Respond on two different days who selected a different scenario than you, in one or more of the following ways:

Share insights on how the factor you selected impacts the disorder your colleague identified.

Ask a probing question regarding the disorder that your colleague identified.

Suggest an alternative disorder for the scenario your colleague selected.

                                                                Main Post

Scenario 3:

 

Maria is a 36-year-old who presents for evaluation of a cough. She is normally a healthy young lady with no significant medical history. She takes no medications and does not smoke. She reports that she was in her usual state of good health until approximately 3 weeks ago when she developed a “really bad cold.” The cold is characterized by a profound, deep, mucus-producing cough. She denies any rhinorrhea or rhinitis—the primary problem is the cough. She develops these coughing fits that are prolonged, very deep, and productive of a lot of green sputum. She hasn’t had any fever but does have a scratchy throat. Maria has tried over-the-counter cough medicines but has not had much relief. The cough keeps her awake at night and sometimes gets so bad that she gags and dry heaves.

Acute Cough

     Coughs are the body’s way of clearing airways via forceful expiration.  Inflammation, inhaled particles, accumulated mucus, or foreign bodies stimulate a cough reflex by irritant receptor stimulation in the airway.  An acute cough is classified as lasting 2-3 weeks, and chronic cough is greater than three weeks in a non-smoker. Frequent cough causes are allergic rhinitis, upper respiratory infections, pneumonia, aspiration, pulmonary embolus, and congestive heart failure.  Due to the above-listed scenario, this cough would be diagnosed as acute cough due to timeframe, cough characteristics, and patient history (Huether & McCance, 2019).

Green Sputum

     Sputum contains immune cells and white blood cells from the lower respiratory tract that protect the airway from infections.  Sputum can be clear or colored.  Color sputum may be yellow, white, green, red or blood-tinged, or pink.  Neutrophils are white blood cells that can take on a green color.  This color sputum can be indicative of bacterial infections of the lower respiratory tract.  Pneumonia and cystic fibrosis can produce this color sputum.  To indeed rule out something benign, a sputum culture would need to be obtained and tested (Verywell Health, 2019).  At three weeks in, it would likely be premature to order cultures with limited symptoms. 

Treatment

     Due to the timeframe of cough and only accompanying symptom being green sputum, as a practitioner, I would prescribe an expectorant and schedule a follow up if symptoms persist or worsen.  Teaching should include that adverse effects of expectorants might be GI upset, headache, drowsiness, and dizziness.  Advise patient that expectorants are designed to be short-term (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Additional home treat to loosen secretions would be a humidifier, staying adequately hydrated and warm salt water gargles if sore throat should appear (Barkley, 2018).

Patient Factors- Behavior and Age

          Maria is an otherwise, healthy 36-year-old female.  Due to her age and symptom status, Maria would be treated conservatively.  Maria is a non-smoker and takes no prescribed medications.  Further investigation would be required if she was a smoker, currently on prescriptions medications, had current disease processes that may factor into the treatment plan.

References

Arcangelo,  V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.).  (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams  & Wilkins.

Barkley, T.  (2018).  Adult-gerontology primary care nurse practitioner.  West Hollywood, CA:  Barkley & Associates.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.

Verywell Health.  (2019). What causes the amount of sputum to increase?  Retrieved from https://www.verywellhealth.com/what-is-sputum-2249192

 

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Please respond to post to each of the post listed below as if it were me. These are my classmates and each response needs to be  min 200 words, 1 source (no older than 5 years), and APA. 

