Respond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described.
In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
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Clinical Scenario
The patient is a tall, lanky 67-year-old male with end-stage renal failure and cirrhosis of the liver. He presents to the Emergency Department (ED) with an inguinal hernia that he cannot reduce. He rates his pain 10/10 on a scale of 1-10, with 0 being no pain and 10 being extreme pain. The patient appears uncomfortable, complains of dizziness, and constipation. Social history consists of smoking a pack a day or cigarettes for 25 years, moderate alcohol consumption, daily marijuana use, poor diet, and decreased mood. His medications are centered around pain control and include the use of narcotics every 4 hours. The patient is given a dose of Toradol 30mg, intravenously (IV). After ten minutes, the patient is asking for more pain medication. Fentanyl 50 mcg, IV is given with no pain relief reported by the patient. Finally, Hydromorphone 1mg, IV is administered. After an hour, the patient still reports pain 10/10.
Pharmacokinetics and Pharmacodynamics
Pharmacokinetics studies the absorption, distribution, metabolism, and excretion of drugs within the body system (Ball, Dains, Flynn, Solomon, & Stewart, 2019). The use of pharmacokinetics enables providers to determine the appropriate drug for a patient’s diagnosis. Pharmacodynamics refers to how the body is affected by the use of certain medications (Fox, Hawney, & Kaye, 2011). Due to the individualized nature of the human body, finding a drug that responds with minimal side effects are desired.Pharmacokinetics, as it relates to this patient’s pathophysiology, creates difficulty for the patient due to the diagnosis of kidney failure and cirrhosis. Cirrhosis of the liver prevents the body from absorbing, distributing, and metabolizing the drug. With significant disease process in effect, it is difficult for the body to absorb the drug at a rate that provides effective pain control. The first-pass metabolism with hydromorphone is decreased in liver cirrhosis and has a likelihood of high hepatic extraction (Wehrer, 2015). Whereas, fentanyl, is a protein-bound medication is reportedly unaffected by cirrhosis (Wehrer, 2015). Though the patient tolerated the fentanyl in our case, no specific relief is found due to the chronic nature of the pain. Decreased kidney function reduces the excretion of drugs from the body creating an accumulation of medication in the entire body (Ball et al., 2019). Frequent use of medications creates a tolerance to that medication and accelerates metabolism of the drug. Tolerance and increased metabolism results in ineffective pain management outcomes (Ball et al., 2019). The use of opioids for pain management, in this case, may create an antagonist effect causing unwanted consequences such as constipation, the potential for abuse, and withdrawal (Walter, Knothe, & Lotsch, 2016). Due to the patient’s continued alcohol consumption and disease processes, the use of acetaminophen or ibuprofen is not encouraged (Wehrer, 2015).
Contributing Factors
For the patient above, behavioral and pathophysiological changes are contributing factors for the choice of medications given. Alcohol use is the highest contributing factor to cirrhosis (Askgaard, Gronbaek, Kjaer, Tjonneland, & Tolstrup, 2015). This behavior, as well as smoking, will need to be eliminated to be on the transplant list. The pathophysiological changes created altered renal excretion and inability of the liver to metabolize medications given for pain control.
Personalized Plan of Care
The plan of care for this patient is to control the pain from the inguinal hernia until it can either be repaired or reduced. The ability to control pain at a level of 5/10 is the first goal. A discussion with the patient is necessary to establish realistic goals in light of the chronic conditions. Focusing on the pain from the hernia is our primary focus. Initiation of other medications for pain such as Ketamine, Benadryl, or Reglan can decrease pain by 50 percent. Lastly, non-medication alternatives such as positioning, distraction, and ice-therapy can provide temporary relief.
References
Askgaard, G., Gronbaek, M., Kjaer, M. S., Tjonneland, A., & Tolstrup, J. S. (2015). Alcohol drinking pattern and risk of alcoholic liver cirrhosis: a prospective cohort study. Journal of Hepatology, 62(5), 1061-1067. http://dx.doi.org/10.1016/j.jhep.2014.12.005Ball, 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.Fox, C. J., Hawney, H. A., & Kaye, A. D. (2011). Opioids: Pharmacokinetics and Pharmacodynamics. New York, NY: Springer.Walter, C., Knothe, C., & Lotsch, J. (2016). Abuse-deterrant opioid formulations:Pharmacokinetic and pharmacodynamic considerations. Clinical Pharmacokinetics, 55(7), 751-767. http://dx.doi.org/10.1007/s40262-015-0362-3Wehrer, M. (2015, December 14). Pain management considerations in cirrhosis. U.S. Pharmacist, 40(12), HS5-HS11. Retrieved from https://www.uspharmacist.com/article/pain-management-considerations-in-cirrhosis
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Post Tami 19270647
/in Uncategorized /by developerRespond on two different days by making recommendations for how they might strengthen the leadership behaviors profiled in their CliftonStrengths Assessment, or by commenting on lessons to be learned from the results that can be applied to personal leadership philosophies and behaviors.
