Overview/Description of Final Paper: The final written assignment will synthesize what you have discovered about the different advanced practice roles and scope of practice found in the master of nursing curriculum: APRNs, nurse educator, nurse informaticist, and nurse administrator/executive. You will review all roles and then examine the specialty for which you were admitted, focusing on the scope of practice, core competencies, certification requirements, and legal aspects of practice for that specific role. You will also identify the practice environment and population you will be working with, as well as peers and colleagues. In addition, you will discuss your future leadership role and participation in professional organizations.

Your paper is to be based on current literature, standards of practice, core competencies, and certification bodies for your chosen role. The paper should be 8-10 pages excluding the title and reference pages, and APA format is required.

Criteria:  

• Advanced Practice Roles in Nursing:
  • Briefly define advance nursing practice and the roles in advanced practice nursing pertaining to clinical practice, primary care, education, administration, and health information. Distinguish between ANP and the APN.
  • Describe the advance nursing practice role you aspire and briefly share the experiences and/or qualities you have that have influenced your decision. Include your personal philosophy.
• Selected Advanced Practice Role:
  • Identify the AP you interviewed and summarize the interview, which should/may include (if not in the interview, please address):
  • Examine regulatory and legal requirements for the state in which you plan to practice/work.
  • Describe the professional organizations available for membership based on your selected role.
  • Identify required competencies (domains), including certification requirements for your selected role.
  • Describe the organization and setting, population, and colleagues with whom you plan to work.
• Leadership Attributes of the Advanced Practice Role:
  • Determine your leadership style
  • Define Transformational Leadership and as it relates to your identified leadership attributes that you possess or need to develop
  • Apply the leadership style you will embrace in AP to one of the domains
• Health Policy and the Advanced Practice Role

Based on your program of study, review the literature and address the following:

• FNP/AGNP:Medicare reimbursement for NPs is 85%for the same health care that MDs receive at 100% reimbursement? Please address questions below and state your position on this mandate.
• FNP/AGNP:What states have NP Full Practice Authority and which states have limitations or restrictions? How does this apply to your state? Please address questions below and state your position on this regulation.
• Nurse Executive: What is value based care and how will it impact decisions made at the executive level relative to nursing and AP nursing? Please address and state your position on the regulation.
• Nurse Informaticists:What law(s) was enacted to regulate health information? Please address questions below and state your position on this regulation. 
• Nurse Educator:What agency regulates nursing education?  Explain in detail.

For the above category chosen, address the following:

• Describe the current policy or trends and determine if it needs to change; if opposed to change state why
• Provide the process required to make the change with key players and parties of interest; support opposition
• Explain how you could lead the effort to make or influence the change in policy or keep the policy the same and the impact in healthcare quality.
• Conclusion-Summarize your role paper by highlighting key points made in your paper.

Submission Details:

• Support your responses with examples.
• Cite any sources in APA format.
• Submit your document to the Submissions Area by the due date assigned.

End-of-Life Issues

With our framework of ethical theories and principles in hand, we begin our look at some of the critical ethical issues in our contemporary world, starting with end-of-life issues. This assessment covers ethical questions related to end-of-life care. Passive euthanasia is the removal or refusal of life-sustaining treatment. Examples of passive euthanasia include removal of a feeding tube or a ventilator, or forgoing a life-prolonging surgery. Passive euthanasia is legal in all 50 states, and the principle of autonomy gives informed patients the right to refuse any and all treatments. Patients who are unable to make such decisions in the moment (because they are unconscious, for example) might have made their intentions clear beforehand with an advance directive or similar document. Things become more complicated, however, when a patient who is unable to make treatment choices has not made his or her wishes clear, either formally in a written document, or informally in conversations with family members or friends. Another problem concerns cases in which there is disagreement about whether the treatment is sustaining the life of a person in the full sense or merely as a body that, because of severe and irreversible brain trauma, is no longer truly a living person.

Active euthanasia, or assisted suicide, introduces further difficult moral questions. A patient who has a terminal illness and who has refused treatments that would merely prolong a potentially very painful and debilitating death might want the process of dying to be hastened and made less painful. The patient might want to take his or her own life before the disease reaches its horrible final stages. Should patients be legally allowed to have help in this endeavor? If suicide itself is not morally wrong, at least in cases like these, is it wrong for another person to directly help bring about the patient’s death? Is it wrong for doctors, a role we naturally associate with healing and the promotion of life, to use their medical expertise to deliberately end a patient’s life if the patient wants this?

