DISCUSSION 1 

TO.

Disorder: Depression

I chose to complete the scenario on a 70-year-old male presenting with symptoms of depression.  

Background information: 

70-year-old Hispanic male 

Death of mother at a young age 

Occasional back pain & stiff shoulders 

Insomnia 

Poor concentration 

Montgomery Asberg Depression Rating Scale 51 I indicates (severe depression). 

I would not prescribe phenelzine 15mg TID because it’s an MAOI and could interact with common tyramine foods such as processed meats, cheese, & avocado commonly found in the diet of Hispanic people. 

Common barriers to treatment of depression in Hispanics include lack of information about mental health services, fewer linguistically & culturally trained providers representative of the Hispanic community (Camacho et al.,2018). 

SSRIs are the first-line treatment for major depression (McCance & Huether, 2019). 

I chose to treat the patient with an SNRI (Venlafaxine). I believe it would benefit the patient by treating his to major depression & chronic pain. Other benefits of Venlafaxine include it is deemed to have fewer side effects, is safe in older adults, and has fewer drug interactions. 

Venlafaxine (Effexor) can be used to treat major depression & chronic pain (McCance & Huether, 2019). 

I decided to start the patient on Effexor (Venlafaxine) 37.5mg 1 PO QD. 

Pathophysiology of Venlafaxine: Venlafaxine was found to be effective in managing depression by blocking Norepinephrine and serotonin reuptake. It also has weak blocking of dopamine reuptake (McCance & Huether, 2019). 

As a result of this, the patient returns in 4wks with no change in depressive symptoms. I later decided to increase the dose to 75mg PO QD. A second Montgomery Depression screening was completed, the patient scored a 38. 

Next, the Client returns to the clinic in 4wks, 

reports improvement of depressive symptoms.  

Rosenthal & Burchum (2021) explain a clinician has the following options if the first dose is ineffective: increase the dose of the first drug, switch to another drug in the same class, switch to another drug in a different class, or add an atypical antidepressant as a second drug. 

To prevent a relapse, I would continue the therapy for 4 to 9 mos.  I would educate the patient on continuing therapy even if there are no symptoms. I would encourage the patient to attend Behavioral Health counseling and include his family members in his plan of care. Camacho et al. (2018) suggest recruiting a bilingual psychotherapist to help promote a welcoming & safe environment for a patient to express emotions. Frequent monitoring of the patient would be necessary, to observe for s/s of suicidal ideation. 

References: 

Camacho, D., Estrada, E., Lagomasino, I. T., Aranda, M. P., & Green, J. (2018). Descriptions of depression and depression treatment in older Hispanic immigrants in a geriatric collaborative care program. Aging & Mental Health, 22(8), 1056–1062. https://doi-org.ezp.waldenulibrary.org/10.1080/13607863.2017.1332159 

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier. 

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier. 

DISCUSSION 2

L.

The psychological disorder that was presented in my presentation was bipolar I disorder. A female of Korean decent presented with bipolar disorder in a manic state. She had been recently hospitalized and discharged on lithium for mania. Prior to her follow up in the clinic the patient had decided to discontinue the medication on her own which had exacerbated her condition. When presenting to the clinic, she was labile and euphoric. I had made the decision to start her on Risperdal 1 mg orally BID. After this decision point, she returned to the clinic accompanied by her mother and was very sedated and lethargic. The mother had stated that she had been like this for about a week after her left office visit. Though I was happy that she continued to take her medication and it was obviously controlling some of her symptoms, that obviously had been too strong of a dosage. This is most likely because of her CYP2D6*10 allele from her Korean descent, simply her genetics which led her course of treatment following differently. At the second office visit, I had decided to decrease the Risperdal to 1 mg at HS With another follow-up visit in four weeks again. When the client had returned, she was much less sedated, and showing symptoms of improvement. Her young mania rating scale had been priest from 22 for 16, which was a 25% decrease in her presenting symptoms. At this point I had advised the patient to continue the same dose of Risperdal and reassess again in another 4 weeks. I wanted to see how the patient would respond while on this same dose of Risperdal as the CYP2D6*10 allele gives her a slower clearance of Risperdal from her system which is most likely what had resulted in higher than normal levels of sedation. Puangpetch et. al. 2016 states that CYP2D6 is associated with plasma concentrations of risperidone as it is a poor metabolizer and showed more serious adverse events than those without this allele. This is why the patient’s symptoms while on this medication were of that extreme for a relatively low dose especially to start with. Vuppalaanchi also states that the metabolism of risperidone specifically is again by CYP2d6 and is also is responsible for up to 20% of drugs that undergo biotransformation and is a poor metabolizer. 

References

Bipolar Therapy. (2020). http://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/index.html

Puangpetch, A., Vanwong, N., Nuntamool, N., Hongkaew, Y., Chamnanphon, M., & Sukasem, C. (2016). CYP2D6 polymorphisms and their influence on risperidone treatment. Pharmacogenomics and personalized medicine, 9, 131–147. https://doi.org/10.2147/PGPM.S107772

Vuppalanchi, R. (2011). Metabolism of Drugs and Xenobiotics. Retrieved from https://doi.org/10.1016/B978-0-443-06803-4.00004-6

1.

