This patient is most likely to have plaque psoriasis, the most common form of psoriasis in young adults, with the average age of onset in the early twenties (Dunphy, Winland-Brown, Porter, & Thomas, 2015).)

            The risk factors for the development of psoriasis are family history. One-third of all patients with psoriasis have a relative with the disease, as in the case study above. When a parent is affected the children have a tendency for an early onset of the condition. Not only that but when both parents are affected the chance increases to forty-one percent of the children having the condition. This patient had an upper respiratory infection prior to the outbreak of the rash; this predisposes her for an outbreak of psoriasis. Even though there is a genetic disposition of the offspring of the parents having the disease, the exact genetic cause is unknown. Research is ongoing regarding the genetic and environmental influences on the cellular effects of the disease (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

          The diagnostic tests to order for this patient are a CBC with differential and serum chemistry profile, serum uric acid level, antinuclear antibody titer, and rheumatoid factor. The serum uric acid level may be elevated. Diagnostic procedures are the Psoriasis Area and Severity Index, which evaluates overall severity and BSA involvement, and the Dermatology Life Quality Index. The top three differentials are seborrheic dermatitis, nummular eczema, and atopic dermatitis (Dominic, Bolder, & Golding, 2019)

            The goal of treatment for the condition of Psoriasis is to identify and avoid triggers. If the condition is mild to moderate keeping the skin hydrated with petrolatum ointments is helpful. Topical corticosteroids are also helpful initially in treating the disease and preventing skin atrophy. In the adult, initial therapy should be corticosteroids with varying potencies. These treatments should not be used longer than 4 weeks (Hendriks… et al, 2013).

            Follow-ups should be done to measure the body surface area involvement and to see if the therapy is working. If the therapy is not working alternative treatments should be prescribed or the addition of another agent to treat the condition should be done. If the psoriasis is greater than twenty percent of the body surface area, or severe extremity involvement especially of the hands and feet develops, a referral is needed (Menter, Gottlieb, Feldman, Van Voorhees, Leonardi, Gordon, et al…2008).

References

Domino, F., Baldor, R. A., & Golding, J. (2019). The 5-minute clinical consult. (27th

Ed.). [Mobile application software.] Retrieved from http://itunes.apple.com

Dunphy, L.M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary

care: the art and science of advanced practice nursing. (4th Ed.). Philadelphia, PA. F. A. Davis Company.

Hendriks, A. G., Keijsers, R. R., de Jong, e. M., Seyger, M. M., van de Kerkof, P. C.

(2013). Efficacy and safety of combinations of first-line topical treatments in chronic plaque psoriasis: a systematic literature review. J Eur Acad Dermatol Venereol. 27(8) 931-951. doi:10.1111/jdv.12058

Menter A, Gottlieb A, Feldman SR, Van Voorhees AS, Leonardi CL, Gordon KB,et al.

(2008). Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 58(5):826-50. 

•  

 

Research and report on the current software being used for speech recognition. Your report should consist of three parts:

1. List current speech recognition software products and the approaches being used by those products. Include hyperlinks to each product’s website. 
2. Give two examples of how speech recognition is currently being used outside of the healthcare industry.
3. Discuss the benefits of speech recognition within healthcare. Be sure to elaborate on its effect on both costs and performance. 

 Your work will be graded for completion of all three parts, and for clear and complete explanation and discussion. 

Review the Institute of Medicine’s 2010 report “The Future of Nursing: Leading Change, Advancing Health.” Write a 750-1,000 word paper discussing the influence of the IOM report on nursing practice. Include the following:

1. Summarize the four messages outlined in the IOM report and explain why these are significant to nursing practice.
2. Discuss the direct influence the IOM report has on nursing education and nursing leadership. Describe the benefits and opportunities for BSN-prepared nurses.
3. Explain why it is important that a nurse’s role and education evolve to meet the needs of an aging and increasingly diverse population.
4. Discuss the significance of professional development, or lifelong learning, and its relevance in caring for diverse populations across the life span and within the health-illness continuum.
5. Discuss how nurses can assist in effectively managing patient care within an evolving health care system.

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. 

You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.

  

Module 4 DQ 1 and DQ 2

Tutor MUST have a good command of the English language

These are two discussion questions

DQ1 and DQ2 posts must be at least 150 words and have at least one reference cited for each question. In-text citation, please

Tutor MUST have a good command of the English language

Sources need to be journal/scholarly articles. 

