1) Develop formulas or functions that calculate totals for the budgeted and actual encounters for June 2018, May 2018, and 2018 Year-to-Date (YTD) in the appropriate shaded cells of row 12.

2) Develop formulas or functions that calculate the variance between June 2018 budgeted and actual amounts in the appropriate shaded cells in Column D.

3) Develop formulas or functions that calculate totals for personnel expenses and non-personnel expenses in the appropriate shaded cells in rows 17 and 24. 

4) Develop formulas or functions that calculate totals for health center expenses and their variances in the shaded cells in B25 through G25.

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.

Evaluate the Health History and Medical Information for Mr. M., presented below.

Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.

Health History and Medical Information

Health History

Mr. M., a 70-year-old male, has been living at the assisted living facility where you work. He has no know allergies. He is a nonsmoker and does not use alcohol. Limited physical activity related to difficulty ambulating and unsteady gait. Medical history includes hypertension controlled with ACE inhibitors, hypercholesterolemia, status post appendectomy, and tibial fracture status postsurgical repair with no obvious signs of complications. Current medications include Lisinopril 20mg daily, Lipitor 40mg daily, Ambien 10mg PRN, Xanax 0.5 mg PRN, and ibuprofen 400mg PRN.

Case Scenario

Over the past 2 months, Mr. M. seems to be deteriorating quickly. He is having trouble recalling the names of his family members, remembering his room number, and even repeating what he has just read. He is becoming agitated and aggressive quickly. He appears to be afraid and fearful when he gets aggressive. He has been found wandering at night and will frequently become lost, needing help to get back to his room. Mr. M has become dependent with many ADLs, whereas a few months ago he was fully able to dress, bathe, and feed himself. The assisted living facility is concerned with his rapid decline and has decided to order testing.

Objective Data

1. Temperature: 37.1 degrees C
2. BP 123/78 HR 93 RR 22 Pox 99%
3. Denies pain
4. Height: 69.5 inches; Weight 87 kg

Laboratory Results

1. WBC: 19.2 (1,000/uL)
2. Lymphocytes 6700 (cells/uL)
3. CT Head shows no changes since previous scan
4. Urinalysis positive for moderate amount of leukocytes and cloudy
5. Protein: 7.1 g/dL; AST: 32 U/L; ALT 29 U/L

Critical Thinking Essay

In 750-1,000 words, critically evaluate Mr. M.’s situation. Include the following:

1. Describe the clinical manifestations present in Mr. M.
2. Based on the information presented in the case scenario, discuss what primary and secondary medical diagnoses should be considered for Mr. M. Explain why these should be considered and what data is provided for support.
3. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
4. Describe the physical, psychological, and emotional effects Mr. M.’s current health status may have on him. Discuss the impact it can have on his family.
5. Discuss what interventions can be put into place to support Mr. M. and his family.
6. Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.

You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 

Sonia,

Asthma is a frequent health problem in children. It is chronic. There are more than 3 million cases per year in the USA. It can be a minor problem or it can interfere with daily activities. In some cases can be life-threatening. As adults get older the illness can decrease in frequency and severity. We need to instruct our patients that certain foods can trigger asthma symptoms, for example milk, eggs, shellfish, peanuts, soy, and wheat might be responsible. Children with asthma should have a humidifier in their rooms, avoid sleeping with pets, avoid dust, and avoid dust mites, that can get in sheets and pillows. 

We need to tell the parents as well as the child to try to always have inhalers available. The most common are beta agonist, which give quick bronchodilatation, also useful are steroids and leukotrine modifiers.
We as nurse practitioners are in a unique place to give appropriate health care advice, by instructing the patient and their parents or caregivers what to avoid in the environment and the diet, and what things would be beneficial. On of the most common question is what foods to avoid and which ones to use. All exercises are useful but never to over do it. Some individuals can have an attack trigger by vigorous exercise. Also avoid changes in temperatures,because it is well known that bronchospasm occurs in colder temperatures. 

In my personal experience I had a 5 year old that developed attacks of difficulty breathing, which was treated successfully in the emergency room on several occasions, when we got involved with the family, we were able to obtain an extensive history, including the fact that they had recently moved to a new house, which turned out to have lot of mold, when this was addressed then the frequency and severity of the attacks diminished.

