Discussion: Pharmacotherapy for Cardiovascular Disorders

As the leading cause of death in the United States for both men and women, cardiovascular disorders account for 7 million hospitalizations per year (NCSL, 2012). This is the result of the extensive treatment and care that is often required for patients with these disorders. While the incidences of hospitalizations and death are still high, the mortality rate of cardiovascular disorders has been declining since the 1960s (CDC, 2011). Improved treatment options have contributed to this decline, as well as more knowledge on patient risk factors. As an advanced practice nurse, it is your responsibility to recommend appropriate treatment options for patients with cardiovascular disorders. To ensure the safety and effectiveness of drug therapy, advanced practice nurses must consider aspects that might influence pharmacokinetic and pharmacodynamic processes such as medical history, other drugs currently prescribed, and individual patient factors.

Consider the following case studies:

Case Study 1:

Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following:

· Atenolol 12.5 mg daily

· Doxazosin 8 mg daily

· Hydralazine 10 mg qid

· Sertraline 25 mg daily

· Simvastatin 80 mg daily

Case Study 2:

Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following:

· Warfarin 5 mg daily MWF and 2.5 mg daily T, TH, Sat, Sun

· Aspirin 81 mg daily

· Metformin 1000 mg po bid

· Glyburide 10 mg bid

· Atenolol 100 mg po daily

· Motrin 200 mg 1–3 tablets every 6 hours as needed for pain

Case Study 3:

Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following: 

· Glipizide 10 mg po daily

· HCTZ 25 mg daily

· Atenolol 25 mg po daily

· Hydralazine 25 mg qid

· Simvastatin 80 mg daily

· Verapamil 180 mg CD daily

To prepare:

· Review this week’s media presentation on hypertension and hyperlipidemia, as well as Chapters 19 and 20 of the Arcangelo and Peterson text.

· Select one of the three case studies, as well as one the following factors: genetics, gender, ethnicity, age, or behavior factors.

· Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.

· Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.

· Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.

With these thoughts in mind:

Post an explanation of how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you selected. Then, describe how changes in the processes might impact the patient’s recommended drug therapy. Finally, explain how you might improve the patient’s drug therapy plan.

Link to Media:

https://class.waldenu.edu/bbcswebdav/institution/USW1/201930_27/MS_NURS/NURS_6521/adobePresenter/Week03/media2/index.htm

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DQ 1

Comment 1

An internal method for dissemination of my EBP project results would be scheduling a short meeting with nurse managers of the unit to discuss the findings through questionnaires and interviews. External may be to schedule meeting which includes the nurse managers and staffing personnel. The importance of including all these persons in one meeting would be to provide a connect with the data and information that is discussed daily with regard to staffing and the hiring of nurses to fill vacant positions. Providing visual displays of the research that provides a clear picture showing the impact of nurse turnover and the orientation process. This meeting would be a platform for discussion and information that involves staffing, hiring and retention of staff and the impact on the unit/facility. According to  the  Agency for Healthcare Research and Quality (AHRQ) (2014),  all dissemination should have a purpose and promote the project development. This can be accomplished by raising awareness, informing and educating, engaging and involving, and promotion of the results.

Staffing levels and nurse retention is in the news daily and involving the community in discussions would offer clarification. Yes, the community is aware of the shortage, but do they know what avenues of change are taking place in the facility that hopefully will affect their healthcare now and in the future.

Strategies of communication for each group focuses on the delivery of information. Internal information transfer is effective through conversation and visual evidence. External needs to be concise and factful with a clear plan of implementation that is also visual. Time constraints for both groups is evident so many short meetings for the internal dissemination would benefit both staff and the managers/leaders of the nursing unit. The external group would also have time limitations so being concise and thorough with a limited time frame is a challenge.

Comment 2

An important part in delivering “high-quality patient care is nursing implementation of evidence-based practice (EBP); institutional leadership, such as nurse managers (NMs), plays an integral role in the implementation of EBP on nursing units” (Kueny, Shever, Lehan, & Titler, 2015, p.1). Thus, one internal method would be meeting with the NM of the unit to discuss my research findings regarding the implementation of acuity based tools specific for the unit to adjust staffing appropriately to improve patient outcomes, improve quality of care and decrease nurse burnout. Addressing the importance of measuring acuity, provide different tools that measure acuity and how to implement the use of these tools with proper education and directions. NMs are an important part of driving change, they can lead EBP projects, provide resources and educational activities to promote change and schedule workshops to assist nurses with the changes.  According to Kueny et. al (2015), “NMs have the potential to remove some of the autonomy in decision making for EBP recommendations” (p. 37). NM’s can help with culture of expectations, empowering their nurses to implement EBP to improve patient outcomes and improve nurse burnout.