Use only articles that are published between 2015-2018 (except for your theory articles which will be older as you must cite primary sources).

No textbook or direct quotes

Please separate the two DQ with their reference page

My project is CLABSI prevention

DQ 1

Describe a vulnerable population in terms of research. Why is the population considered vulnerable? What other groups might also be considered vulnerable populations

DQ 2

Assume you want to do a project that compares the survey results before an intervention to those after an intervention in the same sample (the same people will take both surveys). You plan to use a paired t-test to analyze your results. Using the “Determining the Appropriate Sample Size,” Topic Material, perform a sample size calculation to determine how large your sample should be. Justify your sample size calculation with citations. Discuss how your sample size may affect the validity of your study.

 Please I need a response to this case study.

1 page

zero plagiarism

three references

The Case:

The sleepy woman with anxiety

This week’s discussion presents a case study involving a 44-year old woman with a chief complaint of anxiety beginning at age 15 years old. She has a long history of mental illness and continued therapies. The purpose of this discussion is to analyze her case history to determine medication and treatment effectiveness.

Client Questions

Question 1. Are you having feelings of harming yourself or harming someone else?

Rationale: This is a possibly uncomfortable yet important set of questions to ask each client. Primary care providers may be in a unique position to prevent suicide due to their frequent interactions with suicidal patients. Reviews suggest that among patients who committed suicide, 80 percent had contact with primary care clinicians within one year of their death, whereas only 25 to 30 percent of decedents had contact with psychiatric clinicians within the year of their death (Stene-Lars & Reneflot, 2017).

Question 2. What was happening in your life as a teenager when the anxiety started and you began to self-medicate?

Rationale: Per our report, this patient began suffering signs and symptoms of anxiety at 15-years old. Asking these types of questions we may gain insight into an underlying cause or triggering event. Anxiety disorders are the most common psychiatric disorders with onset in childhood, with prevalence estimates ranging from 10 to 30 percent. Nearly 37 percent of behaviorally inhibited preschool-age children had social anxiety disorder at age 15, compared with 15 percent of non- behaviorally inhibited children. Children with anxiety disorders are more likely to have persistent anxiety disorders into adulthood. (Rapee, 2014).

Question 3. What was happening in your life a year ago when these symptoms returned and became debilitating? Let’s discuss what the triggering events may have been.

Rationale: Self-discovery of triggering events may help the client to come to terms with the determinants of her anxiety and depression. Studies have shown that specific types of stressors were found to differentially predict increases in specific facets of anxiety sensitivity; health-related stressors predicted increases in disease-related concerns and fear of mental incapacitation, whereas stressors related to family discord predicted increases in fear of feeling unsteady, fear of mental incapacitation, and fear of having publicly observable symptoms of anxiety (McLaughlin & Hatzenbuehler, 2009).

Support System

            The support system as reported by our client is her husband. She states he is supportive and has little to no contact with the family of origin. She has a few friends and a few outside interests. As PMHNP, discussing relationships with the client is one avenue to gain insight into anxiety patterns and coping mechanisms as seen by outside support. With the client’s permission, speaking to her husband may assist us in this situation. Learning how the patient functions at home, what critical changes have occurred with this recent bout of depression and what coping mechanisms are utilized by the couple may assist us in reaching a state of remission. In addition, these disorders are associated with significant decreases in patient well-being and social functioning and can cause considerable pain and suffering, not only for affected individuals but for their family and friends as well. Despite the availability of proven treatments, both disorders remain underrecognized and undertreated (Ballenger, 2000).

1. Are you aware of when your wife is entering a state of anxiety or depression?
2. What have you noticed happening in your lives when this occurs?
3. When these events occur, what response does that create for you?
4. What coping mechanisms do you utilize for yourself and your relationship when these events occur?

Physical Exams and Diagnostic Tests

First a complete physical assessment of the patient is required to rule out any underlying medical issues. This would also include a full blood panel with CBC, CMP, TSH and urinalysis and toxicology. Research findings suggest that mood and anxiety symptoms result from a disruption in the balance of impulses from the brain’s limbic system. A 2015 study reported that individuals with comorbid depression and anxiety have increased resting-state functional connectivity of the limbic network when compared with depression or anxiety alone. FK506 binding protein 51 (FKBP5) is a co-chaperone binding protein which modulates the function of glucocorticoid receptors. In a study examining allelic variants of FKBP5, the T allele was more frequent among patients with comorbid depression and anxiety (Pannekoek et al., 2015). Additionally, rating scales have shown good reliability for assessing anxiety and depression. The Depression and Anxiety Stress Scale (DASS) is suitable for assessing clients with co-occurring depression and anxiety.

