reply candace

Rheumatoid arthritis (RA) is an autoimmune disease in which the body’s own immune system attacks the joints on both sides of the body including the hands, wrist and knees. Early stages of RA include:

• Joint pain, tenderness, swelling or stiffness for 6 weeks or longer
• Morning stiffness for 30 minutes or longer
• More than one joint is affected
• Small joints ( wrists, certain joints of the hands and feet) are affected
• The same joints on both side of the body are affected

The history would include complaints of the above systems along with deformities of the affected areas depending on the severity. Rheumatoid nodules are commonly observed over the olecranon process or other extensor surfaces of the limbs and may be tender (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The patient may present with a low grade fever. A thorough history of other systems is elicited because of the involvement of other extra-articular organ systems. Physical exam would include inspection and palpation of the joints on both sides of the body. Passive and active range of motion may be limited due to the swelling and tenderness to the affected area. The initial diagnostic test is the presence of Rheumatoid factor (RF) in the blood. This test alone is not diagnostic and specific test such as circulating anti-CCP autoantibodies. Other test include a ESR, CRP, CBC, platelet count and joint fluid analysis. Studies for a more progressive diagnosis include ANA and comprehensive autoantibody panel. Management of RA progresses from conservative interventions to aggressive symptom management. Initial management would include heat/cold applications, exercise, rest, OT/PT, assistive devices, splints, and weight loss. Subsequent management for a more progressive version of the disease include drug therapies such as NSAIDs, analgesics, corticosteroids and DMARDs.Patient education focuses on medication therapy and control of pain and inflammation. Both primary and secondary medication nonadherence may be affected by low levels of health literacy and patient education (Joplin, Zwan, Joshua, & Wong, 2015). Emotional, spiritual and social education is advised due to disability and pain.

References

Joplin, S., Zwan, R., Joshua, F., & Wong, P. (2015). Medication adherence in patients with rheumatoid

arthritis: the effect of patient education, health literacy, and musculoskeletal ultrasound. BioMed

Research International, 2015, 10. 

Dunphy, L., Brown, J., Porter, B., & Thomas, D. (2015). Primary Care: The Art and Science of

Advanced Practice Nursing. Philadelphia: F.A. Davis Company.

 reply vivian

Rheumatoid arthritis is a condition that is chronic and consists of inflammation to different joints. RA in the hands is very common. This condition is related to an autoimmune response where the patient’s immune system ends up attacking its own body tissues. This condition can be very painful and requires certain testing for diagnoses and treatment (Mayo Clinic, 2018).  

       I would get a health history on this patient to determine if she has RA and what she has done for treatment of it. If this patient has a “flare up” then this patient most likely is educated and familiar with her condition. Risk factors for this condition include being female, age 40-60, having a family history of RA, smoking or other environment exposures like asbestos, and being obese (Mayo Clinic, 2018).  

       Some testing for this patient would include a blood test looking for elevated erythrocyte sedimentation rate or C-reactive protein. Imaging could be helpful to see how this condition is progressing for the patient. Medication to help include NSAIDs, steroids, antirheumatic drugs, and biological agents. The goal is to decrease inflammation and slow the progression of the disease. Physical therapy is also an option to help the patient maintain joint flexibility (Mayo Clinic, 2018).  

       For patient education, it could be helpful to make sure the patient has signs to be aware of a flare up starting. It can be easier to prevent flare ups than treat them. Some signs of a flare up include an increased stiffness to the joints, entire body pain, swelling that may cause shoes not to fit, a change in fatigue that is intense, and even flu-like symptoms. Some foods or medications could be the cause of a flare up and this is something for the patient to be aware of (Healthline, 2019).  

Reference 

Healthline. (2019). Signs of rheumatoid arthritis exacerbations and how to prevent them. Retrieved from https://www.healthline.com/health/rheumatoid-arthritis-exacerbations 

 Mayo Clinic. (2018). Rheumatoid arthritis. Retrieved from https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648 (Links to an external site.)Links to an external site. 

 

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

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

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

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

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

Peer Responses/Participation [Due Sunday]   

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

 

 

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Critical Appraisal   

           As advanced practice nurses, it is vital to critically appraise research studies.  Barr-Walker (2017) discusses that critical appraisal is the practice of systematically analyzing research to evaluate its trustworthiness, value, and pertinence in a specific situation (p. 71).  When critically appraising quantitative studies, it is imperative to assess three factors.  

