Respond  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 as a Psychiatric Nurse Practitioner.

NOTE: Positive comment

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The three questions this writer would as the patient are: 

Did your depressive symptoms worsen after the death of your husband? 

How many hours per night do you sleep on average? 

Do you sleep throughout those hours of sleep or do you wake constantly? 

Do you ingest any stimulants like coffee or chocolate before bed? 

Do you sleep during the daytime? 

The rationale behind question one is to gauge the timeline of the  patient’s depression. She appears to have been suffering with untreated  depression for a long time, however the additional symptoms of insomnia  and tearfulness seemed to worsen after his death. With this information  the nurse practitioner will know if her depression is in an acute state  and the severity of her illness.The patient is reporting sleeplessness;  however the nurse practitioner needs to gauge if the patient is  participating in restful sleep. Sleep of two hours or less may only  consist of REM sleep (Boland et al., 2020). If the patient is not  getting restful sleep, she is not benefiting from the bodily repair that  takes place during sleep (Fitzgerald et al., 2017).  This can place her  at an increased risk for other illnesses and heighten depressive  symptoms (Uchmanowicz et al., 2019).Knowing if the patient sleeps  consistently throughout those hours of sleep will provide information to  the nurse about the kind and amount of sleep the patient is getting.  Ingesting certain stimulants like caffeinated drinks, coffee or  chocolate can affects the client’s sleep by providing wakefulness (Ulke  et al., 2017).  If the patient is sleeping during the daytime, her  circadian rhythm could have been reversed where she will need less sleep  during the night time hours (Fitzgerald et al., 2017).

The people this writer would interview are:

The patient’s aide 

The patient’s son 

The patient aide may be able to provide more information about  observed sleepiness during the daytime. In addition, she will be able to  provide information on the patient’s dietary patterns and physical  activity. The questions to the aide would be:    

Does she easily nod off during the daytime? 

Does she easily become fatigued? 

Does she consume a well-balanced diet? 

Question one would illicit answers about her getting sleep. 

It appears that she in fact getting sleep but because of a revered  circadian rhythm she is not able to get the sleep at the night which is  the desired time.  Question two will help the nurse practitioner gauge  the extent of the effects that non sleep has taken on the patient’s  life. The patient, if constantly fatigued throughout the day has a life  that has been highly impacted by the lack of sleep. The aide would be  able to provide a clear, picture of the patient’s diet. The aide would  be able to reveal if the patient consumes a vast amount of sugar or  caffeine which could interrupt sleep.

Questions to the son would surround the family’s psychiatric history.   These questions will help the nurse practitioner construct the family  history of the patient and rule out or consider familial history as a  cause for her symptoms.

Can you recall any maternal family members with psychiatric disorders including depression and insomnia? 

Did the symptoms start after the death of the client’s husband?  

This would help the nurse practitioner rule out depressive symptoms as the cause of her insomnia.

Physical Examinations and Tests

Sleep Study:

Polysomnogram – The sleep study or polysomnogram  measures the brain waves, blood oxygen, leg movements and breathing  during sleep (Meghdadi et al., 2019). The Nurse Practitioner would be  able to rule out physiological reason’s ad the cause for the patient’s  insomnia.

Actigraphy: This is where a small device is worn on  the wrist and it measures the person’s sleep wake cycle for a specified  period (Meghdadi et al., 2019). This is convenient for this client and  the Nurse Practitioner would be able to monitor the client’s sleep  health and gauge the severity of the disruption of her sleep.The nurse  practitioner could also physically examine the patient’s nares for  septal occlusion.

Septal occlusion or deviation could lead to problems  with sleeping even during sleep, this would be important for the nurse  practitioner to evaluate as this could be interfering with the patient’s  sleep.

Epworth sleepiness scale – assesses the patient’s  tendency to nod off in various situations (Meghdadi et al., 2019).  For  this client it would be necessary for the nurse practitioner to assess  the severity of her nodding off during the day time especially at  unexpected times like during eating and other activities that would put  her safety at risk. 

Differential Diagnosis

G47.00 Unspecified Insomnia Disorder– The patient is  experiencing insomnia at nighttime that could be related to several  factors. She reports staying up late to watch T.V., depressive symptoms,  restless leg syndrome, sleep apnea and sleeping during the daytime.  Some of these factors have not been ruled out yet as the cause of her  anxiety. 