Reference:

Stucky, B. D., Sherbourne, C. D., Edelen, M. O., & Eberhart, N. K. (2015). Understanding asthma-specific quality of life: moving beyond asthma symptoms and severity. The European respiratory journal, 46(3), 680-7.

Van Aalderen W. M. (2012). Childhood asthma: diagnosis and treatment. Scientifica, 2012, 674204.

Lisette,

NAME: E.B  AGE: 50 y/o SEX: male 

*SUBJECTIVE INFORMATION*

CHIEF COMPLAINT : ”I have cough and expectoration every morning for month”

HISTORY OF PRESENT ILLNESS:

Pt is a 50 y/o hispanic male with past medical history of infertility for which it was studied years ago and was diagnosed with α1 antitrypsin deficiency, non-smoker who comes with a chief complaint of cough and morning sputum for month. The espectoria is abundant and smells of wet plaster, thick. Also in these last days he has presented fever of 102 F and the cough has become constant and annoying and sputum more green and abundant.

PAST MEDICAL HISTORY: α1 antitrypsin deficiency

IMMUNIZATIONS:

Vaccine updated

ALLERGIES: to Dust, type of reaction: runny noise.

CURRENT MEDICATION: Vitamin C PO 500 mg daily.

FAMILY HISTORY:

Mother: Bronchial Asthma

Father: CVD, PVD

SOCIAL HISTORY:

Denies illicit drugs, or drink alcohol.

MARITAL STATUS: married without child for infertility

REVIEW OF SYSTEMS

• • RESPIRATORY: Productive cough and smelly expectoration with a smell of wet plaster

*OBJECTIVE INFORMATION*

VITALS SIGNS: Blood Pressure: 110/65 Pulse: 60 bpm Respiration: 22rpm Temperature:102 F O2 saturation: 93% at room air.

Weight: 1300 lb.

Pain level: 0/10

RESPIRATORY:  Crackles and wheezing on lung auscultation. No dyspnea noted.

MUSCULOSKELETAL: Clubbing of the digits

• ⎫ Dieses/Condition 

DIAGNOSIS: BRONCHIECTASIS WITH (ACUTE) EXACERBATION

Bronchiectasis refers to an irreversible airway dilation that involves the lung in either a focal or a diffuse manner and that classically has been categorized as cylindrical or tubular (the most common form), varicose, or cystic.

DIFFERENTIAL DIAGNOSTIC:

1- COPD

3- Strep Pneumonia 

4- Tuberculosis

• ⎫ Population affected:

The overall reported prevalence of bronchiectasis in the United States has recently increased, but the epidemiology of bronchiectasis varies greatly with the underlying etiology. For example, patients born with CF often develop significant clinical bronchiectasis in late adolescence or early adulthood, although atypical presentations of CF in adults in their thirties and forties are also possible. In contrast, bronchiectasis resulting from MAC infection classically affects nonsmoking women >50 years of age. In general, the incidence of bronchiectasis increases with age. Bronchiectasis is more common among women than among men.
The most affected population is:

1. 1. People that aspirated foreign body or had a tumor mass
2. 2. People with recurrent infection (bacterial, nontuberculous mycobacterial)
3. 3. People with Immunodeficiency (hypogammaglobulinemia, HIV infection, bronchiolitis obliterans after lung transplantation)
4. 4. People with genetic causes (cystic fibrosis, Kartagener’s syndrome, α1 antitrypsin deficiency) 
5. 5. People that suffer from Autoimmune or rheumatologic causes (rheumatoid arthritis, Sjögren’s syndrome, inflammatory bowel disease); immune mediated disease (allergic bronchopulmonary aspergillosis)
6. 6. Recurrent aspiration of toxics agents
7. 7. People with α1 Antitrypsin Deficiency.

• ⎫ Impact on Quality of Life. 

Manifestations The most common clinical presentation is a persistent productive cough with ongoing production of thick, tenacious sputum.

The aspect that most affects people with bronchiectasis are recurrent respiratory infections that can limit their quality of life due to a compromise of respiratory function.

Outcomes of bronchiectasis can vary widely with the underlying etiology and may also be influenced by the frequency of exacerbations and (in infectious cases) the specific pathogens involved. In one study, the decline of lung function in patients with non-CF bronchiectasis was similar to that in patients with COPD, with the forced expiratory volume in 1 s (FEV1) declining by 50–55 mL per year as opposed to 20–30 mL per year for healthy controls.

• ⎫ Current EBP that will benefit this patient with the specific disease. 

