Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

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Communication/Interviewing

This is a 40 -year old black man recently migrated from Africa. He is currently uninsured. To begin communicating with this individual, I would make sure he was able to speak English and that we under stand each other. If language is a barrier, I would get an interpreter on the interpretation Line. Communication techniques doesn’t always have to be spoken word, it can be pointing to an area of the body or using pictures. Communicating across language barriers is a challenge for clinicians and health systems. Federal law requires linguistic services for patients with LEP. Title VI of the US Civil Rights Act states that people cannot be discriminated against as a result of their national origin, race, or color, which has been extrapolated to include primary language by the US Office for Civil Rights and Department of Health and Human Services (Karliner, 2018). If the patient can speak some English the target would be to make sure our words mean the same thing and that’s where pointing to items and using hand gestures could come in handy. I would keep the questions fairly short with simple as possible terminology.

Risk Assessment 

Being that this patient is newly immigrated to the U.S., I would want to give this patient resources that are free due to not having insurance but certainly would not deny treatment to the patient. I would focus on screening for any diseases that need immunizations, for one. Components of the health assessment for immigrants and refugees include addressing patient health concerns, screening for diseases associated with the country of origin and migration history, initiating age-appropriate immunizations, and routine health care maintenance (Walker, Barnett, & Stauffer, 2019). The question would be “have you had any illness, sicknesses, or hospitalizations that required any type of medications? Any immunizations? Any infections in your body or out breaks on your skin?” I would also ask about the living conditions and the nutritional conditions.

Other Potential Health Risks

Because of the ethnicity, the age and gender, I would certainly screen for any cardiac issue, hypertension, diabetes, and cancer. The acquisition of risk factors for chronic diseases such as coronary artery disease, hypertension, diabetes and cancer is poorly understood among African immigrants. More information must be gathered in the broad categories of chronic disease, health attitudes and health access to better promote the health of African immigrants (Venters & Gany, 2011).

Screening tool

Because of the area from which this patient came from. I would start by screening for infectious disease. I would focus on food and water exposure for things like Giardia or E. Coli, turn to the lungs and check for tuberculosis and so on. These screenings would require blood, urine, and fecal samples and a chest X-ray as most foreign folks get the Bacille Calmette-Guérin immunization and can cause a false positive when given the skin test.

5 Target Questions

I had mentioned some questions earlier but other questions would be 

1. Have you had any coughing with bloody sputum, 

2. Can you tell me about where you used to live in Africa?

 3. Are you married? Are you sexually active with more than one partner?

4. Have you had any infections or illnesses? 

5. Any diarrhea, nausea, or vomiting? 

                                                 References

Karliner, L. S. (2018, April 2018). When Patients and Providers Speak Different Languages. AHRQ. Retrieved from https://psnet.ahrq.gov/webmm/case/440/when-patients-and-providers-speak-different-languagesVenters, H., & Gany, F. (2011, April 13, 2011). African immigrant health. US National Library of Medicine, 333-344. https://doi.org/doi: 10.1007/s10903-009-9243-xWalker, P. F., Barnett, E., & Stauffer, W. (2019). Medical screening of adult immigrants and refugees. Retrieved from https://www.uptodate.com/contents/medical-screening-of-adult-immigrants-and-refugees

 

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Respond to the post bellow, offering additional/alternative ideas regarding opportunities and risks related to the observations shared.

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                                                                  Introduction

            In my psychiatric facility, we have introduced telepsych which is the same as telehealth. This is where the psychiatrist can see patients briefly from a remote location. The doctor can be in another country and still see his patients, give orders to the nurse to write, and do initial psych assessments. This is all done through the web via chatting, video, skype and phone. All these new technologies are very convenient for the doctor. This is an inpatient facility but it can also be done from home when a patient needs to see the doctor for non-emergent issues.