G47.23 Persistent Irregular Sleep Wake type severe 

F32.9 Unspecified Depressive Disorder 

G25.81 Restless legs syndrome 

Medications:

Trazodone 50 mg – This medication would be the first choice as it  offers antidepressant properties as well as promotes sleep in those  diagnoses with insomnia. It is generally safe for the elderly population  at low doses (Pagel et al., 2018). The Nurse Practitioner should  monitor the patient and evaluate the needs to slowly increase or in some  cases decrease the dose. 

Rozerem 8 mg- Is a nonbenzodiazepine hypnotic that promotes sleep.  The patient would benefit from his, but an added benefit would be that  she would be at a diminished risk of falls as this is a concern  following the use of hypnotics in the elderly. This drug is reported as  one that would prevent less falls from over sedation (Pagel et al.,  2018).

Lessons Learned            

This writer has learned that it is important to conduct a complete  evaluation of the patient and not just focus on the presenting symptoms.  There are additional environmental and physiological symptoms that  could be attributed to the patient’s insomnia. In this case the patient  had several factors that could be contributing her insomnia and they  needed to be ruled out. The cause of her insomnia could have been  physiological from the sleep apnea or from her habits of staying up tool  late at nights and sleeping during the daytime. It is also important to  evaluate medications, social and economic factors before the resorting  to pharmacological interventions. 

References

Boland, E. M., Vittengl, J. R., Clark, L. A., Thase, M. E., &  Jarrett, R. B. (2020). Is sleep disturbance linked to short- and  long-term outcomes following treatments for recurrent depression? Journal of Affective Disorders, 262, 323–332. 

FitzGerald, J. M., O’Regan, N., Adamis, D., Timmons, S., Dunne, C. P., Trzepacz, P. T., & 

Meagher, D. J. (2017). Sleep-wake cycle disturbances in elderly acute  general medical inpatients: Longitudinal relationship to delirium and  dementia. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, 7, 61–68. 

Meghdadi, A. H., Popovic, D., Rupp, G., Smith, S., Berka, C., &  Verma, A. (2019). Transcranial Impedance Changes during Sleep: A  Rheoencephalography Study. IEEE Journal of Translational Engineering  in Health and Medicine, Translational Engineering in Health and  Medicine, IEEE Journal of, IEEE J. Transl. Eng. Health Med, 7, 1–7.  

Pagel, T., Seithikurippu R. Pandi-Perumal, & Jaime M. Monti. (2018). Treating insomnia with medications. Sleep Science and Practice, (1), 1. Uchmanowicz I, Markiewicz K, 

Uchmanowicz B, Kołtuniuk A, & Rosińczuk J. (2019). The  relationship between sleep disturbances and quality of life in elderly  patients with hypertension. Clinical Interventions in Aging, 155. 

Ulke, C., Sander, C., Jawinski, P., Mauche, N., Huang, J., Spada, J.,  Hegerl, U. (2017). Sleep disturbances and upregulation of brain arousal  during daytime in depressed versus non-depressed elderly subjects. World Journal of Biological Psychiatry, 18(8), 633–640.    

 Think of a time when you had a different opinion than another person. 

Reflect on personal values evident in encounters/challenges with patients, friends, teachers, and others.

Note what they think and feel about these situations. 

Trace how they developed each value and how their value(s) affected these encounters. 

Identify value differences that may have contributed to conflict or misunderstanding. 

respond 

Healthcare Delivery System Nonprofit 130 Bed Community Hospital

Payer Mix

Percentage

Medicare

 50.2

Medicaid/Managed Care

 10.5

HMO

 0

PPO

 34.4

IPA

 0

Self-pay/ Uninsured

 4.5

Dr. Strong and Class,

I work in a small community hospital in south-central Nebraska. We are in the Midwest farm belt.  The breakdown of our payor source for our organization. I do believe this is an accurate reflection of the community.  The city itself is an aging sleepy community that caters to the Medicare type clientele. There are very few fast food joints, and new and upcoming businesses do not happen in this city.  The town is a large commuter town in which there are many that travel 20-30 mins away to work but “doctor” in their hometown. Many of the Medicaid/managed care people are here due to family support or the decreased cost of living that this community provides. The PPO is primarily the families of those that work in the city and or hospital. 

