Respond on two different days who selected different factors than you, in the following ways:
Share insights on how your colleague’s factors impact the pathophysiology of pain.
Suggest alternative diagnoses and treatment options for acute, chronic, and referred pain.
Main Post
Pain is both an easy and complex symptom to diagnose and treat due to its subjective nature. As future practitioners, we are diagnosing pain in the era of the opioid crisis will only add to the complexity of analyzing all of the signs and symptoms while trying to provide comfort to our patients. Pain confronts us with basic questions such as the tension between an objective and a subjective approach, the concept of brain disease, human consciousness, and the relationship between body and mind (Dekkers, 2017).
Pain
According to the National Library of Medicine (2018), pain is a signal activated within the nervous system signaling to an individual that something may be wrong; it is an unpleasant feeling that can be described as burning, stinging, aching, tingling, etc. It ranges from dull to severe, can be treated in a variety of ways, or can dissipate on its own. Every individual reacts differently to pain; pain can present differently in genders despite being the same disease process.
Acute Pain
Acute pain is brief and can last several seconds or up to three months; acute pain occurs in an attempt to protect the body from harm by causing withdrawal from painful stimuli and encourages individuals to avoid painful stimuli in the future (Huether & McCance, 2017). The damage to the tissue is usually easily seen, with the naked eye or imaging that can reveal the source. Acute pain also involves biological functions that protect against further injury. For example, pain produces protective reflexes, including an unconscious withdrawal from the noxious stimulus, muscle spasms, and other autonomic reactions such as flight (Rodriguez, 2015). Noxious stimulation in the periphery leads to activation of nociceptors and the transmission of signals to the central nervous system, which will lead to the perception of acute pain (Berger & Zelman, 2016).
Chronic Pain
Chronic pain persists for at least three months or greater, despite intervention to relieve the injury, surgical, holistic, or medicinal, when the treatment does not control the original issue. Chronic pain is disruptive to sleep patterns and activities of daily living, and as a pain syndrome, it serves no protective or adaptive function (Rodriguez, 2015). Anwar (2016) acknowledges that there are three ascending pathways: the first-order neuron; start from the periphery (skin, bone, ligaments, muscles, and other viscera) travels through the peripheral nerve reaches the dorsal horn of the spinal cord, second-order neuron: start at the dorsal horn cross over to the contralateral side and then ascend in the spinal cord to the thalamus, and other brain areas like dorsolateral pons and third order neuron: starts at the thalamus and then terminates in the cerebral cortex. The descending pathway begins in multiple areas of the brain, sending signals across nerve fibers.
Referred Pain
Referred pain is felt in an area removed or distant from its point of origin-the area of referred pain is supplied by the same spinal segment as the actual site of pain (Huether & McCance, 2017). Making the diagnosis difficult for practitioners, referred pain also presents differently in men and women. It is fairly common in some conditions, such as heart attacks and osteoarthritis (Ungvarsky, 2019). Impulses from many cutaneous and visceral neurons converge on the same ascending neuron, and the brain cannot distinguish between the different sources of pain (Huether & McCance, 2017).
Impact of Gender and Age on Pain
Focusing on the factors of age and gender and the effects on the experience of pain showed the importance of understanding different factors relating to pain. Persistent pain affects the elderly disproportionally, occurring in 50 % of elderly community-dwelling patients and 80 % of aged care residents (Veal & Peterson, 2015). In the United States, the fastest growing population is the baby boomers generation, and in ten years they will represent one out of five citizens. Pain is also increasingly difficult to manage in the elderly patient population as drug interactions, absorption rates and drug clearances begin varying as a result of the aging process. With the opportunity of placing a high fall risk population in even more danger, dosing for the elderly population can become difficult for a practitioner. Petrini, Matthiesen, and Arendt-Nielsen (2015) acknowledged that the experience of pain in the elderly may differ from the experience in younger populations on multiple dimensions (sensory, affective, and cognitive). As the body physically wears down, so does the nervous system. In many patients seeking pain relief, the number of neurotransmitter cell receptors decreases with age-associated cortical and subcortical atrophy of brain tissue (Kaye et al., 2014). The practitioner must take into account all of the aging population’s comorbidities plus, fully assess the patient to determine if they are accurately representing their pain description.
Females have always been associated with a higher threshold for pain, and I can attest to this as I would gladly take an open heart female patient over a male patient but, this is not fair to assume those female patients have a higher tolerance for pain. Practitioners must still assess their patients, monitor their vital signs, and ask questions that can reveal answers that patient may not know themselves until the question is asked. Women do have more difficulty when attempting to have their pain managed. The tendency to underdiagnose and undertreat the pain of certain groups of patients, especially women, is greater when patients present with symptoms that are less objective and more grounded in complaints of pain (coronary artery disease, collagen vascular disease, nonspecific abdominal or pelvic pain) (Becker & Mcgregor, 2017). While pain does not differentiate between genders, male masculinity has taught generations of men to accept pain as normal while at the same time, women who complain of pain are frequently underdiagnosed.
Conclusion
Pain can be acute or chronic, and it can be referred or direct, practitioners must take into account all the factors that can mask or enhance the pain experience of their patients. Understanding the role the pain experience has can vary due to age or gender and pain is whatever the individual states it is or in some cases, fail to state. High-quality physical assessments and asking the appropriate questions can help practitioners manage their pain, taking into account the aging process and comorbidities that present throughout life.
References
Anwar, K. (2016). Pathophysiology of pain. Disease-a-Month, 62(9), 324–329. https://doi-org.ezp.waldenulibrary.org/10.1016/j.disamonth.2016.05.015
Becker, B., & Mcgregor, A. J. (2017). Article Commentary: Men, Women, and Pain. Gender and the Genome, 1(1), 46-50. https://doi-org.ezp.waldenulibrary.org/10.1089/gg.2017.0002
Dekkers, W. (2017). Pain as a Subjective and Objective Phenomenon. Handbook of the Philosophy of Medicine, 1-15. doi:10.1007/978-94-017-8706-2_8-1
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.
