Reply to Amanda 

Do you take any medications?

Some medications (Lithium) are notorious for causing hypothyroid.

Have you ever been diagnosed with a thyroid disorder?

Surgeries to the thyroid may result in hypothyroid.

Are you allergic to anything?

Relevant to treatment regimen.

Have you experienced any significant life changes? Additional stress etc?

Depression may manifest similar symptoms.

PE:

Hypothyroidism is six times more common in women than men, and is most common in older women (Carson, 2009). A thorough physical assessment should be completed. Clinical signs and symptoms may include paleness, brittle appearing hair and skin, elevated blood pressure, and bradycardia (Carson, 2009). The patient may have a “puffy” appearance to her face, irregular periods, and report sustained fatigue (Roberts et al, 2009).

Differential Diagnoses

Anemia, Depression

Diagnostics

           TSH – Will be elevated in Hypothyroid

           Free T4 – Result will be low in Hypothyroid

           Cholesterol – Often elevated with Hypothyroid

           CBC – To rule out anemia

           CMP – To monitor other electrolytes

           EKG – to assess for any blocks, prolonged QRS, or electrolyte abnormalities

Treatment

           Patients with symptomatic hypothyroidism should be treated to prevent long-term complications (Roberts et al, 2004) Depending on the results of her TSH & T4 I would initiate a daily regimen of Levothyroxine. 4-6 weeks after the initiation of Levothyroxine I would recheck the patients TSH. After the TSH has reached a therapeutic level – I would recheck it again in 6 months.

References

Carson, M. (2009). Assessment and management of patients with hypothyroidism. Nursing Standard (through 2013), 23(18), 48-56; quiz 58. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/219883523?accountid=167104 (Links to an external site.)Links to an external site.

Roberts, C. G. P., & Ladenson, P. W. (2004). Hypothyroidism. The Lancet, 363(9411), 793-803. doi:http://dx.doi.org/10.1016/S0140-6736(04)15696-1

reply to Quiana

1. What additional questions should you ask the patient and why?

Some questions include:

• How much weight has been gained? What kinds of meals/foods do you typically take? Do you exercise?
• Quantifying the amount of weight provides perspective. A gain of 5 lbs does not carry the urgency that a 20 lb weight gain does. Asking about her lifestyle habits can offer some insight into factors that can aggravate what sounds like hypothyroidism. This creates teachable opportunities for improving lifestyle habits.
• Are you still menstruating and if so, how regularly?
  • This can rule out pregnancy or hormone changes that precipitate menopause. Also, with hypothyroidism, this condition can disrupt a normal menstrual cycle. For a woman in menopause, hypothyroid symptoms can be masked or ignored when it is assumed that it is a lack of ooestrogen that is causing her concerns (Baisier, Hertoghe, & Eeckhaut, 2000).
• Bowel habits, specifically any problem with constipation?
  • (Chaker, Bianco, Jonklaas, & Peeters, 2017)
• Any hx of depression?
  • Her reported complaints are common findings for hypothyroid but they can also be related to depression. Though the rate of depression in hypothyroid patients is >60% (Bathla & Singh, 2016), the patient should be screened for depression. Her symptoms could be psychosomatic.

1. What should be included in the physical examination at this visit?

• Included items to address are skin for dryness, hair for thinning or irregular growth pattern, eyes for exopthalmus, neck/throat and thyroid for possible goiter, cardiac sounds for bradyarrhythmias, and also for peripheral manifestations like delayed relaxation of deep tendon reflexes (Chaker, et al., 2017).

1. What are the possible differential diagnoses at this time?

• Hypothyroidism
• Depression
• Anemia
• What tests should you order and why?
• TSH and free T3 and T4
• EKG
• CMP
• CBC
• Lipid Panel
• A depression screen can be done in office

Hypothyroidism can increase lipids and alter cardiac function (Chaker, et al., 2017). EKG may reveal cardiac abnormalities. CBC can reveal anemia. The metabolic panel can reveal diabetes or problems with hepatic or renal function. Hypothyroidism continues to be researched as far as the specific link to renal and hepatic dysfunction (Chaker, et al., 2017). The depression screen serves, like the other lab orders, to exclude causes of her symptoms. The most obvious test is a thyroid panel. To assess the circulating amount of hormone in the body is to judge her thyroid function.