Quantitative Studies 

Validity, reliability, and applicability are three essential components of quantitative studies that must be assessed.  Melnyk and Fineout-Overholt (2015) discuss that the validity of a study addresses whether the results of the specific study were acquired from valid scientific resources (p. 93).  If confounding variables are identified in the study, one can conclude that the findings are in jeopardy.  Melnyk and Fineout-Overholt (2015) explain that quantitative studies utilize statistics to release their conclusions (p. 96).  As a provider, one must evaluate the statistics in order to gain an understanding of the reliability of the reviewed study.  Melnyk and Fineout-Overholt (2015) point out that the primary considerations are the breadth of the intervention’s effect and how accurately that effect was predicted.  Combined, these decide the reliability of the study findings (p. 97).  In order to properly assess for accountability, providers must exhaustingly evaluate if the quantitative study is directly applicable to the specific patient population.  Melynyk and Fineout-Overholt (2015) discuss that each study addresses explicit questions that, when addressed, help providers in critically appraising the study in order to determine its worth in the practice setting (p. 107).  

Although each of these three factors are vital components to assess, applicability is the most important.  If the quantitative study results cannot be directly applied to the specific patient population, the results can simply not be utilized.  Melynk and Fineout-Overholt (2015) emphasize that analysis of quantitative study results requires the provider to consider the clinical significance of the findings (p. 93).  Consequently, if the quantitative study findings are not directly applicable to one’s specific practice setting, the study results lack pertinence.  

Conclusion 

LoBiondo-Wood and Haber (2014) explain that it is essential to initially examine the level of evidence that is supported by the design and how the promising strength and quality of the findings can be utilized to improve or alter practice (p. 177).   As advanced practice nurses, it is key to consistently critically appraise studies in order to boost patient outcomes.  Furthermore, consistent appraisal of quantitative studies will assist in expanding one’s clinical knowledge base.  

References 

Barr-Walker, J. (2017). Evidence-based information needs of public health workers: A 

              systematized review. Journal of the Medical Library Association, 105(1), 69-79. 

LoBiondo-Wood, G., & Haber, J. (2014). Nursing research: Methods and critical appraisal for 

evidence-based practice (8th ed.). St. Louis, MO: Mosby Elsevier.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: 

A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health.  

 

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Measuring expected change outcomes is crucial in research to ascertain effectiveness of planned change into real-world clinical practice.  Outcome evaluation is important at all levels including patient, clinician, and organization level.  Outcomes need to be measured throughout the process including at the beginning, short-term, and long-term (Melnyk & Fineout-Overholt, 2015).  Cultivating change mentors and champions can help improve outcomes and provide ongoing training with clinicians including “circulate information, encourage peers to adopt the innovation, arrange demonstrations, and orient staff to the innovation” (LoBiondo-Wood & Haber, 2014, p. 434). 

Expected Change Outcomes

The expected outcome from this change will be a decrease in surgical site infections (SSI) with postoperative patients.  Many factors come into play when measuring outcomes which include measurement tools, validity of instruments and tools to measure outcomes, as well as accurate self-reporting in regard to clinician compliance (Melnyk & Fineout-Overholt, 2015).  Outcomes can be measured by tracking statistics on postoperative patients regarding type of preoperative bathing solution used prior to surgery, the incidence of postoperative SSI, clinician compliance with intervention at point-of-care, 30-day hospital readmission data as well as patient satisfaction surveys (HCAHPS) over a 6-month period.  The results will determine if the change will be translated into practice.  

Implementation Process Outcomes

       Utilizing EBP leaders (mentors) can help with all aspects of the change process.  Mentors give guidance, encouragement, help foster self-confidence in clinicians as well as reinforce values to the team.  The ARCC change model stresses the importance of utilizing change mentors and champions to improve quality of care as well as patient outcomes.  Assigning a change leader and unit champions will help to provide support such as ongoing organizational assessment, conduct EBP workshops and provide ongoing education, encouragement with clinicians and staff focused on a culture of EPB, institute EBP implementation strategies (EBP rounds, newsletters, journal clubs, etc.), assess for and focus on overcoming barriers, facilitate involvement of staff and point-of-care clinician compliance, and implement a culture of multidisciplinary collaboration to promote and sustain EBP (Melnyk & Fineout-Overholt, 2015, p. 378).

References

LoBiondo-Wood, G., & Haber, J. (2014). Nursing research:  Methods and critical appraisal for evidence-based practice (8th ed.). St. Louis, MO: Mosby Elsevier.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare:  A guide to best practice (3rd ed.). Retrieved from Amazon Kindle App

 

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