Assignment: Decision Tree

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting symptoms of a mental health disorder.

                                                          The Assignment:

Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

• Decision #1: Differential Diagnosis
  • Which Decision did you select?
  • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources. 
  • Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
• Decision #2: Treatment Plan for Psychotherapy
  • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources. 
  • Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
• Decision #3: Treatment Plan for Psychopharmacology
  • Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources. 
  • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also include how ethical considerations might impact your treatment plan and communication with clients and their families.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. 

                                                                                Case #2
Anxiety disorder, OCD, or something else? 

                                                                    BACKGROUND

Tyrel is an 8-year-old black male who is brought in by his mother for a variety of psychiatric complaints. Shaquana, Tyrel’s mother, reports that Tyrel has been exhibiting a lot of worry and “nervousness” over the past 2 months. She states that she notices that he has been quite “keyed up” and spends a great deal of time worrying about “germs.” She states that he is constantly washing his hands because he feels as though he is going to get sick like he did a few weeks ago, which kept him both out of school and off the playground. He was also not able to see his father for two weekends because of being sick. Shaquana explains that although she and her ex-husband Desmond divorced about 2 years ago, their divorce was amicable and they both endeavor to see that Tyrel is well cared for. 

Shaquana reports that Tyrel is irritable at times and has also had some sleep disturbances (which she reports as “trouble staying asleep”). She reports that he has been more and more difficult to get to school as he has become nervous around his classmates. He has missed about 8 days over the course of the last 3 weeks. He has also stopped playing with his best friend from across the street. 

His mother reports that she feels “responsible” for his current symptoms. She explains that after he was sick with strep throat a few weeks ago, she encouraged him to be more careful about washing his hands after playing with other children, handling things that did not belong to him, and especially before eating. She continues by saying “maybe if I didn’t make such a big deal about it, he would not be obsessed with germs.” 

Per Shaquana, her pregnancy with Tyrel was uncomplicated, and Tyrel has met all developmental milestones on time. He has had an uneventful medical history and is current on all immunizations. 

                                                                OBJECTIVE

During your assessment of Tyrel, he seems cautious being around you. He warms a bit as you discuss school, his friends at school, and what he likes to do. He admits that he has been feeling “nervous” lately, but when you question him as to why, he simply shrugs his shoulders. 

When you discuss his handwashing with him, he tells you that “handwashing is the best way to keep from getting sick.” When you question him how many times a day he washes his hands, he again shrugs his shoulders. You can see that his bilateral hands are dry. Throughout your assessment, Tyrel reveals that he has been thinking of how dirty his hands are; and no matter how hard he tries to stop thinking about his “dirty” hands, he is unable to do so. He reports that he gets “really nervous” and “scared” that he will get sick, and that the only way to make himself feel better is to wash his hands. He reports that it does work for a while and that he feels “better” after he washes his hands, but then a little while later, he will begin thinking “did I wash my hands well enough? What if I missed an area?” He reports that he can feel himself getting more and more “scared” until he washes his hands again.  

        

                                                         MENTAL STATUS EXAM

Tyrel is alert and oriented to all spheres. Eye contact varies throughout the clinical interview. He reports his mood as “good,” admits to anxiety. Affect consistent to self-reported mood. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes were apparent. He denies suicidal ideation. 

Lab studies obtained from Tyrel’s pediatric nurse practitioner were all within normal parameters. An antistreptolysin O antibody titer was obtained for reasons you are unclear of, and this titer was shown to be above normal parameters. 