Kaye, A. D., Baluch, A. R., Kaye, R. J., Niaz, R. S., Kaye, A. J., Liu, H., & Fox, C. J. (2014). Geriatric pain management, pharmacological and nonpharmacological considerations. Psychology & Neuroscience, 7(1), 15–26. https://doi-org.ezp.waldenulibrary.org/10.3922/j.psns.2014.1.04
National Library of Medicine – National Institutes of Health. (2018). Retrieved June 7, 2019, from https://www.nlm.nih.gov/
Petrini, L., Matthiesen, S. T., & Arendt-Nielsen, L. (2015). The Effect of Age and Gender on Pressure Pain Thresholds and Suprathreshold Stimuli. Perception, 44(5), 587–596. https://doi-org.ezp.waldenulibrary.org/10.1068/p7847
Rodriguez, L. (2015). Pathophysiology of Pain: Implications for Perioperative Nursing. AORN Journal, 101(3), 338–344. https://doi-org.ezp.waldenulibrary.org/10.1016/j.aorn.2014.12.008
Ungvarsky, J. (2019). Referred pain (reflective pain). Salem Press Encyclopedia of Health. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=133861288&site=eds-live&scope=site
Veal, F., & Peterson, G. (2015). Pain in the Frail or Elderly Patient: Does Tapentadol Have a Role? Drugs & Aging, 32(6), 419–426. https://doi-org.ezp.waldenulibrary.org/10.1007/s40266-015-0268-7
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Post Casey Fg
/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
Throughout my years as an ICU nurse, critical thinking has become a skill that I utilize on a daily basis in my clinical practice. Not only are critical thinking skills a part of my daily practice, but I also observe my colleagues putting their critical thinking skills to use in their every day clinical practice. One example of critical thinking skills being used in ICU clinical practice is when multiple drips are being titrated on a patient that is extremely ill. As an ICU nurse, it is essential and vital that you utilize critical thinking skills when choosing which drip to titrate up or down or which drip to start or stop. Another instance where I have observed critical thinking skills being used in the ICU is when I would attend a rapid response on one of the medical floors. As the critical care nurse, I must use my critical thinking skills to choose the right lab tests to run, determine what might be going on with the patient that is in distress, and choose the right treatment pathway.
I try to improve my clinical competence in every way I can, especially by employing my critical thinking strategies. Some of the strategies I use most often include listening, continuing to learn every chance I get, and explaining to my colleagues why I came to a specific conclusion. I use the strategy of listening to improve my clinical competence because it helps me find new solutions to everyday problems that I might face in the ICU. Learning helps improve my clinical competence because it makes me a better ICU nurse. The more I learn, the more proficient I can become. I like to explain my rationale for the conclusion I came to because another colleague might have something important to add that would aid in solving the problem at hand.
Clinical scholarship is defined as an approach that enables evidence-based nursing and the development of best practices to meet the needs of clients efficiently and effectively (Stanley et al., 1999).
Critical thinking is defined as the objective analysis and evaluation of an issue in order to form a judgment (Benner, Hughes, & Stuphen, 2008, p. [Page 120]).
Clinical practice is defined as either the field of principal professional clinical activity (Wilkes, Mannix, & Jackson, 2013).
After reviewing the definitions of clinical scholarship, critical thinking, and clinical practice I was able to see how each term is interconnected. In order to have a clinical scholarship like approach in clinical practice, it is essential that critical thinking tools be utilized. The development of the best practices in clinical nursing practice will not occur if there is no critical thinking involved in the process (Wilkes, Mannix, & Jackson, 2013).
These three terms should be looked at as a single unit; one cannot exist without the other.
Benner, P., Hughes, R. G., & Stuphen, M. (2008). Patient Safety and Quality: An
Evidence-Based Handbook for Nurses.Rockville, MD.
Stanley, J., PhD, Keating, S. B., EdD, Edwardson, S., PhD, Easley, C. E., PhD, Alichnie,
C., PhD, & Edwards, J., PhD. (1999, March 15). Defining Scholarship for the
Discipline of Nursing. Retrieved December 31, 2018, from
https://www.aacnnursing.org/News-Information/Position-Statements-White-
Papers/Defining-Scholarship
Wilkes, L., Mannix, J., & Jackson, D. (2013). Practicing nurses perspectives of clinical
scholarship: a qualitative study. BMC nursing, 12(1), 21. doi:10.1186/1472-6955-
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Post Chrismene
/in Uncategorized /by developerRespond to at least two of your colleagues who were assigned a different patient than you. Critique your colleague’s targeted questions, and explain how the patient might interpret these questions. Explain whether any of the questions would apply to your patient, and why.
Main Post
CASE STUDY 2
AG is a 54-year-old Caucasian male who was referred to the clinic to establish care after a recent hospitalization after having a seizure related to alcohol withdrawal. He has hypertension and a history of alcohol and cocaine abuse. He is homeless and is currently living at a local homeless shelter. He reports that he is out of his amlodipine 10 mg which he takes for hypertension. He reports he is abstaining from alcohol and cocaine but needs to smoke cigarettes to calm down since he is not drinking anymore.
The Communication Techniques
A nurse practitioner chooses to use the RESPECT Modell to communicate with the patient to stay productive and patient-centered in all her communication with the patient. RESPECTS stand for (Rapport, Empathy, Support, Partnership, Explanation, Cultural Competence, and Trust) (Ball, Dains, Flynn, Solomon, & Stewart, 2019). The nurse practitioner establishes rapport by seeking the patient’s point of view to avoid being judgmental. She asked the question of how the patient wanted to be addressed. The nurse practitioner shows empathy by asking the patient how he becomes homeless to understand how she can help him get his life back in order. The nurse practitioner supports the patient by asking him about his financial situation to direct him to the proper agency. The patient is at risk for cardiac diseases, lung cancer, and stroke, so the nurse practitioner partnered with the patient to help him stop smoking (Ball et al., 2019).The nurse practitioner needs to explain to the patient to know what cigarette smoking does to the body. Nicotine is a sympathomimetic medicine that releases catecholamines, increases heart rate and cardiac contractility, constricts cutaneous, and coronary blood vessels, and rapidly increases blood pressure (Benowitz, 2009). It is crucial to present the patient with evidence-based practice to address health risks across cultures, and it is essential to assure the patient that what he said will be kept confidential to establish trust (Ball et al., 2019).