** please start out by………. Hello, I enjoyed reading you post on BLANK. (go from there). for post 1 only ***

THANK you in advnce 

……………………………………………………………………………………………

Post 1

Human immunodeficiency virus or HIV is a virus that is transmitted through body fluids through sexual contact, needle sharing, as well as mother to baby. The virus attacks the immune system and causes the CD4 cells, what helps fight infections, to be low (Center for Disease Control and Prevention, 2018). There have been great strides made, since the first diagnoses in the early 1980s, when it comes to Human Immunodeficiency Virus (National Prevention Information Network, 2017). The ELISA or the rapid HIV test is used to test someone for HIV. If the individual is positive, a confirmation test called the Western Blot test is done to confirm these results (Lawrence & Ashely, 2018). It is mandatory that all practitioners and laboratories report positive results to the local or state health department. The state department will then send this information to the Center for Disease Control and Prevention (CDC) (Hartog, 2013). When treated with the correct antiretroviral therapy (ART) patients can remain in the clinical latency phase for decades and live a normal life and are less likely to infect others at this stage (Center for Disease Control and Prevention, 2018). While there has been a national decrease of new HIV cases, Florida is seeing an increase in new HIV cases (U.S. Department of Health and Human Services, 2017). For family nurse practitioners mainly seeing patients in the clinic setting, it is important that prevention is key and, education and screening needs to be the focus to help reduce the new cases of HIV. While it is not possible to prevent all cases of new HIV, we must make sure that individuals that are infected with HIV have the resources to receive their ART regimen and take it correctly.      

Post 2 

What do you think would be an intervention to help decrease the amount of new HIV interventions?

 

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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.

    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.

 Case #29 The depressed man who thought he was out of options.

The patient is a 69-year-old male with unremitting chronic depression. He has suffered from depressive episodes for 40 years and has always had a good response to treatment until 5 years ago when he relapsed on venlafaxine. Two years ago, he underwent nine treatments of ECT with partial response. He has tried every known antidepressant and augmentation available in the past few years.

The patient should be asked about recent stressful life events, consumption of illicit drugs, alcohol abuse, current medical conditions and prescribed medications (Preda, 2018). If the patient was in my office, I would also want to ask questions to gain an understanding of the severity of his depression. It is important to assess the overall severity of depression symptoms because symptom severity corelates with suicide risk (Preda, 2018). The PHQ-9 screening could be used, and this screening asks about feelings of hopelessness, loss of pleasure in doing things, and feelings of being better off dead. A focused severity assessment for hopelessness, suicidal ideation, and psychotic symptoms is recommended; these symptoms independently increase the risk for suicide (Preda, 2018). This patient reports feeling severely depressed and demoralized, as well as, helplessness, hopelessness, and worthlessness. His depression is the worst it has ever been.

            Family members are helpful informers, they can ensure medication compliance, and can encourage patients to change behaviors that continue depression (Halverson, 2019). Some questions I would ask family members would include whether the patient is taking their medication and I would ask the family to provide some insight as to how the patient behaves at home. The wife reports that she feels he is letting go and giving up.

There are no lab tests that will confirm depressive disorder, however, labs can be ordered to rule out illnesses that may present as depressive disorder such as endocrinological or neurological diseases. Labs tests may include TSH, B12, RPR, HIV test, electrolytes, BUN and creatinine, blood alcohol, and blood and urine toxicology screening. Neuroimaging can help clarify the nature of the neurologic illness that may produce psychiatric symptoms, but these studies are costly and may be of questionable value in patients without discrete neurologic deficits (Halverson, 2019). CT scanning or MRI of the brain should be ordered for suspected organic brain syndrome. PET scans provide a means for studying receptor binding of certain ligands and the effect a compound may have on receptors (Halverson, 2019).

Differential diagnosis would include major depressive disorder, bipolar disorder, and/or poor or rapid metabolism. From 25-50% of cases of Treatment Resistant Depression (TRD) are associated with bipolar disorder; this is by far the most common individual cause of TRD (Preda, 2018). The remaining 50-75% are associated with noncompliance, poor or rapid metabolism, or misdiagnosis (Preda, 2018). This patient is exhibiting signs and symptoms consistent with major depressive disorder, such as anhedonia, loss of energy, feelings of worthlessness, depressed mood, which have been consistent for more than a two week period. TRD is defined as MDD that fails to respond to at least two antidepressant trials that are of adequate dose and duration; the two antidepressants may belong either to the same class or to different classes (Preda, 2018).

SSRIs, which include fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine, have become the first-line treatment for major depression (Brown, 2011). SSRIs work by selectively blocking the reuptake of serotonin to increase the amount of serotonin available in synapses in the brain (Brown, 2011). The STAR*D trial examined various strategies for treatment resistant depression in patients who did not respond to an initial SSRI, including switching to another SSRI antidepressant, changing medication class, and switching to CBT. Fair quality studies have indicated a trend toward greater effectiveness when switching to an SNRI such as venlafaxine than with citalopram, fluoxetine, or paroxetine (Halverson, 2019).

