Review the following Prioritization Principles videos:

1. Prioritization

https://www.youtube.com/watch?v=WRElSFt674M (Links to an external site.)

1. Nursing Leadership – ABCDE Principle and Patient Prioritization

https://www.youtube.com/watch?v=hWTKT4Z1ae0 (Links to an external site.)

1. Nursing Leadership – Efficient Nursing Practice & Delegation

https://www.youtube.com/watch?v=iI4HIZpScPQ (Links to an external site.)

Maslow’s Hierarchy of Needs as it relates to Prioritization

Introduction:

• Setting priorities is an essential and critical thinking skill.
• Priority setting is perhaps the most critical skill in good time management, because all actions we take have some type of relative importance.
• Management of a patient load depends heavily on setting priorities.
• Generally, the new nurse tends to focus on one problem at a time rather than seeing the whole picture and may have difficulty in priority setting.
• Through the assessment process, patients help the nurse define their needs, establish interventions, and implement the plan of care. This is where individualized priority-setting between patients and nurses occurs.
• By necessity some care needs will be delayed in preference to more pressing needs of other patients.
• Priorities will be influenced by the acuity of the patient’s condition and the acuity of all patient’s assigned to a nurse

Time Management:

• Three Basic Steps in Time Management
  • Allow time for planning and establish priorities.
  • Complete the highest priority task whenever possible, and finish one task before beginning another.
  • Reprioritize based on the remaining tasks and on new information that may have been received.

Priority ranking of patients:

• First level patient problem
  • These are threats to a patient’s immediate survival or safety and demand immediate nursing intervention. ABC’s (airway, breathing, circulation).
• Second level patient problem
  • Concerns such things as mental status change, acute pain, acute urinary elimination, untreated medical problems requiring immediate attention (diabetic needing insulin) abnormal pathology lab results, risks of infection, safety, or security.
• Third level patient problem
  • Those that do not fit into the above two categories such as monitoring for medication side effects, lack of patient knowledge, longer patient longer-term problems with living activities, etc.
• No life-threatening problems exist
  • The nurse used both professional judgment and the patient to set priorities and determine planning.
  • This is a continually changing aspect of assessment of patients.

Priority Setting Traps:

“Whatever hits first”

• This trap occurs when an individual simply responds to things as they happen rather than thinking first and then acting. This is common to new nurses.
• “Path of least resistance”
  • In this trap the individual makes the assumption that it is easier to do a task by himself or herself and fails to delegate appropriately.
• “Squeaky wheel”
  • In this trap, the individual falls prey to those who are most vocal about their requests and then feels a need to respond to the time frame imposed by the ““squeaky wheel” rather than his or her own.
• “Default”
  • The individual feels obligated to take on tasks that no one else has come forward to do.
• “Inspiration”
  • In this trap, individuals wait until they become “inspired” to accomplish a task. Some tasks will never be inspiring, and the wise time manager recognizes that the only thing that will complete these tasks is hard work and appropriate attention to the matter.

Managing time at work:

• Being overwhelmed by work and time constraints lead to increased errors, omission of important tasks, and general feelings of stress and ineffectiveness.
• Time management skills are learned although some people are better at it than others.
• Disorganization results from poor planning and prioritization.
• Simple suggestions for time management:
  • Gather all the supplies and equipment that will be needed before starting an activity. Breaking down a job mentally into parts before beginning the activity may help the nurse identify what supplies are needed.
  • Group or “cluster” activities that are in the same location. If you have walked a long distance down a hallway, attempt to do several things there before going back to the nurses station. Another example is a home health nurse, group client visits geographically when possible to minimize travel time.
  • Document your nursing interventions as soon as possible after an activity is completed. Waiting until the end of the workday to complete necessary documentation increases the risk of inaccuracies and incomplete documentation.
  • Strive to end the workday on time. Although this is not always possible, delegating appropriately to others and making sure that the workload goal for any given day is reasonable are two strategies that will help accomplish this goal.
  • Schedule difficult tasks during the period of the day you are most productive and simpler, more routine tasks during less productive times.