1. How should this patient be managed?

• Pending the diagnosis, the patient should be encouraged to complete all lab work in a timely fashion. Since these labs can be resulted within 24hrs, if not same day, that would be my biggest priority for completion. For hypothyroidism, pending the thyroid results, the patient should start on hormone replacement with a drug like levothyroxine. Often, levothyroxine 50-100mcg is a starting dose (Dunphy, Winland-Brown, Porter, & Thomas, 2015), it should be taken daily, on an empty stomach, in the morning. She should return in about 1 mo to reassess symptoms and lab value. If the patient is difficult to manage, due to comorbid conditions or lack of therapeutic response, endocrine may be consulted.

References

Baisier, W. V., Hertoghe, J., & Eeckhaut, W. (2000). Thyroid insufficiency. is TSH measurement the only diagnostic tool? Journal of Nutritional & Environmental Medicine, 10(2), 105-113. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/215623935?accountid=167104

Bathla, M., & Singh, M. (2016). Reply to “how prevalent are depression and anxiety symptoms in hypothyroidism?”. Indian Journal of Endocrinology and Metabolism, 20(6) doi:http://dx.doi.org/10.4103/2230-8210.192913

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. doi:http://dx.doi.org/10.1016/S0140-6736(17)30703-1

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing, (4th ed.). [VitalSource Bookshelf version].  Retrieved from https://bookshelf.vitalsource.com/books/9780803655621

 

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Ms. Brown comes into the emergency department to secure treatment for a head injury, plus minor bruises and abrasions she reportedly received during an assault that happened about 20 hours ago. Ms. Brown is 34 years old and accompanied by her boyfriend, Roy. She indicates they were sleeping in a protected entrance to an elevator in the city parking garage when two young men began beating and kicking them. The two men took Ms. Brown’s purse, a sack of food she and Roy had accumulated, and Roy’s wallet which contained $5.00.

Ms. Brown indicates she has been homeless for more than a year. She occasionally stays in city shelters but spends most of her time roaming the city and walking to procure meals at the various programs that feed the poor. She is tall and thin, with a variety of skin lesions. She came to the hospital due to dizziness that prevented her from walking to the church, where she could eat. She and Roy occasionally work odd jobs but use the bulk of their income to support Roy’s drug habit. She is trying to get Roy to quit using.

The nurse practitioner (NP) cleans Ms. Brown’s scalp and tapes the traumatic lesion. A contusion is suspected, and the NP suggests Ms. Brown rests for a few days and goes to the neurological clinic if the dizziness worsens. Ms. Brown points out that she has no place to rest and cannot get to the clinic without public transportation. The NP realizes this but indicates it is beyond her control. Because the contusion is not definitively diagnosed, the NP must discharge Ms. Brown with follow-up orders to seek help if things get worse.

Using the Resolution Guidelines with the mnemonic ETHICAL, consider the following questions:

• E—Examine what other data are needed to make informed choices.
• T—Think about who should be involved in the decision-making process and who should make the ultimate decision. Should Roy be involved? What agencies are available in your community to assist Ms. Brown?
• H—Humanize Reflect on all the possible options with resulting consequences and humanize them by constructing a decision tree.
• I—Incorporate the ethical principles (autonomy, beneficence, nonmaleficence, veracity, confidentiality, fidelity, and justice) when appropriate. Are there any legal statutes that apply? What standards of care should be incorporated
• C—Choose an option.
• A—Act on your ethical choice.
• L—Look back and evaluate your option to see if you need to make any other choices. This also will be a guide for the next time a similar situation arises.

Peer Responses/Participation [Due Sunday]   

• Make sure to respond to at least two of your fellow classmates postings as well and challenge each other to go beyond just the surface.
• Share your thoughts on how you support their ideas and explain why.
• Present new references that support your opinions.

 

 

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Change Model

To bridge the gap between scientific evidence and patient care we need an in‐depth understanding of the barriers and incentives to achieving change in practice.  Various theories and models for change point to a multitude of factors that may affect the successful implementation of evidence.  When planning complex changes in practice, potential barriers at various levels need to be addressed. The nature of the EBP, characteristics of the professionals and patients involved, the social, and organizational culture all should be taken into account when planning and executing the implantation phase of change.  Ultimately, unorganized change with no implementation science is little more than “expensive trial and error” (Nelson, 2015, p.1).

                                                         Benefit

Utilizing a theory, model, or framework will provide structure to the process of change.  A benefit of utilizing a theory of change model will aid in understanding why the implementation of the practice either succeeds or fails (Nilsen, 2015).  Nilsen 2015 clearly describes three reasons for the importance of following implementation science. The following aims are included in the article Making Sense of Implementation theories, models, and frameworks 2015, (1) describing and /or guiding the process of translating research into practice, (2) understanding and/or explaining that influences implantation outcomes and  (3) evaluating implementation (Nilsen, 2015, p. 2). After reading the weekly article assignment by Nilsen it is clear that there is a benefit of incorporating a change model outweigh the time and effort it took to include it?