Benefits and Risks

            There are benefits and risks to using telehealth. According to Harper, there are 5 benefits. Those are convenience, less time in the waiting room, expedited transmission of MRI’s or X-rays for a second opinion, privacy assurance (Harper, 2012, p. 1). These are benefits that help the patient. Some benefits for the physician would be that they can see more patients and from remote places. On the other hand, there are a few risks as well. Some risks include, electronic glitches, physician resistance, and inadequate assessment. Physician resistance would be about change and change is hard to do. The nurse is a big part of the telehealth scene as the doctor will be giving her orders via phone or video. Telehealth is still a new and evolving technology; while the offsite interventions or contacts often lead to less time being wasted on non-care oriented tasks because of the efficiencies offered by the technology applications, its use must never be associated with less care (McGonigle & Mastrian, 2018, p. 361). Glitches can be inherent to this type of technology and potential hackers can disrupt internet/web using technology. Privacy can ultimately be at risk.

            Legislatively, December 21, 2017 – Some 63 pieces of legislation focusing on telehealth or telemedicine were approved by 34 state Legislatures this year, according to the Center for Connected Health Policy (“Mobile healthcare, telemedicine, telehealth, BYOD,” 2017, p. 1). It seems that each state is adding to the services of telehealth and it appears there is an ongoing discussion of regulations as far as Medicare and private payer insurances are concerned.

Most Promising Trends

            The most promising trends in healthcare today, in my own opinion, would be the Electronic Health Record (EHR). My facility is hesitant to join this trend and therefore we still use paper for everything. This technology is already impacting healthcare. In nursing practice, it saves a lot of time, it is efficient for treatment planning, its is able to be shared amongst all disciplines. The significance of the EHR to nursing cannot be underestimated. Although EHRs on the surface suggest a simple automation of clinical documentation, in fact their implications are broad, ranging from the ways in which care is delivered, to the types of interactions nurses have with patients in conjunction with the use of technology, to the research surrounding EHRs that will inform nursing practice of tomorrow (McGonigle & Mastrian, 2018, p. 267).

 

References

2017: A Look Back At The Year In State Telemedicine Legislation. (2017). Retrieved from https://mhealthintelligence.com/news/2017-a-look-back-at-the-year-in-state-telemedicine-legislation

Harper, J. (2012, July 24, 2012). Pros and Cons of telemedicine for todays worker. US NEWS, 1-6. Retrieved from https://health.usnews.com/health-news/articles/2012/07/24/pros-and-cons-of-telemedicine-for-todays-workers

McGonigle, D., & Mastrian, K. G. (2018). Nursing informatics and the foundation of knowledge. Burlington, MA: Jones & Bartlett Learning.

 

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Respond to the post bellow,  using one or more of the following approaches:

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

Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.

Offer and support an alternative perspective using readings from  the classroom or from your own review of the literature in the Walden  Library.

Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.

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                          Music Therapy for Dialysis Patients

             The research article that I selected was conducted to see if music  therapy was a good non-pharmacological intervention to manage  hemodialysis patient’s anxiety, stress, and depression. The researchers  recognized that these patients experience anxiety, stress, and  depression due to their dire health issue of end-stage renal disease.  There were 40 subjects who were receiving dialysis and 20 subjects  received music therapy.  Blood pressures and pulses were taken before  and after music therapy. The randomized control group was given  pre-tests, post-tests, and Depression Anxiety Stress Scale Tool (DASS). 

                                       Data & Results

The  data that was collected that lead to their final conclusion was  comparing the vital signs collect before and after music therapy,  demographic survey, DASS, pre and post-tests. The researchers completed a  paired t-test and design table with the data to determine the  effectiveness of the experiment. According  to Fernandas & D’silva   (2019), “To find the association between depression, anxiety and stress  level with selected demographic variables, chi-square test or likelihood  ratio test used” (p. 128). Their conclusion stated that the group that  received music therapy did have a reduction in anxiety, stress, and  depression levels. According to Fernandas & D’silva  (2019), “In the  present study the investigator made an attempt to relieve stress,  anxiety, and depression among haemodialysis patient by providing music  therapy and results shows that there was a significant difference in  depression, anxiety and stress level among the experimental and control  group” (p. 129).

                                 Conclusion & Weakness

The  researchers were able to formulate their conclusion by analyzing the  data and using careful calculations that they collected from their  research. The weakness of the study I believe is that the subjects  weren’t select randomly. The participants were selected by assessing if  they liked or showed interest in music. The dialysis patients that were  interested in music received music therapy. 