For patients with major depressive disorder, I would start the patient on citalopram 20mg and increase the dose to a maximum of 40mg. If the patient failed to respond, I would change to venlafaxine 75mg daily extended release tablet and increase dose if tolerated. I could not find any contraindications or dosing alterations needed for Citalopram or venlafaxine related to ethnicity.

Week 20 follow-up concluded with ordering venlafaxine levels. This had been considered 20 weeks prior. I agree with ordering this lab and I would have opted to do this before pursuing ECT. A lab is much less invasive, less expensive, and without the side effects he is experiencing at this point.

The patient’s aphasia and mood are improving but his mood is still low. He hadn’t had labs completed. The venlafaxine stayed at 225mg and aripiprazole was increased. Aripiprazole was increased to 15mg. When used to augment treatment with an SSRI or SNRI for depression, the dose would be no greater than 10mg. I disagree with this change.

By week 28 the patient labs show low levels of venlafaxine on a 225mg dose. The dose was increased to 300mg. Up to 600mg/day has been given for heroic cases (Stahl, 2014). I agree with this change. His aripiprazole was discontinued. I agree with discontinuing since the venlafaxine was not at a therapeutic level.

The patient was still not showing improvement by week 32. Another blood level was drawn. At week 36, the level was low on a 300mg dose. The dose was increased to 375mg. The patients BP is good and there have not been any side effects. He has shown some improvement after the dose increase. An increase to 450mg was made and levels ordered. By week 40, the patient was feeling hopeful and mood was improving. His lab values were in the low therapeutic range. At 450mg/day, the patient was still within the dosage for a heroic case. He was tolerating well. The suggestion at this point was to raise dose by 75mg/day, redraw level and raise again to 600mg if still in therapeutic range. I think this is a good strategy based on the patient’s improvement and his ability to tolerate the dose. Lessons learned include the importance of therapeutic drug level monitoring when this is an option. Possible reasons for low levels could be: pharmacokinetic failure, genetic variant causing pharmacokinetic failure, or noncompliance. Finally, never give up.

 

                                                                 References

Bienenfeld, David. (2018). Screening tests for depression. Medscape. Retrieved from https://emedicine.medscape.com/article/1859039-overview

Brown, Charles. (2011). Pharmacotherapy of major depressive disorder. US Pharmacist, 36(11), HS3-HS8. Retrieved from https://www.uspharmacist.com/article/pharmacotherapy-of-major-depressive-disorder

Halverson, Jerry. (2019). Depression. Medscape. Retrieved from https://emedicine.medscape.com/article/286759-overview

Howland, R. H. (2008a). Sequenced treatment alternatives to relieve depression (STAR*D). Part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(19), 21–24. doi:10.3928/02793695-20081001-05. Retrieved from Walden Library databases.

Howland, R. H. (2008a). Sequenced treatment alternatives to relieve depression (STAR*D). Part 1: Study design. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 21–24. doi:10.3928/02793695-20080901-06. Retrieved from Walden Library databases.

Preda, Adrian. (2018). Major depressive disorder: Disabling and dangerous. Medscape. Retrieved from https://reference.medscape.com/slideshow/major-depressive-disorder

Pigott H. E. (2015). The STAR*D Trial: It Is Time to Reexamine the Clinical Beliefs That Guide the Treatment of Major Depression. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 60(1), 9-13.

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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                       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

                                Critical Thinking in the Workplace

While there is no clear definition of critical thinking, it can often be associated with the terms “evaluation”, “analysis”, and “higher-thinking” (Horvath & Forte, 2011, pg. 1). Critical thinking can be described as the process in which one uses logic and reason to determine a solution to a problem. As nurses, we develop critical thinking skills through our practices and expansion of knowledge. To critically think one must assess the problem, determine solutions, and apply them to the current situation. Critical thinking is a sought out skill that improves one’s ability to make reasonable decisions in and out of the workplace.