Find a minimum of ten peer-reviewed journal articles in regards to the use of steroids injections for chronic or acute pain written in the last 5 years or less. Use the Appendix G Individual Evidence Summary Tool to synthesize and organize your findings (SEE APPENDIX G FORM ATTACHED BELOW). 

Submit the completed Appendix G table with the attached reference for all articles in APA format.

2.

When appraising the literature complete either Appendix E or F (SEE APPENDIX E and F FORM ATTACHED BELOW). Depending on whether your article is research or non-research. Do this for one of your final articles. 

Reference in APA format for the article 

Reflection on Learning 2

Reflective inquiry allows for expansion in self-awareness, identification of knowledge gaps, and assessment of learning goals. Each week, you will reflect upon what you have learned and complete a reflective journal assignment: Reflection on Learning. Each weekly reflection is placed in one document, which will be submitted for grading at the end of Week 7. There is no weekly reflection in Week 8 because a reflection is incorporated into the discussion question. Create a document where you will keep your weekly reflection.

Access your reflection document. Reflect upon your Week 2 learning journey in NR701 and consider the following in one or two paragraphs.

·  Provide one specific example of how you achieved the weekly objectives.

·  Why is the information important?

·  In what ways will you use this learning? 

Week 2: Readings

American Association of Colleges of Nursing. (2004, October). AACN Position Statement on the Practice Doctorate in Nursing. https://www.aacnnursing.org/Portals/42/News/Position-Statements/DNP.pdf (Links to an external site.)

American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Education-Resources/AACN-Essentials (Links to an external site.)

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care (2nd ed.). Springer Publishing Company.

Chapter 6: Translation of Evidence for Leadership

The Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act of 1987, has dramatically improved the quality of care in the nursing home over the last twenty years by setting forth federal standards of how care should be provided to residents. 

This Act is interpreted with the U.S. Code of Federal Regulations (42 CFR Part 483). Such improvements include less use of antipsychotic drugs, a reduction in chemical and physical restraint use, and a reduction in inappropriate use of indwelling urinary catheters.

Mandates

The quality of care mandates contained within OBRA, and the regulations, require that a nursing home must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. 

In order to participate in Medicare and Medicaid programs, nursing homes must be in compliance with the federal requirements for nursing homes.

The mandates of OBRA are regarded in the nursing home setting to represent minimum accepted standards of care. The failure of a nursing home to comply with the OBRA quality of care mandates in caring for a resident represents a failure to exercise the degree of reasonable care and skill that should be expected.

Penalties

The Indiana State Department of Health is responsible for ensuring that nursing homes follow these mandates through the state survey process. The Department of Health and Human Services (DHHS) and the states may apply penalties against nursing homes for failure to meet the minimum standard of care as defined in the OBRA regulations. 

Such penalties may include fines, appointment of administrative consultants to run the nursing home while deficiencies are remedied, and even closure of a nursing home.

• Residents must be assessed to identify their medical problems and their abilities to perform basic self-care activities. The DHHS established a uniform data set, referred to as the minimum data set (MDS), to document this assessment.
• The nursing home is responsible for the safety of each resident. This includes being responsible for orders written by the resident’s primary physician or other medical provider. If the physician writes an order that does not comply with the federal regulations, the nursing home is responsible for making sure the physician changes such order. The mere presence of a physician’s inappropriately written order does not absolve the nursing home of responsibility in providing safe care.
• Provide services that will enhance each resident’s quality of life to its fullest (42 CFR §483.15).
• Maintain the dignity and respect of each resident (42 CFR §483.15).
• Develop a comprehensive care plan for each resident (42 CFR §483.20).
• Conduct a comprehensive and accurate assessment of each resident’s overall health upon admission and at each required interval (42 CFR §483.20).
• Prevent a decline in activity of daily living (ADL) activities, including the ability to eat, toilet, bathe and walk. Staff must provide for ADL care when necessary (42 CFR §483.25).
• Prevent the development of pressure sores, and if a resident has pressure sores, provide the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing (42 CFR §483.25).
• Provide appropriate care to those who have urinary incontinence and restore bladder function if possible. This also includes only using urinary catheters when appropriate as outlined in the regulations to prevent adverse consequences related to such use (42 CFR §483.25).
• Prevent accidents, including falls, accidental poisonings and other incidents that could cause injuries (42 CFR §483.25).
• Maintain adequate nutrition to prevent unnecessary weight loss (42 CFR §483.25).
• Provide each resident with sufficient fluid intake to prevent dehydration (42 CFR §483.25).
• Ensure that residents are free from significant medication errors (42 CFR §483.25).
• Have sufficient nursing staff (42 CFR §483.30).
• Ensure that each resident’s rights to choose activities, schedules, and health care are maintained (42 CFR §483.40).
• Provide pharmaceutical (medication) services to appropriately meet the physical and psychological needs of each resident (42 CFR §483.60).
• Maintain accurate, complete, and easily accessible clinical records for each resident (42 CFR §483.75).

Mrs. J is repeatedly asking for a nurse; other patients are complaining, and you simply cannot be available to Mrs. J for long periods.  Considering the setting and the OBRA guidelines, what would you do to manage the situation?

1. Analyze the challenges anatomical and physiological changes in the aging individual have on providing safe and effective care
2. Conclude the health outcomes of the health promotion, disease prevention, and early detection and treatment of diseases
3. Organize an interdisciplinary plan of care for the aging client
4. Advocate for the protection of the aging population in the conduct of research