2023 Discussion Assignment Respond to the following Case study Explain how you might apply knowledge gained from the Response case studies

Nursing 2023 Response # 3

Discussion Assignment Respond to the following Case study Explain how you might apply knowledge gained from the Response case studies 2023 Assignment

 

Discussion Assignment:

Respond to the following Case study:

Explain how you might apply knowledge gained from the Response case studies to your own practice in clinical settings.

· Share additional interview and communication techniques that could be effective with your colleague’s selected patient.

·  

· Suggest additional health-related risks that might be considered.

·  

· Validate an idea with your own experience and additional research.

·  

· Explain your reasoning using at least TWO different references from current evidence-based literature in APA Format.

Case Study Response

  

Case 1: Volume 1, Case #13: The 8-year-old girl who was naughty 

List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions

1.How are you performing in school?

     Rationale:  Children with ADHD portray academic underachievement due to inattentiveness and disruptive as well as disruptive behavior. Their general academic achievement is affected by these behaviors and the results are challenges in reading, spelling and math (Leahy, 2018).

2.How is your relationship with your family members, your teachers and your friends?

Rationale: This question is meant to elicit information regarding this patient’s social skills. Most ADHD children have problematic peer relations as well as emotional dysregulation . Therefore, it is possible that  this patient will report always being in trouble with teachers, as well as not being like by her peers due to her poor social skills ( Sjowall, D., & Thorell, L. B. 2014)

3. Do you find it hard to read and follow instructions, and do you have a hard time understanding and finishing your assignments?

Rationale: Most children with ADHD have trouble following instructions, either because they do not understand the instructions or because they do not want to. Most children are therefore academically challenged ( Parker, 2005)

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

The patient’s parents( Mother, father), the patient’s grandparents if they are close to the child, the child’s siblings, peers, and teachers who interact with the patient.

The questions would include

1.When did you start getting concerned about her symptoms?

Rationale: This question would be asked to parents or grandparents who help take care of  the patient .  Most children generally have inattentiveness and hyperactivity. Most of them cannot adequately follow orders or concentrate on a task for a long time. However, there is that time when a parent gets concerned about these symptoms and decide to seek for professional opinion or diagnosis.

2. Is there somebody in either her father’s or mother’s side of the family that has ADHD?

This question is to the parents and grandparents who know the patient’s background. This question is meant to find out if ADHD runs in the family and if it is genetic.

3. To the mother: Were you smoking or drinking when you were pregnant with the patient?

Rationale:  Alcohol and tobacco use during pregnancy can cause a child to be born with ADHD.

4. Is the patient able to finish her homework on time?

Rationale: This question can be asked to both the parents and the teacher. This is to find out if the patient is able to complete her tasks.

5. Is the patient  able to interact and play normally with friends?

Rationale: This is a question to her teachers and her friends. Most ADHD patients do not have social skills and so they prefer to stay on their own and do not play well with their peers (CDC 2019).

6. Is the patient disruptive in class?

Rationale: This question is to the teacher. Most ADHD  patients have disruptive behavior, they talk too much, are overly active and have trouble controlling impulses.

7.What learning disabilities does the patient have?

Rationale: Most children with ADHD have problems with math, reading and spelling (Wender, 2000).

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

As of date, there is no single laboratory test that is used to diagnose ADHD. Psychiatrists rely on continuous performance tests( CPT) for the diagnosis This is an automated scoring test whose results analysis and interpretation are also automated ( Boutros, Fraenkel,  & Feingold, 2005). 

A neurologic exam such as EEG or MRI  of the brain  would also be necessary to ensure that the patient does not have any brain injury   since one of the causes of ADHD is brain injury. A DSM5 diagnostic exam would be done to find out if the patient has all the symptoms of ADHD ( Leahy, 2018).

Head to toe physical exam would be the first thing to conduct on this patient. Since the patient comes in with fever and sore throat, it is important to first find out why she has fever and sore throat. Throat cultures will be collected to check for the organisms causing t sore throat. Also, blood cultures will need to be sent to find out if the patient has systemic infection. The other test to conduct would be the hearing and vision test. This is to make sure that these problems are not causing  all these issues (CDC2019).