Main Post
Leadership Profile
Leadership of people begins with a leader who knows themselves and can cultivate the strengths in others. Personal and professional growth occurs when time is spent reflecting on your strengths and weaknesses. Marshall (2011) states, “your daily reflection might include where you improved trust, how you promoted respect, where you feel pride, and what happened to instill joy. From your reflection can also emerge your sense of direction” (p. 29). As a person and as a leader, it is essential to have a mission or purpose for your life.
Assessment Findings
Taking the Gallup StrengthsFinder Assessment provided definitive insight into my personality. The top 5 signature themes of talent that were dominant in my life are learner, developer, input, empathy, and belief. Each of these themes resounded with my observations and further enlightened my understanding of who I am. As a lifelong learner, the goal has never been to finish but to be continually learning something new every day. By being a life-long learner, it increases self-esteem, satisfaction with personal development, reduces negative emotions, and is part of a pursuit to a meaningful and better life (Lee, 2016). This strength ties into my other strengths of input and developer. Empathy, however, is a fundamental skill for getting through life that many individuals are never able to actualize. For me, empathy is the ability I experience to share in and understand other’s lives (Cameron et al., 2019). This strength pairs well with belief. I have a firm belief in people and in their ability to show resiliency and experience growth in their lives. In order to have a belief, empathy has to be present.
Values, Strengths, and Characteristics
Values that are important in my life are deep relationships and being a life-long learner. Being a person that pays attention to the thoughts and feelings of others; I find it easy to move past superficial conversations quickly to really get to know someone. Working in the Emergency Department, I have found this skill very helpful. By peeling away the small talk in order to help my patients, I can discover their thought patterns and help them better. This skill helps with the value of being a life-long learner. I believe you can learn something from everyone you meet. These experiences help you to grow as an individual and professionally.
Strengths are not necessarily skills. Often, I heard it said that my strength is being able to start an IV. That is a skill, whereas strength is something inherent to who I am. I believe I have insight into people’s emotions and vulnerabilities. I notice people, their body language, sense their moods, and adapt accordingly to help them feel comfortable. This leads to my second strength, and that is an ability to make people feel comfortable and heard. People are most comfortable around others who can relate with them and reassure them that their pain is real.
Lastly, there are characteristics that I would like to strengthen in myself. I have always been able to listen to others, but I desire to be more present in my daily life by working on being an active listener. Actively looking to listen instead of talk or provide reassurance. I also desire to have a lasting positive impact on people. In order to do this, I need to be in a good place emotionally, physically, cognitively, and spiritually. This means making time to be refreshed outside of the work environment. It is said that empty people cannot help empty people. As future nurse practitioners, I believe this is one of the hardest and yet most important things we can do to show others the value of rest.
References
Cameron, C. D., Hutcherson, C. A., Ferguson, A. M., Scheffer, J. A., Hadjiandreou, E., & Inzlicht, M. (2019). Empathy is hard work: People choose to avoid empathy because of its cognitive costs. Journal of Experimental Psychology, 148(6), 962-976. doi:/10.1037/x.xge0000595
Lee, S. (2016). Lifelong learning as a path to happiness? Adult Education & Development, 83, 68-73. Retrieved from https://ezp.waldenlibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=121879727&site=eds-live&scope=site
Marshall, E. (2011). Transformational Leadership in Nursing. New York, NY: Springer Publishing Company, LLC.
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Post Tami 19446005
/in Uncategorized /by developerRespond to two colleagues in one of the following ways:
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.