Critical thinking is an essential part in the delivery of high-quality patient care.  In the Emergency Department (ED) for example, patients are triaged and treated based on their level of acuity.  Let’s say that two patients present to the ED. The first patient is a 58 year old female who presents with chest pain and productive cough that started three days ago. The second patient is a 69 year old male who presents with sudden 10/10 “tearing” pain in his upper abdomen and chest. Based on signs and symptoms the nurse would use critical thinking to prioritize and determine which patient needs immediate treatment. In this circumstance, patient number two would be evaluated first; this is due to the high possibility of aortic dissection.  Prioritization and critical thinking are not only used in the ED but as well as other healthcare settings.  Critical thinking skills are essential in the nursing field because they allow nurses to prioritize and make key decisions that can save lives (Nurse Journal, 2005-2018, para. 1). 

                                 Strategies to Critical Thinking

In recent years there has been emphasis placed on the quality of care provided by nurses. To ensure the delivery of high quality patient care, it is essential that nurses maintain a high level of competence to respond effectively to complex clinical situations (Carvalho et al., 2017, pg. 103-107).   Two strategies that are often used to encourage the development of critical thinking include problem-based learning (PBL) and simulations.

PBL is a student-centered learning method that focuses on applying theory to real life situations. The use of open-ended questions in PBL allows students to think critically and provide feedback. Simulation labs are mock scenarios that allow health care professionals to practice in a controlled environment. Simulation labs are found to be highly effective as they allow students to critique their skills until competent. While there are several strategies used to develop critical thinking, it is essential to determine which strategies works best for each individual to promote adequate learning.

                           Critical Thinking, Nursing Practice, and Scholarship

            Critical thinking is an essential part of one’s nursing practice as it helps to build confidence and competency in the delivery of patient-directed care. With continued education and practical application nurses can develop skills needed to practice at a scholarly level. To continue to advance in one’s nursing practice nurses must evaluate strategies essential for the development of critical thinking skills. 

       

                                                  Resources

Carvalho, D. P., Azevedo, I. C., Cruz, G. K., Mafra, G. A., Rego, A. L, Vitor, A. F., . . .Junior, M. A. (2017). Strategies Used for the Promotion of Critical Thinking in Nursing Undergraduate Education: A Systematic Review. Nurse Education Today, 57, 103-107. Doi10.1016/j.nedt.2017.07.010

Horvath, C. P., & Forte, J.M. (2011). Education in a Competitive and Globalizing World: Critical Thinking: Retrieved December, 31, 2018, from https://ebook.central.proquest.com/lib/waldenu/reader.action?docID=3021945&ppg=155.

Nurse Journal. (2005-2018). The Value of Critical Thinking in Nursing & Examples. Retrieved from https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/ [Accessed 31 Dec. 2018].

 

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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

                                             Main Post

 Case  Study: Volume 2, Case #21 focuses on the treatment of an adult  client  diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).   

 

Questions 

Question 1: Are you having problems with your loved one’s due being “argumentative and temperamental”?  

Rationale:  The client may have additional stress due to broken  relationships and  this could be due to his disorder.  “Emotional  dysregulation is  increasingly recognized as a core feature of ADHD”  (Stralen, 2016).  Signs of ADHD include low frustration tolerance and  explosive behavior  (Stralen, 2016).  

Question 2: 

What causes you the most anxiety?

It  is important to determine the triggers of the anxiety to help the   patient prepare for times when he is likely to be in high stress   situations. Planning a response when feeling overwhelmed can help the   patient remain in control of his emotions and allow the patient to   monitor his behavior. 

Question 3: 

You  stated that your father was abusive, was this physical or verbal  abuse  or both? Do you contribute some of your anxiety from previous  issues  with your father? 

It  is important for the provider to understand the client’s point of  view  in regards to his upbringing. He realizes it has affected in him  in some  way, as he has obtained psychotherapy in the past. I would want  to know  if he has ever spoken to his father about this and if his  father has  ever apologized for his actions. 

