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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Assessing a patient begins by developing a relationship through effective communication.  Gathering details for an accurate history and chief complaint further aids the practitioner in aiding a plan of care. To address the needs of a 54-year-old Caucasian male, that is referred to establish primary care after a recent hospitalization after a seizure related to alcohol withdrawal requires accurate history taking.  Additional information includes hypertension with medication use, history of alcohol and cocaine abuse with current abstinence, and homelessness.  This male patient reports lack of medication to treat his hypertension and active cigarette smoking.          

Some issues that the practitioner would need to be sensitive to when interacting with this patient would be his homelessness and drug and alcohol abuse history. By using cross-cultural communication that is open with respect, the RESPECT Model can help practitioners to remain effective and patient centered during communication with patients. The components of RESPECT are rapport, empathy, support, partnership, explanations, cultural competence, and trust (Ball, Dains, Flynn, Solomon, & Stewart, 2019, p.31).    This patient has age and socioeconomical barriers that are affected by his homelessness.  Ball, Dains, Flynn, Solomon, & Stewart 2019 note that those in poverty and poorly educated die at higher rates that those who are educated and economically stable. This male patient’s high-risk factors of being homeless and coupled further with smoking and hypertension increase his susceptibility to mortality.  It is the responsibility of the practitioner to use appropriate screening tools when assessing a patient with these characteristics. Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based practice to identify, reduce and prevent alcohol and drug use which is one tool (Acquavita, Van Loon, Smith, Brehm, Diers,…Baker, 2019).     

Once the practitioner completes an accurate intact or past medical history (PMH), the chief complaint (CC) is identified to establish care.  The patient reports only one medication, amlodipine 10 mg’s, and other medications must be researched and documented.  A social history (SH) is gathered to assess all risk factors and specifically for this patient would include the number of cigarettes smoked per day, and length of time smoking.  Alcohol and drug abuse are also two risks that patient reports as prior use and knowing when the patient last drank.  It is also the responsibility of the practitioner to counsel this patient on risk factors associated with smoking and his hypertension, because if is the practitioner’s responsibility to provide patient education and counseling. The practitioner knows that 70 to 80% that are homeless smoke and are at high risk to smoke because they are exposed to smoking around shelters and feel pressured to smoke which makes it hard to quit (Pratt, Pernat, Kerandi, Kmiecik, Strovel-Ayres, Joseph,…Okuyemi, 2019). 

Questions the Practitioner might ask include:

What has contributed to your homelessness and are you engaged in changing your situation? 

Whom was treating your hypertension and how long have you had hypertension where you have required medication? 

Do you take any other medications? 

When is the last time you drank alcohol or used cocaine or any other types of drugs? 

Have you participated in any programs to help you not drink alcohol, avoid drug use, or quit smoking? 

Do you understand the risk factors of hypertension and smoking?

      Developing a plan would be for regular blood pressure monitoring, appropriate medication management, referral to an alcohol and drug treatment program, obtain lab work to evaluate for dyslipidemia, smoking cessation program referral and options for quitting, and the next follow up appointment. Goals to support this patient would be to identify any mental health issues as there is a correlation with mental illness and homelessness.  Currently the major reason for homelessness is affordable housing and the reduction in programs to assist (National Homelessness, 2019).  Engaging the patient in programs to support his history of alcohol, drug use, and current situation with smoking.  Managing his known health condition of hypertension and other associated risk factors with his reported history. 

 

                                                  References

Acquavita, S. P., Anne Van Loon, R., Smith, R., Brehm, B., Diers, T., Kim, K., & Baker, A. (2019). The SBIRT Interprofessional Curriculum and Field Model. Journal of Social Work Practice in the Addictions, 19(1/2), 10–25. https://doi-org.ezp.waldenulibrary.org/10.1080/1533256X.2019.1589883 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.National Homelessness.org (2019). National Coalition for the Homeless. Building a movement to end homelessness.  Retrieved from: http://nationalhomelss.org/about-homelessnessPratt, R., Pernat, C., Kerandi, L., Kmiecik, A., Strobel-Ayres, C., Joseph, A., … Okuyemi, K. (2019). “It’s a hard thing to manage when you’re homeless”: the impact of the social environment on smoking cessation for smokers experiencing homelessness. BMC Public Health, 19(1), 635. https://doi-org.ezp.waldenulibrary.org/10.1186/s12889-019-6987-7

 

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Respond to at least two of your colleagues on two different days by sharing ideas for how shortcomings discovered in their evaluations and/or their examples of incivility could have been managed more effectively.

