Read Chapter 5

1. Describe the organizational characteristics of the facility in which you currently have a clinical assignment. Include the following:

a. Type of organization

b. Overall climate of the facility 

c. How the organization is structured 

d. Formal and informal goals and processes of the organization 

2. Why is the work climate of an organization important to nurse leaders and managers?

3. What are the ways in which a nurse can enhance his or her expertise?

4. Explain “shared governance,” and describe how it can affect the power structure of a health-care organization. 

5. Why is it important for staff nurses to understand the culture and real goals of the organization in which they work? 

1. Describe your ideal organization. Explain each feature and why you think it is important.

2. Interview one of the staff nurses on your unit. Find out what practices within the organization help to empower the nurses. Compare this list of practices with those discussed in the textbook. 

3. Recall the last time you walked into a hospital, clinic, or physician’s office for the first time. What was your first impression? Did you feel comfortable and welcome? Why or why not? If you could change the first impression this facility makes, what would you do?

4-What changes could be made at a very low cost? What changes would be expensive? Finally, discuss why it is important for a health-care facility to make a good first impression

  

Adult/Geriatric Depression

Introduction 

According to Mace et al. (2017), geriatric depression disorder is a health condition that affects adult people with the main symptoms see for a patient with the condition being the frequent change in moods and the sadness. The condition is as well common among younger people although this is not a common health issue. As a result of the impact of the condition, there is a need for getting an understanding of the condition and the best medical process that is to be followed. With the treatment of the patients there is a need for understanding the fact that if one medication does not succeed, there is a need for implementation of a new medication or change of the prescription for the patient. This paper focuses on the options chosen for managing the conditions for a patient. 

Symptoms of adult/geriatric depression disorder

A patient with geriatric depression disorder will be seen to have issues of mood swings as the main symptoms of the condition. The other symptoms that will be evident will include issues of the feeling of despair and sad and the patient will have issues of pain and aches in all parts of the body. Laird et al. (2019) allude that a patient with the health condition will have risks of loss of appetite and lack of hope or lacking any willingness to get help. There are risks of the patient as well as lacking any morale in improving their condition. 

Causes

Vlasova et al. (2019) allude that one of the main risk factors that increased the chance of a patient getting geriatric depression is old age. As such, a patient who is old will be at high risk of being affected by the health condition. The other risk factor is that women are at higher risk of suffering from the health issue as compared to their male counterparts. The people who have a low-level education as well as those that have physical illnesses and influencing the standard of thinking of the person.

Thus, there is a need for healthcare providers to help in the education of the patients who are at risk of suffering from the health condition. The patients who are found to be making use of various drugs and that have psychological stressors are at high risk of being affected by the health concern. The patients as well may lead to affecting the patients who have white matter changes.

Patient case

This is a case of 32-year-old patients of Hispanic origin and who came to the US for his education. The patient has his mother passing on while he was in school and ended up being admitted to the healthcare facility as a result of depression issues. On having an assessment, it is found that the patient does not suffer from any other health issue and the patient has presented that he has had pain and stiff parts of the body.

There are various signs and symptoms expressed by the patient with the main issue faced by the patient being undermined as a result of the color of his skin. There is evidence of the patient having little socialization since he has not been seen to be having any friends. The patient has had a reduction in the morale to interact with the other people living in the community and has had a detachment and does not have the evidence of being with the others. 

The indication is that he has had an issue of lack of sleep for most of the days for the last 6 months and the patient claims that the condition has become worse each day. The patient as well presents that he does not have enough exposure and does not present his best at work. On the Montgomery Asberg depression rating scale, the patient is found to score 51 and this shows that he has a severe case of depression. 

Decision #1

Which decision did you select?

Begin Effexor XR 37.5 mg orally daily

Why did you select this decision?

The selection of this medication is to help in the reduction of the issue of depression and is fundamental for patients as a way of therapy. The selection of this medication is attributed to the fact that the medication has fewer side effects as compared to the use of medications such as Zoloft or phenelzine (Crocco et al., 2017).