The Risk Assessment Instrument
The CAGE questionnaire is a precise tool that has been used for many years to screen patients for addictive behaviors. The GAGE questions have been modified to apply to smoke behavior. The CAGE questions are as following: 1) Have you ever felt the necessity to cut down or control your smoking, but had trouble doing so? 2) Do you ever get angry or annoyed with people who criticize your smoking or demanding you quit smoking? 3) Do you feel guilty regarding your smoking or about something you did while smoking? And 4) Do you ever smoke within half an hour of waking up (Eye-opened)? The patient is screen positive to two yes responses. The CAGE instrument is used because it is nonthreatening. A study showed that the CAGE questionnaire was used in a medical outpatient embedded in a self-administered questionnaire regarding health habits. Most of the patients did not know that they were filling out an assessment for addictions. The patient must be willing to stop smoking for treatment to be effective (American Family Physician, 2000).
Targeted Questions
1) How do you want to be addressed?
2) How are you feeling?
3) How may we help you?
4) How do you become homeless and tell us about your financial situation?
5) Do you need help getting your prescription refill?
6) When was the last time you drink alcohol or use cocaine?
7) When was the last time you check your blood pressure and take your amlodipine medication?
8) When was the last time you had a seizure episode?
9) When do you start smoking and how many packs do you smoke a day?
10) How can we help you to stop smoking?
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.Benowitz, N. L. (2009). Pharmacology of nicotine: addiction, smoking-induced disease, and therapeutics. Annual review of pharmacology and toxicology, 49, 57–71. doi:10.1146/annurev.pharmtox.48.113006.094742American Family Physician. (2000). Assessing Nicotine Dependence. Retrieved from https://www.aafp.org/afp/2000/0801/p579.html
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Post Douglas 19256625
/in Uncategorized /by developerRespond on two different days who selected different factors than you, in the following ways:
Share insights on how your colleague’s factors impact the pathophysiology of pain.
Suggest alternative diagnoses and treatment options for acute, chronic, and referred pain.
Main Post
Pain is both an easy and complex symptom to diagnose and treat due to its subjective nature. As future practitioners, we are diagnosing pain in the era of the opioid crisis will only add to the complexity of analyzing all of the signs and symptoms while trying to provide comfort to our patients. Pain confronts us with basic questions such as the tension between an objective and a subjective approach, the concept of brain disease, human consciousness, and the relationship between body and mind (Dekkers, 2017).
Pain
According to the National Library of Medicine (2018), pain is a signal activated within the nervous system signaling to an individual that something may be wrong; it is an unpleasant feeling that can be described as burning, stinging, aching, tingling, etc. It ranges from dull to severe, can be treated in a variety of ways, or can dissipate on its own. Every individual reacts differently to pain; pain can present differently in genders despite being the same disease process.
Acute Pain
Acute pain is brief and can last several seconds or up to three months; acute pain occurs in an attempt to protect the body from harm by causing withdrawal from painful stimuli and encourages individuals to avoid painful stimuli in the future (Huether & McCance, 2017). The damage to the tissue is usually easily seen, with the naked eye or imaging that can reveal the source. Acute pain also involves biological functions that protect against further injury. For example, pain produces protective reflexes, including an unconscious withdrawal from the noxious stimulus, muscle spasms, and other autonomic reactions such as flight (Rodriguez, 2015). Noxious stimulation in the periphery leads to activation of nociceptors and the transmission of signals to the central nervous system, which will lead to the perception of acute pain (Berger & Zelman, 2016).
Chronic Pain
Chronic pain persists for at least three months or greater, despite intervention to relieve the injury, surgical, holistic, or medicinal, when the treatment does not control the original issue. Chronic pain is disruptive to sleep patterns and activities of daily living, and as a pain syndrome, it serves no protective or adaptive function (Rodriguez, 2015). Anwar (2016) acknowledges that there are three ascending pathways: the first-order neuron; start from the periphery (skin, bone, ligaments, muscles, and other viscera) travels through the peripheral nerve reaches the dorsal horn of the spinal cord, second-order neuron: start at the dorsal horn cross over to the contralateral side and then ascend in the spinal cord to the thalamus, and other brain areas like dorsolateral pons and third order neuron: starts at the thalamus and then terminates in the cerebral cortex. The descending pathway begins in multiple areas of the brain, sending signals across nerve fibers.
Referred Pain
Referred pain is felt in an area removed or distant from its point of origin-the area of referred pain is supplied by the same spinal segment as the actual site of pain (Huether & McCance, 2017). Making the diagnosis difficult for practitioners, referred pain also presents differently in men and women. It is fairly common in some conditions, such as heart attacks and osteoarthritis (Ungvarsky, 2019). Impulses from many cutaneous and visceral neurons converge on the same ascending neuron, and the brain cannot distinguish between the different sources of pain (Huether & McCance, 2017).
Impact of Gender and Age on Pain
Focusing on the factors of age and gender and the effects on the experience of pain showed the importance of understanding different factors relating to pain. Persistent pain affects the elderly disproportionally, occurring in 50 % of elderly community-dwelling patients and 80 % of aged care residents (Veal & Peterson, 2015). In the United States, the fastest growing population is the baby boomers generation, and in ten years they will represent one out of five citizens. Pain is also increasingly difficult to manage in the elderly patient population as drug interactions, absorption rates and drug clearances begin varying as a result of the aging process. With the opportunity of placing a high fall risk population in even more danger, dosing for the elderly population can become difficult for a practitioner. Petrini, Matthiesen, and Arendt-Nielsen (2015) acknowledged that the experience of pain in the elderly may differ from the experience in younger populations on multiple dimensions (sensory, affective, and cognitive). As the body physically wears down, so does the nervous system. In many patients seeking pain relief, the number of neurotransmitter cell receptors decreases with age-associated cortical and subcortical atrophy of brain tissue (Kaye et al., 2014). The practitioner must take into account all of the aging population’s comorbidities plus, fully assess the patient to determine if they are accurately representing their pain description.