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Articulate ethical issues in health care. 
  • Articulate the moral issues associated with limiting life support.
• Competency 2: Apply sound ethical thinking related to a health care issue. 
  • Demonstrate sound ethical thinking and relevant ethical principles when considering limiting life support.
  • Explain important considerations that arise when contemplating limiting life support.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals. 
  • Exhibit proficiency in clear and effective academic writing skills.

Preparation

• Case Study: Mr. Martinez. 

This media piece provides the context for this assessment; make sure you have reviewed the case study thoroughly.

Additionally, it may be useful to think through the following issues as they relate to Mr. Martinez’s case:

• Should Mr. Martinez be transferred to intensive care, where his respiratory failure can be treated by a ventilator, and by CPR if necessary, and his oxygen level can be monitored? 
  • What are the key ethical issues or models at play in this case study?
  • What are the key end-of-life issues at play in this case study?
  • How can an understanding of models and best-practice help to guide health care practitioners to make ethical and legal decisions?

Instructions

In a 2–3 page analysis of the case study, address the following:

• The patient’s directives.
• The patient’s quality of life.
• The family’s stated preferences.
• The moral issues associated with limiting life support.
• The ethical principles most relevant to reaching an ethically sound decision.
• Important considerations such as implications, justifications, and any conflicts of interest that might arise because of the patient’s respiratory failure.

When writing your assessment submission assume that doctors cannot contact Mrs. Martinez and must make this choice on their own. To help you reach an objective, ethically sound decision, draw upon concepts and arguments from the suggested resources or your independent research. Support your response with clear, concise, and correct examples, weaving and citing the readings and media throughout your answer.

Clinical Scenario:

REASON FOR CONSULTATION: Desaturation to 64% on room air 1 hour ago with associated shortness of breath.

HISTORY OF PRESENT ILLNESS: Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.

REVIEW OF SYSTEMS:

Constitutional:  Negative for diaphoresis and chills. Positive for fever and fatigue.

HEENT: Negative for hearing loss, ear pain, nose bleeds, tinnitus. Positive for throat pain secondary to her laryngeal cancer.

Eyes:  Negative for blurred vision, double vision, photophobia, discharge or redness.

Respiratory: Positive for cough and shortness of breath. Negative for hemoptysis and wheezing.

Cardiovascular: Negative for chest pain, palpitations, orthopnea, leg swelling or PND.

Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.

Genitourinary: Negative for dysuria, urgency, frequency, hematuria and flank pain.

Musculoskeletal: Negative for myalgias, back pain and falls.

Skin: Negative for itching and rash.

Neurological: Negative for dizziness, tingling, tremors, sensory changes, speech changes.

Endocrine/hematologic/allergies: Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.

Psychiatric: Negative for depression, hallucinations and memory loss.

PAST MEDICAL HISTORY:

1. Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately 3 years ago.
2. Laryngeal cancer
3. Hypertension
4. Hypercholesterolemia
5. Pneumonia
6. Arthritis
7. Hypothyroidism
8. Atrial fibrillation
9. Acute renal failure
10. Chronic kidney disease, stage IV – on 07/30/2013 a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9.
11. Peptic ulcer disease
12. Skin cancer
13. Anemia
14. Osteoporosis

PAST SURGICAL HISTORY:

1. Laparoscopic gastric bypass – 3 years ago
2. Closure of mesenteric defect.
3. Radical neck resection on -3 months ago

FAMILY HISTORY:

1. Mother has diabetes diagnosed at age 55 and high blood pressure. She is deceased.
2. Father had heart disease diagnosed at age 60. He is deceased.
3. She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology.

SOCIAL HISTORY: She denies any smoking or alcohol use. She denies any drug use.