What were you hoping to achieve by making this decision?

The expected results for the use of this medication is that the patient will have a change in his condition and that he would be found to have a reduction in cases of depression. Thus, the use of the medication is expected to help in the enhancement of the social skills of the patient hence he may be able to interact with more people as depicted by Beyer and Johnson (2018).

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

The use of the medication is expected to help in the improvement of the depressive condition of the patient and that the patient will have had improved symptoms. After the use of the medication and the follow up being made after four weeks, it is found that there were no changes in the symptoms expressed by the patient. As a result of the lack of changes in the depressive symptoms of the patient, there has been a need for having another decision to help in healing the patient.

Decision #2

Why did you select this decision?

The second decision is to increase Effexor XR to 75 mg orally daily. The medication that is focused on in this case is to help in the enhancement of the quality of health of the patient. The patient is expected to have an increase in the dosage for the change in the symptoms and the medication does not have excessive side effects. 

What were you hoping to achieve by making this decision?

The decision, in this case, is made with the expectation of an improvement in the quality of health. The patient can learn of the improvement in the quality of health and that there is the ease in the development of the standard of care with the symptoms that the patient has including issues of depression being improved. This is of importance in ensuring that one can have a better living standard and that the skills of socialization are eliminated (Vlasova et al., 2019).

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

The use of the medication is expected to help in ensuring that there is the ease in the advancement of the standard of health for the development of the quality of health. The patient’s condition is expected to ensure that one can manage the condition of depression. The patient comes after four weeks to the healthcare facility and indicates that there is an improvement in the depressive symptoms. As such, the patient has had an improvement in the quality of health. At this time, the patient has been able to do the exam on the rating MADRS scoring 38 out of the initial 51 which shows that the patient has had a reduction in the quality of health.

Decision #3

Why did you select this decision?

The third choice that is to be made is to increase the dose to 112.5 mg orally daily. This is an indication that the patient should be in a position to have changes in the standard of health. The selection of the medication is expected to help in the development of the quality of health. The issue of patient care facing health concern is that one is supposed to learn of the changes in the kind of medication being used. The process is expected to help in improving the chances of depressive disorder as pointed out by Crocco et al. (2017).

What were you hoping to achieve by making this decision?

The use of this medication is expected to help in that it allows for the development of the improved standard of patient care. There will be an improvement in the standard of health of patients and that the healthcare quality of the patients as well as the improvement in the health standard of patients. 

Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

The use of the medication is of importance in that there will be ease in increasing the dosage allowing for the patient to have a better standard of health. This is as well an important process in that it ensures that the patient can have an improvement in the quality of life. There is a need for taking into account the fact that patient care standards are taken into account at the time of making use of this medication. The change in dosage is expected to help in making the healing process to be faster.

Ethical considerations

In the process of provision of medication for patients, there is a need for ensuring that there is ethics taken into account. The ethical standards that should be taken into account, in this case, is that the patient’s health should not be misunderstood and that there should not be a challenge in the advancement of the quality of health of the patients. The decision making should not be seen to influence the health of patients and that the doses that are given to the patient should not affect the health of the patient.

Summary

The patient taken into account, in this case, is one with depressive concerns. The start of the condition is seen to be from the time of death of his mother. The selection medication that is expected to be used is Effexor XR. The initial dose during the first one moths is 37.5 mg orally daily, this is followed by Effexor XR 75 mg orally daily and 112.5 mg after 4 consecutive weeks.

References

Beyer, J. L., & Johnson, K. G. (2018). Advances in pharmacotherapy of late-life depression. Current psychiatry reports, 20(5), 34.

Crocco, E. A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological management of anxiety disorders in the elderly. Current treatment options in psychiatry, 4(1), 33-46.

Laird, K. T., Lavretsky, H., Paholpak, P., Vlasova, R. M., Roman, M., Cyr, N. S., & Siddarth, P. (2019). Clinical correlates of resilience factors in geriatric depression. International psychogeriatrics, 31(2), 193-202.

