemic stroke and poor functional outcome (Nair et al., 2019).  

Conclusion

  For researchers, understanding which design method to use when creating a research study can be a great asset to promoting the change that they wish to bring about. Utilizing the wrong research design may diminish the quality of the results and may create doubt about the study overall. Understanding that quantitative studies aim to explain cause-and-effect relationships will help to guide the researcher to design their research to demonstrate causality and bring attention to the problem that they are determined to address (Polit & Beck, 2017).

 

References

Boulos, M. I., Elias, S., Wan, A., Im, J., Frankul, F., Atalla, M., … Murray, B. J. (2017). 

Unattended Hospital and Home Sleep Apnea Testing Following Cerebrovascular Events. Journal of Stroke & Cerebrovascular Diseases, 26(1), 143–149. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jstrokecerebrovasdis.2016.09.001

Nair, R., Radhakrishnan, K., Chatterjee, A., Gorthi, S. P., & Prabhu, V. A. (2019). Sleep 

Apnea-Predictor of Functional Outcome in Acute Ischemic Stroke. Journal of Stroke & Cerebrovascular Diseases, 28(3), 807–814. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jstrokecerebrovasdis.2018.11.030

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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Respond  using one or more of the following approaches:

Ask a probing question, substantiated with additional background information, and evidence.

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.

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Qualitative research utilizes a research design that takes shape over the course of a study and seeks to understand the realities and viewpoints of the participants (Polit & Beck, 2017). The qualitative study that I will be discussing for this week’s discussion is by Dannecker, Warne-Griggs, Royse & Hoffman (2019) on  Listening to Patients’ Voices: Workarounds Patients Use to Construct Pain Intensity Ratings. The researchers used an interpretivist design within this study. Interpretivism is a theoretical perspective that strives to make sense and understand the world from subjective experiences of individuals (Dannecker, Warne-Griggs, Royse, & Hoffman, 2019). 

 The purpose of this study was to understand the challenges that people who suffer from chronic pain face when trying to describe and rate their pain. A recurring theme within the study was that everyone perceives pain differently and that trying to rate it using traditional methods often times did not accurately represent their current pain levels (Dannecker, Warne-Griggs, Royse, & Hoffman, 2019). Many of the participants found it easier to remember a specific physical activity that caused their pain to become worse and use that experience to provide a valued context for communicating pain experiences (Dannecker, Warne-Griggs, Royse, & Hoffman, 2019). 

Appropriateness of Design 

 When conducting a qualitative study, it is important that the design used is appropriate for answering the questions the study seeks to answer (Polit & Beck, 2017).  The study conducted by Dannecker, Warne-Griggs, Royse, & Hoffman (2019) sought to understand and explain patients’ point of view regarding how they describe pain intensity, and the usefulness of pain intensity measures for describing their pain. This type of design incorporates phenomenology, which focuses on the meaning of lived experiences (Polit & Beck, 2017). By better understanding how physical activities can inflict pain, providers may be able to better evaluate and treat it. 

Ethical Challenges

There are some ethical challenges that researchers can face when conducting a qualitative study specifically in regards to informed consent. As mentioned earlier, a qualitative study design can change over the course of a study (Polit & Beck, 2017). Since the design can change throughout the study,  researchers cannot guarantee the direction of data collection methods such as interviews and observation (Houghton, Casey, Shaw, & Murphy, 2010). In order to address this concern, the researchers within this study obtained informed consent that was reviewed by their institutional review board and provided those patients with written study information before focus group meetings and written and verbal study information at those meetings (Dannecker, Warne-Griggs, Royse, & Hoffman, 2019). 

Qualitative Design

A qualitative research design was most appropriate for this specific study because it seeks to investigate phenomena in an in-depth and holistic fashion using a flexible research design (Polit & Beck, 2017). If the researchers would have used a quantitative design, they would have only sought to quantify or measure those patients pain without seeking to determine how or why different factors influenced their pain. The interpretivist approach was appropriate in seeking to understand those patient’s subjective view of pain (Dannecker, Warne-Griggs, Royse, & Hoffman, 2019). 