Time wasters:

• Procrastination
  • The three most common reasons for procrastination are:
    • Not wanting to begin
    • Not knowing where to begin
    • Not knowing where to begin, even if you wanted to do, which you don’t.
    • Poor planning
    • Failure to establish goals and objectives
    • Inability to delegate
    • Inability to say no
    • Management by crisis
    • Haste
    • Indecisiveness

Coping with short short-staffing:

• Prioritize you assignments
• Organize your workload
• Be a team player
  • Make a rule that no one can sit until everyone can sit. Pitch in and help others.
• Use unlicensed personnel wisely
• Encourage family participation
• Inform and involve nursing administration
• Communicate effectively and nicely
• Take care of yourself
• Maintain a positive attitude
  • Attitude is everything. If you go into a is challenging situation with a positive attitude you can achieve great results. A negative attitude can bring down the morale and performance of the entire team.

Scenario:

Assume that you are the Charge Nurse of a team with one LPN and one nursing assistant on the 7A-3P shift at an acute care hospital. The three of you are responsible for providing total care to 10 patients. Prioritize the following list of 10 things you need to accomplish this morning. Use a 1 for the first thing you will do and a 10 for the last.

________

Check MAR against the orders

________

Listen to night shift report from 0700-0720

________

Perform walking rounds to assess the night shift report and to introduce yourself to patients.

________

Hang four (4) 0900 IV medications

________

Set up the schedule for breaks and lunch among your team members

________

Give the 0845 pre-op on patient going to surgery at 0900

________

Pass the 0830 breakfast trays

________

Read the charts on new admissions that you are responsible for on the unit

________

Check 0600 blood glucose results for 0730 insulin administration

________

Consult with the interdisciplinary healthcare team to develop and/or revise patient plans of care

Now, create an initial discussion posting that provides the rationale for how your prioritized your day in relation to Maslow’s Hierarchy of Needs. Your initial posting must be completed by Wednesday, 3/17/2021 by 11:59 pm. On another day, you must respond to two of your classmates by Sunday, March 21/2021 by 11:59 pm.

References: 

Hägg-Martinell, A., Hult, H., Henriksson, P., & Kiessling, A. (2020). Nursing Students Learn to Handle Stress and to Prioritize in a Complex Context During Workplace Learning in Acute Internal Medicine Care – An Ethnographic Study. Advances in medical education and practice, 11, 21–30. https://doi.org/10.2147/AMEP.S230476

Toney-Butler TJ, Thayer JM. Nursing Process. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. [Figure, Maslow’s Hierarchy of Needs for…] Available from: https://www.ncbi.nlm.nih.gov/books/NBK499937/figure/article-26037.image.f1/

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Discuss how elimination complexities can affect the lives of patients and their families. Discuss the nurse’s role in supporting the patient’s psychological and emotional needs. Provide an example. 

Discuss how functional patterns help a nurse understand the current and past state of health for a patient. Using a condition or disease associated with an elimination complexity, provide an example.

1. Economic Theories and Models in Health Care

Complete the “NUR-621 Economic Theories and Models in Health Care” worksheet. This assignment explores the efficiency and components of current health care models.

Your responses should be based on evidence. Include references to your textbook and one scholarly article.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

   

2. Health Care Reimbursement Training Plan

Scenario: You are an administrator at a health care facility providing a training session for new employees.

Create a training plan using the “NUR-621 Health Care Reimbursement Training Plan” template provided that describes how Medicare, Medicaid, and private insurance reimburse health care organizations for their services.

Include two to three references, including your textbook.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

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. Refer to the LopesWrite Technical Support articles for assistance.