Mace, R. A., Gansler, D. A., Suvak, M. K., Gabris, C. M., Areán, P. A., Raue, P. J., & Alexopoulos, G. S. (2017). Therapeutic relationship in the treatment of geriatric depression with executive dysfunction. Journal of affective disorders, 214, 130-137.

Vlasova, R. M., Siddarth, P., Krause, B., Leaver, A. M., Laird, K. T., St Cyr, N., … & Lavretsky, H. (2018). Resilience and white matter integrity in geriatric depression. The American Journal of Geriatric Psychiatry, 26(8), 874-883.

Mr. E is a pleasant, 70-year-old, black, male

Source: Self, reliable source

Subjective:

Chief complaint: “I urinate frequently.”  

HPI:  Patient states that he has had an increase in urination for the past several years, which seems to be worsening over the past year. He estimates that he urinates clear/light yellow urine approximately every 1.5-2 hours while awake and is up 2-4 times at night to urinate. He states some urgency and hesitancy with urination and feeling of incomplete voiding. He denies any pain or blood. Denies any head trauma. Denies any increase in thirst or hunger. He denies any unintentional weight loss.

Allergies: NKA

Current Mediations:

Multivitamin, daily

Aspirin, 81 mg, daily

Olmesartan, 20 mg daily

Atorvastatin, 10 mg daily

Diphenhydramine, 50 mg, at night                                                                                                                   

Pertinent History: Hypertension, hyperlipidemia, insomnia

Health Maintenance. Immunizations: Immunizations up to date

Family History: No cancer, cardiac, pulmonary or autoimmune disease in immediate family members

Social History: Patient lives alone. He drinks one cup of caffeinated coffee each morning at the local diner. He denies any nicotine, alcohol or drug use. 

ROS: Incorporated into HPI

Objective:

VS – BP: 118/68, HR: 86, RR: 16, Temp 97.6, oxygenation 100%, weight: 195 lbs, height: 70 inches.

Mr. E is alert, awake, oriented x 3.  Patient is clean and dressed appropriate for age.

Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop

Respiratory: Clear to auscultation 

Abdomen: Bowel sounds positive. Soft, nontender, nondistended, no hepatomegaly           

Neuro: CN 2-12 intact                                                                                                                        

Renal/prostate: Prostate enlarged, non-tender. No asymmetry or nodules palpated

Labs:

Test Name

Result

Units

Reference Range

Color

Yellow

Yellow

Clarity

Clear

Clear

Bilirubin

Negative

Negative

Specific Gravity

1.011

1.003-1.030

Blood

Negative

Negative

pH

7.5

4.5-8.0

Nitrite

Negative

Negative

Leukocyte esterase

Negative

Negative

Glucose

Negative

mg/dL

Negative

Ketones

Negative

mg/dL

Negative

Protein

Negative

mg/dL

Negative

WBC

Negative

/hpf

Negative

RBC

Negative

/hpf

Negative

Lab

Pt’s Result

Range

Units

Sodium

137

136-145

mmol/L

Potassium

4.7

3.5-5.1

mmol/L

Chloride

102

98-107

mmol/L

CO2

30

21-32

mmol/L

Glucose

92

70-99

mg/dL

BUN

7

6-25

mg/dL

Creat

1.6

.8-1.3

mg/dL

GFR

50

>60

Calcium

9.6

8.2-10.2

mg/dL

Total Protein

8.0

6.4-8.2

g/dL

Albumin

4.5

3.2-4.7

g/dL

Bilirubin

1.1

<1.1

mg/dL

Alkaline Phosphatase

94

26-137

U/L

AST

25

0-37

U/L

ALT

55

15-65

U/L

Pt’s results

Normal Range

Units

WBC

9.9

3.4 – 10.8

x10E3/uL

RBC

4.0

3.77 – 5.28

x10E6/uL

Hemoglobin

11.5

11.1 – 15.9

g/dL

Hematocrit

35.0

34.0 – 46.6

%

MCV

85

79 – 97

FL

MCH

28

26.6 – 33.0

Pg

MCHC

34

31.5 – 35.7

g/dL

RDW

14

12.3 – 15.4

%

Platelets

220

150 – 379

X10E3/uL

PSA

5.4

0-4.0

ng/mL

Assessment:

Diagnosis: Benign prostatic hyperplasia, ICD-10: N40.1

Please answer the following:

For the sake of this case study, the patient has confirmed BPH and prostate cancer has already been ruled out. Hence, please document your prescribed treatment plan for this patient (i.e. don’t state “refer to urology”).