Females have always been associated with a higher threshold for pain, and I can attest to this as I would gladly take an open heart female patient over a male patient but, this is not fair to assume those female patients have a higher tolerance for pain. Practitioners must still assess their patients, monitor their vital signs, and ask questions that can reveal answers that patient may not know themselves until the question is asked. Women do have more difficulty when attempting to have their pain managed. The tendency to underdiagnose and undertreat the pain of certain groups of patients, especially women, is greater when patients present with symptoms that are less objective and more grounded in complaints of pain (coronary artery disease, collagen vascular disease, nonspecific abdominal or pelvic pain) (Becker & Mcgregor, 2017). While pain does not differentiate between genders, male masculinity has taught generations of men to accept pain as normal while at the same time, women who complain of pain are frequently underdiagnosed.
Conclusion
Pain can be acute or chronic, and it can be referred or direct, practitioners must take into account all the factors that can mask or enhance the pain experience of their patients. Understanding the role the pain experience has can vary due to age or gender and pain is whatever the individual states it is or in some cases, fail to state. High-quality physical assessments and asking the appropriate questions can help practitioners manage their pain, taking into account the aging process and comorbidities that present throughout life.
References
Anwar, K. (2016). Pathophysiology of pain. Disease-a-Month, 62(9), 324–329. https://doi-org.ezp.waldenulibrary.org/10.1016/j.disamonth.2016.05.015
Becker, B., & Mcgregor, A. J. (2017). Article Commentary: Men, Women, and Pain. Gender and the Genome, 1(1), 46-50. https://doi-org.ezp.waldenulibrary.org/10.1089/gg.2017.0002
Dekkers, W. (2017). Pain as a Subjective and Objective Phenomenon. Handbook of the Philosophy of Medicine, 1-15. doi:10.1007/978-94-017-8706-2_8-1
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.
Kaye, A. D., Baluch, A. R., Kaye, R. J., Niaz, R. S., Kaye, A. J., Liu, H., & Fox, C. J. (2014). Geriatric pain management, pharmacological and nonpharmacological considerations. Psychology & Neuroscience, 7(1), 15–26. https://doi-org.ezp.waldenulibrary.org/10.3922/j.psns.2014.1.04
National Library of Medicine – National Institutes of Health. (2018). Retrieved June 7, 2019, from https://www.nlm.nih.gov/
Petrini, L., Matthiesen, S. T., & Arendt-Nielsen, L. (2015). The Effect of Age and Gender on Pressure Pain Thresholds and Suprathreshold Stimuli. Perception, 44(5), 587–596. https://doi-org.ezp.waldenulibrary.org/10.1068/p7847
Rodriguez, L. (2015). Pathophysiology of Pain: Implications for Perioperative Nursing. AORN Journal, 101(3), 338–344. https://doi-org.ezp.waldenulibrary.org/10.1016/j.aorn.2014.12.008
Ungvarsky, J. (2019). Referred pain (reflective pain). Salem Press Encyclopedia of Health. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=133861288&site=eds-live&scope=site
Veal, F., & Peterson, G. (2015). Pain in the Frail or Elderly Patient: Does Tapentadol Have a Role? Drugs & Aging, 32(6), 419–426. https://doi-org.ezp.waldenulibrary.org/10.1007/s40266-015-0268-7
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Post Douglas 19263659
/in Uncategorized /by developerRespond on two different days who selected different alterations and factors than you, in one or more of the following ways:
Share insights on how the factor you selected impacts the cardiovascular alteration your colleague selected.
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.
Main Post
The purpose of this paper is to explore coronary artery disease (CAD), the roles of hypertension and dyslipidemia affect CAD, and exploring if genetics is a factor in CAD. The progression of CAD can lead to myocardial ischemia, infarction, and even death if left untreated. Heart disease remains the number one cause of death in the United States, and understanding these factors plays a continued role in developing strategies, both preventive and treatment efforts.
Coronary Artery Disease
CAD is normally the result of atherosclerosis, the build-up of plaque due to damaged endothelium that allows fat to accumulate and decrease the diameter of the vessel. The decrease in vessel size allows for blockage and decreased blood flow to the coronary vessel; this leads to ischemia, where the cells are deprived of blood and begin the process of dying if left untreated. Persistent ischemia or the complete occlusion of a coronary artery causes the acute coronary syndromes, including infarction, or irreversible myocardial damage (Huether & McCance, 2017). Also, known as a heart attack or myocardial infarction (MI). Fortunately, the incidence and mortality statistics for CAD have been decreasing over the past 15 years because of more aggressive recognition, prevention, and treatment (Huether & McCance, 2017).
Hypertension’s Role in Coronary Artery Disease
Hypertension is a consistent elevation of systemic arterial blood pressure (Huether & McCance, 2017). Fortunately, hypertension a key factor in CAD is modifiable and can be monitored closely to prevent further disease progression. Hypertension is common; it ranks as the number one primary diagnosis in America. Pathophysiological mechanisms of blood pressure as a risk factor for CAD are complex and include the influence of blood pressure as a physical force on the development of the atherosclerotic plaque, and the relationship between pulsatile hemodynamics/arterial stiffness and coronary perfusion (Weber et al., 2016). The presence of hypertension further increases the risk of CAD and may explain why some individuals are more predisposed than others to developing coronary events (Rosendorff et al., 2015). Pathophysiological mechanisms of blood pressure as a risk factor for CAD are complex and include the influence of blood pressure as a physical force on the development of the atherosclerotic plaque, and the relationship between pulsatile hemodynamics/arterial stiffness and coronary perfusion (Weber et al., 2016). Hypertension, when diagnosed early, can be treated accordingly, decreasing the opportunity for the role of exacerbation of CAD.