Main Post
Agonist-to-Antagonist Spectrum
The agonist-to-antagonist spectrum of action refers to the action that is taken by a neurotransmitter to produces a conformational change (Stahl, 2013). The spectrum starts with the agonist action, which, with the help of a second-messenger, can turn on the full potential of change (Stahl, 2013). Full agonists can be natural transmitters used to produce change. An antagonist blocks the conformational change of the potential of the transmitter for binding with the intended agonist (Stahl, 2013). The role of the antagonist is to keep the receptors in a baseline state in order to reverse what the agonist has done (Stahl, 2013). This is the opposite end of the spectrum and seeks to block agonists. In the middle, some partial agonists mimic its agonist partner to a lesser degree, and inverse agonists stop all activity from occurring on the receptor (Stahl, 2013). The conformational change is needed for a receptor to open to the action of drugs, particularly, psychopharmaceutical medications in this case.
G couple proteins and Ion gated channels
G couple proteins are used at the binding site of a neurotransmitter to act as a conduit for enzymes (Stahl, 2013). Whereas, ion gated channels exist as targets to regulate chemical neurotransmitters (Stahl, 2013). Ion gated channels consist of channels and receptors that can only be opened by the neurotransmitters. Conversely, G couple proteins attach to neurotransmitters and conform to enzymes to serve as a channel for a second messenger (Stahl, 2013). Most psychotropic medications aim for the ion gated channels, which open through chemical neurotransmission and initiate the signal transduction cascade (Stahl, 2013). The cascade results in faster uptake of psychotropic medications into the system.
The Role of Epigenetics
According to DeSocio (2016), epigenetics is the study of how genomes that undergo changes with certain molecular compounds and environmental changes can leave the essential DNA unchanged. It is a modification of gene expression that is independent of the DNA (DeSocio, 2016). DNA is the code that determines much of who we are. Changes in that code can be seen as a result of heredity, the environment, or neurotransmission (Stahl, 2013). These alterations affect individuals at a physical, emotional, and psychological level. Stress and adversity play a significant role in epigenetics by changing the genomes, which in turn leads to changes in a person’s DNA (Park et al., 2019). These alterations influence psychological issues related to many individuals. It is essential to know how to combat these changes when determining a plan of care for clients.
Implications of Findings to Prescribing
As nurse practitioners, it is essential to have an extensive understanding of how the above processes affect the way we prescribe medications to clients. It is also essential to take into consideration how the environment impacts maintaining optimal health and healing (DeSocio, 2016). Knowing the mechanisms of action for medications that we are prescribing is vital to providing competent care. For example, a patient with a generalized anxiety disorder (GAD) is prescribed Venlafaxine. The PMHNP needs to understand that the Venlafaxine works by boosting the serotonin, norepinephrine, and dopamine neurotransmitters (Stahl, 2014). This action blocks serotonin reuptake, norepinephrine reuptake, and the dopamine reuptake (Stahl, 2014). Each of these actions then increases these neurotransmissions in the brain providing therapeutic results.
References
DeSocio, J.E. (2016). Epigenetics: An emerging framework for advanced practice psychiatric nursing. Perspectives in Psychiatric Care, 52(3), 201-207. https://doi.org/10.1111/ppc.12118
Park, C., Rosenblat, J.D., Brietzke, E., Pan, Z., Lee, Y., Cao, B., Zuckerman, H., Kalantarova, A., McIntyre, R.S. (2019). Stress, epigenetics, and depression: A systematic review. Neuroscience and Biobehavioral Reviews, 102, 139-152. https://doi.org/10.1016/j.neubiorev.2019.04.010
Stahl, S.M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Stahl, S.M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications. (4th ed.). New York, NY: Cambridge University Press.
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Post Tami Pharmacology
/in Uncategorized /by developerRespond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described.
In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
Main Post
Clinical Scenario
The patient is a tall, lanky 67-year-old male with end-stage renal failure and cirrhosis of the liver. He presents to the Emergency Department (ED) with an inguinal hernia that he cannot reduce. He rates his pain 10/10 on a scale of 1-10, with 0 being no pain and 10 being extreme pain. The patient appears uncomfortable, complains of dizziness, and constipation. Social history consists of smoking a pack a day or cigarettes for 25 years, moderate alcohol consumption, daily marijuana use, poor diet, and decreased mood. His medications are centered around pain control and include the use of narcotics every 4 hours. The patient is given a dose of Toradol 30mg, intravenously (IV). After ten minutes, the patient is asking for more pain medication. Fentanyl 50 mcg, IV is given with no pain relief reported by the patient. Finally, Hydromorphone 1mg, IV is administered. After an hour, the patient still reports pain 10/10.