Questions for family

I  would want to talk with his mother to ask her how he did as a  child in  school and at home in regards to schoolwork, chores and would  want to  know if he had friends. Although  social problems are not part  of the diagnostic criteria for ADHD, the  peer relationship difficulties  faced by youth with this disorder are  profound (Hoza, 2007)

Diagnostics & Exams

A  full psychiatric evaluation which would include the Adult  Self-Report  Scale (ASRS). ASRS was been developed by the World Health  Organization  to determine if an individual (adult) may have ADHD. The  scale is made  up of 6 questions, and if a client has at least 4 of 6  symptoms, there  may need to be a diagnosis of ADHD made by a  professional (ADDA, 2018). Seay  et al. (2009) suggests the PMHNP should  utilize intelligence test,  broad-spectrum scales, tests of specific  abilities, and brain scans to  confirm the diagnosis and to rule out  other disabilities, autism,  auditory processing disorders or mood  disorders. In addition, a full medical work-up by a PCP in order to rule  out other medical conditions that could present similarly to ADHD. 

Differential DX

General Anxiety Disorder: The  patient exhibits symptoms of  generalized anxiety disorder, DSM-5 300.02  (F14.1). He has had the  symptoms for greater than six months with the  symptoms being severe  enough to interfere with the patient’s daily  functioning. The patient  complains of feels of worry that is difficult  to control, irritability,  restlessness, difficulty concentrating and  feeling on edge. The  patient symptoms have not been linked to a physical  condition or to  substance use (Reynolds & Kamphaus,2013).

ADHD:  client consistently complains of feeling tense, irritable, and  anxious  (Stahl Online, 2019).  Questions arise once the general  anxiety symptoms  are resolved and the client is left feeling  hyperactive, inattentive,  and the inability to focus (Stahl Online).

Post-Traumatic  Stress Disorder: The client’s diagnosis of anxiety  may have been  related to underlying issues related to a traumatic event  that he  experienced as a child. The client’s father was verbally  abusive to him  and was an alcoholic. It is a possibility that the  client’s issues could  have some relations to previous exposure as a  child. Post-Traumatic  Stress Disorder is a serious condition that can  occur in clients who  have experienced various incidents including abuse  (PTSD, 2018).

Medications

The  case states by year six the client has failed to achieve  remission on  an SSRI, a 5-HT1A receptor partial agonist, an  antihistamine anxiolytic  and an SGRI (Stahl Online, 2019).

Based on the pharmacological agents, I would select either  Cymbalta  60mg or Effexor XR 150mg.  Cymbalta did illicit a response,  but side  effects prevented the escalation of the dosage.  Augmenting  with  guanfacine an alpha-adrenergic agonist proved to be the therapy  that  elicited remission for this client.

Lessons Learned

I  learned to always consider additional differential diagnosis and   evaluate and re-evaluate every situation separately to be sure of the   correct diagnosis.  Patient’s  often have comorbid diagnosis and  treating both is vital to a  successful outcome for the patient.  Symptoms of mental illness change  overtime making continued care  necessary for the patient. The provider  must always be approachable and  helpful for the client to feel  comfortable in his/her presence. 

                                                References

Attention Deficit Disorder Association. (2018). Adult ADHD Test. Retrieved from https://add.org/adhd-test/

Generalized Anxiety Disorder. (2018). Anxiety and Depression Association of America. Retrieved from https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

Posttraumatic Stress Disorder. (2018). Anxiety and Depression Association of America. Retrieved from https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd

Seay, B., McCarthy, L. F., and Williams, P. (2009). Your complete ADHD/ADD diagnosis guide.

            Retrieved from https://www.additudemag.com/adhd-testing-diagnosis-guide/

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical

            Applications (4th ed.). New York, NY: Cambridge University Press.

Stralen, J. W. (2016). Emotional dysregulation in children with attention-deficit/hyperactive disorder.

            Attention Deficit Hyperactivity Disorder. 8(4). p. 175-187. Retrieved from

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110580/

Hoza  B, Mrug S, Gerdes AC, Bukowski WM, Kraemer HC, Wigal T, et al.  What  aspects of peer relationships are impaired in children with   attention-deficit/hyperactivity disorder? Journal of Consulting and  Clinical Psychology. 2005b;73:411–423. 

Reynolds, C. & Kampaus, R. (2013). Generalized Anxiety Disorder. Pearson. Retrieved from:

www.images.pearsonclinical.com/images/assets/basc-3/basc3resources/DMS-5_

 

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