Dyslipidemia’s Role in Coronary Artery Disease
Huether & McCance (2017) define dyslipidemia as an abnormal concentration of serum lipoproteins, the result of genetic and dietary factors. The hardening aspect of this disease is the result of cholesterol deposits in the vessel, which decrease elasticity and make the vessel wall stiff (Marsh & Rizzo, 2019). The elevation of lipoproteins creates a narrowing of the vessel diameter, which in turn decreases blood flow to arteries. When dyslipidemia occurs in the coronary arteries, the decreased blood flow can lead to ischemia or infarct, depending on the size of the blockage. Controlling the progression of the disease is important, modifying lifestyle habits; diet and physical activity can help to prevent further complications. Medications are also available to keep lipid levels balanced.
Genetics Affects of Risk Factors in Coronary Artery Disease
Dyslipidemia is known as a heritable risk factor for CAD; patients with a family history should inform their practitioner to manage the disease process in the early state. Plasma lipids and lipoproteins are heritable risk factors for CAD, with heritability estimates ranging from 40% to 60% (Tada, Kawashiri, & Yamagishi, 2017). The best treatment is prevention, knowing a patient’s family history is paramount in controlling the lipid levels and keeping them at rates that will prevent CAD. Monitoring labs and dietary modifications assist those with family history and can avoid the progression of CAD.
Conclusion
Cardiovascular disease is still the leading cause of premature death world-wide with factors like abdominal obesity, hypertension and dyslipidemia being central risk factors in the etiology (Lidin, Hellénius, Rydell-Karlsson, & Ekblom-Bak, 2018). Hypertension and dyslipidemia both can accelerate the development of CAD. Fortunately, both factors are modifiable and are manageable by lifestyle modifications. Genetics plays a role in both hypertension and dyslipidemia; obtaining an accurate family history allows for early monitoring and controlling the modifiable factors, diet, and physical activity can keep both hypertension and dyslipidemia well controlled.
References
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.
Lidin, M., Hellénius, M.-L., Rydell-Karlsson, M., & Ekblom-Bak, E. (2018). Long-term effects on cardiovascular risk of a structured multidisciplinary lifestyle program in clinical practice. BMC Cardiovascular Disorders, 18(1), 59. https://doi-org.ezp.waldenulibrary.org/10.1186/s12872-018-0792-6
Marsh, C. C. . P. D., & Rizzo, C., MD. (2019). Hypertension. Magill’s Medical Guide (Online Edition). Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=89093446&site=eds-live&scope=site
Rosendorff, C., Lackland, D. T., Allison, M., Aronow, W. S., Black, H. R., Blumenthal, R. S., … White, W. B. (2015). Treatment of hypertension in patients with coronary artery disease: A scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Journal of the American Society of Hypertension, 9(6), 453–498. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jash.2015.03.002
Tada, H., Kawashiri, M., & Yamagishi, M. (2017). Clinical Perspectives of Genetic Analyses on Dyslipidemia and Coronary Artery Disease. Journal of Atherosclerosis and Thrombosis, 24(5), 452-461. https://doi-org.ezp.waldenulibrary.org/10.5551/jat.RV17002
Weber, T., Lang, I., Zweiker, R., Horn, S., Wenzel, R. R., Watschinger, B., . . . Metzler, B. (2016). Hypertension and coronary artery disease: Epidemiology, physiology, effects of treatment, and recommendations. Wiener Klinische Wochenschrift, 128(13-14), 467-479. doi:10.1007/s00508-016-0998-5
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Post Douglas 19276313
/in Uncategorized /by developerRespond on two different days who selected a different scenario than you, in one or more of the following ways:
Share insights on how the factor you selected impacts the disorder your colleague identified.
Ask a probing question regarding the disorder that your colleague identified.
Suggest an alternative disorder for the scenario your colleague selected.
Main Post
Respiratory Alterations
Windell (2018) acknowledges the clinical name for croup is laryngotracheobronchitis, which reveals that it is an inflammation of the larynx, trachea, and bronchi caused by a viral infection that mostly affects children between the ages of six months and three years. The incomplete immunization history could explain the croup in an older child. The low-grade temperature also guides in the diagnosis of viral croup. According to Henningfeld (2019), viral croup is often accompanied by a low-grade fever and is responsible for 70 to 75 percent of croup cases.
Pathophysiology of Croup
The pathophysiology of croup stems from the infection; the infection causes the immune system to respond. The virus that causes croup inflames the windpipe and voice box, and this swelling means they become narrowed (Windell, 2018). This narrowing causes the barking cough that is associated with croup. The mucous membranes of the larynx are tightly adherent to the underlying cartilage, whereas those of the subglottic space are looser and thus allow accumulation of mucosal and sub-mucosal edema (Huether & McCance, 2017). The edema, the mucous, and swelling make croup a life-threatening disease, children’s airways are smaller than adults and time is valuable.
Factors of Genetics and Gender
For gender, croup is more prevalent in males than females by a 5:1 ratio. Huether and McCance (2017) report that approximately 15% of children who experience croup have a family history of the disease.
Conclusion
Respiratory alterations or disease processes can turn into life-threatening moments quickly, it is important that the practitioner be able to differentiate and diagnose the disease to begin the treatment process. A thorough physical examination coupled with an active interview with both patient and parents can guide the practitioner towards the correct diagnosis.
References
Henningfeld, D. A. P. D. (2019). Croup. Magill’s Medical Guide (Online Edition). Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=86194029&site=eds-live&scope=site
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.