Pharmacokinetics and Pharmacodynamics
Pharmacokinetics studies the absorption, distribution, metabolism, and excretion of drugs within the body system (Ball, Dains, Flynn, Solomon, & Stewart, 2019). The use of pharmacokinetics enables providers to determine the appropriate drug for a patient’s diagnosis. Pharmacodynamics refers to how the body is affected by the use of certain medications (Fox, Hawney, & Kaye, 2011). Due to the individualized nature of the human body, finding a drug that responds with minimal side effects are desired.Pharmacokinetics, as it relates to this patient’s pathophysiology, creates difficulty for the patient due to the diagnosis of kidney failure and cirrhosis. Cirrhosis of the liver prevents the body from absorbing, distributing, and metabolizing the drug. With significant disease process in effect, it is difficult for the body to absorb the drug at a rate that provides effective pain control. The first-pass metabolism with hydromorphone is decreased in liver cirrhosis and has a likelihood of high hepatic extraction (Wehrer, 2015). Whereas, fentanyl, is a protein-bound medication is reportedly unaffected by cirrhosis (Wehrer, 2015). Though the patient tolerated the fentanyl in our case, no specific relief is found due to the chronic nature of the pain. Decreased kidney function reduces the excretion of drugs from the body creating an accumulation of medication in the entire body (Ball et al., 2019). Frequent use of medications creates a tolerance to that medication and accelerates metabolism of the drug. Tolerance and increased metabolism results in ineffective pain management outcomes (Ball et al., 2019). The use of opioids for pain management, in this case, may create an antagonist effect causing unwanted consequences such as constipation, the potential for abuse, and withdrawal (Walter, Knothe, & Lotsch, 2016). Due to the patient’s continued alcohol consumption and disease processes, the use of acetaminophen or ibuprofen is not encouraged (Wehrer, 2015).
Contributing Factors
For the patient above, behavioral and pathophysiological changes are contributing factors for the choice of medications given. Alcohol use is the highest contributing factor to cirrhosis (Askgaard, Gronbaek, Kjaer, Tjonneland, & Tolstrup, 2015). This behavior, as well as smoking, will need to be eliminated to be on the transplant list. The pathophysiological changes created altered renal excretion and inability of the liver to metabolize medications given for pain control.
Personalized Plan of Care
The plan of care for this patient is to control the pain from the inguinal hernia until it can either be repaired or reduced. The ability to control pain at a level of 5/10 is the first goal. A discussion with the patient is necessary to establish realistic goals in light of the chronic conditions. Focusing on the pain from the hernia is our primary focus. Initiation of other medications for pain such as Ketamine, Benadryl, or Reglan can decrease pain by 50 percent. Lastly, non-medication alternatives such as positioning, distraction, and ice-therapy can provide temporary relief.
References
Askgaard, G., Gronbaek, M., Kjaer, M. S., Tjonneland, A., & Tolstrup, J. S. (2015). Alcohol drinking pattern and risk of alcoholic liver cirrhosis: a prospective cohort study. Journal of Hepatology, 62(5), 1061-1067. http://dx.doi.org/10.1016/j.jhep.2014.12.005Ball, 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.Fox, C. J., Hawney, H. A., & Kaye, A. D. (2011). Opioids: Pharmacokinetics and Pharmacodynamics. New York, NY: Springer.Walter, C., Knothe, C., & Lotsch, J. (2016). Abuse-deterrant opioid formulations:Pharmacokinetic and pharmacodynamic considerations. Clinical Pharmacokinetics, 55(7), 751-767. http://dx.doi.org/10.1007/s40262-015-0362-3Wehrer, M. (2015, December 14). Pain management considerations in cirrhosis. U.S. Pharmacist, 40(12), HS5-HS11. Retrieved from https://www.uspharmacist.com/article/pain-management-considerations-in-cirrhosis
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Post Tiffany Ni
/in Uncategorized /by developerRespond to the post bellow offering additional/alternative ideas regarding opportunities and risks related to the observations shared.
Main Post
iPhone technology, secure texting, and telehealth
The hospital that I currently work for piloted the use of iPhones in addition to our work station on wheels (WoW). We can use this iPhone technology for charting simple nursing interventions, receive STAT orders and discharge orders, and communicate with our colleagues through texting. Our WoWs enable us to do “secure texting” to a physician, some physicians prefer the secure texting technology some don’t, but surely there are times that the answering service may fail to page them in a timely manner and the secure texting technology becomes very useful. As nurses, we can see through our WoWs as soon as the physician reads the text message, that way we know they are aware. This technology saves us some precious time we spend on the phone waiting on hold just to page a physician for orders, condition and/or results. Our hospital also offers telehealth services especially for those who are likely to be readmitted due to chronic diseases. We mostly see a telehealth order for a patient with cardiac issues.
