APA format.  EACH DISCUSSION NEEDS SEPERATE RESPONSE. 1 paragraph for each response. Scholar authors only. References needs to be include.       

Discussion 1

  It is common practice in my ICU to stop all non-life sustaining medications. This seems practical at first given most of the medications we think of are doing the opposite of what we are trying to achieve (adequate blood pressure, protecting airway) but it also includes any psychiatric medications they were on. I spoke with two physicians in my practice and several charge nurses and they have seen the same thing repeated with the same results, longer stay in the ICU with a longer intubation time. In a study done by Gacouin et al., they found that psychiatric patient admitted for a self-harm event were more likely to survive their admission than their admission for medical reason counterparts (2017). Those with admission for chronic or acute medical needs were more difficult to treat and is thought to be associated with poor adherence to treatment required to stay healthy (Gacouin et al., 2017). Some common medications have been found to increase inflammatory responses so stopping those in many cases would be appropriate, however, not restarting them after the acute phase may cause setbacks in extubation.

          To bring the problem to light I will explain a common scenario and the most extreme case I worked with: Patient comes in for respiratory failure and all medications are stopped. Patient is found to have sepsis due to pneumonia and it is now known they are on several psychiatric medications, but they are not restarted or even considered during rounds. Daily awakening trials take place with no success due to agitation. Patient then self-extubates and codes, we get the patient back. Spouse is also a psychiatric patient and has attempted suicide upon hearing of the changes. Patient remains a full code is on four pressers (that is the limit unless we get creative) and it looks grim. Patient rebounds, recovers enough to get a tracheostomy and feeding tube placed. The state designated crisis responder for this patient asks when the last dose of psychiatric medication was administered, it had never been restarted. Nearly 30 days into the stay home medications are restarted. Patient fully recovers but must do it in the hospital setting without formal rehabilitation, due to their psychiatric diagnosis on file no facility would accept the patient.

          The quality of care in this case was lacking in respect to the patient and their full picture of health. Our facility ignored a significant diagnosis and it led to challenges that may have been avoided if we had continued to treat their chronic illness. This is not the first facility I have practiced in that employs this way of thinking, but it needs to change. Having a dedicated psychiatric practitioner available in the ICU would decrease these incidences and improve outcomes. This is not just a national problem but a global problem. In India they found on average 20%-60% of ICU patients have a psychiatric diagnosis and early identification along with early treatment resumption could lead to shorter stays and better outcomes (Nongmeikapam et al., 2018).

Discussion 2:

Participating in the collaborative interview was two staff nurses, a pharmacist, and a nursing administrator.  It was discussed in the collaborative meeting that obtaining adverse drug event (ADE) data is challenging because of a lack of reporting.  Current evidence suggests that only 5% of ADEs are reported in the clinical setting (Bailey et al., 2016).  Both nursing and pharmacy participants reaffirmed that they believe ADEs are underreported through their practice.  They informed that fear of being reprimanded, personal insecurity due to the error, time, workload, termination, and possible revoking of their licenses were core to not reporting ADEs.

           Additionally, ADE reporting standardization and tools to report these events are lacking.  Currently, the U.S. Food and Drug Administration tracks ADEs, which are relayed to them from manufacturers, healthcare facilities, and individuals.  This system, however, is limited because it houses duplicate and incomplete reports.  Also, the reports have not been verified, there is no causation, and national rates of incidence cannot be established (U.S. Food and Drug Administration, 2019).  Currently, there is no comprehensive database to compare ADEs.  I would propose that the Agency for Healthcare Research and Quality (AHRQ) incorporate ADEs as a core healthcare quality indicator and develop means of tracking data without repercussion and with anonymity.  I believe that the need for more aggressive tracking is justifiable due to current evidence suggesting that most ADEs are not reported.  Also, medication errors are the most common challenges within healthcare that are endangering patients worldwide (Mirzaee et al., 2015).  Individuals must develop shareable and standardized tracking tools to provide transparency concerning ADEs between clinical settings and nationwide.  

           Causation of ADEs was discussed with errors occurring in multiple stages of administration.  The stages of administration considered were prescribing, transcribing, dispensing, administration, and monitoring.  The pharmacy participant reports that the most common ADEs, within the facility, occur at the dispensing and administration stages.  The pharmacist did say that throughout his time as a pharmacist, he has noticed a considerable reduction in medication errors from transcribing.  He attributed this reduction to the implementation of electronic medical records resulting in decreased handwritten orders.  Still, however, reported medication errors cause at least 1.5 million injuries and cost 3.5 billion dollars in the U.S. annually (Shitu et al., 2020).  The unfortunate part regarding ADEs in the clinical setting is that most are preventable (Bailey et al., 2016).

In my clinical setting, there have been 27 ADEs over the past three months.  My facility uses the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) index to classify potential severity and outcome of medication errors.  Twenty-three of the errors were classified as severity B.  In contrast, four were classified as severity A.  Both are the lowest two classifications of potential harm.  Even though these severity errors posed low severity ratings, nonintervention can cause more severe errors.  Knowing that most ADEs are preventable, healthcare facilities need to develop robust protocols and procedures to prevent medication errors from occurring because even one preventable ADE can be detrimental to the health of an individual.

Every family has to come to a decision regarding end of life at some point.  In the case of the COVID pandemic, families are making this painful decision at a moment when they are not even able to visit with the patient.

In my ER, a patient came in from a memory care facility where multiple residents tested positive for COVID, including my patient.  When he arrived his sats were at 68% and we was on a non-rebreather.  We switched him over to a high flow oxygen and his O2 went up to 95%.  He had Alzheimer’s and communication was difficult.  There was no DNR in place for him and I contacted his daughter, who is his proxy, to let her know his current situation.  The admitting doctor spoke to her and they decided to put in DNR in place.  I Facetimed with her so she could say goodbye to her father.  It was the most heartbreaking thing I have ever done.  When we brought him up to the ICU he was stitched over to a nasal cannula at 2 liters and passed away shortly afterwards.  The family was unable to visit with him before he passed because he was COVID positive.