Bronchiectasis doesn’t have reversibility; however, we can compensate it with an adequate therapeutic. After I have carried out a search, such as FNP, the therapeutic alternatives within our reach are the following:

1. 1. clearance techniques: Manual techniques may be offered to enhance sputum clearance when the patient is fatigued or undergoing an exacerbation.
2. 2. Mucoactive: Consider the use of humidification with sterile water or
3. 3. Normal saline solution to facilitate the purification of the respiratory tract. You can also use some mucolytic mucinex.
4. 4. Anti-inflammatory therapies: Do not routinely offer corticosteroids to patients with bronchiectasis without other indications (such as ABPA, chronic asthma, COPD and inflammatory bowel disease) 
5. 5. Antibiotic: Consider long-term antibiotics in patients with bronchiectasis who experience 3 or more exacerbations per year and in the short term in case of exacerbations. The choice of antibiotic depends on the type of patient: 

P. aeruginosa colonised patients  

1. a. Use inhaled colistin for patients with bronchiectasis and chronic Pseudomonas aeruginosa infection. 
2. b. Consider inhaled gentamicin as a second line alternative to colistin for patients with bronchiectasis and chronic P. aeruginosa infection. 
3. c. Consider azithromycin or erythromycin as an alternative (eg, if a patient does not tolerate inhaled antibiotics) to an inhaled antibiotic for patients with bronchiectasis and chronic P. aeruginosa infection. 
4. d. Consider azithromycin or erythromycin as an additive treatment to an inhaled antibiotic for patients with bronchiectasis and chronic P. aeruginosa infection who have a high exacerbation frequency. 

Non- P. aeruginosa colonised patients  

1. a. Use azithromycin or erythromycin for patient with bronchiectasis. 
2. b. Consider inhaled gentamicin as a second line alternative to azithromycin or erythromycin. 
3. c. Consider doxycycline as an alternative in patients intolerant of macrolides or in whom they are ineffective. 
4. 6. Bronchodilators: Use of bronchodilators in patients with bronchiectasis and co-existing COPD or asthma should follow the guideline recommendations for COPD or asthma,
5. 7. Pulmonary rehabilitation: Offer pulmonary rehabilitation to individuals who are functionally limited by shortness of breath (Modified Medical Research Council (MMRC) Dyspnea Scale ≥ 1)

• ⎫ Recommendation for treatment.

In the case of this patient as FNP I indicated: 

1. 1. Tylenol PO 400 mg every 8 hours PRN
2. 2. Azithromycin PO 500 mg daily per 3 days
3. 3. Mucinex 1 tablets every 12 hours.
4. 4. Follow-up with pneumology.
5. 5. Follow-up with physiotherapeutic for specialized respiratory physiotherapy

• ⎫ How as the FNP caring for this patients (teaching)

As FNP I can contribute to the quality of life of the patient by educating him in avoiding the factors that trigger an exacerbation and how to control his illness 

1. 1. Educate on medication compliance.
2. 2. Chest physiotherapy (eg, postural drainage, traditional mechanical percussion in the chest through palms in the chest hand)
3. 3. Drink plenty of liquid
4. 4. Reversal of an underlying immunodeficient state (e.g., by administration of gamma globulin for immunoglobulin-deficient patients) and vaccination of patients with chronic respiratory conditions (e.g., influenza and pneumococcal vaccines) can decrease the risk of recurrent infections. 
5. 5. Patients who smoke should be counseled about smoking cessation.
6. 6. After resolution of an acute infection in patients with recurrences (e.g., ≥3 episodes per year), the use of suppressive antibiotics to minimize the microbial load and reduce the frequency of exacerbations has been proposed, although there is less consensus with regard to this approach in non-CF-associated bronchiectasis than in patients with CF-related bronchiectasis. Possible suppressive treatments include (1) administration of an oral antibiotic (e.g., ciprofloxacin) daily for 1–2 weeks per month; (2) use of a rotating schedule of oral antibiotics (to minimize the risk of development of drug resistance); (3) administration of a macrolide antibiotic (see below) daily or three times per week (with mechanisms of possible benefit related to non-antimicrobial properties, such as anti-inflammatory effects and reduction of gramnegative bacillary biofilms); (4) inhalation of aerosolized antibiotics (e.g., tobramycin inhalation solution) by select patients on a rotating schedule (e.g., 30 days on, 30 days off ), with the goal of decreasing he microbial load without eliciting the side effects of systemic drug administration; and (5) intermittent administration of IV antibiotics (e.g., “clean-outs”) for patients with more severe bronchiectasis and/or resistant pathogens.