As a future nurse leader, one of the predications that I foresee with the aging population that the Medicare percentage will continue to grow, at least until Medicare itself is exhausted.  The PPO percentage will decrease due to the aging of the people. Like many farm communities, the “kids” leave the area after graduating from high school. Without local businesses growing and investing in the future of the community as a whole, they will not come back.

One of the recent concerns for our organization that within 20 miles, there is a brand new hospital that will be opening up to the community. They have the potential to entice staff to leave our facility. This adds additional burdens to the system.  Our organization needs to be more competitive pay and staff benefits with neighboring community hospitals. These benefits would entice staff into staying.  Early estimations from the hospital include expected loss if ten percent of the team to this new place.  The employees that will leave initially are the ones that drive past it every day.  That is a lot of people in an already struggling healthcare environment of the 1200 employees that our facility employees that would 120 people.

respond 

Department of Veterans Affairs (VAMC) is a federal government agency organization that provides healthcare services to its service members. The way the VA charges for service is based on service connection and means test to determine financial eligibility for a copay. A veteran is eligible to seek care within the VA organization if he/she enrolls within the VA, and received in the past twenty-four months. With the passage of the Mission Act 2019, VA is partnered with the community to allow veterans more accessible access to care within their community. For whatever the care the individual is seeking in the community, if it is service-connected, the VA will cover the entire bill. If it is not service-connected, the VA will submit a claim to the individual insurance in an attempt to collect the payment. Again, the way the organization obtains its reimbursement is: based on an individual’s disability acquired during federal service (Service-connected) fees would be determined based on the percentage of coverage. If the care is related to service connection, no copayment is required. Inpatient services no additional charges. If the individuals need to have service that is not related to service connection, the VA will file a claim to the insurance in an attempt to collect payment. Primary care services – individual with service connection- no copay. Non-service-connected for primary care $ 15.00 copay and specialty care (eyes, heart, hearing etc.) $50.00 copay and particular test like MRI/CT scan $50.00 copay.

           If the individuals are not able to pay their bills, the treatment will be provided regardless. The VA is required by law to collect all copay dept for VA health care services 30 days to pay the bill in full, dispute the charge, or request a financial hardship for assistance such as a payment plan or debt relief before the 30 days otherwise, late fees and interest will accrue. As of January 1, 2020, some veterans do not have copay due to their disability rating, income level, or special eligibility. 

Urgent Care Copay rates are in group priority based on military service has eight priority group when the individual enrolled in VA Health care. Priority group 1-5 no copay for the first three visits in each calendar year, and additional visits within the same year will be $30. Group 6 if the condition is related, no copay for the 3 visits, and if not related $ 30 each visit. Group 7-8 $30 copay. 

NR533: Touchpoint Reflections Experience Table

Your Name’s Healthcare Organization: VA Medical Center

Healthcare Delivery System (Type)

 Federal government agency

Payer Mix

Percentage

Medicare

% of service connected

Medicaid

 % service connected

Managed Care

n/a

HMO

 n/a

PPO

 n/a

IPA

 n/a

Self-pay

 welcome

Uninsured

 welcome

Reflection:  

In completing this assignment, I have learned a lot about the organization.  I did not know before to answer patients’ questions about their eligibility for care, details about copay, and what was required for their service or not. Recently with the passage of the Mission Act in June of 2019, everyone was required to complete the modules to learn about the process. The modules completed to fulfill administration requests for their deadlines; however, minimum information retained about the outpatient urgent care services.   Base on this data, the assumptions that could be made about the veterans’ population that the VA health care is not really free. What I have noticed that the individuals are on a fixed income, and they are accruing additional copay, which they cannot afford.  I believe if the frontline staff is empowered with the knowledge of how the institutions can assist the veterans with financial difficulties, this will alleviate some of their burdens. I know each veteran assigns to a social worker. Still, at the time the conversation is taking place, the provider can inform the patient to apply for financial hardship or place a consult with the social worker to address the situation. The variables in coverage do not affect the services provided to the individuals. No one will be turned away for not having the means to pay for care. The organization will do anything to give care to the individuals to fulfill President Lincoln’s promise. “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans (VA Mission statement). The other implication I noticed that might happen that VA is funded based on the federal budget; it does not have sufficient funds then, that will affect care.