Windell, J. (2018). Coping with Croup. Community Practitioner, 91(8), 22–24. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=rzh&AN=132575714&site=eds-live&scope=site
Week 6 Discussion Post .doc (56.5 KB)
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Post Douglas 19304723
/in Uncategorized /by developerRespond on two different days who selected at least one different factor than you, in one or more of the following ways:Offer alternative diagnoses and prescription of treatment options for urinary tract infections.Share an insight from having read your colleague’s posting, synthesizing the information to provide new perspectives
Main Post
Urinary tract infections (UTI) are one of the most common infections in the world, and advanced practitioners must be able to diagnose and treat the varying types of UTIs. Understanding the location of the UTI, upper or lower, the pathophysiology, and specific signs and symptoms are crucial for treatment. An advanced practitioner must also be aware of the roles that gender and age play in the development of a UTI. UTIs are common in the outpatient setting but can also happen in the hospital and can also be caused by a Foley catheter, which is considered a hospital-acquired event that the hospital will not receive reimbursement.
Pathophysiology of Lower Urinary Tract Infection
A lower urinary tract infection involves the path of least resistance or the most opportunistic point of entry for an organism, usually bacterial and involves the urethra and the bladder. An infection in the urethra or bladder (cystitis) are considered a lower urinary tract infection. The microbial spectrum of UTIs consists mainly of Escherichia coli, with occasional other species of Enterobacteriaceae such as Proteus mirabilis and Klebsiella pneumoniae and other bacteria such as Staphylococcus saprophyticus (Yamamichi, Shigemura, Kitagawa, and Fujisawa, 2018).
Pathophysiology of Upper Urinary Tract Infection
The upper urinary tract consists of the kidneys and ureters. Infection in the upper urinary tract generally affects the kidneys (pyelonephritis), which can cause fever, chills, nausea, vomiting, and other severe symptoms. It can be caused by an infection that has made its way up the urinary tract and can become a complicated infection from an obstruction, such as benign prostatic hypertrophy, and calculi.
Similarities and Differences
Although the location of the infection is different many of the signs and symptoms can present the same; fever, dysuria, frequency, or urgency may be present in both. Many lower tract UTIs may be asymptomatic, and in upper tract UTIs, the symptoms may be more severe, including nausea and vomiting, flank pain, or costovertebral angle tenderness. Finding the underlying cause and treatment is the same; antibiotics for bacterial infections and analgesics for pain control. Intravenous antibiotics are preferred for upper tract UTIs in an attempt to preserve organ damage, but mat be converted to oral after initial treatment.
Gender and Age as Factors
While common in both males and females, females are more prone to community-acquired UTIs than men, basically because of anatomical differences. Lema (2015) acknowledges that the close proximity of the vagina and urethral meatus to the anal opening, the shorter length of the female urethra, and the opportunity for trauma during intercourse allows for the opportunity for a UTI to be acquired. Although this happens across the lifespan of a woman, the peak times are from mid-teens to the early forties or the sexually active years. Young children, especially females, are a high-risk group due to not being able to clean themselves properly after using the bathroom or poor technique. Older patients are also high risk; men with prostate issues cannot empty their bladder are also at risk.
Diagnosis and Treatment
Diagnosis of a lower tract UTI can be done with the assessment of signs and symptoms and urine culture, midstream is preferred. Research by Lee (2018) acknowledges that patients with non-febrile uncomplicated UTIs, active pain control and minimal use of antibiotics should be prioritized, including uncomplicated cystitis. Pain in acute cystitis is a natural consequence of the inflammatory response, and pain-mediated urinary frequency or urgency is the chief complaint of patients. Painkillers, including nonsteroidal anti-inflammatory drugs (NSAIDs), are a good choice for managing symptoms while reducing the usage of antibiotics. Urinalysis and urine culture confirms the diagnosis of acute pyelonephritis and according to the Infectious Diseases Society of America (2019) a urine culture showing at least 10,000 colony-forming units (CFU) per mm3 and symptoms compatible with the diagnosis. Symptoms management and oral antibiotic therapy are needed, and in severe cases, hospitalization with intravenous antibiotic therapy may be required.
Conclusion
As future practitioners, understanding the pathophysiologies of an upper tract UTI and a lower tract UTI is paramount to obtaining a diagnosis. Untreated and under treated UTIs can lead to life-threatening complications. Management of the signs and symptoms is important, but the treatment of the underlying cause can stop a lower tract UTI from spreading into the upper urinary tract. Age and gender play significant roles in UTIs, women of childbearing years, and older men who have trouble emptying their bladder are at high risk. Assessment and quality interviews can assist the practitioner in prevention through education.
References
Acute pyelonephritis. (2019). Retrieved July 18, 2019, from https://www.idsociety.org/clinical-practice/patient-care/patient-care/
Lee, S. (2018). Recent advances in managing lower urinary tract infections. F1000Research, 7, 1964. https://doi-org.ezp.waldenulibrary.org/10.12688/f1000research.16245.1
Lema, V. M. (2015). Urinary Tract Infection In Young Healthy Women Following Heterosexual Anal Intercourse: Case Reports. African Journal Of Reproductive Health, 19(2), 134–139. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=mnh&AN=26506666&site=eds-live&scope=site
Yamamichi, F., Shigemura, K., Kitagawa, K., & Fujisawa, M. (2018). Comparison between non-septic and septic cases in stone-related obstructive acute pyelonephritis and risk factors for septic shock: A multi-center retrospective study. Journal Of Infection And Chemotherapy: Official Journal Of The Japan Society Of Chemotherapy, 24(11), 902–906. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jiac.2018.08.002
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Post Ericka
/in Uncategorized /by developerRespond on two different days by sharing ideas for how shortcomings discovered in their evaluations and/or their examples of incivility could have been managed more effectively.
Main post
Workplace Assessment
Prior to taking my last position in the hospital setting, I did some research on the organization. I was leaving a hostile environment and wanted to make sure I was looking at organizations that aligned with my professional integrity, had good recommendations from staff and the patient population. Clark (2019) discusses that “in the patient care environment, uncivil encounters can provoke uncertainty and self-doubt, weaken self-confidence, and compromise critical thinking and clinical judgment skills” (p.64). At this time in my career, I needed stability and a healthy work environment that supported me both professionally and personally.