An external method would be contacting a professional nursing organization, such as the American Psychiatric Nurses Association (APNA). Contacting the APNA via the internet would provide me with feedback on the next steps I need to take. Becoming a member of APNA or joining a committee, would allow me to take action addressing the importance of using acuity based tools in measuring safe staffing levels to improve patient outcomes and improve quality care. There is a lack of studies or research regarding staffing inpatient geriatric psychiatric units. The APNA (2015), encourages nurse researchers to study both populations, in order to establish specific nurse-to-patient ratios for inpatient psychiatric units and to foster the development of innovative, effective, recovery-oriented and safe-staffing models. Thus, it would be beneficial to address these populations, providing evidence that implementation of acuity based tools for safe staffing levels has improved patient outcomes.

Strategies for communication would be different for internal methods versus external methods. Internal methods require a more personal approach, addressing the problem, reviewing evidence for solutions to the problem with the NM, outlining the project, asking for feedback, projected costs involved to implement EBP, time constraints, and required nursing education on implementing acuity based tools for the unit. Promoting nursing feedback and shared governance in the decision making process and areas that need to be addressed in regards to safe staffing and equitable nurse workloads. External methods require a less formal approach, writing to APNA, would require addressing the problem, providing a solution with evidence based research, evaluating nursing practice, quality of care, improving nurse’s mental health, minimizing nurse burnout, reducing health care cost, and improving patient outcomes.

DQ 2

Comment 1

An important challenge to any evidence-based practice project evaluation is whether it was effective. I came across an article discussing the use of a premortem plan to identify outcomes and their success. In the healthcare arena we have all heard of postmortems where we discuss what happens after a sentinel event or adverse patient outcome. A premortem addresses the anticipated failures of the project before implementation. By doing this we can develop strategies that would aid in successful implementation according to Ginex (2018).

Since my project relates to staff retention and turnover on the night shift, seeing staff be successful using mentor/mentee programs after the original orientation period would offer proof the program change is working. Evaluating the cost of orientation and the cost of loosing qualified staff due to inadequate or ineffective orientation would also provide positive feedback and data. Follow up interviews with staff who have left or changed shifts would offer information related to differences in shift orientations. Also, the number of staff participating in mentor/mentee program would show the level of acceptance and commitment to the project change.

Comment 2

One way that I would evaluate whether my project made a difference in practice would be to implement some of my findings, such as talking with the DON and supervisor of my facility about scheduling equal nurse-to-patient ratios. I currently work on a sub-acute unit of my facility and there are about 6 patients that have pressure ulcers and all of them are at risk for pressure ulcer development. I have worked at the facility for a year and some pressure ulcers have developed while those residents were in the facility. All of the resident require total care and to ensure that they are changed and turned in a timely manner, there must be an appropriate staff-to-patient ratio. This means that each nurse should not have more than 7 patients because, they also only have on CNA. Each CNA has up to 14 patients, so they heavily rely on the assistance of the nurses. If the nurses feel overworked, then it shows in their patient care and the residents are at more risk for pressure ulcer development. According to Hartmann, Mills, Pimentel, Palmer, Allen, Zhao, and Snow (2018), positive interactions between the staff and patients contributes to better quality care and better patient outcomes.

I would also talk with the wound care nurse, DON, and supervisor to provide in-services to teach the staff how to implement the wound care orders properly. The wound care nurse only works from 0800-1630 and although he tries to change the dressings every day, the orders also include changing the dressing PRN if they become soiled. Many of the wounds are located on the sacrum region. All of the residents are incontinent of bowel and bladder and require total care. Orders constantly change depending on the status of the wound and there have been times when the dressing gets soiled and requires changing. I often work the even shift and there are times where I do not see the wound care nurse. I and my coworkers that work the evening and night shift have needed to change the dressing based on the order in the MAR. there have been times in which the directions of the order were unclear and/or we did not have the correct supplies. The wound care nurse only works during the week, so if we do run out of supplies, we do not have access to the storage unit that has them or the facility has run out. When there is a change in an order, it would be very helpful if the wound care nurse holds in-services to show the nurses how to perform the dressing change and make sure that at least half of the nurses from the evening and night shift know how to change it as well, so they can help their co-workers if needed. Knowing how to properly change the dressings improves wound healing and prevent worsening of the wound.