Differential Diagnoses

1. Post-Traumatic Stress Disorder (PTSD)- This patient could be showing physical manifestations of PTSD. Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are prevalent and frequently co-occurring psychiatric illnesses that are both highly associated with disturbed sleep. PTSD affects an estimated 5 million people in the U.S. each year and is characterized by an inability to recover from a stress reaction following exposure to a traumatic event (Vandrey et al., 2014).
2. Generalized Anxiety Disorder (GAD)- This patient falls into the DSM-V criteria for anxiety. Generalized anxiety disorder produces fear, worry, and a constant feeling of being overwhelmed. Generalized anxiety disorder is characterized by persistent, excessive, and unrealistic worry about everyday things. This worry could be multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms (Munir & Takov, 2019).
3. Polypharmacy and (GAD)- This patient may be suffering issues relating to polypharmacy as evidenced by sleep disturbances combined with anxiety disorder. As the number of available medication options increases, so does the potential for polypharmacy, a practice with possible complications. Such complications include a greater number of side effects with the initiation of additional medications and the consequences of drug-drug interactions.

Pharmacologic

            This patient does not appear to be a good self-historian regarding medication, compliance and lacks the ability to determine medication effectiveness. It is the thought of the PMHNP that the patients issue with narcolepsy is related to medication and polypharmacy issues. Simplifying the patients eight medications by discontinuing sodium oxybate, pramipaxole and DDAVP seem to improve her daytime sleepiness. This patient was taking several medication relating to sleep, causing other issues including bed-wetting for which she was prescribed DDAVP (Desmopressin), and reports it is not very helpful. By tapering and discontinuing these medications and educating the patient on sleep hygiene and perhaps sleep studies, we can assist this patient into improved sleep at night without excessive daytime sleepiness.

Lessons Learned

 This case is an excellent example of long term mental health issues and polypharmacy. This patient seemed to be a good candidate for Vagus Nerve Stimulation (VNS) to which she received relief from sleep disturbances. Many patients with chronic anxiety have a poor quality of life. The education of both the patient and family by the pharmacist, nurse, and provider as a team is important to reduce the high morbidity and addiction problems with treatment medications. Family members should help ensure medication compliance and provide a supportive environment. Unfortunately, despite optimal treatment, relapse rates are high (Dold et al., 2017).

References

Ballenger J. C. (2000). Anxiety and Depression: Optimizing Treatments. Primary care companion to the Journal of clinical psychiatry, 2(3), 71–79. https://doi.org/10.4088/pcc.v02n0301

Dold M, Bartova L, Souery D, Mendlewicz J, Serretti A, Porcelli S, Zohar J, Montgomery S, Kasper S. Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders – results from a European multicenter study. J Psychiatr Res. 2017 Aug;91:1-13.

McLaughlin, K. A., & Hatzenbuehler, M. L. (2009). Stressful life events, anxiety sensitivity, and internalizing symptoms in adolescents. Journal of abnormal psychology, 118(3), 659–669. https://doi.org/10.1037/a0016499

Munir S, Takov V. Generalized Anxiety Disorder (GAD) [Updated 2019 Nov 22]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441870/

Rapee RM. Preschool environment and temperament as predictors of social and nonsocial anxiety disorders in middle adolescence. J Am Acad Child Adolesc Psychiatry 2014; 53:320.

Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health 2019; 47:9.

Pannekoek JN, van der Werff SJ, van Tol MJ, et al. Investigating distinct and common abnormalities of resting-state functional connectivity in depression, anxiety, and their comorbid states. Eur Neuropsychopharmacol 2015; 25:1933.

Vandrey, R., Babson, K. A., Herrmann, E. S., & Bonn-Miller, M. O. (2014). Interactions between disordered sleep, post-traumatic stress disorder, and substance use disorders. International review of psychiatry (Abingdon, England), 26(2), 237–247. https://doi.org/10.3109/09540261.2014.901300