Clark Healthy Workplace Inventory Results
Based on the Clark Healthy Workplace Inventory results it appears that I made a good decision, I knew that myself within six months of starting there. Scoring an 82 out of 100 this sets my workplace in the moderately healthy category. Answering the question is my workplace civil or not? I would have to say that from administration down my organization is civil. Overall the organization is true to its proposed pillars of excellence and standards for patient care, outcomes, and employee satisfaction. No organization is perfect, but I have experienced growth and change with the organization and I feel like they are moving in the right direction. In reflecting on workplace culture Clark (2105) notes that purposeful relationships and interactions with others facilitate the success of the individual, team, and organization (p.19).
Experience
Unfortunately, I have experienced incivility in the workplace that is why I am with the organization I am with now. It was an unhealthy work environment where management was concerned, I shared the organization’s vision for patient care, but my manager did not. Often our ideas were shot down and then retaliated upon if she thought it might shade her as the manager. She was not a leader. The team I worked with was one of the only reasons I stayed as long as I did. We all experienced incivility at her hands collectively and individually. It was not something that administration was unaware of, she had multiple complaints in previous years and prior to my group, her turnover rate was high. Communication had to be both verbal and in writing so that there was no miscommunication from all parties. We all could have been secretaries in our biweekly meetings. We were to add human resources (HR) to our communication when asked to do so. We worked along with HR to address issues and work on communication as a group as well as individuals. One might ask why I stayed with them as long as I did and to be honest it was the patient population. I have since come to understand that it was not me individually or the team that was the issue, but that not all managers are leaders (Marshall and Bloom, 2017).
Clark, C. M. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18–23.
Clark, C. M. (2018). Combining cognitive rehearsal, simulation, and evidence-based scripting to address incivility. Nurse Educator.
Marshall, E., & Broome, M. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd ed.). New York, NY: Springer.
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Post Graduation Plan 19311207
/in Uncategorized /by developerPost-Graduation Plan
In this Discussion, you complete the Post-Graduation Plan you began to develop in Weeks 6 and 7. Your Post-Graduation Plan is an opportunity to explore how you may continue to develop your professional and leadership skills, promote change in your department and organization, and stimulate progress in the nursing profession.
Your Post-Graduation Plan (geared toward the next 2–3 years) should feature two to five career and/or personal goals; goals should be specific, measurable, attainable, realistic, and timely. In your plan, outline necessary steps for achieving these goals. Also, consider how you can reflect these goals in your curriculum vitae (CV).
To prepare:
By Tomorrow Tuesday 8/6/19 before 10pm, in APA format and a minimum of 3 references, create a short summary PowerPoint with a minimum of 10 slides that features five goals and describes steps for achieving these goals.
Required Readings
Resources for the Post-Graduation Plan (also shared during Weeks 6 and 7):
Dickerson, P. S. (2010). Continuing nursing education: Enhancing professional development. The Journal of Continuing Education in Nursing, 41(3), 100–101.
This article examines current frames of reference for continuing nursing education and the work that is guiding the future.
American Association of Colleges of Nursing. (2012). Career resource center. Retrieved from http://www.aacn.nche.edu/students/career-resource-center
This website provides a battery of resources for nursing graduates seeking employment.
Robert Wood Johnson Foundation. (2010). Career tools and advice. Retrieved from http://www.newcareersinnursing.org/scholars/career-central/tools
This website supplies a variety of guides on applying for jobs.
American Nurses Association. (2012). Career & credentialing. Retrieved from http://www.nursingworld.org/MainMenuCategories/CertificationandAccreditation
This website provides links to guides on careers and credentialing. The website also highlights special membership benefits for ANA members.
Optional Resources
Bolles, R. N. (2012). What color is your parachute? 2012: A Practical Manual for Job-Hunters and Career-Changers. New York, NY: Ten Speed Press.
Isaacs, K. (2010). Surviving and thriving in the workplace: Resume tips for nurses. Ohio Nurses Review, 85(6), 5.
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Post Holly 19088807
/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 at least 3 references
The Stigma of Mental Illness
As a society, how do we view mental illness? Often with disdain, discomfort, or fear. Often we ridicule people with mental health disorders. Our culture fosters negative views of mental illness by using terms such as “crazy”, “nuts”, “psycho”, and the media perpetuates these concepts by depicting people with mental illness as scary, silly, stupid, or defective.
The policy issue that most affects my professional, as well as, personal life is Disability. I am a psychiatric nurse who also happens to have a mental health issues. Mental illness discrimination and access to healthcare are protections meant to be provided under the law. According to the Americans with Disabilities Act (ADA), it is illegal to revoke licensure or otherwise prevent a healthcare provider from working due to mental disorders. The conditions included are illnesses such as depression, bipolar disorder, and schizophrenia. Another form of discrimination the ADA protects is “employment tests or other selection criteria that screen out or tend to screen out an individual with a disability or a class of individuals with disabilities” (Samuel, L, 2017). However, professional licensing boards still actively engage in discriminatory actions every single day. “Boards’ hands are often tied in terms of what state legislatures will let them do” (Dyrbye, 2017). According, to Dyrbye, at the state level, the quandary is between protecting the public from impaired healthcare workers and the provider’s right to make a living. New studies have shown that nearly 40% of physicians and an even higher percentage of nurses reported that they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their licensure.
In the Kingdon’s Model the problem is having special protections under the American Disabilities Act (ADA) to prevent increased discrimination for licensed professional healthcare workers suffering from mental illness who are far more susceptible to bias related to the nature of their professions as providers of patient care.