                                    Additional Research

I  do believe that further research should be completed to prove the  benefits of music therapy for a dialysis patient. Further studies should  be randomized. I also think one-way researchers could add to testing is  measuring cortisol in saliva. According to Choi, Kim, & Yang  (2014), “Salivary cortisol concentration serves as a biomarker of psychological stress. Cortisol measurements should be carried out in real time”. 

                                            References

Choi,  S., Kim, S., Yang, J. S., Lee, J.H., Joo, C., & Jung, H. (2014).  Real-time measurement of human salivary cortisol for the assessment of  psychological stress using a smartphone. Sensing and Bio-Sensing Research., 2, 8-11. 

Fernandes,  S. T., & D’silva, F. (2019). Effectiveness of Music Therapy on  Depression, Anxiety, and Stress among Haemodialysis Patients. International Journal of Nursing Education, 11(1), 124–129. https://doi-org.ezp.waldenulibrary.org/10.5958/0974-9357.2019.00024.2

 

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Respond  of your colleagues who were assigned to a   different case than you. Explain how you might apply knowledge gained   from your colleagues’ case studies to you own practice in clinical   settings as a Psychiatric Nurse Practitioner.

NOTE: Positive comment

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The three questions this writer would as the patient are: 

Did your depressive symptoms worsen after the death of your husband? 

How many hours per night do you sleep on average? 

Do you sleep throughout those hours of sleep or do you wake constantly? 

Do you ingest any stimulants like coffee or chocolate before bed? 

Do you sleep during the daytime? 

The rationale behind question one is to gauge the timeline of the  patient’s depression. She appears to have been suffering with untreated  depression for a long time, however the additional symptoms of insomnia  and tearfulness seemed to worsen after his death. With this information  the nurse practitioner will know if her depression is in an acute state  and the severity of her illness.The patient is reporting sleeplessness;  however the nurse practitioner needs to gauge if the patient is  participating in restful sleep. Sleep of two hours or less may only  consist of REM sleep (Boland et al., 2020). If the patient is not  getting restful sleep, she is not benefiting from the bodily repair that  takes place during sleep (Fitzgerald et al., 2017).  This can place her  at an increased risk for other illnesses and heighten depressive  symptoms (Uchmanowicz et al., 2019).Knowing if the patient sleeps  consistently throughout those hours of sleep will provide information to  the nurse about the kind and amount of sleep the patient is getting.  Ingesting certain stimulants like caffeinated drinks, coffee or  chocolate can affects the client’s sleep by providing wakefulness (Ulke  et al., 2017).  If the patient is sleeping during the daytime, her  circadian rhythm could have been reversed where she will need less sleep  during the night time hours (Fitzgerald et al., 2017).

The people this writer would interview are:

The patient’s aide 

The patient’s son 

The patient aide may be able to provide more information about  observed sleepiness during the daytime. In addition, she will be able to  provide information on the patient’s dietary patterns and physical  activity. The questions to the aide would be:    

Does she easily nod off during the daytime? 

Does she easily become fatigued? 

Does she consume a well-balanced diet? 

Question one would illicit answers about her getting sleep. 

It appears that she in fact getting sleep but because of a revered  circadian rhythm she is not able to get the sleep at the night which is  the desired time.  Question two will help the nurse practitioner gauge  the extent of the effects that non sleep has taken on the patient’s  life. The patient, if constantly fatigued throughout the day has a life  that has been highly impacted by the lack of sleep. The aide would be  able to provide a clear, picture of the patient’s diet. The aide would  be able to reveal if the patient consumes a vast amount of sugar or  caffeine which could interrupt sleep.

Questions to the son would surround the family’s psychiatric history.   These questions will help the nurse practitioner construct the family  history of the patient and rule out or consider familial history as a  cause for her symptoms.

Can you recall any maternal family members with psychiatric disorders including depression and insomnia? 

Did the symptoms start after the death of the client’s husband?  

This would help the nurse practitioner rule out depressive symptoms as the cause of her insomnia.

Physical Examinations and Tests

Sleep Study:

Polysomnogram – The sleep study or polysomnogram  measures the brain waves, blood oxygen, leg movements and breathing  during sleep (Meghdadi et al., 2019). The Nurse Practitioner would be  able to rule out physiological reason’s ad the cause for the patient’s  insomnia.