List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.

Attention-Deficit and Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a  Inability to pay attention, control impulses and behaviors as well  as overactivity. Although most children will have some of these characteristics, ADHD is set apart by the  intensity, pattern and persistence of these characteristics (CDC 2019).  

Some symptoms of ADHD include extreme day dreaming,, forgetfulness, loosing or displacing things a lot, over talkativeness, making careless mistakes as well as extreme fidgeting and squirming ( CDC 2019). The causes of ADHD include alcohol and tobacco  consumption by the mother while pregnant, low birth weight, brain injury, premature delivery and exposure to pollutants such as lead ( Parker,2005).

Diagnosis of ADHD is often difficult since the symptoms resemble  characteristic behavior of some normal children and therefore, no one particular  test has been discovered and tried out to successfully diagnose  ADHD. Tests may include physical exams to rule out deficits such as hearing and vision, which could be responsible for some behaviors.

Attention-Deficit and Hyperactivity Disorder and

Oppositional Defiant Disorder  (ODD) co morbidity

Oppositional Defiant Disorder (ODD), is a condition in which a child exhibits extreme anger, irritability, temper tantrums, refuses to follow orders and directions and is easily annoyed, for a period of at least 6 months (Ehmke, 2019). According to  Wender, (2000), between 20-30% of children with ADHD also have learning disabilities, while 35% of those with ADHD have Oppositional Defiant Disorder(ODD).Children with ADHD are likely to have learning disabilities such as problems reading, spelling and math (Wender, 2000).

Developmental Delays

           Children who have developmental or intellectual  delays normally have learning, behavior, physical and language challenges in life. Developmental delay begins at infancy, but proper diagnosis is only possible after 5 years of age when IQ tests can be performed reliably . Children with developmental delays are always lagging behind in achieving age-related  milestones. When a child lags behind in more than one area of development, they are said to have global developmental delays(Stojanovic,2020).

           The cause of developmental delays is not clearly known, but premature birth,  genetic factors, infection during pregnancy are thought to be some of the causes of developmental delay. Developmental delays may also be a sign of other underlying problems such as Down’s Syndrome, autism, cerebral palsy, fetal alcohol spectrum disorders and Angelman’s Syndrome among other neurological and genetic conditions(Chung et al, 2011).

List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

Methylphenidate (D,L) is an FDA approved central nervous system stimulant which is commonly prescribed to both children and adults for the treatment of ADHD. According to CDC (2019), children on fast acting methylphenidate have between 70-80% decrease in ADHD symptoms. Methylphenidate inhibits dopamine reuptake while at the same time it increases norepinephrine and dopamine activity, thus enhancing concentration, attention and wakefulness ( Fairman,  Peckham, & Sclar, 2020).

At this age, the patient can get the transdermal patch with a starting dose of 10mg every 9 hours, with an increase of 5mg weekly to a maximum dose of 30mg every 9 hours (Stahl,2014b). The pharmacokinetics of methylphenidate (D.L.) in children present a delay in minimum peak concentrations and second peak concentrations when compared to adults causing children to have higher concentrations of the drug, due to their smaller body size and the total volume of distribution(Rafael, 2008).

Guanfacine XR is a selective  adrenoreceptor  agonist that  works on alpha 2A agonist  sites on the prefrontal cortex of the brain It is an FDA approved  non-stimulant medication for children and adolescents with ADHD  and Oppositional Defiant Disorder symptoms ( Ngairita, 2007).

Guanfacine increases attention,, improves memory, planning and control, as well as  reduces impulsivity.  Dosage is calculated on mg/kg basis (0.05mg/kg to 0.12mg/kg) to be taken once daily. It may take days for  full benefits of Guanfacine to be realized ( Stahl,2014b).  Guanfacine  should be swallowed whole with a small amount of water or milk and high fat foods should be avoided as they cause an increase in the blood levels of guanfacine  (Guanfacine extended release (XR). (2013 ).