References

Dannecker, E. A., Warne-Griggs, M. D., Royse, L. A., & Hoffman, K. G. (2019). Listening to 

Patients’ Voices: Workarounds Patients Use to Construct Pain Intensity Ratings. Qualitative Health Research, 29(4), 484–497. https://doi.org/10.1177/1049732318773714

Houghton CE, Casey D, Shaw D, & Murphy K. (2010). Ethical challenges in qualitative 

research: examples from practice. Nurse Researcher, 18(1), 15–25. Retrieved from 

https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=rzh&AN=104957511&site=ehost-live&scope=site

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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Respond on two different days who selected different types of anemia than you, in the following ways:

Share insights on how the anemia you selected is similar to or different from the one your colleague selected.

Discuss how genetic, gender, ethnic, age, and behavioral factors impact the diagnosis and prescription of treatment for anemic patients.

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                                                 Iron Deficiency Anemia

            Iron deficiency anemia (IDA) can come from two etiologies or a combination of the two: inadequate dairy intake or chronic blood loss. In both, there is no intrinsic factor in the metabolism of iron and both possible causes deplete the iron stores and decrease the hemoglobin production. In the form of hemoglobin, iron is in constant demand by the body. Blood loss can interrupt this constant demand and causes a depletion of stores even faster than usual (Huether & McCance, 2017, p. 517). 

            “Iron is an element that is usually recycled from aged erythrocytes by macrophage phagocytosis and lysis. Hepcidin is a 25-amino acid peptide that is produced by the liver that bind to ferroportin, a transmembrane protein, inducing its internalization and lysosomal degradation. When iron stores are low, hepcidin production is reduced and ferroportin molecules are expressed on the basolateral membrane of enterocytes, when they transfer iron from the cytoplasm of enterocytes to plasma transferrin” (Hammer & McPhee, 2019, p. 153). 

Pernicious Anemia

            “Pernicious Anemia (PA) is the most common type of macrocytic anemia and is caused by a vitamin B-12 deficiency” (Huether & McCance, 2017, p. 515). The absence of intrinsic factor (IF) is the underlying alteration in PA and this is a required transporter for gastric absorption of dietary vitamin B12. Most of these cases result from a type of autoimmune gastritis which causes atrophy from the destruction of parietal and zymogenic cells. Often, there are antibodies that are against the gastric H+-K+ ATPase, and this is a major protein constituent of parietal cell membranes. Also, autoantibodies that are against IF prevent the formation of the B12-IF complex and this causes PA to be secondary to autoimmune destruction of parietal cells (p. 515). 

Comparison

            IDA is the most common type of anemia in the world and usually is from inadequate dairy intake or chronic blood loss (Huether & McCance, 2017, p. 517). Usually, there is no intrinsic dysfunction but both causes potentially destroy iron stores and reduce hemoglobin synthesis (p. 517). 

            PA is the most common type of macrocytic anemia and is caused by a vitamin B12 deficiency (Huether & McCance, 2017, p. 515). This type of anemia is because of the absence of intrinsic factor (IF) (p. 515).

 

Gender and Iron Deficiency Anemia

            Gender plays a fairly large role in Iron Deficiency Anemia with women of childbearing age being the main victims. The risk of IDA in women of childbearing age is the highest during reproductive years and decreases during menopause. For men, which is does affect, the highest period of time for IDA is during childhood and adolescence (Huether & McCance, 2017, p. 517). In a study by Malik, et al, (2016), “it was found that 39.1% of pregnant women were actually anemic”. One more fact in support of women being more prone to anemia. 

Genetics and Pernicious Anemia

            Genetics actually plays a fairly large role in the Pernicious Anemia as “deficiency of intrinsic factor (IF) may be congenital. In cases like this, it is a genetic disorder with an autosomal recessive inheritance pattern. There has been identification of family cluster and 20-30% of individuals related to someone with PA have it themselves. Usually, it is first-degree female relatives (Huether & McCance, 2017, p. 515). 

 

References

 

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