                                                   

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Workplace civility is linked to organizational excellence and creates an environment where employees respect and value one another through cooperation, fair resolution of disputes, teamwork, and non-discriminatory behavior (Department of Veteran Affairs, 2017). Organizational leaders and managers must create an environment that is respectful and inclusive of all people (Clark, 2015; Marshall & Broome, 2017).

Work Environment Assessment

According to the Clark Healthy Workplace Inventory results, my organization is a moderately healthy environment. Why my workplace is civil? The VA understands that civility is a significant determinant not only to employee outcomes ( job satisfaction, stress levels) but also to higher level outcomes directly connected to the organizational mission (quality of patient care, operational costs, ability to retain quality workforce ). The organization continues to create a healthy work environment and measures civility annually through the All Employee Survey (Department of Veteran Affairs, 2017).

Incidence of Incivility

A physician assistant (PA) ordered Versed, and  I was not comfortable giving this medication to my patient. I asked him to explain his rationale for ordering the medication because I knew this drug was not part of the ACLS chest pain protocol and although in pain morphine was the better drug of choice.  The PA pretending to understood my concern and contacted his pharmacist friend who works in our department, but was off duty. The pharmacist became enraged and began to text me with vulgar language and statements, feeling under attack, I  stood up for myself told the pharmacist and the PA I would not be bullied into unsafe practice, and it was my responsibility to advocate appropriately. I shared the messages with the supervising physician, management, and union representative. The pharmacist and PA both issued a formal apology and suspended for two weeks.

Clark, C. M. (2015). Conversations to inspire and promote a more civil workplace. American Nurse Today, 10(11), 18–23. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2015/11/ant11-CE-Civility-1023.pdf

Department of Veteran Affairs. (2017). Civility, respect, and engagement in the workplace (crew). Retrieved from https://www.va.gov/ncod/crew.asp

Marshall, E., & Broome, M. (2017). Transformational leadership in nursing: From expert clinician to influential leader. New York, NY: Springer Publishing Company.

 

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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  references

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The behavioral risk factor that I selected from the Healthy People 2020 objectives is overweight and obesity among children and adolescents (ages 6 through 19), which has increased significantly over the last three decades (Knickman & Kovner, 2015). Currently, only 36% of Floridians are at healthy weight, and if we stay on our current trend, by 2030, almost 60% will be obese (Florida Health, 2017). Additionally, six out of ten children born today will be obese by the time they graduate from high school (Florida Health, 2017). Five areas in which reform is critically needed in order to prevent obesity are creating safe environments for physical activity, healthy food and beverage choices, message environments, and health care, work and school environments (Knickman & Kovner, 2015). The population-based intervention model describes downstream, midstream and upstream interventions for preventing overweight and obesity among children and adolescents (Knickman & Kovner, 2015).

A downstream health prevention program focuses on changing behaviors at an individual level, rather than preventing risk behaviors (Knickman & Kovner, 2015). Given parents’ influence and control over their children’s diet, physical activity, media use, and sleep, family interventions are a key strategy in the effort to eliminate childhood obesity (Ash, Agaronov, Young, Aftosmes-Tobio & Davison, 2017). An example of a downstream intervention that would be effective is to provide a hand-out for parents and children through the school with helpful tips on reducing screen time, suggestions for healthy food swaps (having an apple instead of chips after school) and suggestions for easy ways to incorporate exercise into your day, such as go for a walk as a family for 20-30 minutes after school each day.

A midstream health prevention program focuses on changing behaviors at a community level, with health promotion programs that are targeted at populations to change or prevent risk factors (Knickman & Kovner, 2015). An example of a midstream intervention that would be effective is to provide school-based sports and physical activity to children each day. Two main individual behavior determinants of health are diet and physical activity (ODPHP, 2018). The school would provide coaches and equipment for children to participate in sports who may not have the ability to otherwise in their home environment.