Actigraphy: This is where a small device is worn on  the wrist and it measures the person’s sleep wake cycle for a specified  period (Meghdadi et al., 2019). This is convenient for this client and  the Nurse Practitioner would be able to monitor the client’s sleep  health and gauge the severity of the disruption of her sleep.The nurse  practitioner could also physically examine the patient’s nares for  septal occlusion.

Septal occlusion or deviation could lead to problems  with sleeping even during sleep, this would be important for the nurse  practitioner to evaluate as this could be interfering with the patient’s  sleep.

Epworth sleepiness scale – assesses the patient’s  tendency to nod off in various situations (Meghdadi et al., 2019).  For  this client it would be necessary for the nurse practitioner to assess  the severity of her nodding off during the day time especially at  unexpected times like during eating and other activities that would put  her safety at risk. 

Differential Diagnosis

G47.00 Unspecified Insomnia Disorder– The patient is  experiencing insomnia at nighttime that could be related to several  factors. She reports staying up late to watch T.V., depressive symptoms,  restless leg syndrome, sleep apnea and sleeping during the daytime.  Some of these factors have not been ruled out yet as the cause of her  anxiety. 

G47.23 Persistent Irregular Sleep Wake type severe 

F32.9 Unspecified Depressive Disorder 

G25.81 Restless legs syndrome 

Medications:

Trazodone 50 mg – This medication would be the first choice as it  offers antidepressant properties as well as promotes sleep in those  diagnoses with insomnia. It is generally safe for the elderly population  at low doses (Pagel et al., 2018). The Nurse Practitioner should  monitor the patient and evaluate the needs to slowly increase or in some  cases decrease the dose. 

Rozerem 8 mg- Is a nonbenzodiazepine hypnotic that promotes sleep.  The patient would benefit from his, but an added benefit would be that  she would be at a diminished risk of falls as this is a concern  following the use of hypnotics in the elderly. This drug is reported as  one that would prevent less falls from over sedation (Pagel et al.,  2018).

Lessons Learned            

This writer has learned that it is important to conduct a complete  evaluation of the patient and not just focus on the presenting symptoms.  There are additional environmental and physiological symptoms that  could be attributed to the patient’s insomnia. In this case the patient  had several factors that could be contributing her insomnia and they  needed to be ruled out. The cause of her insomnia could have been  physiological from the sleep apnea or from her habits of staying up tool  late at nights and sleeping during the daytime. It is also important to  evaluate medications, social and economic factors before the resorting  to pharmacological interventions. 

References

Boland, E. M., Vittengl, J. R., Clark, L. A., Thase, M. E., &  Jarrett, R. B. (2020). Is sleep disturbance linked to short- and  long-term outcomes following treatments for recurrent depression? Journal of Affective Disorders, 262, 323–332. 

FitzGerald, J. M., O’Regan, N., Adamis, D., Timmons, S., Dunne, C. P., Trzepacz, P. T., & 

Meagher, D. J. (2017). Sleep-wake cycle disturbances in elderly acute  general medical inpatients: Longitudinal relationship to delirium and  dementia. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, 7, 61–68. 

Meghdadi, A. H., Popovic, D., Rupp, G., Smith, S., Berka, C., &  Verma, A. (2019). Transcranial Impedance Changes during Sleep: A  Rheoencephalography Study. IEEE Journal of Translational Engineering  in Health and Medicine, Translational Engineering in Health and  Medicine, IEEE Journal of, IEEE J. Transl. Eng. Health Med, 7, 1–7.  

Pagel, T., Seithikurippu R. Pandi-Perumal, & Jaime M. Monti. (2018). Treating insomnia with medications. Sleep Science and Practice, (1), 1. Uchmanowicz I, Markiewicz K, 

Uchmanowicz B, Kołtuniuk A, & Rosińczuk J. (2019). The  relationship between sleep disturbances and quality of life in elderly  patients with hypertension. Clinical Interventions in Aging, 155. 

Ulke, C., Sander, C., Jawinski, P., Mauche, N., Huang, J., Spada, J.,  Hegerl, U. (2017). Sleep disturbances and upregulation of brain arousal  during daytime in depressed versus non-depressed elderly subjects. World Journal of Biological Psychiatry, 18(8), 633–640.    

 

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Respond 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.

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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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