Assignment: Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

Impulsivity, compulsivity, and addiction are challenging disorders for patients across the life span. Impulsivity is the inclination to act upon sudden urges or desires without considering potential consequences; patients often describe impulsivity as living in the present moment without regard to the future (MentalHelp.net, n.d.). Thus, these disorders often manifest as negative behaviors, resulting in adverse outcomes for patients. For example, compulsivity represents a behavior that an individual feels driven to perform to relieve anxiety (MentalHelp.net, n.d.). The presence of these behaviors often results in addiction, which represents the process of the transition from impulsive to compulsive behavior.

In your role as the psychiatric nurse practitioner (PNP), you have the opportunity to help patients address underlying causes of the disorders and overcome these behaviors. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with impulsivity, compulsivity, and addiction.

Reference: MentalHelp.net. (n.d.). Impaired decision-making, impulsivity, and compulsivity: Addictions’ effect on the cerebral cortex. https://www.mentalhelp.net/addiction/impulsivity-and-compulsivity-addictions-effect-on-the-cerebral-cortex/

To prepare for this Assignment:

• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring therapy for impulsivity, compulsivity, and addiction.

The Assignment: 5 pages

Examine Case Study: A Puerto Rican Woman With Comorbid Addiction. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

Week 10: Therapy for Patients With Impulsive/Substance Use Disorders (SUD)

Impulsivity and compulsivity have a wide range of clinical presentations and often overlap with many other psychiatric disorders. Some individuals act without forethought and have difficulty saying “no” to certain things, such as using illicit drugs or spending money, whereas other individuals engage in compulsive behaviors with undesirable consequences. In some cases, these impulsive and compulsive behaviors also fuel issues with addiction. To effectively assess and treat patients, you must understand how these disorders differ as well as how their symptoms impact patients and their families.

This week, as you examine therapies for individuals with impulsivity, compulsivity, and addiction, you explore the assessment and treatment of patients with these disorders. You also consider ethical and legal implications of these therapies.

Learning Objectives

Students will:

• Assess patient factors and history to develop personalized therapy plans for patients with impulsivity, compulsivity, and addiction
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for impulsivity, compulsivity, and addiction
• Synthesize knowledge of providing care to patients presenting for impulsivity, compulsivity, and addiction
• Analyze ethical and legal implications related to prescribing therapy for patients with impulsivity, compulsivity, and addiction

Learning Resources

Required Readings (click to expand/reduce)

Kelly, J. E., & Renner, J. A. (2016). Alcohol-Related disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.

Renner, J. A., & Ward, N. (2016). Drug addiction. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 163–182). Elsevier.

Substance Abuse and Mental Health Services Administration. (1999). Treatment of adolescents with substance use disorders: Treatment improvement protocol series, no. 32. http://www.ncbi.nlm.nih.gov/books/NBK64350/
Chapter 1, “Substance Use Among Adolescents”
Chapter 2, “Tailoring Treatment to the Adolescent’s Problem”
Chapter 7, “Youths with Distinctive Treatment Needs”

University of Michigan Health System. (2016). Childhood trauma linked to worse impulse control. Journal of Psychosocial Nursing & Mental Health Services, 54(4), 15.

Grant, J. E., Odlaug, B. L., & Schreiber, L. N. (2014). Pharmacological treatments in pathological gambling. British Journal of Clinical Pharmacology, 77(2), 375–381. https://doi.org/10.1111/j.1365-2125.2012.04457.x

Hulvershorn, L. A., Schroeder, K. M., Wink, L. K., Erickson, C. A., & McDougle, C. J. (2015). Psychopharmacologic treatment of children prenatally exposed to drugs of abuse. Human Psychopharmacology, 30(3), 164–172. https://doi.org/10.1002/hup.2467

Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10–15. https://doi.org/10.3928/00989134-20160314-04

Salmon, J. M., & Forester, B. (2012). Substance abuse and co-occurring psychiatric disorders in older adults: A clinical case and review of the relevant literature. Journal of Dual Diagnosis, 8(1), 74–84. https://doi.org/10.1080/15504263.2012.648439

Sanches, M., Scott-Gurnell, K., Patel, A., Caetano, S. C., Zunta-Soares, G. B., Hatch, J. P., Olvera, R., Swann, A. C., & Soares, J. C. (2014). Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents. Comprehensive Psychiatry, 55(6), 1337–1341. https://doi.org/10.1016/j.comppsych.2014.04.018

Medication Resources (click to expand/reduce)

IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.