MEDICATIONS:

1. Calcitriol 0.5 mcg PO every other day
2. Vitamin B12 2500 mcg sublingual every Monday and Thursday
3. Docusate sodium 100 mg PO BID
4. Fentanyl patch 100 mcg every 72 hours
5. Gabapentin 800 mg PO BID
6. Levothyroxine 50 mcg daily
7. Multivitamin 1 PO Daily
8. Oxybutynin 5 mg PO BID
9. Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain

ALLERGIES: SHE IS ALLERGIC TO CIPRO, WHICH CAUSES URTICARIA AND HIVES, CONTRAST DYE, HONEY AND BEE VENOM, ADHESIVE, AND SULFAS, WHICH CAUSE HIVES.

PHYSICAL EXAMINATION:

Vital signs: 38.6, 120, 22, 138/38, 64% on room air. O2 sat of 91 on 4 liters nasal cannula.

Constitutional: She is somnolent. Oriented to person and place. Appears ill and mildly dyspneic.

Head: Normocephalic and atraumatic. Nose: Midline, right and left maxillary and frontal sinuses are nontender bilaterally.

Oropharynx: Clear and moist. No uvula swelling or exudate noted.

Eyes:  Conjunctivae, EOM and lids are normal. PERL. Right and left eyes are without drainage or nystagmus. No scleral icterus.

Neck: Normal range of motion and phonation. Neck is supple. No JVD. No tracheal deviation present. No thyromegaly or thyroid nodules. No cervical lymphadenopathy noted bilaterally.

Cardiovascular: rapid rate, S1 and S2 without murmur or gallop. Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally.

Chest: Respirations are regular and even with mild dyspnea.

Lungs are coarse and with some rales posterior bases.

Abdomen:  Soft. Bowel sounds are active, nontender, no masses noted. No hepatosplenomegaly noted. No peritoneal signs.

Musculoskeletal: Full range of motion of the bilateral shoulders, wrists, elbows.

Neurologic: Somnolent. Cranial nerves II-XII are intact.

Skin: Warm and dry.

Psychiatric: Mood and affect are normal. Calm and cooperative. Behavior, judgment is intact.

LABORATORIES AND DIAGNOSTICS:

WBC 7.2, Neutrophil 63%

Creatinine 2.5 mg/dL, BUN 45 mg/dL, Na 144 mEq/L, Potassium 4.4 mEq/L, Total Bilirubin is 0.9 mg/dL, Platelets 100,000

BNP 242 pg/mL

Lactate 1.0 mg/dL

All other labs are unremarkable

Chest x-ray: Right lower lobe infiltrate

EKG: NSR, no ST or T wave changes

Questions:

1. Develop a list of differential diagnoses specific to hypoxia. What are the four most important differential diagnoses to consider? 
2. Based on the available clinical data, what is the most likely diagnosis for the hypoxia? What other acute (new) diagnoses do you need to treat? List them all below. There are a total of 4 diagnoses. 
3. What additional diagnostic tests should be ordered to further evaluate this patient? 
4. Write an assessment and treatment plan for all four acute diagnoses you identified in question 2. Each diagnoses must have a complete treatment plan. All written orders must have complete instructions. For instance, a medication order must have the name, dose, frequency, and route. Lab orders must include the lab name and frequency. If an order should be done now, stat, urgent or routine that also should be indicated. 
5. What is the most appropriate level of care for this patient?
6. What physician specialty or other interprofessional consults should be ordered?
7. What anticipatory guidance/patient education should you provide to the patient?

 

Health Policy Group Project

Work with your assigned group and assigned question. Identify the historical perspective, current issues/ problems (include regulations), and what is currently being done to change or improve.  Students will be graded as a group.

Please demonstrate engagement within group work.

• Review the literature and address one of the following:
  • Nurse Informaticists:Your group has been assigned to determine the impact the role of the NI has on patient outcomes. Select a topic from Ch 24 ( Hamric). What law(s) was enacted to regulate health information? Please address questions below and the position on this regulation in a narrative format. 

For the above assignment,  use the following guide:

• Describe the current policy/status, which organization regulates and determine if it needs to change; if opposed to change, state why.
• Provide the process required to make the change with key players and parties of interest; identify the groups who are opposed
• Explain how AP roles (which ones) could lead the effort to make or influence the change in policy or keep the policy the same and the impact in healthcare quality.
• Demonstrate group cohesiveness

Submission Details:

• Support your responses with examples.
• Cite any sources in APA format.
• Submit your document to the Submissions Area by the due date assigned.