Respond 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.

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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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Respond  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.

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                                         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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 Respond to at least two 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. 

NOTE: Positive Comment

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      Case #13 the 8-year-old girl who was naughty  

This  case study will examine an 8-year-old girl who initially presents to  the pediatrician’s office with complaints of a fever and sore throat.  After further examination, the client is diagnosed with attention  deficit hyperactivity disorder (ADHD) and oppositional defiant disorder  (ODD). According to Ghosh, Ray, & Basu (2017), characteristics of  ODD include persistent anger or irritable mood, argumentativeness,  defiance, and vindictiveness for at least 6 months. ADHD is  characterized by a pattern of inattention, hyperactivity, and  impulsivity that interferes with daily functioning or development  (American Psychiatric Association, 2013). 

3 Additional Assessment Questions for the Client:

1.  I would ask the client and her mother how often her daughter displays  symptoms that are congruent with ODD and? According to the authors  Ghosh, Ray, & Basu (2017), the occurrence of ODD symptoms must be  disproportionate to the child’s developmental stage and age. 

2. I  would ask the client if she had trouble learning in class when she was  younger. The onset of ADHD symptoms usually occurs before a child  reaches age 12, and in some children, these symptoms are noticeable at  age 3 (Sibley, Rohde, & Swanson, 2017). 

3. A  final question that I would ask the client is if she interrupts her  classmates when they are speaking. Children suffering from ADHD feel the  need to be constantly active and struggle with controlling impulsive  behaviors (American Psychiatric Association, 2013).  

Feedback From the Client’s Loved Ones

The  first person in this client’s life that I would like to further  interview is the client’s mother. According to Stahl (2019), the  client’s mother is 26 years old and is a single parent of two children,  ages 8 and 6. I would want to ask the client’s mother more about her  daughter’s academic performance in earlier grades. Identifying the  precise onset of the client’s ADHD symptoms will assist the provider in  creating the most appropriate treatment for the client (Stahl, 2014). I  would also like to interview the client’s teacher in order to gain  another perspective on the client’s behavior in the classroom. The  client’s teacher did use an ADHD rating scale, but scales of that nature  are very broad and do not elaborate on the child’s specific classroom  behaviors. A third person that I would interview is the client’s  6-year-old sister. According to Stahl (2019), the client began  displaying signs of anger and resentfulness when her sister was born. I  would ask the client’s sister if she felt safe at home and if she and  her sister fought often, in order to determine if the home environment  is safe for both children. 

Physical Exams and Diagnostic Tests

The  physical assessment of the client is essential for developing an  appropriate diagnosis and treatment plan. Visual assessment of the  client’s behaviors during the physical assessment will be extremely  useful to the provider. The provider would also want to obtain and  review the client’s report cards along with any behavior reports, and  attendance records from the client’s school (Adesman, 2011). The  healthcare provider should also review the client’s pediatric health  records to see if her symptoms are congruent with a learning disability,  auditory processing disorder, signs of language delay, spacial  orientation confusion, and complete a more thorough family history  involving learning disabilities (Adesman, 2011). A complete blood count  should be down to rule out physical illness as a causetive factor for  the client’s ODD symptoms. The client is currently suffering from a  fever and sore throat, which could be an indicator of PANDAS (pediatric  autoimmune neuropsychiatric disorder associated with streptococcal  infections). Since  the client does have a current sore throat, a rapid strep test should  be ordered. If the client does test positive for strep, it could explain  the client’s symptomologies impulsivity, temper tantrums, and aggressiveness.  

Differential Diagnoses

Autism Spectrum Disorder: there  are deficits in social-emotional reciprocity, ranging from an abnormal  social approach and failure to communicate in a standard back-and-forth  conversation (American Psychiatric Association, 2013). There is also a  reduced sharing of interests, emotions, or affect, along with a failure  of the patient to initiate or respond during social interactions (American Psychiatric Association, 2013). The client’s history does not show any indication of impaired communication. 

Conduct Disorder:  characterized by behavior that violates either the rights of others or  major societal norms, the symptoms must be present for at least 3 months  with one symptom having been present in the past 6 months. The symptoms  of conduct disorder must cause significant impairment in social,  academic or occupational functioning (American Psychiatric Association,  2013). Per the client’s medical record, her symptoms fit the time frame  for conduct disorder, however, her behavior is not this severe in  nature. 

ADHD with Co-occurring ODD: The authors Ghosh, Ray, & Basu (2017), describe the characteristics  of ODD as persistent anger or irritable mood, argumentativeness,  defiance, and vindictiveness for at least 6 months. ADHD is  characterized by a pattern of inattention, hyperactivity,  and impulsivity that interferes with daily functioning or development  (American Psychiatric Association, 2013). The client’s behavior is  congruent with ADHD with co-occurring ODD.

Pharmacological Agents for ADHD/ODD Therapy: 

Risperdal  is the first pharmacological agent that I would choose for this client.  This medication is not listed on the suggested medication list of the  case study, however, the medication list does list “other” as a possible  choice. According to Stahl (2014), Risperidone  is also used to treat behavior problems such as aggression,  self-injury, and sudden mood changes in teenagers and children 5 to 16  years of age. Risperidone  is in a class of medications called atypical antipsychotics. It works  by changing the activity of certain natural substances in the brain. The  second medication that was chosen for this client is Vyvanse.  Vyvanse increases norepinephrine and dopamine actions by blocking their  reuptake and creating an environment that allows their release (Stahl,  2013). Vyvanse also causes an enhancement of dopamine and  norepinephrine in specific areas of the brain that may improve  attention, concentration, executive dysfunction, and wakefulness (Stahl,  2013). According to Stahl (2014), it is thought that the increased  dopamine action caused by Vyvanse, may help with hyperactivity. I would  initially start this client on Vyvanse due to its efficacy in treating  symptoms of ADHD. If the child’s academic performance and classroom  behavior improve, perhaps ODD symptoms will improve. 

CheckPoints: 

According  to Stahl (2019), the closest child psychotherapist is an hour away,  therefore the client did not receive therapy. I would refer the client  and her mother to case management in order to connect the client with  resources that are closer to her home. I would also ask the client’s  school what type of resources are available in terms of psychotherapy.

Lessons Learned: 

Through  this case study I have learned that co-occurring childhood disorders  can be difficult to treat. Pediatric clients can respond differently to  medication dosages than adults, so careful dose titration is essential.  Pediatric clients also rely on their parents or caregivers to provide  them with their prescribed medications and transportation to medical  appointments. It is essential that the healthcare provider conveys how  important treatment regime compliance is to both the client and their  caregiver.

Adesman, A. R. (2011). The Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in     

          Pediatric Patients. Primary care companion to the Journal of clinical psychiatry, 3(2), 66-77.     

          https://doi.org/10.4088/pcc.v03n0204

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, DC: Author.

Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: current insight. Psychology     

research and behavior management, 10, 353-367. https://doi.org/10.2147/PRBM.S120582

Sibley, M. H., Rohde, L. A., & Swanson, J. M. (2017). Late-Onset ADHD Reconsidered with     

           Comprehensive Repeated Assessments between Ages 10 and 25. American journal of psychiatry,     

175(2), 140-149. https://doi.org/10.1176/appi.ajp.2017.17030298

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (fourth ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Stahl Online. (2019). Volume 1 case #5: The sleepy woman with anxiety. (PDF file). 

Retrievedfrom http://stahlonline.cambridge.org.ezp.waldenulibrary.org/viewPdf?p

age=csEP_05.pdf                

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Respond 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

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                                                        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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