An upstream health prevention program focuses on developing policies at state and national levels in order to reduce the promotion of unhealthy products and behaviors (Knickman & Kovner, 2015). An example of an effective upstream intervention is the great efforts made in the public-school system to improve the quality of food provided in school lunches, and to eliminate the availability of junk-food to kids. In April 2014, the US Department of Agriculture (USDA) issued new regulations, which took effect in July 2014, banning the sale of all junk-food in schools (Ballaro & Griswold, 2018). The regulations stated that only fruits, vegetables, dairy products, lean-protein foods, and whole-grain items could be sold in cafeterias or vending machines, limiting the maximum calorie count of 200 for snacks and 350 for entrées (Ballaro & Griswold, 2018). Foods containing trans-fats could not be sold, and drinks could contain no more than 35% sugar or fat, and must be limited to water, low- or no-fat milk, and 100% fruit or vegetable juice (Ballaro & Griswold, 2018).

References

Ash, T., Agaronov, A., Young, T., Aftosmes-Tobio, A., & Davison, K. (2017). Family-based childhood obesity prevention interventions: a systematic review and quantitative content analysis. International Journal of Behavioral Nutrition & Physical Activity, 14(1), 1-12. doi:10.1186/s12966-017-0571-2

Ballaro, B., & Griswold, A. (2018). Junk food in schools. Salem Press Encyclopedia. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ers&AN=89158234&site=eds-live&scope=site

Florida Health. (2017). Healthy weight. Retrieved from http://www.floridahealth.gov/programs-and-services/prevention/healthy-weight/index.html

Knickman, J. R., & Kovner, A. R. (Eds.). (2015). Health care delivery in the united states (11th ed.). New York, NY: Springer Publishing.

Office of Disease Prevention and Health Promotion. (2018). Determinants of health. Retrieved from https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health

 

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Respond  on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

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Knee Pain SOAP Note  

Patient Information:SJ, 15-year-old WM

S.

CC– Pain in both knees.

HPI: 15-year-old white male presents with pain in bilateral knees.  Pain onset was 1 week ago after football practice.  Pain is described as “dull”.  Associated s/s include clicking in one or both knees and a catching sensation under the patella. SJ describes pain as dull and constant, pain rated at 3 on a scale of 0-10. Pain is exacerbated by movement and relieved by rest.  

Current Medications: No medications, no OTC medications or vitamins.

Allergies: seasonal allergies only

PMHx: Immunizations current, flu shot received from PCP 10/5/19.  No previous injuries, hospitalizations, or surgeries.

Soc Hx: 10th grade student, on high school football team (offensive lineman), has played football since age 6.  Denies alcohol use, denies tobacco use, Denies use of illicit drugs.  Honor student, popular in school with many friends. Lives at home with dad and two younger sisters.  Mom is active duty/deployed currently.  Currently learning to drive in driver’s education at school.

Fam Hx: No significant medical history in parents. Maternal grandmother died at 80 of lung cancer, grandfather at 81 of MI.  Paternal grandmother has osteoarthritis, grandfather has DM.  

ROS: GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Head: denies headache, 

Eyes: Denies visual loss, blurred vision, or double vision, denies hearing loss, nasal dysfunction or sore throat.

SKIN:  denies rash or puritis.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Denies change in bowel or bladder control.

MUSCULOSKELETAL:  Knee pain, with clicking and catching sensation under the patella. Denies back pain, stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.PSYCHIATRIC:  Denies depression or anxiety.

ALLERGIES:  Denies food or drug allergies, allergy to pollen.

O.

VS: BP 123/68; P 89; RR 18; T 97.6; O2 98%; Wt 179; BMI 25.68

General– AOx4. Pt appears healthy and well nourished, athletic build.  Well groomed, no acute distress noted.

Cardiovascular- Regular rate/rhythm. S1/S2 heard, no murmurs, gallops, or rubs noted.   

Respiratory– RR even and unlabored. Clear to auscultation bilaterally with no wheezing, rales, rhonchi, or crackles.

Musculoskeletal- joint stability normal in upper extremities, no tenderness to palpation.  Lower bilateral popliteal tenderness upon palpation, Rt quadricep angle 18 degrees, Lt quadricep angle 20 degrees.  Bilateral inflammation present in the distal extensors.