If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.

This case shows several weeks of ADHD treatment with little success. Although the diagnosis of ADHD  was properly diagnosed and was being treated as a solo case, the Physicians did not diagnose ODD as an accompanying diagnosis for this patient. The patient experiences increased attention while on Lisdexamfetamine and dextroamphitamine, but has no improvement on Symptoms related to ODD. To top it all, the patient has insomnia, which could be as a result of  D-methylphenidate XR stimulant in the initial stages.

Multi drug therapy  approaches should have been initiated  to help decrease ODD symptoms (Vitiello et al., 2015).  A combination therapy of guanfacine XR and lisdexamfetamine  should have been utilized as they have been  proven to be effective  for these two conditions. (Diane Christopher, 2010).

Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

           From this case, I have learnt that an effective diagnosis leads to effective and timely treatment. In this case, there was delay in achievement of full therapeutic effects of treatment because the diagnosis was not completed on time.  I have also learnt that at times, it is necessary to try a multi-drug therapy instead of using just one drug for  the treatment of some conditions. In this case, the original belief was that Guanfacine XR alone would be sufficient in the treatment of the patient because unlike methylphenidate its efficacy in the treatment both ADHD and ODD is known.  However, after reviewing the outcome, it was decided that this patient required Multidrug therapy in order to achieve full therapeutic benefits.  From this case, it is clear that PMHNP should keep their knowledge on mental health up to date in order to be effective in diagnosing and treating mental health disorders.

            It is also clear from this case that in order for diagnosis and therapy to be effective, there should be cooperation from family members, teachers and peers. Sometimes parents tend to cover up for their children and excuse their behavior, leading to delayed diagnosis and start of therapy.

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2023 1 Select the state Florida where you plan to practice as a nurse practitioner and investigate the state s

Nursing 2023 Health Care Policy Discussion Board.

1 Select the state Florida where you plan to practice as a nurse practitioner and investigate the state s 2023 Assignment

1-Select the state (Florida) where you plan to practice as a nurse practitioner and investigate the state’s policies on access to contraception and abortion for women with insurance and those without. 

2-What are the state’s infant and maternal mortality rates? Discuss the possible relationship between these factors. 

State: Florida. 

APA style. 250 words. 3 References (less than5-7years).

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2023 Need help to reply three post DO NOT JUST REPEAT SAME INFORMATION DO NOT JUST SAY I

Nursing 2023 reply w4

Need help to reply three post DO NOT JUST REPEAT SAME INFORMATION DO NOT JUST SAY I 2023 Assignment

  

Need help to reply three post.

DO NOT JUST REPEAT SAME INFORMATION, DO NOT JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED TO ADD NEW INFORMATION TO DISCUSSION.

1- Each reply should be at least 200 words.

2- One scholarly reference ( NO MAYO CLINIC/ AHA)

3- APA style needs to be followed.

4- Each response should have reference at the end

5- Reference should be within last 5 years

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2023 Please read the instructions references citation Learning styles represent the different approaches to learning based on preferences weaknesses and

Nursing 2023 Analysis paper

Please read the instructions references citation Learning styles represent the different approaches to learning based on preferences weaknesses and 2023 Assignment

Please read the instructions.     (references, citation)

Learning styles represent the different approaches to learning based on preferences, weaknesses, and strengths. For learners to best achieve the desired educational outcome, learning styles must be considered when creating a plan. Complete “The VARK Questionnaire,” located on the VARK website, and then complete the following:

  1. Click “OK” to receive your questionnaire scores.
  2. Once you have determined your preferred learning style, review the corresponding link to view your learning preference.
  3. Review the other learning styles: visual, aural, read/write, kinesthetic, and multimodal (listed on the VARK Questionnaire Results page).
  4. Compare your current preferred learning strategies to the identified strategies for your preferred learning style.
  5. Examine how awareness of learning styles has influenced your perceptions of teaching and learning.