Risks and benefits
The biggest threat that I believe healthcare technology is at risk for is privacy. According to Chaet, Clearfield, Sabin and Skimming (2017), privacy and confidentiality are just “as important in the context of telehealth and telemedicine as in hospital and office settings” (p. 1138). I surmise, organizations providing this type of technology in healthcare have an incredible security system in place. The secure texting technology, we are instructed not to use full names, instead, we use room numbers of the patients.
The biggest benefit of the use of telehealth and mobile devices for healthcare is accessibility. Use of the iPhone technology in our hospital is quick and easy to navigate, we can get in touch with virtually anybody logged in for that shift in the whole hospital. From a distance, telehealth helps those patients who are unable to manage their chronic illnesses very well.
Trends in healthcare technology
The most promising healthcare technology to me is virtual visits, mobile health, telehealth, and telemedicine technology. One can get in touch with a healthcare provider as long as one has a smartphone and internet access. It could provide access to so many more patients in need of healthcare that resides in rural areas or have no means to transport themselves to the physician’s office. It could save time and money for patients as we all know healthcare can get expensive very easily and very fast. According to Abuhaimidd, Meetoo and Rylance (2018), technology in healthcare with the use of mobile devices can “truly offer the potential to promote healthcare management and health behaviour change outside formal clinical settings” (p. 1176). This does not take away the significance of having a physical visit with a physician, those visits are intended for more complicated health issues, but I believe this technology has potential to truly help those with chronic illnesses to be able to manage their health on their own, make them accountable for their own wellbeing, patients can share data, interact with clinicians over a mobile device instead of having to go to the doctor’s office.
Telehealth rules
According to Mastrian and McGonigle (2017), nurses who participate in telehealth must be “licensed to practice in all of the states in which they provide telehealth services by directly interacting with patients” (p. 381). This can be challenging as states have different rules and regulations regarding licensure, continuing education requirements are different as well as fees and renewal process.
References
Abuhaimid, H. A., Meetoo, D., & Rylance, R. (2018). Health care in a technological world. British Journal of Nursing, 27(20). 1172-1177.
Barreto, E. A., Cohen, A. B., Donelan, K., Estrada, J. J., Michael, C., Schwamm, L. H., … Wozniak, J. (2019). Patient and clinician experiences with telehealth for patient follow-up care. American Journal of Managed Care, 25(1), 40-44.
Chaet, D., Clearfield, R., Sabin, J. E., & Skimming, K. (2017). Ethical practice in telehealth and telemedicine. Journal of General Internal Medicine, 32(10), 1136-1140.
Mastrian, K. G., & McGonigle, D. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
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Post Traumatic Stress Disorder
/in Uncategorized /by developerFollowing the
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Post Walter Dq
/in Uncategorized /by developerI decided to return to school for my BSN at this time due to the increased need for further education. As the hospitals and the medical field advances so should our education. I have always wanted to teach and after many years of floor nursing this is a good time for me. I watch the new nurses coming in and often help them getting started in their careers. It is exciting seeing them starting out and remembering how I felt. Maybe I can help in some way make ths transition for others easier. And it would be a great learning experience for me.
I love learning and school. Classroom is my perferred way of learning but at this time that will not work. I work full time nights and am helping raise two of my grandchildren. My life is full, but I still have plenty of time to do what is needed to be a sucess in this career choice. I have my own office and all the things needed to complete my assignments and research. Sleep is my biggest problem, what with working nights. So I need to plan my time off well. I try to make my schedule to allow me several days off at a time. This allows for my rest and getting things done.
I am looking forward to this exciting advancement in my career and learning experience. I will need to use all of my resources and available help to make it but I think it will be a lot of fun. My famiy is very excited and more then willing to help me.
Regina DQ
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Poster Presentation 19403757
/in Uncategorized /by developerAll the instructions are on the Word document attached. There is an example and a template
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Poster Response
/in Uncategorized /by developerABCDE primary assessment tool.
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Postpartum It Has Been Used Use As A Guide Paper 19108797
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