                                                    Conclusion

A crucial factor in delivering high-quality patient care is the nursing implementation of evidence-based practice (EBP); nurses, more than the institutional leadership, play an integral role in the implementation of EBP on nursing units (Kueny, et al., 2015).  EBP allows nurses to make complex health care decisions based on findings from rigorous or high-quality research reports, clinical expertise, and patient perspectives.  According to Kueny et al., 2015, models for EBP implementation provide stepwise guidance; however, particular contextual factors act as facilitators or barriers to the process (p. 29).  Only through using implementation science to achieve EBP will what is learned from research be translated into making care safer.                     

                                                       References

Kueny, A., Shever, L. L., Lehan Mackin, M., & Titler, M. G. (2015). Facilitating the

implementation of evidence- based practice through contextual support and nursing leadership. Journal of healthcare leadership, 7, 29-39. doi:10.2147/JHL.S45077

Nilsen, P. (2015). Making sense of implementation theories, models and frameworks.

Implementation Science, 10(53), 1-13. https://doi.org/10.1186/s13012-015-0242-0.

 

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here are several definitions available for the term “vulnerable population”, the words simply imply the disadvantaged sub-segment of the community requiring utmost care, specific ancillary considerations and augmented protections in research (Shivayogi, 2013).  The risk of a vulnerable population is the decreased freewill to inability to make informed choices.  The vulnerable populations refers to but not limited to “children, minors, pregnant women, fetuses, human in vitro fertilization, prisoners, employees, military persons and students in hierarchical organizations, terminally ill, comatose, physically and intellectually challenged individuals, institutionalized, elderly individuals, visual or hearing impaired, ethnic minorities, refugees, international research, economically and educationally disabled and healthy volunteers” (Griffith, 2015). Ethical dilemmas are widely prevalent in research involving these populations with regard to communications, data privacy and therapeutic deliberations (Shivayogi, 2013).  In this discussion board, I will focus on the avoidance of paternalism in healthcare. 

Misuse of Power

The word paternalism also alludes to patriarchal power structures. Paternalism reduces the patient to a passive recipient of care and forces the patient to depend on the integrity and self-regulation of the providers (Cody, 2003).  Certain persons are far more likely than others to be treated in a paternalistic manner.  In regards to research, with respect to research involving children, incompetent adults, and other arguably vulnerable populations such as prisoners, there can be a misuse of power.

The Federal Policy for the Protection of Human Subjects or the “Common Rule” was published in 1991 to protect women, fetuses, children, and prisoners (Miller & Wertheimer, 2007).  Common Rule outlines the basic requirements for IRBs, informed consent, and Assurances of Compliance.  Last year, the Common Rule was revised for the first time since its publication in 1991 in order to strengthen protections for study participants.  High on the list of priorities is helping people make better decisions about whether to participate in a clinical trial. One key goal: ensuring the risks and benefits of participation are clear. The need for the revision was because participant consents have become documents that protect the agency performing the procedure more than outlining the risks and benefits to the potential participant. 

Conclusion

Nurse advocacy plays an important role in helping patients understand their rights and exercise their autonomy; protecting those who are vulnerable and advocating conscientious clinical and ethical research systems.  A lack of informed consent (IC), with coercive, guileful, forceful influences and methods to secure potential participants results in deficient evidence-based health care (Griffith, 2015).  NP’s are held to professional standards for professional practice and behavior in all areas of medicine.

                                                               References

Cody, W. K. (2003). Paternalism in Nursing and Healthcare: Central Issues and their Relation to

Theory. Nursing Science Quarterly, 16(4), 288–296. https://doi.org/10.1177/0894318403257170

Griffith, R. (2015). Understanding the Code: safeguarding vulnerable adults. British Journal Of

Community Nursing, 20(11), 564–566. https://doi-org.arbor.idm.oclc.org/10.12968/bjcn.2015.20.11.564

Miller, F. G., & Wertheimer, A. (2007). Facing up to paternalism in research ethics. The

Hastings Center Report, 37(3), 24–34. Retrieved from http://arbor.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=17649900&site=ehost-live&scope=site

Shivayogi P. (2013). Vulnerable population and methods for their safeguard. Perspectives in

clinical research, 4(1), 53-7.

 

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