Technology and reimbursement patterns have increased the amount of surgery performed on an ambulatory basis. Hospitals all over the country are experiencing a rise in the number of surgical patients who come into the hospital and go home on the same day; cases that previously required at least an overnight stay in the hospital. The move to outpatient treatment can significantly affect a hospital’s use of beds and its overall organization. However, the move to outpatient care also poses some risks, especially to patients with difficult medical histories. The move from inpatient to outpatient care is driven by cost containment, as well as by new technologies. However, there are risks to care provided in the ambulatory setting. For example, advanced age (especially older than 70 years) is associated with increased hospital stay and perioperative morbidity and mortality. Additionally, the type of surgery is important in the risk assessment.

In the following three case scenarios, determine if the patient has an increased risk for surgical complications based on their current health status and medical history. Write a 1-2 paragraph response for each scenario, and determine the following:

1. Does the patient’s medical history pose a potential risk for complications prior/post surgery? Explain your reasoning.
2. Based on the patient’s current health status and their medical history, should they receive surgery or be evaluated and treated outside of the ambulatory care setting? Explain your reasoning.

Case Scenario 1:

Mr. Rogers is a 51-year old male. During his pre-operative examination, he tells the nurse, “I have an ache in my right foot”. He offers an explanation, suggesting, “I must have stepped on something or twisted my ankle. Maybe I got bitten by a bug when I was outside yesterday”. The nurse notes that the patient’s ankle is reddened, slightly swollen, and warm to the touch. However, his temperature is within normal limits. Mr. Roger’s ankle is x-rayed and there is no fracture noted. He has full range-of-motion of his right ankle. Mr. Rogers has a preexisting medical condition of gout. He is scheduled for outpatient surgery on his thyroid.

Case Scenario 2:

Mr. Sanders is a 61-year old male who presents with nausea and has been vomiting for two days. He is also experiencing mental confusion. His blood glucose is 796 mg/dL. He is a newly diagnosed diabetic and has not been getting medical treatment. Intravenous regular insulin is administered to Mr. Sanders in order to bring his blood glucose level down to a normal level. Further tests show that his Hemoglobin A1C is 10.3%. Mr. Sanders has a preexisting medical condition of coronary heart disease and hypertension. He is scheduled for outpatient surgery on his thyroid.

Case Scenario 3:

Mrs. Miller is an 88-year old woman who presents with nausea, vomiting, and severe abdominal pain. Further tests reveal that her white blood cell count is 13,000/mm3. Her physical examination reveals that her abdomen is distended and very tender to the touch. Her doctor suspects that she has acute pancreatitis. Mrs. Miller has a preexisting medical condition of heart failure and gastroesophageal reflux disease (GERD). She is also scheduled for outpatient surgery on her thyroid.

NOTE. this paper is link to the community teaching presentation

Note: This is an individual assignment. In 1,500-2,000 words, describe the teaching experience and discuss your observations. The written portion of this assignment should include:

1.Summary of teaching plan

2.Epidemiological rationale for topic

3.Evaluation of teaching experience

4.Community response to teaching

5.Areas of strengths and areas of improvement

Prepare this assignment according to the APA 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.

 I need a response to this assignment

1 page

zero plagiarism

Influencing Social Change

Advocacy is one of the core aspects of nursing professions and is considered an ethic of nursing practice. Advocacy is an essential practice that is important in influencing social change and promoting better nursing practices. This discussion explores how I can steer positive social changes in my community.

Positively Influencing Social Change

Being a psychiatric mental health nurse practitioner (PMHNP), I must advocate for mental health issues. I endeavor to be actively involved in eliminating the stigma faced by individuals with mental health issues. Many individuals with mental health problems come from communities that discriminate against them and hold prejudices, beliefs, and behaviors that make it harder for those living with mental health issues to receive proper treatment or help (Mannarini & Rossi, 2019). Given this issue, an approach that I can use to positively impact how the community views mental health issues is through community education to create awareness for individuals on the issues affecting people with mental health issues – especially risk factors, diagnosis, and treatment.

According to Ahuja, Dhillon, Juneja, and Sharma (2017), educating the community on what is mental health and how people with mental health issues feel can help to change the perspectives of the community about mental health. Educative strategies targeting the normative behaviors of the community will help the public to better understand how mental health issues develop and why the community needs to support individuals with mental health issues rather than stigmatize them. As a change agent, this will represent the process of speaking up for those who may not be able to speak for themselves through community campaigns for better community health outcomes (Rafferty, 2017).

