Cathy Giomblanco 

Tuesday 

Feb 5 at 7:45pm

 

Manage Discussion Entry 

U5 DB Initial Post

Presenting and Associated Symptoms

            Chest pain from acute myocardial infarction is usually sudden onset in the substernal area, which may or may not radiate. Associated symptoms are weakness, dyspnea, diaphoresis, nausea, vomiting, palpitations, and anxiety. The pain usually lasts thirty minutes or more. Morphine and nitroglycerin do not completely relieve the pain (Uphold, & Graham, 2013).

Specific diagnostic tests used in the work up

            Vital signs including heart rate, temperature, and blood pressure, and oxygen saturation should be done at regular intervals. Diagnostic tests include a 12 lead ECG, the cardiac biomarkers of CPK with isoenzymes, troponin T or I, high sensitivity C-reactive protein, CBC, erythrocyte sedimentation rate, serum electrolytes, BUN and serum creatinine. Perform a complete heart and lung exam. Assess peripheral pulses, and assess extremities for edema, cyanosis, and clubbing. Echocardiography should be ordered. This is the gold standard in diagnosing wall motion abnormalities, ventricular function, valvular or septal defects, and ejection fractions (Mcconaghy, & Oza, 2013).

1st line therapeutic interventions, patient education and follow up expectations

            The first line therapeutic interventions are: aspirin 162-325 mg chewed, give nitroglycerin every 5 minutes times three doses or until chest pain is perceived as a 0 out of 10 on the pain score. Monitor the patient for hypotension. The patient should be transferred to a hospital emergency department with access to a cardiac catheterization lab. This will allow immediate reperfusion therapy with angioplasty within 2 hours if available (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

Support whether or not you would refer the patient to another health care provider for treatment. Include the name of the specialty and your rationale for the referral.

            Patients who present with chest pain, with or without radiation, SOB, weakness, diaphoresis, nausea, lightheadedness and a suspected MI, should be transported to the ER (Uphold & Graham, 2013). Patients with a negative ECG but their clinical presentation is suspicious should be referred to the ER. Non-urgent cases can be referred to cardiology for further investigation (Biesemans, Cleef, Willemsen, Beatriis, Reniere, Buntinx…Dinant, 2018).

Patient Education

            Patient education should include teaching about medications usage, adverse effects, and how to take nitroglycerin prophylactically. Patients should also be taught proper care of the nitroglycerin tablets. Patients with a higher BMI should be placed on a low-fat reduced calorie diet. Patients should be encouraged to enter a cardiac rehabilitation program of safe exercise and risk factor modification including smoking cessation (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

 

References

 

Biesemans, L., Cleef, L. E., Willemsen, R. T. A., Beatrijs, B. N. H., Renier, W. S.,

Buntinx, F., . . . Dinant, G. (2018). Managing chest pain patients in general practice: An interview-based study. BMC Family Practice, 19doi:http://dx.doi.org/10.1186/s12875-018-0771-0

 

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. A. (2015). Primary care. The art and science of advanced practice nursing. (4th Ed.). Philadelphia, PA. F. A. Davis Company.

 

 

Mcconaghy, J. R., & Oza, R. S. (2013). Outpatient diagnosis of acute chest pain in adults.

American family physician. 87(3)177-82. Retrieved from www.aafp.org/afp

 (Links to an external site.)

Links to an external site.

 

 

Uphold, C. R., & Graham, M. V. (2013). Clinical guidelines in family practice.

Gainsville, FL. Barmarrae Books, Inc.

 CASE STUDY 3 – Reflecting on week 4’s lessons in the syllabus,select a patient population (pediatric, young adult, adult or geriatric), and briefly analyze a chronic cardiovascular disease (HTN, Heart failure, Dyslipidemia, Heart murmur etc.…), that may affect this population. 

-Tell how it impacts the patient’s quality of life.

– analyze the current research evidence on this topic and gold standard of care for your chosen population (CDC guidelines) . (You may use an example from your clinical rotation (past or present) that you have encountered). 

-Describe how you as Family Nurse Practitioner, can/or have made a difference in the care of patients with this specific disease and tell of one specific patient care teaching that he/she may do to help minimize disease symptoms. Use apa format and References scholarch article no older than 5 years.  (Due 02/12/19.  

 

Moving beyond medical errors: How EHRs are ‘nudging’ practices to change certain behaviors

by Eli Richman | Jan 28, 2019 6:00amThe University of Chicago Medical Center is one health system experimenting with ways the EHR can nudge physician and nurse behavior. (Courtesy of University of Chicago)ShareFacebookTwitterLinkedInEmailPrint

Electronic health records (EHRs) are usually cited for their ability to help diagnose diseases and reduce medical errors. But several health systems are testing how EHRs can be used to target other factors, like patient comfort and drug shortages.

Since EHRs are frequently used to guide patient care, adjusting the output of those systems can have considerable impact on patients—beyond just their immediate health condition.

Consider the University of Chicago Medical Center, which has been experimenting with a study module called SIESTA (Sleep for Inpatients: Empowering Staff to Act) to help patients in hospitals sleep better. The study is aimed at reducing nighttime awakenings for inpatients so they don’t experience in-hospital sleep deprivation.