                                                   Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

 

Generalized Anxiety Disorder (GAD)

Obsessive Compulsive Disorder

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (“PANDAS”)

 ANSWER CHOOSEN: Obsessive Compulsive Disorder 

                                                 Decision Point Two

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

 

Begin Zoloft 50 mg orally daily

Begin Fluvoxamine immediate release 25 mg orally at bedtime

Begin Fluvoxamine controlled release 100 mg orally in the morning

 

Discontinue Zoloft and begin Fluvoxamine controlled release 100 mg orally every morning In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this. Zoloft is FDA-approved to treat OCD in children. However, between ages 6 and 12, it should be started at 25 mg orally daily. If starting doses are too high, the child may experience side effects that he associates with the medication and as such, may refuse to take the medication. Starting at too high a dose can result in unfavorable side effects (gastrointestinal side effects are notable in this drug), and we can see that Tyrel is experiencing nausea and decreased appetite. In this case, it is recommended to wait to see if the side effects dissipate. Decreasing the dose to 12.5 mg orally daily for about 3 or 4 days, then going back to 25 mg orally daily may help to overcome the unfavorable side effects. If side effects persist, the PMHNP may need to consider switching to a different medication.Fluvoxamine controlled release is not FDA-approved for use in children with OCD (see “Special Populations: Children and Adolescents” in the Fluvoxamine monograph of Stahl’s Prescriber’s Guide for further details). Fluvoxamine 100 mg orally daily may not be tolerated in the morning secondary to the drug’s sigma-1 antagonist properties, which can cause sedation. Dosing of Fluvoxamine should be such that the larger dose is given in the evening to minimize daytime sedation. It is also worth noting that nothing in the scenario tells us that the Zoloft will not be effective. 

ANSWER CHOOSEN: Begin Fluvoxamine immediate release 25  

mg orally at bedtime 

·Client returns to clinic in four weeks

·Upon return to the clinic, Tyrel’s mother reported that he has had some 

 decrease in his symptoms. She states that the frequency of the handwashing 

  has decreased, and Tyrel seems a bit more “relaxed” overall. 

·She also reports that Tyrel has not fully embraced returning to school, but that 

 his attendance has improved. She reported that over this past weekend, Tyrel  

 went outside to play with his friend from across the street, which he has not done in a while.

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

· Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.

·  She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.

                                                       Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

 

Increase Fluvoxamine to 50 mg orally at bedtime

Augment with an atypical antipsychotic such as Abilify

Augment treatment with cognitive behavioral therapy

ANSWER CHOOSEN: Increase Fluvoxamine to 50 mg orally at 

 bedtime

 

Guidance to Student

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

                                                 Learning Resources

Required Readings

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

• Chapter      31, “Child Psychiatry” (pp. 1253–1268)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

• “Anxiety Disorders”

American Academy of Child & Adolescent Psychiatry (AACAP). (2012a). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98–113. Retrieved from http://www.jaacap.com/article/S0890-8567(11)00882-3/pdf 

McClelland, M., Crombez, M-M., Crombez, C., Wenz, C., Lisius, M., Mattia, A., & Marku, S. (2015). Implications for advanced practice nurses when pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is suspected: A qualitative study. Journal of Pediatric Health Care, 29(5), 442–452. doi:10.1016/j.pedhc.2015.03.005

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press. 

SEE ATTACHED ASSIGNMENT OF DECISION TREE AND ASSIGNMENT EXAMPLE/SAMPLE 

Due Tomorrow At 1:00 PM

Discussion Board #6

HCA 340

Discussion Board Assignment #6

Chapter 7–The Health Care Workforce and Chapter 8—Financing Health

Answer the following questions on Health Care Workforce/Personnel:

1. The majority of schools of medicine, dentistry, nursing, and other professions and their teaching hospitals are heavily subsidized by federal and state funds. Many of those graduates, when they become health practitioners, feel no obligation to society for their publicly supported education. Do health care providers who reap the benefits of high compensation and social position have an ethical responsibility to repay taxpayers by meeting the needs of the medically underserved?
2. Technical advances in health care have spawned an ever-increasing number of specialty- trained personnel. More recently, however, hospitals and other institutions are promoting the cross-training of personnel so that they can perform multiple tasks and work more flexibly, based on institution needs. What are the implications of cross training, in terms of quality of care, costs, and efficiency?
3. Men comprise a small segment of the nurse population, although their numbers are increasing.  Given the good income potential of the nursing profession and continuing demand, what is your opinion about why nursing does not attract more males?