In a paper (750‐1,000 words), summarize your analysis of this exercise and discuss the overall value of learning styles. Include the following:

  1. Provide a summary of your learning style according the VARK questionnaire.
  2. Describe your preferred learning strategies. Compare your current preferred learning strategies to the identified strategies for your preferred learning style.
  3. Describe how individual learning styles affect the degree to which a learner can understand or perform educational activities. Discuss the importance of an educator identifying individual learning styles and preferences when working with learners.
  4. Discuss why understanding the learning styles of individuals participating in health promotion is important to achieving the desired outcome. How do learning styles ultimately affect the possibility for a behavioral change? How would different learning styles be accommodated in health promotion?

Cite to at least three peer‐reviewed or scholarly sources to complete this assignment. Sources should be published within the last 5 years and appropriate for the assignment criteria.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

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

You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.

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2023 Moral resilience has been defined as the capacity of an individual to sustain or restore their integrity in response to

Nursing 2023 Combating Moral Distress

Moral resilience has been defined as the capacity of an individual to sustain or restore their integrity in response to 2023 Assignment

Moral resilience has been defined as “the capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress, or setbacks” (Rushton, 2016a, p. 112a). Moral resilience is an evolving concept and other definitions have focused on “the ability and willingness to speak and take right and good action in the face of an adversity that is moral/ethical in nature” (Lachman, 2016, p. 122).

I would like to believe that nurses have innate and learned capacities that can be used to combat the negative of forces of moral distress, burnout, compassion fatigue, and incivility that plagues our nursing profession.

As a result of this one course in Ethics, you have been given some tools to develop critical thinking skills, use ethical decision making models to strengthen and clarify your values. I believe all of you will need to be on an intentional journey to use and leverage these skills to keep your nursing practice resilient and meaningful.

How do you see yourself cultivating moral resilience within yourself,  with your colleagues and the organizations where you will work?  What specific interventions can you envision for yourself as you continue your journey in the socialization of becoming a nurse?  What contributions do you intend to create to make meaningful and sustainable change in your role as a nurse?

                                                             

Do not use the Lachman and Rushton articles since they have already been referenced in the assignment stem, and Write this using academic considerations:

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2023 Assignment must be typed and a minimum of 10 pages 5 evidence based references

Nursing 2023 10 page Essay on schizophrenia

Assignment must be typed and a minimum of 10 pages 5 evidence based references 2023 Assignment

Assignment must be typed and a minimum of 10 pages, 5 evidence-based references are required and cited accordingly. The prevailing hypothesis for schizophrenia implicates the neurotransmitter dopamine as playing a key role in the development of the disease. Dopamine acts on several areas of the brain with differing effects. Please outline the key dopamine pathways and the implications of antipsychotic use on each pathway.

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We give our students 100% satisfaction with their assignments, which is one of the most important reasons students prefer us to other helpers. Our professional group and planners have more than ten years of rich experience. The only reason is that we have successfully helped more than 100000 students with their assignments on our inception days. Our expert group has more than 2200 professionals in different topics, and that is not all; we get more than 300 jobs every day more than 90% of the assignment get the conversion for payment.

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2023 200 words each 1 My plan to develop my professional partnership with

Nursing 2023 Responding

200 words each 1 My plan to develop my professional partnership with 2023 Assignment

200 words each

1)

 