Another way in which I will become a change agent for mental health is by motivating people to discover the reason why supporting individuals with mental health is needed. According to Cosejo (2018), motivation increases the person’s desire to change, and as a social-change agent, I will assume the role of an instructor, facilitator, and motivator to facilitate the understanding of mental health issues at both the individual and community levels. With the backing of empirical evidence, I can lead change through championing mental health at different levels.

Advocating for the Community

An approach I can use to advocate for change in my community includes providing expertise in public forums to improve the understanding of mental health issues. This involves using my expertise in mental health to persuade not only the community leaders but also those in authority regarding issues about mental health. I can also lobby for mental health issues by sharing the statistics, stories, and other information related to mental health with community leaders and elected leaders. These strategies will enable the development of effective partnerships that can enhance support directed at promoting mental health in my community (Williams, Phillips, & Koyama, 2018).

In addition to the above strategies, I can advocate for my community by joining or forming civic interest groups. By forming joint partnerships and/or special interests’ groups about mental health, I can facilitate continuing community partnerships that will help manage mental health issues (Carter, et al., 2010). It will also enable me to develop specific mental health initiatives that will continually foster the management of the mental health needs in the community.

References

Ahuja, K. K., Dhillon, M., Juneja, A., & Sharma, B. (2017). Breaking barriers: An education and contact intervention to reduce mental illness stigma among Indian college students. Psychosocial Intervention, 26(2), 103-109. doi:https://doi.org/10.1016/j.psi.2016.11.003

Carter, N., Martin-Misener, R., Kilpatrick, K., Kaasalainen, S., Donald, F., Bryant-Lukosius, D., . . . DiCenso, A. (2010). The role of nursing leadership in integrating clinical nurse specialists and nurse practitioners in healthcare delivery in Canada. Nursing Leadership, 23, 167-185. doi:10.12927/cjnl.2010.22274

Cosejo, D. (2018). Nurse – As the Change Agent. Retrieved from https://www.rnspeak.com/nurse-as-the-change-agent/

Mannarini, S., & Rossi, A. (2019). Assessing mental illness stigma: A complex issue. Frontiers in Psychology, 9, 2722. doi:10.3389/fpsyg.2018.02722

Rafferty, A. M. (2017). Nurses as change agents for a better future in health care: The politics of drift and dilution. Health Economics, Policy, and Law, 13(3-4), 475-491. doi:https://doi.org/10.1017/S1744133117000482

Williams, S., Phillips, J., & Koyama, K. (2018). Nurse advocacy: Adopting a health in all policies approach. OJIN: The Online Journal of Issues in Nursing, 23(3), online. doi:10.3912/OJIN.Vol23No03Man01

An understanding of the neurological and musculoskeletal systems is a critically important component of disease and disorder diagnosis and treatment. This importance is magnified by the impact that that these two systems can have on each other. A variety of factors and circumstances affecting the emergence and severity of issues in one system can also have a role in the performance of the other.

Effective analysis often requires an understanding that goes beyond these systems and their mutual impact. For example, patient characteristics such as, racial and ethnic variables can play a role.

An understanding of the symptoms of alterations in neurological and musculoskeletal systems is a critical step in diagnosis and treatment. For APRNs this understanding can also help educate patients and guide them through their treatment plans.

In this Assignment, you examine a case study and analyze the symptoms presented. You identify the elements that may be factors in the diagnosis, and you explain the implications to patient health.

To prepare:

By Day 1 of this week, you will be assigned to a specific case study scenario for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Assignment (2-page case study analysis)

In your Case Study Analysis related to the scenario provided, explain the following:

• Both the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms.
• Any racial/ethnic variables that may impact physiological functioning.
• How these processes interact to affect the patient.

Day 7 of Week 8

Submit your Case Study Analysis Assignment by Day 7 of Week 8.

Reminder: 

The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The sample paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates). All papers submitted must use this formatting.

  

For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.  

Case: An elderly widow who just lost her spouse. 

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications: 

• Metformin 500mg BID 

• Januvia 100mg daily 

• Losartan 100mg daily 

• HCTZ 25mg daily 

• Sertraline 100mg daily 

Current weight: 88 kg

Current height: 64 inches

Temp: 98.6 degrees F

BP: 132/86 

By Day 3 of Week 7

Post a response to each of the following:

• List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. 

• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why. 

• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. 

• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 

• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?

• Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. 

Respond to the these discussions. All questions need to be addressed.

Discussion 1 En

Three questions to ask the patient and a rationale for asking these questions.

How may I be of assistance today? This question creates a rapport between you and the patients, and it makes her know that the doctor is ready to listen and help her.