Diagnostic results: CBC: WBC-5.9 Hgb- 16.1  Hct- 49 Platelet count- 210, X-ray McMurry test negative, Lachman test negative, MRI- negative for meniscus tear, negative for ACL tear, negative for CP.

A.Patellar tendinitis- This overuse syndrome is characterized by inflammation in the distal extensors of the knee joint (Dains, Baumann, & Scheibel, 2019). Patellar tendinitis is more common in athletes who habitually place excessive strain on their knees from jumping or running (Dains, Baumann, & Scheibel, 2019). Determine the quadriceps angle by measuring the angle between the center of the patella to the anterior superior iliac spine and from the center patella to the tibial tubercle (Dains, Baumann, & Scheibel, 2019). An angle greater than 10 degrees in males and 15 degrees in females suggests patellar tendinitis (Dains, Baumann, & Scheibel, 2019). People affected complain of dull, achy knee pain that may have associated clicking or popping (Dains, Baumann, & Scheibel, 2019).

Medial meniscus tear- clinically examined with McMurray’s test and joint line tenderness for clinical diagnosis of medial meniscus tear (Gupta, Mahara & Lamichhane, 2016). The presence of pain and/or click/snap/clunk/thud was considered positive for the McMurray’s test. Joint line tenderness was tested in 90 degree of knee flexion (Gupta, Mahara & Lamichhane, 2016).Anterior cruciate ligament tear- Patients with ACL tears typically present with acute injury, sometimes with an associated “pop,” a sensation of tearing, the immediate onset of effusion, or any combination thereof.  Better tests are the Lachman test and the pivot-shift test, which have reported respective sensitivities of 0.87 and 0.49 and specificities of 0.97 and 0.98 (Volker & Karlsson, 2019). The pivot-shift test is a dynamic test of the rotatory laxity of the knee that produces subluxation and reduction (felt as a “clunk”) of the lateral tibial plateau (Volker & Karlsson, 2019). Although plain radiography is often the first diagnostic step after the physical examination to rule out fracture, dislocation, or both, magnetic resonance imaging (MRI) is strongly recommended as part of the diagnostic evaluation, given its reported high sensitivity and specificity (97% and 100%, respectively) for the detection of ACL injury (Volker & Karlsson, 2019).

Acute leukemia- Leukemia is the most common cancer in children, and bone and joint pain is the most common presenting complaint (Dains, Baumann, & Scheibel, 2019). The bone pain is diffuse and nonspecific and may extend to adjacent joints (Dains, Baumann, & Scheibel, 2019). Laboratory findings may show the WBC count as elevated, depressed, or normal; severe anemia is common, as is a depressed platelet count (Dains, Baumann, & Scheibel, 2019). Radiographs of the limb at the distal end of the femur and the proximal end of the tibia show abnormal areas of radiolucency (Dains, Baumann, & Scheibel, 2019). 

Chondromalacia Patellae- Chondromalacia patellae (CP) represents a spectrum of abnormalities, including softening, swelling, fraying and erosion of the hyaline cartilage overlying the patellae and sclerosis of underlying bone (Harman et al., 2003). Patients with CP experience pain as the articular cartilage begins to degenerate and abnormal stresses are transferred from the elastic, shock-absorbing cartilage to the subchondral bone (Harman et al., 2003).  MRI, with its multiplanar capabilities, excellent soft tissue resolution and noninvasive nature, has been studied in the evaluation and staging of chondral lesion in the knee (Harman et al., 2003)

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

                                              References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care(6th ed.). St. Louis, MO: Elsevier Mosby. Gupta, Y., Mahara, D., & Lamichhane, A. (2016). McMurray’s Test and Joint Line Tenderness for Medial Meniscus Tear: Are They Accurate? Ethiopian Journal of Health Sciences, 26(6), 567–572. https://doi-org.ezp.waldenulibrary.org/10.4314/ejhs.v26i6.10Harman, M., Ipeksoy, U., Dogan, A., Arslan, H., & Etlik, O. (2003). MR arthrography in chondromalacia patellae diagnosis on a low-field open magnet system.Clinical Imaging, 27(3), 194-9. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1016/S0899-7071(02)00521-1 Volker, M., & Karlsson, J. (2019). Anterior cruciate ligament tear. The New England Journal of Medicine, 380(24), 2341-2348. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1056/NEJMcp1805931

 

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Respond  in one or more of the following ways:

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.

Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

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When conducting research, it is necessary that the researcher not only know how to find the sources needed to answer the question that they have created but also how to analyze that information to understand which research design was used. Doing so will allow the researcher to provide the evidence needed to support or reject the question being asked. Quantitative research is the investigation of phenomena that lends themselves to precise measurement and quantification, often involving a controlled design (Polit & Beck, 2017). This discussion will look at two different quantitative studies and the qualities that make them so. 

Sleep Apnea Study Number One

 This study by Boulos et al.(2017) looks at the effectiveness of using home sleep apnea testing (HSAT) as a means of detecting obstructive sleep apnea (OSA)  in stroke or transient ischemic attack (TIA) inpatients and outpatients. OSA can negatively impact poststroke functional recovery and by using HSAT these patients can be screened and diagnosed for OSA sooner and improve their poststroke functional and motor recovery (Boulos et al., 2017).

The question being asked is therapeutic in nature. The design of the study is listed under the methods section as a single-center prospective observational study. An observational study means that the researchers do not intervene by manipulating the independent variable  (Polit & Beck, 2017). The independent variable within this study would be that all participants have had a stroke or TIA. Prospective designs are studies that begin with a presumed cause and look forward in time for its effect (Polit & Beck, 2017). Within this study, OSA was the presumed cause in a delay of functional and motor recovery for those patients who suffered a stroke or TIA. This design method was appropriate for the group being used. A control group would not have helped to validate the use of HSAT in stroke recovery since those within that group would not be suffering from the same effects. The use of t-tests, Wilcoxon rank sum-test, and multivariate logistic regression were used to analyze the data (Boulos et al., 2017). The results demonstrated that the use of HSAT in the poststroke or TIA population was effective at expediting the diagnosis and treatment of OSA (Boulos et al., 2017). 

Sleep Apnea Study Number Two

The second study is similar to the first in that it evaluated patients with acute ischemic stroke for the prevalence of sleep apnea and compared the functional outcomes of patients with and without sleep apnea at the 3rd month after an acute ischemic stroke (Nair et al., 2019). The type of question being asked is an etiology in that it looks to see if OSA is a risk factor for stroke. The design of the study is under the methodology section and is listed as a prospective observational study. This type of study is also known as a cohort design and as stated by Polit & Beck (2017), it is the strongest design for etiology questions when randomization is impossible. This method study is appropriate in that no manipulation was done to the independent variable (stroke). Randomization would not be appropriate for this particular study as the only treatment option would be the use of Continuous Positive Airway Pressure (CPAP) and the use of such treatment was not evaluated.

Questionnaires such as the sleep disordered Questionnaire, Berlin Questionnaire, and Epworth sleepiness scale were used to diagnose sleep apnea in the patients being evaluated and the results divided the group into those who had sleep apnea and those who did not. The two groups were then compared using Barthel scores at baseline and at 3 months. Using repeated measure of ANOVA, the results showed a significant difference with an improved functional gain in patients in the no sleep apnea group demonstrating that sleep apnea is associated with an increased risk of ischemic stroke and poor functional outcome (Nair et al., 2019).  

Conclusion

  For researchers, understanding which design method to use when creating a research study can be a great asset to promoting the change that they wish to bring about. Utilizing the wrong research design may diminish the quality of the results and may create doubt about the study overall. Understanding that quantitative studies aim to explain cause-and-effect relationships will help to guide the researcher to design their research to demonstrate causality and bring attention to the problem that they are determined to address (Polit & Beck, 2017).

 

References

Boulos, M. I., Elias, S., Wan, A., Im, J., Frankul, F., Atalla, M., … Murray, B. J. (2017). 

Unattended Hospital and Home Sleep Apnea Testing Following Cerebrovascular Events. Journal of Stroke & Cerebrovascular Diseases, 26(1), 143–149. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jstrokecerebrovasdis.2016.09.001

Nair, R., Radhakrishnan, K., Chatterjee, A., Gorthi, S. P., & Prabhu, V. A. (2019). Sleep 

Apnea-Predictor of Functional Outcome in Acute Ischemic Stroke. Journal of Stroke & Cerebrovascular Diseases, 28(3), 807–814. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jstrokecerebrovasdis.2018.11.030

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for 

nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer.

 

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