My plan to develop my professional partnership with my selected site is the first understand the mission statement of the what the company is about and what the company believes in.  I will do some reading and researching, locate reviews on the business and its’ relationship with the community.  Make a phone call and ask if I could speak with the owner or manager of operations of the business.  During my initial contact, I will make sure that I inform the manager about my plans and goals for the presentation that I want to present before their staff.  I will ask the manager if there was a time available that we could meet in person, at their convenience.  If I am given the opportunity for a face to face, I will have my presentation layout and allow them to look at it.  In return, I will answer questions that the manager has for me.  Doing this time, I will utilize my chance to ask them their opinion about what I want to present.  This will allow me to get them to be open about their knowledge on the discussion topic of choice.  Ask them if they would like to see something added to the presentation, that will help their staff be healthier and more conscious about their lifestyle.  Schedule my date of presentation, if the manager approves of me doing the presentation.  Upon setting a schedule presentation date, I would send a thank you message via email and then weekly reminders about the benefits of the presentation to the manager.  Checking in with the manager on a weekly basis, to keep the manager and staff looking forward to the presentation that is going to improve their health.  I would make sure to meet with the manager once more prior to the date of presentation, at least two weeks in advance; to give an update or receive information from the manager about the presentation.  I would focus on not taking up too much of the managers’ time with small talk.   

It is important that we as healthcare providers collaborate with other professionals in the healthcare field to ensure that our patients are treated holistically.  When we experience health issues, many other problems can arise from that health issue.  People that have uncontrolled pain, can become depressed or angry; because the pain is interfering with their lives.  We must know who to refer patients to for help with their concerns.  The more options we utilize to assist our patients, the better the development of trust we can have with our patients.  We want our patients to trust us and come to us for help, because they are sure they will receive help or be guided in the proper directions to get help.    

Clark, M. J. (2015). Population and community health nursing (6th ed.). Boston, MA: Pearson

 

2)

 

 I have selected my church medical group to partner with to help educate the people in the church about sickle cell disease that predominantly affects the African-American people. The church medical group is made up of a group of medical professionals that volunteer their time and expertise in helping build strong and healthy church members. Education about sickle cell disease is very important especially in the African-American community because having knowledge about sickle cell disease and how it is genetically passed on will help the young people take that into consideration when planning on choosing a life partner to have a family with. This will help reduce the number of babies born with sickle cell disease.

            Partnering with a church outreach group is very important in helping my role as a disease prevention nurse. The church is a big community with a lot of young adults. Since most of the church members are African-American, we seem to have a lot in common in terms of our diet, attitudes towards exercise or physical activities and also common diseases that affect us.  The medical professionals collaborating with each other in the group will help identify the educational materials and methods of how information is to be presented to the community and also find out the available resources to help provide other assistance to the population in terms of getting lab test or referring them to other places for further treatment if needed. 

            The importance of collaborating with other healthcare professionals in order to establish trusting relationships to gain commitment is that, it helps build a stronger network of medical professionals, who are focused on attaining a common goal for the community. The education they have in different medical setting, their positive attitudes and their willingness to work together to help promote good health and prevent an increase in diseases among the targeted population.

            A team environment could provide support for these community-based health care providers as well as allow for more efficient sharing of information Dieleman et al. (2009). Effective communication among healthcare workers helps build a strong team.  A good team work is mostly characterized by trust, respect and collaboration. Whether it is a professional or a non-professional setting, members are in the team mostly for a common goal, and all the members work together with the aim of achieving that goal. This is what makes it very important for the members to effectively communicate among each other to help promote continuity and clarity among the team and also help prevent problems or errors.

Dieleman, S. L., Farris, K. B., Feeny, D., Johnson, J. A., Tsuyuki, R. T. & Brilliant, S. (2009).      Primary health care teams: tem members’ perception of the collaborative process.           Journal of Interprofessional Care. 18(1), 75-78.

            https://doi.org/10.1080/13561820410001639370Di

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2023 Instructions Before beginning work on this assignment please review the expanded grading rubric

Nursing 2023 Healthcare Marketing and Strategy

Instructions Before beginning work on this assignment please review the expanded grading rubric 2023 Assignment

 

Instructions

Before beginning work on this assignment, please review the expanded grading rubric for specific instructions relating to content and formatting.