There was discussion about hospitals considering DNR for COVID patients so that staff is not put at risk because of PPE shortages (Masson, 2020).   Hospitals such as Northwestern Memorial Hospital in Chicago, are considering placing orders regardless of family and patient wishes (Masson, 2020).  This is an uncertain time, where we really don’t know where the disease process will go.  In another study it was found approximately 77% of participants believed the decision about DNR should a team decision which consists of the physician, nurse, patient, and the families (Tajari et al., 2018).  Many of these decisions are made when the patient is critical. 

In finding the CPR decision aid for patients and their families on the Ottawa Hospital Research Institute site, this is a useful tool in aiding with this painful decision.  The tool went into detail about what occurs during CPR and lets families know what the outcomes would be and the small chance of a normal life.  There is an honest paragraph about the side effects of CPR such as broken bones, punctured lungs, and impaired mental function (OHRI, 2019).  When discussing this with families and the patient it is important to have an honest discussion so an informed decision can be made.  I will use this aid for work because it’s important to have open communication about the reality of life.

Tajari, M., Jalali, R., Vafaee, K.  Attitudes of patients’ relatives in the end stage of life about do not resuscitate order. Journal of Family Medicine and Primary Care.  Doi: 10.4103/jfmpc.jfmpc_144_18:10.4103.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6259503/?report=printable

Masson, G.  (2020) Hospitals consider do-not-resuscitate order for all COVID-19 patients.  https://www.beckershospitalreview.com/public-health/we-re-going-to-be-coding-dead-people-hospitals-consider-do-not-resuscitate-order-for-all-covid-19-patients.html

The Ottawa Hospital Research Institute. (2019) Patient Decision Aids.  https://decisionaid.ohri.ca/

Reading Assignment from Smith and Parker Textbook

Chapter 25: The Community Nursing Practice Model

Chapter 26: Rozzano Locsin’s Technological Competency as Caring in Nursing

Discussion Initial post Due: 07/22/2020 By 11:59 PM

Respond to two peers by Saturday, July 25, 2020 at 11:59 PM

 1- How do you see the benefit of using both the Community Nursing Practice Model and Locsin’s Technological Competency as Caring in Nursing in today’s nursing environment?

 Please remember to adhere to APA 6th edition publication standards and please following the grading rubric. One post is your original submission and two responses to your peers are required.

Discussion Board Rubric

Proficient

Novice

Introduction and quality of discussion’s Argument 

1 point

It is consistent with application in research related to its context. Clarity of ideas.

0.50 point

The topic has a partially weak association to the clarity of ideas and related topics. 

The objectivity of Tone, overall quality & Review of

Literature in APA 6th format within the past 7 years

1 point

The tone is consistent, addressed professionally and objectively. 

Evidence in literature supports arguments.

0.50 point

The tone is not consistently objective. Partially poor evidence in the review of the literature.

Quality of Reply posts

1 point

Consistent clarity and supported by research evidence.

0.25 point

Partially lack clarity or lack of support with research evidence.

 Dr. Davis

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.

Evaluate the Health History and Medical Information for Mrs. J., presented below.

Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.

Health History and Medical Information

Health History

Mrs. J. is a 63-year-old married woman who has a history of hypertension, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal cannula at home during activity, she continues to smoke two packs of cigarettes a day and has done so for 40 years. Three days ago, she had sudden onset of flu-like symptoms including fever, productive cough, nausea, and malaise. Over the past 3 days, she has been unable to perform ADLs and has required assistance in walking short distances. She has not taken her antihypertensive medications or medications to control her heart failure for 3 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure and acute exacerbation of COPD.

Subjective Data

1. Is very anxious and asks whether she is going to die.
2. Denies pain but says she feels like she cannot get enough air.
3. Says her heart feels like it is “running away.”
4. Reports that she is exhausted and cannot eat or drink by herself.

Objective Data

1. Height 175 cm; Weight 95.5kg.
2. Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58.
3. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint: all peripheral pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation.
4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%.
5. Gastrointestinal: BS present: hepatomegaly 4cm below costal margin.

Intervention

The following medications administered through drug therapy control her symptoms:

1. IV furosemide (Lasix)
2. Enalapril (Vasotec)
3. Metoprolol (Lopressor)
4. IV morphine sulphate (Morphine)
5. Inhaled short-acting bronchodilator (ProAir HFA)
6. Inhaled corticosteroid (Flovent HFA)
7. Oxygen delivered at 2L/ NC

Critical Thinking Essay

In 750-1,000 words, critically evaluate Mrs. J.’s situation. Include the following:

1. Describe the clinical manifestations present in Mrs. J.
2. Discuss whether the nursing interventions at the time of her admissions were appropriate for Mrs. J. and explain the rationale for each of the medications listed.
3. Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.
4. Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide a rationale for each of the interventions you recommend.
5. Provide a health promotion and restoration teaching plan for Mrs. J., including multidisciplinary resources for rehabilitation and any modifications that may be needed. Explain how the rehabilitation resources and modifications will assist the patients’ transition to independence.
6. Describe a method for providing education for Mrs. J. regarding medications that need to be maintained to prevent future hospital admission. Provide rationale.
7. Outline COPD triggers that can increase exacerbation frequency, resulting in return visits. Considering Mrs. J.’s current and long-term tobacco use, discuss what options for smoking cessation should be offered.

You are required to cite to a minimum of two sources to complete this assignment. 

Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

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.