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Inpatient sleep deprivation occurs when EHRs prompt doctors and nurses to take vital signs, administer medication or perform a test irrespective of the time of day. If a patient is being consistently woken up this way, they can suffer grogginess, delirium and falls.

“As a frequently hospitalized patient, I am used to being woken up as often as every one to two hours,” Sara Ringer, a hospital patient, told the University. “It never feels like your body has a chance to rest and heal. My last hospitalization at University of Chicago was one of the easiest I’ve had because the hospital staff made it possible for me to sleep.”

Alerting clinicians to potential problems—constantly

SIESTA works by adding alerts to the EHR, which remind healthcare workers they may want to delay disruptions that are minimally important (such as measuring vital signs). While it’s certainly possible to simply provide training to clinicians to avoid nighttime awakenings, the researchers said the EHR reminders work better.

“Efforts to improve patients’ sleep are not new, but they do not often stick because they rely on staff to remember to implement the changes,” said the study’s lead author Vineet Arora, M.D., professor of medicine at the University of Chicago.

But alerts aren’t always effective either because clinicians can start mentally blocking them out, said Raj Ratwani, M.D., director of the national center for human factors in healthcare at Medstar Health. When a physician gets an alert for something or other every few minutes (a suggestion to use a certain drug, a suggestion about when to perform a test, etc.), it stops being a concern and starts becoming an interruption of their workflow, according to Ratwani’s research.

Ratwani pointed to an eye-tracking study done on residents completing certain tasks in an EHR. It found that after a time, physicians would by habit bring their cursor to the place on the screen ready to close an alert box after selecting certain options—before it had even popped up. They had become that inured to the reminders.

“Those are the kind of alerts that drive physicians nuts, because think about how many of those they get, how busy they are,” Ratwani told FierceHealthcare in an interview. “What’s happening is you just get used to it, it becomes an interruption of your workflow, and you just want to get past it.”

Background UI changes—subtle and concerningly unnoticeable

Another approach to nudging clinicians’ behavior is to change the EHR’s user interface (UI) to cognitively disincentivize certain choices. Putting undesired options further down on a drop-down list, for instance, or graying them out, can cause clinicians to select them less often without interrupting workflow.

Many EHRs already do this to avoid negative health outcomes, like unintended drug interactions or dangerous opioid doses. But all those tools are available to nudge behavior for other reasons, Ratwani said. They can just as easily be employed to avoid a drug that’s on shortage or out of range.

“Oftentimes what happens is providers get emails, and they’ll get an email that says ‘please don’t prescribe medication A, prescribe medication B instead’. And then they’re tasked with having to remember that information on top of all the other things they have to do. So that’s a great instance where it would be far more effective to manipulate the interface a little bit to make it more difficult to order those medications that are on shortage,” he said.

“Things that you want to prevent or push people away from—you want that to take more cognitive effort than you want people to actually use,” Ratwani added. “So you’re guiding them without them needing to do a lot of effort to acknowledge them or interrupt their workflow. And that’s where it’s most effective—where it’s very passive and doesn’t require a lot of effort on the part of the physician.”

The trouble here is that the UI changes can tread into the territory of making decisions instead of clinicians. And while the grayed-out options should still be available to select in most cases, the psychological disincentive it provides is powerful, Ratwani said. One study showed that even a one- to two-second delay in the time that it takes to do something will push people away from that action most of the time.

Furthermore, it’s not clear that the suggestions pushed by the UI will always be appropriate. It would be easy for a drug shortage to end, for instance, but not have the EHR update to reflect that until months later.

“There is tremendous potential for unintended consequences in this kind of change—to any interface. Just in the example of order sets, many have been updated but the clinician’s not aware that it’s been updated, so they may be operating under the previous conditions of that order set,” Ratwani said. “This can be a big problem, and it’s similar to the drug shortage scenario, where there is a change and it’s not obvious.”

Ultimately, no solution is perfect. Personal reminders are too forgettable, EHR reminders are too repetitive and easy to ignore, and UI changes are too difficult to notice and overrule.

So while EHR changes can be a powerful tool for hospitals and health systems to incentivize certain behavior, they will have to be vigilant about the unintended consequences.

Read More On 

Cardiovascular Medication Discussion. 

This is for a discussion post. There are TWO parts to this post

There are numerous medications to treat disorders of the cardiovascular system. Below are just four of the medication categories used to treat hypertension.

Diuretics

ACE inhibitors

Calcium Channel Blockers

Vasodilators

1.Discuss the difference between each medication.

2. Choose from one of the four categories listed above. Provide an example patient scenario (can be from your own experience as a nurse) where a patient would be treated with the class of medication you chose from the four listed above. You only need to provide one scenario, but make sure it is using a medication that correlates to one of the four classes above.

For example…

Patient A has _________ diagnosis. His baseline BP is _______. The physician would most likely prescribe this class of medication ___________ and more specifically this drug ________.

Of course, this is just an example to get you started. 

Please elaborate on your patient scenarios and support your statements with evidenced based literature.

Pleas provide at least two references in APA format 

 

Submit a paper (1,250-1,500 words) focusing on public health reform. Provide an overview of the current status of public health in the United States.

Review a portion of the Affordable Care Act and present the strengths and weaknesses of the plan, as well as make suggestions for plan improvement.

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.