You are the director of marketing for a regional hospital. The board of directors at your hospital has studied the 2011 Institute of Medicine (IOM) report Early Childhood Obesity Prevention Policies. The alarming statistics quoted in the IOM report stated that “almost 10 percent of infants and toddlers carry excess weight for their length, and slightly more than 20 percent of children between the ages of two and five already are overweight or obese” (IOM, 2011, pg. 1). A survey conducted among the pediatricians who admit patients to the hospital validated that area children under the age of 5 years follow or exceed the national trend of being overweight or obese. The board is very concerned about childhood obesity rates for the children in the hospital’s marketing area. At the last meeting, the board directed the marketing department determine the demand for childhood obesity programs and to review the IOM report and propose a marketing campaign to provide information to parents and guardians concerning ways to prevent children from birth to 5 years of age from becoming overweight. Click here to access the IOM report.

  • Do you think the hospital needs to complete more marketing research before embarking on the campaign?
  • What advertising media would you suggest to be used during the campaign?
  • What products or services could the hospital offer to assist in reducing the number of infants and toddlers who are overweight?
  • Do you expect to generate any revenue for the hospital from the campaign?
  • How long will the campaign last? How long would you continue to measure the effectiveness of the campaign?

To support your work, use your course and textbook readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Submission Details:

  • Your assignment should be addressed in a 2- to 3-page document.

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2023 Instructions Write your evaluation in the Word document provided Critique 1 answer sheet You

Nursing 2023 Critique

Instructions Write your evaluation in the Word document provided Critique 1 answer sheet You 2023 Assignment

Instructions:

  1. Write your evaluation in the Word document provided (Critique 1 answer sheet).  You can insert the cursor after each question, and type in your answers.  Use full sentences, with paragraph breaks, to describe each point.  Double space all writing; number pages.
  2. Provide rationales for your decisions (citing sources). For example, if you write that the theory framework is strong, describe how it is strong with at least one citation (Author, year) to a theory book, research book, or article.
  3. List all sources at the end of the answer sheet, following APA format for a reference list.  Remember to cite the article you are evaluating at least once in the text, and put it in the reference list as well.
  4. Remember to type your NAME at the top of the answer sheet to get credit for it!

Critique #1 Content:

Authors, Title, and Abstract

  1. Discuss author(s) qualifications to conduct the study, including educational preparation and clinical experience of author[s].
  2. Discuss the clarity of the article title (type of study, variables, and population stated).
  3. Discuss the quality of the abstract (purpose, design, sample, intervention, and key results presented). (10 pts)

Literature Review/Background

  1. Briefly describe the clinical problem that prompted the study.  This is not the research question, but the clinical issue that needed investigation.
  2. Discuss the data provided for the significance of the clinical problem, and whether or not you believe it is an important problem for nursing science.
  3. Identify the major topics discussed in the background section and evaluate whether there were any missing ideas or topics.
  4. Briefly explain whether the background section included sources current at the time of the study (ie. within 5 years of publication).
  5. Discuss whether the studies were critically evaluated and synthesized to provide a clear summary of the current knowledge about the problem of interest.
  6. Evaluate whether or not the background section provided support for the current research study. In other words, whether a gap(s) in research knowledge was/were clearly described.  (20 pts)

Research Problem, Purpose, Research Questions/Hypotheses

  1. State the study purpose and evaluate whether or not the purpose clearly addresses the gap in nursing knowledge identified in the background section.
  2. If there are research questions and/or hypotheses, list them, and discuss whether they logically follow from the research problem and purpose. If questions/hypotheses were only implied, rather than explicitly stated, describe that. (10 pts)

Theoretical Framework

  1. Describe the theory/framework that supported the study, and list the important concepts in the theory framework. 
  2. Evaluate the clarity of the presentation of the framework. If it was vague or had missing elements, describe those.
  3. Discuss how well the theory’s concepts were linked to the study variables.  (10 pts)

Writing Style & Format

  1. Grammar: full sentences, precision, clarity, spelling, and punctuation.
  2. Use APA format throughout this paper, specifically citations and a reference list. (10 pts)

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2023 Respond to at least two of your colleagues who were assigned to a different case than you Explain how

Nursing 2023 Post-Starr

Respond to at least two of your colleagues who were assigned to a different case than you Explain how 2023 Assignment

 

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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