1. What is your treatment plan (include specific dosage and frequency)? Why did you choose this treatment plan? Do you change any of his current medications?  In your answer, please describe, briefly, the pharmacodynamics (1 point) and pharmacokinetics (1 point) of your treatment choice and how they influenced your decision. Does the patient have any comorbidities that influenced your choice as well (1 point)? 

       Three months later, the patient notes improvement, but no resolution of symptoms. What would be your next prescribed treatment option (1 point)?

1. Document the education you would provide for this patient, specific to the prescribed medication. Please include information pertinent to the patient (2 points) and common potential adverse effects (2 points).

What are your thoughts? Reply to this discussion question.

Per our infection control nurse, one area in which my hospital lacks is with patients diagnosed with sepsis. I have yet to get ahold of the numbers which I will have later this week, but per Melissa, these numbers are not great and could be improved. She believes and even from working as a bedside nurse in the Intensive Care Unit (ICU), I agree with her that we are lacking in the department of handoff communication between nurses. Report from the emergency room to the floors, or from the floors to a higher level of care (I.e. ICU’s, Cardiac ICU’s, ICU step downs or telemetry), there is a lack of effective communication between nurses. 

We all are aware of a sepsis bundle as it was drilled into our minds during our nursing programs and very well followed us into our careers. Whether you work medical-surgical, telemetry, critical care, mother/baby, labor and deivery, pediatrics, etc., we will always have patients of all ages who can have sepsis. Although the sepsis bundle is quite straightforward, communicating that is not always easy. Many times, nurses are not thorough in their reports of interventions and cares already provided, fail to notify the receiving nurse of sepsis protocol interventions that were canceled by physicians although this is not allowed in my facility or miss handing off important parts of report. By discontinuing interventions I am talking about a physician saying it is not necessary to achieve repeat lactates, administer fluid boluses, more than one sets of blood cultures, etc. Main things you would do during a sepsis bundle. It is now the nurses responsibility, per protocol, to reorder any interventions that a physician has canceled despite the discontinuation.  

Our hospital is beginning to implement a paper form, strictly for nursing to complete and then hand into our quality department for review. We are calling this the “Sepsis Handoff Tool”. It is a form that has the nurse fill out the time and date of when severe sepsis was recognized and what systemic inflammatory response syndromes (SIRS) were identified. It also requires the hospitalist notified three sets of vital signs to be noted. The form also has two boxes, one with a three hour sepsis bundle power plan and the other with a six hour sepsis bundle power plan; all which much be checked off with no exceptions. Then registered nurse and physician both must sign the paper and send to the quality department. With this new implemenation, infection control will then perform a study on whether this new tool increased patient outcomes or not. 

As nurses, there are many implications to our job. WIth sepsis and nursing in general, we are expected to be on top of our patients, their cares and interventions. We are responsible for making sure our patients are receiving all of the treatments they have ordered and that they are appropriate. WIth sepsis, a patients condition can rapidly deteriorate. We are a part of the team that attempts to prevent this from occuring, which means implementing our protocols and policies to the fullest extent. This handoff tool has the potential for nurse to nurse and nurse to phyisicians to both be on the same page and aware of patient care. The second implication for nurses would be that we are here to help our patients. As nurses, we do what we do to help those who are sick. Accurately implementing interventions that have been proven to decrease morbidity related to sepsis when performed together are interventions that we should be doing. Having a form that helps nurses reduce time wasted in determining what has and has not been done is very beneficial as we can go right ahead to implement appropriate interventions that are left.