References 

1. 1. Haworth C, Banks J, Capstick T, et al. BTS Guidelines for the management of nontuberculous mycobacterial pulmonary disease. Thorax 2017;72:1–64.
2. 2. Seitz AE, Olivier KN, Steiner CA, et al. Trends and burden of bronchiectasis-associated hospitalizations in the United States, 1993-2006. Chest 2010;138:944–9
3. 3. Bibby S, Milne R, Beasley R. Hospital admissions for non-cystic fibrosis bronchiectasis in New Zealand. N Z Med J 2015;128:30–8
4. 4. Quint JK, Millett ER, Joshi M, et al. Changes in the incidence, prevalence and mortality of bronchiectasis in the UK from 2004 to 2013: a population-based cohort study. Eur Respir J 2016;47:186–93
5. 5. van der Bruggen-Bogaarts BA, van der Bruggen HM, van Waes PF, et al. Screening for bronchiectasis. A comparative study between chest radiography and highresolution CT. Chest 1996;109:608–11.

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who were assigned a different patient case study, and provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples.

Main Post

Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

Patients today are much sicker than they used to be. The advanced practice nurse needs to manage all comorbidities in the plan of care. In this post, I will discuss the patient’s health care needs and a recommended treatment plan, including pharmacotherapeutic choices. Also, I will present an education strategy to assist the patient in managing their disease conditions. The patient has a history of hypertension, myocardial infarction, hyperlipidemia angina, and diabetes type two. Her needs center around the management of these comorbidities. Also, I noticed that her serum creatinine is on the high end of the range if not outside of it. This fact is not surprising considering her diabetes. The case reports that she was doing well until about a month ago. It was tempting to consider adding another medication to the regimen. However, I believe that either the metoprolol is not high enough to manage her current disease state or she has been missing doses, and I am leaning toward the latter. If withdrawn suddenly, the drug can increase the incidence and intensity of anginal attacks. Metoprolol is the first-line drug for stable angina and should be working (Rosenthal & Burchum, 2018).  

A review of her current drug therapy appears appropriate. Aspirin, simvastatin, and metformin are competent choices, and the doses are adequate. My plan would include an assessment of how she takes medication at home and manages them before making any changes. If this were in order, I would increase the metoprolol to 75 mg twice a day and set a follow-up appointment in two weeks. I prefer to increase the dose of metoprolol first before adding any new drug because of polypharmacy considerations, and the drug does not require renal adjustment (Epocrates, 2019). This fact is beneficial to consider because she has diabetes. Assuming that the patient has missed doses over the last month, the priority is to determine why. Costa et al. (2015) recommend explaining how to take medication, discussing reluctance to take drugs, and a conversation about the patient’s beliefs and knowledge about their health and treatment. I believe that this is a great strategy to use with the patient. Medication adherence is troubling and particularly so with the elderly who have multiple medications and conditions. I think it is essential for the patient and provider to be partners in the plan of care. The patient must agree to it and fully understand their conditions and the purpose of each medication. 

                                                References

Costa, E., Giardini, A., Savin, M., Menditto, E., Lehane, E., Laosa, O., … Marengoni, A. (2015). Interventional tools to improve          medication adherence: review of literature. Patient Preference And Adherence, 9, 1303–1314. doi:10.2147/PPA.S87551Epocrates. (2019). Metoprolol Tartrate Adult Dosing. Retrieved from https://online.epocrates.com/drugs/25501/metoprolol-        tartrate/Adult-DosingRosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO:        Elsevier.

• Review the Resources and reflect on the mission of state/regional boards of nursing as the protection of the public through the regulation of nursing practice.
• Consider how key regulations may impact nursing practice.
• Review key regulations for nursing practice of your state’s/region’s board of nursing and those of at least one other state/region and select at least two APRN regulations to focus on for this Discussion..

Post a comparison of at least two APRN board of nursing regulations in your state/region with those of at least one other state/region. Describe how they may differ. Be specific and provide examples. Then, explain how the regulations you selected may apply to Advanced Practice Registered Nurses (APRNs) who have legal authority to practice within the full scope of their education and experience. Provide at least one example of how APRNs may adhere to the two regulations you selected.