• naltrexone (revia/vivitrol)
• naloxone
• acamprosate
• disulfiram

Required Media (click to expand/reduce)

Case Study: A Puerto Rican Woman with Comorbid Addiction 
Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources (click to expand/reduce)

Lupi, M., Martinotti, G., Acciavatti, T., Pettorruso, M., Brunetti, M., Santacroce, R., Cinose, E., Di Iorio, G., Di Nicola, M., & Di Giannantonio, M. (2014). Pharmacological treatments in gambling disorder: A qualitative review. Biomed Research International, 2014. https://doi.org/10.1155/2014/537306

Comorbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past 2 years, she has been having more and more difficulty maintaining her sobriety since the opening of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during its grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past 2 years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much,” but she enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much. She currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she borrowed over $50,000 from her retirement account to pay off her gambling debts, and her husband does not know.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. When you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation and self-reported mood. She denies visual or auditory hallucinations, and no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact; however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Select what you should do:

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeksAntabuse (disulfiram) 250 mg orally dailyCampral (acamprosate) 666 mg orally three times/day

Comorbid Addiction (ETOH and Gambling)
53-year-old Puerto Rican Female

Decision Point One

Vivitrol (naltrexone) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Mrs. Perez says she feels “wonderful” as she has not “touched a drop” of alcohol since receiving the injection
• Client reports that she has not been going to the casino, as frequently, but when she does go she “drops a bundle” (meaning, spends a lot of money gambling)
• Client She is also still smoking, which has her concerned. She is also reporting some problems with anxiety, which also has her concerned

Decision Point Two

Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Mrs. Perez reports that when she first received the Valium, it helped her tremendously. She states “I was like a new person. This is a miracle drug!” However, she reports that she has trouble “waiting” between drug administration times and sometimes takes her Valium early
• She is asking today for an increase the Valium dose or frequency

Decision Point Three

Continue current dose of Vivitrol, increase Valium to 10 mg orally TID/PRN/anxiety. Refer to counseling for her ongoing gambling issue

Guidance to Student
Anxiety is a common side effect of Vivitrol. Mrs. Perez reports that she is doing well with this medication, and like other side effects, the anxiety associated with this medication may be transient. The psychiatric mental health nurse practitioner should never initiate benzodiazepines in a client who already has issues with alcohol, or other substance dependencies. Additionally, benzodiazepines are not to be used long-term. Problems associated with long-term benzodiazepine use include the need to increase the dose in order to achieve the same therapeutic effect. This is what we are seeing in Mrs. Perez’s case.
The most appropriate course of action in this case would be to continue the current dose of Vivitrol, while decreasing the Valium with the goal of discontinuation of the drug within the next two weeks. At that point, you would need to evaluate whether or not the side effect of anxiety associated with Vivitrol persists.
Increasing the dose of Valium would not be appropriate, neither would maintaining her on the current dose of Valium. Additionally, the client should be referred for counseling to help with her gambling addiction, as there are no FDA approved medications gambling disorder.
Medication should never be added treat side effect of another medication, unless that side effect is known to be transient (for instance, benzodiazepines are sometimes prescribed to overcome the initial problem of “activation” associated with initiation of SSRI, or SNRI therapy). However, in a client with multiple addictive disorders, benzodiazepines should never be used (unless they are only being used for a limited duration of therapy such as acute alcohol detoxification to prevent seizures).
Additionally, it should be noted that Mrs. Perez continues to engage in problematic gambling, at considerable personal financial cost. Mrs. Perez needs to be referred to a counselor who specializes in the treatment of gambling disorder, and should also be encouraged to establish herself with a local chapter of gamblers anonymous.
You need to discuss smoking cessation options with Mrs. Perez in order to address the totality of addictions, and to enhance her overall health.