A policy stream can easily be defined as a think tank. The primary objective is to collaborate to refine the problem to best address the proposed policy. In the case of disabilities related to mental illness in healthcare professionals this may be difficult because it is a narrowly defined subset of both the mentally ill and the disabled populations. However, because the subset can pull from two communities for support it may be easier gain support. Ultimately, the goal is to put policy into law that forces all healthcare licensure boards and healthcare employers from gathering mental health information and that employers will face serious penalties for discrimination and/or wrongful termination. The burden of proof is then on the employer rather than the employee to prove rational for separation.
Engaging members from all facets of the healthcare community, as well as, the American Psychiatric Association (ADA) to serve as experts is paramount in generating political support. Having political connections foster influence from organizations such as NAMI, MHA, Congressman LaHood from IL, Representative Tim Murphy from PA, Linda Rosenberg, CEO of the National Council for Behavioral Health, Executive Director of Mental Illness Policy Org DJ Jaffe, ANA, AMA, and EEOC. Finally, identifying successful lobbyists to push policy forward is fundamentally crucial if any bill is to become law. Eliciting the support of a successful lobbyist can help to identify windows of opportunity and to approach legislators at the right time and under the best circumstance to have a bill well received.
Reference
Dyrbye, L., West C., Synsky, C., goders, L., Satele, D., Shanafelt, T. (2017). Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions. Mayo Clinic Proceedings. 92, 10, p1463-1604, e133-e153. DOI: https://doi.org/10.1016/j.mayocp.2017.06.020
Farmer, J., (2011, May 16). Disclosing a Mental Health Problem to an Employer. The Guardian. Retrieved by https://www.theguardian.com/careers/careers-blog/mental-health-at-work
John Kingdon, Agendas, Alternatives, and Public Politics, 2nd ed. (New York: Harper Collins, 1995). p. 19.
Samuel, L; (2017, October 16). Stat. Doctors Fear Mental Health Disclosure Could Jeopardize Their Licenses. Retrieved from https://www.statnews.com/2017/10/16/doctors-mental-health-licenses/
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Post Holly 19108459
/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 at least 3 references
Main Post
Ethical Issues
“Two traditional theories can be considered regarding health resource allocation: ‘macro-allocation’ – which is defined by respecting the public health policy allocation and distribution – and ‘micro-allocation’ – which supports the belief that individualized selection of those who should benefit from the available services are the beneficiaries” (Jonsen, A., Edwards, K., 2016). The micro-allocation problem suggests prioritization of patients for things such as limited vacancies, intensive care services, or prioritized organ transplant. The ethical questions become; is there a fair and equitable way of allocating health care resources and can a fair and just allocation really be implemented in our current social, economic and medical environment? Some public policy supports devising an allocation system focused on the criteria of efficiency and cost-effectiveness. Are we better served by considering how cost-effectiveness can to be applied to persons with shorter natural life expectancies, such as the elderly? These questions are not easily answered but they must be considered whenever allocation is proposed. Some forms of allocation are egregiously unethical in any society that values equality. However, it is also unethical when you make the ability to pay the only option for obtaining medical care or distributing medical resources to those in power. Many other problems are less obviously wrong but still need to be evaluated and debated.
Ideally, all persons should have access to a “standard” of health care to sustain life, prevent illness, relieve distress, and prevent injury. It is the responsibility of nurses and doctors to empower their patients by having a voice in how they die. We need better education for our healthcare providers in the care of the dying, options for palliative care, and of hospice programs. Currently, 75 percent of the public, regardless of educational efforts, do not have a living will. The majority of people only have vague talks with family members about how they want to die. Most physicians still resist having an open discussion with patients and families about death; and by the time patients in hospice have these conversations it is much too late, often less than two weeks before they die. Many doctors, patients, and families are either in denial, emotional distress, or both when death is eminent or during the process of the patient dying. As healthcare providers, we have an opportunity, to create and sustain an open dialog with our patients and their families about advanced life directives. Some statistics have shown that 58% of patients did not want to discuss their wishes with their doctors. However, for those who did what was found to be significant is that 25% of the elderly did not want to be resuscitated. In 50% of the advanced live saving cases, most were initiated by doctors and/or requested by the families without the patients’ consent. Therefore, it seems reasonable to say that rationing healthcare for elderly patients should be based on objective information and in the patient’s best interest and wishes (End of Life, 2016).
In my opinion, the ethical issues related to “resourcing” can be mitigated by healthcare workers doing a better job discussing advanced directives and end of life wishes with their patients, and whenever appropriate, their families. Conversations should begin early in the doctor/nurse to patient relationship or at least upon hospital admission regarding the patient’s wishes regardless of their diagnosis or severity. Our present healthcare practices foster unnecessary, and more importantly, unwanted patient interventions that are better allocated for those who can benefit from these resources.
References
Ethical Issues with an Aging Population (2012). Researchomatic. Retrieved from http://www.researchomatic.com/ethical-Issues-With-An-Aging-Population-47844.html
Jonsen, A., Edwards, K., (2016). ETHICS IN MEDICINE. University of Washington School of Medicine. Retrieved from https://depts.washington.edu/bioethx/topics/resall.html
Lawler, P., Callahan, D., (2012, July 24). Ethics and Health Care: Ethics and Health Care Rethinking End-0f-Life-Care. Retrieved from https://www.heritage.org/health-care-reform/report/ethics-and-health-care-rethinking-end-life-care
Milstead, J. A. (2019). Health policy and politics: A nurse’s guide (6th ed.). Burlington, MA: Jones and Bartlett Publishers.
Chapter 7, “Health Policy and Social Program Evaluation” (pp. 114-127)
Schütz GE. Quando o igual tratamento acaba em injustiça. Um paradoxo bioético das políticas sanitárias universalistas de alocação de recursos [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública, Fundação Fiocruz; 2003. Revista Brasileira de Terapia Intensiva. Print version ISSN 0103-507X. Rev. bras. ter. intensiva vol.21 no.4 São Paulo Oct./Dec. 2009 http://dx.doi.org/10.1590/S0103-507X2009000400014
End of Life. (2016, Jul 29). Retrieved from https://studymoose.com/end-of-life-2-essay
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