What are you doing to cope with grief after losing your husband? This question will help the care provider assess the approaches the patient is using to cope with grief and be able to identify the ones working and not working for the patient.

Are you living with someone at home, and are you following your regimen correctly? By asking this question, the care provider will understand the type of support system available at home and know which support to prescribe for the patient and if the support at home is helping the patient follow her regimen correctly.

People in the patient’s life to speak to or get feedback from to further assess the patient

People in the patient’s life to speak to include her children, her aide, and close friend per her authorization. The feedback I will get from these people will help me know the severity of the patient’s problem. Some of the questions I will ask them are;

1. Has the patient been experiencing worse symptoms of depression since her husband’s dead? This question will help me understand people close to her can know when she is depressed.

2. Does the patient complain about her treatment regimen? This question will allow me to know the side effects of the treatment if any.

3. Has the sleeping patterns changes recently? This question will help me understand the severity of insomnia.

Physical and diagnostic tests

The physical exams appropriate for this patient include heart rhythm, eye assessment, and oxyhemoglobin saturation. The diagnostic tests for this patient include polysomnography and actigraphy tests. These tests will be used to measure the patient’s sleep patterns. The actigraphy measures sleep efficiency, sleep latency, and total sleep time, and polysomnography will diagnose sleep disorders (Niel et al., 2020)

Differential diagnoses for the patient

The patient’s differential diagnoses include generalized anxiety disorder, major depressive disorder, and restless leg syndrome. Major depressive disorder (MDD) is likely to explain why the patient is experiencing insomnia. MDD’s clinical presentation include insomnia, difficulty concentrating, appetite loss, and hopelessness. The patient’s husband’s loss contributed to depression, which affected her sleeping pattern. According to Bennabi et al. (2019), patients with MDD are at risk of experiencing sleeping disorders.  Since the patient is responding to grief, her chances of developing MDD are high.

Pharmacologic agents and their dosing

Selegiline Transdermal patch. Apply 6mg daily dose, which is applied every day. If symptoms do not improve, the dose can be increased by 3mg daily for two weeks until it reaches a maximum of 12gm daily. The drug inhibits Monoamine Oxidase-B isoenzyme (Bied et al., 2015).

Eszopiclone. The required dose is 3mg, which is administered orally before the patient goes to bed. It is the first-line drug for insomnia, and it interacts with gamma-aminobutyric acid (GABA) receptors at the allosterically binding sites at the benzodiazepine receptors. The drug works by slowing brain activities to allow sleep. The drug induces sedation and hypnosis hence causing sleep (Dixon et al., 2015). Since the patient is complaining of insomnia, eszopiclone will be appropriate in improving this symptom.

Drug therapy contraindications

Contraindications of using selegiline transdermal include increased risks of serotonin syndrome. The drug contraindicates in the patients taking selective serotonin reuptake inhibitors, mirtazapine, and other vasoconstrictors and analgesics.

Check points

After administering these drugs, the patient will be assessed after a four-week interval to determine if the symptoms have improved. If the symptoms have not improved after four weeks, selegiline transdermal will be increased by 3mg for four weeks until 12gm, which is the maximum dose per day. If the symptoms improve within the first four weeks, the regimen will be maintained until the patient completes the dose. After completing the dose, the patient will sleep well and the symptoms of depression will be well managed.   

References

Bennabi, D., Charpeaud, T., Yrondi, A., Genty, J. B., Destouches, S., Lancrenon, S., … & Haffen, E. (2019). Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental. BMC psychiatry, 19(1), 1-12.   https://doi.org/10.1186/s12888-019-2237-x

Bied, A. M., Kim, J., & Schwartz, T. L. (2015). A critical appraisal of the selegiline transdermal system for major depressive disorder. Expert review of clinical pharmacology, 8(6), 673-681. https://doi.org/10.1586/17512433.2016.1093416

Dixon, C. L., Harrison, N. L., Lynch, J. W., & Keramidas, A. (2015). Zolpidem and eszopiclone prime α1β2γ2 GABAA receptors for longer duration of activity. British journal of pharmacology, 172(14), 3522-3536. https://doi.org/10.1111/bph.13142

Niel, K., LaRosa, K. N., Klages, K. L., Merchant, T. E., Wise, M. S., Witcraft, S. M., Hancock, D., Caples, M., Mandrell, B. N., & Crabtree, V. M. (2020). Actigraphy versus polysomnography to measure sleep in youth treated for craniopharyngioma. Behavioral sleep medicine, 18(5), 589-597. https://doi.org/10.1080/15402002.2019.1635133