Answer the following questions on Health Care Financing:

1. Name one (1)  way each of the following has affected the costs of health care in the US?
   • The health insurance industry
   • Advances in medical care technology
   • Changes in U.S. demographics
   • Government support for health care
   • Consumer expectations
2. If we accept the premises that resources available to meet the costs of health care are finite, and that continuing to increase dollars allocated for health care expenses carries “opportunity costs“ for the nation and society, discuss your position on the following: As a national policy should we allocate a set level of resources and apply them to achieving “the greatest good for the greatest number” (necessarily leaving some out) OR should we adopt the individualist approach of “those who can pay get, those who can’t pay, don’t?”
3. From the patient perspective, what might be some of the positive and negative aspects of “disease management programs?”

Discussion: Discussing End-of-Life Care

There is a human tendency to postpone uncomfortable or unpleasant tasks.

—Nancy Kummer, geriatric patient

This human tendency to avoid the unpleasant makes end-of-life care and hospice decisions difficult for many patients to discuss with their families. Kummer is a former social worker who used to counsel patients with terminal illnesses, yet she avoided discussing her own end-of-life wishes with her children. While many Americans, like Kummer, agree that these discussions need to take place, few have actually had these conversations with their families (Lazar, 2012). Although initiating conversations about end-of-life care and hospice might be difficult for patients, as an advanced practice nurse, facilitating these conversations is an integral part of your geriatric nursing practice. For this Discussion, consider how you would facilitate care conversations with the patients and families in the following case studies:

Case Study 1

Mrs. Sloan, a 69-year-old widow, is about to enter the hospital for an elective cholecystectomy; she is being medically cleared by her primary care provider. During the discussion, she requests to be placed on a no code status during her hospitalization. Mrs. Sloan claims that besides her gallbladder problem, her general health status is good. She wishes to have the surgery to avoid any further attacks, which have been very painful. She states, however, that if during surgery or her postoperative period, she undergoes a cardiac arrest, she would prefer not to be resuscitated. She has read about the chances of successful resuscitation, and has determined that the risk of brain damage is too high. For this reason, she is requesting a no code status.

Case Study 2

Ms. Stearns is an 83-year-old nursing home resident with hypertension, coronary artery disease, arthritis, renal insufficiency, hearing impairment, and a previous history of stroke. She also has a foot deformity from childhood polio. She is disoriented at times. She has lived in the nursing home for 10 years and rarely leaves the chair beside her bed. She has recently developed urinary incontinence, but has refused a bladder catheterization to determine postvoid residual urine or possible bladder infection. She does not have a diagnosis of dementia; however, current testing reveals that she performs poorly on a standardized mental status examination. She can, however, identify all the staff in the nursing home, and she can describe each patient who has been in the bed next to hers over the past 10 years. When asked to explain why she does not want bladder catheterization, she gives several reasons. She states that the incontinence does not bother her, and that she has always been a very private person. She particularly dislikes and objects to any examination of her pelvic organs; in fact, she has never had a pelvic examination nor has she ever had sexual intercourse. She realizes that she has a number of medical problems and that any one of them could worsen at any time. She states she is not willing to undergo any treatment for any of her current problems should they become worse.

Case Study 3

Mr. Marley, age 91, is admitted to the intensive care unit following a stroke. The stroke progressed from mild hemiparesis and difficulty speaking to complete unresponsiveness and an inability to swallow. His daughter feels certain, based on prior explicit conversations with her father, that he would not want to have any treatment that would prolong his life and leave him in a severely disabled state. Mr. Marley’s oldest son disagrees with his sister’s assessment of their father. The son claims that their father still has a strong desire to live, and that he has been very active in his church until this stroke. Because Mr. Marley cannot swallow, he cannot be fed. The family is asked about insertion of a feeding tube. It is explained to the family that without food and fluids, their father will die fairly quickly. There are no existing advance directives or a designated health care decision maker noted for Mr. Marley.

To prepare:

• Review Chapter 14 of the Holroyd-Leduc and Reddy text.
• Reflect on the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families.
• Think about how you, as an advanced practice nurse, would approach a family who wants “everything” done for a patient with only a limited time to live.
• Consider when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services.
• Select one of the three provided case studies related to the end-of-life care of the frail elderly. Reflect on potential patient outcomes and how you would facilitate the discussion of care with this patient’s family.

By Day 3

Post an explanation of the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families. Explain how you would approach a family who wants “everything” done for a patient with only a limited time to live. Then, explain when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services. Finally, explain potential outcomes of the patient in the case study you selected and how you would facilitate the discussion of end-of-life care with this patient’s family.

 

Diagnosis and Management of Hematologic and Metabolic Disorders

 

 

Case Study 2:

 

 Jimmy is a 3-year-old “picky” eater according to his mother. He refuses to eat anything but waffles for breakfast and macaroni and cheese or chicken nuggets for lunch and dinner. He will eat apples and bananas but refuses all vegetables except corn. After a normal physical examination, you obtained blood testing that revealed the hemoglobin is 11.4 mg/dl and his hematocrit is 30% (both obtained by venipuncture). The CBC revealed microcytic hypochromic RBCs.

 

To prepare:

 

•Review “Endocrine and Metabolic Disorders” and “Hematologic Disorders” in the Burns et al. text.

 

•Review and select one of the three provided case studies. Analyze the patient information.

 

•Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.

 

•Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.

 

•Consider strategies for educating patients and families on the treatment and management of the hematologic or metabolic disorder.

 

 

 

POST   1 TO 2 PAGES DISCUSSION PAPER ON :  1.An explanation of the differential diagnosis for the patient in the case study you selected.

 

2. Explain which is the most likely diagnosis for the patient and why.

 

3. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis.

 

4. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments.

 

5. Finally, explain strategies for educating patients and families on the treatment and management of the hematologic or metabolic disorder.

 

 

 

 

 

References

 

•Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.

 

◦Chapter 25, “Endocrine and Metabolic Disorders” (pp. 529–556)

 

◦Chapter 26, “Hematologic Disorders” (pp. 557–584)

 

•Hyperbilirubinemia: current guidelines and emerging therapies by Schwartz,H.P., Haberman, B.E., & Ruddy, R.M. in  Pediatric Emergency Care, 27(9), 884-889.

 

 

 

Select one of the below-listed topics to use for your final project. Submit topic choice and a minimum of three references related to your topic to your instructor for approval. References should be five years or less since publication and be listed in the current APA Style. No Blog sites, WIKI, or another school of nursing references, please.

1. Nurse managers must work with staff to foster respect of different lifestyles. As a future manager, how can you provide culture-centered leadership to influence your team members and care for a culturally diverse patient population? Please incorporate concepts of cultural humility, sensitivity, or competence and one cultural theory into your response.  
2. Use Kouzes and Posner model to show how the nurse manager on a 30-bed rehabilitation unit would decide the best approach to finding out the cause of increasing urinary tract infections (UTIs) on her unit over the past 6 months. 
3. Quadruple Aim of Healthcare
   1. What are the guidelines for the quadruple aim?
   2. What is the importance of achieving the quadruple aim?
   3. What outcomes may be seen from promoting the leader-follower relationship?
4. The Chief Nursing Officer (CNO) of an acute care hospital is interested in becoming a Magnet-designated hospital. The CNO would like to create a strategic plan for nursing excellence. If you were the CNO, what would the mission statement for nursing say? What would the vision statement for nursing say? What would be the core values of the nursing department? Create an Incivility Statement/Policy. 
5. You are assigned some risk management activities in the nursing facility where you work. In investigating incident reports filed by staff, you discover that this is the third incident this week in which a patient has fallen while attempting to get out of bed and sit in a chair. How would you begin to address this issue? Decide how you would start a more complete investigation of this issue. For example, is it a facility-wide issue or one that is confined to one unit? Does it affect all shifts or only one? What safety issues are you going to discuss with your staff, and how are you going to discuss these issues? Do these falls involve the same staff member? 
6. Analyze differences among research, evidence-based practice, practice-based evidence, comparative effectiveness research, outcomes research, and quality improvement. How do these practices affect nursing and patient outcomes? 
7. Review the educational program TeamSTEPPS. Identify two strategies you can incorporate into your practice. Present your rationale for selecting those and create an action plan to incorporate those strategies into your practice.